Effect of psilocybin versus escitalopram on depression symptom severity in patients with moderate-to-severe major depressive disorder: observational 6-month follow-up of a phase 2, double-blind, randomised, controlled trial

Abstract

Background: Psilocybin therapy (PT) produces rapid and persistent antidepressant effects in major depressive disorder (MDD). However, the long-term effects of PT have never been compared with gold-standard treatments for MDD such as pharmacotherapy or psychotherapy alone or in combination.

Methods: This is a 6-month follow-up study of a phase 2, double-blind, randomised, controlled trial involving patients with moderate-to-severe MDD. Participants were recruited from a hospital in the UK. Male or female patients with major depressive disorder (DSM-IV), moderate to severe depression (HAM-D ≥17), no MRI or SSRI contraindications, confirmed diagnosis by a GP or mental healthcare professional, aged 18-80, and competent in English were eligible. Patients were randomly assigned (1:1) to receive either two 25 mg doses of the psychedelic drug psilocybin administered orally combined with psychological support ('psilocybin therapy' or PT) and book-ended by further support or a 6-week course of the selective serotonin reuptake inhibitor (SSRI) escitalopram (administered daily at 10 mg for three weeks and 20 mg for the subsequent three weeks) plus matched psychological support ('escitalopram treatment' or ET). The primary outcome measure was change from baseline in the score on the 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR-16) at week 6, which has been reported previously. Herein, we present results at the 6-month follow-up time point. Measures of social functioning, connectedness, and meaning in life constituted the study's secondary outcomes during follow-up. Safety in the follow-up period was not assessed. This trial is registered at ClinicalTrials.gov, NCT03429075.

Findings: Between January 15th, 2019 and March 20th, 2020, 59 patients were enrolled and 30 (11 females [37%] and 19 males [63%]) were assigned to the psilocybin group and 29 (9 females [31%] and 20 males [69%]) to the escitalopram group. 25 participants in the PT group and 21 in the ET group completed the 6-month follow-up. At the 6-month follow-up, both PT and ET conditions yielded sustained improvements in depressive symptom severity. The mean between-condition difference in QIDS-SR-16 scores at 6-months was 1.51 (95% CI: -1.35, 4.38; p = 0.311). Secondary outcomes demonstrated that PT had greater mean between-condition differences in functioning (WSAS: -7.46; 95% CI: -12.4, -2.47; p < 0.001), psychological connectedness (WCS: 11.02; 95% CI: 1.25, 20.83; p = 0.033), and meaning in life (MLQ: 4.86; 95% CI: 0.67, 9.05; p = 0.021) compared to ET.

Interpretation: Six-week intensive treatments with either psilocybin or escitalopram (with psychological support) for MDD were associated with long-term improvements in depressive symptom severity. The greater degree of improvement in the PT arm at follow-up on psychosocial functioning, meaning in life, and psychological connectedness suggests warrant future research. However, these results are descriptive and should be interpreted with caution. Key limitations of the study include its suboptimal power to detect small but meaningful differences between treatments, missing data, the potential use of additional interventions during the follow-up period, and reliance on self-reported treatment assessments. These factors may affect the interpretation of the study findings and should be considered when evaluating the results.

Funding: The Alexander Mosley Charitable Trust and by the founding partners of Imperial College London's Centre for Psychedelic Research.

Keywords: Depression; Follow-up; Psilocybin; SSRIs.

Fig. 1

Trial profile and follow-up profile with missing data at each follow-up timepoint.

Fig. 2

Changes in depressive symptomatology during the follow-up period (A) Mean change from baseline in the score on the 16-item Quick Inventory of Depressive Symptomatology–Self-Report (QIDS-SR-16; on which scores range from 0 to 27, with higher scores indicating greater depression). No significant between-condition differences between Psilocybin Therapy and Escitalopram Treatment were found, except for 1-month (10 weeks) follow-up, both groups appeared to present sustained improvements. I bars indicate standard errors and dots individual change scores in the two arms. (B) QIDS-SR-16 remitters (QIDS-SR-16 scores ≤5) over the follow-up period. (C) QIDS-SR-16 responders (≥50% QIDS-SR-16 reduction). FDR-corrected p values, ∗ indicates a superiority of PT over ET, ‘p < 0.05, ∗p < 0.01, ∗∗p < 0.005.

Fig. 3

Changes in work and social impairment and meaning in life during the follow-up period (A) Mean change from baseline in the scores of work and social impairment (WSAS), with lower scores indicating lower impairment. (B) Mean change from baseline in the scores of meaning in life (MLQ), with higher scores indicating higher meaning in life. (FDR-corrected p values, ∗ indicates a superiority of PT over ET, ‘p < 0.05, ∗p < 0.01, ∗∗p < 0.005. I bars indicate standard errors and dots individual change scores in the two arms.

Fig. 4

Changes in connectedness and flourishing during the follow-up period (A) Mean change from baseline in the scores of connectedness (WCS), with higher scores indicating higher connectedness. (B) Mean change from baseline in the scores of flourishing (FS), with higher scores indicating higher flourishing. FDR-corrected p values, ∗ indicates a superiority of PT over ET, ‘p < 0.05, ∗p < 0.01, ∗∗p < 0.005. I bars indicate standard errors and dots individual change scores in the two arms.