Naturalistic Psychedelic Use: A World Apart from Clinical Care

Glynos and colleagues situate this study in the context of rapidly expanding research and public interest in psychedelic-assisted therapy, noting positive signals from clinical trials of psilocybin and MDMA for several psychiatric conditions alongside evolving policy changes that have decriminalised or legalised psychedelics in some U.S. jurisdictions. The authors highlight that naturalistic, non‑clinical use of psychedelics has increased in recent years and that many people report self‑medicating for mental health problems; however, the relationship between this naturalistic use and mainstream healthcare remains poorly characterised. They also note potential safety concerns arising from lack of medical oversight, possible adverse reactions in at‑risk individuals, and the presence of adulterants in unregulated substances, which could be mitigated by drug testing kits or laboratory services.

The investigators conducted an anonymous online survey via Qualtrics between 19 September and 15 October 2021. Recruitment was by posted advertisements at a psychedelic activism event in Ann Arbor, MI, and via e‑mail listservs and posts in psychedelic interest groups on social media (Reddit, Facebook). Eligible participants were aged 18 or older and reported prior use of a psychedelic substance; Qualtrics settings were used to prevent duplicate responses. No compensation was offered and participants could withdraw at any time. Institutional review board approval was obtained. Survey development involved stakeholders, advocacy groups, students and academics experienced in survey design. The instrument collected demographic data, past clinical diagnoses, detailed self‑reported psychedelic use (substances, frequency, dose, set and setting), motivations for use, perceived outcomes on health and well‑being, and questions about integration with conventional healthcare. Specific items asked whether participants had discussed psychedelics with their primary care provider (PCP), reasons for disclosure or nondisclosure, perceived PCP knowledge, likelihood of using psychedelics under therapist guidance if legal, and awareness and frequency of use of at‑home test kits or laboratory testing services to confirm substance identity. Key measures included a checklist of commonly used psychedelics (psilocybin, LSD, DMT, MDMA, ketamine, ibogaine and others) and the Patient Global Impression of Change (a 7‑point Likert scale ranging from “Made my symptoms very much worse” to “Made my symptoms very much better”) for those reporting past diagnoses. Statistical analyses comprised descriptive statistics, attrition comparisons using contingency analyses and χ2 tests with Cramer V effect sizes, t‑tests with Cohen's d for continuous variables, and binary logistic regression to identify predictors of two primary outcomes: disclosure to PCP and awareness of substance testing services. Male served as the reference category for gender comparisons, significance was set at α = .05, and analyses were conducted in SPSS v27.

A total of 1,930 participants started the survey and 1,435 completed it; the mean completion time was 25.0 minutes. The analysed sample was predominantly White (88.8%) with a mean age of 35.2 ± 12.5 years, and comprised 52.9% men, 40.8% women, and 6.1% identifying as transgender, gender fluid or another gender. Most respondents (78.1%) lived in the U.S., with Michigan, California, New York and Colorado being the most represented states. Attrition analyses compared 251 incomplete responses with completers and found no demographic differences or differences in reporting psychedelic use to a healthcare provider or in use of testing services. The incomplete group was, however, less likely to report willingness to consume psychedelics under therapeutic support if legal. Patterns of use showed that 55.8% of participants used psychedelics every 2–5 months or more frequently. The most commonly reported substances were psilocybin mushrooms (92.1%), LSD (76.8%) and MDMA (55.5%). Primary motivations were spiritual/psychological/personal exploration (81.6%), personal growth (72.2%) and improving general mental health (63.4%). Nearly half (47.2%) reported using psychedelics to treat a medical condition or manage past trauma, with depression (75.4%), anxiety (66.8%) and PTSD (40.6%) the most frequently cited conditions. Use typically occurred at home (81.9%) or outdoors (65.4%); only 3.0% reported use in clinical or hospital settings and 4.4% reported using psychedelics with a therapist or healthcare professional. Among those who used with a therapist, 71.4% rated the therapist’s presence as important or very important, and 77.8% of the overall sample said they would be very or extremely likely to use psychedelics with a trained therapist if legally available. Communication with primary care was limited: 72.5% reported never discussing psychedelics with their PCP. Reasons for nondisclosure included perceived stigma (56.3%), a preference for privacy (40.9%), legal concerns (37.5%) and belief that the PCP lacked adequate knowledge (38.1%). When asked about PCP knowledge, 68.3% said they did not know and 20.5% rated it as poor; among those who had disclosed use, 52.0% reported being very comfortable sharing details. Regarding substance testing, 62.6% were aware of laboratory or at‑home testing options, but 42.6% of those aware reported never using these services; overall, 64.1% were either unaware of or never used testing. Binary logistic regression identified several predictors. Greater age, higher frequency of psychedelic use, a larger total number of different psychedelics used, higher self‑reported likelihood of consuming psychedelics under therapist guidance, and identifying as “Other” gender were significantly associated with having discussed psychedelics with a PCP. Awareness of substance testing services was associated with younger age, higher total number of psychedelics used, higher frequency of use, and not identifying as a woman. Perceived health outcomes were largely positive: 93.2% indicated improvements in overall psychological, emotional, mental or physical well‑being. Among respondents with past diagnoses, reported symptom improvements were common for depression (89.9%), anxiety (81.7%) and PTSD (90.0%). Worsening of symptoms was uncommon (<5% for most conditions), although higher proportions reported worse outcomes for bipolar disorder (9.0%) and sleep disorders (9.3%). Many participants reported reductions in other substance use following psychedelic experiences: alcohol decreased for 37.2%, tobacco/nicotine for 18.3% and prescription opioid use for 7.2%, while only small percentages reported increases in those substances.

