By Alice Lineham
*Note that throughout this article the term ‘teenager’ is used to refer to individuals between the ages of 13-18.
Since the turn of the century, an influx of psychedelic trials have taken place at renowned institutions across the globe. Weekly news stories are lauding these compounds for their benefits in treating adults with everything from PTSD and depression, to problems with addiction and cluster headaches. But virtually none of this research has investigated a large cohort with the conditions listed above. With a tidal wave of youth mental health disorders submerging an already inundated health system, is it time we began investigating the potential of psychedelics for people under the age of 18?
The question of using drugs to treat teen mental health will inevitably raise eyebrows. Figures state that if you start using illicit drugs during this period, you have a whopping 25% chance of becoming addicted, compared to just 4% if use starts in adulthood. This increased susceptibility results from a whole host of social and biological factors, but one of significance is brain maturation. The ‘reward’ centre of the brain – responsible for feelings of euphoria, or the ‘let’s do that again’ factor – develops at a much faster rate than the prefrontal regions – which govern cognitive control processes like inhibition and rational decision making. So, the teenage brain is basically like a car operating with a fully functional gas pedal (the reward centre) but no working brakes (prefrontal regions), a mismatch which means young individuals are extremely motivated to pursue pleasurable rewards like drugs, but are ill-equipped to weigh up the risks and make sound and rational decisions.
Of course, not all teenagers are equally at risk. Genetic predispositions and certain adverse life experiences may make teens more susceptible to addiction. But why take the risk? Isn’t it best we just tell our kids to stay away from drugs, or as the famous three-word mantra goes: “Just Say No”?
Well yes, research does appear to suggest that it’s probably for the best if teenagers abstain from highly addictive substances, but the point is that psychedelics are not highly addictive substances. Although many psychedelic substances have been placed in the most stringent of drug groupings (Class A / Schedule I), meaning they are regarded as having no known medical value and a very high potential for abuse, many experts strongly dispute this categorisation.
David Nutt – neuropsychopharmacologist and Founder of Drug Science- contends that classic psychedelics, including LSD, psilocybin, DMT and mescaline, may well be the safest of all scheduled substances when it comes to physiological harm and addictive potential (Nutt, 2007). Compared to other drugs of abuse, like cocaine or alcohol for example, classic psychedelics are unique in their chemical makeup as they don’t cause withdrawal symptoms – a key determinant in whether a substance has addictive potential. In fact, the human body develops an almost immediate tolerance to the psychoactive effects of these substances, which means virtually no desire to use them in succession.
Nonetheless, the question of safety is still a concern. Psychedelics are powerful mind-altering drugs, and the experiences notoriously lack much predictability. At times, they are immensely pleasurable, with individuals experiencing enhanced colours, clearer sounds, powerful feelings of connectedness, spirituality, or love. But at others, experiences can be dark and harrowing, causing intense feelings of fear and sadness, disturbing hallucinations, or the resurfacing of old traumas or memories.
Although experts claim it is often these negative psychedelic experiences which can hold the greatest healing potential, developing brains could bode differently. The set of brain structures known as the limbic system- key to emotion perception and behaviour- is highly active during the teen period. When this is combined with insufficient prefrontal control, teenagers can experience heightened, unpredictable, and turbulent emotions. Could adding a psychedelic experience to the mix just be a disaster waiting to happen?
Ultimately, we just don’t know yet. There is a scant amount of rigorously controlled scientific data on psychedelics and developing brains, so we can’t entirely refute the possibility that teenagers may struggle with the psychedelic experience.
But what does exist are findings from naturalistic studies where psychedelic substances are consumed by children and teens for various religious, spiritual, therapeutic, or festive purposes. Indigenous Huichol Indians in Mexico give small doses of peyote- a cactus containing the psychedelic compound mescaline- to children as young as 6 years old, believed to be the age at which children can communicate their psychedelic experience with elders. Larger, vision-inducing doses can be administered around age 8 (Dorrance et al, 1975). In some cases, psychedelic substances are used even earlier than this. Families in the Brazilian ayahuasca churches Santo Daime and Unioa do Vegetal give miniscule doses of ayahuasca- a plant-based brew containing the psychedelic DMT – to newborns just hours after they are born (Labate, 2011), with such practices believed to symbolise initiation into tradition and enable healthy development.
