(applause)
3,4-Methylenedioxymethamphetamine: MDMA.
Now you're probably heard of this compound in the context of the recreational drug Ecstasy.
But today I want to talk about MDMA not as a recreational drug,
but as a potential new treatment in medicine.
And then very important treatment for psychiatry because MDMA could offer us
in psychiatry for the first time the opportunity to tackle trauma.
And psychological trauma particularly that caused by child abuse and maltreatment
is at the heart of all or most psychiatric disorders due to anxiety and addictions.
Psychiatry is in need of this innovative approach,
because current treatments are failing patients.
Hi, my name's Ben Sessa. I'm a child and adolescent psychiatrist.
Now that means I trained as a medical doctor,
then specialized in mental health
and then specialized in child and adolescent mental health.
But for the last five years I've been working with adults with
mental health disorders and addictions due to misuse of drugs.
And that developmental pathway of my own,
from working with child abuse into adults
with mental disorders and addictions has brought me to the door of MDMA.
And I'm gonna propose today that MDMA could be
important for the future of psychiatry as the discovery of antibiotics was
for general medicine a hundred years ago.
So when we think about child abuse we think about physical abuse, mental abuse,
emotional abuse, sexual abuse and neglect.
And we think about noxious environments.
About parents with mental disorder.
We think about parents who are addicted to drugs.
And social issues like poverty and poor housing, poor education.
Now I'm going to illustrate my talk today with a patient
and I'm going to call her Claire.
Now Claire was no single particular patient of mine.
Rather she's an amalgamation of many different people
I've met in the last 18 years working as a medical doctor.
She's certainly not the worst.
Now what was Claire's environment like when she was growing up?
Well, her mother was depressed.
Now unfortunately the family doctor didn't have time to accurately
diagnose and treat depression, rather,
Claire's mother was put onto one antidepressant after another,
never really got therapy.
Claire's mother also had a lot of aches and pains
typical what we call psychosomatic symptoms in depression,
and as a result the family doctor put her on to opiate based painkillers
which she promptly became addicted to.
Now Claire's father, now he was alcoholic and he was often
not around in and out of prison.
Which is just as well because when he was there
he was physically abusive to Claire and her mother.
Okay so what does this kind
of chaotic, frightening environment do
to the developing child brain?
I'm going to give you a brief neurophysiology lesson if I may.
There's a part of the brain called the amygdala.
Now the amygdala is a very ancient part of the mammalian brain
and many other animals other than humans have an amygdala.
The amygdala lights up when stimulated by
fear in the environment, by a frightening stimulus.
It lights up and it says: fight-or-flight, get out!
Now there's another part of the brain much more sophisticated part,
called the prefrontal cortex and it's right here at the front above the eyes.
Now the prefrontal cortex only humans have.
And it's in the prefrontal cortex where we use logic and reasoning to
rationalize the situation and we can use
our prefrontal cortex to overcome that
instinctive fear response from the amygdala.
Now when Claire was growing up
she never knew from one moment to the next
whether the adult coming into the room's going to give her a kiss
or a cuddle or do a jigsaw with her,
or were they going to punch her or kick her
or burn her with their cigarette.
Or were they going to rape her.
Because throughout her childhood Claire was also subjected to sexual abuse.
Now, there's a group of disorders called the anxiety disorders,
and one of the most important is what we call post-traumatic stress disorder or PTSD.
Now PTSD, some of the core features:
very low mood, anxiety, high levels of anxiety,
what we call hyper vigilance:
this edginess, this jumpiness.
Exactly how Claire felt throughout her childhood and adolescence.
Never knowing whether the next assailant or assault
was around the corner.
Another core feature of PTSD, what we call re-experiencing phenomena.
Flashbacks, when the patient has sudden remembrances of painful traumatic memories.
They can just pop into the head
at any time, triggered by some cue in the environment.
And when they have those experiences, those daytime flashbacks,
they relive the trauma in all the sensory modalities and this results in
them freezing or dissociating to try and block out the pain.
Claire experienced all of this as she was growing up.
High levels of self-harm and suicide are associated with PTSD.
Claire would cut her thighs and her breasts.
Pretty common form of cutting in children who've been sexually abused.
She was being sexually abused by her mother's clients,
because her mother had moved on from the addiction to painkillers and
was using street heroin when Claire was a teenager.
Because of the way the war on drugs has set up that reduces access to treatment
for people with opiate dependence, she had to pay for her
heroin using sex work and the clients would sexually abuse Claire.
It's very hard to treat PTSD and it has a high treatment resistance,
50% of people do not respond to the traditional treatments.
How do we treat it?
We can treat it with medications. We can treat it with psychotherapies.
And the medications we use: there's a broad range of drugs.
No single drug, and this is very important, no single drug cures PTSD.
Rather we treat the disorder symptomatically:
If the patient's depressed give them an antidepressant.
If their mood fluctuates give them a mood stabilizer.
If they can't sleep give them a hypnotic.
