A Survey of Quality of Life in Brazilian Members of the União do Vegetal – Luís Fernando Tófoli

A Survey of Quality of Life in Brazilian Members of the União do Vegetal – Luís Fernando Tófoli


Well, it’s very good to be preceded by Brian’s speech because that relates a lot to me, I’m a psychiatrist I’m starting to study ayahuasca, well, I’ve been studying it for a while in a more scientific way, but I also used to be a member of the UDV I started drinking and stayed there for quite a long time and I’ve just departed from that institution for new ways, new paths So, definitely, it influences in many ways. I mean, us who are among this field or in this field and have contact with ayahuasca or other psychedelics and the expansion that might bring to us, and how this can relate to science So, in some sort of way, the questions I’m going to bring and some of the answers which are not much strong they kind of bring more questions to us, have to do with this story that I’m telling you So let’s see, it’s a very simple presentation, I’m going to present results from some studies we’ve been doing and analyzing, actually because this study has been done, collected, it is a multidisciplinary team, led by Paulo Barbosa who wasn’t able to come here, with people from the University of New Mexico and myself, from Campinas, and also Paulo is from a University in Bahia, Brazil, and also Michael Winkelman So, one thing important that we have to keep in mind, because I’m going to talk about quality of life and also, this is kind of two presentations, really, we should’ve put separately but since we have some interesting information to show you, we decided to put it together Originally the ideas was, for this study, to analyze the history of past drug use in UDV members But we also included an instrument of quality of life, and also, since we were going to do a survey, an inquiry about the use of SSRIs I’m going to show you why this But first of all, before we talk about quality of life, we have to keep in mind that we are not talking about just giving ayahuasca to people, that’s a context of religious use and that relates as well, we have some studies that relate religious use to quality of life and there are some criticism about even the concept of spirituality within quality of life saying that perhaps people may be confusing wellness, well-being, mental wellness with quality of life so there are some issues, some methodological issues, which in my opinion are unresolved you probably know that there are connections between psychedelics and well-being sometimes not so direct, sometimes may be very harsh, but in a long term, that’s something worth studying and also, that has been done and shown here in other ways of publicizing research that there is a connection between mental wellness and ayahuasca I won’t go through all these studies, but just to let you know that, just to make a picture Of course, there’s no much research done in terms of hard core scientists and neuroscientists and psychiatrists, they will say we know, we don’t have enough data, but people who’ve been working with that are proud to show that there is some evidence in different settings and situations, either evaluated qualitatively or quantitatively, that there is some connection between ayahuasca and some sort of well being and that could be connected to quality of life as well So this is a set of qualitative studies, and we also have some, sorry, quantitative studies, and we also have some qualitative studies which also present the experience of ayahuasca as something that would bring new life and new light to previous experiences and that could be connected also to quality of life and that’s worth measuring it also, as I said, I’m going to talk about two themes, the other theme is the question of SSRIs SSRIs are mostly used as antidepressants and there is a, now we can say it, a little bit old paper by Callaway and Grob, where they alerted about the risk of a serotonin syndrome by the combination of ayahuasca and SSRIs, and whenever you go to any people who have some information, specially westerners, they will say “never take ayahuasca with an SSRI” you might die, this is absolutely forbidden At the same time, in the religious settings in Brazil, people are taking these drugs for depression for anxiety disorders, and they are going to, even because they are looking for healing, they are going to this religious institutions and there might be no such tight a control and people are not so well informed about it And we know a lot of people are taking these drugs and they are drinking ayahuasca and they are not dying, this is a fact And then we wanted to measure that in some way, so that’s one of the reasons why we inserted this questions within the survey and we are gonna see what we have, in a very preliminar way, what we can assess from that So, the aims of the study was to assess factors associated with quality of life, high or low in the sample subjects from the UDV, and it’s important to stress that they regularly drink ayahuasca in a religious context, and also to analyze reports of effects of possible interactions of SSRIs and ayahuasca The study was in the UDV, Brian told you a bit about this religion to you, it was founded in 1961 by Mestre Gabriel, a rubber-tapper named Jo達o Gabriel da Costa It is a Christian synchretic, has some reincarnationist principles, and the rituals are very well structured Also, there is a stress on discipline The survey subjects, there is a very important point about the sample, it wasn’t random We didn’t made a lottery to see who would be included, to collaborate with us we just went to the temples and asked who would help, who wanted to collaborate, who would volunteer So there’s this self selection situation, we’re gonna see it might have been important, it is certainly important for the interpretation of our results !8 years and older and they had to be literate because it was a self-rated questionnaire they had to use So they had to know how to read and