Russia's invasion of Ukraine has killed tens of thousands of Ukrainian soldiers and civilians, and injured hundreds of thousands more. But the war has also taken a less visible toll, with millions suffering from acute PTSD. Now a study co-authored at UC Berkeley proposes that use of the psychedelic MDMA, under close clinical supervision, could bring relief to millions of patients - with fewer therapists, lower costs and better results than conventional care.
In the new study published in World Medical and Health Policy, a U.S.-Ukrainian research team led by Berkeley health economist Elliot Marseille concluded that the controlled therapeutic use of MDMA along with group therapy could save tens of thousands of lives, while allowing a vast population of survivors to be healthier and more productive. That could save Ukrainian society billions of dollars in long-term health care costs and lost productivity, the team concluded.
"Ukraine is facing enormous levels of PTSD," Marseille said in an interview. "From a public health perspective and from an economic perspective, MDMA-assisted therapy can be a viable option. It makes sense in addressing the public health crisis, and makes economic sense."
Co-author Oleh Orlov, a co-founder of Heal Ukraine Trauma, said the magnitude of post-traumatic stress disorder (PTSD) in his country is almost inconceivable. "Even I, living here, catch myself doubting the scale," he said. "But that doubt isn't because the numbers are wrong. It's because we've become so used to living this way. People who return from abroad often notice it more clearly - how much Ukrainians suppress or normalize what they're going through. The full psychological toll is likely far larger than any of us realize."
Orlov is a co-founder of the Ukrainian Psychedelic Research Association, and is the deputy director for research and experimentation at the Yarmachenko Institute of Special Education and Psychology in Ukraine's National Academy of Educational Sciences. Marseille is the director of Berkeley's Collaborative for the Economics of Psychedelics. A third co-author, Ukrainian medical researcher Olga Chernoloz, is on the faculty of the University of Ottawa in Canada, and has written extensively about psychedelic therapies.
Marseille emphasized that many legal, political and cultural challenges remain to be addressed, and that years might pass before Ukraine is prepared for large-scale medical use of MDMA. But as described in the research, it could be the most innovative and ambitious targeted, therapeutic use of MDMA ever attempted.
An urgent need for innovative therapy
The novel intervention is justified, the co-authors argue, by the level of suffering in a population that has been ravaged by Russia's invasion, continual bombardment and war crimes. Ukraine's population before the Russian invasion was about 44 million, a little larger than California's. Today, nearly 3½ years after the first attack, some 6.4 million Ukrainians are suffering severe, chronic post-traumatic stress, the authors estimate.
People with PTSD are subject to a range of impacts, from insomnia and anxiety to depression, substance abuse and suicide.
You're able to confront the traumatic event, whatever it is, and allow it to be. … [Y]ou can reframe your relationship to it.
Elliot Marseille
Orlov said Ukrainians exposed to violence and atrocities have "described horrific experiences - things so extreme that I realized no standard trauma-focused therapy could help without additional support. Even as a trained therapist, I struggled to believe conventional methods would suffice."
Conventional therapies are only partially effective, the authors explained. They cited studies showing that nearly half of PTSD patients fail to show significant improvement. Meanwhile, an advanced clinical trial with patients in the U.S., Canada and Israel showed that after MDMA treatment, 67% of patients no longer met PTSD criteria; among patients given intensive psychotherapy plus a placebo, just 32% showed such improvement.
Already, the unaddressed need for psychological therapy has Ukrainians considering new approaches. News accounts have described soldiers' use of ketamine, a powerful dissociative anesthetic with hallucinogenic effects, for pain and trauma management. Its medical use is legal under Ukrainian law.
In recent months, the government has moved to facilitate research and patient access to other psychedelic-assisted therapies, particularly MDMA. This spring, the Multidisciplinary Association for Psychedelic Studies worked with the Ukrainian Psychedelic Research Association to train nearly 60 Ukrainian therapists in MDMA therapy protocols.
Reframing the relationship to trauma
The healing power of MDMA appears to lie in how it changes the brain. According to Marseille, the effects of the drug are complex. In simple terms, the drug acts to quiet the amygdala, an almond-sized structure that is a center for processing emotion, including fear and anxiety. This allows for what psychologists call "fear extinction" and supports emotional connectedness and enhanced introspection.
"So you're in this relaxed, open, accepting state of mind," he explained. "In the therapeutic context, you're able to confront the traumatic event, whatever it is, and allow it to be. Standing there, you can reframe your relationship to it."
If we don't adopt more effective solutions now, we risk losing precious time, lives and the chance to rebuild our society in a healthy, resilient way.
Oleh Orlov
Because trained Ukrainian therapists are in short supply, the researchers say, the country's medical and social systems would have to pioneer another innovation: Combining MDMA treatment with group therapy. When MDMA is used therapeutically in the U.S., Marseille said, there are typically two clinicians for every patient while the MDMA is administered, and also in the non-drug sessions before and after..
In Ukraine, he said, medical personnel would have to determine the best mix of individual and group therapy to make more efficient use of limited staff. Even in the United States and in other high income countries there is a move to experiment with group psychedelic therapy.
The economics of MDMA therapy are appealing, too. The new research concludes that by improving health, the MDMA therapy would cut health care expenses and improve productivity.
Treating just 1,000 patients would cost $1.1 million, but prevent some 20 deaths and yield 717 "quality-adjusted life-years," a health-economics term for human years of good health.
If Ukraine were able to treat half of all PTSD patients over the span of a decade, the new report concludes, the care could save 48,000 lives, while generating over 1.5 million quality-adjusted life years and $5.6 billion in societal savings.
"Ukraine has been so bold…so courageous and so innovative," Marseille said. "They have earned the admiration of any fair-minded person who looks at how they have responded to the attack from Russia. Really, it's not for me here in the U.S. to urge the Ukrainians to do anything, but nevertheless, I would urge that Ukraine's medical and public health establishment be just as bold and courageous in accelerating the adoption of this promising new public mental health intervention."
"We can't spend years trying treatments that don't work," added Orlov. "MDMA-assisted therapy offers real hope, especially for those who haven't responded to existing treatments. If we don't adopt more effective solutions now, we risk losing precious time, lives and the chance to rebuild our society in a healthy, resilient way."
Read the full study, "The Potential Economic and Public Health Impact of MDMA-Assisted Group Therapy for PTSD in Ukraine"
