Journal of Psychoactive Drugs

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Psilocybin’s Potential Mechanisms in the

Treatment of Depression: A Systematic Review

Harrison J Lee, Vivian WL Tsang, Brandon S Chai, Michelle CQ Lin, Andrew

Howard, Christopher Uy & Julius O Elefante

To cite this article: Harrison J Lee, Vivian WL Tsang, Brandon S Chai, Michelle CQ Lin, Andrew
Howard, Christopher Uy & Julius O Elefante (2023): Psilocybin’s Potential Mechanisms in
the Treatment of Depression: A Systematic Review, Journal of Psychoactive Drugs, DOI:
10.1080/02791072.2023.2223195

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JOURNAL OF PSYCHOACTIVE DRUGS
https://doi.org/10.1080/02791072.2023.2223195

Psilocybin’s Potential Mechanisms in the Treatment of Depression: A Systematic

Review
Harrison J Lee M.D. a, Vivian WL Tsang M.D., M.C.G., etc.a, Brandon S Chaib, Michelle CQ Linb,
Andrew Howard M.D., F.R.C.P.C.a, Christopher Uy M.D., F.R.C.P.C.c, and Julius O Elefante M.D., F.R.C.P.C.a
a
Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; bFaculty of Medicine, University of
British Columbia, Vancouver, BC, Canada; cDepartment of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, BC,
Canada

ABSTRACT ARTICLE HISTORY

Evidence suggests that psilocybin has therapeutic benefit for treating depression. However, there Received 1 December 2022
is little consensus regarding the mechanism by which psilocybin elicits antidepressant effects. This Revised 05 March 2023
systematic review summarizes existing evidence. Ovid MEDLINE, EMBASE, psychINFO, and Web of Accepted 15 March 2023
Science were searched, for both human and animal studies, using a combination of MeSH Terms KEYWORDS
and free-text keywords in September 2021. No other mood disorders or psychiatric diagnoses were Psilocybin; Mechanism of
included. Original papers in English were included. The PRISMA framework was followed for the action; Treatment;
screening of papers. Two researchers screened the retrieved articles from the literature search, and Depression
a third researcher resolved any conflicts. Of 2,193 papers identified, 49 were selected for full-text
review. 14 articles were included in the qualitative synthesis. Six supported psilocybin’s mechanism
of antidepressant action via changes to serotonin or glutamate receptor activity and three papers
found an increase in synaptogenesis. Thirteen papers investigated changes in non-receptor or
pathway-specific brain activity. Five papers found changes in functional connectivity or neuro­
transmission, most commonly in the hippocampus or prefrontal cortex. Several neuroreceptors,
neurotransmitters, and brain areas are thought to be involved in psilocybin’s ability to mitigate
depressive symptoms. Psilocybin appears to alter cerebral blood flow to the amygdala and
prefrontal cortex, but the evidence on changes in functional connectivity and specific receptor
activity remains sparse. The lack of consensus between studies suggests that psilocybin’s mechan­
ism of action may involve a variety of pathways, demonstrating the need for more studies on
psilocybin’s mechanism of action as an antidepressant.

Introduction
Depression is a leading cause of world-wide disease
burden, as quantified by disability-adjusted life years
(DALYs) (Lépine and Briley 2011). This is due to its
high lifetime prevalence of up to 21%, in addition to its
potentially devastating impacts on quality of life
(Gutiérrez-Rojas et al. 2020). Compared to healthy con­
trols, those with depressive disorders are at risk of
a higher mortality rate, tend to be of lower socioeco­
nomic status, have poorer physical health outcomes,
and have higher prevalence of comorbid psychiatric
conditions such as generalized anxiety disorder
(Gutiérrez-Rojas et al. 2020; Walker, McGee, and
Druss 2015). The burden of depression strains health­
care systems because of its high impact on economic
productivity in all age groups (König, König, and
Konnopka 2019). Consequently, financial and health
impacts will increase as the prevalence of depression
rises globally (Moreno-Agostino et al. 2021).
The monoamine theory of depression hypothesizes
that reductions in the monoamines serotonin, norepi­
nephrine, and/or dopamine in specific areas of the
brain are associated with clinical depression and has
led to the development of many antidepressant med­
ications (Mulinari 2012). Antidepressants such as ser­
otonin selective reuptake inhibitors (SSRIs) are widely
recognized as first-line pharmacological treatment for
depression. Unfortunately, these and other first-line
agents for major depressive disorder require several
weeks to achieve therapeutic effect and often cause
unwanted side effects; up to 43% of patients discon­
tinue antidepressants due to adverse effects (Carvalho
et al. 2016). Although several clinical guidelines exist,
there is a lack of agreement over the appropriate

CONTACT Harrison J Lee hjefflee@gmail.com Department of Psychiatry, Faculty of Medicine, University of British Columbia, 2255 Wesbrook Mall V6T
2A1, Vancouver, BC, Canada
*First authorship is shared between these two individuals.
Supplemental data for this article can be accessed online at https://doi.org/10.1080/02791072.2023.2223195.
© 2023 Taylor & Francis Group, LLC
2 H. J. LEE ET AL.
treatment for those with treatment-resistant depres­
sion, defined as inadequate response to two or more
antidepressants (Gabriel et al. 2020; Kennedy et al.
2016; McIntyre et al. 2014; Taylor, Barnes, and
Young 2018). Furthermore, only 40–60% of patients
will respond to initial pharmacological treatment and
only 30% will attain remission (Gabriel et al. 2020;
MacQueen et al. 2017).
Recently, psychedelics have reemerged as a potential
therapeutic option for treatment-resistant depression.
There is mounting evidence that psychedelics are effec­
tive at reducing symptoms of depression and are gen­
erally well tolerated (Kuypers 2020; Muttoni,
Ardissino, and John 2019). Psilocybin is of particular
interest, with initial studies demonstrating both rapid
and sustained antidepressant activity (Carhart-Harris
et al. 2018; Griffiths et al. 2016). In their randomized,
double-blind trial, Griffiths et al. (2016) found that
about 80% of participants sustained clinically signifi­
cant reductions in depressed mood six months follow­
ing treatment. Similarly, Carhart-Harris et al. (2018)
found psilocybin treatment to significantly improve
depressive symptoms within one week, and these
effects remained significant at six months with
a favorable safety profile compared to other psychede­
lics (Hendricks, Johnson, and Griffiths 2015). Castro
Santos and Gama Marques (2021) also found no sig­
nificant differences in reducing depressive symptoms
when comparing psilocybin to escitalopram in
a 6-week trial of patients with depression. As a result,
psilocybin is one of the most prominent psychedelics
being studied for depression (Castro Santos and Gama
Marques 2021; Li et al. 2022; Thomas, Malcolm, and
Lastra 2017; Vargas et al. 2020).
Psilocybin’s antidepressant pharmacology has been
proposed to result from its binding to 5-HT2A and
5-HT1A receptors with high and lower affinity, respec­
tively (Lowe et al. 2021). However, the exact mechanism
of action of its antidepressant effect is still uncertain
(Inserra et al. 2021). Previous studies have explored
the neurobiological mechanisms behind psilocybin
causing the “psychedelic experience” itself, character­
ized by alteration in perception, space, and self
(Tagliazucchi et al. 2014), while others have focused
on specific receptor and neurotransmitter activity
(Vollenweider et al., 1999). Although many studies sup­
port the therapeutic benefit of psilocybin, there is little
agreement on its antidepressant mechanism of action
(Castro Santos and Gama Marques 2021; Li et al. 2022;
Thomas, Malcolm, and Lastra 2017; Vargas et al. 2020).
The current systematic review consolidates the litera­
ture on the evidence for various proposed mechanism(s)
of action of psilocybin antidepressant effect, with the
aim of better understanding its therapeutic role in the
treatment of depression.
Methods
The Preferred Reporting Items for Systematic Review
and Meta-Analysis (PRISMA) guidelines were used to
ensure clarity and transparency in the methodology.
A protocol for this review has been registered with
PROSPERO (registration number: 282710).
The databases Ovid MEDLINE (1946–
September 2021), EMBASE (1952-September 2021),
psychINFO (1959–September 2021) and Web of
Science (1900-September 2021) were searched using
a combination of MeSH Terms, non-Mesh keywords
and free-text keywords (see supplementary material).
Search items were adapted with database-specific filters.
References of all included papers were hand-mined, and
any additional documents were added from gray litera­
ture such as from theses, dissertations, and Google
Scholar. The last search was completed on
September 28, 2021.
The search included human and animal studies
focusing on the mechanism of psilocybin’s antidepres­
sant effects. Original papers, including randomized con­
trolled trials, observational, case control, and cohort
studies were included. Review articles, posters, abstracts,
conference proceedings, dissertations, commentaries,
letters, editorials, and toxicology or coroner’s reports
were excluded. Only articles available in English or
those that could be translated into English were
included. Papers were excluded if they: 1) did not dis­
cuss specific mechanism(s) of action, 2) did not specifi­
cally mention psilocybin, depression or antidepressant
effects, or 3) focused on other psychedelic drugs or
psychiatric illnesses unrelated to psilocybin and
depression.
Articles were reviewed systematically using the
PRISMA flow diagram (Figure 1). Two of four reviewers
(BC, MCQL) independently screened each title and
abstract, strictly adhering to the inclusion and exclusion
criteria to minimize bias. Conflicts were resolved by
a third reviewer (VWLT or HL). At least two of the
four independent reviewers evaluated each full-text
manuscript and inconsistencies were resolved by dis­
cussion and consensus. Data on demographics, meth­
ods, and outcomes were compiled using
a predetermined, standardized table by all reviewers.
Quality synthesis and evaluation of bias for article
inclusion was completed in alignment with the
Modified Newcastle-Ottawa Quality Assessment
scale for cohort studies (Shamsrizi et al. 2020).
Randomized controlled trials were evaluated with

