When patients ask about psychedelics

“Maybe it isn’t smart, but I’m desperate,” my patient, on her second antidepressant trial and frustrated by limited mood improvement and weight gain, told me. She had heard about psilocybin through social media, and her friend had offered to share some.

My instinct was to express concern, noting the limited evidence and dangers of uncontrolled use. At the same time, I realized the potential benefits of off-label use. I decided to ask more questions – around what she had heard, what she wanted to gain, what alternatives she was open to and what safety precautions she would take.

Over the past decade, scientific interest in psychedelics such as psilocybin and MDMA has risen. There are currently 18 trials of psilocybin approved by Health Canada – before 2022, only two had been approved in the preceding 40 years. Media coverage quickly followed suit, and illegal dispensaries became staples across major Canadian cities. Substances once dismissed as recreational are being rebranded as potential medicines, shifting public perception and resulting in more and more patients asking their doctors about psychedelics for their mental health.

For patients, it can be an act of desperation but there is concern the pendulum has swung too far. Early research into therapeutic use in a medical setting shows promise, but most studies have small samples, short follow-ups and controlled settings hard to replicate in community practice. Meanwhile, recreational psilocybin use among young adults has reached as high as 13.9 per cent This has put physicians in a difficult place – one our medical training has not prepared us for.

The longer I talked to my patient, the more I began to realize that in a resource-constrained system in which mental health options are limited and appointment times are far apart, psilocybin offers an accessible solution. To her, psilocybin was a source of hope, something she hadn’t felt in months.

This moment revealed a gap between clinical guidelines and reality. The American Psychiatric Association has acknowledged that conversations around psychedelics pose “unique challenges” requiring a “complicated ethical balancing act.” Unlike other treatments, psychedelics have grown to be easily accessible and branded as “miracle” drugs, forcing physicians in a difficult situation.

The American Psychiatric Association emphasizes the need to take an “active, exploratory and non-judgmental role,” one centered around harm reduction and careful counselling. It also warns against biases toward either excessive enthusiasm or blanket opposition. But what does an ethical and nuanced conversation look like with a desperate patient, where hope becomes a clinical factor, and the line between harm reduction and enabling blurs?

But what does an ethical and nuanced conversation look like with a desperate patient, where hope becomes a clinical factor, and the line between harm reduction and enabling blurs?

The Hub at Oxford for Psychedelic Ethics, an interdisciplinary centre working on frameworks for psychedelic ethics, law and policy, recently highlighted this knowledge gap in its response to the U.S. Congress. It noted that clinicians often rely on media coverage that “skews overly positive or negative” rather than evidence-based education. Without proper training, we risk either dismissing potentially beneficial treatments or failing to adequately warn patients about real harm.

These researchers emphasize that “robust public education and interdisciplinary collaboration will be necessary to prevent misinformation, mitigate risks and establish trust with patients, clinicians and policymakers.” This applies equally to physician education. We need evidence-based education, not just for psychiatrists, but for family doctors, emergency physicians and other frontline providers who field these questions. The challenge isn’t just clinical – it’s systemic and sociopolitical.

My patient left that day intending to try psilocybin. I remain unsure if I handled it correctly, but one thing is clear: these conversations require different approaches than typical treatment discussions. Until we have better systems and education supporting them, we owe patients honesty about our limitations alongside our care.

It is uncomfortable to talk about psychedelics because it forces us to confront uncertainty – yet this is the reality some of our patients face. As research advances and policy evolves, questions around access, safety and efficacy will shed further light on the future of psychedelic medicine and inform the advice we ought to give.

In the meantime, patients will continue asking. Until we have more answers, we owe them our humility, our curiosity, and our care.