Introduction
Psilocybin is a naturally occurring psychedelic compound found in certain species of mushrooms that produces alterations in mood, perception, and cognition through serotonergic mechanisms (Tylš, Páleníček, & Horáček, Reference Tylš, Páleníček and Horáček2014). In recent years, psilocybin use and availability have increased in the United States (US) alongside growing public interest and policy changes, including decriminalization and legalization in several jurisdictions (Black et al., Reference Black, Bau, Cook, Bemis and Monte2026; Palamar et al., Reference Palamar, Fitzgerald, Carr, Rutherford, Keyes and Cottler2024; Rockhill et al., Reference Rockhill, Black, Ladka, Sumbundu, Olsen, Jewell, Hunt, Wolf, Nerurkar, Dart and Monte2025; Yang et al., Reference Yang, Satybaldiyeva, Allen, Ayers and Leas2024). Randomized controlled trials have demonstrated the efficacy of psilocybin-assisted therapy across a range of psychiatric conditions, including major depressive disorder (Carhart-Harris et al., Reference Carhart-Harris, Bolstridge, Day, Rucker, Watts, Erritzoe, Kaelen, Giribaldi, Bloomfield, Pilling, Rickard, Forbes, Feilding, Taylor, Curran and Nutt2018; Davis et al., Reference Davis, Barrett, May, Cosimano, Sepeda, Johnson, Finan and Griffiths2021; Goodwin et al., Reference Goodwin, Aaronson, Alvarez, Arden, Baker, Bennett, Bird, Blom, Brennan, Brusch, Burke, Campbell-Coker, Carhart-Harris, Cattell, Daniel, DeBattista, Dunlop, Eisen, Feifel and Malievskaia2022; Griffiths et al., Reference Griffiths, Johnson, Carducci, Umbricht, Richards, Richards, Cosimano and Klinedinst2016), with trials reporting rapid and sustained reductions in depressive symptoms. However, these therapeutic effects have been observed in carefully controlled clinical settings that include structured dosing, psychological support, and close monitoring (Griffiths et al., Reference Griffiths, Johnson, Carducci, Umbricht, Richards, Richards, Cosimano and Klinedinst2016).
In contrast to clinical trials, psilocybin is often used in naturalistic, nonmedical settings without structured support or clinical monitoring (Hutchison, Hooper, & Karoly, Reference Hutchison, Hooper and Karoly2026), including recreational contexts such as nightclubs and festivals (Palamar, Le, Cleland, & Keyes, Reference Palamar, Le, Cleland and Keyes2023). Accordingly, efficacy and safety findings from psilocybin-assisted therapy conducted under highly structured clinical conditions should not be assumed to generalize to naturalistic use. Naturalistic psilocybin use occurs across a broad spectrum of contexts and motivations, including recreational use, self-directed symptom management, and use that occurs concurrently with conventional mental health treatment. Consequently, it remains unclear how naturalistic psilocybin use relates to engagement with conventional mental health care. One possibility is that some individuals may substitute psilocybin use for conventional mental health treatment, particularly in the context of increasing public perception of psychedelics as a therapeutic (Barnett et al., Reference Barnett, Arakelian, Beebe, Ontko, Riegal, Siu, Weleff and Pope2024; Biba & O’Shea, Reference Biba and O’Shea2025; Corrigan et al., Reference Corrigan, Haran, McCandliss, McManus, Cleary, Trant, Kelly, Ledden, Rush, O’Keane and Kelly2022). Alternatively, psilocybin use may reflect unmet need for care, with individuals seeking alternative approaches in the absence of adequate access to treatment (Danek et al., Reference Danek, Blackburn, Greene, Mazurenko and Menachemi2023). Further, psilocybin use may occur adjunctively alongside conventional mental health treatment, such as among individuals dissatisfied with a partial response to conventional care, such that its use does not reflect a change in treatment engagement at all. Recent evidence suggests that individuals with depression have elevated odds for psilocybin use (Yang, Eun, & Palamar, Reference Yang, Eun and Palamar2026), yet, to our knowledge, no nationally representative studies have examined whether such use among individuals with depression is associated with greater or lower utilization of conventional mental health treatment or with perceived unmet need for care.
