Psychiatry Tomorrow

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

Explore the emerging field of metabolic psychiatry and its potential to revolutionize mental health treatment. Discover the inspiring story of the Baszucki family and how a ketogenic diet helped their son overcome severe bipolar disorder. Learn about the science behind the gut-brain connection and the mechanisms by which the ketogenic diet can improve brain health. Gain insights from leading experts Dr. Georgia Ede and Dr. Bret Scher on implementing metabolic psychiatry in clinical practice, including how to assess metabolic health, collaborate with nutrition professionals, and address objections from traditional psychiatry and insurers. Finally, explore practical considerations for patient empowerment and learn how you can get involved in the growing metabolic psychiatry movement to help shape a brighter future for mental health care.Psychiatry Tomorrow Podcast Show Notes00:00:00 - Introduction- Over 50% of U.S. adults have insulin resistance, which affects blood sugar levels and impairs the brain's ability to process glucose- Interview with Dr. Georgia Ede, a psychiatrist specializing in nutritional and metabolic approaches to mental health, and Dr. Bret Scher, a cardiologist and director of Metabolic Mind- Ketogenic diet can fundamentally improve brain health by providing an alternate fuel source 00:02:00 - Introductions and background- Dr. Bret Scher's journey from cardiology to metabolic health and involvement with the Bazouki family and metabolic psychiatry- Dr. Georgia Ede's background and gradual incorporation of nutrition principles into her psychiatric practice 00:05:00 - Defining metabolic psychiatry- Understanding and addressing the metabolic root causes of mental health conditions, often through nutritional strategies 00:06:00 - The Baszucki family story- Matt Bazouki's struggle with bipolar disorder and remarkable improvement on a ketogenic diet under the guidance of Dr. Chris Palmer- The Baszuki family's commitment to advancing metabolic psychiatry research and education 00:10:00 - Research in metabolic psychiatry- Explosion of research in the field across a wide spectrum of psychiatric conditions- Dr. Albert Danan's study on the ketogenic diet in treatment-resistant patients with serious mental illness 00:14:00 - Ongoing and upcoming studies- Completed pilot studies by Dr. Shabani Sethi and Dr. Ian Campbell- New randomized controlled trials at McLean and University of Pittsburgh- Metabolic Mind's role in bringing together the scientific community 00:16:00 - Balancing the need for more research with helping patients today- Relying on clinical experience while working to speed up research and randomized controlled trials 00:17:00 - Metabolic psychiatry in mainstream psychiatric education- Lack of programming in traditional psychiatric training- McLean and Stanford now have formal programs 00:18:00 - Resources for psychiatrists to learn about metabolic psychiatry- Metabolic Mind website, Dr. Ede's book "Change Your Diet, Change Your Mind," clinician training programs, and literature 00:19:00 - Including a simple metabolic evaluation in psychiatric intake- Testing fasting insulin, triglycerides, HDL cholesterol, and waist circumference- Encouraging patients to improve overall metabolic health 00:21:00 - Metabolic assessment details- Problems with relying solely on fasting blood sugar and hemoglobin A1c- Importance of testing fasting insulin levels and other markers of metabolic health 00:24:00 - Scaling the ketogenic diet for the average person- Strategies for making the ketogenic diet affordable and accessible- Adapting the diet to various preferences, including vegetarian and vegan approaches 00:28:00 - GLP-1 agonists and their role in metabolic health- Dr. Ede's preference for food-first, lifestyle approaches- Limitations of medication-based solutions for the metabolic health crisis 00:31:00 - Empowering patients to improve their mental and metabolic health- The role of psychiatrists in supporting and encouraging patients while emphasizing the importance of patient ownership and self-efficacy 00:32:00 - Working with nutritionists and dietitians- Dr. Ede's unique experience incorporating nutrition principles into her practice without a dietitian- The value of collaborating with nutrition professionals for most psychiatrists 00:34:00 - Helping patients get started with metabolic psychiatry- Working with dietitians, therapists, or health coaches when doctors are not available or knowledgeable- Dr. Ede's clinician training course and directory 00:36:00 - Addressing polarization and myths on social media- Countering the perception that metabolic psychiatry is an alternative to conventional care- Emphasizing the importance of combining metabolic interventions with medication, psychotherapy, and other evidence-based treatments 00:38:00 - The role of ketogenic diets in mitigating the adverse effects of psychiatric medications- Metabolic damage caused by antipsychotics and certain anticonvulsants- The ketogenic diet as a powerful add-on treatment to improve metabolic health 00:41:00 - Mechanisms of action: how ketosis helps various psychiatric disorders- Multiple mechanisms, including lowering blood glucose levels, reducing inflammation, oxidative stress, and glutamate excitotoxicity- Providing an alternative fuel source in the form of ketones for those with insulin resistance 00:46:00 - Addressing the drug paradigm and the complexity of metabolic interventions- The ketogenic diet changes whole-body physiology, which may be off-putting to some physicians accustomed to the drug paradigm 00:47:00 - Insurance reimbursement and advocacy- The need for research demonstrating both efficacy and cost savings for insurance coverage- Precedents set by companies like Virta Health for type 2 diabetes treatment- The long-term cost-saving potential of metabolic interventions compared to lifelong medication use 00:50:00 - Getting involved in the metabolic psychiatry movement- Metabolic Mind's advocacy efforts led by Hannah Warren- The growing mainstream media coverage of metabolic psychiatry 00:51:00 - Resources for further learning and support- Metabolic Mind website, podcast, YouTube channel, and social media presence- Dr. Ede's website, DiagnosisDiet.com, offering trainings, a clinician directory, and articles 00:52:00 - Conclusion and final thoughts- The power of dietary interventions for mental health concerns- The potential for metabolic psychiatry to transform clinical practice and improve patient outcomes Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice

In this episode of Psychiatry Tomorrow, Dr. Jake Behrens shares his insights on navigating the complexities of diagnosing and treating adult ADHD. He discusses his comprehensive framework for ADHD assessments, the importance of psychoeducation, and strategies for medication management amidst the stimulant shortage. Dr. Behrens also explores the potential of digital health tools, the power of measurement-based care, and busts common myths about the condition. Throughout the conversation, he emphasizes the underrecognized dangers of ADHD underdiagnosis and undertreatment, and the importance of addressing it as a core issue that can open up profound possibilities for patients' lives.Timestamps and Show Notes:[00:01:00] Introduction: Adult ADHD is the second most prevalent adult psychiatric disorder, yet the U.S. lacks formal diagnostic guidelines, making it challenging for clinicians to properly diagnose and treat.[00:03:00] How Dr. Behrens got into specializing in adult ADHD during his residency working with high-functioning patients who responded robustly to treatment.[00:06:00] Dr. Behrens' framework for thorough ADHD assessments: Gathering detailed patient history, collateral information, using rating scales like the ASRS, and objective measures of executive function.[00:11:00] The importance of devoting significant time in initial evaluations to psychoeducation, explaining ADHD neurobiology and the full range of treatment options.[00:12:00] Navigating stimulant medication options and considering both effectiveness and affordability for patients.[00:18:00] Strategies for dealing with stimulant medication shortages, including working with a virtual assistant to locate medications and establishing relationships with pharmaceutical reps.[00:26:00] The benefits and challenges of working with pharmaceutical reps as a psychiatrist.[00:29:00] The multifaceted reasons behind the current stimulant medication shortage.[00:35:00] The potential impact of the DEA reinstating the Ryan Haight Act's in-person visit requirement for controlled substance prescriptions.[00:36:00] How Dr. Behrens provides patients with blood pressure cuffs for remote monitoring.[00:40:00] The exciting potential of digital health tools and wearables to passively track data that could enhance ADHD assessment and treatment.[00:44:00] The power of measurement-based care and involving patients in tracking their own data.[00:45:00] Busting common myths and misconceptions about adult ADHD, including that it's just about hyperactivity and that stimulant medications work like typical stimulants.[00:47:00] The underrecognized dangers of ADHD underdiagnosis and undertreatment, including increased risk of car accidents, job loss, relationship issues, and other adverse outcomes.[00:50:00] The importance of treating ADHD as a core issue that, when addressed, can remove barriers to other treatments and positive life changes.[00:51:00] Conclusion and sharing of Dr. Behrens' favorite ADHD resources for clinicians and patients. Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice

Dr. Rebecca Allen, a pioneering interventional psychiatrist and president of the Clinical TMS Society, is transforming mental health care delivery through her innovative outpatient clinic in Seattle. By offering a wide range of cutting-edge treatments like ECT, TMS, ketamine, and running COMPASS clinical trials for psilopsybin under one roof, she aims to expand access to life-changing treatments for patients with treatment-resistant conditions. In this interview, Dr. Allen shares her experiences growing a leading interventional psychiatry practice, spearheading groundbreaking research on psychedelic-assisted therapy, and navigating the challenges of insurance reimbursement and unregulated treatment models. She offers candid advice for fellow psychiatrists looking to enhance their practice and make a meaningful impact in the lives of their patients. Through her leadership and unwavering commitment to evidence-based innovation, Dr. Allen is paving the way for a brighter future in mental health care.Timestamps and Shownotes:[00:00:00] Introduction to the Psychiatry Tomorrow podcast and today's guest, Dr. Rebecca Allen[00:01:46] Dr. Allen's background and role as an interventional psychiatrist offering ECT, TMS, VNS, esketamine, IV ketamine, and ketamine-assisted psychotherapy at Seattle NTC[00:03:52] How Dr. Allen got started offering outpatient ECT and the logistics of partnering with Swedish Hospital[00:09:46] Seattle NTC as one of the largest outpatient ECT programs in the U.S., ECT stigma and underutilization[00:13:02] Busting myths about modern ECT and efforts to minimize cognitive side effects[00:16:15] A day in the life at Seattle NTC - ongoing treatments and clinical trials[00:19:45] Seattle NTC's involvement in the COMPASS trial on psilocybin-assisted therapy for treatment-resistant depression[00:20:26] How Dr. Allen's clinic got involved in clinical trials (BEAM study, VNS trial) and became a top enroller for COMPASS[00:27:52] Logistics and challenges of the COMPASS protocol, DEA scrutiny for psychedelic trials[00:29:33] Dr. Allen's concerns about Oregon's unregulated psilocybin program and the importance of robust clinical trials and medical oversight[00:35:17] Psilocybin is powerful but not a panacea - the need for thorough safety monitoring and the dangers of broad unregulated access[00:37:50] The advantages of offering multiple interventional psychiatry modalities to match treatments to patients[00:39:44] Dr. Allen's role as president of the Clinical TMS Society and initiatives to grow the organization[00:45:17] Balancing clinical work, research, and leadership roles[00:47:50] Advice for psychiatrists looking to scale a private practice - seeking expert consultation, reading contracts thoroughly[00:50:47] The importance of negotiating fair insurance reimbursement rates from the start[00:52:12] Conclusion and thanks to Dr. Allen Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice

Legal experts Daniel Sternthal and Ethan Minkin explore the legal intricacies surrounding ketamine therapy for psychiatric conditions. They delve into the importance of interdisciplinary respect, the legal challenges and malpractice risks associated with off-label ketamine use, and the vital role of informed consent. The discussion also highlights trends in the ketamine space, including the impact of COVID, private equity involvement, and the emergence of home ketamine therapy. With a focus on safeguarding practitioners through meticulous documentation and adherence to evolving legal standards, this episode is a must-listen for clinicians and legal professionals in the psychedelic medicine space. It wraps up with actionable advice on advocacy, education, and maintaining ethical practice standards to mainstream ketamine therapy safely. Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice