The Frontier Psychiatrists

Owen Muir, M.D. of The Frontier P This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

Oh my. The irony is thick with this one. Your author, and sometimes scientist, Owen Scott Muir, M.D. has been doing research on Tardive Dyskinesia. And…he might have the disorder. The search function lets you search for other articles on the topic. If you are interested in treatments for psychiatric disorders that don't cause this adverse effect—a permanent movement disorder—they exist. The care we provide in New York, California, and now, South Carolina works, diligently, to advance the science of safer treatment. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The frontier Psychiatrists breaks down a publication on the topic of immune modulation of TMS response in depression. And Dr. Owen Muir explains what inflammation is for mental health conditions in the process. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

I've been obsessed with the Peloponnesian War as a historical event for 20 years now. I wrote an article about it recently, and also recorded a song about it many years back.Enjoy the listen!If you like the music, there is more of it on Spotify…The Frontier Psychiatrists is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

This podcast was edited on a plane ride to Japan, and the intro was recorded in a bathroom while my kids slept off the jet lag. It's still good. I recently went down with Ben Greenzweig, the Executive Director of the non-profit Living Water Brain Treatment Center in Myrtle Beach, South Carolina. We are—right now—providing TMS treatment and, soon to be more, in a local community in Ben's beloved home of Horry County. There are 400,000 residents and less than 30 psychiatric inpatient beds in the county. There are not enough services to meet the needs he saw in his community—so he started Living Water to help. I'll remind readers that not only did he write an article about it, but he is also running a non-profit. Thus, consider donating.The audio from today's podcast was recorded mainly on my phone, which I had in my pocket as I gave the talk. Please share it with friends. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

My readers and listeners know that this project, The Frontier Psychiatrists, is daily. Sometimes, I don't get the thing done till the end of the day. Today is one of those days. I was running on empty when it came to narrative this morning, so I decided to try to make a podcast. One of the tricky things about these more experimental days is that I don't know if the story is going to work. It's like walking a tightrope. I'll choose something— anything— to write about. And today I decide to make it even more difficult for myself, because I didn't feel like typing anything, and so I made a podcast instead. Today's was going to be about Machine Gun Kelly and being old. That's all I knew. The podcast you're about to listen to explains what happened, and the lessons I took away from the journey of trying to figure out who the heck Machine Gun Kelly is. The podcast features some of my favorite people, including Michelle Bernabe, RN , Courtny Hopen, RN, and my mom, Vita Muir. Surprisingly, it ends up featuring Drew Barrymore, and I'll let you listen to figure out how that happened. Thanks for joining me on this publication's experimental journey. I really hope you listen to the episode. It took all day to land, and I think it's good enough.Yes, the podcast was created—top to bottom— today. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

Today, The Frontier Psychatrists welcomes back my friend Ben Spielberg. He's been a reader for a long time and has contributed to the newsletter in the past. It was on Clinical Trial design, a perennial favorite around these parts.With only light edits, what follows is his work, narrated by me, for the Audio Version.I would invite you to the live class today on working as an out-of-network provider, but it sold out last night, so you'll have to wait for the next one. My prior article on Spravato is available here.The year is 2024. OpenAI has just launched its latest update to ChatGPT, promising more natural and less artificial-sounding language. Donald Trump has won the nomination for President of the United States. Another chain of ketamine clinics has engaged in a corporate reorganization. There is conflict in the Middle East. Are we sure that we're not living Groundhog's Day?I am the founder of Bespoke Treatment, an integrative mental health facility with multiple locations that has at times been referred to as a "ketamine clinic." I have also seen countless so-called "ketamine clinics" sell for pennies on the dollar and go bankrupt seemingly overnight. In this case, Numinus, a company that was publicly traded in Canada and owned a number of psychiatric clinics specializing in ketamine in the US and Canada, has sold its clinics to Stella (a company