Manuscript Draft. Keywords: MDMA, PTSD, serotonin, psychotherapy, oxytocin, randomized trial, psychedelic

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1 Psychiatry Elsevier Editorial System(tm) for The Lancet Manuscript Draft Manuscript Number: THELANCETPSYCH-D R2 Title: MDMA-assisted Psychotherapy for Posttraumatic Stress Disorder in Military Veterans, Firefighters and Police Officers, a Randomized Clinical Trial Article Type: Article (Clinical Trials) Keywords: MDMA, PTSD, serotonin, psychotherapy, oxytocin, randomized trial, psychedelic Corresponding Author: Dr. Allison Anne Feduccia, Ph.D. Corresponding Author's Institution: MAPS Public Benefit Corporation First Author: Michael C Mithoefer, MD Order of Authors: Michael C Mithoefer, MD; Ann T Mithoefer, BSN; Allison Anne Feduccia, Ph.D.; Lisa Jerome, PhD; Mark Wagner, PhD; Joy Wymer, PhD; Julie Holland, MD; Scott Hamilton, PhD; Berra Yazar-Klosinski, PhD; Amy Emerson, BA; Rick Doblin, PhD Manuscript Region of Origin: USA Abstract: Background: PTSD is prevalent in military personnel and first responders, many of whom do not respond to currently available treatments. This study examined the efficacy and safety of MDMA-assisted psychotherapy for treating chronic PTSD in this population. Methods: Veterans, police officers, and fire fighters with moderate to severe PTSD were randomized to receive 30 mg (n=7), 75 mg (n=7), or 125 mg (n=12) MDMA in two blinded eight-hour sessions with concomitant manualized psychotherapy. The primary outcome was change in CAPS-IV Total scores from baseline to one month after the second experimental session. Participants in the 30 and 75 mg groups subsequently underwent three 125 mg MDMA-assisted sessions in an open label crossover, and all were assessed 12 months after the last MDMA session. Outcomes: At the primary endpoint, the 75 mg and 125 mg groups had significantly greater decreases in PTSD symptom severity [CAPS-IV mean (SD) change (9 78) and (28 7), P = 001] than the 30 mg group [-11 4 (12 7)]. Compared to the 30 mg group, Cohen's d effect sizes were large, 2 8 [75 mg, 95% CI (0 8, 4 8)] and 1 1 [125 mg, 95% CI (0 1, 2 1)]. Interpretation: Active doses of MDMA with adjunctive psychotherapy in a controlled setting were well tolerated and effective in reducing PTSD symptoms in veterans and first responders. Funding: Multidisciplinary Association for Psychedelic Studies (MAPS) Trial Registration: clinicaltrials.gov Identifier: NCT

2 Figure A. B. 112 Preliminary telephone screening Informed consent and screening SCID, CAPS, neuropsychological measures, physical exam, blood tests, EKG 70 Excluded for not meeting eligibility criteria Three 90 min preparatory sessions with co-therapy team 42 In-person assessment 2 Randomized, intent-to-treat 14 Excluded for not meeting eligibility criteria Stage 1 (Double-blind) Two 8-hour MDMA or comparator experimental sessions, approximately 1 month apart Overnight stay with attendant 90 min integration session morning after Daily phone contact during following week Two non-drug integration sessions after each experimental session, approximately weekly Primary Endpoint (1-month post 2nd experimental session) 7 Assigned to receive 30 mg MDMA + psychotherapy 7 Assigned to receive 75 mg MDMA + psychotherapy 12 Assigned to receive 125 mg MDMA + psychotherapy Blind Broken 125 mg Group 30 mg and 75 mg Groups 1 Treatment Discontinuation 1 Adverse events 1 Treatment Discontinuation 1 Efficacy attained One openlabel (125 mg) session with 3 integration sessions Preparatory session Two open-label ( mg) sessions with 3 integration sessions 7 Completed primary assessment Completed 3 open-label sessions, Secondary and End of Stage 2 assessment 7 Completed primary assessment Completed 3 open-label sessions, Secondary and End of Stage 2 assessment 12 Completed primary assessment 12 Completed 1 open-label session and End of Stage 1 assessment End of Stage Endpoint (2-months post 3rd MDMA session) Secondary Endpoint (1-month post 2nd experimental session) One open label experimental session with 3 integrative sessions Stage 2 Crossover (Open-label) Completed 12-month follow-up 7 Completed 12-month follow-up 11 Completed 12-month follow-up 12-month Follow-up

3 Figure CAPS-IV Mean (+/- SD) Total Severity Scores mg, n=7 75 mg, n=7 125 mg, n=12 open-label, n=12 0 Baseline Primary Endpoint End of Stage 1 Secondary Endpoint End of Stage 2 12-month Follow-up 0 30 mg 75 mg 125 mg BDI- II Mean (+/- SD) Total Scores open-label, n=12 0 Baseline Primary Endpoint End of Stage 1 Secondary Endpoint End of Stage 2 12-month Follow-up mg 75 mg 125 mg PSQI Mean (+/- SD) Total Scores open-label, n=12 5 Baseline Primary Endpoint End of Stage 1 Secondary Endpoint End of Stage 2 12-month Follow-up

