In this episode, Seth Mehr, MD joins to share his expertise on safety planning prior to a patient undergoing psilocybin therapy. After a 20 year career as an Emergency Medicine physician, Seth founded Cascade Psychedelic Medicine in 2021, treating clients with depression, anxiety and PTSD with psychedelic ketamine therapy. He also serves as the Health & Safety Director and a state licensed psilocybin facilitator at the Innertrek service center in Portland, Oregon.
In this conversation, Dr. Mehr outlines key risk categories for psilocybin therapy: medical conditions, medication interactions, and mental health history. He emphasizes the importance of individualized safety planning over binary yes/no decisions. Dr. Mehr discusses specific considerations such as cardiovascular issues, diabetes, serotonergic medications, substance use disorders, suicidal ideation, and family history of psychosis. The conversation also covers strategies for mitigating risk, including delaying treatment, contingency plans, improving support systems, and ensuring informed consent. Throughout, Dr. Mehr stresses a collaborative, nuanced approach that balances potential benefits with careful preparation and personalized care.
In this episode, you'll hear:
- Stories from Dr. Mehr's practice of helping patients with different conditions and histories ensure safe psilocybin experiences
- Interactions between GLP-1 agonists and psilocybin
- How Dr. Mehr works with patients who have family histories of psychosis
- Harm reduction practices which leverage other psychedelics or non-psychedelic interventions to help prepare a client for a psilocybin session
- Why insulin dependent diabetes can be a contraindication for psychedelic therapy
- What medication combinations can increase the risk of serotonin toxicity with psilocybin
- Supporting clients experiencing spiritual emergency following psilocybin therapy
- Safety considerations when working with clients who have a history of seizures
- The importance of having contingency plans if medical emergencies arise during psilocybin therapy
- The intricacies of providing fully informed consent for psychedelic therapy
Quotes:
"There is some evidence now that taking a single serotonergic agent—say, taking Lexapro—and no other medications that increase the risk of serotonin toxicity seems safe where I am not at this point recommending that people stop, skip, or taper a single SSRI in preparation for a psilocybin session due to safety." [12:20]
"One of the difficulties with making these decisions or speaking with some confidence or authority on the matter is that the clinical trials that have been done largely exclude people with lots of conditions—family history and specifically first degree relatives with history of psychosis and bipolar disorder… So we have anecdotal evidence, we have population based surveys to go by. And so when I talk to clients about this, I speak from a place of humility." [27:30]
"I always emphasize to clients that while we're talking about a specific safety issue like serotonin toxicity, we don't want to trade that for psychological instability and crisis and declare success because we've helped somebody taper off of a medication that seems less safe and now they aren't sleeping, they're agitated, they're depression is worse, their suicidality is worse. So we have to take a holistic approach to this and consider the totality of what's happening with that client." [36:45]
"There are so many different components to trying to set somebody up for success rather than a yes/no, black and white approach [to psilocybin therapy]." [48:44]
Links:
Cascade Psychedelic Medicine website
InnerTrek website
Managing Medical Risk In Patients Seeking Psilocybin Therapy CME/CE Course
Psychedelic Medicine Association
Porangui