And if that edginess and that fear spills over into paranoia and psychosis,
give the patient an anti-psychotic drug.
And they have to take these drugs day in day out for weeks, months, decades.
They have to keep taking them because the drugs we use to treat trauma when it's
due to this level of severity do not attack the root cause of trauma.
They paper over the cracks.
A good analogy would be taking aspirin or ibuprofen when you have a fever.
A fever is caused by an infection, by a microorganism.
Sure, you can take paracetamol or ibuprofen and this will lower the temperature
and make you feel a bit better but it doesn't attack the root cause.
And that's what we do when we give these patients these daily SSRI drugs.
We paper over the cracks.
We maintain the symptoms at a manageable level.
We also use psychotherapies to treat PTSD, and there's
again a broad range of these: DBT, CBT, EMDR, trauma focused psychotherapy,
CAT, APT... Now all of them have a pretty
similar approach which actually is an old wives tales which is:
a problem shared is a problem halved.
"Let's talk about your trauma. Claire tell me about your rape."
Now that's fine for 50% of patients but for a significant half they just cannot do that.
As soon as Claire is asked to talk about her rape she freezes,
she flees, she drops out of treatment.
By the time she was 15 Claire had been removed from the family home and she was
brought up in a succession of foster placements and children's houses and
hostels where the abuse continued.
She was self-harm cutting and she started drinking and
by the time she was 18, she was using heroin as well.
Sometimes working in psychiatry can feel pretty desperate, can feel pretty hopeless.
Sometimes it feels as if psychiatry is a palliative care profession.
And this is the truth because the treatments we use do not get to the
root cause of the problem, the trauma.
They paper over the cracks.
And I think the pharma industry know this and they queue up and they
provide us with product after product to give to our patients that doesn't quite
cure them but it gets them slightly better to function.
And they have to keep taking them.
I'd say that we're in psychiatry today where we were in general medicine 100 years ago.
100 years ago in general medicine,
humanity was losing the battle to the infectious diseases.
Oh we were very good at classifying and diagnosing them.
We knew who got smallpox.
We knew people died of post-operative surgery.
We knew there were microorganisms but we didn't have a treatment.
And then at the beginning of the 20th century we discovered the antibiotics.
Not symptomatic treatment but treatment that goes to the core of the cause
and we started getting on top of infectious disease.
Psychiatry today is in a similar place.
We're very good at classifying and diagnosing.
Our epidemiology is superb.
We write these thick diagnostic manuals.
We know who gets depression.
We know who gets anxiety.
We even know the cause: trauma, child abuse, maltreatment, poor social conditions.
But our treatments are lousy.
And I'm quite shocked the way the empathy
switch and our understanding of these patients seems to be switched off.
We have lots of gushing sentimentality for the little five and six year old who's
being abused and we throw money at our television sets on these campaigns to
improve the lives of these poor little innocent victims.
Let me tell you what happens to that little five or six year old,
when they're 11 or 12.
On goes the hood, start smoking weed.
By the time they're 16 they're buying and selling amphetamine
and by the time they're Claire's age in their mid-20s,
they're addicted to heroin and alcohol.
And suddenly we have lost our empathy.
These people are public enemy number one.
"It's your fault Claire. You brought this upon yourself. It's your lifestyle choice."
And I'm quite shocked and having worked in pediatrics and seen the developmental
trajectory that is so inevitable from early trauma into adolescent and then
adult mental health and addictions, we have to hold on to that sense of compassion
and evidence-based understanding about the developmental trajectory there.
So it does sound desperate, but all is not lost.
MDMA. MDMA has some fascinating qualities.
I would suggest that if you were to invent a hypothetical drug to treat trauma,
it would be MDMA.
The way it works in terms of its receptors and its subjective psychological effects
ticks all the right boxes.
At one level of receptors it causes a increased positive mood.
Lowering of depression, lowering of anxiety.
At another group of receptors it speeds the patient up,
mild stimulation which motivates them to engage in therapy.
At another level it relaxes the patient paradoxically
at the same time as the stimulation and this puts the patient into the optimal arousal
zone where they can engage in psychotherapy.
But perhaps the most important thing about MDMA and the most important clinical tool
is its ability to provide a sense of empathy and understanding and emotional security.
It can hold the patient in a place where they can think about and access their trauma
like they've never been able to do before.
One of the ways in which MDMA works is
it increases the release of a hormone called oxytocin.
Oxytocin is released from the brains of breastfeeding mothers.
It's a hormone that engenders a sense of attachment and bonding.
And that's what's happening in the patient who takes MDMA.
And also it acts directly on the amygdala to reduce
that fear response whilst at the same time boosting the prefrontal response,
allowing the patient to see things in a new light.
A positive light.
So let's go back to Claire.
She's 40 now.
She's been in and out of psychiatric hospitals,
having tried to take her own life and the inception.
She's been on all the antipsychotic and antidepressant mood stabiliser drugs.
