Trial PaperAnxiety DisordersBipolar DisorderDepressive DisordersMajor Depressive Disorder (MDD)Ayahuasca

Antidepressant effects of a single dose of ayahuasca in patients with recurrent depression: a preliminary report

This open-label study (n=6) found that a single dose of ayahuasca has fast-acting anxiolytic and antidepressant effects (up to 21 days later, MADRS) in patients with a current depressive episode.

Authors

  • Jamie Hallak
  • Rafael dos Santos
  • Jordi Riba

Published

brazilian Journal of Psychiatry
individual Study

Abstract

Objectives

Ayahuasca (AYA), a natural psychedelic brew prepared from Amazonian plants and rich in dimethyltryptamine (DMT) and harmine, causes effects of subjective well-being and may therefore have antidepressant actions. This study sought to evaluate the effects of a single dose of AYA in six volunteers with a current depressive episode.

Methods

Open-label trial conducted in an inpatient psychiatric unit.

Results

Statistically significant reductions of up to 82% in depressive scores were observed between baseline and 1, 7, and 21 days after AYA administration, as measured on the Hamilton Rating Scale for Depression (HAM-D), the Montgomery-Åsberg Depression Rating Scale (MADRS), and the Anxious-Depression subscale of the Brief Psychiatric Rating Scale (BPRS). AYA administration resulted in nonsignificant changes in Young Mania Rating Scale (YMRS) scores and in the thinking disorder subscale of the BPRS, suggesting that AYA does not induce episodes of mania and/or hypomania in patients with mood disorders and that modifications in thought content, which could indicate psychedelic effects, are not essential for mood improvement.

Conclusions

These results suggest that AYA has fast-acting anxiolytic and antidepressant effects in patients with a depressive disorder.

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Research Summary of 'Antidepressant effects of a single dose of ayahuasca in patients with recurrent depression: a preliminary report'

Editorial

βBlossom's Take

This early clinical report matters because it brought ayahuasca into modern depression research with a structured inpatient protocol rather than anecdote. The sample is tiny and open-label, but the time course is useful, it shows rapid symptom change that lasted beyond the acute session and helped make ayahuasca a serious question for later controlled trials.

Introduction

Depression is highly prevalent, causes substantial suffering, and current antidepressant treatments have limitations including delayed onset, incomplete response, and adverse effects. The introduction frames interest in rapidly acting treatments, citing ketamine as an example of a novel rapid antidepressant, and positions ayahuasca (AYA) — a traditional Amazonian brew containing DMT and b-carboline MAO-A inhibitors (harmine, THH, harmaline) — as a candidate for investigation. The authors describe AYA’s pharmacology as a combination of peripheral MAO-A inhibition by b-carbolines and central serotonergic agonism by DMT, and they note animal and limited human data suggesting antidepressant potential for AYA or its alkaloids, while also acknowledging the paucity of controlled clinical data and limited evidence on long-term safety. This preliminary, open-label study set out to evaluate whether a single dose of AYA produces acute antidepressant effects in patients with recurrent major depressive disorder (MDD). The stated objective was to measure changes in clinician-rated depressive and related symptoms over hours to weeks after administration, testing the hypothesis that AYA could produce rapid reductions in depressive symptoms in a clinical population.

