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Mental health safety of ayahuasca religious use: Results from an epidemiological surveillance system by the Uniao do Vegetal in Brazil
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Mental health safety of ayahuasca religious use: Results from an epidemiological surveillance system by the Uniao do Vegetal in Brazil

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Presented at the 2010 MAPS Conference Psychedelic Science in the 21st Century. The video from the conference is available at the following link: ...

Presented at the 2010 MAPS Conference Psychedelic Science in the 21st Century. The video from the conference is available at the following link:
http://www.maps.org/videos/source3/video7.html

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  • 1. Mental Health Safety of Ayahuasca Religious Use:Results from an Epidemiological Surveillance System by the União do Vegetal in Brazil Luís Fernando Tófoli, MD, PhD
  • 2. Agenda • Introduction – União do Vegetal (UDV) – UDV & Biomedical Research – Demec – Religion, Mental Health and Ayahuasca – Mental Health Commission • Aims • Methods • Results • Discussionwww.udv.org.br 2
  • 3. Centro Espírita Beneficente União do Vegetal (UDV) • Christian, syncretic, reincarnationist religion • Founded in the 1960s by José Gabriel da Costa (Mestre Gabriel) in Rondônia, Brazil • Confluence of: – Religiosity of migrant rubber-tappers from Northeastern Brazil – Ayahuasca traditions of mestizo vegetalistas from the Western Amazonwww.udv.org.br 3
  • 4. Centro Espírita Beneficente União do Vegetal (UDV) • Headquarters in Brasília, DF • ≈ 15,000 members – Brazil, USA, Spain, UK and Portugal – Annual growth ≈ 9% (1990-2007) – Urban development – Diversity of socioeconomic and educational level CEBUDV 1999; 2008 – Respect for caboclo (mestizo) rootswww.udv.org.br 4
  • 5. Ayahuasca use in the UDV • Named as Hoasca or Vegetal • Prepared with B. caapi and Psychotria sp. only • Firm control of the plants and their usage • Commercialization not allowed by any means • During this presentation: hoasca = “ayahuasca within UDV”www.udv.org.br 5
  • 6. UDV and Biomedical Research • 1985 – Brazilian government adds Banisteriopsis caapi to list of controlled substances – UDV halts hoasca distribution, pleads for reconsideration • 1986 – Government allows ayahuasca use by religions as provisional decision (final decision in 2010) – UDV creates Medical-Scientific Departmentwww.udv.org.br 6
  • 7. UDV and Biomedical Research • The Hoasca Project (1993) – Pharmacokinetics – Tolerability – Effects on physical and mental health Callaway et al. 1994; Grob et al. 1996; Callaway et al. 1999; Callaway, 2005 • UDV Adolescents Project (2002) – Neuropsychological assessment – Attitudes – Substance use patterns Doering-Silveira et al. 2005a, 2005b; Silveiraet al. 2005; Dobkinde Rios et al. 2005www.udv.org.br 7
  • 8. Demec: Medical-Scientific Department TM TM TM • Structure: TM – National coordination TM Regional TM TM TM TM Monitor – 15 Regional monitorships Regional Regional Monitor – Temple monitorships Monitor TM TM TM National Coordinator TM TM TM Regional Regional Monitor Monitor TM TM TM TM TM TMwww.udv.org.br 8
  • 9. Demec: Medical-Scientific Department • Hierarchical Structure: – National coordination National Coordinator – 15 Regional monitorships – Temple monitorships – Collaborators Mental – Two Commissions: Health Clinical • Mental Health Commission • Clinical Commissionwww.udv.org.br 9
  • 10. Demec: Medical-Scientific Department • Aims – Converse with civil and health authorities – Provide scientific information about hoasca to the Academic Community – Understand potential interaction between hoasca use and health conditions • Prevention of medicalizing the ayahuasca experiencewww.udv.org.br 10
  • 11. Mental Disorder and Religion • Religion: source of support for individuals in vulnerable situations, including those at risk of psychotic outbreak. • People search religions for help and comfort when in mental distress Koenig et al. 2001 • This might have an effect on ayahuasca religionswww.udv.org.br 11
  • 12. Hoasca and Mental Health: Positive Effects • Ayahuasca: – Potential antidepressant effect in animal models Lima et al. 2006; 2007 – Relief of anxiety symptoms Santos et al., 2007 – Neophytes: Positive subjective evaluation, reduction of minor psychiatric symptoms, increased feelings of assertiveness, serenity and vivacity Barbosa et al. 2005www.udv.org.br 12
  • 13. Hoasca and Mental Health: Positive Effects • Ayahuasca: – Lower levels of deleterious use of substances Doering-Silveira et al. 2005a; Grob et al. 1996; Santos et al. 2006 – UDV: Positive association with adult mental health Grobet al. 1996; de Rios et al. 2005 – UDV: Optimistic and altruist teenage attitudes de Rios et al. 2005 – Otherwww.udv.org.br 13
  • 14. Hoasca and Therapeutics • Hoasca/UDV: – for religious use only – not for therapeutic purposes per se • Spiritual curative powers within UDV rituals: acknowledged and evoked • Positive health effects may occur during sessions in UDV’s viewwww.udv.org.br 14
  • 15. Psychedelics and Psychoses • Strong evidence of a causal link between cannabis and psychoses Arseneault et al. 2004; McLaren et al. 2010 • Psychosis recurrence or onset in association with of 5-HT2A agonists — a non-clear relationship Hermle et al. 2008; Johnson et al. 2008 • Set and setting very important for mental health risks and symptom evolution Johnson et al. 2008www.udv.org.br 15
