November 15, 2023
In the ever-evolving landscape of psychiatric care, few areas have demanded as much attention as the treatment of Post-Traumatic Stress Disorder (PTSD), particularly among veterans. General Stephen Xenakis, M.D., Executive Director of the American Psychedelic Practitioners Association, brings a unique blend of military and psychiatric expertise to the forefront of this challenge. His insights offer a beacon of hope in a field seeking innovation, especially in an era where conventional therapies have plateaued.
General Stephen Xenakis's journey into the realms of psychiatry and military service is marked by a comprehensive view of healthcare. His academic training, including a residency at the University of California, San Francisco (UCSF), laid a strong foundation for his career.
Reflecting on his experiences, he notes, "Throughout medical school and my surgical internship, I was constantly reminded of the importance of considering the whole person in treatment - not just their disease, but their life circumstances, illnesses, injuries, and how these factors would shape their future."
General Xenakis's holistic approach was deeply influenced by his time treating soldiers returning from Vietnam in the early 1970s. He shares, "As I treated soldiers and experienced being a patient at Walter Reed after an injury, I gained a profound understanding of the impact of severe injuries on soldiers' lives.
Witnessing the challenges faced by men and women on an amputee ward reinforced my belief in the necessity of considering the broader implications of their injuries on their future lives." This perspective underpinned his approach to mental health care, particularly his focus on the complexities of PTSD among veterans.
General Xenakis critiques the historical reductionism in psychiatry, highlighting a transition to biological explanations in the 1980s. He acknowledges the value in this approach but notes its limitations in fully addressing patient needs. "The field gravitated towards discrete treatment protocols, which, while necessary, didn't meet the holistic needs of patients, particularly in areas like substance abuse and addiction," he explains.
General Xenakis sees the current interest in psychedelic treatments as a pivotal moment, urging a return to more comprehensive methods of care. "We're at an inflection point where we must intelligently integrate holistic approaches from the past with current innovations. It's about finding the right balance between the two."
Alison McInnes, MD, MS, Osmind’s VP of Scientific Affairs, drawing on her experience as a geneticist, questions the adequacy of the DSM in capturing the etiological basis of symptoms. She advocates for a shift towards patient-centered models, where treatments are tailored to individual profiles and goals. "Depression, for instance, involves hundreds of genes and environmental factors. We need to understand that patients come with unique profiles and purposes, necessitating a more personalized approach in therapy," she emphasizes. "Genetics plays a significant role in conditions like depression, which demands a move towards more precise, individualized treatment methods," she states.
General Xenakis is enthusiastic about the potential of AI and large language models in psychiatry. "AI allows us to identify patient narratives and patterns, moving beyond checklists to a more systematic, pattern-based analysis. This is a step towards precision psychiatry, where treatment is highly individualized," he remarks.
Highlighting his work in EEG, General Xenakis discusses its potential in diagnosing and selecting treatments based on neurophysiology. "Quantitative EEG can provide insights into brain states and help select medications based on neurophysiological changes, not just diagnosis. This approach aligns with the goals of precision psychiatry," he concludes.
General Xenakis discusses his journey to becoming the Executive Director of the American Psychedelic Practitioners Association. "My advocacy for veterans and vocal support in this field led to my invitation to join the board," he shares. "Aligning with my lifelong professional and personal purpose, I embraced the opportunity to lead and shape this organization."
The General's vision for the Association is expansive and inclusive. "We aim to be a voice for practitioners across disciplines, influencing the development and transition of mental healthcare. It's about grounding everything in clinical practice - policies, programs, reimbursement, and support systems," he explains.
General Xenakis emphasizes the importance of establishing professional practice guidelines and accredited training. "Our focus is on identifying good clinical practices and specifics of different modalities. We're working towards becoming the accrediting organization for training in psychedelic-assisted therapy," he states.
Building on the foundation of strong practice guidelines, General Xenakis also recognizes the critical role of education in the field.
General Xenakis expresses hope for the Association's involvement in residency programs and medical schools, envisioning a future where psychedelic medicine is part of mainstream psychiatric education. "Integrating this education at the residency level and even in medical schools is crucial. We need to balance biological models with psychodynamic approaches," he asserts.
Alongside educational initiatives, collaboration with key institutions forms another pillar of General Xenakis's strategy.
Regarding collaboration with the VA and Department of Defense General Xenakis sees potential in piloting and studying new treatment options. "We aim to collaborate with the VA as a pilot platform for studying and validating effective treatments. It's about ensuring that our veterans receive the care they need," he concludes.
Despite these efforts, General Xenakis is aware of the significant challenges that lie ahead in mainstreaming psychedelic medicine.
Discussing the integration of psychedelic medicine into mainstream healthcare, General Xenakis acknowledges significant challenges. "The shift from a disease-based model to a more holistic approach is difficult. We also face challenges in how treatments are reimbursed and recognized," he remarks, emphasizing the necessity of combining medication with therapy and building interdisciplinary teams for effective treatment.
An integral part of overcoming these challenges is learning from past experiences, especially concerning the use of psychedelics.
He touches upon the historical misuse of psychedelics, emphasizing the need to distinguish between medical and recreational use. "The blurring of lines between these uses in the past led to the shutdown of psychedelic research. We must learn from these mistakes and proceed with a clear ethical framework," General Xenakis asserts.
Addressing specific alternative therapies, General Xenakis shares his insights on Ibogaine and MDMA.
General Xenakis discusses the potential and challenges of Ibogaine therapy, especially for veterans seeking treatment abroad. "Ibogaine treatment is complex and requires careful patient selection. The use of tools like large language models and QEEG may aid in identifying suitable candidates," he explains, highlighting the need for thorough support and caution due to the medical issues associated with this treatment.
He notes the potential of MDMA-assisted therapy in enhancing prolonged exposure therapy, a frontline approach for PTSD. "Combining MDMA with therapy might overcome some of the challenges patients face with traditional prolonged exposure therapy, particularly adherence issues due to heightened symptoms," he suggests.
Beyond these specific therapies, General Xenakis advocates for a diverse and integrative approach to treating PTSD.
General Xenakis advocates for exploring a range of therapies for PTSD, including processing therapy and EMDR. "What's most important in therapy is the therapeutic alliance, trust, rapport, and working towards the patient's goals," he states.
Emphasizing the social determinants of health, General Xenakis underscores the necessity of involving families in PTSD treatment. "In my clinical practice, I've found it's essential to include the family in the treatment process. Good practitioners understand the importance of this holistic approach," he concludes.
General Xenakis also addresses the broader mental health crisis, including opioid deaths and suicides. "We are facing a mental health crisis, with staggering numbers of opioid-related deaths and suicides. It's a call to action for us to care for those in need and ensure they receive the right treatments and support," he asserts.
General Xenakis concludes with a call to action, emphasizing the importance of tackling difficult challenges in mental health care. "We have the opportunity to make significant improvements in mental health care, but it requires hard work and a commitment to doing things right, without getting caught up in hype or drama.”
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