On April 18, 2026, President Trump issued an executive order to “accelerate medical treatments for serious mental illness.” It addresses fastracking four issues:
- Psilocybin for treatment-resistant depression
- Psilocybin for major depressive disorder
- Methylone for post-traumatic stress disorder (PTSD)
- The further study of ibogaine compounds for substance misuse disorders and PTSD, particularly for Veterans
Psilocybin is the psychoactive chemical in mushrooms. Methylone is an altered form of MDMA (ecstasy). Ibogaine is from the bark of a shrub in West Africa that has been discussed on internet message boards for decades and recently on a number of podcasts, including Joe Rogan.
I have some serious concerns, which I will detail forthwith, about this executive order. The speed of this is my biggest concern, as it is pushing policy before there is enough evidence.
To be clear, I am not anti-psychedelic nor anti-research. I do believe in a very high standard of evidence before giving drugs to the American people, particularly vulnerable populations.
I am willing to change my position if:
- there is a large N (over 1000 per study)
- there are multi-site studies
- there are strong controls over the administration of the drugs, including as much blinding as possible
- there are long-term studies on side effects, with a six-month minimum but preferably 12 months as the standard
- there is full adverse-event reporting
If all the above conditions are met and the research shows that the drugs are effective in treating any or all of those disorders, I’ll change my position.
As anyone even passingly familiar with my work knows, I served in the US Army from 1996 to 2004 and again from 2014-2024. I have worked in addiction treatment since 2004 and I’ve run a free Veterans group since 2020 where PTSD is the dominant issue. So, this is an issue near and dear to my heart and work.
Proper Clinical Drug Trials
Blinded outcome assessors are needed. That means that the evaluators don’t know which treatment a patient received. This prevents biased scoring.
The trials need to control for patient expectation, as what the patient believes strongly influences outcome (this is simply known as the placebo effect). Psychedelics have strong expectancy effects, so the trials must try to equalize those expectations across groups. This is a challenge, as participants often know if they have received psychedelic drugs.
These types of trials usually include prep sessions, guided psychedelic dosing and therapy. Because of the prep sessions and therapy, it is difficult to isolate the drug effect.
I would caution people to remember that an intense experience is not treatment and a short-term improvement is not recovery. We need to know what happens at six months, one year and beyond that.
There is a massive gap between clinical trials and real-world use that I feel obligated to remind people of. Clinical trials screen their patients and exclude high-risk groups. They have extremely controlled environments and highly trained providers. In the real-world, many of the patients who will seek this treatment have very complex cases often with a number of comorbidities. There is a major variability of providers out there (as someone who has taught, trained and observed thousands of therapists, I know this as well as anyone). There is also less monitoring outside of clinical trials, so I would remind all that safety is probably going to be worse in the real-world.
I have grave concerns about the vulnerable populations that are more likely to have adverse reactions to these treatments. They include:
- People with a history of substance misuse or serious addiction risk in their families.
- People who have psychosis or have had it in the past
- People on the Bipolar spectrum
- People with Complex PTSD (multiple traumas)
- People with a history of suicidality
The major takeaway is that those identified as having the highest need for these treatments also pose the highest risk.
The Problem of Anecdotes
When he issued the executive order, President Trump was surrounded by people who shared their positive experiences with these substances. On Joe Rogan and other podcasts, Veterans and civilians alike have talked about how these drugs have helped them.
I am happy for them. I am glad that it worked and that they have found some peace.
I have anecdotes too. I have worked with over 100 patients after they were exposed to some sort of psychedelic therapy, some fairly recently after their treatment and others much later. Many reported a variety of negative outcomes (it’s like seeing a different doctor after a botched procedure). I don’t offer these anecdotes up as evidence, but rather as a signal. There are positive stories out there, just as there are negative ones. These are not evidence. I’ve taught my students at Rutgers for just about two decades that anecdotes are not evidence. Medical policy should not come down to who is the most persuasive story-teller or who has the biggest podcast audience.
Veterans
Once again, we are hearing from elected officials about how these drugs need to be fast tracked to help Veterans. This is a classic public policy move, as it increases support and reduces scrutiny.
Twelve years ago, there was a major push to give Veterans marijuana for their PTSD. It was framed as an urgent issue with a lot of emotional testimony. I fought this issue in New Jersey and said on panel after panel and in a variety of newspaper interviews that I rejoined the Army to deal with this very issue and if that I thought it would be helpful, I would support it. I lost that debate as marijuana was approved for PTSD treatment in 2016 and eventually was legalized for recreational use in 2021.
While some Veterans have claimed that it has been helpful, I’ve met hundreds who only experience PTSD symptom relief by being under the influence of marijuana nearly all the time.
Now, here we are again hearing about the urgency of this matter and how Veterans need these drugs to fix their PTSD. I ask, more for the historical record than my readers, what will be pushed in the 2030s to treat this population if these psychedelic drugs don’t deliver what their advocates are promising?
Insurance
I am curious whether or not insurance companies will pay for psychedelic treatment. If not, this will become a treatment for those who can afford to self pay. The prep sessions, the guided doses and the therapy are all time-intensive. This is likely to become concierge medicine, available mostly to those who can pay for it. This flies in the face of the executive order, which was framed as being for Veterans.
More significantly though, one needs to examine malpractice/liability coverage from insurance companies for treating patients with psychedelics. As of 2026, depending upon the state, a professional can buy specialized insurance for engaging in that kind of treatment, but it is far more expensive than regular medical liability insurance. Because the insurance companies currently view this as treatment that is uncertain and risky.
Much like how insurance companies are not issuing new policies in housing markets that have higher rates of fires (California, Colorado) or storms (Florida), they are either charging higher premiums, issuing exclusions or just refusing to cover providers of psychedelic therapy. Insurance companies are currently pricing psychedelic therapy as high-risk.
Another thought: if malpractice insurance is not offered or is prohibitively expensive, then there will probably be a number of providers who are willing to engage in the treatment without adequate coverage. And this is not who we want providing treatment.
These are systems-level issues that deserve more public attention than they are currently receiving.
International Context
Part of my training in public policy requires me to look at what other states and countries are doing.
In Australia, MDMA is allowed for PTSD and psilocybin is permitted for treatment-resistant depression. Their use is on a small scale and only in a tightly controlled psychiatrist-only model.
In the United Kingdom, psychedelics are only allowed in research settings. Ketamine is legal for treatment but it is off-label use.
In Germany, there is limited clinical approval for psychedelic therapy. There is some limited research-only access right now. It is strictly regulated.
In Japan, psychedelics are highly restricted. There is no way to get them in a clinical setting and the research is very limited.
Most countries are extremely cautious right now. Post-executive order, the US will be moving faster than other comparable countries right now. Australia is the exception, but the use is small in scale and limited to psychiatrists only.
Final Thoughts
All that written, I leave the reader with a few questions to consider:
- Do they work?
- if it is reported that they do, please examine the studies
- For whom is it safe?
- consider the above-mentioned vulnerable populations
- Can the American medical system deliver it responsibly?
- trained providers, standardized protocols, insurance participation, liability coverage
Currently, the answers are incomplete, at best, on all three questions. As of now, I believe this executive order moves faster than the evidence base justifies.
Disclosure: A large language model was used for copy editing, clarity review and hostile-review/risk assessment in accordance with my AI Use & Writing Standards. All arguments, interpretations and conclusions are my own.