Whitewashing psychedelics: racial equity in the emerging field of psychedelic-assisted mental health research and treatment

Introduction

Growing research on potential therapeutic applications of highly restricted Schedule I hallucinogens, including the ‘classic psychedelic’ psilocybin, and the entactogen 3,4-Methylenedioxymethamphetamine (MDMA¹), has demonstrated notable promise for a range of mental health conditions (Garcia-Romeu et al., 2016; Reiff et al., 2020). Preliminary findings suggest substantial benefits of psilocybin-assisted treatment in major depression (Carhart-Harris et al., 2016; Davis et al., 2020), alcohol and tobacco dependence (Bogenschutz et al., 2015; Johnson et al., 2014), and cancer-related existential distress (Griffiths et al., 2016; Grob et al., 2011; Ross et al., 2016). Similarly, MDMA-assisted therapy has demonstrated persisting improvements in symptoms of post-traumatic stress disorder (PTSD) (Mithoefer et al., 2019). As such, both psilocybin and MDMA have been granted ‘breakthrough therapy’ designation by the US Food and Drug Administration (FDA), and pending positive outcomes of ongoing and upcoming clinical trials, could emerge as a novel treatment paradigm with considerable ramifications for mental healthcare (Reiff et al., 2020).

Psychedelics and people of color

In the current issue, Williams et al. (2020) conducted a cross-sectional online survey of 313 Black, Indigenous, and People of Color (BIPOC) in North America, which suggests that naturalistic use of classic psychedelics or MDMA is associated with significant reductions in traumatic stress, depression, and anxiety symptoms related to experiences of racism. While this observational study has some limitations, including reliance on participant self-report and recall, and questions of sample representativeness due to self-selection of participants, the study’s findings are noteworthy because they are the first to our knowledge to focus exclusively on psychedelic use outcomes in addressing racial trauma in a racial-ethnically diverse study sample. Pooled analyses of contemporary clinical trials on psychedelics have found that white individuals comprise large majorities (>80%) of study participants, substantially underrepresenting BIPOC, and calling into question the generalizability of findings to non-white populations and equity of access to such trials (Garcia-Romeu et al., 2021; Michaels et al., 2018). Nationally representative data on past-year lysergic acid diethylamide (LSD) use from 2015 to 2018 in the US suggest 71–74% of individuals who are using identify as non-Hispanic white, while only 13–16% identify as Hispanic, and 4–5% as Black (Yockey et al., 2020). Data on hallucinogen use (not including MDMA) in the US indicate greatest prevalence of lifetime and past-year use among Native American and white respondents, with lower prevalence among Hispanic, Black, and Asian individuals (Shalit et al., 2019). The disparities in substance use patterns and clinical trial enrollment, coupled with Williams et al. (2020) findings on psychedelics’ impact on race-based trauma, raise important questions regarding the sociocultural status of psychedelics, systemic reasons for the underrepresentation of BIPOC in this research, and the potential role of psychedelic-assisted treatments in ameliorating mental health disparities among diverse populations.

Systemic reasons for underrepresentation of minorities in psychedelic research

The timeliness of Williams et al. (2020) findings cannot be overstated in the current backdrop of racial and political unrest in the U.S. Movements like Black Lives Matter (BLM) have gained considerable momentum in calling attention to systemic racism and police violence against Black and other communities of color, and widespread race-based inequalities (Jee-Lyn García & Sharif, 2015). However, the racial-ethnic divide remains an ongoing and urgent affliction as evidenced by substantial economic and health disparities (Williams, 2012). Given the promise of psychedelic-assisted treatments, and the growing commercial interest in developing them, it is imperative to consider how we as a field can ensure research on psychedelic-assisted therapies is conducted equitably in diverse samples, and if approved, that these treatments are accessible and beneficial to those communities most negatively impacted by structural inequities.

Multiple reasons for the lack of diversity and underrepresentation of BIPOC as participants in psychedelic science have been proposed in the literature. These include a lack of cultural inclusivity and racial diversity within the research community, stigma related to mental disorders and lack of treatment access among BIPOC, recruitment methods that do not emphasize recruitment of BIPOC, as well as differences in attitudes and norms towards psychedelic use (Michaels et al., 2018). In addition, we submit that larger historic and systemic factors are at play. For Black Americans in particular, underrepresentation in psychedelic research studies is likely related to the history of racist and unethical research practices and resulting mistrust in biomedical research institutions. High-profile examples include the Tuskegee Syphilis study (Feagin & Bennefield, 2014), wherein Black men were deceived regarding their syphilis diagnosis and deprived of appropriate treatment over the course of decades, or the case of Henrietta Lacks, a Black woman whose cells were taken without her consent while undergoing cancer treatment at Johns Hopkins Hospital in 1951 and contributed to multiple important medical discoveries (Skloot, 2011). On the basis of such history, and the vulnerability inherent in high-dose psychedelic administration, it is clear why many BIPOC might look askance at participating in such studies today.

Unfortunately, underrepresentation of BIPOC remains a problem not only for psychedelic research, but in clinical research across the board (Nazha et al., 2019; Sardar et al., 2014). Thus, rebuilding trust between research institutions and BIPOC is vital to improving this situation, and an important factor therein is the presence of diverse medical and research personnel, who also remain widely underrepresented in the field (Cell Editorial Team, 2020; LaVeist et al., 2003). Furthermore, the time-intensive nature of psychedelic-assisted clinical trials, and their largely non-profit funding to date, have made it challenging to provide financial incentive for study participation, thus posing further issues for recruiting individuals from lower socioeconomic status backgrounds, who may be unable to take time away from work and family responsibilities to participate in uncompensated trials. With the median net worth of Black and Hispanic families being less than 15% that of white families, BIPOC additionally face substantial barriers to research participation in psychedelic trials due to economic inequity (Dettling et al., 2017).