4 Manuscript Manuscript word count: 4,755 Abstract word count: 239 Number of References: 37 Number of Tables: 4 Number of Figures: 2 Lancet Psychiatry Title: MDMA-assisted Psychotherapy for Posttraumatic Stress Disorder in Military Veterans, Firefighters and Police Officers, a Randomized Clinical Trial Authors: Michael C. Mithoefer M.D. Clinical Assistant Professor Medical University of South Carolina Private Practice Office of Michael C. Mithoefer 208 Scott St #A Mount Pleasant, SC 2944 Ann T. Mithoefer, B.S.N Sub-Investigator Private Practice Office of Michael C. Mithoefer 208 Scott St #A Mount Pleasant, SC 2944 Allison A. Feduccia Ph.D. Clinical Data Scientist MAPS Public Benefit Corporation 1

5 Manuscript word count: 4,755 Abstract word count: 239 Number of References: 37 Number of Tables: 4 Number of Figures: Mission St Santa Cruz, CA 9500 Lisa Jerome Ph.D. Clinical Research and Information Specialist MAPS Public Benefit Corporation 1115 Mission St Santa Cruz, CA 9500 Mark Wagner, Ph.D. Professor of Neurology Medical University of South Carolina 9 Jonathan Lucus St. Room 307 CSB Charleston, South Carolina Joy Wymer, Ph.D. Assistant Professor of Neurology Medical University of South Carolina Neuropsychologist Tidewater Neuropsychology 913B Bowman Rd 2

6 Manuscript word count: 4,755 Abstract word count: 239 Number of References: 37 Number of Tables: 4 Number of Figures: 2 Mount Pleasant, SC 2944 Julie Holland, M.D. Psychiatrist Private Practice Office 200 E 33 rd St #2A New York, NY 1001 Scott Hamilton, Ph.D. Associate Professor Stanford School of Medicine Stanford Stroke Center 780 Welch Road, Suite 350 Palo Alto, CA Berra Yazar-Klosinski, Ph.D. Associate Director of Clinical Research Multidisciplinary Association for Psychedelic Studies 1115 Mission St Santa Cruz, CA

7 Manuscript word count: 4,755 Abstract word count: 239 Number of References: 37 Number of Tables: 4 Number of Figures: 2 Amy Emerson, B.A. Executive Director and Director of Clinical Research MAPS Public Benefit Corp Mission St Santa Cruz, CA 9500 Rick Doblin, Ph.D. Executive Director Multidisciplinary Association for Psychedelic Studies 1115 Mission St Santa Cruz, CA 9500 Corresponding Author: Allison Feduccia, Ph.D. Clinical Data Scientist MAPS Public Benefit Corporation 1115 Mission St Santa Cruz, CA 9500 Office: x110 alli@mapsbcorp.com Author Contributions: 4

8 Manuscript word count: 4,755 Abstract word count: 239 Number of References: 37 Number of Tables: 4 Number of Figures: 2 Dr. Scott Hamilton is responsible for integrity of the data and accuracy of data analyses. Study concept and design: M. Mithoefer, A. Mithoefer, L. Jerome, A. Emerson, B. Yazar- Klosinski, R. Doblin Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: M. Mithoefer, A. Feduccia, L. Jerome Critical revision of the manuscript for important intellectual content: All authors. Obtained funding: R. Doblin Study supervision: M. Mithoefer, A. Mithoefer 5

9 Abstract Background: PTSD is prevalent in military personnel and first responders, many of whom do not respond to currently available treatments. This study examined the efficacy and safety of MDMA-assisted psychotherapy for treating chronic PTSD in this population. Methods: Veterans, police officers, and fire fighters with moderate to severe PTSD were randomized to receive 30 mg (n=7), 75 mg (n=7), or 125 mg (n=12) MDMA in two blinded eight-hour sessions with concomitant manualized psychotherapy. The primary outcome was change in CAPS-IV Total scores from baseline to one month after the second experimental session. Participants in the 30 and 75 mg groups subsequently underwent three 125 mg MDMAassisted sessions in an open label crossover, and all were assessed 12 months after the last MDMA session. Outcomes: At the primary endpoint, the 75 mg and 125 mg groups had significantly greater decreases in PTSD symptom severity [CAPS-IV mean (SD) change (9 78) and (28 7), P = 0 001] than the 30 mg group [-11 4 (12 7)]. Compared to the 30 mg group, Cohen s d effect sizes were large, 2 8 [75 mg, 95% CI (1 19, 4 39)] and 1 1 [125 mg, 95% CI (0 04, 2 08)]. Interpretation: Active doses of MDMA with adjunctive psychotherapy in a controlled setting were well tolerated and effective in reducing PTSD symptoms in veterans and first responders. Funding: Multidisciplinary Association for Psychedelic Studies (MAPS) Trial Registration: clinicaltrials.gov Identifier: NCT

10 Research in Context Evidence before the study: The sponsoring non-profit organization, MAPS, was founded in 198, one year after MDMA was placed in the most restrictive drug schedule in the US. MDMA was first synthesized in 1912 as an intermediary compound, but subjective effects were first formally reported by Shulgin and Nichols in Shulgin, who had resynthesized it, introduced MDMA to a psychotherapist, who in turn introduced other therapists to its use in conjunction with psychotherapy. Prior to development of this study s protocol, we searched PubMed, the clinicaltrials.gov registry, and books containing extensive bibliographies of MDMA research for all articles and listings containing the terms MDMA or ecstasy, including nonclinical studies, clinical trials and case reports of varying quality published until December 17, In 2001, the first comprehensive review was presented in our MDMA Investigator s Brochure; 1044 MDMA-related papers were included. Early reports published in the mid-1980s described the use of MDMA as a psychotherapeutic adjunct, including use in psychotherapy for PTSD. These accounts, an early uncontrolled study, and an incomplete dose-response study that provided safety data led to the design and implementation of two randomized, doubleblind studies of MDMA-assisted psychotherapy in people with chronic PTSD, one using inactive placebo and the other comparing an active dose MDMA with a low dose. The studies followed a manualized form of psychotherapy similar but not identical to psychotherapy using classic psychedelics. The current study design was informed by confirmation that no other research of MDMA-assisted psychotherapy had been published, and by the design and preliminary results of two pilot studies that were ongoing at the time of development of this study. When completed, one pilot study reported a significant reduction in PTSD symptoms in MDMA versus inactive 7

11 placebo that lasted beyond 12 months after study completion. The second study with a smaller sample had a similar effect size as the first study, but failed to detect a significant difference in CAPS scores two months after treatment in the small sample (p=.0); however, it did show significant symptom reduction compared to baseline one year after treatment with active-dose MDMA. In developing these studies, the sponsor and investigators addressed the additional challenges involved in human trials with Schedule 1 substances, including obtaining licenses for storage and handling of the drug. Added Value of This Study: This is the first dose-response study of MDMA-assisted psychotherapy to compare three doses of MDMA, and the first to enroll only veterans, firefighters and police officers with PTSD. Implications of all the Available Evidence: This study is among the six Phase 2 trials that led to FDA designation of MDMA-assisted psychotherapy for PTSD as a Breakthrough Therapy. Together these Phase 2 studies support MAPS drug development program aimed at making MDMA-assisted psychotherapy a prescription treatment delivered in specialized clinics. Pending the results of multicenter Phase 3 clinical trials, this well tolerated and efficacious treatment may prove to be an important addition to the available treatments for PTSD, and may also have implications for future exploration of other pharmacologic agents that could act as adjuncts or catalysts to psychotherapy. Introduction 8

12 Posttraumatic stress disorder (PTSD) is a major public health problem, particularly among military veterans. Prevalence of PTSD in military personnel and veterans (17 1%) 1 and first responders (10-32%) 2 is much higher than the lifetime occurrence in the general population (8%). In addition to the severe burden of psychological suffering, chronic PTSD is associated with increased rates of medical morbidity, occupational and relationship problems, decreased quality of life 3, overall decreased life satisfaction and happiness, and increased risk of suicide 4. Treatment options for PTSD include pharmacotherapy and psychotherapies. The two FDAapproved medications for PTSD, sertraline and paroxetine, reduce symptom severity with limited effectiveness 5, especially in veterans. Off-label prescription of drugs, including antidepressants, antipsychotics, mood stabilizers, and benzodiazepines, is common, though risks and benefits for PTSD have not been established in randomized controlled trials. Trauma-focused psychotherapies (TFTs) are more effective than pharmacotherapy 7. A meta-analysis of trials for military-related PTSD found that both Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) had large effect sizes with 49-70% of participants attaining clinically meaningful symptom improvement; however, 0-72% of veterans receiving CPT or PE retained their PTSD diagnosis 9. High dropout rates (27-40%) occur with TFTs partially due to adverse outcomes, such as worsening symptoms, hospitalization, or disengagement from treatments 10,11. Relatively few randomized clinical trials of military-related PTSD have been conducted. Development of new treatments should address the common reasons for treatment avoidance, failure and dropout. One approach to developing more effective psychotherapy is to administer a drug during psychotherapy sessions intended to catalyze the psychotherapeutic process,8. 3,4- methylenedioxymethamphetamine (MDMA) has shown promise as a psychotherapeutic adjunct 9

13 12. Two published clinical trials of MDMA-assisted psychotherapy showed large effect sizes (1 24 and 1 05) with low dropout rates (8 7% and 14%) 13,14 and durable improvements (average 45 months in 74% of one cohort) 15. Most participants had crime-related PTSD, such as sexual abuse, assault and rape. To study applicability to service personnel, we conducted a randomized, dose-response trial investigating the safety and efficacy of MDMA-assisted psychotherapy in military veterans, firefighters and police officers with PTSD resulting from their service. Based on the promising results of this and other Phase 2 studies, FDA recently granted Breakthrough Therapy Designation for MDMA as an investigational new drug for the treatment for PTSD. Methods Study design This randomized, double-blind trial was conducted at an outpatient psychiatric clinic in Charleston, S.C. between December 2010 and August 201 (protocol). Data were collected during the active treatment period (baseline to two months after the final MDMA session) and through 12-month follow-up. The protocol was approved by Western-Copernicus Group IRB. Participants Recruitment occurred through referrals by mental health professionals (4 participants enrolled) and internet advertisements or word of mouth (22 participants enrolled). Candidates were veterans, firefighters or police officers with chronic PTSD resulting from traumatic experience during service. Participants were 18 years old, with PTSD duration months, and a Clinician Administered PTSD Scale (CAPS-IV) 1 Total score 50. Inclusion criteria required failure to respond to or inability to tolerate prior pharmacotherapy or psychotherapy. Participants were 10