Methods

This was an open-label trial conducted on an inpatient psychiatric unit. Six volunteers (two men, four women; mean age 44.17 ± 13.55 years) with recurrent MDD and a current depressive episode (two mild, three moderate, one severe) participated. Participants were recruited by advertisement and clinical referral. At enrolment they were not taking psychotropic medications, were reported never to have used illicit drugs or ayahuasca, and were screened to exclude bipolar disorder, prior mania/hypomania, pregnancy, and significant medical conditions by interview, physical examination and laboratory tests. Written informed consent was obtained and the trial had local ethics committee approval. The intervention was a single oral dose of a standard ayahuasca batch prepared by members of the Santo Daime community. Each subject drank 120–200 mL (reported as 2.2 mL/kg). The extraction text reports alkaloid concentrations for the batch as 0.8 mg/mL DMT and 0.21 mg/mL harmine with harmaline below the 0.02 mg/mL detection threshold; however, the Discussion later refers to a DMT concentration of 0.08 mg/mL, a discrepancy in the extracted text that is not resolvable here. Quantification was performed by GC/MS as described in the methods text. Patients were admitted two weeks before dosing and remained medication-free during that period. The experimental session lasted on average about 4 hours; participants were seated in a quiet, dimly lit room and monitored, then observed for 24 hours post-session and discharged if no complications occurred. Clinical assessments included the SCID-IV at screening and clinician-administered scales at baseline (–10 min), at +40, +80, +140 and +180 minutes post-dose, and on days 1, 7, 14 and 21 after administration. Scales used were the Hamilton Rating Scale for Depression (HAM-D), Montgomery–Åsberg Depression Rating Scale (MADRS), Brief Psychiatric Rating Scale (BPRS) with subscales (Withdrawal–Retardation, Thinking Disorder, Anxious–Depression, Activation), and the Young Mania Rating Scale (YMRS). Vital signs (systolic and diastolic blood pressure) were recorded at the same short-term time points. Adverse effects were not systematically assessed; dysphoric effects were recorded via spontaneous reports. For analysis the investigators used descriptive statistics and repeated-measures analysis of variance (ANOVA) after verifying data distribution. Statistical significance was set at p < 0.05.

Results

Baseline characteristics indicated moderate depression on average: mean HAM-D 17.56 ± 7.73 and mean MADRS 23.56 ± 11.14. On the HAM-D there was a 62% mean decrease at day 1 (D1) compared with baseline (p = 0.01) and a 72% decrease at day 7 (D7, p = 0.01). Scores increased by D14 but remained 45% below baseline (this D14 change did not reach statistical significance, p = 0.11), and a further significant decrease was reported at D21 (p = 0.01). The largest item-level reductions were in depressed mood, guilt, suicidal ideation, and work/activity difficulties. MADRS results paralleled HAM-D findings. A significant 38% decrease was observed at +180 minutes (p = 0.01). By D1 the reduction was more robust (p = 0.003) and by D7 mean MADRS scores were 82% below baseline (p = 0.009). A significant increase occurred at D14 (p = 0.001), followed by a significant decrease at D21 (p = 0.002). The most marked MADRS item changes concerned apparent sadness, pessimistic thinking, suicidal ideation, and concentration difficulties. On the BPRS, participants were generally asymptomatic at baseline on the Withdrawal–Retardation, Thinking Disorder and Activation subscales. Nonsignificant increases in these subscales were observed, peaking around +80 minutes then returning to baseline by +180 minutes; reported acute features included transient disorientation/confusion, conceptual disorganisation, psychomotor retardation and emotional withdrawal. The Anxious–Depression subscale, which was elevated at baseline, showed significant reductions at +140 minutes (p = 0.02) and remained approximately 72% below baseline until D7, when scores began to rise but stayed significantly lower than baseline. The YMRS showed no significant changes across the study, although transient irritability, reduced insight and sleep disturbance were more prevalent during the first 80 minutes. AYA was described as well tolerated. Vomiting occurred in 50% of participants; this was reported as expected and not regarded by participants as severe. Blood pressure rose moderately but nonsignificantly. The authors note that adverse effects were not systematically queried, so reporting of subtler or less spontaneously reported effects may be incomplete.