Figure 1. PRIMSA Flow Diagram.
the Jaded Scales (Halpern & Douglas 2005). Animal
studies were analyzed with SYRCLE risk of bias tools
for animal studies (Hooijmans et al. 2014). For case
series, the JBI Checklist was used (Munn et al. 2020).
Meta-analyses and reviews were not included in this
study.
Results
Of the 14 included articles, six supported psilocybin’s
mechanism of antidepressant action via its changes to
serotonin or glutamate receptor activity and three
found an increase in synaptogenesis in regions such
as the medial frontal cortex and hippocampus
(Table 1). Thirteen papers investigated changes in
gross, non-receptor or pathway-specific brain activity
resulting from the administration of psilocybin. Of
these, four articles proposed reduced blood flow to
the amygdala, two found altered blood flow to the
prefrontal cortex and one found a reduction in delta
power during sleep. Five papers found changes in
functional connectivity or neurotransmission, most
commonly in the hippocampus or prefrontal cortex,
but with little consensus. There were five animal
JOURNAL OF PSYCHOACTIVE DRUGS 3
studies and nine studies with human participants.
These results will be discussed separately in the fol­
lowing section (Tables 2, 3).
Functional imaging observations
The imaging modality most used in our included arti­
cles was fMRI, including blood oxygenation level depen­
dent (BOLD) and arterial spin labeling (ASL) imaging
techniques. In studies that employed these modalities,
the amygdala and prefrontal cortex were areas of speci­
fic focus.
Carhart-Harris et al. used both BOLD/ASL fMRI in
healthy human participants and found contrasting pre-
post changes between placebo and psilocybin, with psi­
locybin inducing relative decreased activity in the med­
ial prefrontal cortex (mPFC), ventral posterior cingulate
cortex (vPCC), putamen, and subthalamic nuclei. In
addition, decreased brain blood flow and venous oxyge­
nation, reduced cerebral blood flow and BOLD signal in
the anterior cingulate cortex (ACC) and mPFC, and
decreased positive coupling between mPFC and PCC
were observed. There were no differences seen in BOLD
signal during breath hold for patients on psilocybin
4 H. J. LEE ET AL.

Table 1. Summary of findings and study quality.

Title Summary of findings Study quality
Randomized Controlled Trials
Bernasconi et al. Increased top-down control of the prefrontal cortex and reduced neural responses to neutral Jadad Scales for RCT 3/5
(2014) and emotional faces was found after psilocybin administration
Carhart-Harris Psilocybin-induced decrease in activity in mPFC, vPCC, putamen, and subthalamus as shown 3/5
et al. (2012) on BOLD/ASL fMRI relative to placebo. Reduced cerebral blood flow and BOLD signal to ACC
and mPFC. Decreased positive coupling between mPFC and PCC.
Dudysová et al. Decreased absolute delta power during slow-wave sleep during the first sleep cycle was found 2/5
(2020) post-psilocybin administration. Increased REM sleep onset latency and a trend to reduced
REM sleep duration was also noticed.
Kometer et al. Patients taking psilocybin had enhanced positive mood states, decreased recognition of 4/5
(2012) negative facial expression, and increased behavior toward positive cues in comparison to
negative cues. Psilocybin-induced emotional bias is possibly due to stimulation of 5-HT1A
or 5-HT2C receptors rather than 5-HT2A receptors.
Kraehenmann Reduced right amygdala activation to negative and neutral pictures post-psilocybin treatment 3/5
et al. (2015) as measured by BOLD fMRI. Decreased left amygdala activation to negative pictures.
Reduced visual cortex activation.
Mason, et al., Higher relative glutamate concentration levels in the mPFC and lower relative glutamate 4/5
2020 concentration levels in the hippocampus were found in patients receiving psilocybin.
Animal Studies
Shao et al. Psilocybin showed long-lasting increases in spine density and spine head width in mouse SYRCLE risk of bias tool for 8/10
(2021) medial frontal cortex, elevating the formation rate of dendritic spines in vivo. Pretreatment animal studies
with ketanserin did not block structural plasticity from psilocybin. Elevated excitatory
neurotransmission was also noticed post-psilocybin.
Hesselgrave Psilocybin reversed anhedonic responses in mice after being subjected to a chronic 7/10
et al. (2021) multimodal stress paradigm. Excitatory synapses in the hippocampus were strengthened.
Pretreatment with ketanserin did not prevent psilocybin effectivity.
Raval et al. Psilocybin increased synaptogenesis, with higher synaptic vesicle protein 2A density in both 6/10
(2021) the hippocampus and PFC.
Grandjean et al. Reduced focal connectivity in the ventral striatum, along with increased focal connectivity 5/10
(2021) between the serotonin system and various striatal, cortical, and thalamic regions were
observed following psilocybin administration
Mahmoudi et al. Reduced total distance traveled in open field tests for the high-dose psilocybin group as 5/10
(2018) compared to placebo. No decrease in total distance moved between the low dose ketamine
or psilocybin group and the placebo group. However, co-administration of low dose
ketamine and psilocybin resulted in decreases in movement time similar to fluoxetine.
Case Series
Mertens et al. Reduced functional connectivity between the amygdala and vmPFC using BOLD fMRI. JBI checklist for case series Good
(2020) Increased functional connectivity between the vmPFC and the parietal and occipital lobe quality
during face processing. Enhanced connectivity in the precuneus, right angular gyrus, lingual
gyrus, supracalcarine cortex, intracalcarine cortex and lateral occipital cortex. Increased
functional connectivity between vmpFC with right angular gyrus and lateral occipital cortex
when viewing fearful faces.
Roseman et al. Increased amygdala activity using BOLD/ASL fMRI data post-psilocybin treatment and Good
(2018) increased functional connectivity between amygdala and visual areas in response to quality
emotional faces.
Cohort Study
Carhart-Harris Reduced cerebral blood flow as measured by BOLD/ASL fMRI in the temporal cortex including Modified Newcastle Ottawa 5
et al. (2017) the left amygdala which are associated with reductions in depressive symptoms. Increased Quality Assessment Scale
resting state functional connectivity (RSFC) within the default mode network. Increased
ventromedial-prefrontal cortex-bilateral inferior lateral parietal cortex RSFC in patients
responding to psilocybin treatment. Decreases in cerebral blood flow in Heschl’s gyrus, left
precentral gyrus, left planum temporale, left superior temporal gyrus, left amygdala, right
supramarginal nucleus and right parietal operculum.

versus placebo indicating the lack of effect of psilocybin
on vasculature directly (Carhart-Harris et al. 2012).
The same group subsequently studied BOLD/ASL
fMRI in individuals with treatment-resistant depression
given oral psilocybin across two sessions (10 mg, 25 mg).
They observed reduced cerebral blood flow in the tem­
poral cortex, including the left amygdala, with
a statistically significant relationship found when com­
pared to reductions in depressive symptoms (Carhart-
Harris et al. 2017). There was also increased resting
state functional connectivity (RSFC) observed within
the default mode network. Increased ventromedial pre­
frontal cortex-bilateral inferior lateral parietal cortex
RSFC and decreased parahippocampal-prefrontal cortex
RSFC was observed in patients who responded to psilo­
cybin treatment (Carhart-Harris et al. 2017). Specific
areas demonstrating statistically significant decreases in
CBF included left Heschl’s gyrus, left precentral gyrus, left
planum temporale, left superior temporal gyrus, left
amygdala, right supramarginal gyrus and right parietal
operculum. Using data from the same study, Roseman
et al. found increased amygdala activity after psilocybin