14 required to taper and abstain from psychotropic medications during study participation except for sedative hypnotics or anxiolytics used as-needed between MDMA sessions. Candidates who gave written informed consent were evaluated by an independent rater for psychiatric screening using the CAPS-IV and SCID 17, and by a physician for assessment of nonpsychiatric medical criteria. Exclusion criteria included major medical conditions except controlled hypertension or adequately treated hypothyroidism. Permitted comorbid disorders were anxiety disorders, affective disorders except bipolar disorder type 1, substance abuse or dependence in remission for 0 days, and eating disorder without active purging. Randomization and masking After screening (Figure 1A), participants were randomized through a web-based randomization system that used unique container numbers instituted by randomization monitors who did not communicate with site staff, study monitors or data and statistical analysts. Approximately 24 hours prior to the first experimental session, participants were randomized in a 2:1:1 ratio to receive oral doses of MDMA 125 mg (n=12), 75 mg (n=7), or 30 mg (active control, n=7) on two occasions spaced 3-5 weeks apart (initial dose followed 1 5 to 2 hours later by an optional supplemental dose of half the initial dose). MDMA, produced by David Nichols at Purdue University, was compounded by a pharmacist into gelatin capsules with lactose to ensure all blinded capsules had similar appearance and weight. Investigators, independent outcome raters, and participants were blinded until after the primary endpoint. Methods 11

15 The first MDMA session was preceded by three 90-minute psychotherapy sessions to establish a therapeutic alliance and prepare participants for the MDMA experience. MDMA was administered at monthly intervals during eight-hour experimental sessions of manualized psychotherapy with a male/female co-therapy team. The relatively non-directive/client-directed psychotherapy used during MDMA-assisted sessions, and the approaches to preparation and follow-up sessions are described in the Treatment Manual 18 Experimental sessions were followed by an overnight stay onsite, seven days of telephone contact, and three 90-minute psychotherapy sessions aimed at integrating the experience. Overall, a course of treatment included 18 hours of non-drug psychotherapy and 1-24 hours (2-3 sessions) of MDMA-assisted psychotherapy. Outcome measures were administered by blinded independent raters at baseline and one month after the second experimental session (Primary Endpoint), just before the blind was broken. Subsequently, participants randomized to 125 mg had one open-label (125 mg) session (within 3-5 weeks of the previous blinded MDMA session) with associated integrative visits and a two-month follow-up with outcomes assessed (End of Stage 1). Participants randomized to 30 mg or 75 mg crossed over to have one 90-minute preparatory session (within 5 months of the primary endpoint), then three open-label sessions spaced a month apart with flexible dosing of MDMA ( mg) followed by the integrative visits and outcome assessments (Secondary, End of Stage 2) at corresponding intervals to the blinded segment. Participants in all three groups were assessed 12 months after the last full dose MDMA session. A choice between 100 mg and 125 mg (according to participant s preference and investigators judgment) was added in the open-label crossover as part of a protocol amendment (see supplemental material) in order to gain pilot data about this dose without affecting the blinded stage of the study. 12

16 Outcomes CAPS-IV is a semi-structured interview conducted by independent rater that identifies and assesses PTSD through diagnostic and symptom severity scores. Depression symptoms were measured by self-report with the Beck Depression Inventory-II (BDI-II) 19. Self-reported sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) 20. Perceived growth following trauma was assessed with the Post Traumatic Growth Inventory (PTGI) 21. Personality factors, including Neuroticism, Extroversion and Openness, were assessed via NEO Personality Inventory Revised (NEO-PI-R) 22. A subset of participants (n = 12) completed the Dissociative Experiences Scale II (DES-II), a self-report assessment of symptoms of dissociation 23. Independent raters scored general psychological function on the single-item Global Assessment of Functioning (GAF) 24. Safety was monitored through collection of adverse events, spontaneously reported expected reactions, vital signs, and suicidal ideation and behavior. Adverse events requiring medical intervention were collected until two months following the last experimental session. Events requiring changes in psychiatric medication were collected throughout the study. Expected reactions were collected during experimental sessions and seven days after. Blood pressure and heart rate were measured via automated sphygmomanometer (Welch Allyn, Skaneateles Falls, NY) every 15 minutes for the first 4 hours, then every 30 minutes until session end. Body temperature was measured at 0-90 minute intervals via tympanic thermometer (Braun, Kronberg, Germany). 13

17 The clinician-administered Columbia Suicide Severity Rating Scale (C-SSRS) 25, a structured interview addressing presence and intensity of suicidal ideation and behavior, was administered at all visits and twice during the seven days of telephone contact. Statistical analysis Efficacy analyses were performed on the intent-to-treat set, which included all randomized participants with at least one drug exposure. This trial was a pilot dose-response study; therefore, it was not powered to detect statistical significance. The study design and sample sizes were informed by two previous Phase 2 pilot studies The primary outcome was the change in CAPS-IV Total scores from baseline to one-month post second MDMA session, analyzed by an Analysis of Variance (ANOVA) at an alpha level of Preplanned t-tests were used to compare each MDMA group. Changes in secondary measure scores were analyzed in the same manner. Effect sizes were computed using Cohen s d independent-groups pretest-posttest design. Open-label crossover data were analyzed by within-subjects t-tests, comparing scores at primary to stage 2 secondary endpoint. Scores at 12-month follow-up were compared with baseline by within-subjects t-tests. Exploratory analyses of effects after two vs. three sessions were conducted with within-subjects t-tests. Peak vital signs from MDMA sessions were analyzed with ANOVA, then t-tests for pairwise comparisons. Analyses were done using SPSS 20 (IBM, Chicago IL). The trial was registered on clinicaltrials.gov (Identifier: NCT ). Role of the funding source 14

