Assessing readiness for implementation of psychedelic-assisted mental health therapy, in low- and middle-income countries

Mental health disorders are described as a major and persistent global cause of disease burden, with substantial social and economic costs and limited recent innovation in treatment. The authors note that although psychedelic research has expanded rapidly in high-income countries, most of the global burden of mental illness sits in low- and middle-income countries (LMICs), where the feasibility of implementation has not been well examined. They also highlight that psychedelic therapies may need to be considered alongside cultural traditions, legal restrictions, and health-system capacity, especially in settings where indigenous use or task-sharing models already exist. Lam and colleagues therefore aimed to assess how ready 136 LMICs might be for implementing psychedelic-assisted mental health therapy (PAT). Their framework was intended to capture both demand for treatment and the capacity to deliver it, while also incorporating cultural familiarity with psychedelics and legal context as additional determinants of readiness.

The researchers carried out a country-level readiness assessment across 136 LMICs, using the World Bank classification for low- and middle-income status. They built a framework with 34 criteria grouped into eight domains: disease epidemiology, existing mental health infrastructure, prevention, workforce, mental health payment coverage, historical or cultural use of psychedelics, legal psychedelic retreats, and signatory status for the 1971 Convention on Psychotropic Drugs. Data were drawn from publicly available sources, including the 2019 Global Burden of Disease study, WHO suicide-rate data, the Mental Health Atlas, WHO Global Health Observatory indicators, and World Bank datasets. To identify countries with historical or cultural psychedelic use, and those with legal psychedelic retreats, the authors performed literature searches in MEDLINE, PsycINFO, Global Health databases, Journal of Psychedelic Studies, and Journal of Psychoactive Drugs, then verified findings using the ICEERS psychoactive plants report and independent online searches. For each criterion, countries were assigned one of three rankings. Criterion scores were summed within each domain, and countries were then noted if they fell into the top tertile for that domain. An overall summary score counted how many of the eight domains each country ranked in the top tertile, with a maximum possible score of eight. The authors did not weight criteria or domains differently. They also ran two versions of the analysis to handle missing data: one excluding unavailable values from tertile calculations, and one treating missing values as zero.

Among the 136 LMICs assessed, 28 were low-income and 108 were middle-income, spanning Africa, Asia, Europe, North America, Oceania, and South America. In both missing-data analyses, five countries stood out consistently: South Africa, Thailand, Mexico, Brazil, and Jamaica each ranked in the top tertile for seven of the eight domains. These countries were highlighted as having strong disease burden indicators, health-system infrastructure, prevention capacity, workforce availability, payment coverage, cultural familiarity with psychedelics, and legal psychedelic retreat presence. A second tier of countries included Malaysia, Colombia, Costa Rica, Peru, and Ecuador, which ranked in the top tertiles across six of eight domains in the missing-data-excluded analysis; Ecuador dropped out of this group when missing values were treated as zero. The authors note that historical or cultural psychedelic use and the existence of legal retreats helped lift some countries into higher overall scores. Equatorial Guinea and China also entered the top ten percent in the missing-data-excluded analysis, while Mauritius, Tunisia, Sri Lanka, Türkiye, Belize, and Samoa completed the top ten percent based on achieving top-tertile status in five domains. At the other end of the distribution, 25 countries did not rank in the top tertile for any domain in the missing-data-excluded analysis. This number fell to 23 in the missing-data-included analysis because Madagascar and Mali then achieved top-tertile status in at least one domain.

The authors interpret the findings as identifying a small group of LMICs that may be relatively well placed for PAT implementation, particularly South Africa, Thailand, Mexico, Brazil, and Jamaica. They argue that the strongest-scoring countries combine high mental health need with enough infrastructure, workforce, and payment coverage to potentially support implementation, and in some cases already have active psychedelic research or therapy initiatives. Examples they cite include trials in Brazil, ongoing work at Peru’s Takiwasi centre, a psilocybin study in South Africa, a published psilocybin treatment protocol in Jamaica, and Thailand’s approval for medical use and research involving psilocybin mushrooms. Lam and colleagues suggest that cultural familiarity with psychedelics and legal openness are important but not the only determinants of readiness. They note that some countries without a strong historical psychedelic background still scored highly because of broader health-system strengths and disease burden. They also discuss a striking tension in the index: some countries, such as China and Malaysia, scored highly despite very strict legal prohibitions on psychedelics, indicating that the index captures theoretical readiness rather than immediate legal feasibility. The authors emphasise that the two missing-data approaches produced broadly similar rankings, which they present as supporting the robustness of their approach. However, they acknowledge several limitations, including uncertainty in government-reported data, uneven data availability, and the difficulty of choosing readiness indicators and weighting them. They also note that some potentially relevant indicators, such as country-level PTSD prevalence, were not included because data were unavailable. A further limitation is that the index has not been validated as a predictor of actual implementation, approvals, clinical trials, or patient access. They therefore propose future validation work, including direct engagement with officials and follow-up studies comparing readiness scores with real-world PAT implementation outcomes. The authors conclude that the readiness rankings could help researchers, consortia, and funders prioritise countries for pilot studies, capacity-building, or policy work, while also identifying settings that would need investment in workforce, stigma reduction, or regulatory reform before PAT could be implemented at scale.

The authors conclude that 18 LMICs across five continents appear to have potential for PAT implementation at a public health scale, with South Africa, Thailand, Mexico, Brazil, and Jamaica standing out most clearly. They present the study as an initial step towards identifying countries for further investigation and for future research and policy development around psychedelic-assisted mental health therapy.