Since the 1950s there have been moments where there is a frisson of professional excitement that new treatments might prove to bring breakthroughs in clinical effectiveness, perceived greater civil liberties and comparatively more positive ratings by those who are treated with them. Use of psychedelics as part of treatment for a range of psychiatric conditions is currently generating significant research and clinical interest.
Unfortunately, all people are not always conceptualised as equal in this interest – and early-stage research into the potential role of psychedelics in mental health has significant gaps in ethnoracial data.
In this paper, Hughes and Garcia-Romeu (2024) present their systematic review of research papers, with attention placed on the inclusion of ethnoracial data.
This paper is unique in offering frameworks to understand the origins and the impacts of ethnoracial differences, on both the scientific validity of clinical trials, and on answering the real world question of whether access to the benefits of psychedelic-assisted treatments could be equitably expanded to ethnic minorities,.
Are all men created equal in psychedelics research – or does representation in clinical trials emulate the imbalance of social trials faced by minority ethnic communities?
Methods
This systematic review screened 787 studies and 39 were included at final review, spanning research into psychedelic therapies for mental illness and substance use disorders, for a little over 30 years from January 1994 to May 2024.
The authors took care to highlight that the effect of ‘race’ on inclusion is not only mediated directly by individuals’ ethnicity, but compounded by ‘racialisation’ of certain individual or collective ethnic identities in different national contexts. In that regard, they conducted separate analyses for USA-only studies, and all cohort studies.
The authors identified that all participant ethnicity information was self-reported, but they utilised USA-standardised racial identifiers for assessing inclusion in pooled data: such as “Latinx/Hispanic”, “non-Hispanic White”, “Black”, “Asian”, “Indigenous”, “mixed race”, and “other”.
A prior review of the inclusion of ethnoracial data in psychedelics studies (Michaels et al. 2018) allowed for a comparison of inclusion rates before December 2017 and those after, up to 24th May 2024.
The researchers used a PRISMA-approved five-point ranking to screen included studies for quality, and also used a Mann-Whitney test to compare inter-rater reliability for quality rankings where appropriate, between 2018 and 2024.
Results
Among included studies, the total number of participants was 1,393:
- 1,074 of these were participants from studies based in the USA.
- 1,183 (85%) across pooled data were White, whereas other ethnic groups were less represented, and only 1.9% were Indigenous.
Across the US trials’ pooled data of 1,074 participants:
- 5% (908) were non-Hispanic White; while only 3.4% (36) were Black, and 7.4% (80) Latinx/Hispanic, with other groups in even smaller numbers;
- This stands in disproportion to 2020 Census population ratios, around the times of the trials: Non-Hispanic White people accounted for 57.8% of the USA population, with 12.1% being Black and 18.7% being Latinx/Hispanic.
The pooled results indicate the headline finding, that reporting of ethnoracial data in studies into the potential uses of psychedelics in treatment protocols for a range of psychiatric conditions is less diverse, and in particular the non-Hispanic White ethnic group are overrepresented in clinical trials, relative to the ethnoracial diversity in the general population.
Although the majority of studies were based in the USA (n=25), the UK and Switzerland also had multiple trials represented (n=4 each), and Brazil, Mexico, New Zealand, Spain, Canada and Netherlands also had a study represented each.
Of the studies in the USA, the authors observed that in studies after 2018 compared to before, greater proportions of non-White participants were found in more recent studies. However, though they observed that, “active attempts to diversify psychedelics research” are likely a contributor to this, “[w]hile notable, observed changes in diversity were small in absolute terms.”
Of interest, as this paper focused on ‘clinical trials’, the included studies did not have any qualitative, reflexive, community-based or autoethnographic research, particularly among minority ethnic and indigenous communities, but included 14 RCTs, 8 open-label studies, and 1 placebo-controlled, fixed-order study.
The most common psychedelics investigated were psilocybin (n=20) and MDMA (n=10), which is broadly inkeeping with global interest in therapeutic use of these substances. However, while other psychedelics such as ayahuasca, LSD, ibogaine and DMT derivatives, traditionally associated with indigenous community and rituals of spirituality, were investigated, they were not investigated from naturalistic or ritualistic perspectives, only from the viewpoint of inclusion in non-qualitative allopathic drug trials.
Across studies in the USA and globally, there was an overrepresentation of the non-Hispanic White ethnic group in psychedelic clinical trials – turning their backs on the ethnoracial diversity in the general population served by the research.
Conclusions
Hughes and Garcia-Romeu’s landmark work paints a glaring picture of weakness in ethnoracial diversity in psychedelics research, and the utility of this study is strengthened by the authors’ explicit acknowledgment of the socio-historic reasons why inclusion of indigenous and other racialised people may be challenging.
The problems that arise out of this research are three-fold:
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Research methods tend to reproduce existing power relations and reflect the therapeutic priorities of privileged communities, while excluding racialised people and rendering their needs invisible in knowledge and practice.
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Research practices can repeat a historical pattern, where psychedelics which rose to awareness through indigenous naturalistic and/or ritualistic psychedelic use, such as ayahuasca or ibogaine, have their community or cultural purpose under-investigated and stripped of meaning, before research into the drug is ‘formalised’ by assessing it only through a quantitative therapeutic drug trial lens.
