ADHD, Psychedelics and other Questionables

I’m excited this week to offer you a special treat. Recently psychiatrists extraordinaire Martin Greenwald, Awais Aftwab, and I (a psychotherapist and philosopher) met up on Zoom to speak to questions submitted by our readers and subscribers on Substack. You can listen to (or watch) our conversation. Hat tip to Martin for organizing and editing this, and for including a transcript and time stamps so you can find what interests you. You can find all this, and links to our first Q&A back in 2024 here: Q&A. We discussed critics of psychiatry, as well as ADHD, bipolar disorder, psychedelics, PTSD & borderline personality disorder, and more. It hope you enjoy it as much as we did. But wait. There’s more!

Psychiatry Q&A #2 (part 2) with Awais Aftab and Gary Borjesson

Martin Greenwald, MD also sat down with psychiatrists and Substack authors Thomas Reilly and Nils Wendel, MD for a Zoom conversation that spoke to other questions from readers on a range of topics, from questions about self-awareness in psychosis to the use/misuse of cannabis for self-medication, psychedelics, psychosomatic illness, suicide protocols, and much more.

Psychiatry Q&A #2 with Thomas Reilly and Nils Wendel

Among the comments Awais, Martin and I have received, there has been the most interest in ADHD and psychedelics. Both subjects are polarizing. Yet I think a few things can be said with confidence. First, anyone who tries to reduce the cluster of symptoms gathered under the heading of ADHD to either genetics on the one hand or environment on the other is mistaken. It is both, in varying degrees, as is the case with many other neurodevelopment disorders, including autism. (The reductive urge remains strong in some people, even in the face of much observation and research suggesting the need for nuance.) The NYT published Have We Been Thinking About A.D.H.D. All Wrong?, a valuable review of just how far we are from understanding the causes and best treatment for ADHD. Here’s a big takeaway.

most scientists I spoke to agreed that the condition is produced by some combination of biological and environmental forces, though there is little consensus about the relative importance of each. But it does have certain implications for the field, including for the question of medication. If we’re no longer confident that A.D.H.D. has a purely biological basis, does it make sense that our go-to treatment is still rooted in biology?

For those interested in the state of the art regarding ADHD, Andrew Huberman’s recent conversation with expert John Kruse is one of the best in-depth overviews I’ve come across recently. Notably non-dogmatic.

As for psychedelics, the jury is not out. Psychedelics have been used for millennia. I’ve heard no credible argument for questioning their value in alleviating some kinds of suffering, or in supporting self-development. That said, those who tout them as a panacea are as mistaken as those skeptical of their value.

Does that mean everyone stands to benefit from using them? Or that their clinical use doesn’t pose challenges? Of course not. But that goes for every intervention psychiatry and psychotherapy have dreamed up so far! Will some misuse or be harmed by psychedelics? Misuse, no doubt! We’re talking about human beings after all. But remember, noncompliance is the most common reason for medication failure generally. Psychedelics are safer and less prone to abuse or addiction than widely prescribed drugs such as opiates and stimulants. The chance of doing harm is small—if used in a clinical setting that includes a screening process. I should add that I do not equate clinical with medical supervision; by clinical I mean psychedelic use that includes skilled facilitation and is part of a larger treatment plan that gives a broader context and intention to their use.

I welcome comments, except of the all or nothing variety!