Table 2. Results Table Condensed.
Author last
name, year of Number of participants (n), patient
publication type, type of study
Bernasconi et al. 30, healthy humans, double-blind,
(2014) placebo-controlled RCT
Carhart-Harris et al. 15, healthy human controls, subject-
(2012) controlled RCT
Carhart-Harris et al. 19, patients suffering from treatment- ASL and BOLD RSFC (resting
(2017) resistant depression, open-label
clinical trial
Dudysová et al. 20, healthy human participants,
(2020) double-blind placebo-controlled
crossover design
Grandjean et al. 50, mice, placebo-controlled trial
(2021)
Hesselgrave et al. 8, mice, exposed to a chronic
(2021) multimodal stress paradigm
Kometer et al. 17, healthy human controls, double
(2012) blinded RCT
Kraehenmann et al. 25, healthy human controls, double- fMRI/BOLD
(2015) blinded, placebo-controlled RCT
Mahmoudi et al. 8 groups (8 mice each), placebo-
(2018) controlled behavioral trial
Mason, et al., 2020 60, healthy human controls, double
blind RCT
Mertens et al. 20, humans with moderate to severe fMRI/BOLD – Anatomical scan Increased FC between amygdala and visual areas;
(2020) MDD, case series study
Raval et al. (2021) 24, pigs, placebo-controlled trial
Roseman et al. 20, humans with moderate to severe fMRI/BOLD – Anatomical scan Increased BOLD signal in right amygdala (and visual areas)
(2018) MDD, case series study
Shao et al. (2021) 12, mice, placebo-controlled trial
administration, as well as increased functional connectiv­
ity between amygdala and the visual areas in response to
emotional faces (Roseman et al. 2018). Further examina­
tion of the sample group by Mertens et al. (2020), found
reduced functional connectivity between the amygdala
and the ventromedial prefrontal cortex (vmPFC). The
authors also reported increased functional connectivity
between the vmPFC and the parietal lobe and occipital
lobe during face processing. Specific regions with
enhanced connectivity included the precuneus and the
right angular gyrus of the parietal lobe and the lingual
gyrus, supracalcarine cortex, intracalcarine cortex and
lateral occipital cortex. The right angular gyrus and lateral
occipital cortex also demonstrated increased functional
connectivity with the vmPFC, but only when viewing
fearful faces (Mertens et al. 2020).
In a study with healthy human participants using
BOLD fMRI, Kraehenmann et al. found reduced right
amygdala activation to both negative and neutral pictures
after oral psilocybin (0.16 mg/kg) administration, as well
as decreased activation in the left amygdala to negative
JOURNAL OF PSYCHOACTIVE DRUGS 5
Neurobiological changes and proposed mechanisms of
Method of imaging (if any) action
Continuous EEG Increased top-down control of the PFC, resulting in reduced
initial neural response to both negative and neutral faces
ASL (arterial spin labeling) and Decreased brain blood flow and venous oxygenation.
fMRI/BOLD Reduced CBF in ACC/mPFC;
Decreased positive coupling between mpFC and PCC;
Decreased mPFC activity via 5-HT2A receptor stimulation
Decreased cerebral blood flow in whole brain;
state functional Increased default mode network integrity;
connectivity) analysis Reduced amygdala CBF and RSFC between bilateral
parahippocampus and PFC
Whole-night polysomnography Decreased absolute delta power during SWS in first sleep
(EEG spectral analysis) cycle (similar to other antidepressants)
fMRI/BOLD – Resting state Reduced FC within ventral striatum;
The RSN predominantly affected by psilocybin was enriched
in DA receptors
Strengthened excitatory synapses in the hippocampus and
increased AMPA/NMDA ratios, unaffected by ketanserin
(5-HT2A blocker)
EEG recordings, with additional Higher P300 amplitudes for positive and negative faces
electrodes attached near the compared with neutral stimuli, unaffected by ketanserin
eyes (5-HT2A blocker)
Reduced amygdala activation to negative pictures;
Decreased activation in visual cortex
NMDA antagonist and psilocybin co-administration led to
most significant antidepressant behavioral change
fMRI/BOLD and structural MRI Higher relative glutamate concentration levels in the mPFC,
and lower relative glutamate concentration levels in the
hippocampus
Increased FC between vmPFC and other regions
In vitro autoradiography Transient decrease in 5-HT2AR density in hippocampus and
PFC; Higher SV2A density in hippocampus
Two-photon microscopy Increased neurotransmission and spine density in medial
frontal cortex, unaffected by ketanserin (5-HT2A blocker)
but not neutral pictures. There was also reduced activa­
tion in the visual cortex (Kraehenmann et al. 2015).
Mason et al. explored structural MRI/MRS in healthy
human participants to analyze relative glutamate levels
in the brain. They found that oral psilocybin (0.17 mg/
kg) administration resulted in higher glutamate concen­
trations in the mPFC and lower concentrations in the
hippocampus. The authors also reported an increase in
between-network functional connectivity after psilocy­
bin, but not placebo, in all networks other than the
lateral motor network. Within their respective net­
works, there was a decrease in co-activation in visual
networks 1 and 2 and both subcomponents of the
default mode network (DMN) post-psilocybin in com­
parison to post-placebo (Mason et al. 2020).
Electrophysiological observations
EEG and other electrophysiological data were used as
investigative tools for psilocybin’s effects in three
human studies. Bernasconi et al. performed analyses
Table 3. Results table.
6

Proposed mechanism of
action – i.e. receptor
Number of activity/expression
Author last participants (n), Method of psilocybin (5-HT2a, dopamine,
name, year of patient type, type of administration (route, glutamate) and or Mode of neurological Resulting brain activity/Functional
pub study dose, timing) synaptogenesis investigation connectivity/[Enhanced neurotransmission] Clinical outcomes
Bernasconi 30, healthy humans, Oral, 170ug/kg Continuous EEG (electrical Increases top-down control of the PFC,
et al. (2014) double-blind, neuroimaging analyses resulting in reduced neural response to
H. J. LEE ET AL.

(3) placebo- on visual evoked both neutral and emotional faces

controlled RCT potentials [VEPs])
Carhart-Harris 15, healthy human Intravenous, 2mmg in 10 Decreased mPFC activity ASL (arterial spin labeling) Psilocybin decreased brain blood flow and Subjective ratings on nineteen items
et al. (2012) controls, subject- mL saline over 60s via 5-HT2A receptor and fMRI/BOLD brain venous oxygenation. immediately after the ASL scan showed an
(4) controlled RCT stimulation scans Reduced CBF in ACC/mPFC; decreased increase in items such as seeing the
positive coupling between mpFC and PCC surroundings change, seeing geometric
patterns, the experience having
a dreamlike quality, etc.
Carhart-Harris 19, patients Two doses of psilocybin, Decreasing cerebral blood ASL and BOLD RSFC Increased default mode network integrity; Mean depression score measured by the
et al. (2017) suffering from 10 mg followed by 25 flow in whole brain (resting state functional reduced amygdala CBF QIDS-SR16 was lower in all patients one
(5) treatment- mg one week apart connectivity) analysis Reduced RSF between bilateral week post-treatment, and all but one
resistant parahippocampus and PFC patient showed some decrease in QIDS-
depression, SR16 score at week 5.
open-label
clinical trial
Dudysová 20, healthy human Capsules adjusted N/A Whole-night Decreased absolute delta power during SWS Psilocybin increases REM sleep onset latency
et al. (2020) participants, according to body polysomnography (EEG in first sleep cycle (similar to other and shows a trend to reduced REM sleep
(6) double-blind weight, ~0.26 mg/kg, spectral analysis) with antidepressants) duration.
placebo- around 9am a gel cap with 19
controlled electrodes
crossover design
Grandjean 50, mice, placebo- IV, 1 mg/kg, 2 mg/kg,or Resting-state, BOLD fMRI − Reduced FC within ventral striatum
et al. (2021) controlled trial vehicle only, 20 min − The RSN predominantly affected by
(7) prior to imaging psilocybin is enriched in DA receptors
Hesselgrave 8, 8-week-old male Intraperitoneal injection, 1 [Independent of 5-HT2A N/A Strengthened excitatory synapses in the Psilocybin causes a rapid beneficial action in
et al. (2021) mice exposed to mg/kg, an hour after a i. (elicited effects despite hippocampus models of chronic stress and depression-
(8) a chronic p injection of ketanserin ketanserin)] [enhanced neurotransmission] relevant hedonic behaviours
multimodal (2 mg/kg)
stress paradigm,
[animal study?]
Kometer et al. 17, healthy human [route?], Placebo or 5-HT1A or 5-HT2C Electroencephalogram Contrary to the crucial contribution of 5-HT2A Psilocybin enhanced positive mood states;,
(2012) (10) controls, double ketanserin (50 mg) pathways rather than recordings were taken receptors in modulating mood states and decreased recognition of negative facial
blinded RCT (pretreatment) followed 5-HT2A pathway. using 64 scalp emotional face recognition, the psilocybin- expression; and, increased behavior toward
after 1 hour by placebo electrodes, with induced relative bias toward the positive relative to negative cues. Validated
or psyilocybin (215 g/ additional electrodes processing of positive emotions in the go/ scales used include: 5-Dimensions Altered
kg) (treatment). attached near the eyes nogo task were not blocked by States of Consciousness (5D-ASC) the
pretreatment with ketanserin. Thus, the German version of the Positive and
psilocybin-induced emotional bias might Negative Affect Schedule (PANAS) and the
rather be due to a stimulation of 5-HT1A or State-Trait Anxiety Inventory (STAI)
5-HT2C receptors than 5-HT2A receptors.
However, the strong valence-independent
reduction of the P300 seen after psilocybin
administration was partially reversed by
ketanserin, indicating an involvement of
5-HT2A receptors in the valence-
independent attentional performance.
(Continued)
Table 3. (Continued).
Proposed mechanism of
action – i.e. receptor
Number of activity/expression
Author last participants (n), Method of psilocybin (5-HT2a, dopamine,
name, year of patient type, type of administration (route, glutamate) and or Mode of neurological Resulting brain activity/Functional
pub study dose, timing) synaptogenesis investigation connectivity/[Enhanced neurotransmission] Clinical outcomes
Kraehenmann 25, healthy human Oral, 0.16 mg/kg, two Inhibiting glutamate? fMRI/BOLD Reduced right amygdala activation; Positive and Negative Affect Schedule
et al. (2015) controls, Double- sessions (14 days apart) (NMDA receptor decreased activation in visual cortex (PANAS): Psilocybin significantly increased
(11) blinded, antagonists) positive affect (Bonferroni- corrected p
randomized = .001, Figure 1) but not negative affect
placebo- (Bonferroni-corrected p 5 .87) or state
controlled trial. anxiety (Bonferroni-corrected)
Mahmoudi 8 mice per group, Intraperitoneal injections, Co-administration of low N/A Associated with a rapid beneficial result in
et al. (2018) male NMRI mice 10, 40, or 100 mg/kg dose ketamine and mouse model of chronic-stress induced
(12) weighing 20-25 PCE, 30 minutes before psilocybin caused deficits in depression-relevant hedonic
g, [RCT animal each test a significant decrease in behaviours
study?] movement time (similar
to fluoxetine)
Mason, et al., 60, healthy human [route?], 0.17 mg/kg Glutamate was higher in MRI – structural and fMRI/ Higher relative glutamate concentration Psilocybin was associated with increased
2020 (13) controls, double mPFC; Glutamate was BOLD levels in the mPFC, and lower relative ratings in dimensions of 5 Dimensions of
blind RCT lower in hippocampus glutamate concentration levels in the Altered States of Consciousness (5D-ASC)
hippocampus. and Ego Dissolution Inventory (EDI)
Mertens et al. 20, Human Oral, low and 25 mg dose, N/A Anatomical scan using Increased FC between amygdala and visual N/A?
(2020) (14) participants with low dose on trial day BOLD fMR areas; Increased between vmPFC and other
moderate to and 25 mg dose one regions
severe MDD, case week later
series study
Raval et al. 24, pigs, placebo- IV, 0.08 mg/kg, 1 day prior Transient decrease in In vitro autoradiography
(2021) (15) controlled trial to euthanization 5-HT2AR density in
hippocampus and PFC
Higher SV2A in
hippocampus
(synaptogenesis)
Roseman et al. 20, Human subjects Oral, low and 25 mg dose, N/A Anatomical scan using Increase BOLD in right amygdala (and visual Beck’s Depression Inventory (BDI): Change
(2018) (16) with moderate to low dose on trial day BOLD fMRI areas) (10.2 ± 5.3), response (63.2%) and
severe MDD, and 25 mg dose one remission (57.9%) in BDI scores at 1-week
Case series study week later Quick Inventory of Depressive Symptomology
(QIDS): Response at 1-day (68.4%), 1-week
(63.2%) and 3-weeks (63.2%)
13 participants were responders 1-day after
therapy and 9 maintained response 5
weeks after therapy.
Shao et al. 12, mice, placebo- IV, 1 mg/kg, 24 h before − Increase in spine density Two-photon microscopy Elevates neurotransmission in medial frontal
(2021) (17) controlled trial euthanization in medial frontal cortex cortex
- Increase in density [enhanced neurotransmission]
unaffected by
ketansarin (5-HT2A
JOURNAL OF PSYCHOACTIVE DRUGS