- Not only can this kind of research remove important ethnoracial cultural context in the use and access to psychedelics in the first place, the overall ethnocracial homogeneity in studies relative to the diverse real-world population, limits generalisation of clinical findings from psychedelics trials to support non-White patients.
Indigenous knowledge can be erased, appropriated and stripped of meaning, to reproduce the priorities of power structures of white dominant narratives and needs in research.
Strengths and limitations
This paper has a number of strengths.
The singular focus of this study on ethnoracial disparities, compared to more recent broadly structured systematic reviews on “participant diversity” across various demographics in psychedelics research (Haft et al, 2025), allow this study to deeply explore the modern research challenges, which align with the historical and political context of colonisation and criminalisation of non-White perspectives (Koram 2019) in context of naturalistic psychedelic use.
For instance, a strong contextualised discussion of research in this study, is when the authors identify that people of colour may report reduction in racial trauma following psychedelic experiences (Williams et al., 2021), and recently studies (Carter et al., 2023) demonstrate there is a greater willingness to engage with psychedelic-assisted therapy for Black rather than White Americans. Unfortunately this stands in stark contrast with the fact their ability to access benefits from therapy relative to White individuals is reported to be hampered (Jones & Nock, 2022), which may be mediated by the very fact that they are systemically disadvantaged from accessing, and criminalised for possessing such substances (Rosenberg et al., 2017).
The analysis of both pooled and subset data for the USA and other geographies, and in particular the attention to racialised categories in context of their cultures, provides some assurance that the systematic review was rigorous – and its findings on a lack of ethnoracial diversity in ‘formalised’ psychiatric research are reliable and somewhat generalisable transnationally.
While the paper does primarily examine drugs like classical psychedelics, MDMA and ibogaine “given the interventional interest in those compounds”, and similarly restricts its study focus to trial design research rather than qualitative capturing of non-White experiences, this is a limitation they themselves identify and discuss. It is acknowledged that there is a risk that the attention to psychedelics as allopathic treatments alone further entrenches a biological paradigm within psychiatry, and one that risks being ignorant of the naturalistic, cultural or spiritual utility of psychedelics, particularly to minoritised communities.
Unique needs of racialised groups could be subsumed into the dominant research narrative of treating psychedelics like any other allopathic chemical drug compound, stripped of its cultural and sociopolitical context for non-White ethnoracial groups.
Implications for practice
The most important finding from this study to translate into practice, is asking how to resolve the paradox: Why, although non-White persons may be more open to engaging with psychedelic-assisted interventions, are they less likely to be able to access interventions in research and practice, to see equal benefits?
The title of the book ‘Racism without racists’ (Bonilla-Silva 2021), could offer a novel perspective on this phenomenon – where formalised research into psychedelics that does not involve the communities who first used or identified the substances in their communities, over time creates a vicious cycle of under-representation and exclusion, without any active or express ‘intent’ to write them out of their own stories.
Even if performed impartially, researchers in clinical trials are only operating to exclude ethnoracial diversity within supposed limitations of time, resource and relationships – the overall impact is the same, that convenience reproduces the over-representation of White populations, participants and priorities in psychedelics research, disproportionate to their representation in the general population.
Paying attention to racialised differences in future clinical trials is essential to avoid the weakness addressed through the systematic review. Recruitment of research participants for clinical trials is often through a partnership between researchers and clinical staff, but co-production is also important through minority ethnic and indigenous communities, to enable them to be better represented on clinical trials that may affect how they use psychedelics in the modern day.
There may also be a role for clinical trial researchers developing their methodology while considering more qualitative, reflexive or autoethnographical research from minority ethnic and indigenous researchers which has preceded their work; to enhance the ‘clinical effect’ of a psychedelic as an allopathic drug, with its role in reducing minority trauma and its cultural purpose in diverse populations.
Whether out of intent or inaction, clinical trial researchers should be careful not to ‘sanitise’ psychedelics through the sterile lens of White participants and priorities, at the cost of their utility to ethnoracially and culturally diverse populations.
Statement of interests
None.
Links
Primary paper
Hughes, M.E. and Garcia-Romeu, A., 2024. Ethnoracial inclusion in clinical trials of psychedelics: a systematic review. EClinicalMedicine, 74.
Other references
Bonilla-Silva, E. (2021).Racism without racists: Color-blind racism and the persistence of racial inequality in America. Rowman & Littlefield.
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Carter, S., Packard, G., Coghlan, C. ∙ et al. Perceptions of psychedelic-assisted therapy among Black Americans J Mood Anxiety Disord. 2023; 4, 100023
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Rosenberg, A., Groves, A. K. & Blankenship, K. M. Comparing black and white drug offenders: Implications for racial disparities in criminal justice and reentry policy and programming. J. Drug Issues 47, 132–142 (2017).
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Williams, M.T., Davis, A.K., Xin, Y. ∙ et al.People of color in North America report improvements in racial trauma and mental health symptoms following psychedelic experiences. Drug (Abingdon Engl). 2021; 28:215-226