The applicability of these findings to Western psychiatric paradigms is subject to debate. Most are evidencing the use of small, or “micro”, doses of these compounds. Given that lower doses induce less psychoactive effects, it is difficult to untangle the relevance of these naturalistic findings when discussing the potential of using higher, or “macro”, doses with minors (as is the case in current Western trial paradigms with adults).
Still, some pertinent insights can be drawn from these age-old practices. For the Huichol, rather than fixing a chronological age for psychedelic initiation, the maturity, interest, and personal circumstances of each child are individually considered. This is something Mark Haden– Executive Director of MAPS Canada and an expert in substance abuse – also believes to be critical when discussing psychedelics for younger populations. Haden likens psychedelics to other prescribed medications (e.g., birth control), asserting that the emphasis should be on maturity rather than age. If the young individual truly understands what they are asking for, Haden contends that they too should be able to access the psychedelic experience whilst under the care, guidance, and expertise of trained professionals.
Perhaps most importantly, is that these psychedelic traditions have been going on for several millennia. This arguably attests, at least in part, to the safety of these compounds, as it’s highly unlikely these practices would have continued had they been causing deleterious effects in youth. In fact, findings show that, compared to controls matched for sex, age, and education levels, individuals between 15 and 19 years old who engage in ayahuasca ceremonies are healthy, show no differences in neuropsychological or psychiatric measures (Doering- Silveira et al, 2005), and may even exhibit lower anxiety and attentional problems (Da Silveira et al, 2005).
Once we step outside stringent western prototypes, we see that the benefits of psychedelic agents are harnessed in many intriguing ways, for people of all ages. And yet in Western societies, we are taught only of the harmful consequences of these compounds but remain happy to prescribe millions of children, even toddlers, with Adderall and Ritalin – drugs that can cause multiple adverse side effects (growth suppression, insomnia and hallucinations) and potentially even alter brain development.
This shrouding of psychedelics in stigma and fear can be traced back to the early stages of drug prohibition in the 1970s. The two decades before this saw a very fertile period for psychedelic research with studies documenting the healing benefits of these substances for various medical conditions, and few even reporting on the therapeutic promise in children (e.g., LSD for the treatment of children with autism). But the government crackdown, or as the movement is better known: The War on Drugs, resulted in a strict black and white “zero tolerance” approach to drug use. With this came a draconian legal agenda which grouped all drugs into one demonised cloud looming over society, governments perpetuating fear instead of honest information, and the immediate termination of fruitful scientific research into these substances.
Still, 50 years on and the drug ketamine is beginning to make waves in this area. Although not psychedelic in the classic sense of the word, ketamine produces profound altered states of consciousness which closely resemble the more classic compounds, like LSD or psilocybin for example. Following two decades of adult research showcasing ketamine’s powerful antidepressant effects, and the recent FDA approval of esketamine (a nasal spray derived from ketamine), researchers have begun testing this compound for younger populations.
In early 2021, a group of Yale researchers released initial findings evidencing that 76% of a cohort of severely depressed 13-17 year-olds, showed a significant decrease in their depression symptoms just 24 hours following a ketamine infusion, with no reported safety concerns. These findings were especially pertinent given that several other treatment modalities had previously failed to alleviate symptoms in any of these patients. These researchers aim to investigate ketamine for other adolescent indications, such as suicidality and eating disorder pathologies.
However, encouraging as this may be, any successes in the ketamine field may not necessarily accelerate the investigation of other psychedelics with children. Ketamine has been licensed as a paediatric anaesthetic in mainstream medicine since 1970. Along with providing 50 years of safety data, this also means ketamine is Schedule 4(i) (or Schedule III in the US), which gives scientists much more leniency to work with this compound.
Even given this, ketamine has only just passed through the first phase of trials with children in the US. Although a phase II trial is now underway (NCT03889756), with the second two phases lasting up to 6 years and the final stage alone warranting between 300 to 3000 participants, there is still a long way to go before this drug is available on prescription. For a successful NHS rollout, a similar 3 stage trial process will be required before the National Institute for Health and Care Excellence and the Medicines and Healthcare Regulatory Agency can approve ketamine as a safe, cost-effective treatment for teenage mental health problems.