blocker)
7
8 H. J. LEE ET AL.
on visual evoked potentials (VEPs) in response to
facial expressions (fearful, happy, and neutral) after
placebo administration or oral psilocybin(0.17 mg/kg).
They found a significant global field power (GFP)
interaction between treatment and face valence, as
well as within the visual areas, limbic areas, tempor­
oparietal areas, and the prefrontal areas. In these
areas, reductions of brain activity were observed for
both neutral and fearful faces, but not for happy faces
(Bernasconi et al. 2014).
Kometer et al. used EEG to analyze emotional go/no-
go tasks in response to face recognition, using oral
psilocybin (0.215 mg/kg), placebo, and pre-treatment
with ketanserin (a 5-HT2A receptor antagonist).
Psilocybin enhanced positive mood and attenuated
recognition of negative facial expression, as well as
increased goal-directed behavior toward positive com­
pared with negative cues. Psilocybin administration also
facilitated positive and inhibited negative emotional
effects, and valence-dependently attenuated P300
amplitude. Ketansarin alone had no effects but blocked
psilocybin-induced mood enhancement, and decreased
recognition of negative facial expression (Kometer et al.
2012).
Dudysova et al. conducted a placebo-controlled sleep
study that found a small but significant increase in REM
latency the night after oral psilocybin (0.26 mg/kg)
administration. Absolute delta power (which is repre­
sentative of deeper stage 3/4 sleep) during slow wave
sleep (SWS) in the first sleep cycle was found to be
significantly lower after psilocybin administration in
comparison to placebo, and locally at averaged frontal,
central, parietal, temporal, and occipital derivations.
Sleep latency, total sleep time, sleep efficiency, and the
number of sleep cycles, however, were not significantly
different in placebo and psilocybin conditions
(Dudysová et al. 2020).
Observations from imaging studies in animals
Imaging studies using psilocybin in animals used
a variety of modalities including BOLD fMRI, micro­
scopy, and autoradiography. Grandjean et al. used rest­
ing-state BOLD fMRI in mice and observed a reduction
in focal connectivity within the ventral striatum post-
intravenous psilocybin administration (1 or 2 mg/kg).
Psilocybin was also shown to affect resting state striatal
networks enriched in dopamine receptors to the greatest
degree. When testing for the effects of psilocybin on the
serotonin and dopamine associated networks, it was
found that while focal connectivity decreased between
the dopamine system and striatal regions as mentioned,
there was an increase in focal connectivity between the
serotonin system and various striatal, cortical, and tha­
lamic regions (Grandjean et al. 2021).
Using two-photon microscopy to image layer 5 pyr­
amidal neurons in the mouse medial frontal cortex,
Shao et al. found that a single dose of intraperitoneal
psilocybin (1 mg/kg) increased the rate of dendritic
spine formation, leading to significant increases in
spine protrusion lengths, width and density. In particu­
lar, Cg1/M2 (homologous to the mid-anterior cingulate
cortex/medial prefrontal cortex in humans) was an area
of interest which sustained greater spine density and
protrusion length; however, increases in spine density
were greater in female mice compared to males.
Dendritic spine formation rate peaked shortly after psi­
locybin administration dose, then returned to baseline
to match the unchanged elimination rate in both
females and males. Long-term changes in psilocybin-
induced dendritic modeling were found, as a portion of
psilocybin-induced spines were retained after 1 month.
After ketanserin pretreatment, they found that head-
twitch responses induced by psilocybin were eliminated,
but not psilocybin-induced dendritic remodeling (indi­
cating that this effect was likely not mediated by sero­
tonergic neurotransmission). Consistent with this,
excitatory neurotransmission in the medial frontal cor­
tex was enhanced by psilocybin, where most dendritic
spines have functional glutamatergic synapses (Shao
et al. 2021).
Raval et al. used in vitro autoradiography to study the
synaptic vesicle protein 2A (SV2A; a membrane protein
used to measure pre-synaptic density) and 5-HT2AR
densities in the pig hippocampus and PFC. They
found increased SV2A protein and reduced 5-HT2AR
density in the hippocampus one-day post-treatment
with intravenous psilocybin (0.08 mg/kg), with only
the SV2A density remaining significantly increased
after seven days. In the PFC, SV2A density remained
unchanged and 5-HT2AR density was reduced one day
after treatment; however, SV2A density was increased,
with no change in 5-HT2AR from baseline after seven
days (Raval et al. 2021).
Observations from behavioral studies in animals
There were two animal studies that focused on beha­
vioral analyses. Mahmoudi et al. (2018) used open field
tests, tail suspension tests, and forced swimming tests in
mice after various doses of intraperitoneal psilocybin
(10, 40, 100 mg/kg), ketamine (NMDA receptor antago­
nist), fluoxetine, and placebo administration. They
found a significant difference in the total distance
moved between the applied group in open fields at
high, but not low doses of psilocybin and ketamine