  • 16. Hoasca and Mental Health: Recommendations • UDV — four-decade awareness of the interaction between hoasca and mental distress: – Persons with “weak” or “unbalanced memory” to be: •tended with attention •given smaller doses when necessarywww.udv.org.br 16
  • 17. Hoasca and Mental Health: Recommendations • UDV — four-decade awareness of the interaction between hoasca and mental distress: – Excessive solicitation for increase of hoasca ingestion to be followed with care and denied whenever mental distress is noticeable. – One must not offer hoasca to individuals with severe mental disorder.www.udv.org.br 17
  • 18. Mental Health Commission • Demec’s Mental Health Commission answers to: – Concerns about the mental health status of UDV members or neophytes – Questions regarding psychopharmacological agents • 1994 – Psychiatric Monitoring System of Hoasca Users: an internal epidemiological surveillance system for mental health incidentswww.udv.org.br 18
  • 19. Study Aims • Assess the number and diagnoses of new cases with psychotic features elicited by the UDV surveillance system. • Appraise the incidence of psychosis in the UDV during the monitored period. • Estimate the approximate number of hoasca doses needed to trigger a psychotic episode.www.udv.org.br 19
  • 20. Pilot Study • All reports of severe mental health crises that could be traced by UDV psychiatrists between 1991 and 1995 (South/Southeastern Brazil) • Twenty cases were identified and analyzed. • Seven presented features that allowed a diagnosis of a psychotic disorderwww.udv.org.br 20
  • 21. Case Classification • Categories based on the described cases 1. Onset 2. Predisposing factor 3. Relapse/Recurrence 4. No relationship 5. Indeterminate • Diagnoses based on the 10th edition of the International Classification of Diseases (ICD-10)www.udv.org.br 21
  • 22. Case Notification • Mental Health Guidelines: orientation for Demec monitors and temple directorates • Object: severe mental health occurrences and/or pharmacological treatment for psychosis • Use of a standardized form • Call for help from Demec monitors, collaborators and those in charge of templeswww.udv.org.br 22
  • 23. Case Notification • Universe: every non-retrospective case reported by the Surveillance System • Study period: 1994-2007 • Analysis: cases with psychotic features (operational definition of psychosis)www.udv.org.br 23
  • 24. Incidence calculation “new” (onset/predisposing) cases reported by the surveillance system disease onsets incidence rate time spent in population persons Sum of the annual UDV population/estimation from each year (1994-2007)www.udv.org.br 24
  • 25. Psychosis/Dosis Ratio affiliates during study 12 doses/member/year period (underestimation) (underestimation) averagehoasca servings number of member–years member–years cases of psychosis Bergman 1971 all cases with psychotic features (overestimation)www.udv.org.br 25
  • 26. General Results • 51 notifications from Brazil and Spain • 29 cases (57% among the 51) with features of operational psychosis • Remaining 43% — miscellanea of mental health disorders and symptomswww.udv.org.br 26
  • 27. Results: Psychosis & UDV membership 18 (62%) quit/never joined the UDV UDV members: 11 n=29, 1994-2007www.udv.org.br 27
  • 28. Results: ICD-10 Diagnoses of Psychosis Schizophrenia (F20): 9 cases Acute and transient psychotic disorders (F23): 4 Unspecified nonorganic psychosis (F29): 2 n=29, 1994-2007www.udv.org.br 28
  • 29. Results: ICD-10 Diagnoses of Psychosis Substance-related psychotic disorder (F10.5-F19.5): 6 Bipolar affective disorder, mania, psychotic(F31.2) : 4 Depressive episode with psychotic symptoms (F32.3): 4 n=29, 1994-2007www.udv.org.br 29
  • 30. Results: Psychosis & Causality no causal relationship: 10 Relapse/recurrence: 5 n=29, 1994-2007www.udv.org.br 30
  • 31. Results: Psychosis & Causality predisposing factor: 10 cases onset: 4 no indeterminate case 14 “new” cases n=29, 1994-2007www.udv.org.br 31
  • 32. Results: Incidence of Psychosis • Incidence rate estimation of psychoses in Brazil: 15.8 (95% CI 14.3-17.6) / 100.000 persons-years Menezes et al. 2007 • Extrapolation for UDV population: 18 to 23 new cases were expected 14 were notified (onset/predisposing)www.udv.org.br 32
  • 33. Results: Doses and Psychoses • Ayahuasca servings during the studied period: ≈ 130,000 person-years × 12 doses/person-year ≈ 1.56 million doses • Number of ayahuasca servings needed to trigger a psychotic event (considering all 29 cases): ≈ 53.793 doses (Native American Church: ≈ 1/70.000) Bergman 1971www.udv.org.br 33
  • 34. Discussion: Limitations • Conflict of interest • Undernotification of cases • Tendencies, not absolute numbers • Careful clinical analysis is needed • Surveillance system must be improvedwww.udv.org.br 34
  • 35. Discussion: Implications • Ayahuasca religious experience is fairly safe with: – minimal set of principles – surveillance initiative – institutional commitment • Indirectly, clinical knowledge is being accumulated • Ongoing awareness of temple leaders / local directorates is importantwww.udv.org.br 35
  • 36. Discussion: How the UDV deals with that? • Mestre Gabriel: not all persons are able to undergone the ayahuasca experience • Hoasca: – Sacrament, not panacea – Unveiler of truth • A culture of care: – interest for the health of its members – token of institutional accountabilitywww.udv.org.br 36
  • 37. Discussion: Future Challenges • Improve awareness and coverage of the surveillance system • The need for academic partners outside the UDV • Further analysis of clinical data • Ayahuasca for clinical psychiatrists: a review • SSRIs and hoascawww.udv.org.br 37
  • 38. Thank you for your attention tofoli@ufc.br