that has stealthily become one of the larger mental health providers in the country and is the first to bring the awesome SGB treatment to scale). It's not the first time this has happened. It's not the second, nor the third, nor even the fourth time this has happened. But yet, the common consensus is that ketamine clinics are a cheap, easy business with recurring revenue. So, what gives?Figure 1. A reddit user asking anesthesiologists if they should start a ketamine or Botox clinic for easy cash on the side. Does this make you feel gross? Should it?The Ketamine Clinic Model 101The most basic outline for a ketamine clinic is as follows: a provider rents an office space with, on average, five or so exam rooms. They buy equipment for infusions like a pump, catheter, needles, and syringes. They buy some comfortable recliner chairs. They hire a receptionist to answer phones, field patient questions, charge credit cards, and handle medical record requests. They hire a nurse to insert the IV, monitor vital signs, check blood pressure, juggle multiple patients at once, and make sure the ketamine is flowing into patients' veins unencumbered. Two SKUs are typically offered: ketamine infusions for mood, which last approximately 40 minutes, and ketamine infusions for pain, which last for up to 4 hours. Zofran is offered for nausea, and some clinics have fun add-ons like magnesium or NAD. An average mood infusion costs around $400-$500 in a medium cost-of-living area, while mood-infusions can run up to $700 in a higher cost-of-living area. Some clinics offer package discounts if patients buy six or more upfront, which helps with cash flow for the clinic (cash now is better than cash later, of course).A Note on Scope of PracticeThe first wave of ketamine clinics was started mainly by providers who were not mental health specialists. Instead, they were owned by anesthesiologists, ER physicians, and sometimes CRNAs. These providers were especially experienced with ketamine in hospital settings, as well as setting up infusions. Psychiatrists, on the other hand, do not usually order infusions in outpatient settings, and very few had actual hands-on experience with ketamine in practice. That being said, there are a number of variations to the model above: psychiatrist-owned ketamine clinics would often prefer to use intramuscular injections in lieu of infusions, but 2-3 injections would have to be given during a single session for mood and pain sessions were out of the question. Other ways to save costs might include having an EMT do the actual injections (this is highly state-dependent), asking nurses or MAs to work the front desk, or working a full-time regular doctor job. In contrast, your nurses run the actual ketamine services via standing orders, a written document that details routine and emergent instructions for the clinic.Some clinics offer full evaluations prior to rendering treatment, but many offer a simple brief screening on the phone to check for contraindications before scheduling a patient for their first session. The clinics owned by psychiatrists have historically been a bit more thorough in terms of the initial psychiatric evaluations, given that they can actually perform initial psychiatric evaluations within their respective scope of practice. Sometimes clinics may have therapists on-site who can render ketamine assisted therapy (meaning, therapy occurring concurrently) for an additional $100-$300. Otherwise, there is not much decision-making that goes on— other than deciding on medication dosages. Most infusions start off at .5mg/kg of body weight, which is by far the most evidence-based dosage. In practice, most clinics increase dosage every session because even though ketamine is considered to be a weight-based medicine for anesthesia, there is thought to be a “sweet spot” of dosage for everyone, if one can imagine an inverted U shape curved, where the ideal dosage for each patient is at the tippity-top of the inversion. Dosage increases are highly variable depending on the clinic: some have a maximum dosage, some will only increase a certain percentage, and some may even use standardized increments (e.g., only offering dosages in increments of 50mg). A typical series of infusions is 6-8 over 3-4 weeks, followed by boosters as needed.Fool's GoldAt first glance, the business model seems fantastic. As a cash business, there are no AR issues, no third party billing companies to deal with, and no prior authorizations to fight over. Sure, the cost is high, but it's not that high compared to many other healthcare services. Since the benefits fade over time, a ketamine clinic has built-in recurring revenue from patients every week, month, quarter, or year – it's like a subscription business! Ketamine is trendy and sexy; TV shows like White Lotus mention it, and ravers from the 90's recall it with great fondness. Unlike SSRIs and psychotherapy, ketamine works for