write This is very important because the UDV was very collaborative with this study and the UDV use, and gave the help of the monitors of the Medical Department of the UDV and they helped distributing the forms for people or the assess codes for the online survey and one important part of it is that there was a strong stress on confidentiality and anonymity So the monitors didn’t know what people were answering and the researchers didn’t know which person was answering what, so we made some sort of double blind, we were blind in different situations so we couldn’t connect, monitors couldn’t get to the information, researchers couldn’t identify subjects 62% of the forms were online, the rest on paper All there should be a picture here, a map of Brazil, I wanted to tell you that UDV has, at the moment 16.000 members distributed in 17 regions of Brazil Some states have two regions, some regions encompass two or three states But let’s see, these are the states where we had some subjects surveyed the distribution wasn’t a random distribution, it depended on how many people wanted to collaborate and also depended on the local situation of the temple, if there was support from the local leader or not So we had a pretty variable response rate, but in general, we had a 40% response rate but we couldn’t really say about response rate because we didn’t really asked everybody we didn’t select people and then would see if they would adhere or not to the study but just to let you know, that considering the temples, in therms of temples, we have done the survey 40% of the members of these temples did the research, voluntarily 36 temples, if we would consider the universe, it would be a universe of almost 10.000 people That would be, this sample, 12% of the whole UDV population We used a socio-demographic questionnaire, we use also WHO structured instrument for evaluation of quality of life, called WHOQOLBref, which was validated for portuguese language I won’t go into the data about drug use and drug abuse, but we also used a structured and validated interview and we also asked them about previous and present use of antidepressants, basically SSRIs and Monoamino-oxidase inhibitors, and we also asked them wether thay had taken these drugs with ayahuasca and if so, if they had an experience, and if so if they would describe the experience to us and they didn’t have much space for that, it was very short, but it gives us an idea of what was happening About the analysis, we compared quality of life and SSRIs use rates we don’t have much population references in Brazil for that, we have some sort of incomplete papers for that, so it’s not gonna be very profound, we also performed a multilevel analysis, since we had this data that we cannot say about prevalence because for prevalence we should have a random sample, but we can, since we had nested data individuals within temples, in this different levels of comparison, we used multilevel analysis and also a general description of SSRIs interaction, the way they were described by the members Just for you tog et a grio on our sample, you can see here, this is our data from the UDV census, from 2012, just the end of last year And you can see we had, in this sample, an over representation of male subjects this is important for something I’m going to say later There is a little bit different profile as well, considering marital status a little over representation of married people less single and less, unfortunately, I don’t have the data from the UDV about age, but I think part of this distinction probably is because the mature adults, but not old age and not young people, we had people with a higher chance of being married who participated probably people who were most involved with the institution as well There might be a situation here, where people more involved with the institution would have a greater chance of volunteering Also, in terms of education, you’re gonna see that as well, we have a higher representation of High School and University, and there is an important point, to stress about the UDV there is much higher proportion of people with university degree, or even post-graduate degrees compared with the general population. The UDV is, in a broad sense, a middle-class religion and its population is not representative of Brazilian population at all Here we have the comparison of results of quality of life, separated by male and female subjects above males and below females Here we have the percentile 50, which separates in a study originally done in Rio Grande do Sul in Brazil separates the half of their sample and would be like an average, expected value for this instrument for quality of life. So if you have the higher score, that would mean that you have a better score than the general population at least this particular population They didn’t work with the total score, so I can only compare the different domains of this instrument physical, psychological, social and environmental domains And one interesting thing is about the social domain of the UDV. It’s below the percentile 50, which doesn’t mean it’s pathological or anything, the other scores are higher, and they fall between 25 and 50, which is pretty normal, but it’s also interesting to ask why might it have happened? I don’t have an answer, but I think it’s a good question Thank you Well, related to quality of life, as age increases, quality of life gets worse Gender, women tend to report a worse quality of life than men This is what we would expect from the general population, this is normal in all studies Years of membership in the UDV was non significant, but there was a significant relation between the frequency of ayahuasca use and a better quality of life score. So people that would drink more ayahuasca would report better quality of life, or higher scores of quality of life. Also there was a connection between education and socio economic status, but we chose to include only socio economic status because of their high correlation and SES was a