Beliefs and Perceived Barriers Regarding Psychedelic-assisted Therapy in a Pilot Study of Service Members and Veterans With a History of Traumatic Brain Injury

Randomised controlled trials have recently strengthened interest in psychedelic-assisted therapy (PAT), particularly MDMA-assisted therapy for post-traumatic stress disorder (PTSD) and psilocybin-assisted therapy for major depressive disorder. Gray and colleagues note that Phase III data have shown promising efficacy signals (for example, a substantial proportion of MDMA-treated participants no longer met PTSD criteria in a Phase III trial) and that a Phase III programme for psilocybin is planned. Service members and veterans have high rates of PTSD, depression and co-occurring traumatic brain injury (TBI), and standard treatments often yield modest or incomplete responses in these populations; the authors argue that PAT could be a novel option worthy of attention for patients with treatment-resistant presentations. This study sought to characterise beliefs, familiarity, and perceived barriers regarding PAT among service members and veterans with a history of TBI and co-occurring cognitive or psychological symptoms. Using a brief written psychoeducation module and a questionnaire administered at baseline, the investigators aimed to measure participants' baseline knowledge and attitudes toward psychedelic drugs and PAT, to assess changes in those attitudes after reading the psychoeducation, and to identify anticipated logistical, stigma-related, and health concerns that might affect uptake if PAT becomes FDA approved and available in medical settings. Given the exploratory nature of the work, the authors expected a wide range of familiarity and views among participants.

Participants were recruited from multiple channels including a referral programme for current or former service members and civilians with TBI. Interested individuals completed a phone screening for eligibility. Inclusion criteria were being an active duty service member, veteran, retired service member, TRICARE-eligible reservist, or national guard member aged over 18 with a history of mild or moderate TBI occurring more than 3 months earlier, as determined by the Ohio State University Traumatic Brain Injury Identification Method (OSU-TBI). The authors note that the OSU-TBI criterion was formally added after the first six participants were enrolled. Lack of English fluency sufficient to complete measures was an exclusion criterion. The study received Institutional Review Board approval from the Uniformed Services University. Participants provided informed consent and were compensated US$90 for participation except for active duty individuals who did not receive payment due to Department of Defense restrictions. Study procedures comprised three appointments spaced roughly 4 weeks apart that included self-report assessments, performance-based executive functioning tasks, and interviews about TBI and depression; this paper reports data exclusively from the baseline session. Four participants completed the PAT-related questions after their final appointment because those items were added after study initiation. Trained research staff administered the assessments. Perceptions of PAT were measured with a bespoke Psychedelic Perceptions Survey. Participants rated familiarity with psychedelic drugs and PAT and interest in PAT on 1–5 scales, completed a brief written psychoeducation about psychedelic drugs and PAT, and then re-rated the same items. Additional items probed agreement (1 = disagree strongly to 5 = agree strongly) with statements about PAT (for example, support for availability in medical settings, trust in therapists) and asked participants to endorse barriers and concerns across three domains: logistical barriers (time commitment, transportation, work, childcare, financial concerns), stigma (fear of judgment, fear of legal or workplace consequences), and health concerns (fear of TBI complications, long-term effects, personality changes). Clinical measures completed at baseline included demographics and validated symptom scales: the Montgomery–Åsberg Depression Rating Scale (MADRS) and the Patient Health Questionnaire-9 (PHQ-9) for depression, the Generalized Anxiety Disorder screener (GAD-7) for anxiety, and the PTSD Checklist (PCL-5) for PTSD symptoms. TBI history was assessed with the OSU-TBI semi-structured interview. Analyses were conducted in R (version 3.5.1); descriptive statistics summarised sample characteristics and questionnaire responses, summary scores were computed for symptom measures, and paired-samples t-tests evaluated changes in views of psychedelics and PAT before and after the brief psychoeducation.

