The Frontier Psychiatrists

This newsletter is quite the multi-media shop. It gave me a new tool here on Substack, and I’ll use it less-than-polishedly. I wrote a column earlier this week on infidelity, which seemed to strike a chord. This video experiment was created in response to reader feedback on that piece of writing. It’s a new format for me and far from perfect. Let me know if you dig it anyway.

Remember—I’ve got music on Spotify!

I’m broadly not very talented in a wide range of media.

The Frontier Psychiatrists is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

My mom and dad left a lot unsaid between them, and after his second stroke, the ability to have the conversation that they had put off? It was like visiting a ski slope in the summer. You can see the runs, you can see where the snow would have been, and imagine the speed, the presence, the thrill, breath taking cold. But none of it is that, at that moment. Many close relationships are actually three relationships happening at once. One relationship is the explicit relationship— what you say to each other. The others live inside each of your heads, separately, and it's all the things you haven't said. Explicit is shared, and the implicit are islands, in the middle of the Pacific, surrounded by saltwater, perilous to approach. Only the most intrepid ever approach these islands of the inside and the unsaid.

It remains to be seen why what we don't say is so scary. Maybe it's the sharks we imagine in the water? Maybe it's the dying of thirst on the way there? Maybe once you get there, you wouldn't like what you found? Maybe you will kill everyone who lives in that island with the memetic infections, vector-borne diseases of the explicit?

A plague, that's what you didn't talk about…maybe. Some of us have a different set of experiences, are novelty seeking, and will take a risk. Some of us have already drowned once, and been revived.

There's a secret, it turns out, to finding everything you ever wanted, across expenses, time, Atlantics away. There's a way to traverse the gap between each other. It requires understanding that you don't understand anybody else. It starts by acknowledging that you haven't said the most important things—and neither has he, she, they. The same fear that drives you drives everybody else, to an uncomfortable small talk, instead of impossible silence, with all the weight of all the things that you were afraid to say.

I love you, and worse, I loved you. Past-tense, tense. I hated you, once. I did things I regret. I fear things that you have left, in another life, on another continent, frozen deep in the ice of the Antarctic, and boiling away in the water around that volcano. In letting our fears guide our conversations, and their malicious edits, we leave each other bereft—the walking dead.

The truth is we're gonna die, together or apart, and living together, with the most important things kept unsaid is as pointless as it is poisonous.

All of us have something to own up to. The sooner we do it, the less lonely and dead we are.

In Memoriam, Jake Seliger.

If you don't read Bess Stillman, now is the time.

Recently, the leadership of all three big health PBMs testified in front of Congress…and…have now been asked to correct the congressional record.

So, I made a podcast instead of an article about it today cause my kids are away, and I love the format. I hope you all enjoy it. The transcript is in the top right if you just want to read, and not listen!

A few prior articles include:

The Frontier Psychiatrists is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

The Frontier Psychiatrists is a daily enough health-themed publication. It’s also a podcast. Sometimes, I need a break from serious coverage of policy. In those cases, I amuse myself with David Foster Wallace-esque fan fiction about health policy, like this first chapter in my Wizard of Oz-themed parody about health insurance. Dorothy gets strep…then psoriasis…then OCD! Join us for a little health-themed absurdity, and maybe, just maybe, we will all learn something.

The Frontier Psychiatrists is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

I have been writing about PTSD treatments quite a bit in The Frontier Psychiatrists newsletter. One is offered at Fermata, the clinic I co-run in Brooklyn. I recently wrote an article about it. We provide Prism treatment for PTSD at our clinic, much like our colleagues at Homebase in Boston, with Veteran Populations.

Sometimes, you’d rather listen. On that note, here is the podcast version of that article.

Other PTSD-themed writing includes…

Medical Cannabis for PTSD?

Prazosin

The ICU is Traumatic For Everyone

As well as a whole… Saga… on MDMA:

Can MDMA-AT Be Saved, Part I

Can MDMA-AT Be Saved, Part II

Should MDMA-AT Be Saved, Part III

Saving MDMA from AT: Part IV

Bad Touch!: MDMA Part V

Saving MDMA (and other psychedelic therapies), Part VI

Saving MDMA VII: This Isn't The First Drug to Have Problems Getting Approved

It’s worth noting I’ll be appearing on a webinar with the Psychedelic Medicine Association to discuss the following…and I’ll include the info from my friend and co-author Dr. Morski, MD, JD:

The FDA Said No, What’s Next? Exploring the Field’s Next Chapter After the MDMA Decision

Register now!

In case you missed the news last week, the FDA officially denied Lykos Therapeutics’ New Drug Application for MDMA-assisted therapy, requesting a new Phase III trial be conducted. 

This was a huge blow to the practitioners and patients who were hoping that MDMA would soon be a legal option to address PTSD, a condition where no other therapy has shown the same levels of efficacy as MDMA-assisted therapy.

So you may have questions, like, “When is the next psychedelic medicine likely to be up for FDA approval” and “Which medicine may be the next to reach that stage?” And you may also want an update on what psychedelics (like ketamine) are legally available and how might they serve as a stand-in for the others while we await FDA approvals.

This month we are truly fortunate to have panelists working in various arenas within psychedelic medicine and research to help lead a discussion regarding what psychedelic options are currently available and what’s to come, including:

* Which psychedelic medicines are next in the FDA pipeline

* When might we see another psychedelic therapy up for FDA approval

* How can we utilize the available psychedelic options in the meantime

...and much more!

