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

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
• Discussion
www.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 Amazon
www.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) roots
www.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 Department
www.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. 2005
www.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 TM
www.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 Commission
www.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
experience
www.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 religions
www.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. 2005
www.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
– Other
www.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 view
www.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. 2008
www.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 necessary
www.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 incidents
www.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 disorder
www.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 temples
www.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 symptoms
www.udv.org.br 26

27. Results:
Psychosis & UDV membership
18 (62%) quit/never joined the UDV
UDV members: 11
n=29, 1994-2007
www.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, 1994-2007
www.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, 1994-2007
www.udv.org.br 29

30. Results:
Psychosis & Causality
no causal relationship: 10
Relapse/recurrence: 5
n=29, 1994-2007
www.udv.org.br 30

31. Results:
Psychosis & Causality
predisposing factor: 10 cases
onset: 4 no indeterminate case
14 “new” cases
n=29, 1994-2007
www.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 1971
www.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 improved
www.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 important
www.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 accountability
www.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 hoasca
www.udv.org.br 37

38. Thank you for your attention
tofoli@ufc.br