Most other psychedelics are farther away from being a licensed medicine than Ketamine is, as researching these substances is arduous. Currently, to work with schedule 1 compounds in the UK requires obtaining a special licence which can cost several thousands of pounds and often years to acquire. An extra level of complexity is added when discussing under 18s. Given the abundance of ethical challenges already associated with conducting clinical trials in children, Research Ethics Committees are likely to recoil at the prospect of giving under-18s a schedule 1 drug. Further still, a responsible parent or guardian is always required to provide consent for their minor to take part in these trials. Given the stigma engulfing these substances, this typically straightforward aspect of the trial is likely to be a tricky feat.
The sooner the topic of teens enters psychedelic dialogue, the sooner stigma will start to dissipate and one man initiating this is Rick Doblin- founder of the Multidisciplinary Association for Psychedelic Studies (MAPS). Doblin has publicly expressed his own positive views on this matter on several occasions and most recently at the Interdisciplinary Conference on Psychedelic Research (ICPR). This is promising given the respected voice MAPS has in the psychedelic sphere. Even more promising is that assuming success in their final trial phase of MDMA-assisted therapy for PTSD, the FDA is poised to greenlight the organisation to carry out similar research for teenagers.
MAPS also has several online platforms which are important to the discussion of teens and psychedelics. The Rites of passage project and Psychedelic fundamentals, for example, are dedicated to the sharing of family-based psychedelic experiences, and scientifically-informed education materials, both providing honest alternatives to the counterproductive and inadequate approach “Just Say No”.
Under this “just say no” approach, drug use in UK school-aged children (11-15) has increased by over 40% since 2014, with notable rises in the use of psychedelic substances like LSD, MDMA and ketamine. Inevitably, our teens are continuing to “Just Say Yes” whether drug laws prohibit it or not, so these alternative educational programmes will be key to changing current narratives which pathologize normal teenage experimentation and do little to prevent harm amongst our youth.
So, what is actually wrong with current treatments? Of course, many treatments do already exist for teenage mental health which can be very helpful and lead to temporary or lifelong remission of symptoms. Talking therapies such as Cognitive Behavioural Therapy (CBT) can be effective, especially when taken in combination with drug treatments, such as those that support serotonin levels.
But the problem is this is not the case for everyone. Post-covid figures suggest that 1 in 4 youth globally are experiencing clinically elevated depression symptoms and one third are failing to achieve remission with available treatments. This undoubtably leaves too many teenagers out of options.
Even for those who do respond, benefits can take several weeks to months to kick in and often come alongside nasty side effects. Also, antidepressant medications- of which only one is currently licensed for treating under 18s, work by controlling symptoms, rather than tackling the underlying root cause of the illness. This means the drugs must be taken every day and often across the lifetime. If not, there’s a good chance the illness will return.
In contrast, psychedelics are consistently showing minimal side effects, and have shown effective changes after just one dose. Debate exists surrounding the exact mechanisms through which psychedelics exert their therapeutic benefit, but some emerging consensus suggests the disruption of brain activity which allows the individual to see the world in a different light, or enable freedom from previous negative thought patterns or habits.
This is important because the teenage period is critical for laying down social and emotional habits. Younger brains are more ‘plastic’, or adaptable than fully mature brains, but as the individual progresses through the pubertal period, processes known as ‘synaptic pruning’ and ‘myelination’ reduce this malleability. The former works to remove unnecessary connections, whilst the latter enables faster communication between connections that are still needed.
Whilst the young brain is becoming more refined and specialised in certain pursuits, it is also losing its ability to think flexibly, alter habits, and learn new things. As Mark Haden points out, it could just be the case that the plastic nature of the teenage brain provides the perfect opportunity for psychedelics to tackle maladaptive habits and positively shape the future trajectories of our youth.
Of course, the integration of psychedelics into mainstream medicine isn’t going to happen overnight, and the question of young people is perhaps the most provocative. The use of these mind-altering drugs is still very much foreign territory, and many questions remain unanswered. Whilst many experts agree on these medicines having efficacy for psychiatric disorders in adults, we need to be careful with overstating the effects of these medicines, especially when considering developing brains.
Teenage mental health is already in crisis. Services are understaffed, inadequately funded and the NHS has been unable to address the influx of children that are needing help. Current medications are failing too many of our youth and doctors undeniably need new tools in their arsenal. So yes, psychedelics may come with risks, but it’s either try this as a last resort or omit to do anything and play the Russian roulette that is teenage mental health.