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A group of Estonian psychiatrists and civic activists believe that allowing the therapeutic use of currently prohibited psychedelic substances could help alleviate the country’s ongoing mental health crisis. According to a representative from the Estonian Medicines Agency, the scientific study of psychedelics is legal in Estonia. However, due to their novelty, it is necessary to carefully evaluate the balance between their risks and benefits.
Psychedelics likely evoke associations for many readers with illicit narcotics and their misuse, whether it be the hippies of the 1960s who used LSD, electronic dance music enthusiasts consuming MDMA or mushroom foragers in Viimsi seeking psilocybin. These complex compounds are just a few examples of psychoactive substances that induce altered states of consciousness, characterized by changes in perception, thinking, mood and cognition. It is precisely these effects that lead many doctors and researchers to see therapeutic potential in them.
Just as the use of psychedelics has a long history, so does their scientific study. The first wave of research into the potential of psychedelic substances for mental health treatment emerged in the 1950s and 1960s. This momentum was halted by the administration of U.S. President Richard Nixon, which viewed the use of psychedelics as a root cause of anti-Vietnam War sentiment and societal divides. This era also marked the beginning of a broader war on drugs in the United States.
A second wave of research began in the late 1990s and continues today. For instance, MDMA has now reached phase three of clinical trials for the treatment of post-traumatic stress disorder (PTSD). At this stage, a larger group of patients participates in studies and the drug’s effectiveness is compared against existing treatments or placebos.
Similarly, the U.S. Food and Drug Administration (FDA) recently advanced LSD, for the treatment of generalized anxiety disorder, and psilocybin, which shows promising results in combating depression, to the same critical stage before a drug can apply for market authorization.
The FDA has designated all three substances — MDMA, LSD and psilocybin — as “breakthrough therapies.” This status reflects the significant therapeutic potential researchers see in these drugs, allowing their study data to be processed on an expedited basis.
The topic is not unfamiliar in Estonia either. Last week, the Foundation for the Development and Innovation of Psychedelic Therapy (TAIP) held its opening seminar in Tallinn. The foundation aims to promote a science-based approach to psychedelic-assisted therapy in Estonia. Specifically, its mission is to advance the use of psychedelics either as a primary therapeutic intervention or as tools to support psychotherapeutic treatments.
According to Viljar Veede, chair of TAIP’s supervisory board and a psychiatrist, the foundation was established to raise awareness about the existence and necessity of this field. “There remains a lack of understanding, both at the level of agencies and even among physicians,” Veede explained. He added that TAIP is part of a pan-European network representing Estonia, alongside professional organizations such as the European Psychiatric Association.
Who needs psychedelics and why?
According to Anne Kleinberg, chair of the board of the Estonian Psychiatric Association, the need for new treatment methods stems from the poor state of mental health support. “Access to care today is insufficient. All existing treatment options have their limitations. For instance, antidepressants, which are the most widely used, are at most 60 percent effective and one-third of patients do not respond to standard treatment. Anxiety and depression are simply so prevalent and have such a detrimental impact on people’s ability to cope. This is why we need to expand treatment options,” Kleinberg explained.
In addition, antidepressants work too slowly, in Kleinberg’s view. It typically takes at least a month for a patient’s condition to improve and symptoms to subside, meaning they cannot provide quick relief for those in severe distress.
Both Kleinberg and Viljar Veede noted that some mental health conditions leave psychiatrists with virtually no effective treatment options. One of the most striking examples in Estonia is alcohol addiction. “Especially when alcohol use is accompanied by co-occurring disorders such as PTSD and depression, it is extremely difficult for a doctor to treat these with the methods currently available,” Kleinberg added.
According to Veede, research shows that psychedelic-assisted therapy could help many individuals. For example, it could benefit those suffering from chronic depression that is resistant to conventional treatments or struggling with anxiety disorders that therapy and medication fail to address. Psychedelics may also be useful for treating addiction, whether the substance involved is alcohol, nicotine, cocaine or heroin.
However, psychiatrists caution that psychedelics are unsuitable for individuals with certain conditions, including psychotic disorders, bipolar disorder or severe personality disorders. They are also not recommended for those with conditions such as intellectual disabilities or dementia, where physical changes or abnormalities in the brain are present.
Kleinberg described the use of psychedelics in mental health treatment as an opportunity to revisit and properly implement old methods for the benefit of patients. She emphasized that their therapeutic potential should be fully utilized. “Psychedelics are not a new discovery. Medicine has dealt with them before, not to mention people trying to self-medicate with them. The time has come to revisit them. Science has significantly advanced. We now have the opportunity to unravel how they work, stabilize their effects and develop medications from them. This, in turn, requires clear treatment principles,” Kleinberg explained.
The psychiatrist noted that her colleagues in Estonia tend to take a conservative stance on psychedelics, as physicians are naturally skeptical of innovations. However, Kleinberg pointed out that the topic is being discussed and doctors are attending training sessions and conferences in Europe and the United States, where psychedelics receive much more attention.
She stressed the importance of fostering an intelligent and science-based dialogue on psychedelics in society. According to Kleinberg, it is crucial for both those affected by decisions in this field and the doctors influencing their lives to have up-to-date knowledge.
As a negative example, she cited the decades-long use of medications for attention-deficit/hyperactivity disorder (ADHD). “There are stories of pharmacists refusing to dispense them because they consider them narcotics. That is an unacceptable attitude. Many medications are, by nature, narcotic, and we simply need to know how to use them properly,” Kleinberg said.