Discussion

Crippa and colleagues interpret the findings as evidence that a single dose of ayahuasca produced rapid and clinically meaningful reductions in depressive and anxiety-related symptoms that persisted for days in this small, treatment-seeking sample. They highlight the similarity of effects across participants regardless of baseline severity and note that the time course — early improvement evident at hours and maintained at D1 and D7 — contrasts with the typical multi-week onset of conventional antidepressants, making AYA of interest as a putative fast-acting treatment. The authors discuss possible mechanisms linking AYA pharmacology to antidepressant action, including MAO-A inhibition by b-carbolines, THH-mediated serotonin reuptake inhibition, and animal evidence that harmine can increase brain-derived neurotrophic factor (BDNF) and exert antidepressant-like effects. They draw a parallel to ketamine in which synaptogenesis and BDNF have been implicated in sustained antidepressant effects, while acknowledging that intracellular cascades underlying AYA’s time course remain speculative. In terms of subjective and psychotomimetic effects, the study found only transient, mild increases in thinking-disorder and related BPRS subscales around the peak subjective effect window; these effects were not statistically significant and resolved by +180 minutes. The Discussion notes that the relatively low DMT concentration reported for the batch used in this study (the extracted text contains an inconsistent report of batch DMT levels, see Methods) may explain the limited psychotropic effects and suggests that marked changes in sensory perception or thought content may not be necessary for antidepressant benefit. Important limitations are acknowledged: a very small sample size, open-label uncontrolled design, lack of placebo or active comparator, and absence of systematic adverse-effect assessment. The investigators recommend larger, controlled trials, systematic side-effect monitoring, exploration of optimal dosing and formulations (for example freeze-dried AYA which may induce less vomiting), cautious consideration of antiemetic premedication given potential interactions, and incorporation of neuroimaging and other biological measures in future work. They position the present results as preliminary but supportive of further investigation into AYA and related alkaloids as sources of faster-acting antidepressant treatments.

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RESULTS

After verification of data distribution, descriptive statistics and repeated-measures analysis of variance (ANOVA) were used for statistical analysis. Significance was set at p , 0.05.

CONCLUSION

The results of the present investigation demonstrate that AYA has significant and quite impressive acute antidepressive effects. Score reductions were observed in both the HAM-D and MADRS scales on D1 and D7, and these effects lasted for several days. It is noteworthy that these changes showed a profile that was very similar across volunteers, regardless of the prior level of depression, i.e., the severity of the current depressive episode. The antidepressant potential of AYA was previously demonstrated in a study that reported a decrease in hopelessness symptoms after acute AYA intake.The average time necessary for the onset of therapeutic action of commercially available antidepressants is 2 weeks.Considering currently available medications, the fast antidepressant action of AYA is promising, as it may provide faster reductions in depressive symptoms. Moreover, the antidepressant effects of AYA alkaloids may inspire a new area of depression research. Interestingly, symptoms increased on D14 as measured by the HAM-D and MADRS scales, although a subsequent significant decrease occurred on D21 in both scales. Although increased, HAM-D scores still remained 45% below baseline values, but this difference was nonsignificant. On the other hand, MADRS scores on D14 were significantly increased. The decreases and increases in depressive symptoms after AYA administration could reflect complex intracellular events that remain active after the acute effects of AYA have subsided. The acute antidepressive effects of ketamine, for instance, may be sustained for weeks to months and are associated with increased synaptogenesis and spine formation, which seem to be related with increases in brain-derived neurotrophic factor (BDNF) protein levels.Studies conducted in rodents by our group and by others using doses of 10-15 mg/kg harmine have demonstrated antidepressive effects for this compound, which were associated with increases in BDNF levels.Furthermore, harmine, THH, and harmaline are potent natural, selective, reversible, and competitive inhibitors of the MAO enzyme, especially of the MAO-A subtype.THH acts as a selective serotonin reuptake inhibitor as well as an MAOI. 9,37 Inhibition of both systems --MAO and serotonin reuptake --may result in elevated levels of brain serotonin and other monoamines, producing antidepressant effects.The statistically significant reductions in BPRS-AD scores from D1 to D21 suggest that AYA produced antidepressive and anxiolytic effects. A previous study reported decreased panic-related signs after acute AYA intake.AYA administration did not produce statistically significant sensory, cognitive, or affective modifications as assessed by the BPRS and YMRS scales. Although nonsignificant, in the present study these effects were observed during a period ranging from 80 to 140 min after AYA administration, which is the time point when the subjective effects of AYA are peaking, as are DMT plasma levels.The absence of statistically significant effects on BPRS-TD scores could be explained by the DMT concentration found in our AYA batch (0.08 mg/mL), which is lower than DMT doses used in previous studies that reported significant psychotropic effects of AYA (0.53 mg/ mL DMT).The nonsignificant effects of AYA on the BPRS-TD subscale suggest that changes in sensory perception and thought content may not be essential for therapeutic effects. AYA was well tolerated by all patients, suggesting that it can be safely administered to depressed patients. This result corroborates previous studies reporting a good tolerability profile for AYA administration to healthy volunteers.In the present study, the psychoactive effects of AYA were considered by participants as mild and short-lived, corroborating the nonsignificant effect of AYA on the BPRS-TD subscale. The nonsignificant increases in blood pressure replicate previous findings in human studies suggesting that AYA produces moderate cardiovascular effects.Early academic research on classical hallucinogens was designed considering the powerful influences of set (psychological state) and setting (environment) on the effects of this class of substances.Considering this background, in the present study volunteers were kept as comfortable as possible, remaining seated in a recliner in a quiet, dimly lit room throughout the experimental session. Investigator interference was minimal, allowing patients to concentrate on the effects of AYA. This safe environment may have reduced the probability of dysphoric reactions.Vomiting was the only adverse effect reported by volunteers (50%). Patients were informed before the experimental session that vomiting was a possible effect of AYA, as nausea and vomiting are the most frequently reported adverse effects in clinical trials of acute AYA administration.In the present study, vomiting apparently did not have a significant influence on the antidepressive effects of AYA. Patients did not consider this emetic effect to be a severe discomfort, a result that is in line with previous studies of acute AYA administration to healthy volunteers, which reported that most participants regarded their AYA experience as pleasant despite the occurrence of vomiting.In future studies, it would be interesting to try to reduce the emetic effect of AYA by premedicating with an antiemetic. However, this possibility should be explored with caution, considering that AYA alkaloids could interact with antiemetic drugs. Another possibility could be to administer AYA in different formulations. Freeze-dried AYA appears to produce less vomiting than oral AYA.Interestingly, variable degrees of nausea, vomiting, and, occasionally, simultaneous diarrhea are common in AYA rituals. In these contexts, however, these purgative effects are considered positive and cleansing.Important limitations of the present open-label study include the small sample size, the absence of a systematic inquiry about side effects, and the lack of placebo and control groups. Although patients did not spontaneously report adverse effects other than vomiting, the lack of a systematic assessment of adverse effects may have reduced the likelihood of registering more subtle effects, such as impacts on cognition. Future studies should assess the possible adverse effects of AYA in clinical populations by using other subjective measures, such as visual analogue scales and other scales that measure hallucinogenic effects, and by exploring other variables that could be modified by AYA administration as reported in previous studies, such as neuropsychological, neurophysiological, autonomic, neuroendocrine, and immunological parameters.Ideally, future studies involving AYA and depressed patients or other clinical populations should also be designed to include a control group. This group could receive a placebo, a comparator drug with an established therapeutic indication, or AYA preceded by pretreatment with a 5-HT 2A receptor antagonist to investigate possible The 140-min time point was chosen because the subjective effects of AYA peak around this time, as do DMT plasma levels.All blood pressure values expressed in mmHg. HR values expressed in beats per minute. mechanisms of action. Regarding the small number of patients, additional studies with larger sample sizes and using neuroimaging techniques (single photon emission tomography, SPECT) are underway in our laboratory. The aforementioned limitations should be considered taking into account the novelty of this research and its preliminary nature. To our knowledge, the use of AYA in a controlled clinical setting in patients with current depression --or in any other clinical population --has never been investigated. Moreover, the results of the present study, although preliminary, are corroborated by mounting research showing antidepressive potentials for AYA alkaloids in nonhuman animalsand in humans.Finally, the reported results may prompt novel research into substances with faster therapeutic actions than currently available pharmacological resources, thus making antidepressive treatment more effective. The findings of this preliminary study demonstrate the potential antidepressant and anxiolytic effects of AYA, effects that, importantly, have an earlier onset of action when compared to traditional antidepressants. These findings suggest that AYA may represent a powerful new substance for the treatment of depressive and anxiety symptoms. However, these results deserve careful analysis, given the inherent limitations of an uncontrolled, open-label study with a small sample size. Other studies are needed to replicate these preliminary observations and to test, for example, the most effective dose (or doses) of AYA and the safety, tolerability, and effectiveness of AYA administration over a longer period of time.

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