Highlights:

• A 60-year-old man with recurrent depression and history of delusions died after psilocybin-assisted therapy.
• Psilocybin-triggered delusions and emotional dysregulation may have contributed.
• Weak therapeutic alliance hindered assessment of patient’s internal state.
• Delusional symptoms may contraindicate psychedelic interventions.
• This case emphasizes the need for thorough assessment and close follow-up in complex cases.

Excerpt:

A 60-year-old male patient with a 20-year history of recurrent depression was admitted to our hospital in March 2023. His primary diagnosis was a severe depressive episode without psychotic symptoms. He presented with feelings of hopelessness, emptiness, low mood, rumination, and anxiety about work and his future existence. The patient also reported severe exhaustion and episodes of sudden mental blankness, described as “brain fog”. Notably, there was a significant discrepancy between the patient’s self-reported symptoms and his actual everyday competencies. The patient exhibited a tendency towards pathological hoarding, particularly of car parts. Passive suicidal ideations had been present for a long time, although there was no history of suicide attempts. The family medical history was unremarkable except for dementia in both parents. …

While a definitive causal relationship between the psilocybin treatment and the patient’s suicide cannot be established, this case underscores critical considerations for psychedelic-assisted therapy. Patients with a history of psychotic symptoms in the context of depression may require more cautious approaches or exclusion from such treatments. Morevoer, it is plausible that intense emotions triggered by the psilocybin treatment contributed to this outcome. This case highlights the importance of comprehensive patient assessment and follow-up, especially for individuals with complex psychiatric histories. For such patients, inpatient care may be advisable, as the administration of psychedelics can lead to temporary psychological instability. Furthermore, this incident emphasizes the need for heightened caution when treating patients whose inner experiences remain partially opaque to the clinical team.