Ketamine
Although psychedelics are essentially prohibited in Estonia, there has been one exception on the Estonian pharmaceutical market for years — ketamine. Originally used in military medicine and as an anesthetic for animals, later research found that the compound is also effective in treating pain and depression. According to the Estonian Medicines Agency, both the nasal spray Spravato, containing esketamine, and ketamine injection solutions are available for psychiatric use.
Estonia’s first systematic ketamine treatment service was established by Viljar Veede himself. “Essentially, ketamine is a medication available for general use here. It began being used in psychiatry about 20 years ago. In certain cases of depression, where traditional antidepressants are ineffective or require a month to show results, ketamine can pull someone out of a severe state within a few hours,” Veede explained.
The discovery caused a sensation in psychiatry and neuroscience. Ketamine became the first fast-acting antidepressant of a so-called new generation of treatments, a group of compounds that now includes psilocybin. This breakthrough was followed by clinical trials, which led to its widespread practice and use.
As with other psychedelics, two distinct treatment approaches are possible with ketamine. In the first, the physician administers a small dose without any psychological support.
In the second approach, ketamine administration is accompanied by psychological support or psychotherapy. Patients are prepared for the experience, doses are increased and a characteristic psychedelic experience is induced to support the therapeutic process.
According to Veede, during ketamine infusions, doses are deliberately kept as low as possible to minimize the psychedelic experience. The treatment aims to achieve purely biological effects. In his view, most Estonian psychiatrists consider altered states of consciousness to be a side effect that should be avoided.
“I belong to the group of doctors who, in addition to considering the biological effects, also think about how a conscious experience can influence a person’s recovery. For me, it’s a fundamental part of the treatment. Sometimes, for the therapy to work, the experience needs to be intense and result in lasting outcomes,” Veede explained.
So, what does a psychedelic-assisted therapy session look like? According to Anne Kleinberg, two key factors are critical: a safe therapeutic environment and the presence of a clinical psychotherapist.
As with conventional therapy, the physician must understand the condition they are addressing. “You need to grasp the psychological problem you are dealing with, the patient’s state at the beginning of therapy and how to support them. This requires specific training in addition to an understanding of psychopathology,” the psychiatrist said.
Therapy versus drug
A clear distinction between therapy and simple drug administration has also been established in scientific research.
In the United States, several large companies have minimized the psychological intervention — or therapy — component in their studies. This shift followed a decision by the FDA in August last year to deny a usage license for an MDMA-based drug developed by Lykos Therapeutics. The company intended the drug for the treatment of post-traumatic stress disorder (PTSD).
According to Viljar Veede, this decision partly reflects the FDA’s inability to separately evaluate the effects of the drug and the therapy. “First, conducting a blind trial with psychedelics is extremely difficult. Essentially, patients always know whether they received the psychedelic or not. This complicates the assessment of outcomes,” Veede explained. Additionally, he noted that while the FDA excels at evaluating the impact of drug administration, it struggles to assess therapy in conjunction with the drug. In other words, it becomes difficult to determine how much of the effect was due to the therapy versus the drug itself.
For example, a company developing LSD for generalized anxiety disorder has stated on its website that its goal is to administer the drug similarly to Spravato (esketamine nasal spray). This approach excludes psychotherapy, which, according to Veede and most specialists in the field, is a crucial component for effective treatment.
Indications
At the same time, the United States remains significantly ahead of Europe in psychedelic research. According to Viljar Veede, this lead likely influences when these substances will receive official indications for use. “The European Medicines Agency doesn’t simply adopt U.S. decisions but makes its own evaluations. These decisions are often different. However, since most of the research is conducted in the U.S., it undoubtedly gives them an advantage,” Veede explained.
Switzerland, however, stands out as a major exception in Europe. Therapeutic use of psychedelics there has progressed further than anywhere else in the world. Under certain conditions, the use of LSD, MDMA and, for the past five years, psilocybin, is permitted. Veede believes Estonia could initially learn from Switzerland’s example.
He suggests that even if these drugs have not yet received full approval, psychedelics demonstrating excellent results in clinical trials could, like in Switzerland, the U.S. and Australia, be made available through special permits to patients who have exhausted all other options. “I think regulations should allow patients who have already tried all standard treatments to legally access these drugs and therapies,” Veede said.
In addition to ketamine, which is already available, Estonia allows psychedelic-related research under special permits issued by the Medicines Agency. Before granting a permit, the agency evaluates each study individually, considering data provided in the application and research conducted elsewhere on the same topic.
According to a representative of the Medicines Agency, clinical trials assess not only therapeutic effects but also the balance of risks and benefits, with particular attention to participant safety. This includes evaluating the potential for psychological disorders, addiction or other serious side effects.
Veede also noted that TAIP plans to fund a clinical trial if possible. Additionally, the organization aims to support therapist training and offer scholarships to ensure that Estonia has specialists in this field in the future.
TAIP’s initial efforts will focus on “integration circles,” where psychological support will be provided to individuals who have used psychedelics independently and had challenging experiences they cannot process alone. Veede explained that this would give people the chance to discuss their experiences with someone knowledgeable about the subject.
“The most important thing to understand is that psychedelics, when used in a controlled medical setting, are quite safe. Their potential effectiveness can be very high and they do not cause addiction,” Veede stated.
However, a representative of the Medicines Agency added that while psychedelics are not new substances, their use for therapeutic purposes is relatively recent. As a result, scientific and clinical information on them remains limited.
This article was originally published on the Estonian Public Broadcasting online news portal.
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