compared to control. However, co-administration of
low-dose ketamine and psilocybin did cause
a significant decrease in movement time (similar to
fluoxetine) (Mahmoudi et al. 2018).
Hesselgrave et al. exposed a group of mice to
a chronic multi-modal stress paradigm (CMMS) under
psilocybin and placebo conditions, with or without pre-
treatment with ketanserin (5-HT2A receptor antago­
nist). They reported significantly increased sucrose and
female urine preferences following stress in ketanserin-
pretreated mice receiving psilocybin, whereas ketan­
serin pretreatment alone had no significant effect on
either behavior. After completion of the behavioral
assays, hippocampal brain slices were taken from the
animals for extracellular recordings. They found that
AMPA/NMDA receptor ratios in slices taken from psi­
locybin-injected CMMS-susceptible mice were signifi­
cantly greater than those in slices taken from CMMS
susceptible animals injected with vehicle or ketanserin
alone, and pretreatment with ketanserin did not impair
the ability of psilocybin to restore AMPA/NMDA recep­
tor ratios (Hesselgrave et al. 2021).
Study quality
Of the 14 papers included in this review, one was
a cohort study, six were randomized control trials, five
were animal studies, and two were case series. The
cohort study was of moderate quality (a score of 5)
due to the lack of a control cohort and short follow-up
duration. Of the six randomized controlled trials, two
were of good quality, ranking 4 out of 5 only losing
points for lack of long-term follow-up. Four studies
ranked 2 or 3 out of 5, losing points for the lack appro­
priate randomization and long-term follow-up. Of the
five animal studies, two scored 5 out of 10, one scored 6
out of 10, one scored 7 out of 10 and one scored 8 out of
10 most commonly losing points for lack of blinding,
inadequate allocation sequence application, and pre­
sence of confounders. This systematic review included
two case series which were of overall good quality,
scoring low only for the lack of consecutive inclusion
of participants and lack of clear reporting of the pre­
senting site’s demographic information (Table 4).
Discussion
Upon review of the literature, it appears that various
brain regions and neurotransmitter pathways are poten­
tially involved in the potential antidepressant mechan­
ism of action of psilocybin. Anatomical areas of interest
include the amygdala, prefrontal cortex, and hippocam­
pus. Depression has been characterized by neuronal
JOURNAL OF PSYCHOACTIVE DRUGS 9
atrophy and impaired neuroplasticity at the molecular
level within these areas (Duman and Aghajanian 2012;
Duman et al. 2016). Chronic stress may induce activa­
tion of localized immune cells in the brain (microglia),
which engulf nearby pyramidal neurons, contributing to
neuronal atrophy (Wohleb et al. 2018). Psilocybin
potentially reverses these pathogenic mechanisms.
Depression is also associated with altered functional
connectivity across the PFC and limbic areas, including
the amygdala and hippocampus (Siegle et al. 2007), with
alterations in affective processing, and establishment of
negative biases and appraisal of self and the environ­
ment (Gotlib and Joormann 2010). Our review illus­
trates evidence of alteration in functional connectivity
between these key structures after psilocybin adminis­
tration, as well as in specific neurotransmitter pathways.
Amygdala
The amygdala plays a key role in affective regulation,
including evocation of negative emotions and response
to fearful stimuli. Morphological changes in the amyg­
dala, as part of an altered limbic-thalamic-cortical cir­
cuit, have been implicated in the pathogenesis of
depression (Bellani, Baiano, and Brambilla 2010; Zou
et al. 2010). Studies have also shown increased amygdala
CBF and functional connectivity in negative affect states
(Abercrombie et al. 1998; Coombs et al. 2014). Stress
also increases excitability in the amygdala in response to
stress, resulting in increased reactivity and decreased
cognitive processing (Dean and Keshavan 2017). In the
articles reviewed, variation in amygdala activity and
functional connectivity were found following psilocybin
administration.
Carhart-Harris et al. (2017), reported decreased CBF,
and therefore reduced activity in the left amygdala, in
a population with treatment-resistant depression
one day after psilocybin administration, which corre­
lated with reduced depressive symptoms. There is
uncertainty as to whether or not psilocybin may
increase whole-brain CBF (Lewis et al. 2017) as acute
increases in CBF have been reported with other psyche­
delics such as LSD (Carhart-Harris et al. 2012, 2016).
This post-acute reduction in amygdala CBF reported by
Carhart-Harris (in addition to other structures) could
represent a “reset mechanism,” and re-integration in
a lower activity state.
In the same population as (Carhart-Harris et al.
2017), Roseman et al. and Mertens et al. observed
increased amygdala activity and decreased functional
connectivity between the amygdala and the vmPFC
one day after psilocybin administration, in response to
negative and neutral facial affective recognition tasks.
10 H. J. LEE ET AL.

Table 4. Study Quality.

Scale Used and Score

JBI
Author Last Modified Newcastle Ottawa Jadad Checklist SYRCLE Risk of
Name, Year of Quality Assessment Scale Scales for Case Bias Tool for
Publication Study Methodology Data Analysis (COHORT STUDIES) for RCT Series Animal Studies
Bernasconi et al. Randomized, double-blind, 3/5
(2014) (3) placebo-controlled trial
Carhart-Harris Two trials, each of which Seed-based pharmaco- 3/5
et al. (2012) (4) had their own placebo physiological interaction
functional connectivity
analysis
Carhart-Harris Open-label clinical trial ASL and BOLD RSFC, QIDS-SR16 5
et al. (2017) (5)
Dudysová et al. Double-blind RCT 2/5
(2020) (6)
Grandjean et al. Placebo-controlled trial 5/10
(2021) (7) (animal)
Hesselgrave et al. Placebo-controlled trial 7/10
(2021) (8) (animal)
Kometer et al. Double-blinded RCT More complicated version of 4/5
(2012) (10) ANOVA
Kraehenmann Randomized, double-blind, 3/5
et al. (2015) placebo controlled,
(11) crossover design
Mahmoudi et al. Animal study 5/10
(2018) (12)
Mason et al. Double-blind, placebo Nonparametric Mann-Whitney 4/5
(2020) (13) controlled, parallel U tests
group design
Mertens et al. Follow-up to an open-label Psychophysiological interaction 7
(2020) (!4) trial analyses on fMRI imaging data
Raval et al. (2021) Placebo controlled trial 2/5
(15) (animal)
Roseman et al. Open-label trial 7
(2018) (16)
Shao et al. (2021) Randomized placebo 8/10
(17) controlled trial (animal)

They also found increased functional connectivity
between the amygdala and visual areas after administra­
tion of psilocybin. This increase in emotional reactivity
in the post-acute phase may represent a temporary
increase in emotional salience, opening an avenue for
psychotherapeutic intervention during this period, prior
to the “reset.” One recognized mechanism of action of
traditional antidepressants, specifically SSRIs, is of nor­
malizing overactivity in the amygdala (Godlewska et al.
2012), given prior fMRI findings of increased amygdala
activation in clinically depressed individuals (Yang et al.
2010). It may be that these traditional antidepressants
have a general effect on reducing responsiveness to all
stimuli regardless of valence (Price, Cole, and Goodwin
2009), which is seen clinically with overall emotional
blunting. Further studies looking at longer term changes
after psilocybin administration would help determine if
there is a similar decrease in reactivity beyond the acute/
post-acute phase.
Kraehenmann et al. found decreased amygdala acti­
vation in response to negative emotional stimuli 210
min after psilocybin administration in healthy partici­
pants, which is in opposition to what Roseman and
Mertens found in the post-acute phase. This may high­
light the difference in the acute/post-acute effects of
psilocybin, but are also confounded by methodological
differences (lower dosing, healthy patient population).
A future study looking at resting state, acute, post-acute,
and long-term changes to amygdala reactivity/func­
tional connectivity may help reconcile these findings.
Prefrontal cortex
According to the neuroplasticity models of depression,
the PFC and the hippocampus suffer from neuronal
loss, reduced synaptic density, and functionality result­
ing from prolonged reductions in brain-derived neuro­
trophic factor (BDNF) and chronic stress (Price and
Duman 2020). Additionally, reduced glutamatergic
metabolites in the medial frontal cortex have been
observed in patients with depression compared to
healthy controls (Moriguchi et al. 2019). The changes
seen in the PFC are thought to lead to impaired func­
tional connectivity within key areas of the limbic sys­
tem, leading to dysfunctional top-down control of the
amygdala and hippocampus (Arco and Mora 2009;

