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Psychiatry Tomorrow: Daily Summaries Delivered
by Osmind
Psychiatry is entering a new era. Join host Carlene MacMillan, M.D., Psychiatrist and Chief Medical Officer at Osmind, for Psychiatry Tomorrow, where we delve into captivating conversations with mental health leaders advancing the field. From groundbreaking research and technology, to the modern private practice and the policies shaping psychiatry’s future. Navigate the exciting realms of neuromodulation, rapid-acting antidepressants, metabolic psychiatry, psychedelic medicine, starting a private practice, and much more.Join us on this thrilling journey, and let’s transform mental health together.
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- Aug 26, 20261h 7m
The Interventional Psychiatry Clichés Dr. Lisa Harding Would Kill
Dr. Lisa Harding was a teenager when patients burned down the psychiatric hospital her father built in Guyana, and the care that resumed afterward happened in tents. That gap between what gets built and who actually gets treated has followed her from emergency medicine to a Yale chief residency in interventional psychiatry to the insurance-based practice she runs in Connecticut. On this episode of Psychiatry Tomorrow, she tells Will Sauvé and Brittany Albright which cliché she would erase from the field forever, why she thinks new treatments will only ever reach the top two percent of patients, and how becoming a trialist on the EQUIVALENCE comparison of IV ketamine and Spravato made her tighten her own response thresholds. She also explains what worries her about sublingual ketamine arriving at a patient's door in watermelon flavor, and why the field has no warning sign for pushing an NMDA receptor too far. The conversation ends where practices actually break, which is the money. Timestamped show notes Approximate. [00:00] Recording on Juneteenth, and why Harding calls herself a "freedom day baby" [03:02] Training as chief resident of interventional psychiatry at Yale, the field's one open spot [04:57] Two rejections from Yale, and a made-up specialty for people who wanted to do ER psych [05:48] From the ER to psychiatry: "I'll be the most empathetic physician you will ever meet" [07:59] Why she left academia: hospitals are a poor delivery mechanism [09:40] Sauvé on the Bethesda center of excellence that treats ten patients a month [10:30] The psychiatric hospital her father designed in Guyana, and the day patients burned it down [11:56] ECT in a bus, a detox bus, mobile TMS: bringing intervention into communities [13:47] The referral pipeline and the illness-perception threshold [15:52] "I don't think we've been successful." Harding pushes back [17:20] The worry: new treatments that only reach the top two percent [18:06] Set and setting: the broom closet and the sanitized ECT suite [19:11] Sauvé's Frankenstein-basement TMS story [21:02] The effect Harding refuses to call placebo [22:59] Why she does not check in with patients before ketamine [27:12] Building the Mood Institute: insurance-based TMS, Spravato, ketamine, yoga, four retreats a year [31:44] You can take insurance and not see thirty patients a day [32:40] EQUIVALENCE: IV ketamine vs. esketamine, and why she said yes [37:12] How strict the regulatory posture is on lifetime ketamine exposures [38:36] Subscribe-and-save ketamine, and a U-shaped response curve [41:04] Sublingual bioavailability and hitting a moving bullseye [42:16] "We don't have precision psychiatry. I tell patients that it is guesswork" [43:10] NMDA receptor homeostasis, overshoot, and the missing warning sign [46:02] Trial design: randomization, the switch option, and the observational arm [49:12] How becoming a trialist made her question the weighing ritual [50:20] Her thresholds: four weeks, 50 percent, and no dose escalation for partial response [52:28] The number one piece of advice for adding interventions [54:30] Why practices fail on economics, not medicine [58:42] REMS audits you can fail, and the "belly" to carry risk [59:40] The silent survivors of the Spravato launch [01:00:32] Lightning round: the cliché she'd kill ("more is better") [01:01:15] Why depression deserves more aggressive treatment [01:04:27] A pessimist who's still hopeful for science Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice
- Jul 29, 202658 min
The Psychiatrist Who Fought the FDA Over How Women's Desire Gets Measured | Anita Clayton, MD
