Here at Shrink Speak, we have been talking recently about the need for rigorous research before psychedelic drugs become widely available. That isn’t an abstract policy debate for me. It is personal.
I vividly recall a discussion in which I participated regarding a young man whose story has troubled me ever since. He was a promising third-year college student at Winston-Salem University. Intelligent. Motivated. The kind of young person with every reason to expect a bright future.
He volunteered to participate in an LSD research study.
Shortly afterward, he developed psychosis.
Whether the psychedelic directly caused the illness, precipitated an illness that would have otherwise emerged later, or interacted with some vulnerability we still do not understand, the outcome was devastating. He never fully recovered, eventually leaving college as his life took a dramatically different course.
As psychiatrists, we know that psychosis is rarely explained by a single factor. Genetics play an important role, but they are only part of the picture. Brain development, environmental stressors, sleep deprivation, previous substance use, individual differences in brain chemistry, and chance may all contribute. Psychedelic drugs may also act as a trigger in susceptible individuals—even those with no known family history of schizophrenia or other psychotic disorders.
In this young man’s case, there was no known family history of psychosis. The only obvious risk factor was one we recognize all too well: he was a young man in the age range when schizophrenia and related disorders most commonly first appear.
His story has remained in the back of my mind, and it came rushing back unexpectedly during a very different experience.
Recently, my wife and I decided to try THC gummies that had been marketed as a sleep aid. What followed surprised me. Instead of becoming sleepy, I became profoundly paranoid. I began hallucinating—at one point, clothes draped over a chair transformed into what looked like a “friendly lion.” I developed irrational beliefs that I might be dying. Waves of fear alternated with deep despair. At one point, I was convinced I was on the verge of a panic attack. Holding onto my wife and reminding myself that someone I trusted was beside me helped keep me grounded.
The experience lasted nearly eight hours.
Intellectually, I knew what was happening. I am a psychiatrist. I understood that the THC was altering my perception and that these frightening experiences were drug-induced. But understanding something and believing it in the moment are two very different things.
During those hours, I kept thinking about that young man from Winston-Salem University.
What if my brain never bounced back?
What if this wasn’t temporary?
Fortunately, it was. By the next day, I felt like myself again.
I also recognize that I made a mistake. The gummy contained 15 milligrams of THC, and the manufacturer recommended starting with one-quarter to one-half of that dose. I took the entire gummy.
Even so, the experience reminded me how dramatically people can respond differently to the same substance. My wife took the identical dose. She experienced far more than a pleasant buzz, but nothing approaching the paranoia, hallucinations, or terror that I experienced. That variability is exactly what concerns me.
As psychedelic therapies move closer to FDA approval for certain psychiatric conditions, we should absolutely follow the science wherever it leads. If these treatments prove to be safe and effective for carefully selected patients under appropriate medical supervision, they may become an important addition to psychiatric care.
But approval is not the finish line. It is the beginning of a much larger responsibility.
Once treatments become commercially available, there is always pressure to expand access. Clinical protocols that are carefully followed in research settings may not be followed as rigorously in everyday practice. Patients may receive inadequate screening for risk factors such as a history of psychosis or bipolar disorder. Some individuals may assume that because a substance is FDA approved, it is safe for everyone. Others may seek higher doses, combine psychedelics with other drugs, or use them outside the therapeutic settings in which they were originally studied.
FDA approval is not the finish line. It is the beginning of a much larger responsibility.
We have seen versions of this story before with opioids, benzodiazepines, stimulant medications, and increasingly potent cannabis products. Scientific promise can coexist with real risk, particularly when treatments move from controlled research environments into widespread use.
That is why the research matters so much.
Clinical trials cannot simply demonstrate that psychedelics work for the average participant. They must also help us identify who benefits, who does not, and who may be harmed. They need to include participants from diverse racial and ethnic backgrounds, different ages, both sexes, people with varying medical histories, and individuals from different socioeconomic and cultural backgrounds. Diversity in research is not about checking boxes—it is about ensuring that findings are applicable to the patients we actually treat. Differences in genetics, metabolism, coexisting illnesses, environmental exposures, and access to care can all influence both effectiveness and safety.
Just as importantly, we need long-term follow-up. Most clinical trials tell us what happens over weeks or months. Psychiatry often requires us to think in years. If a treatment carries even a small risk of precipitating persistent psychosis in susceptible individuals, we need to understand that risk before the treatment becomes commonplace—not after.
The young man from Winston-Salem reminds me that behind every discussion of policy or drug approval is a human life. His experience does not prove that psychedelics are inherently dangerous, nor should it be taken as evidence that they have no therapeutic value. But it does remind us that caution is not the enemy of innovation. It is what makes innovation worthy of the trust we place in it.
Let’s not put the cart before the horse. Science should lead the way—and it should do so carefully, transparently, and with the humility to recognize what we still do not know.
Considering the state of psychotherapy research ~50 years ago, Gordon Paul (1967) asked:
"What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?"
Not the worst guiding light for psychedelic clinical research today.
This is an important point. While there are many possibilities, it is entirely possible that your student's single LSD experience caused triggered a lifelong psychotic disorder that would have never emerged otherwise. After all, some studies find there's only about a 50% chance that an identical twin of a schizophrenic will also be diagnosed with schizophrenia. Environment matters, and drug use is probably the biggest modifiable risk factor.