Methods
Data source and study population
Data for this study were obtained from the 2024 National Survey on Drug Use and Health (NSDUH), a nationally representative, cross-sectional survey conducted annually of the noninstitutionalized US population age ≥ 12 years (Substance Abuse and Mental Health Services Administration, 2025). NSDUH employs a multistage area probability sampling design to assess substance use, mental health, and treatment utilization. The analysis was limited to 2024 data, as this was the first iteration of the survey to include assessment of psilocybin use recency, allowing identification of past-year psilocybin use. The weighted screening response rate was 21.9%, and the weighted interview response rate was 51.5%.
The present analysis was restricted to respondents who met criteria for past-year major depressive episode (MDE), defined per the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as experiencing ≥ 5 of 9 depressive symptoms during the same 2-week period, with at least one symptom being depressed mood or loss of interest or pleasure (American Psychiatric Association, 2013), yielding a sample of 6,793 individuals.
Measures
Psilocybin use was assessed by asking participants: ‘Have you ever, even once, used psilocybin, found in mushrooms?’ Participants who reported use were then asked about recency of use. This analysis focused on those who reported use within the past year.
Eight mental health treatment outcomes were examined across three domains. General mental health outcomes included past-year receipt of any mental health treatment (a composite of outpatient treatment, inpatient treatment, treatment by phone or video [hereafter referred to as telehealth], and prescription medication for mental health), as well as each component assessed individually. Depression-specific outcomes included seeing or speaking with a medical professional about depressive feelings and prescription medication use specifically for depressive feelings. Perceived unmet need for mental health treatment was assessed as a third domain, defined as having reported seeking or thinking that one should get treatment in the past year but not receiving it.
Sociodemographic covariates included age group, sex, race/ethnicity, annual household income, education, marital status, employment status, and health insurance status. Past-year substance use covariates included cannabis, lysergic acid diethylamide (LSD), 3,4-methylenedioxymethamphetamine (MDMA/ecstasy), ketamine, any prescription psychotherapeutic misuse (of pain relievers [opioids], tranquilizers, stimulants, or sedatives), and alcohol use disorder (AUD). Prescription misuse was defined as use in any way not directed by a doctor, including use without a prescription and in greater amounts, more often, or longer than directed. Past-year AUD was defined as endorsing ≥ 2 of 11 DSM-5 criteria within the past 12 months (American Psychiatric Association, 2013).
Statistical analysis
First, weighted percentages and 95% confidence intervals (CIs) were calculated to estimate the prevalence of past-year psilocybin use overall and within categories of sociodemographic and substance use characteristics. Bivariable associations were then assessed using Rao-Scott chi-square. Next, to examine associations between past-year psilocybin use and mental health treatment outcomes, we estimated separate generalized linear models using a Poisson distribution and log link to produce adjusted prevalence ratios (aPRs) and 95% CIs for each outcome. Models were adjusted for sociodemographic characteristics and other past-year substance use. Educational attainment (assessed only among individuals aged ≥ 18 years), marital status (assessed only among individuals aged ≥ 15 years), and employment status (assessed only among individuals aged ≥ 15 years) each included a separate category for younger respondents in the models to prevent casewise deletion.
All analyses were conducted using Stata SE 17 (StataCorp, College Station, TX) with sample weights used to account for the complex survey design, nonresponse, selection probability, and population distribution. Statistical significance was defined as a two-sided alpha of 0.05. Because associations between past-year psilocybin use and measures of mental health treatment utilization and perceived unmet need were examined as exploratory outcomes and given that these outcomes were correlated rather than statistically independent, no correction for multiple comparisons was applied. This secondary analysis was exempt from review at NYU Langone Medical Center’s Institutional Review Board.
Results
Among individuals with past-year MDE, an estimated 7.3% (95% CI: 6.4–8.3) used psilocybin in the past year. Table 1 presents bivariable associations between past-year psilocybin use and sociodemographic characteristics and other past-year substance use. Individuals who used psilocybin were more likely to be younger, male, never married, employed full-time, and to have used each of the other examined substances (all ps < 0.05).
Characteristics of US individuals with past-year major depressive episode by past-year psilocybin use status
Table 1. Long description
A data table titled Characteristics of U.S. individuals with past-year major depressive episode by past-year psilocybin use status.
Column headers include: Characteristic, Overall sample weighted % (95% CI), and Past-year psilocybin use divided into Yes weighted % (95% CI), No weighted % (95% CI), and p-value.
Key findings by row:
* Overall: 7.3% used psilocybin, while 92.7% did not.
* Age group: Age distribution differed by psilocybin use status (p < 0.001). Among individuals reporting past-year psilocybin use, 33.5% were aged 18–25 and 28.2% were aged 26–34.
* Sex: Males accounted for 54.3% of psilocybin users compared to 34.8% of non-users (p < 0.001).
* Race/ethnicity: Non-Hispanic white individuals made up 71.4% of users and 64.1% of non-users (p = 0.19).
* Employment: 50.0% of users were employed full-time compared to 38.5% of non-users (p < 0.001). * Marital status: 67.0% of users were never married compared with 55.9% of non-users (p = 0.045).
* Other substance use: Psilocybin users had significantly higher rates of other substance use (all p < 0.001), including cannabis (90.2% vs. 39.5%), LSD (14.4% vs. 0.7%), MDMA/ecstasy (9.5% vs. 1.0%), ketamine (6.7% vs. 0.8%), and psychotherapeutic prescription misuse (25.4% vs. 10.5%).
* Alcohol use disorder: 36.2% of psilocybin users had past-year alcohol use disorder compared with 17.9% of non-users (p < 0.001).
Note: CI, confidence interval; LSD, lysergic acid diethylamide; MDMA, 3,4-Methylenedioxymethamphetamine. The overall row presents row percentages; all other percentages are column percentages.
a Includes non-Hispanic American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and multiracial individuals. These races were collapsed into one category because there were too few participants to produce stable estimates.
b Educational attainment was assessed only among individuals aged ≥ 18 years.
c Employment status was assessed only among individuals aged ≥ 15 years.
d Includes students, people keeping house or caring for children full time, retired or disabled people, or other people not in the labor force.
e Marital status was assessed only among individuals aged ≥ 15 years.
Table 2 and Figure 1 present the bivariable and multivariable associations between past-year psilocybin use and mental health treatment outcomes among individuals with past-year MDE. In bivariable analyses, psilocybin use was associated with greater telehealth utilization (p = 0.02) and greater perceived unmet need for mental health treatment (p = 0.01). In multivariable analyses, the association with telehealth utilization was no longer significant after adjustment. However, the association with perceived unmet need remained significant (52.0% vs. 33.9%; aPR = 1.44; 95% CI: 1.04–2.01). Psilocybin use was not significantly associated with any other mental health treatment receipt outcomes, including the composite measure of any mental health treatment, inpatient care, outpatient care, prescription medication use for mental health, seeing a doctor for depressive feelings, and prescription medication use for depressive feelings.
Associations between past-year psilocybin use and mental health treatment utilization among individuals with past-year major depressive episode
Table 2. Long description
The table is organized into six columns: Characteristic, past year; Overall sample weighted % (95% CI); Past-year psilocybin use Yes weighted % (95% CI); Past-year psilocybin use No weighted % (95% CI); p value; and aPR (95% CI).
Key data rows include:
* Any mental health treatment: Overall 64.4%; Yes 66.5%; No 64.2%; p = 0.55; aPR 1.02 (95% CI 0.91–1.14).