Baltimore as a case study

The majority Black U.S. city of Baltimore, where both authors reside, has profound health inequities between Black and white residents, as well as between neighborhoods, and can serve as a case study on the topics of racial inequity and psychedelic research. Baltimore has a long history of racial inequity, including the first municipal segregation ordinance in the U.S. in 1911 (Power, 1983). Though this ordinance was later deemed inadmissible by the U.S. Supreme Court in 1917, de facto segregation continued through denial of rental or sale of housing to Black individuals in established white neighborhoods, or ‘redlining’ practices where certain (largely poor and minority) neighborhoods were deemed high risk and therefore residents were denied opportunities for investment and improvement (e.g. home loans) on that basis (Pietila, 2010). The impact of redlining and housing discrimination continue to the present day. A widely publicized finding of life expectancy by neighborhood has demonstrated stark differences, as much as 20 years, between white affluent neighborhoods, and impoverished Black neighborhoods, a mere 5 mile distance from each other (Marmot, 2017). Moreover, ongoing tensions remain between Baltimore-based Johns Hopkins University (JHU) and impoverished communities of color surrounding the Schools of Medicine and Public Health (Baltimore City Health Department, 2017). Recent examples include concerns over gentrification due to JHU’s East Baltimore Neighborhood Development Initiative (Mitter, 2018) and the controversy over JHU’s plans to establish a private police force (Burke, 2020).

Interestingly, Baltimore has long held a central role in psychedelic research, with large-scale studies of LSD conducted at the Spring Grove State Hospital reaching back to 1963, including one of the few psychedelic research studies with a majority Black sample examining the use of LSD treatment in paroled men with a history of heroin dependence (Savage & McCabe, 1973). More recently, the establishment of the Johns Hopkins Center for Psychedelic and Consciousness Research (CPCR) continues to build on this work in the Baltimore area. However, tensions between JHU and the local community likely contribute to difficulties recruiting Black participants into research studies at the CPCR, underscoring a critical challenge to address going forward.

Poverty, psychedelic medicalization, and public health impact

While increasing diversity among participants and personnel in psychedelic research studies remain fundamental goals, it is equally as important to note these treatments will not solve all health disparities. Health services are responsible for only a fraction of population health outcomes (McGinnis et al., 2002). The story that emerges time and again is that systemic inequalities, like poverty, have a far greater impact on health and longevity, and no individual-focused treatment approaches, even with promise as great as that of psychedelic therapies, will be able to rectify this situation.

Moreover, should psychedelics reach FDA approval status, they will still require extensive healthcare infrastructure and time to implement. Even with the growing enthusiasm around the field, current medical training and treatment systems are unlikely to keep up with interest in psychedelics for public health in the short term. These treatments will almost certainly be expensive, difficult to access, and more easily available to the financially well-off, like many cutting-edge treatments. It is therefore crucial to develop pathways to treatment for the less affluent, and BIPOC who already struggle under the burden of significant health disparities. Work by researchers such as Thomas et al. (2013) provides a notable example of community-based psychedelic treatment approaches in Canadian First Nations tribal members. Considering the long history of indigenous psychedelic use, it is also important that medical adoption of psychedelics not become another ‘discovery of America’ by colonizing forces, but that these interventions be equitably accessible and reciprocal in giving back to BIPOC communities where psychedelic use has deep roots (George et al., 2019). Similarly, from a social justice standpoint, the rapid commercialization of formerly illegal substances for which many BIPOC have faced criminal penalties, while wealthy investors come along to profiteer, will require careful policy and regulatory rollout to ensure appropriate parity. Finally, with decriminalization initiatives around psychedelics gathering momentum (Feuer, 2020), it will be important not to create further disparities by deeming some psychoactive substances primarily used in white communities worthy of decriminalization, while keeping others illegal.

Recommendations and conclusions

Williams et al. (2020) have made an important contribution to the literature on the use of psychedelics and questions of racial equity. Findings suggest that the use of psychedelics has the potential to reduce symptoms of mental distress experienced due to racism. While these findings should give us some hope for the future, the research community has a responsibility to make sure that promising psychedelic therapies are equally effective and accessible to communities of color. Research institutions must work on building trust with BIPOC communities and address systemic and institutional racism. Although psychedelics can potentially make a contribution to reducing racial trauma, systemic interventions will be needed to improve the lives of communities of color in the U.S. Additionally, with increasing use of psychedelics among bisexual individuals (Yockey et al., 2020), and severe health disparities among sexual and gender minority groups (Hsieh & Ruther, 2016; Streed et al., 2017), the issues raised here will have to be expanded to include all people across the spectrum of underrepresented backgrounds. Considering the importance of the sense of unity or oneness that classic psychedelics can evoke in mediating their long-term benefits, the field should take this to heart in applying psychedelics constructively towards ensuring equity of access and reducing health disparities, and make this an urgent priority.

Disclosure statement

Dr. Garcia-Romeu is a scientific advisor to Etha Natural Botanicals.

Additional information

Funding

Support for Dr. Garcia-Romeu was provided by the Heffter Research Institute, and by Tim Ferriss, Matt Mullenweg, Blake Mycoskie, Craig Nerenberg, and the Steven and Alexandra Cohen Foundation.

Notes

1 Although MDMA and classic psychedelics have distinct pharmacological profiles, for simplicity, these will hereafter be referred to as psychedelics.