Zhao et al. 2020). Clinically, this manifests as dysfunc­
tional stress coping, environmental adaptability and
learning (Price and Duman 2020). Experimentally, this
may be recognized by modulation of attentional
resource allocation, and biased facial emotion proces­
sing (Stuhrmann, Suslow, and Dannlowski 2011), with
the PFC playing a key role in generating top-down
control in attention switching (Rossi et al. 2009).
Stuhrmann, Suslow, and Dannlowski (2011) reported
mood-congruent face processing bias in major depres­
sive disorder patients, with hyperactivation to negative
and hypoactivation to positive stimuli in a variety of
brain areas, however with inconsistent findings in the
PFC. Bernasconi et al. (2014) found reduced PFC and
limbic activity in their EEG study, with associated initial
reduction in response to neutral and fearful faces in
comparison to happy faces, which may represent psilo­
cybin’s modulation of this pathway.
Psilocybin appears to increase functional connectiv­
ity and neuroplasticity in the prefrontal cortex which
could explain its antidepressant effects. Mason et al.
(2020) found higher levels of glutamate in the mPFC
post-psilocybin administration compared to baseline in
healthy patients. Although this study was not conducted
on clinically depressed patients, psilocybin’s mechanism
of action for treating depression may involve increasing
glutamate neurotransmission in the mPFC, and its sub­
sequent effects on local BDNF production (Mattson
2008). In the animal imaging studies reviewed, Shao
et al. (2021) and Raval et al. (2021) both found increased
PFC synaptic plasticity initially after psilocybin admin­
istration. Maintenance of PFC plasticity was also
observed by Shao et al. (2021) one month after treat­
ment. This suggests sustained improvement in PFC
functionality and supports clinical studies showing
long-term reduction in depressive symptoms after psi­
locybin administration (Carhart-Harris et al. 2018;
Griffiths et al. 2016). These studies support the neuro­
trophic hypothesis of depression, postulating that
increasing neurogenesis and plasticity in brain regions
like the PFC are important for improving depressive
symptoms (Bus and Molendijk 2016; Dean and
Keshavan 2017).
Hippocampus
Similar to the PFC, chronic stress leads to increased
neuronal atrophy, and decreased plasticity, BDNF
expression, and synaptic density in the hippocampus
(Price and Duman 2020). The hippocampus appears
particularly susceptible to atrophy in a depressed popu­
lation and is supported by a 2016 meta-analysis of
imaging studies looking at subcortical brain volumes
JOURNAL OF PSYCHOACTIVE DRUGS 11
in over 1700 patients with MDD demonstrating robust
reductions in volume (Schmaal et al. 2016).
Studies reviewed here varied in terms of hippocampal
findings with the majority observing greater synaptic
plasticity and neurogenesis. Similar to their results in
the PFC, Raval et al. (2021) found changes to SV2A
protein and 5-HT2AR densities in pigs after psilocybin
treatment, indicating plasticity in this brain region.
Supporting this finding, Hesselgrave et al (2021)
observed greater AMPA/NMDA receptor ratios in the
hippocampus of psilocybin-injected mice, despite pre-
treatment with ketansarin, a potent 5-HT2AR antago­
nist. This finding correlated with significant reduction
in observed stress behaviors. Studies of traditional
monoamine antidepressants have also found increased
AMPA/NMDA receptor ratios (Barbon et al. 2011;
Skolnick et al. 1996), which may represent
a concurrent pathway of psilocybin’s antidepressant
effect independent of the 5-HT2A receptor, as well as
reflecting an increase in neuroplasticity.
These findings suggest there may be a role for psilo­
cybin in alleviating the effects of hypercortisolemia from
hypothalamic-pituitary-adrenal axis dysfunction on the
hippocampus in patients with depression (Dean and
Keshavan 2017). Mason et al. (2020), however, found
reduced glutamate activity in the hippocampus after
immediate psilocybin administration and it remains
unclear if this reduction persists or reverses and what
effect this might have in the longer term on AMPA/
NMDA receptor ratios, neuronal plasticity via BDNF
production in this region.
Observations of changes in clinically depressed
states
While clinical outcomes were not the focus of our review,
six of the included studies reported clinical measures such
as the Quick Inventory of Depressive Symptomology
(QIDS)-SR16, Beck Depression Inventory (BDI), the
Positive and Negative Affect Schedule (PANAS) and the
State-Trait Anxiety Inventory (STAI). Carhart-Harris
et al. (2017) reported lower mean scores on the QIDS-
SR16 in participants with depression, and Roseman et al.
(2018) observed clinical improvement on the QIDS and
BDI following psilocybin administration. However, these
clinical measures were not quantitatively correlated with
biological measures to decisively determine psilocybin’s
mechanism of action.
Limitations
Our study was limited by several factors inherent in the
methodology of the studies selected. We were only able
12 H. J. LEE ET AL.
to include a small number of studies after application of
exclusion criteria. This resulted in a heterogeneous
selection of animal and human studies, as well as both
healthy and depressed patients. The studies reviewed
were also varied in terms of the neuroimaging and
other investigative modalities used, with their integra­
tion requiring reference to other studies positing path­
ways yet to be firmly established in the literature.
Dosing parameters of psilocybin also varied, both in
amount and route of administration (e.g. oral vs. intra­
venous), which may have affected the consistency of
neurobiological response. Our conclusions should be
viewed as an early interpretation of potential neurobio­
logical pathways, hopefully encouraging further study to
confirm the validity of these findings.
Conclusion
Psilocybin may exert antidepressant effects through
a variety of mechanisms. These were investigated in
a selection of studies including functional imaging
and electrophysiological techniques in humans, and
observations from imaging and behavioral studies in
animals. Although there is limited consensus and few
methodologically rigorous studies, it appears that
psilocybin alters amygdala activity and glutamate
levels in the medial prefrontal cortex, and increases
functional connectivity and synaptic plasticity in the
hippocampus. While psilocybin’s impact on seroto­
nergic receptor systems has been described, this
review suggests that its psychotropic therapeutic
effects may not be restricted to this neurotransmitter
system. Further research, in particular pre-, intra-,
and post-treatment studies with molecular and ima­
ging biomarkers will hopefully shed light on a more
unified understanding of how psilocybin may lead to
sustained mood improvement in individuals suffer­
ing from depression.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
The author(s) reported there is no funding associated with the
work featured in this article.
ORCID
Harrison J Lee M.D. http://orcid.org/0000-0002-1966-5104
References
Abercrombie, H. C., S. M. Schaefer, C. L. Larson, T. R. Oakes,
K. A. Lindgren, J. E. Holden, S. B. Perlman, P. A. Turski,
D. D. Krahn, R. M. Benca, et al. 1998. Metabolic rate in the
right amygdala predicts negative affect in depressed
patients. Neuroreport 9 (14):3301–07. doi:10.1097/
00001756-199810050-00028.
Arco, A. D., and F. Mora. 2009. Neurotransmitters and pre­
frontal cortex–limbic system interactions: Implications for
plasticity and psychiatric disorders. Journal of Neural
Transmission 116 (8):941–52. doi:10.1007/s00702-009-
0243-8.
Barbon, A., L. Caracciolo, C. Orlandi, L. Musazzi, A. Mallei,
L. La via, D. Bonini, C. Mora, D. Tardito, M. Gennarelli,
et al. 2011. Chronic antidepressant treatments induce a
time-dependent up-regulation of AMPA receptor subunit
protein levels. Neurochemistry International
59 (6):896–905. doi:10.1016/j.neuint.2011.07.013.
Bellani, M., M. Baiano, and P. Brambilla. 2010. Brain anatomy
of major depression I. Focus on hippocampus.
Epidemiologia E Psichiatria Sociale 19 (4):298–301. doi:10.
1017/S1121189X00000634.
Bernasconi, F., A. Schmidt, T. Pokorny, M. Kometer,
E. Seifritz, and F. X. Vollenweider. 2014. Spatiotemporal
brain dynamics of emotional face processing modulations
induced by the serotonin 1A/2A receptor agonist
psilocybin. Cerebral Cortex 24 (12):3221–31. doi:10.1093/
cercor/bht178.
Bus, B. A. A., and M. L. Molendijk. 2016. The neurotrophic
hypothesis of depression. Tijdschrift Voor Psychiatrie
58 (3):215–22.
Carhart-Harris, R. L., M. Bolstridge, C. M. J. Day, J. Rucker,
R. Watts, D. E. Erritzoe, M. Kaelen, B. Giribaldi,
M. Bloomfield, S. Pilling, et al. 2018. Psilocybin with psy­
chological support for treatment-resistant depression:
Six-month follow-up. Psychopharmacology
235 (2):399–408. doi:10.1007/s00213-017-4771-x.
Carhart-Harris, R. L., D. Erritzoe, T. Williams, J. M. Stone,
L. J. Reed, A. Colasanti, R. J. Tyacke, R. Leech, A. L. Malizia,
K. Murphy, et al. 2012. Neural correlates of the psychedelic
state as determined by fMRI studies with psilocybin.
Proceedings of the National Academy of Sciences
109 (6):2138–43. doi:10.1073/pnas.1119598109.
Carhart-Harris, R. L., S. Muthukumaraswamy, L. Roseman,
M. Kaelen, W. Droog, K. Murphy, E. Tagliazucchi,
E. E. Schenberg, T. Nest, C. Orban, et al. 2016. Neural
correlates of the LSD experience revealed by multimodal
neuroimaging. Proceedings of the National Academy of
Sciences 113 (17):4853–58. doi:10.1073/pnas.1518377113.
Carhart-Harris, R. L., L. Roseman, M. Bolstridge,
L. Demetriou, J. N. Pannekoek, M. B. Wall, M. Tanner,
M. Kaelen, J. McGonigle, K. Murphy, et al. 2017. Psilocybin
for treatment-resistant depression: FMRI-measured brain
mechanisms. Scientific Reports 7 (1): Article 1. doi:10.1038/
s41598-017-13282-7.
Carvalho, A. F., M. S. Sharma, A. R. Brunoni, E. Vieta, and
G. A. Fava. 2016. The safety, tolerability and risks asso­
ciated with the use of newer generation antidepressant
drugs: a critical review of the literature. Psychotherapy
and Psychosomatics 85 (5):270–88. doi:10.1159/000447034.