* Outpatient: Overall 47.6%; Yes 46.1%; No 47.7%; p = 0.72; aPR 0.95 (95% CI 0.79–1.14).
* Inpatient: Overall 5.3%; Yes 7.6%; No 5.1%; p = 0.09; aPR 0.97 (95% CI 0.66-1.44).
* Telehealth: Overall 40.9%; Yes 50.0%; No 40.2%; p = 0.02; aPR 1.15 (95% CI 0.97-1.35).
* Prescription medication for mental health: Overall 48.3%; Yes 43.9%; No 48.7%; p = 0.26; aPR 0.87 (95% CI 0.73-1.04).
Depression-specific treatment section:
* Saw doctor for depressive feelings: Overall 60.1%; Yes 59.2%; No 60.2%; p = 0.81; aPR 1.03 (95% CI 0.90-1.18).
* Prescription medication for depressive feelings: Overall 46.4%; Yes 40.9%; No 46.8%; p = 0.14; aPR 0.85 (95% CI 0.72-1.01).
Perceived unmet need section:
* Sought or thought should get treatment, did not receive: Overall 35.2%; Yes 52.0%; No 33.9%; p = 0.01; aPR 1.44 (95% CI 1.04-2.01).
Footnotes indicate aPR stands for adjusted prevalence ratio and CI stands for confidence interval. The displayed p values correspond to bivariable analyses. Boldface in the original table indicates statistically significant aPRs from the multivariable models (p < 0.05).
Note: aPR, adjusted prevalence ratio; CI, confidence interval. P-values correspond to bivariable analyses. Boldface indicates statistically significant aPRs (95% CIs) (p < 0.05).
a Survey-weighted Poisson regression models for each treatment outcome, adjusted for all variables in Table 1.
Forest plot of associations between past-year psilocybin use and mental health treatment utilization among individuals with a past-year major depressive episode. Note: Dark gray markers indicate statistically significant associations (p < 0.05); light gray markers indicate nonsignificant associations. Estimates are from survey-weighted Poisson regression models for each treatment outcome, adjusted for all variables in Table 1. aPR, adjusted prevalence ratio; CI, confidence interval.
Figure 1. Long description
A forest plot with an x-axis labeled aPR (95% CI) ranging from 0.50 to 2.00, with a vertical dashed line at the null value of 1.00. The y-axis is divided into three categories.
General Mental Health Treatment:
* Any mental health treatment: Light gray marker at approximately 1.02 with a narrow 95% CI crossing 1.00.
* Outpatient: Light gray marker at approximately 0.95 with a 95% CI crossing 1.00.
* Inpatient: Light gray marker at approximately 0.97 with a wide 95% CI crossing 1.00.
* Telehealth: Light gray marker at approximately 1.15 with a 95% CI crossing 1.00.
* Prescription medication for mental health: Light gray marker at approximately 0.87 with a 95% CI crossing 1.00.
Depression-Specific Treatment:
* Saw doctor for depressive feelings: Light gray marker at approximately 1.03 with a 95% CI crossing 1.00.
* Prescription medication for depressive feelings: Light gray marker at approximately 0.85 with a 95% CI crossing 1.00.
Perceived Unmet Need:
* Sought/thought should get treatment, didn’t receive: Dark gray marker at approximately 1.44 with a 95% CI of 1.04–2.01. This is the only statistically significant association, with the 95% CI entirely above the null value of 1.00.
Discussion
In this nationally representative study of individuals with past-year MDE, psilocybin use was not significantly associated with any measures of mental health treatment receipt. However, psilocybin use was associated with a significantly higher prevalence of perceived unmet need for mental health care. To our knowledge, this is the first nationally representative study to examine associations between past-year psilocybin use and mental health treatment utilization and perceived unmet need among individuals with depression. These findings suggest that, among individuals with depression, psilocybin use co-occurs with unmet need for mental health care and is not associated with lower utilization of conventional treatment.