She's tried all the psychotherapies but she cannot engage
because she will not talk about her feelings.
So she comes into a course of MDMA-assisted psychotherapy.
What does it look like?
It's weekly sessions, maybe eight, ten, twelve weeks long.
There're two therapists, male-female pair.
You do not take MDMA everyday, you do not take it every week.
Over that course of 12 sessions you'll take the MDMA three times and the
other sessions you talk about the material that's released on the MDMA session.
So what does Claire actually feel when she takes this MDMA?
What she feels is a sense of warmth and understanding and a sense of containment
within that relationship she's having with the therapist.
MDMA is like a lifejacket like a bulletproof vest
to wear to go into battle with your trauma.
This is not ecstasy!
She's not enjoying some raver's euphoric ecstasy delight.
This is still trauma focused psychotherapy and it's still hard and distressing for her,
but she can just about do it with MDMA on board.
So when the therapist says: "Claire, tell me about your rape".
In the past just the word rape and she'd be out the door,
but on MDMA she says: "yeah, I can talk about that!
I can see him now coming into the room. I can smell the whiskey on his breath and
I can feel the stubble on his face as he's raping me".
And she talks about it and she explores it and she reflects upon it
and she can begin the process of healing.
And from here she can start her journey.
She can attack the root cause of her problems.
Not just maintain the symptoms at a level.
So, does it work?
Well, we've known about MDMA for very long time
and indeed we've used MDMA in underground therapy for 30 or 40 years.
And there are thousands of positive anecdotal cases.
I get five emails a week from all over the world: "Dr. Sessa, I've had PTSD for years.
I've tried everything and now I tried MDMA and I'm starting to make a breakthrough!"
Now, anecdotal reports like that are interesting but they're not science so
we've done the science.
And some important studies in recent years.
Big study in the States showed that a single course of MDMA therapy, 16-week course,
patient takes MDMA three times tested against a placebo.
At the end of that course 85% of the people no longer met the diagnostic criteria for PTSD.
Not just a relief of symptoms, they didn't have PTSD!
Now that cohort were then followed up three years later, the same no PTSD.
Many of those people had come of their daily medications.
They were cured! We don't use the "cure" word in psychiatry.
We've become learned helplessness position of--This is the truth!
If you're diagnosed with a severe mental disorder like anxiety or depression
in your 20s, and the developmental route of that disorder is severe child abuse,
there's a pretty good chance chance-- and I'm sorry to say this--
there's a pretty good chance you will still be going to
psychiatric clinics in your 60s and 70s.
Now that is not good enough and we're in this position because we're not tackling trauma.
So, it works but is it safe?
When we talk about safety of clinical MDMA, what we must not do is
look at the risks of recreational ecstasy.
I don't even know what ecstasy is anymore!
Ecstasy is over here, what is ecstasy?
Some dodgy pill bought in some dodgy club of some dodgy geezer,
that may or may not contain MDMA plus or minus whatever far more toxic substance.
When you hear about the very high-profile deaths of people who take ecstasy,
it invariably is not MDMA.
So, let's not look at ecstasy as a measure of MDMA.
Let's look at clinical MDMA.
When you use clinical MDMA, you take it under medical supervision. It is pure.
The MDMA that I'm using in my studies is 99.98% pure!
Very expensive! (laughter)
We do it under medical supervision with a doctor and a nurse and a psychologist.
And under those conditions the risks are reduced to a absolute minimum.
Indeed, after 40 years of MDMA research,
there has not been a single serious adverse drug reaction, not one!
And certainly no deaths.
So, we need to do this research and
we need to do this research in an evidence-based, compassionate way.
Looking at the data.
We need to ignore the socio-political agenda that says any drug
that's being used recreationally must also be very bad and dangerous.
That sort of attitude hampers research.
And we need scientists to drive this.
It works, it's safe.
And it offers patients like Claire for the first time in their life an opportunity
to break through from that trauma and not become a lifelong chronic PTSD sufferer.
So, where were we going with MDMA research?
Well, we've had some studies, we've got more coming here.
I'm doing a study in Cardiff with neuroimaging in which we're going to give patients
with PTSD, MDMA and placebo and we're going to look at that relationship
between the amygdala and the prefrontal cortex.
We're doing a study here in Bristol giving MDMA to patients with alcohol use disorder
because underlying the root of this addiction is trauma.
This is an exciting time.
Now people say: "This is controversial!"
And indeed, I was introduced as a controversial speaker.
I'm not controversial, I'm a very boring conservative doctor.
I like data.
I like evidence-based data that helps my patients.
I'll tell you what's controversial!
What's controversial is that more people have died returning from Afghanistan and Iraq
because they've committed suicide because of their untreated PTSD
then ever died in the conflict out there.
That is controversial and that is unethical!
So, this is an important time for science.
MDMA could be the antibiotic that psychiatry has been waiting for.
We owe that population of patients who are being failed,
we owe them this research!
We owe this Claire!
Thank you. (applause)