depression fast. It's amongst the fastest treatments for depression that we have today, and there are a lot of depressed people. It can help someone out of debilitating depression in 40 minutes. It has none of the un-sexy side effects of SSRIs like sexual dysfunction, gastrointestinal discomfort, or uncontrollable sweating. Instead, it has sexy side effects: euphoria, hallucinations, and feelings of unity with the universe. Also, unlike SSRIs, it helps most people who try it. It really is an amazing treatment, and I often feel grateful that my clinic is able to offer it to patients in needFigure 2. Most business-savvy reddit user.Supply and Demand… or SomethingMood disorders disproportionately affect individuals who are of lower socioeconomic status compared to individuals with a lot of disposable income. Of course, wealthier individuals are no more immune to mental health disorders than anyone else, but the main target market that benefits most from ketamine just do not have the means to afford it. They don't have $3,000 to burn on yet another treatment that may or may not work. Often, the patients who could really use a series of ketamine infusions cannot scrounge enough money for a single infusion, let alone a whole series and prn boosters. However, there should be enough depressed people with cash to throw around out there… right?Wait, Isn't That A Horse Tranquilizer?Of course, ketamine clinics can find more patients via marketing and advertising. However, I've found that many medical doctors who see this population, like primary care providers, are not up to date with the research. When I first launched my company, I used to go door-to-door to medical buildings in Santa Monica with cookies to speak with them about advancements in interventional psychiatry. I cannot count the number of times that I was laughed out of each office; referring providers are risk-averse, and the perception of ketamine has traditionally been poor. Medical doctors would exclaim, “Of course people feel better; you're getting them high,” and lament that I was administering a drug thought to be highly addictive. Psychotherapists, who would also be fantastic referral partners, generally refer to psychiatry, but it's less common for them to refer to specific treatments. Nowadays, psychotherapists who are particularly invested in ketamine can sign up with venture-backed companies like Journey Clinical and render their own ketamine-assisted psychotherapy with some prescriber supervision. The issue is that despite the media attention, people with depression don't read innovative health newsletters, nor do they review papers in scientific journals. They rely on information from their psychiatrists, medication management providers, and psychotherapists. If they are not told that this is an option for them, they won't hear about it without ad spend. Oh yeah, and there is a major issue with ad spend: the word ketamine itself is a restricted drug term, and legitimate clinics routinely get banned from Google and Meta for mentioning it, which makes digital advertising more difficult than it would be for any other legitimate service.The Matthew Perry EffectKetamine is very desirable for some patients (unfortunately, sometimes the patients who want it most are frankly the worst candidates for it), but I'd wager that the majority of patients who need it are kind of scared of it. They want to feel good, they want relief from depression and trauma, but it's a weird thing to do a drug that is a horse tranquilizer and also an anesthetic in a reclining chair in a medical office that tricks your brain into feeling like you're dead for a little bit. It's kind of far off from acupuncture and more traditional alternative medicine. There is certainly a non-zero addictive potential that needs to be carefully weighed, it's not a particularly comfortable experience for many patients—especially those with a history of trauma—even if it helps after the experience is over. Additionally, the famous actor from the most famous show in the world, who was deemed to have a cause of death relating to ketamine, isn't exactly helping mass adoption. Overall, this just makes marketing and advertising even more expensive, because a) the majority of referring providers are skeptical, b) patients can't pay for it and c) patients who can pay for it are cautious.Disruptive Business ModelsIn the model I've described above, there are 3 sets of cost centers: rent, staff, and marketing. In some areas of the country, rent may be negligible, and in others, it is quite high. Like an owner-operated restaurant, if a clinic is owned by a company that is not a clinician, they have to find one and pay for one. Venture-backed companies like Mindbloom, Better U, and Joyous have also created entire businesses on the back of the COVID-era controlled substance waivers, whereby they send patients ketamine tablets and/or lozenges directly through the mail. Unlike