Authors' reply

I thank Drs Arnone and Schifano for their letter, which opens the debate about the undeniable dangers of recreational drug misuse, compared with the relatively safe clinical use of MDMA. This topic has received considerable media interest, with particular attention centred on the damaged brains of users of ecstasy - an illegal compound, which may or may not contain varying amounts of MDMA, together with any other substance. Ecstasy is usually taken in combination with other illegal drugs (Curran, 1998) or large amounts of alcohol, and often in circumstances involving high temperatures, which are known to exacerbate neurotoxicity (Malberg & Seiden, 1998).

All studies referred to by Drs Arnone and Schifano involve either recreational ecstasy users (mostly with no controls for other illegal drugs) or animal models with high and frequent dosage regimes that do not relate to those used for medically supervised MDMA psychotherapy research. The approach is therefore analogous to opposing the controlled, clinical research of opiate drugs after quoting studies of the morbidity of illegal heroin users.

Physiological studies involving infrequent and moderate doses of pure MDMA (as used in the psychotherapeutic setting) consistently demonstrate that the drug causes insignificant neurotoxicity, neuropsychological, mood or memory effects (Ludewig et al, 2003; Halpern et al, 2004).

Of course, there are risks when using any treatment - even in a controlled setting. All drugs, from paracetamol to cancer chemotherapy, are potentially harmful and must only be used after considering the risks and benefits - which includes considering the risk of doing nothing.

In relation to the opening comments, as a working psychiatrist, far from being ‘repulsed’ by neurobiological psychiatry, I am acutely aware of the importance of a holistic approach. Indeed, psychedelic psychotherapy, and the complexity of issues it raises, is a startling example of the effective interplay of concurrent psychological and organic treatments.

Given their history, MDMA and the other psychedelics are contentious treatments. However, it is possible for psychiatrists to think creatively and also consider safety and realistic risk-benefit ratios.

After all, if these compounds do have the potential to improve the speed and depth of psychotherapy, then they at least deserve clinical research in order to establish whether they can be useful tools to fight the global burden of neurotic illness.