Highlights
Psychedelic-assisted therapy (PAT) demonstrates a large overall effect size (Hedges g = -0.84) in reducing depressive symptoms compared to control conditions.
A greater quantity of pre-dose preparation therapy hours is significantly associated with improved clinical outcomes (beta = -0.13, P = .04).
Counterintuitively, the quantity of post-dose integration sessions and total session count did not show a statistically significant association with symptom reduction in this analysis.
Treatment effects tend to diminish over time, with longer follow-up periods associated with smaller effect sizes.
Background: The Role of Psychotherapy in Psychedelic Medicine
In recent years, psychedelic-assisted therapy (PAT) has emerged as a promising frontier in the treatment of major depressive disorder (MDD) and treatment-resistant depression (TRD). Unlike traditional psychotropic medications that are taken daily, PAT typically involves the administration of a classic serotonergic psychedelic, such as psilocybin or lysergic acid diethylamide (LSD), in a highly controlled clinical environment. However, a defining characteristic of this modality is that the pharmacological agent is never administered in isolation; it is embedded within a structured psychological framework consisting of preparation, dosing, and integration phases.
While the pharmacological mechanisms of psychedelics—primarily their action on the 5-HT2A receptor—are well-documented, the ‘assisted’ component of PAT remains less quantified. Clinicians and researchers have long debated the optimal ‘dose’ of psychotherapy required to ensure safety and maximize efficacy. Is the therapy merely a safety net to prevent adverse psychological reactions, or is it a synergistic component that drives therapeutic change? Understanding the relationship between therapy quantity and clinical outcome is essential for standardizing protocols, reducing costs, and improving patient access to these novel interventions.
Study Design and Methodology
To address these questions, Florineth and colleagues conducted a systematic review and meta-analysis of controlled clinical trials. The researchers searched major databases, including PubMed, PsycINFO, and Scopus, through June 2025. The inclusion criteria were rigorous: studies had to involve adults with depressive symptoms, use classic serotonergic psychedelics, and report specific metrics regarding the quantity of psychological therapy provided.
The analysis focused on 12 trials encompassing a total sample of 733 participants (mean age 43.1 years; 49.8% female). These trials utilized various psychedelics, primarily psilocybin. The primary outcome measure was the standardized mean difference (Hedges g) in depressive symptoms across all available post-treatment time points. To account for the hierarchical structure of the data, the authors employed a multilevel random-effects meta-analysis and multilevel meta-regressions with robust variance estimation. This approach allowed them to assess how different metrics of therapy—duration in hours, number of sessions, and total duration in weeks—correlated with symptom reduction.
Key Findings: Does More Therapy Mean Better Results?
The Primacy of Preparation
The most significant finding of the study was the positive correlation between the number of preparation therapy hours and the magnitude of symptom reduction. The meta-regression revealed that for every additional hour of preparation therapy, there was a significant decrease in depressive symptoms (beta = -0.13; 95% CI, -0.24 to -0.01; P = .04). This suggests that the work done before the psychedelic experience—building therapeutic rapport, managing expectations, and establishing a ‘set’—is a critical determinant of the treatment’s success.
The Integration Paradox
In contrast to preparation, the quantity of post-dosing integration sessions did not show a statistically significant association with outcomes (beta = -0.02; 95% CI, -0.08 to 0.05; P = .53). Furthermore, the total number of therapy sessions (total session count) was not a significant predictor of efficacy (beta = -0.01; 95% CI, -0.09 to -0.08; P = .86). These results challenge the prevailing assumption that more integration therapy necessarily leads to better long-term outcomes, though the authors caution that qualitative nuances of integration might still be vital.
Overall Efficacy and the Effect of Time
The meta-analysis confirmed that PAT is highly effective in the short to medium term. The overall effect size was large (Hedges g = -0.84; 95% CI, -1.15 to -0.54; P < .001). However, the study also identified a temporal decay in these effects. Longer follow-up periods were associated with smaller treatment effect sizes (beta = 0.02; 95% CI, 0.01 to 0.04; P = .003), indicating that while the initial response is profound, some patients may require additional support or subsequent dosing sessions to maintain remission.
Expert Commentary: Interpreting the Data
The finding that preparation therapy is more predictive of success than integration therapy is particularly intriguing for clinical practice. From a mechanistic perspective, preparation hours likely serve to reduce anxiety and enhance the ‘psychological openness’ of the patient. By fostering a strong therapeutic alliance and providing a safe ‘container’ for the experience, preparation may enable patients to fully surrender to the psychedelic state, which is often cited as a predictor of mystical-type experiences and subsequent clinical improvement.
However, we must address the limitations of the existing literature. The researchers noted that the risk of bias was high in 75% of the included studies, primarily due to the inherent difficulty of blinding in psychedelic research. When participants and providers can easily distinguish between a psychedelic and a placebo, the risk of expectancy bias increases. Additionally, the meta-analysis focused on quantitative measures (hours and sessions) rather than the qualitative content or the specific therapeutic modality (e.g., CBT-based vs. existential-humanistic) used during those sessions.
Furthermore, the lack of significance for integration sessions does not imply that integration is unnecessary. It may suggest that beyond a certain threshold, the quantity of integration provides diminishing returns, or that the current metrics used to measure integration do not capture its true therapeutic value. In many protocols, integration is where patients make sense of their experience and translate insights into behavioral change; the absence of a quantitative correlation may simply reflect the high variability in how integration is practiced across different trials.
Conclusion and Clinical Implications
This systematic review and meta-analysis provides the first quantitative evidence that the amount of preparation therapy is a key driver of success in psychedelic-assisted therapy for depression. For clinicians and health policy experts, this highlights the need to prioritize robust pre-dose psychological support when designing PAT protocols. While the pharmacological effect of the psychedelic is substantial, the psychological ‘scaffolding’ provided by preparation appears to be a necessary catalyst for optimal outcomes.
As the field moves toward potential regulatory approval and clinical implementation, further research is needed to determine the ‘sweet spot’ for therapy quantity—identifying the point at which additional therapy no longer adds value. Moreover, future studies should focus on qualitative assessments of the therapeutic relationship to better understand why preparation seems to hold such significant weight in the healing process.
References
Florineth GA, Klima I, Boeker AL, et al. Psychological Therapy Quantity and Depressive Symptom Reduction in Psychedelic-Assisted Therapy: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2026;9(1):e2554843. doi:10.1001/jamanetworkopen.2025.54843.
