While psychedelic experiences are often reported as positive, adverse psychological reactions can occur. We present the case of a 19-year-old Caucasian male who presented to the ER with suicidal thoughts after taking lysergic acid diethylamide (LSD) alone. He was diagnosed with anxious state associated with panic attacks, and suicidal thoughts without ideation or behaviors. He was admitted to the psychiatric ward and treated with trazodone, a serotonin antagonist and reuptake inhibitor antidepressant, and brexpiprazole, an atypical antipsychotic. He responded well and was discharged after 12 days with recommendations to continue therapy with brexpiprazole and attend follow-up at the territorial mental health services. Five days later, he engaged in alcohol consumption with a roommate met during the psychiatric admission, and suicidal thoughts re-emerged. He presented again to the ER but was not admitted to the inpatient unit, since he improved with supportive conversation and medication. One month later, he returned to the ER a third time due to pervasive doubt and confusion that distressed him to the point of triggering unstructured suicidal thoughts. After one week of hospitalization, he was discharged and citalopram (a selective serotonin reuptake inhibitor [SSRI]) was added to the therapy. Following the third admission, the clinical suspicion strengthened that he may have an underlying obsessive functioning pattern that became clinically apparent following LSD use, although the contribution of other vulnerability factors could not be excluded. This case highlights the importance of set and setting, underscores the relevance of harm reduction strategies for both recreational and clinical users, and highlights a potentially negative interaction between serotonergic psychedelics and alcohol.
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