Register now!Panelists joining us for this month's event are:

* Owen Muir, MD, DFAACAP | Co-Founder, Fermata; Chief Medical Officer, iRxReminder

* Carlene MacMillan, MD, FCTMSS, DFAACAP | Co-Founder, Fermata; Chief Medical Officer, Osmind

You can learn more about them on our event page.So please join us for this live panel discussion on Thursday, August 29th at 5 pm Pacific, 8 pm Eastern. A link to the recording will be provided afterward if you cannot make it to the live event.Hope to see you all on the 29th!You can find the Psychedelic Medicine Association on Twitter , LinkedIn, and Facebook.In service,Lynn Marie Morski, MD, JDPresident, Psychedelic Medicine Association

I am usually writing these columns from my perch as a psychiatrist, and a distinguished-ish one at that. However, I have been one with an illness. I’m a…patient. Today’s article is very much from that vantage point, to explain to other health professionals how those of us who are patients think. This is not restricted to psychiatric illness, but is more pronounced the more stigmatized the condition.

I’m going to use we here, but it’s the royal we. We are always on the lookout for bigots. We know you judge us. We know you don't take us seriously. So, especially when we first meet, if we tell you about our lived experience? It is not casual. It is a test. We need to know if we can trust you. And the second you demonstrate we can’t? We're never gonna take you seriously as a health professional. We're never gonna tell you the truth about our suffering, not when it matters the most. The relationship we have with you will be circumscribed. We will treat you the a way lion tamer treat lions. It will be transactional, at best.

We're on the lookout for any little thing. We've been doing this “ being an ill person” as long, or maybe much longer, than you've been a physician. Physician-Hood has only been part of your life. People have been looking at us like we're crazy or sick for maybe as long as we can remember. It’s as least as long as since we got sick. That side eye? That condescending smile? We are on the lookout. Always. We cannot avoid noticing. All of us have some degree of trauma and hyper vigilance about our interactions with people like you, because I guarantee you, they have not all been positive. We have been dismissed. We have been judged. Some of us have actually been behind a door we unable to open because it was locked. Every interaction with you, dear professionals? Dangerous.

There is no reason we should trust you, in advance. This is a test. It will be baked into every interaction.

When we ask you a question? We might already know the answer. Again, we're testing you. We want to know if you will take us seriously. Your predecessors might not have. Some of them, again, almost certainly, did not. It may have been on the worst day of our life.

It's not fair to you. And it's probably not fair to us. But we absolutely, positively, should not blindly trust you. Until, of course, you prove you can be trusted.

The next time somebody like me raises their hand, even at a conference, and discloses the fact that we have a disability? It's not a casual question. We are looking to see how you react, and everyone else in the room in my position is doing the same assessment.

You're less good at hiding your contempt than you think. We are bloodhounds for BS. Respectfully, get comfortable with patients, or expect us to lie you every time it might actually matter to get a valid answer for us both.

My friend and RAMHT co-founder, Grady Hannah, had a quick and dirty conversation with two friends today about the thrilling 2025 CMS Physician Fee Schedule. Every year, there is an open comment period on these proposed changes, and this year has some crucial changes for physicians who’d love to be able to deploy Digital Theraputics in the context of Behavioral Health Disorders.

Thanks for listening. More coverage of this open comment period is coming soon, but here is a quick overview of the issues at stake.

Yes, this is how nerdy we are at baseline. Yes, we talk like this to each other for fun. This time, we recorded it. Yes, I am this boring.

Thank you so much for listening! As a reminder, I have a new book out, and it is available on the Kindle store! It’s the number one new release in:

Depression

Pharmacology

Humor: Doctors and Medicine

And it’s inching up to #11 on the “just generally funny books” charts. Let’s push this one to number one among all funny-ish books.

It’s called Inessential Pharmacology. (amazon link)

Yesterday’s column was a fine article, but what if you miss my snarky tone while reading it to yourself? Problem? Solved. Dear Readers, here is the podcast version of the aforementioned article!

For those hoping for actual solutions? The AACAP Facts for Families series of guides exist! For example, you can learn how to prepare for your child’s first cell phone. You can also get expert guidance from actual child psychiatry doctors on Internet Use In Children. Or we could follow scaremongering from the Surgeon General? That is also an option.

My ChatGPT prompt:

“Please generate a scary warning label for social media that the surgeon general could place on social media platforms that would terrify young people into not using social media quite as much.”

Here is the warning label it came up with:

I think we are really getting somewhere.

The Frontier Psychiatrists started as a room in on the clubhouse app. One of the enduring pleasures from that era is my friendship with @Psych Fox (Jeremy Fox, P.C.). He’s a licensed professional counselor, EMDR therapist, and a delight to speak with. This week’s podcast features a discussion of a paper Jeremy brought to the table:

Are mental health awareness efforts contributing to the rise in reported mental health problems? A call to test the prevalence inflation hypothesis

The inflation hypothesis posits that more talking about mental health problems leads to more actual problems. We also discuss the role of screening, including my very popular thoughts on the DSM-5-TR Level One Cross-Cutting Measure, as featured in my Osmind EHR, that I use in my work at Fermata.

In our conversation, we evaluated the possible takes on this paper. While I’m at it, I’ll remind readers that suicide risk assessment is important, and no one does a better job of explaining it than Dr. Tyler Black:

Thank you for listening! Please share this podcast with your friends drop a a 5-star review on Apple Podcasts. It drives discovery like woah.

The Frontier Psychiatrists newsletter and podcast do a lot of cheerleading for brain stimulation—particularly accelerated TMS. However, I’ve recently added many new readers and have not explained my favorite brain stimulation approach. The podcast version and a useful transcript are intended for educational value. Also, here is Garfield:

Prior articles on the topic are myriad, but include:

TMS is better than Drugs

TMS Should be Covered by Medicaid

Depression Can Be Over in 5 Days, Replicated

The Science Behind the Best Outcomes In Mental Health

Your Depression Should Be Over Already

My Sickboy Podcast Appearance

And many others!

Thanks for reading, listening, and sharing.