The null association between psilocybin use and all measures of mental health treatment utilization, including any mental health treatment, outpatient care, inpatient care, telehealth, prescription medication use for mental health, prescription medication use for depressive feelings, and seeing a doctor for depressive feelings, suggests that psilocybin use does not co-occur with systematic disengagement from conventional mental health care. From a clinical perspective, these findings do not support the assumption that individuals reporting recent psilocybin use are systematically avoiding conventional mental health care. Indeed, approximately two-thirds of respondents with past-year MDE who reported psilocybin use also reported receiving some form of mental health treatment during the past year, a prevalence comparable to that observed among nonusers. Accordingly, disclosure of psilocybin use should not necessarily be interpreted as evidence of disengagement from treatment, but rather as an opportunity to better understand how such use fits within an individual’s broader treatment history, current engagement with care, and motivations for use. Longitudinal and qualitative studies are needed to clarify how naturalistic psilocybin use relates to conventional treatment engagement over time.
These findings diverge from population-based evidence showing that lifetime psilocybin use was associated with lower inpatient treatment receipt among adults (Krebs & Johansen, Reference Krebs and Johansen2013) and that past-year LSD use was associated with lower overall mental health care receipt among young adults (Han, Blanco, Einstein, & Compton, Reference Han, Blanco, Einstein and Compton2022). These discrepancies may reflect differences in the substances examined, recency of use, study populations, and survey periods, and are consistent with evidence that specific hallucinogens may have differential associations with mental health outcomes (Yang, Han, & Palamar, Reference Yang, Han and Palamar2022). More broadly, these findings underscore the heterogeneous motivations underlying naturalistic psilocybin use. Although some individuals may use psilocybin as an alternative to conventional mental health treatment, others may use it adjunctively alongside ongoing treatment, for self-directed symptom management, or for recreational or personal reasons. The null associations observed across all measures of mental health treatment utilization are consistent with several of these possibilities and suggest that naturalistic psilocybin use should not be conceptualized as reflecting a single pattern of treatment engagement. Because the NSDUH does not assess motivations for use, future qualitative and longitudinal studies are needed to better characterize how different motivations relate to engagement with conventional mental health care.
In contrast to the null associations with treatment receipt, psilocybin use was associated with significantly greater perceived unmet need for mental health care, suggesting that psilocybin use among individuals with depression may co-occur with inadequate access to, or dissatisfaction with, conventional treatment. Individuals with depression often face structural barriers to treatment, including cost, limited availability of providers, and stigma, which may contribute to gaps between perceived need and receipt of care (Boehnke et al., Reference Boehnke, Cox, Weston, Herberholz, Glynos, Kolbman, Fields, Barron and Kruger2023; Dockery et al., Reference Dockery, Jeffery, Schauman, Williams, Farrelly, Bonnington, Gabbidon, Lassman, Szmukler, Thornicroft and Clement2015; Mongelli, Georgakopoulos, & Pato, Reference Mongelli, Georgakopoulos and Pato2020; Pabayo et al., Reference Pabayo, Benny, Liu, Grinshteyn and Muennig2022). Psilocybin use in this context may reflect attempts at self-directed symptom management, particularly given increasing public awareness of its potential therapeutic effects (Abboud et al., Reference Abboud, Schiebrel, Nahhas, Durkin, Hua, Redding and Gainer2025; Cioe, Stang, Azam, & Dugal, Reference Cioe, Stang, Azam and Dugal2025) as well as its increasing accessibility (Bhave, Reference Bhave2025). However, the present data cannot establish whether use was motivated by therapeutic intent, recreational interest, or other factors, nor whether perceived unmet need reflects structural barriers to care, attitudinal factors such as treatment skepticism or low motivation, or both. This interpretation is consistent with epidemiologic evidence indicating that psilocybin use is more prevalent among individuals with more severe depression and anxiety symptoms (Rockhill et al., Reference Rockhill, Black, Ladka, Sumbundu, Olsen, Jewell, Hunt, Wolf, Nerurkar, Dart and Monte2025; Yang et al., Reference Yang, Eun and Palamar2026), consistent with the notion that those with greater psychiatric burden may be more likely to seek out alternative approaches when conventional care is inadequate or inaccessible. Longitudinal studies examining the temporal relationship between psilocybin use and treatment engagement, as well as qualitative research exploring motivations for use among individuals with depression, are needed to better characterize these patterns. It should also be noted that past-year psilocybin use was assessed as a binary exposure that does not capture frequency, dose, setting, or context of use. For example, an individual who used psilocybin once recreationally at a festival and another who repeatedly used psilocybin in an attempt to manage depressive symptoms would both be classified simply as having past-year psilocybin use. Future studies capable of distinguishing these patterns will be important for clarifying the mechanisms underlying the associations observed here.
Limitations
This study has several limitations. First, the cross-sectional design precludes determination of causality or temporal relationships between psilocybin use and mental health treatment utilization, and it is not possible to establish whether psilocybin use preceded or followed unmet need for care. Second, all measures were based on self-report, which may be subject to recall and social desirability bias. Third, the NSDUH does not capture information on the context of psilocybin use, including motivations for use, dosing, frequency, or whether use occurred in therapeutic, ceremonial, or recreational settings. Fourth, although analyses adjusted for a range of sociodemographic and substance use characteristics, residual confounding by unmeasured variables, such as chronicity and severity of depression, prior treatment history, treatment response, and attitudes toward conventional mental health treatment, may influence the observed associations; for instance, individuals with greater psychiatric burden or prior dissatisfaction with conventional treatment may have been more likely both to use psilocybin and to report unmet need for care. Fifth, individuals living in institutionalized settings were not represented. As these populations may have greater psychiatric severity, different patterns of psilocybin use, and substantially different mental health treatment utilization than community-dwelling individuals, the findings may not generalize to the full spectrum of individuals with major depressive episode, particularly those receiving inpatient or residential psychiatric care. Sixth, the weighted interview response rate of 51.5% may introduce nonresponse bias. Individuals who do not participate in household surveys may differ systematically from respondents with respect to substance use, mental health, and treatment engagement, potentially influencing both prevalence estimates and observed associations, particularly for lower-prevalence substances such as psilocybin. Seventh, because this was an exploratory study examining multiple correlated mental health treatment outcomes, no formal correction for multiple comparisons was applied. Accordingly, the findings should be considered exploratory and hypothesis-generating and interpreted with caution. Eighth, some subgroup estimates in the descriptive analyses were based on relatively small numbers of respondents, resulting in wide confidence intervals and reduced precision. These estimates should therefore be interpreted with caution. Finally, perceived unmet need for mental health treatment is a subjective measure that may encompass a range of experiences, from structural barriers (e.g. cost and provider availability) to attitudinal factors (e.g. treatment skepticism, low motivation, and dissatisfaction with prior care), and may not fully correspond to clinically defined need.
Conclusions
Among community-dwelling individuals with depression, psilocybin use was not associated with lower utilization of conventional mental health treatment but was associated with greater perceived unmet need for care, suggesting that naturalistic psilocybin use may co-occur with unmet need for mental health services in this population. Clinicians should be aware that patients reporting psilocybin use may represent a subgroup with elevated psychiatric burden and unmet treatment need, warranting proactive assessment of symptom severity and barriers to care. As psilocybin use continues to increase in the context of a changing legal landscape and growing interest in its therapeutic potential for depression and other mental health conditions, understanding who is using psilocybin and their relationship to conventional mental health care will be increasingly important for clinicians and policymakers.
Acknowledgments
Dr. Palamar has consulted for the Washington-Baltimore High Intensity Drug Trafficking Areas program. Dr. Palamar had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Funding statement
Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Numbers R21DA060362 (PI: Palamar) and R01DA057289 (Palamar).
Competing interests
The authors declare no potential conflicts of interest.
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