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.

• Why VNS emerged from an accidental observation during Lamaze classes and what that tells us about vagal modulation
• How VNS creates a clinical "floor" that prevents patients from reaching their lowest depressive episodes
• The Medicare coverage breakthrough after 15 years of insurance denials—and the cost-effectiveness argument that worked
• Patient selection criteria, practical implementation details, and managing the insurance appeals process
• Why functional improvements often precede symptom score changes

[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

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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.

[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

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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

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Dr. 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
 

[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

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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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Dr. Husseini K. Manji takes us behind the scenes of esketamine's development, from basic neuroscience research to FDA approval. Learn about the science of targeting NMDA receptors, the rigorous clinical trial process, and the potential of esketamine as a first-line treatment for depression. Dr. Manji discusses the challenges of bringing a novel psychiatric drug to market, including regulatory hurdles and insurance coverage issues. He also explores the broader implications of esketamine's success for mental health treatment, including the fight for parity and the future of psychedelic medicine development. This episode offers invaluable insights for clinicians, researchers, and anyone interested in the future of psychiatry and drug innovation.

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Charles Miller, CRNA, founder of Scenic City Neurotherapy, takes us through his journey of starting a ketamine infusion therapy clinic from scratch. From cashing out his 401k to navigating complex licensing requirements, Charles shares the ups and downs of building a successful practice. He discusses the importance of patient education, the challenges of insurance reimbursement, and the role of technology in streamlining operations. Charles also offers insights on expanding services, managing supply chains, and building a strong team. This episode is packed with practical advice for clinicians considering opening their own breakthrough treatment clinic or expanding their existing services.

Timestamps with show notes:

[00:00:00] Introduction to Charles Miller and Scenic City Neurotherapy 
[00:01:00] Charles' background in anesthesiology and interest in ketamine therapy 
[00:02:00] The decision to start a ketamine clinic and initial research 
[00:05:00] Starting small: Initial funding and facility setup 
[00:08:00] Navigating business challenges: Licensing and financial management 
[00:11:00] Collaborating with psychiatrists and expanding services to include TMS 
[00:15:00] The importance of patient education in ketamine therapy 
[00:18:00] Securing VA contracts and navigating insurance reimbursement 
[00:22:00] Using Osmind platform for practice management 
[00:24:00] Building a strong team and hiring process 
[00:28:00] Community education and advertising strategies 
[00:31:00] Measuring success and patient outcomes 
[00:35:00] Managing supply chain challenges and diversifying suppliers 
[00:38:00] Proactive approach to regulatory compliance 
[00:41:00] Advice for aspiring clinic owners 
[00:45:00] Concluding thoughts on the rewards of running a breakthrough treatment clinic

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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.

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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.

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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 Notes

00:00:00 - 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

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