Castro Santos, H., and J. Gama Marques. 2021. What is the
clinical evidence on psilocybin for the treatment of psy­
chiatric disorders? A systematic review. Porto Biomedical
Journal 6 (1):e128. doi:10.1097/j.pbj.0000000000000128.
Coombs, G., M. L. Loggia, D. N. Greve, D. J. Holt, and
C. Soriano-Mas. 2014. Amygdala perfusion is predicted by
its functional connectivity with the ventromedial prefrontal
cortex and negative affect. PloS One 9 (5):e97466. doi:10.
1371/journal.pone.0097466.
Dean, J., and M. Keshavan. 2017. The neurobiology of depres­
sion: An integrated view. Asian Journal of Psychiatry
27:101–11. doi:10.1016/j.ajp.2017.01.025.
Dudysová, D., K. Janků, M. Šmotek, E. Saifutdinova,
J. Kopřivová, J. Bušková, B. A. Mander, M. Brunovský,
P. Zach, J. Korčák, et al. 2020. The effects of daytime
psilocybin administration on sleep: implications for anti­
depressant action. Frontiers in Pharmacology 11:602590.
doi:10.3389/fphar.2020.602590.
Duman, R. S., and G. K. Aghajanian. 2012. Synaptic dysfunc­
tion in depression: Potential therapeutic targets. Science
(New York, NY) 338 (6103):68–72. doi:10.1126/science.
1222939.
Duman, R. S., G. K. Aghajanian, G. Sanacora, and
J. H. Krystal. 2016. Synaptic plasticity and depression:
New insights from stress and rapid-acting antidepressants.
Nature Medicine 22 (3):238–49. doi:10.1038/nm.4050.
Gabriel, F. C., D. O. de Melo, R. Fráguas, N. C. Leite-Santos,
R. A. Mantovani da Silva, E. Ribeiro, and G. Fischer. 2020.
Pharmacological treatment of depression: A systematic
review comparing clinical practice guideline
recommendations. PloS One 15 (4):e0231700. doi:10.1371/
journal.pone.0231700.
Godlewska, B. R., R. Norbury, S. Selvaraj, P. J. Cowen, and
C. J. Harmer. 2012. Short-term SSRI treatment normalises
amygdala hyperactivity in depressed patients. Psychological
Medicine 42 (12):2609–17. doi:10.1017/
S0033291712000591.
Gotlib, I. H., and J. Joormann. 2010. Cognition and depres­
sion: Current status and future directions. Annual Review
of Clinical Psychology 6 (1):285–312. doi:10.1146/annurev.
clinpsy.121208.131305.
Grandjean, J., D. Buehlmann, M. Buerge, H. Sigrist, E. Seifritz,
F. X. Vollenweider, C. R. Pryce, and M. Rudin. 2021.
Psilocybin exerts distinct effects on resting state networks
associated with serotonin and dopamine in mice.
NeuroImage 225:117456. doi:10.1016/j.neuroimage.2020.
117456.
Griffiths, R. R., M. W. Johnson, M. A. Carducci, A. Umbricht,
W. A. Richards, B. D. Richards, M. P. Cosimano, and
M. A. Klinedinst. 2016. Psilocybin produces substantial
and sustained decreases in depression and anxiety in
patients with life-threatening cancer: A randomized
double-blind trial. Journal of Psychopharmacology
(Oxford, England) 30 (12):1181–97. doi:10.1177/
0269881116675513.
Gutiérrez-Rojas, L., A. Porras-Segovia, H. Dunne,
N. Andrade-González, and J. A. Cervilla. 2020. Prevalence
and correlates of major depressive disorder: A systematic
review. Brazilian Journal of Psychiatry 42 (6):657–72.
doi:10.1590/1516-4446-2020-0650.
S. H. Halpern, Douglas. ed. 2005. Appendix: Jadad Scale for
Reporting Randomized Controlled Trials. In Evidence-
JOURNAL OF PSYCHOACTIVE DRUGS 13
based Obstetric Anesthesia, 237–38. John Wiley & Sons,
Ltd. doi: 10.1002/9780470988343.app1.
Hendricks, P. S., M. W. Johnson, and R. R. Griffiths. 2015.
Psilocybin, psychological distress, and suicidality. Journal
of Psychopharmacology (Oxford, England) 29 (9):1041–43.
doi:10.1177/0269881115598338.
Hesselgrave, N., T. A. Troppoli, A. B. Wulff, A. B. Cole, and
S. M. Thompson. 2021. Harnessing psilocybin:
Antidepressant-like behavioral and synaptic actions of psi­
locybin are independent of 5-HT2R activation in mice.
Proceedings of the National Academy of Sciences 118 (17):
e2022489118. doi:10.1073/pnas.2022489118.
Hooijmans, C. R., M. M. Rovers, R. B. de Vries, M. Leenaars,
M. Ritskes-Hoitinga, and M. W. Langendam. 2014.
SYRCLE’s risk of bias tool for animal studies. BMC
Medical Research Methodology 14 (1):43. doi:10.1186/
1471-2288-14-43.
Inserra, A., D. D. Gregorio, G. Gobbi, and M. Nader. 2021.
Psychedelics in Psychiatry: Neuroplastic, immunomodula­
tory, and neurotransmitter mechanisms. Pharmacological
Reviews 73 (1):202–77. doi:10.1124/pharmrev.120.000056.
Kennedy, S. H., R. W. Lam, R. S. McIntyre, S. V. Tourjman,
V. Bhat, P. Blier, M. Hasnain, F. Jollant, A. J. Levitt,
G. M. MacQueen, et al. 2016. Canadian network for
mood and anxiety treatments (CANMAT) 2016 clinical
guidelines for the management of adults with major depres­
sive disorder: section 3. pharmacological treatments. The
Canadian Journal of Psychiatry. 61 (9): 540–60. doi:10.
1177/0706743716659417.
Kometer, M., A. Schmidt, R. Bachmann, E. Studerus,
E. Seifritz, and F. X. Vollenweider. 2012. Psilocybin biases
facial recognition, goal-directed behavior, and mood state
toward positive relative to negative emotions through dif­
ferent serotonergic subreceptors. Biological Psychiatry
72 (11):898–906. doi:10.1016/j.biopsych.2012.04.005.
König, H., H.-H. König, and A. Konnopka. 2019. The excess
costs of depression: A systematic review and meta-analysis.
Epidemiology and Psychiatric Sciences 29: doi:10.1017/
S2045796019000180.
Kraehenmann, R., K. H. Preller, M. Scheidegger, T. Pokorny,
O. G. Bosch, E. Seifritz, and F. X. Vollenweider. 2015.
Psilocybin-induced decrease in amygdala reactivity corre­
lates with enhanced positive mood in healthy volunteers.
Biological Psychiatry 78 (8):572–81. doi:10.1016/j.biopsych.
2014.04.010.
Kuypers, K. P. C. 2020. The therapeutic potential of micro­
dosing psychedelics in depression. Therapeutic Advances in
Psychopharmacology 10:2045125320950567. doi:10.1177/
2045125320950567.
Lépine, J.-P., and M. Briley. 2011. The increasing burden of
depression. Neuropsychiatric Disease and Treatment
7 (Supplement 1):3–7. doi:10.2147/NDT.S19617.
Lewis, C. R., K. H. Preller, R. Kraehenmann, L. Michels,
P. Staempfli, and F. X. Vollenweider. 2017. Two dose
investigation of the 5-HT-agonist psilocybin on relative
and global cerebral blood flow. NeuroImage 159:70–78.
doi:10.1016/j.neuroimage.2017.07.020.
Li, N.-X., Y.-R. Hu, W.-N. Chen, and B. Zhang. 2022. Dose
effect of psilocybin on primary and secondary depression:
A preliminary systematic review and meta-analysis.
Journal of Affective Disorders 296:26–34. doi:10.1016/j.
jad.2021.09.041.
14 H. J. LEE ET AL.
Lowe, H., N. Toyang, B. Steele, H. Valentine, J. Grant, A. Ali,
W. Ngwa, and L. Gordon. 2021. The therapeutic potential
of psilocybin. Molecules 26 (10):2948. doi:10.3390/
molecules26102948.
MacQueen, G., P. Santaguida, H. Keshavarz, N. Jaworska,
M. Levine, J. Beyene, and P. Raina. 2017. Systematic
Review of Clinical Practice Guidelines for Failed
Antidepressant Treatment Response in Major Depressive
Disorder, Dysthymia, and Subthreshold Depression in
Adults. Canadian Journal of Psychiatry Revue Canadienne
De Psychiatrie 62 (1):11–23. doi:10.1177/
0706743716664885.
Mahmoudi, E., M. Faizi, R. Hajiaghaee, and A. Razmi*. 2018.
Alteration of depressive-like behaviors by psilocybe cuben­
sis alkaloid extract in mice: The role of glutamate pathway.
Research Journal of Pharmacognosy 5 (2):17–24. doi:10.
22127/rjp.2018.58486.
Mason, N. L., K. P. C. Kuypers, F. Müller, J. Reckweg,
D. H. Y. Tse, S. W. Toennes, N. R. P. W. Hutten,
J. F. A. Jansen, P. Stiers, A. Feilding, et al. 2020. Me, myself,
bye: Regional alterations in glutamate and the experience of
ego dissolution with psilocybin. Neuropsychopharmacology
Article 12. 45 (12):2003–11. doi:10.1038/s41386-020-0718-8.
Mattson, M. P. 2008. Glutamate and neurotrophic factors in
neuronal plasticity and disease. Annals of the New York
Academy of Sciences 1144 (1):97–112. doi:10.1196/annals.
1418.005.
McIntyre, R. S., M.-J. Filteau, L. Martin, S. Patry, A. Carvalho,
D. S. Cha, M. Barakat, and M. Miguelez. 2014. Treatment-
resistant depression: Definitions, review of the evidence,
and algorithmic approach. Journal of Affective Disorders
156:1–7. doi:10.1016/j.jad.2013.10.043.
Mertens, L. J., M. B. Wall, L. Roseman, L. Demetriou,
D. J. Nutt, and R. L. Carhart-Harris. 2020. Therapeutic
mechanisms of psilocybin: Changes in amygdala and pre­
frontal functional connectivity during emotional proces­
sing after psilocybin for treatment-resistant depression.
Journal of Psychopharmacology (Oxford, England)
34 (2):167–80. doi:10.1177/0269881119895520.
Moreno-Agostino, D., Y.-T. Wu, C. Daskalopoulou,
M. T. Hasan, M. Huisman, and M. Prina. 2021. Global
trends in the prevalence and incidence of depression:
A systematic review and meta-analysis. Journal of
Affective Disorders 281:235–43. doi:10.1016/j.jad.2020.
12.035.
Moriguchi, S., A. Takamiya, Y. Noda, N. Horita, M. Wada,
S. Tsugawa, E. Plitman, Y. Sano, R. Tarumi, M. ElSalhy,
et al. 2019. Glutamatergic neurometabolite levels in major
depressive disorder: A systematic review and meta-analysis
of proton magnetic resonance spectroscopy studies.
Molecular Psychiatry 24 (7): 952–64. Article 7. doi:10.
1038/s41380-018-0252-9.
Mulinari, S. 2012. Monoamine theories of depression: histor­
ical impact on biomedical research. Journal of the History of
the Neurosciences 21 (4):366–92. doi:10.1080/0964704X.
2011.623917.
Munn, Z., T. H. Barker, S. Moola, C. Tufanaru, C. Stern,
A. McArthur, M. Stephenson, and E. Aromataris. 2020.
Methodological quality of case series studies: An introduc­
tion to the JBI critical appraisal tool. JBI Evidence Synthesis
18 (10):2127. doi:10.11124/JBISRIR-D-19-00099.
Muttoni, S., M. Ardissino, and C. John. 2019. Classical psy­
chedelics for the treatment of depression and anxiety:
A systematic review. Journal of Affective Disorders
258:11–24. doi:10.1016/j.jad.2019.07.076.
Price, J., V. Cole, and G. M. Goodwin. 2009. Emotional
side-effects of selective serotonin reuptake inhibitors:
Qualitative study. British Journal of Psychiatry
195 (3):211–17. doi:10.1192/bjp.bp.108.051110.
Price, R. B., and R. Duman. 2020. Neuroplasticity in cognitive
and psychological mechanisms of depression: An integra­
tive model. Molecular Psychiatry Article 3. 25 (3):530–43.
doi:10.1038/s41380-019-0615-x.
Raval, N. R., A. Johansen, L. L. Donovan, N. F. Ros,
B. Ozenne, H. D. Hansen, and G. M. Knudsen. 2021.
A single dose of psilocybin increases synaptic density and
decreases 5-HT2A receptor density in the pig brain.
International Journal of Molecular Sciences 22 (2):E835.
doi:10.3390/ijms22020835.
Roseman, L., L. Demetriou, M. B. Wall, D. J. Nutt, and
R. L. Carhart-Harris. 2018. Increased amygdala responses
to emotional faces after psilocybin for treatment-resistant
depression. Neuropharmacology 142:263–69. doi:10.1016/j.
neuropharm.2017.12.041.
Rossi, A. F., L. Pessoa, R. Desimone, and L. G. Ungerleider.
2009. The prefrontal cortex and the executive control of
attention. Experimental Brain Research Experimentelle
Hirnforschung Experimentation Cerebrale 192 (3):489–97.
doi:10.1007/s00221-008-1642-z.
Schmaal, L., D. J. Veltman, T. G. M. van Erp, P. G. Sämann,
T. Frodl, N. Jahanshad, E. Loehrer, H. Tiemeier, A. Hofman,
W. J. Niessen, et al. 2016. Subcortical brain alterations in
major depressive disorder: Findings from the ENIGMA
major depressive disorder working group. Molecular
Psychiatry 21 (6):806–12. doi:10.1038/mp.2015.69.
Shamsrizi, P., B. P. Gladstone, E. Carrara, D. Luise, A. Cona,
C. Bovo, and E. Tacconelli. 2020. Variation of effect esti­
mates in the analysis of mortality and length of hospital stay
in patients with infections caused by bacteria-producing
extended-spectrum beta-lactamases: A systematic review
and meta-analysis. British Medical Journal Open 10 (1):
e030266. doi:10.1136/bmjopen-2019-030266.
Shao, L.-X., C. Liao, I. Gregg, P. A. Davoudian, N. K. Savalia,
K. Delagarza, and A. C. Kwan. 2021. Psilocybin induces
rapid and persistent growth of dendritic spines in frontal
cortex in vivo. Neuron 109 (16):2535–44.e4. doi:10.1016/j.
neuron.2021.06.008.
Siegle, G. J., W. Thompson, C. S. Carter, S. R. Steinhauer, and
M. E. Thase. 2007. Increased amygdala and decreased dorso­
lateral prefrontal BOLD responses in unipolar depression:
Related and independent features. Biological Psychiatry
61 (2):198–209. doi:10.1016/j.biopsych.2006.05.048.
Skolnick, P., R. T. Layer, P. Popik, G. Nowak, I. A. Paul, and
R. Trullas. 1996. Adaptation of N-Methyl-D-Aspartate
(NMDA) receptors following antidepressant treatment:
implications for the pharmacotherapy of depression.
Pharmacopsychiatry 29 (1):23–26. doi:10.1055/s-2007-
979537.
Stuhrmann, A., T. Suslow, and U. Dannlowski. 2011. Facial
emotion processing in major depression: A systematic
review of neuroimaging findings. Biology of Mood &
Anxiety Disorders 1 (1):10. doi:10.1186/2045-5380-1-10.