the clinic model, they don't have rent to pay, and since national marketing campaigns are often cheaper than hyper-local brick and mortar campaigns, they are able to find new patients at lower acquisition costs compared to their clinic counterparts. Some patients do extensive research before treatment and only want to find IV clinics that offer specific dosages, but many are fine with the cheapest ketamine possible, and would prefer to pay as low as $150 for an entire month compared to $3,000.Figure 3. Did you sign up for a discounted ketamine subscription on Black Friday after purchasing a new flat-screen TV?Spravato: Coming In HotJohnson & Johnson's branded esketamine (note the prefix es) is on track to reach coveted “blockbuster status.” While it was FDA approved for Major Depressive Disorder in 2019, it took some time to catch on for a number of reasons including skepticism that the added es only added to pharma pockets and didn't actually work, health insurance companies taking time to decide on what their medical necessity criteria should be, and social isolation due to COVID-19 being a thing. My clinic has become one of the larger Spravato providers in the Los Angeles area, and while we still offer ketamine infusions, our infusion census has decreased by over 70%. The scenario is this: a patient with severe depression comes in to see us, they've heard about ketamine, but they find out that Spravato is covered by insurance for a $20 copay. Maybe ketamine has slightly better efficacy (which, in my opinion, is really just a function of being able to adjust dosage). Still, patients would prefer paying a lot less money to receive almost-the-same benefits.Death By A Thousand SticksThere are a number of other issues with the model that become problematic, especially at scale. Large medical distributors like McKesson and Henry Shein have instituted CYA policies, limiting ketamine sales to licensed anesthesiologists. Medical malpractice carriers alike have followed suit, requesting detailed addendums from providers regarding their ketamine training or flat-out refusing coverage for anyone who isn't an anesthesiologist. Since controlled substance manufacturing is directed by the DEA based on their own predictions, it's not uncommon for ketamine to go on shortage for weeks to months at a time. There are a myriad of problems with the model of point solutions which have been detailed here already, but in short, the old adage rings true: if all you have is a hammer, everything looks like a nail, and if all you have is ketamine, everything looks like a juicy vein. But while ketamine is a highly efficacious treatment, it's not the best treatment for everyone, and patients can become downright dysregulated after ketamine, which a clinic in this model just can't handle adequately at scale. And ultimately, methods to do everything cheaper don't work out that well. For example, putting multiple patients in one room may seem like a good idea, but it is ultimately not conducive to the actual ketamine experience. Any sort of vertical integration also adds an insurmountable amount of complexity, like starting to offer Spravato or TMS, because now they have to start accepting insurance, become in-network, manage billing and AR, and so on. Depending on location and the clinic set-up, they also require specialized providers onsite.Figure 4. Supply chain issues abound.Insurance IssuesSome patients try to be well-informed. They, rightly or otherwise, don't believe everything they hear from their providers, so they call up their health insurance companies and ask. They just call the phone number on the back of the card and ask the representative if ketamine infusions are covered. Undoubtedly, the representative says yes—even though many insurance companies have published guidelines that explicitly deny any coverage for ketamine for a mental health disorder. These patients come in frustrated, distrustful of their providers and reaffirms their belief that ketamine clinics are just cash grabs. Even if one manages to obtain a coveted insurance contract for ketamine, like Ketamine Wellness Centers had with the VA, it kickstarts cashflow and complexity issues that scale should sort out, but ultimately doesn't because of the aforementioned issues above.Overall, it is possible to have a successful ketamine clinic in 2024. Still, it isn't easy due to market conditions, the population served, and the ever-changing landscape of mental health treatment. While many successful clinics exist today, the wheels tend to start to fall off when scaling, where all of a sudden, a clinic's reach has surpassed its captive population. Otherwise, it becomes a series of continual cost-cutting until there is nothing left to cut… save for the business itself.Ben Spielberg is the Founder and Chief Executive Officer of Bespoke Treatment, a comprehensive mental health facility with offices in Los Angeles, CA, and Las Vegas, NV. He is also a PhD Candidate in Cognitive Neuroscience at Maastricht University.For more on psychiatric medications, buy my book Inessential Pharmacology. (amazon link).For pieces by other TFP contributors, follow:Alex Mendelsohn, Michelle Bernabe, RN, @Psych Fox, Carlene MacMillan, MD, David Carreon, M.D., Benjamin Lippmann, DO, Awais Aftab, Courtny Hopen BSN, HNB-BC, CRRN, Leon Macfayden and many others! The Frontier Psychiatrists is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists is a daily-enough health-themed publication. But sometimes, I just want to make a podcast. Today is one such day.Enjoy!The Frontier Psychiatrists is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