better variable to be used Considering age, if we’d control for socio economic status, this age effect would become more evident This is the range of the data that we have, I mean, from 18 to 81 years old, mean around the 40s, and also the frequency of ayahuasca drinking, as I said, when it was included in the model it still had a significant effect, but very small effect perhaps negligible About quality of life, we can say that, generally speaking they have a better quality of life than the general population sample, but we have to be carefull about this, because it is only one study in Brazil We had expected association with gender, age and socio economic status And we might think about this effect, people might think that when someone is drinking more ayahuasca this can obviously relate to a better quality of life, perhaps not. Perhaps we’re talking here about commitment to the institution, perhaps within this commitment to the institution we can get a bias towards giving better results, or just a good effect of being part of this community We don’t really know this For that we need other measures, but what we can say is it is probably safe to drink ayahuasca within this context. It’s not something that’s ruining peoples quality of life, this is interesting to stress as well I won’t have time to go into that, this is gonna be very… I have only two minutes, this is very hard to explain, and also, I don’t know why this didn’t appear well in the monitor, so it won’t be easy What I can tell you here, is here we have the frequency of people who reported the use of different anti-depressants and the most common is fluoxetine, which would be expected, these numbers of the frequency compared to the whole sample, is the percentage of subjects who have reported the use of antidepressants, and it’s pretty much what we would expect from the general population in Brazil specifically a population of middle-class and here we have the number of subjects who have taken ayahuasca while they were having also antidepressants, and it’s important to see the number of subjects taking fluoxetine and also people taking sibutramine. Sibutramine has been forbidden, it doesn’t exist in Brazil anymore It is not an antidepressant, it is a medicament for loosing weight, and it has some serious side effects even without ayahuasca, so I’m glad we won’t see this again, but the reports of effects was higher also with sibutramine which is important But as a general rule, what we can say is, it’s better if I show you this in letters There was no reported use of monoamino oxidase inhibitors within this sample As I said, the pattern of use of SSRIs is what would be expected form the population And we have 64 subjects who reported use of ayahuasca and an SSRI and reported some sort of effect, sorry this is not on the slide, but they reported effects More female subjects use SSRIs, which would also be predicted One interesting point is that being a UDV member does not prevent someone, apparently, from using SSRI. I mean, we’re not talking about very very low rates of antidepressant use people who would enroll as a subject didn’t know we’re going to ask about that So specifically about this point there’s no probable bias of self selection However it’s important to stress that the reporting of the absence of effect while someone was taking the two substances, ayahuasca and one antidepressant, was more common than reporting an effect, and the common effects were increased effect of ayahuasca or unpleasant, but there also were reports of people who felt that taking together the effects were decreased and also that it had pleasan’t effects Well, this is the biggest sample of cases of ayahuasca and SSRI interaction Of course there is no warrant of safety, but perhaps, and probably, the risk might have been exaggerated considering the literature, and I mean the urban legend that has been going in Brazil But we certainly need more studies, I have the accounts of a study that has been done with rats, and the results point to a similar situation as I have shown to you no improvement, no potentiation, but also, no deadly effects between the combination This is a sectional data, we’re talking about sectional data, it’s a survey We cannot talk about cause and effect, it’s just an association, this is also a non random sample One of the things people knew, from the name of the study, was that it was supposed to evaluate past drug use, and this would probably make people who used to be drug users had a tendency to present themselves to the study because they want to show how they’ve changed So this is something we have to take into account, and also the higher probability that someone self selects if he has higher institutional commitment One point that’s very important about the results, and I want to stress it again, is that it’s impossible to distinguish relgion and ayahuasca effects within this sample, so we can never say what is happening We can never say because it’s a survey, we cannot say about anything we cannot extrapolate much about cause and effect, but anyway, even if we could, it’s difficult to draw the limits between what is religion and what is the effect of the brew in this situation Also we might have some recall bias, specially on the recalling of having taken drugs, any drugs but also the SSRIs That’s it, Thank You very much (Applause) Thank You very much Luis, if you have any questions please come up to the microphone Thank you so much, congratulations for your work My question is, so the effect of ayahuasca was less, when taking SSRIs, did I understand it correct? No, some people reported that Some reported… The most commmon response was no response, I mean, we asked them, have you taken this drug? Yes or no, and then, have you taken this drug while you were taking ayahuasca? Yes or no And then we had a special look on this sample that said “Yes”, they have taken together and then we asked them, Have you had any change in the ayahuasca effect while you were taking the drug? Most