18 The Multidisciplinary Association for Psychedelic Studies (MAPS), a 501(c)(3) nonprofit organization, provided the MDMA and fully funded this study. MAPS Public Benefit Corporation (MPBC), a wholly owned subsidiary of MAPS, was the trial organizer. MAPS and MPBC assisted with study design; monitoring of study data; analysis, management and interpretation of data; preparation, review, and approval of manuscript; and decision to submit the manuscript for publication. The funder had no role in the collection of data or conduct of the study. The first author, who was also principal investigator, had full access to all the data in the study and had final responsibility for the decision to submit for publication. Results Table 1 shows the baseline characteristics of the veterans (n=22), firefighters (n=3), or police officers (n=1) who met eligibility criteria and were randomized. The first participant was screened on November 2010 and the last on January Participants had moderate to severe PTSD, mean (SD) baseline CAPS-IV Total score of 87 1 (1 13). Six participants had previously taken Ecstasy two to five times prior to study enrollment. Figure 1B depicts the flow of participants through the study. Twenty-four participants (92 3%) completed treatments through the 1-month follow-up; two (7 7%) completed the baseline assessment, one experimental session, and at least one follow-up assessment. Twelve participants assigned to 30 mg and 75 mg groups completed the crossover open-label sessions and assessments. Twenty-four participants completed the 12-month follow-up assessments. 15

19 The primary efficacy assessment was the change from baseline to one month post second blinded experimental session in the CAPS-IV Total scores (Table 2), with mean (SD) change for 30 mg (12 7), 75 mg (9 78), and 125 mg (28 7). The 75 mg (P = ) and 125 mg (P = 0 004) groups had significantly greater improvements in PTSD symptom severity compared to the 30 mg group [ANOVA, change in CAP-IV Total scores (F 2,25 = 8 99; P = 0 001)]; no significant differences were found between the 75 mg and 125 mg groups (P = 0 185). Compared to the 30 mg group, Cohen s d effect sizes were large, 2 8 [75 mg, 95% CI (1 19, 4 39)] and 1 1 [125 mg, 95% CI (0 04, 2 08)]. At the primary endpoint, a larger percentage of participants in the active dose groups did not meet PTSD diagnostic criteria on CAPS-IV (75 mg, 85 7%; 125 mg, 58 3%) compared to comparator group (30 mg, 28 %). In addition, more participants reached a clinically significant >30% decrease in CAPS-IV total scores (30 mg, 28 %; 75 mg, 100 0%; 125 mg, 7%) after two active doses of MDMA. A sensitivity analysis adjusting for baseline scores produced similar results. One month after the second blinded session (Table 2), depression symptoms for the 125 mg group were significantly reduced (P = ) compared to the 30 mg group, while comparison of the 75 mg vs. 30 mg dose groups approached significance (P = 0 052), with the 75 mg group presenting a larger average drop from baseline [ANOVA, change in BDI-II scores (F 2,25 = 9 13; P = 0 001)]. For PSQI, the 75 mg group showed the greatest improvement in sleep quality followed by the 125 mg and 30 mg groups [ANOVA, change in PSQI scores (F 2,19 = 4 39; P = 0 029)]. T-tests indicated superiority of 75 mg (P = 0 014) and 125 mg (P = 0 022) over 30 mg. Posttraumatic growth followed a similar trajectory [ANOVA, change in PTGI scores (F 2,25 = 15 48; P < )], with active dose groups reporting significant growth over 30 mg (P < )]. Global psychological function improved [ANOVA, change in GAF scores (F 2,25 = 1

20 7 02; P = 0 004)], with significantly higher functioning in the 75 mg (P = 0 004) and 125 mg (P = 0 002) groups compared to 30 mg. Similarly, the active dose groups (75 mg vs. 30 mg, P = 0 024; 125 mg vs. 30 mg, P = 0 011) had significant improvement in dissociative symptoms [ANOVA, change in DES-II scores (F 2,9 = 5 59; P = 0 02)]. For the NEO-PI-R, only changes in Openness produced significant differences between groups [ANOVA, change in NEO-PI-R personality scores (F 2,21 = 4 50; P = 0 025)], with the 75 mg group (P = 0 015) showing qualities of being more open than the 30 mg group. One month after completing two open-label ( mg) sessions in the crossover (etable 3), the group that received 30 mg during blinded sessions showed reductions in symptom severity, mean (SD) change from the primary endpoint were CAPS-IV (17 5) and 33 3% of participants did not meet PTSD Diagnostic Criteria. Within-subject t-tests comparing scores at primary and secondary endpoints showed significant improvements in CAPS-IV Total scores [t(5)=3 79, P = 0 013] and 7% attained a >30% decrease in CAPS-IV Total scores (results of secondary outcome measures in supplemental information). The 75 mg group did not have further significant drops in CAPS-IV scores after two open-label sessions, but the percentage of participants not meeting PTSD criteria increased to 100%. Although scores continued to trend towards further improvement, within-subject comparison of two vs. three sessions did not yield significant differences for any measures or groups (etable 4). At the 12-month follow-up [mean (SD) CAPS-IV Total Scores, 38 8 (28 1)], PTSD symptoms were significantly reduced compared to baseline 87 1 (1 1) with groups combined since all had received three active dose of MDMA [within-subjects t-test, CAPS-IV Total scores [t(23) = , P < ]. Of the 24 participants who completed this visit, 1 ( 7 %) did not meet 17

21 PTSD criteria (Table 3). Two participants that did not meet PTSD criteria at treatment exit (after 3 active dose MDMA sessions) met PTSD diagnostic criteria at 12-month follow-up. On the other hand, three participants who met criteria at exit did not meet criteria at the 12-month assessment. Scores on all secondary measures showed improvement compared to baseline (Table 3). Depression symptom severity as measured on BDI-II was severe at baseline and changed to minimal by 12-month follow-up [BDI, t(23) = 48, P < ]. Similarly, sleep quality was vastly improved at the last endpoint [PSQI, t(17) = 4 5, P = ]. Finding for posttraumatic growth [PTGI, t(23) = -7 58, P < ] and global functioning [GAF, t(23) = -5 92, P < ] demonstrated marked gains, and severity of dissociative symptoms were reduced [DES, t(10) = 2 27, P = 0 04]. Compared to baseline, all NEO personality traits had significantly changed in the positive direction except Conscientiousness [Neuroticism t(23) = 4 85, P < ; Extroversion t(23) = -4 34, P = ; Openness t(23) = -2 4, P = 0 015; Agreeableness t(23) = -2 9, P = 0 007; Conscientiousness t(23) = -0 94, P = 0 3]. Two participants reported taking Ecstasy once during the 12 months following the active treatment phase. At study enrollment, both participants had used Ecstasy two times previously (-months to 2 years prior to enrollment). The treatment was well tolerated. Eighty-five adverse events were reported by 20 participants during the study (etable 7); four occurred prior to drug administration. Four were serious adverse events (SAEs), three deemed unrelated and one possibly related to drug. SAEs deemed unrelated included suicidal ideation in response to life events, major depression (same participant) and appendicitis. One participant who had exhibited a premature ventricular contraction (PVC) at baseline developed an acute increase in PVCs during the third open-label session, detected on-site through routine heart rate readings. He underwent an overnight hospital 18

22 stay for observation and cardiac evaluation, and recovered fully without evidence of vascular or structural cardiac disease. Participants reporting at least one treatment-emergent adverse event (TEAE) were similar across groups (30 mg /7, 75 mg /7, 125 mg 8/12). The most frequently reported TEAEs were psychiatric symptoms (Table 4). The most frequently reported expected adverse reactions during experimental sessions included anxiety, headache, fatigue, and muscle tension. Adverse reactions during seven contact days included anxiety, fatigue, and insomnia (Table 4). Most were mild to moderate in severity, with occurrence decreasing across the seven days. Self-limited elevations in pulse, blood pressure and temperature were observed during MDMA sessions (etable ) and did not require medical intervention. ANOVA of peak vital signs during blinded sessions showed a significant dose effect for systolic blood pressure (SBP; F 2,53 = 18 2; P < ), diastolic blood pressure (DSP; F 2,53 = 4; P = 0 003), heart rate (HR; F 2,53 = 12 ; P < ), but not temperature (P = 0 095). The 125 mg group was significantly higher compared to 30 mg for SBP (P < ), DBP (P = ), and HR (P < ); 75 mg group was significantly higher than 30 mg for SBP (P = 0 007) and HR (P = 0 018). At all post-treatment endpoints, the percentage of participants reporting suicidal ideation and behavior was reduced compared to baseline life-time and pre-treatment reports (Table 1 & etable 5). During the treatment period, transient increases in ideation were observed in the 30 mg, 125 mg, and open-label groups. One participant, who had a history of suicide attempts before enrollment, was hospitalized for six days by her psychiatrist because of suicidal thoughts 13 days after her second 30 mg session. She subsequently completed the study. There were no treatment emergent reports of positive suicidal behavior. 19

23 Discussion MDMA-assisted psychotherapy with 75 mg or 125 mg resulted in marked improvement of PTSD symptoms in veterans and first responders with chronic PTSD who had failed prior treatment. This study extends previous findings of highly significant results combining MDMA with the same manualized psychotherapy for treating crime-related PTSD, 13 and supports the durability of symptomatic improvement seen in a previous report 15. Participants in the comparator group (30 mg) receiving the same psychotherapy had significantly less symptom remission, indicating that adequate doses of MDMA potentiate the effects of psychotherapy. An unexpected finding was that the 75 mg dose led to larger decreases in CAPS scores than the 125 mg dose. This difference may have been due to chance in this small sample size, or may be explained by one or more other possible explanations. The 125 mg group had higher average baseline depression scores than the other groups, and could have been harder to treat. Another possibility is that the 75 mg dose may have allowed for more focused processing of traumatic experiences than the 125 mg dose, and may be the optimal dose for at least some patients. Phase 3 trials will employ a flexible dose range ( mg MDMA), and will provide further information on variables that contribute to response rate. Results from measures of depression and sleep quality parallel findings from the CAPS-IV, providing further evidence of benefits of this treatment. Severity of depression symptoms (BDI- II) was significantly reduced for the 125 mg group compared to 30 mg. The 75 mg group trended in the same direction (p=0 052). Sleep quality and dissociative symptoms also significantly improved for both active dose groups. In addition, there were gains in psychological, occupational, and social functioning for participants treated with active doses of MDMA, and 20