Dr. Anita Clayton, chair of psychiatry at UVA and a former Navy physician, built the CSFQ — the validated scale now used across specialties to measure antidepressant sexual dysfunction — after noticing her fluoxetine patients' real rate of side effects was ten times what the drug's label claimed. In this conversation with Dr. Will Sauvé and Dr. Brittany Albright, she breaks down the three sources of sexual dysfunction clinicians routinely conflate: the illness itself, the medication, and the relationship strain that comes with depression. She explains why bupropion doesn't cause sexual dysfunction and can even rescue it from an SSRI, and the case she made to drug companies to stop hiding that fact. The conversation turns to flibanserin (Addyi), the first FDA-approved drug for low sexual desire in women, and the fight over regulators measuring female desire by a standard borrowed from Viagra trials — a saga now documented in the film The Pink Pill. Clayton also previews where she's headed next: zuranolone for postpartum depression, a single-dose psilocybin-analog injectable now being studied in adjustment disorder tied to serious illness, and gepirone ER (Exxua), a new antidepressant with no sexual-dysfunction warning at all. It's a career-spanning episode about what happens when someone refuses to accept "that's just how it's measured" as an answer. Timestamped show notes Approximate. [00:00] Sauvé on finding psychiatry on an inpatient rotation at Walter Reed [02:30] Welcoming Dr. Anita Clayton and Dr. Brittany Albright [03:00] "Who takes care of all these people?" The nursing-home origin [04:30] One of few women in medical school; choosing OB-GYN and psychiatry [08:00] Wanting to know everyone's story: why psychiatry [12:00] The Navy, HPSP, and becoming a general medical officer at Great Lakes [13:30] Starting an all-women group; treating the whole person [16:30] "I'm examining them": finding what others missed [17:30] The Kmart story and choosing to live your life [18:30] The Pink Pill, and meeting Clayton in it [19:30] Fluoxetine, delayed orgasm, and a label that said 1.9% [21:00] Why you can't trust spontaneous-report side-effect data [21:30] Three kinds of sexual dysfunction: disease, treatment, relationship [24:30] Building the CSFQ scale [25:00] Bupropion, buspirone, and rescuing sexual function [27:00] "Just count the prescriptions": reframing antidepressants for industry [29:30] Should psychiatrists screen for primary sexual disorders? [30:30] Flibanserin, Boehringer Ingelheim, and training actors to model interviews [33:00] The FDA's sedation worries and the fight over approval [35:30] "Successful sexual events" vs. asking women about desire [37:00] Sprout, Cindy Eckert, and patients testifying at the FDA [38:00] Becoming a PI on industry trials since 1991 [40:00] Career and family: a blended family and a summer in Provence [42:30] A father who said "you can do anything" [46:30] Reproductive psychiatry, the midlife clinic, PMDD, postpartum [47:30] Zuranolone and a GABA mechanism that changed the paradigm [48:30] A single-dose psilocybin-analog injectable for postpartum depression [50:30] Adjustment disorder in serious medical illness; an ALS patient at peace [51:30] Gepirone ER (Exxua) and a head-to-head sexual-function design [55:00] What she's proudest of: staying curious [56:30] Mentorship, women in the field, and "I'm still excited" Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice
- Jun 4, 202637 min
TMS Works. Almost Nobody Gets It. Scott West, MD on Closing the Gap
The FDA cleared TMS for depression in 2008, yet by one estimate fewer than 1% of the patients who would qualify for it ever get treated. Dr. Will Sauvé sits down with Dr. Scott West, the psychiatrist who brought TMS to Tennessee in 2010, to ask why a treatment that works remains this hard to reach. West argues the real barrier isn't efficacy or even insurance, it's that patients and the clinicians who could refer them don't know the option exists, illustrated by a woman who lived two miles from his clinic her whole life and had never heard of it. Along the way he reframes TMS as a tool that treats brain circuits rather than a single depression treatment, and makes the case for treating depression as an urgent illness instead of something managed in six-week medication trials. The two also get into responsible off-label use, from a fibromyalgia protocol to a nine-year-old with Tourette's, and where the field is heading with QEEG-guided protocols and EEG captured under a live coil. West's advice to clinicians thinking about adding TMS: standard TMS still works, so build a real plan and don't let your machine become a "dead box." Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice
- Feb 26, 202650 min
A Spravato Patient's Story: From 10 Failed Antidepressants to Marathons and Horror Novels
Ben Leopold spent years on 10 different antidepressants, each one trading his lowest lows for a flatline existence that erased his personality. It wasn't until a psychiatrist stopped prescribing and started digging into the childhood trauma underneath his depression that things began to shift. In late 2020, already armed with years of therapeutic tools he couldn't access through the fog, Ben started Spravato treatment at a clinic in Portland. The dissociative experience let him step outside his anxiety for the first time and see himself the way his family always had. Today, more than two years after his last session, he maintains his recovery through running, surfing, writing horror novels, and showing up for the people he loves. In this episode of Psychiatry Tomorrow, Ben sits down with Osmind's Dr. Will Sauvé and Dr. Brittany Albright to walk through the full journey.Timestamped Show Notes [00:00] Introduction and Ben's opening reflection on where he is today [01:06] Ben begins sharing his story and background [03:09] The morning his father died when he was nine years old [05:58] How early trauma became panic attacks and catastrophic thinking [06:43] Building survival mechanisms and isolation patterns as a child [09:00] The slow decline from 2015 to 2018: getting heavier, losing hobbies, losing himself [10:35] Breaking point: panic attack during a routine work meeting [12:19] Finding his first psychiatrist and starting antidepressants [13:19] How Ben's mother normalized mental health treatment in the late 80s [15:01] Dr. Sauvé on memory loss after 12+ months of depression [16:15] Why supporting someone through depression is a thankless job [16:52] The isolation paradox: pushing people away to "protect" them [22:17] The antidepressant carousel: 10 medications and their side effects [23:44] Emotional blunting: feeling like a shell of yourself [26:18] Ten medications tried over approximately 18 months [27:16] COVID, freefall, and starting fresh with Dr. Combs [28:31] A different approach: addressing root causes instead of just symptoms [32:28] Sister introduces Ben to Spravato [33:47] First impressions of Evolve Health clinic in Portland [35:17] How clinic atmosphere and personalization changed Ben's treatment experience [36:40] Prior psilocybin experience and writing a letter to his mother [37:07] The Spravato experience: the Tasmanian devil tornado metaphor [38:18] Learning to love imperfection [39:07] Why Spravato needed a therapeutic foundation to work [40:11] Integration: zipping up nine-year-old Ben with adult Ben [41:36] Journaling during sessions and learning to express love [42:35] The dissociative sandbox: beta testing yourself [43:38] Off Spravato since 2021 and maintaining recovery through lifestyle [45:37] Taking a year off work to build stability in the boring daily routine [46:26] Current life: running, surfing, writing, family [47:09] Final words: put in the effort, keep pushing Brought to you by: Osmind.org, the #1 All-in-one Billing Solution + EHR for the modern private psychiatry practice
- Jan 21, 202648 min
Why Sleep Is Psychiatry's Blind Spot—And How to Fix It with Avinesh Bhar, MD
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
- Nov 5, 202546 min
Vagal Nerve Stimulation for Depression with Lucian Manu, MD
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
- Oct 23, 202548 min
Should a Psychiatrist Ever Prescribe a GLP-1? with Brittany Albright, MD, MPH
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
- Sep 17, 202553 min
How TMS is Rewiring Psychiatry with Martha Koo, MD
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
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About Psychiatry Tomorrow
Psychiatry is entering a new era. Join host Carlene MacMillan, M.D., Psychiatrist and Chief Medical Officer at Osmind, for Psychiatry Tomorrow, where we delve into captivating conversations with mental health leaders advancing the field. From groundbreaking research and technology, to the modern private practice and the policies shaping psychiatry’s future. Navigate the exciting realms of neuromodulation, rapid-acting antidepressants, metabolic psychiatry, psychedelic medicine, starting a private practice, and much more.Join us on this thrilling journey, and let’s transform mental health together.
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