Twenty-one participants provided baseline data. The sample ranged in age from 31 to 65 years (mean 46.7), was 67% male and 81% White, and included 43% active duty and 57% veterans. Clinical screening indicated that 12 participants screened positive for depression on the PHQ-9, eight for PTSD on the PCL-5, five for probable generalized anxiety on the GAD-7, and 17 reported a history of mild TBI. Familiarity and baseline views were generally low to neutral. One section of the extracted text reports baseline familiarity with psychedelic drugs as slightly familiar (mean = 2.19 on a 1–5 scale) and with PAT as not familiar at all (mean = 1.48). Elsewhere in the extracted text (the abstract) different baseline means are reported (for example, a neutral view of psychedelic drugs M = 2.76 and PAT M = 3.33). The extracted text does not resolve this discrepancy. Despite generally low familiarity, participants on average agreed that they would support PAT being made available in medical settings if proven beneficial (mean = 4.52 on a 1–5 agreement scale) and that they would support a loved one pursuing PAT (mean = 4.29). Trust in therapists during PAT was rated around neutral-to-positive (mean = 3.86). Participants did not endorse the importance of therapist concordance on race/ethnicity (mean = 1.76) or gender (mean = 2.00). After reading a brief written psychoeducation, participants reported an increase in positivity toward psychedelic drugs and interest in PAT. The abstract reports statistically significant increases: for views of psychedelic drugs (mean increased to 3.24, P = .014) and for interest in PAT (mean increased to 3.67, P = .016), and the investigators analysed these changes with paired-samples t-tests. The extracted text does not fully reconcile the differing baseline scores noted above. Regarding barriers and concerns, the most frequently endorsed logistical barrier was time commitment (33%), followed by transportation, financial concerns, work, and childcare (endorsed by 29%–19% of participants). About 48% of participants reported no logistical barriers. Stigma-related concerns included fear of workplace consequences (29%) and fear of judgement (24%). Health concerns most commonly cited were fear of long-term effects (43%), fear of “losing their mind” (33%), fear of personality changes (33%), and fear of TBI complications (24%). One-third (33%) reported no stigma or health concerns related to engaging in PAT.

Gray and colleagues interpret these findings as an initial indication that service members and veterans with a history of TBI and co-occurring cognitive or psychological symptoms are, on average, only slightly familiar with PAT, hold neutral-to-somewhat positive views, and show increased interest after receiving brief psychoeducation. The researchers highlight that participants expressed a mix of enthusiasm and hesitation: there was strong agreement supporting availability of PAT in medical settings if proven beneficial, yet many participants also reported fears about potential long-term effects, loss of mental stability, personality changes and specific concerns about TBI-related complications. The investigators underline logistical and military-specific barriers that may hinder access if PAT becomes available. More than half of participants endorsed at least one logistical barrier, with time commitment, transportation and financial concerns most commonly mentioned. Although few participants reported legal or career concerns, the lowest level of endorsement concerned command support for engaging in PAT; the authors emphasise that how PAT would be integrated into the Military Health System, whether it would affect readiness, and how stigma might play out remain open questions. The paper notes recent policy developments (House-passed amendments in the 2023 National Defense Authorization Act authorising DoD study of PAT) as a sign of growing institutional interest. The discussion also places participant concerns in the context of limited data about safety and efficacy of psychedelics in people with TBI. The authors cite preclinical findings that psychedelics can promote neuroplasticity and mention early clinical research such as a psilocybin trial for migraine showing reduced frequency and intensity without unexpected serious adverse events, and an ongoing study of psilocybin for post-concussive headaches. They conclude that further dedicated investigations of safety and efficacy in TBI populations are warranted. Several limitations are acknowledged. The survey asked conjointly about MDMA- and psilocybin-assisted psychotherapy, preventing substance-specific inferences. The small sample size (pilot study) limited statistical power and representativeness, and four participants completed PAT items later because those questions were added after study start. The volunteer nature of the sample may bias results, and the study was underpowered to compare views between active duty and veteran subgroups. The authors call for larger, more diverse studies including key stakeholders such as Military Health System providers, and for future work to test different informational framings and to examine substance-specific, dosing- and format-specific (for example, group versus individual) beliefs. They emphasise that addressing patient expectations and logistical and military-specific barriers will be important if PAT is approved and implemented, given that expectations can influence treatment effectiveness.