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 care

Key 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

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