said “No”, some said “Yes”, and most of those who said that had an effect, that the effect wasn’t good Could you explain that? Well, the symptoms that were related most commonly was nausea, dizziness, vomiting, tremor That’s the basic group of them, some others related other symptoms as well What are your thoughts…? Sorry, just a second, part of them said that the effect was mild, we cannot explain that We don’t know how to explain that, perhaps people were taking less ayahuasca because they were afraid perhaps there’s some kind of modulation in the situation, and there are so many elements that we have to ponder when we’re talking about psychedelics that it’s difficult The SSRIs and the MAO, I don’t know if the SSRIs can probably block the MAO and… My other question is, do you think the capsule form would change the half-life and the potency effect because you guys were working using the capsules That’s a lomg story, I don’t know if we have the time for that, because there’s some polemics about the results of some studies that have been using the liophilized form of ayahuasca What I can say to you about this study is we cannot say anything about that, perhaps we should talk about later about that Thank you for your presentation, just a quick question, I’m in the Santo Daime for 17 years responsible as a Church Leader, and we have a protocol that has been developed, mostly in north america, but I believe also in some centers in south america For those who are already drinking ayahuasca or Santo Daime, who are advised to go on on an SSRI usually what happens is they drink a little less the day of the work, and they do not take their antidepressant the day of the work, so you didn’t mention any of these, I’m not sure if the same thing was in place Most people also find that they take a little a less, and within themselves they make their adjustment on their medication, they come to have an intuition on how much to drink and also if they don’t take the SSRI the day following the work. Was this looked into in your study? This is an excellent question, because this is, when we’re talking about experienced users, they know how to deal with the effects, and they control the effects using the amounts they are taking and also the way they are taking their medication. There’s no formal indication of that, there is a general reccomendation, specially for newcomers within the UDV, to lower the doses of ayahuasca when people arrive taking these drugs Before we had the recommendation, the UDV had a recommendation saying it wasn’t possible to have that, that people should quit medication before taking ayahuasca but after a while a lot of cases escaped and just happened, and generally what psychiatrists either who are or are not of the ayahuasca religions, but who are used to medicate people who drink ayahuasca, they normally suggest that you talk to the person who is responsible, make the person aware, so the person may lower the dose if necessary, and it’s common to say that the person not take the drug on the day of the session, or the day of the work, as is said for the Santo Daime but this is a problem for fluoxetine that has a very long half life, so specially for fluoxetine it’s not a very good drug to be taken if there is an option It’s a question bout dieting, is dieting also taken into consideration when doing clinical studies on ayahuasca, as a ceremony, and the second question is what happens if you don’t do diet and take ayahuasca? Is there any consequence? Sorry I didn’t understand About the diet… Oh, the diet, OK Specifically for UDV? Yeah, for clinical studies of ayahuasca or your study, is diet part of the preparation? Or not? This is completely different depending on the tradition of ayahuasca drinking There is some sort of dieting withing Santo Daime, which is different from the dieting which is common in Peru for instance. It has nothing to do, and UDV for instance has no diet at all People may have a feijoada and go the same night to a session, so there’s no… and apparently people are not dying from that, that I can be sure I tend to see the diet more as a spiritual connection, more of a spiritual situation perhaps it may enhance the effects of the experience, but it’s probably not necessary for if the person doesn’t want to, to have a diet for a clinical trial for instance But they may make a clinical trial… Please a short question and a short answer Yeah, just a quick comment, do you have any thoughts in the UDV, in our lodge for instance we’re very concerned about SSRIs and we’re part of the scare tactic american-style But one of the reasons why we have promoted that is we are in the jungle, we don’t want to deal with an emergency, and the other reason is that, I have to go to a UDV ceremony, but would you typically use a more concentrated ayahuasca and I think that may play in this issue of dosage Yes, I think that’s a probably very good idea to take more care in a more remote situation, I totally agree Also, Bia reminded me of something very important, when we’re talking about diet, the abstinence of alcohol when someone is taking ayahuasca is also very important it may be very harsh in the situation, this is also part, and this is probably part of all the traditions because there might be a physiological reason for that that we don’t know yet Is there a consideration in this research regarding the strength of, I guess it comes out in the DMT quantities per milliliters, there seems there is a range compared to like the UDV tradition to an indigenous based tradition This is very subjective, but you probably would have to talk with someone who drank in different traditions Bia is someone very good, a person for you to talk with But from what I gather from what people tell me, for instance tradition you’re working with is a much more concentrated ayahuasca and then Santo Daime and probably the UDV is the less concentrated but it varies a lot, depends on the situation Thank You very much Luis

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