Tagliazucchi, E., R. Carhart‐Harris, R. Leech, D. Nutt, and
D. R. Chialvo. 2014. Enhanced repertoire of brain dynami­
cal states during the psychedelic experience. Human Brain
Mapping 35 (11):5442–56. doi:10.1002/hbm.22562.
Taylor, D., T. R. E. Barnes, and A. H. Young. 2018. Prescribing
Guidelines in Psychiatry. 13th ed. ed. Wiley Blackwell.
https://dl.uswr.ac.ir/bitstream/Hannan/32636/1/
9781119442608.pdf.
Thomas, K., B. Malcolm, and D. Lastra. 2017. Psilocybin-
assisted therapy: a review of a novel treatment for psychia­
tric disorders. Journal of Psychoactive Drugs 49 (5):446–55.
doi:10.1080/02791072.2017.1320734.
Vargas, A. S., Â. Luís, M. Barroso, E. Gallardo, and L. Pereira.
2020. Psilocybin as a new approach to treat depression and
anxiety in the context of life-threatening diseases—a systema­
tic review and meta-analysis of clinical trials. Biomedicines
Article 9. 8 (9):331. doi:10.3390/biomedicines8090331.
Vollenweider F. 1999. 5-HT Modulation of Dopamine Release
in Basal Ganglia in Psilocybin-Induced Psychosis in Man—A
PET Study with [11C]raclopride. Neuropsychopharmacology
20 (5):424–433. doi:10.1016/S0893-133X(98)00108-0.
Walker, E. R., R. E. McGee, and B. G. Druss. 2015. Mortality
in Mental disorders and global disease burden implications.
JOURNAL OF PSYCHOACTIVE DRUGS 15
JAMA Psychiatry 72 (4):334–41. doi:10.1001/jamapsychia
try.2014.2502.
Wohleb, E. S., R. Terwilliger, C. H. Duman, and R. S. Duman.
2018. Stress-induced neuronal colony stimulating factor 1
provokes microglia-mediated neuronal remodeling and
depressive-like behavior. Biological Psychiatry
83 (1):38–49. doi:10.1016/j.biopsych.2017.05.026.
Yang, T. T., A. N. Simmons, S. C. Matthews, S. F. Tapert,
G. K. Frank, J. E. Max, A. Bischoff-Grethe, A. E. Lansing,
G. Brown, I. A. Strigo, et al. 2010. Adolescents with major
depression demonstrate increased amygdala activation—
ScienceDirect. Journal of the American Academy of Child
& Adolescent Psychiatry 49 (1):42–51. doi:10.1016/j.jaac.
2009.09.004.
Zhao, J.-L., W.-T. Jiang, X. Wang, Z.-D. Cai, Z.-H. Liu, and
G.-R. Liu. 2020. Exercise, brain plasticity, and depression.
CNS Neuroscience & Therapeutics 26 (9):885–95. doi:10.
1111/cns.13385.
Zou, K., W. Deng, T. Li, B. Zhang, L. Jiang, C. Huang, X. Sun, and
X. Sun. 2010. Changes of brain morphometry in first-episode,
drug-naïve, non–late-life adult patients with major depression:
an optimized voxel-based morphometry study. Biological
Psychiatry 67 (2):186–88. doi:10.1016/j.biopsych.2009.09.014.