On October 15^th, Monte Nido Chief Medical Officer Molly Perlman, MD, MPH, CEDS-C presented “High Hopes or Hard Truths? Psychedelics and Cannabis in Eating Disorder Treatment,” exploring current research, public trends, legal barriers, risks, and clinical implications—with specific attention to eating disorder treatment settings.

Psychedelic Use Emerging in Psychiatric and Eating Disorder Care

Psychedelic use has sharply increased in the general population. This rise reflects shifting cultural attitudes, easier access, and widespread media coverage promoting potential mental health benefits. At the same time, exposure reports and accidental ingestions, especially among youth, have dramatically increased.

Recent trends in psychedelic use:

• 12% of adults in the U.S. had used psilocybin at least once by 2023

• Past-year psychedelic use increased 44% among adults since 2019

• Use increased 188% among older adults

• Poison control calls related to psilocybin rose:

• 201% in adults

• 317% in adolescents

• 723% in children ages 0–11

As recreational use becomes more common, clinicians are increasingly encountering patients asking about psychedelic use, microdosing, or self-treatment.

Legal and Regulatory Barriers to Psychedelic and Cannabis Use

Psychedelics and cannabis remain tightly controlled at the federal level, which creates significant barriers to research and clinical application.

Schedule I substances (1970 Controlled Substances Act):

• Psilocybin

• MDMA

• LSD

• DMT

• Cannabis

• Heroin

Schedule I status means these drugs are considered to have no accepted medical use and high potential for abuse, making them difficult to study. Some states and cities have decriminalized psilocybin or allowed supervised use, but federal law remains unchanged.

Importantly, the American Psychiatric Association states:
There is not yet sufficient scientific evidence to support the clinical use of psychedelics, except within approved research settings. Further study is encouraged, but treatments must be guided by science, not public opinion or ballot measures.

How Psychedelics Affect the Brain

Psychedelics influence multiple neurotransmitter systems, leading to significant changes in perception, mood, and cognition. Their potential therapeutic value lies in their impact on brain flexibility.

Key mechanisms:

• Increase serotonin (5-HT2A receptor activity)

• Influence dopamine and norepinephrine

• Disrupt glutamate pathways (critical for memory and learning)

• Induce neuroplasticity (greater cognitive flexibility)

• Reduce rigid thought patterns and rumination

Some individuals experience “ego dissolution,” a temporary loss of self-boundaries, though it is unclear if this is necessary for therapeutic benefit.

Contraindications include:

• Personal or family history of psychosis

• Bipolar disorder (risk of mania or psychosis)

Psilocybin and MDMA: Current Research Focus

Certain psychedelics have received FDA “breakthrough therapy” status, which expedites research due to promising early results.

Psilocybin:

• Breakthrough therapy for treatment-resistant depression (2018)

• Studied in refractory OCD, end-of-life anxiety, and addiction

• fMRI data show increased brain connectivity and neuroplasticity

MDMA:

• Increases serotonin, dopamine, norepinephrine

• Studied for PTSD and trauma-related disorders

• Promotes emotional openness and decreased fear responses

Dissociatives (e.g., ketamine):

• Act on NMDA (glutamate) receptors

• Already used off-label for depression

• Highlight the importance of glutamate in mood regulation

Despite promising research, many questions remain about long-term efficacy, safety, dosing, and who benefits most.

Microdosing: Popular but Unproven

Microdosing—taking very small amounts of psilocybin or LSD several times per week—is widely promoted online as a mood enhancer or cognitive booster. However, controlled studies have not shown significant benefit beyond placebo.

Concerns with microdosing:

• No definitive evidence of effectiveness

• Unknown long-term safety

• Substances are illegal and unregulated

• Doses may not be accurate or consistent

• Research is ongoing but preliminary

Clinicians should be prepared to address patient beliefs and provide realistic information.

FDA and Policy Obstacles to Psychedelic Therapy for Eating Disorders

Despite breakthrough therapy designations, psychedelic-assisted therapy faces major regulatory challenges.

Barriers to approval:

• No existing FDA pathway for drug + psychotherapy protocols

• 2024: MDMA-assisted therapy for PTSD was not approved

• Need for standardized therapist training

• Manufacturing and regulatory requirements

• Insurance coverage and cost concerns

• Scheduling changes required (currently Schedule I)

Policy development must also consider ethical implications, access equity, and the inclusion of Indigenous perspectives, as many psychedelic practices originate in traditional healing contexts.

Cannabis: Common, Legal in Some States, but Clinically Complex

Cannabis is often viewed as more accessible and less intense than psychedelics. However, its effects on mental health can be harmful, particularly for individuals with psychiatric disorders.

Although often promoted for anxiety or appetite, cannabis use in mental health populations is associated with worsening symptoms, higher relapse rates, and increased suicidality. Cannabis interrupts adolescent brain development and increases risk for psychosis.

A major difference from psychedelics: while psychedelics are being studied as potential treatments, cannabis currently has no evidence-based psychiatric indication.

Cannabis and Eating Disorders

Research suggests cannabis may interact with eating disorder pathology in unique ways. It can affect gastric emptying and alter cannabinoid receptor function in the brain, particularly in the insular cortex. However, these changes do not indicate therapeutic benefit.

Key findings:

• No adequate studies support cannabis or cannabinoids for eating disorder treatment

• Cannabis is associated with increased mortality when combined with eating disorders and SUDs

• Early and persistent use increases risk of psychosis, mood disorders, and cognitive decline

Treating Eating Disorders and Substance Use Together

Many individuals with eating disorders also engage in substance use. Integrated treatment is essential to address both conditions effectively.

Shared motivations between ED and SUD:

• Control

• Numbing/avoidance

• Emotional regulation

Treatment goals differ:

• Eating disorder recovery: reduce rigidity, improve flexibility, restore healthy behaviors

• Substance use disorder recovery: increase control over urges, promote abstinence

Best practices include:

• Concurrent treatment of ED and SUD

• Relapse prevention planning

• Family/support involvement

• Behavioral skills training (e.g., DBT)

• Accountability systems (sponsors, meetings, monitoring)

Clients can fully recover from eating disorders but may remain in long-term recovery for substance use, requiring ongoing support and relapse prevention strategies.

Key Takeaways: Psychedelic Therapy and Cannabis in Eating Disorder Treatment

Psychedelics and cannabis are gaining public attention, but their roles in eating disorder treatment remain complex and largely investigational.

Key insights:

• Psychedelics show promise in early research but require more rigorous study

• Cannabis use is increasing but carries significant psychiatric risks

• Psychedelic-assisted therapy is structured and intensive, not casual or self-directed

• Legal and regulatory barriers limit access and research

• Eating disorder populations have unique vulnerabilities and are often excluded from studies

• Integrated treatment for ED and SUD is essential

• Clinicians need to stay informed to educate and protect clients

This presentation highlighted both the potential and the limitations of psychedelics and cannabis in mental health care. While emerging research is promising, many questions remain—particularly for complex conditions like eating disorders. Ongoing study, ethical consideration, and clinical caution are necessary as the field evolves.

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_References

_{Attia E, Steinglass JE. Psilocybin for anorexia nervosa: If it helps, let's learn how. Med. 2023 Sep 8;4(9):581-582. doi: 10.1016/j.medj.2023.08.003. PMID: 37689054.}

_{Brewerton TD, Lafrance A, Mithoefer MC. The potential use of N-methyl-3,4-methylenedioxyamphetamine (MDMA) assisted psychotherapy in the treatment of eating disorders comorbid with PTSD. Med Hypotheses. 2021 Jan.}

_{Brewerton TD, Wang JB, Lafrance A, Pamplin C, Mithoefer M, Yazar-Klosinki B, Emerson A, Doblin R. MDMA-assisted therapy significantly reduces eating disorder symptoms in a randomized placebo-controlled trial of adults with severe PTSD. J Psychiatr Res. 2022 May;149:128-135.}

_{Calder A, Mock S, Friedli N, Pasi P, Hasler G. Psychedelics in the treatment of eating disorders: Rationale and potential mechanisms. Eur Neuropsychopharmacol. 2023 Oct;75:1-14.}

_{Gukasyan N, Schreyer CC, Griffiths RR, Guarda AS. Psychedelic-Assisted Therapy for People with Eating Disorders. Curr Psychiatry Rep. 2022 Dec;24(12):767-775}

_{Kilmer, Beau, Michelle Priest, Rajeev Ramchand, Rhianna C. Rogers, Ben Senator, and Keytin Palmer, Considering Alternatives to Psychedelic Drug Prohibition. Santa Monica, CA: RAND Corporation, 2024. https://www.rand.org/pubs/research_reports/RRA2825-1.html.}

_{Ledwos N, Rodas JD, Husain MI, Feusner JD, Castle DJ. Therapeutic uses of psychedelics for eating disorders and body dysmorphic disorder. J Psychopharmacol. 2023 Jan;37(1):3-13.}

_{Pollan, Michael. How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression, and Transcendence. Penguin Press, 2018.}

_{Ragnhildstveit A, Slayton M, Jackson LK, Brendle M, Ahuja S, Holle W, Moore C, Sollars K, Seli P, Robison R. Ketamine as a Novel Psychopharmacotherapy for Eating Disorders: Evidence and Future Directions. Brain Sci. 2022 Mar 12;12(3):382.}  

_{Renelli M, Fletcher J, Tupper KW, Files N, Loizaga-Velder A, Lafrance A. An exploratory study of experiences with conventional eating disorder treatment and ceremonial ayahuasca for the healing of eating disorders. Eat Weight Disord. 2020 Apr;25(2):437-444.}

_{Robison R, Lafrance A, Brendle M, Smith M, Moore C, Ahuja S, Richards S, Hawkins N, Strahan E. A case series of group-based ketamine-assisted psychotherapy for patients in residential treatment for eating disorders with comorbid depression and anxiety disorders. J Eat Disord. 2022 May 6;10(1):65}

_{Spriggs MJ, Douglass HM, Park RJ, Read T, Danby JL, de Magalhães FJC, Alderton KL, Williams TM, Blemings A, Lafrance A, Nicholls DE, Erritzoe D, Nutt DJ, Carhart-Harris RL. Study Protocol for "Psilocybin as a Treatment for Anorexia Nervosa: A Pilot Study". Front Psychiatry. 2021 Oct 20;12:735523. doi: 10.3389/fpsyt.2021.735523. PMID: 34744825; PMCID: PMC8563607.}

_{Spriggs MJ, Kettner H, Carhart-Harris RL. Positive effects of psychedelics on depression and wellbeing scores in individuals reporting an eating disorder. Eat Weight Disord. 2021 May;26(4):1265-1270}

_{Wall MB, Demetriou L, Giribaldi B, Roseman L, Ertl N, Erritzoe D, Nutt DJ, Carhart-Harris RL. Reduced Brain Responsiveness to Emotional Stimuli With Escitalopram But Not Psilocybin Therapy for Depression. Am J Psychiatry. 2025 Jun 1;182(6):569-582. doi: 10.1176/appi.ajp.20230751. Epub 2025 May 7. PMID: 40329640.}

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