Psychiatry Tomorrow

Most of Brittany Albright's treatment-resistant depression patients test positive for obstructive sleep apnea. Some longstanding ADHD cases turn out to be sleep apnea too—treated, the diagnosis comes off. Dr. Avinesh Bhar, a sleep medicine physician who founded Sliiip, joins Will Sauvé and Brittany Albright to discuss why sleep disorders hide behind psychiatric diagnoses. They cover how sleep apnea now shows up earlier and in different presentations, why women get missed on standard scoring, and what the 2-3am wake-up really means. The conversation also addresses the access crisis—only 150 sleep fellows graduate annually—and how telemedicine and home testing are starting to close the gap.Timestamped Show Notes:[00:00:00] Introduction: Dr. Bhar's path from pulmonology to sleep medicine [02:19] Sleep as a "single-player experience" and why patients normalize dysfunction[06:18] Psychiatry training teaches us to avoid deep sleep conversations[07:09] Only 150 sleep physicians graduate annually; most were grandfathered in[08:08] "The test is negative, now what?" The Seroquel referral loop[09:22] Tardive dyskinesia case from quetiapine prescribed for sleep[11:58] Financial conflicts in sleep medicine: in-lab vs. home testing[14:05] Setting up virtual sleep medicine for accessibility[16:44] Dr. Albright on 9-12 month waitlists and finding Dr. Bhar[19:04] The deprescribing challenge: when patients don't want to stop meds[21:43] Multi-night home testing vs. single-night in-lab studies[22:53] Skulls at smallest size in evolution; REM-dependent sleep apnea in women[24:06] The 2-3 AM wake-up: tracing the third REM cycle[26:15] "Is insomnia a diagnosis or symptom?"[27:01] Teeth grinding as a sign of sleep-disordered breathing[28:13] Sleep apnea and addiction: the stimulant-alcohol cycle[29:02] AI scoring trained on male patients; women get missed[31:32] PTSD, metabolic syndrome, and sleep apnea overlap[32:08] GLP-1s as "cheat code" for insurance approval[34:07] Weight loss doesn't cure sleep apnea permanently[35:38] Patients don't know what "well" feels like[36:20] ADHD diagnosis removal after sleep apnea treatment[38:09] Teenagers on stimulants: changing long-term trajectories[38:54] Magic wand question: insomnia as diagnosis vs. symptom[40:04] CBTI resources: the VA's free app[43:45] Wearables: useful for trends, not diagnosis Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice

What if one of psychiatry's most effective treatments for treatment-resistant depression emerged from watching childbirth breathing techniques?Around 30-48% of depression patients become treatment-resistant after failing two or more antidepressants. For those who've exhausted every option—medication after medication, therapy combinations, even ECT—psychiatrists face a clinical impasse. But vagal nerve stimulation (VNS) offers something unprecedented: patients don't just maintain improvement—they keep getting better, month after month, year after year.At Stony Brook University, Dr. Lucian Manu has helped over 20 patients access VNS, many of whom have reduced their reliance on weekly ketamine infusions to monthly or less while maintaining stability.What You'll LearnWhy VNS emerged from an accidental observation during Lamaze classes and what that tells us about vagal modulationHow VNS creates a clinical "floor" that prevents patients from reaching their lowest depressive episodesThe Medicare coverage breakthrough after 15 years of insurance denials—and the cost-effectiveness argument that workedPatient selection criteria, practical implementation details, and managing the insurance appeals processWhy functional improvements often precede symptom score changes Timestamped Show Notes[00:00:00] Introduction: VNS as a treatment discovered by accident[00:01:00] Dr. Will Sauvé joins as new co-host[00:02:00] Why VNS is gaining momentum now[00:03:00] Dr. Manu's journey into VNS starting in 2016[00:05:00] The vagus nerve: anatomy and function—80% afferent, pathway to locus coeruleus[00:08:00] Jake Zabara's serendipitous discovery at Lamaze class[00:11:00] From stopping dog seizures to human epilepsy treatment[00:13:00] PET scans reveal VNS targets same brain regions as TMS; patients report feeling better than ever[00:16:00] The two unique features that convinced the FDA: improvement over time, low relapse[00:19:00] Why insurance companies refused coverage 2005-2020: not "class one evidence"[00:22:00] The RECOVER trial and Medicare breakthrough—cost-effectiveness argument[00:27:00] Getting single-case agreements through appeals: "war of attrition"[00:31:00] Patient selection criteria: 4+ failed treatments, bell curve age distribution, no ceiling on failures[00:34:00] Comparing VNS to ECT: "less extreme, more natural—dialing up existing function"[00:35:00] Bipolar depression often underdiagnosed in "treatment-resistant" populations[00:38:00] How VNS reduces ketamine treatment frequency: creating the floor while ketamine provides acute relief[00:42:00] The surgical procedure: outpatient, comparable to pacemaker, 21 patients with zero explantation requests[00:46:00] Quality of life improvements precede symptom scores; using MADRS and CGI to counter self-report bias[00:50:00] Transcutaneous auricular VNS: the non-invasive future, respiratory-gated stimulation research[00:53:00] VNS-assisted psychotherapy: priming the brain to learn by activating locus coeruleus attention systems[00:56:00] Trauma surgery ICU delirium study with ta-VNS—cross-disciplinary collaboration Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice

Nine out of twenty patients in Dr. Brittany Albright's psychiatry practice were taking GLP-1 medications—not for weight loss, but because metabolic and psychiatric disease share the same pathophysiology. About 43% of patients with major depression have obesity, and GLP-1 receptors throughout the brain's mesolimbic reward system explain why these medications reduce alcohol cravings, tobacco cravings, and compulsive eating. A February 2024 JAMA Psychiatry study showed semaglutide significantly reduced drinking episodes in alcohol use disorder at relatively low doses. Dr. Will Sauvé and Dr. Brittany Albright discuss the neurobiological mechanisms, evidence-based patient selection beyond BMI, and why psychiatrists need to stop asking whether they're "allowed" to treat their patients' metabolic dysfunction. By 2030, over 50% of US adults will have obesity—the question isn't whether psychiatrists should prescribe GLP-1s, it's how we've gotten away with ignoring metabolic health for so long. Timestamped Show Notes[00:00:00] Introduction - Brittany's home office with plants and dogs[02:02] The "holistic" medicine debate[04:02] Why Brittany opened Sweetgrass Psychiatry[07:00] Bringing family medicine in-house[10:01] The economics of integrating primary care[11:08] Scaling to 30 clinicians[13:41] Full suite of interventional services offered[15:08] Nine out of twenty patients on GLP-1s[16:15] Depression and metabolic syndrome: 50/50 overlap[19:03] GLP-1s and the mesolimbic system[20:24] JAMA Psychiatry study on semaglutide for alcohol use disorder[21:17] Dr. Stahl quote: "Follow the FDA label and never get anybody better"[22:10] When GLP-1s aren't appropriate[24:01] Case study: patient on paliperidone gaining weight despite tirzepatide[25:52] Discovery of nucleus tractus solitaris[28:26] The "are we allowed to prescribe this?" debate[29:10] Valproic acid, propranolol, and scope of practice[30:01] Bipolar disorder, obesity, and mood episode frequency[30:49] Moving beyond the monoamine hypothesis[31:19] UK paper: no proof depression is serotonin deficiency[33:23] Alternative treatments: TMS, ketamine, GLP-1s[34:03] Dr. Stahl's prediction: MDD is five different illnesses[36:11] 2030 projection: over 50% of adults with obesity[37:27] Starting with clinicians practicing what they preach[38:44] Wild 5 Wellness program[40:34] Force multipliers: treating populations, not just individuals[43:06] Equipping other clinicians rather than scaling[43:48] Private practice summit planned for Vegas 2026 Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice

Dr. Martha Koo bought her first TMS machine in 2009 when colleagues thought she was "crazy"—now she runs 11 centers across California as immediate past president of the Clinical TMS Society. Her biggest revelation came when longtime therapy patients said "I'm good, but I'm not my true full self," showing how psychiatrists often settle for partial recovery. Unlike medications, TMS doesn't require patient belief to work—as one skeptical patient discovered when he achieved complete remission despite thinking the treatment was "silly." Early billing operated in a regulatory gray zone where insurers accidentally processed TMS sessions like MRIs, inadvertently funding the field's growth. She envisions a future with accelerated one-day protocols, mobile devices in oncology and OB-GYN settings, and implantable brain stimulators. Her blunt advice to hesitant colleagues: "The cat's out of the bag—I don't see a world in future psychiatry that's just medicine and therapy."Timestamped Show Notes:‍[08:09] The $100K gamble and early TMS adoption[13:25] Insurance loopholes and money-back guarantees[15:57] "Not my true full self": what patients really want[19:44] Santa's sleigh and the belief problem[22:50] Military medicine and the polypharmacy solution[25:05] Why TMS is five days a week (blame Dr. George's wife)[28:33] Accelerated, mobile, implantable: what's next[34:05] VNS comeback and combination approaches[37:21] Interventional psychiatry as evolution, not revolution[48:09] Advice for hesitant psychiatrists Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice

SummaryDr. Nicholas Fabiano, a third-year psychiatry resident at the University of Ottawa with 70,000+ X followers, explains how exercise can match antidepressants for mild-to-moderate depression through muscle-released proteins called myokines that act like "miracle grow for the brain." He introduces the FIT framework (Frequency, Intensity, Type, Time) for systematically discussing exercise with patients, similar to prescribing medication. Creatine supplementation, typically used by athletes, shows promise for mental health when used alongside traditional treatments, but brain benefits may require higher doses (10g+) than the standard 5g used in fitness. Fabiano warns that excessive exercise can become a form of self-harm when used to transfer emotional pain, with red flags including 6+ hours daily and frequent injuries. His vision for psychiatry's future centers on removing the artificial divide between mental and physical health, enabling better collaboration across medical specialties.Key takeaways:• Exercise intensity matters more than type for antidepressant effects • Creatine costs ~$35 for 90 servings and has favorable risk-benefit ratio • Supervised exercise interventions outperform unsupervised due to adherence • Future psychiatry requires integrated mind-body treatment approaches Timestamps / Shownotes[00:00:00] Introduction - Dr. Fabiano's background and training structure in Canada [00:04:30] Defining lifestyle psychiatry and the mind-body connection[00:06:00] Exercise for depression - research evidence and meta-analyses [00:09:00] Exercise study design challenges and placebo controls [00:11:30] Exercise intensity vs. type - what matters for antidepressant effects [00:15:00] The muscle-brain connection - myokines and BDNF explanation [00:20:00] Creatine for mental health - from gym supplement to brain fuel [00:26:00] Clinical implementation - the FIT framework for prescribing exercise [00:33:00] Exercise as self-harm - warning signs and red flags [00:40:00] Balancing productivity with self-care during medical training [00:42:00] Future of psychiatry - removing mental-physical health divide Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice

After a young patient died by suicide, many psychiatrists might retreat to safer cases—Dr. Matt Bernstein took a different path, choosing to treat our field's highest-risk patients in their communities rather than behind hospital walls. Drawing from his experience at McLean Hospital's acute unit and now at Ellenhorn's community-based program, he shares practical insights on balancing clinical risk with recovery potential. Through the groundbreaking Accord Metabolic Psychiatry Program, Bernstein demonstrates how integrating metabolic approaches with psychosocial rehabilitation can reduce symptoms and medication needs. His team's comprehensive approach combines measurement-based care, metabolic interventions, and meaningful social engagement to help patients rebuild their lives. Perhaps most importantly, Bernstein challenges our field's approach to risk, arguing that acknowledging psychiatry's mortality rate—while maintaining hope for recovery—opens new possibilities for treatment. His work offers a compelling model for moving beyond crisis management to create sustainable paths for recovery, even in our most complex cases.Episode Show Notes and Timestamps:[00:00:00] - Introduction: After a young patient's death by suicide, Dr. Bernstein chose to focus on high-risk psychiatric care in community settings.[00:01:00] - Host Dr. Will Sauvé introduces his background in military psychiatry and interventional approaches.[00:02:00] - Overview of Dr. Bernstein's career trajectory from McLean Hospital to pioneering community-based care.[00:03:00] - Early career at McLean Hospital- 8.5 years on Schizophrenia and Bipolar Inpatient Unit- Experience teaching residents- Transition to longitudinal care focus[00:05:00] - The PACT Model and Ellenhorn's Evolution- Origins in 1970s Wisconsin- Design as "hospital without walls"- Transition from public to private sector implementation[00:08:00] - Ellenhorn's Comprehensive Approach- Holistic treatment model- Integration of psychosocial rehabilitation- Focus on real-world functioning[00:11:00] - Discussion of Risk Management in Psychiatry- Comparison with other medical specialties- Role of clinical judgment- Impact on treatment decisions[00:13:00] - Development of Metabolic Psychiatry Program- Introduction to ketogenic approaches- Implementation of fasting protocols- Creation of Accord program[00:16:00] - Measurement-Based Care Strategies- Standard clinical measures- Functional outcome assessments- Digital phenotyping implementation[00:20:00] - Family Engagement and Risk Assessment- Shared decision-making approach- Balance of clinical liability and treatment access- Case example of successful risk management[00:28:00] - Future Directions- Integration of innovative treatments- Expansion of metabolic approaches- Vision for community-based careKey Quotes:- "What we find is that when we can get people connected psychosocially out there in real jobs or school or relationships, those experiences can reduce symptoms and take the place of medications."- "These are illnesses that have a mortality rate... sometimes someone dies and everyone did everything exactly right."- "It's a great time to be working in psychiatry because of these options that we didn't have even ten years ago."Resources Mentioned:- Program of Assertive Community Treatment (PACT)- Ellenhorn Community Treatment Program- Accord Metabolic Psychiatry Program‍ Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice

Dr. Husseini K. Manji, a visionary scientist behind esketamine, discusses its groundbreaking development as a treatment for depression. He shares insights into targeting NMDA receptors and the rigorous clinical trials leading to FDA approval. The conversation highlights the challenges of introducing novel psychiatric drugs, including regulatory hurdles and insurance issues. Dr. Manji also addresses the broader implications for mental health treatment and the promising future of psychedelic medicine, emphasizing the need for equality in mental health care.

Charles Miller, a CRNA and founder of Scenic City Neurotherapy, shares insights from his journey in establishing a ketamine infusion therapy clinic. He dives into the challenges of financing, navigating licensing, and the importance of patient education. Charles discusses expanding services and partnerships, particularly with the VA, to improve access for veterans. He emphasizes using technology for practice management and building a compassionate team to enhance patient care. This conversation is a treasure trove of practical advice for aspiring clinic founders.

In this episode of Psychiatry Tomorrow, Dr. Carlene MacMillan hosts a panel of experts to discuss the FDA's pending decision on MDMA-assisted therapy for PTSD. The conversation explores the current landscape of clinical enthusiasm and regulatory caution, key challenges facing approval, and potential regulatory requirements. Panelists Dr. Owen Muir, Dr. Boris Heifets, and Andrew Penn share their insights on functional unblinding in clinical trials, safety monitoring, and provider qualifications. The episode concludes with a look at the future of psychedelic medicine and the potential impact of the FDA's decision on mental health treatment. Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice

In this captivating episode, we explore Dr. David Feifel's unconventional journey from quantum physics to pioneering psychiatrist. Dr. Feifel shares how his fascination with consciousness led him to psychiatry, hoping to witness a "golden era" of breakthrough treatments. However, his early career was marked by disillusionment as the field remained stagnant, prompting him to seek innovative solutions.Dr. Feifel discusses his groundbreaking work with Transcranial Magnetic Stimulation (TMS) and ketamine therapy at UC San Diego. He details the challenges of implementing these treatments in academic settings, including the crucial role of set and setting in ketamine therapy. His persistence led to the creation of the Center for Advanced Treatment of Mood and Anxiety Disorders (CATMAD), where he combined TMS and ketamine treatments with remarkable results.The conversation then turns to Dr. Feifel's decision to leave academia and establish the Kadima Neuropsychiatry Institute, allowing him greater freedom to innovate. He also shares insights on his work expanding ketamine therapy to Rwanda, highlighting the challenges and rewards of adapting treatments to different cultural contexts. The episode concludes with a discussion on the future of psychiatry, including the complex interplay between innovation, regulation, and economics in bringing new treatments to patients.Throughout the episode, Dr. Feifel emphasizes the importance of thinking beyond traditional pharmacological approaches in psychiatry, advocating for a more holistic and innovative approach to mental health treatment. His journey offers valuable lessons for clinicians and researchers looking to push the boundaries of psychiatric care and improve outcomes for patients with treatment-resistant conditions. Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice