Psychedelic Medicine’s Biggest Blind Spots | Richard Louis Miller

Clinical psychologist Richard Louis Miller returns to Third Wave’s podcast to argue that the psychedelic “renaissance” needs to confront adverse effects and patient-selection blind spots, not only potential benefits. He says pharmaceutical companies have historically obscured harms, and he frames his new book as a push for fuller disclosure so patients can make informed risk–reward decisions. Miller points to potential cardiovascular impacts at standard psychedelic doses — including elevated heart rate and blood pressure — and says those risks should matter for people with pre-existing heart issues.

He also stresses uncertainty for people with serious pre-existing psychiatric conditions, arguing that many trials exclude higher-risk participants and therefore leave gaps in evidence for groups such as those with schizophrenia, bipolar disorder, OCD, or borderline personality disorder. Miller distinguishes these questions from microdosing, which he portrays as having fewer adverse effects, while adding a personal account of the “paranoia” he felt when psychedelic use was illegal and threatened professional consequences.

The conversation turns to major pharma’s entry into the field, including Eli Lilly’s move into 5-MeO-DMT; Miller questions whether ultra-fast experiences are well-suited to psychotherapy and raises concerns about pricing and access. He suggests the current one-to-one guided model is expensive and argues group formats and peer-guiding may be more scalable. In the final section, Miller previews a forthcoming ageing book and criticises longevity “trends”, supplements, and commercialised wellness, advocating instead for exercise, real food, sleep, and social connection as long-term maintenance practices.

• Miller argues psychedelic medicine should disclose adverse effects transparently, contrasting this with what he portrays as pharma’s history of downplaying harms.
• He says standard-dose psychedelics can elevate heart rate and blood pressure, which he frames as a screening concern for patients with cardiovascular issues.
• He says evidence is limited for people with serious pre-existing psychiatric diagnoses because many clinical studies exclude higher-risk participants.
• Miller describes a non-physiological adverse effect from past illegality: persistent anxiety about legal and professional consequences.
• On Eli Lilly and 5-MeO-DMT, he questions whether very short-acting, intense experiences support therapeutic integration and raises cost/access concerns.
• He suggests group-based psychedelic therapy and peer-guiding as potential paths to scalability versus expensive one-to-one models.
• He criticises commercialised longevity practices and supplements, advocating basic maintenance: exercise, diet, rest, and real-world social ties.