24 like the improvements in PTSD symptoms, these gains continued to grow in the year following treatment. Increased scores on the PTGI indicate that perceptions of self, others, and life events were reframed during the therapeutic processing, demonstrating that treatment effects went beyond reductions in PTSD and mood symptoms to include psychological growth. Change in personality traits showed statistically significant reductions in Neuroticism in the125 mg group and increases in openness in the 75 mg group. While many personality theorists would argue that personality traits are relatively stable constructs throughout much of adulthood and are not subject to change, there is evidence that links certain personality features to traumatic experience 2. MacLean et al. 27 (2011) found an effect of psilocybin on changes in one of the five broad domains of personality (Openness) measured by the NEO PI-R, and speculated about the potential clinical application and therapeutic benefit of change in personality variables as a result of pharmacologically induced mystical experiences. We have previously found persistent personality changes in Openness and Neuroticism following MDMA treatment providing support for the notion that the effect of MDMA-assisted psychotherapy extends beyond effects on specific PTSD symptomatology 28, and fundamentally alters personality structure, resulting in persisting personality change. In the current study the fact that participants exhibited enduring changes in personality traits at 12-month follow-up that included a significant reduction in Neuroticism, an increase in Agreeableness and an increase in Openness further suggests that combining MDMA with psychotherapy can shift aspects of personality that were assumed to be stable across time. These pervasive therapeutic effects raise interesting questions for future research into other possible indications for MDMA-assisted psychotherapy, and about whether MDMA effects may be better understood as equipping people to effectively face a range of psychological challenges than as narrowly targeting specific diagnoses. 21

25 After participants in the 30 mg group crossed over to receive two open-label sessions ( mg), CAPS-IV scores showed an additional 27-point average decline, further demonstrating that the same psychotherapy alone was not nearly as effective without a sufficient dose of MDMA. After the third open-label session, the average drop in CAPS scores (-27 points) and % no longer meeting criteria for PTSD (50%) in this group was less than the other groups, however the proportion with a > 30% drop in CAPS was identical to the 125 mg group (%). The fact that the total decline in CAPS was less for the 30 mg group could mean this group was more difficult to treat, however it is also of note that low dose MDMA appears to have a counter-therapeutic effect as reported by Oehen et al. 14, and as reflected in the fact that a prior study using inactive placebo with the same psychotherapy showed a much greater drop in CAPS than the 30 mg showed in the current study (- 33 vs 11.4) 13. Other factors may also have influenced response in the control groups across these studies with small samples. The study was not designed to determine whether response is greater after two versus three sessions but results suggest that a high degree of improvement can be reached after two sessions. Future studies should evaluate the degree of added long-term benefit that may occur from three versus two sessions. The longterm follow-up results showing significant CAPS reductions 12 months after the last MDMAassisted treatment make it unlikely that the more immediate results were not simply due to placebo effect or lingering expectancy effects of having received MDMA. MDMA was well-tolerated, with a low treatment discontinuation rate (7 7%) that did not correlate with dose. Vital signs transiently increased in a dose-dependent manner during experimental sessions, and returned to approximate baseline levels at the session end. Incidence of expected reactions and adverse events differed little across groups, although known acute effects of MDMA, such as jaw clenching and perspiration, did occur at higher frequency with 22

26 active doses. Most events were mild to moderate, with many of the psychiatric symptoms likely attributable to PTSD. Suicidal ideation was similar across groups. No suicidal behavior occurred during treatment, demonstrating that MDMA-assisted psychotherapy did not potentiate the risk of suicide and, in fact, reduced suicidal ideation and behavior compared to baseline and lifetime occurrence. When MDMA is administered in a controlled clinical setting, the liability for subsequent abuse or compulsive seeking of Ecstasy is presumed low, as demonstrated in the current trial. Participants naïve to Ecstasy prior to study participation did not report taking Ecstasy after receiving MDMA in the trial. Two participants reported taking Ecstasy once during the 12-month follow-up period, but both had taken the drug before study enrollment. Overall safety data support a favorable risk-benefit ratio for limited doses of MDMA in a PTSD population This model of treatment is unlike most pharmacological interventions in that its effectiveness appears to be mediated through pharmacological effects augmenting meaningful psychotherapeutic experiences. MDMA may attenuate response to anxiety-provoking thoughts or feelings during recall of trauma memories by reducing activity in the amygdala 29,30 and insular cortex 31, and simultaneously improving top-down modulation of thoughts and emotions by increasing activity in the pre-frontal cortex 30. In mice, MDMA increases fear extinction learning through a mechanism dependent on increased BDNF signaling in the amygdala 32,33. Increased functional connectivity between the amygdala and hippocampus during MDMA administration 29 suggests that reconsolidation of traumatic memories may occur, rendering them less activating during ordinary states. Conversely, veterans with symptomatic PTSD have shown decreased resting state functional connectivity between the amygdala and hippocampus 34. MDMA 23

27 modulates emotional memory circuits dysfunctional in PTSD 35, and engages neural networks illustrated to be important for other trauma processing therapies 3. By bolstering prosocial and empathetic feelings, e.g. self-compassion and increased authenticity with self 37, MDMA can improve therapeutic alliance and engagement with difficult psychological material. Since this study was not designed to explore mechanisms of action, the importance of these pharmacological effects and neural correlates remains speculative, but is consistent with investigators observations during research sessions. Possible mechanisms should also take into account the interactions between drug effects and participants psychological experiences. The manualized approach to psychotherapy employed 18 includes elements that contribute to the safety and efficacy of MDMA as an adjunct to psychotherapy: careful medical and psychological screening, preparing participants for the MDMA experience and the treatment, a largely non-directive approach that includes periods of inner focus alternating with periods of interaction with male/female co-therapists, and close follow-up to support integration of the MDMA experience. Prior reports comparing MDMA to inactive placebo 13, and the current study using low-dose MDMA as a comparator, demonstrate that this model of psychotherapy without an active dose of MDMA does lead to improvement in CAPS-IV Total scores, but the combined effect of the psychotherapy in conjunction with active doses of MDMA is significantly larger. This study has limitations regarding design and small sample size. The sample was gender balanced, but the majority of participants were Caucasian. Maintaining the study blind was only partially accomplished by using low dose MDMA instead of inactive placebo. The co-therapists guessed dose assignment incorrectly for 40 7% - 42 %, and participants guessed incorrectly for 24