Glynos and colleagues interpret their results as evidence of a substantial disconnect between naturalistic psychedelic use and mainstream medical care in the U.S. They note that most participants do not tell their PCPs about psychedelic use, largely because of stigma, legal concerns, privacy preferences and perceptions that PCPs lack knowledge about psychedelics. Despite limited clinical engagement, a substantial proportion of respondents use psychedelics for self‑treatment of mental health conditions and express strong interest in accessing guided, therapist‑supported psychedelic experiences if made legally available. The authors highlight both the largely positive self‑reported outcomes and the safety concerns revealed by the data. While many respondents reported symptom improvement and reduced use of alcohol, tobacco and opioids, a minority reported worsened symptoms, particularly among people reporting bipolar disorder or sleep disorders—findings that underscore the importance of proper screening and access to preparatory and integration support. Lack of disclosure to healthcare providers also limits opportunities to manage potential adverse interactions with common psychiatric medications and to provide harm reduction advice. Glynos and colleagues discuss systemic factors that amplify risk: the Schedule I status of many classic psychedelics creates legal harms and reduces medical oversight, leaving consumers responsible for product content and purity. They note that many participants were unaware of or did not use available substance testing options, further increasing the risk of exposure to adulterants. To address these gaps, the authors propose several strategies: expanding training programmes and integration services to build a workforce capable of delivering or supporting psychedelic therapy, reconsidering scheduling of substances to align regulation with evidence, improving education for healthcare providers and the public about risks and harm reduction, and increasing visibility and access to substance testing services. The authors acknowledge several limitations. Their convenience sample—recruited via psychedelic‑focused social media, listservs and an activism event—limits generalisability and likely overrepresents enthusiasts while under‑capturing people harmed by psychedelics. The sample was disproportionally White and highly educated and largely U.S.‑based. The cross‑sectional, self‑report design is subject to recall bias and the researchers could not verify reported diagnoses. Finally, because substances are unregulated and many participants did not test samples, some reported experiences may have involved adulterated or different compounds than intended. Strengths noted by the authors include being the first study to assess communication about naturalistic psychedelic use with healthcare providers, a large sample size, and a more balanced gender distribution than is typical in some prior surveys. The authors conclude that their findings point to an unmet need for therapeutic infrastructure, practitioner training and public education to reduce harms and support potential therapeutic benefit as psychedelic use becomes more visible and legally permissive. They suggest future research from healthcare provider perspectives and more focused studies on communication with psychiatrists and psychotherapists.

The study concludes that, although psychedelic therapies are emerging within medicine and regulatory pathways are changing for several substances, naturalistic psychedelic use remains largely separate from conventional healthcare. Minimal patient–provider communication, widespread self‑medication for mental health, changes in other substance use after psychedelic experiences, and unmet demand for therapist‑guided services indicate a need for enhanced training of healthcare professionals, broader public education about safe use and increased availability of substance testing. The authors recommend further research on provider perspectives and on patient–provider communication in clinical contexts.