28 53 7% of blinded sessions, suggesting some success in blinding, though most incorrect guesses were between active doses, not between an active dose and low dose, so we cannot rule out some bias from this limitation. There appears to be a threshold effect beyond which MDMA catalyzes an effective therapeutic process, and participants and therapists can distinguish the active drug effects from sub-threshold effects of low-dose MDMA or inactive placebo. To prevent observer expectancy effects and minimize bias, an observer blind was employed by having blinded independent outcome raters who were not present during therapy sessions. Widely accepted evidence for the effectiveness of trauma-based psychotherapy for PTSD exists, yet it is impossible to effectively blind psychotherapy trials 7. Similar limitations to blinding exist for MDMA and other drugs with prominent psychoactive effects. A limitation of the 12-month follow-up results is that after the primary endpoint, the low and medium dose groups crossed over to receive full dose MDMA so there is no control group for comparison at 12 months. In addition, twelve participants were taking psychiatric medications, although none specifically for an indication of PTSD, at the long-term follow-up visit. The investigation presented here provides further evidence that MDMA-assisted psychotherapy can be used safely and effectively for chronic PTSD. This novel approach to pharmacotherapy offers a means to dramatically accelerate the therapeutic process with a short-acting psychoactive compound administered only a few times at monthly intervals in conjunction with a course of psychotherapy designed to maximize the safety and efficacy of drug administration. Promising Phase 2 efficacy and safety results have now been demonstrated in six studies. If findings are validated in MAPS Phase 3 clinical trials, set to commence in 2018, MDMA-assisted psychotherapy could become a viable, FDA-approved treatment option for PTSD by

29 Acknowledgments In gratitude, we thank Sarah Sadler, AA for coordinating the study; Sarah Braswell, LPC for serving as the night attendant; Flynn for serving as therapy dog; Rebecca Matthews, BA and Ben Shechet, BA for monitoring data; Colin Hennigan, MA for creating and supporting the clinical database, and serving as Randomization Monitor; Allison Wilens, BS for supporting video data collection; Joe Brown, MS and Lance Alster, BA for performing analyses in SAS; Adherence rater group for rating manualized therapy; Evan Sola, Ph.D. for serving as the Adherence Manager; Joshua Sonstroem, BA for serving as Randomization Monitor; and Asia Seltzer, MA for building the randomization system. This study was sponsored by the Multidisciplinary Association for Psychedelic Studies (MAPS), a 501(c)(3) nonprofit organization. MAPS provided the MDMA and fully funded this study from private donations. MAPS Public Benefit Corporation (MPBC), wholly owned by MAPS, was the trial organizer. Declaration of Interests Michael Mithoefer received research funds from MAPS Public Benefit Corporation as a clinical investigator and clinical trial medical monitor as well as for training and supervision of research psychotherapists. Anne Mithoefer received research funds from MAPS Public Benefit Corporation as a clinical investigator and for training and supervision of research psychotherapists. Allison Feduccia received salary support for full time employment with MAPS Public Benefit Corporation. 2

30 Lisa Jerome received salary support for full time employment with MAPS Public Benefit Corporation. Mark Wagner received research funds to conduct study assessments. Joy Wymer received research funds to conduct study assessments. Julie Holland, M.D. has nothing to disclose. Scott Hamilton received research funds from MAPS Public Benefit Corporation for his role as a biostatistician. Berra Yazar-Klosinski received salary support for full time employment with MAPS. Amy Emerson received salary support for full time employment with MAPS Public Benefit Corporation. Rick Doblin received salary support for full time employment with MAPS. Author Contributions Dr. Scott Hamilton is responsible for integrity of the data and accuracy of data analyses. Study concept and design: M. Mithoefer, A. Mithoefer, L. Jerome, A. Emerson, B. Yazar- Klosinski, R. Doblin Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: M. Mithoefer, A. Feduccia, L. Jerome Critical revision of the manuscript for important intellectual content: All authors. Obtained funding: R. Doblin Study supervision: M. Mithoefer, A. Mithoefer 27

31 Figure 1. (A) Study Design & (B) Trial Profile a Participant completed one experimental session and primary endpoint assessment b Participant discontinued treatment after one experimental session due to treatment efficacy (felt further MDMA sessions were unnecessary), completed all assessments through 12-month follow-up. Figure 2. Scores over time on CAPS-IV a, BDI-II b, and PSQI c from Baseline to Endpoints (Intentto-treat set). Assessments for graphs selected based on representation of PTSD severity and most common associated symptoms, i.e. depression and sleep disturbance. a CAPS-IV=Clinician Administered PTSD Scale. Error bars represent standard deviations. b BDI-II=Beck Depression Inventory-II. Error bars represent standard deviations. c PSQI=Pittsburgh Sleep Quality Index. Error bars represent standard deviations. 28

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