Today is a day of mourning. In broad daylight, in the city I love, Brian Thompson, the CEO of UnitedHealthcare's insurance subsidiary, was murdered. According to CNN:Brian Thompson was walking toward the New York Hilton Hotel in Midtown Manhattan, dressed in a suit and tie, to attend UnitedHealthcare's annual investor conference being held in the ballroom.A gunman, who investigators tell CNN was masked in the sub-freezing temperatures, waited for about 10 minutes before Thompson's arrival, before opening fire from 20 feet away shooting multiple times, striking Thompson.The gunman fled, cutting through an alleyway and hopping on to a bicycle, the official told CNN. Investigators are continuing to canvas the area. Police currently believe that the suspect fled into Central Park.Brian was 50 years old. I don't know the man, personally. I do know that he was doing his job, and somebody murdered him in cold blood.This is not the way. Assassinations are not how we resolve disputes in a civil society. I get frustrated with United Healthcare, and I make fun of them for some of their decisions. This should never be mistaken for malice: these people are doing their jobs, just like the rest of us. They need to feel safe to make good decisions. They deserve to feel safe, even if they make what some might consider bad decisions. There is no level of a bad decision in a business context that gives anybody the right to put a bullet in your chest.I don't know why this masked shooter did it; I'm guessing this was somebody with a rationale of their own. We'll find out—or we won't. But none of us should celebrate this; everyone should decry targeted violence.It's also worth noting that United Healthcare's decisions have made people tremendously angry. Your anger about a business policy isn't an excuse to joke about someone's murder. This is a man with a family, friends, and loved ones.This isn't remotely funny. This isn't ok. Mr. Thompson and all of us deserved better.Let's all get on our knees and pray that this sort of violence leaves our cities and threatens our lives no more. We can have disputes about best practices and employment law like adults, but never, ever should we make light of the murder of a man who deserved dignity and life.Today, I stand unapologetically and without hesitation with UnitedHealthcare and its team. You are loved and deserve better. I hope and pray for justice and healing. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

Synopsis:Bobby, alone on the side of the road driving back to Manhattan after loading a bear carcass into his Cybertruck, reveals his intention to play the villain. He then pretends to console Donald, the first victim of this villainy. After Donald is led off toward the White House, Bobby greets Elon, who tells him that someone is very ill from an infectious disease. Bobby, once again alone onstage, outlines his plan to have Donald killed by preventable illness and to marry Lady Melania.—Act I, Scene IBobby: Now is the administration of our discontent Made glorious summer by this son of New York Real Estate, And all the regulatory burdens that loured upon our agency, In the deep bottom of the grave, buried. Now are our Houses of Congress o'erflowing with victorious representatives, Our primary battles ceased, and our districts justly called, Our stern alarums about “voter fraud” turned to merry winnings, Our dreadful attack ads to smug tweets. Grim-messaged campaigns hath chilled the f- out; And now, instead of threatening election workers with a bloody revolution To fright the souls of LibTards, Donald Capers clumsily in Laura Loomer's chamber, But I, who am well-shaped for sportive adventures thanks to my healthy diet, And made to drink raw milk from a cool glass; I, that am built, healthy, robust, and also sexually functional To strut before a wanton ambling nymph such as Melania; I, that am curtailed of his fair proportion of the wives of others, Cheated of affairs by regulatory limits on supplements to enhance my male nature, Unengorged, under aroused, sent before my tumescence Into this bedroom scarce half ready, And that so lamely and lacking prompt virility That ladies will ask, “Are you ready?” and “Maybe this is a bad time?” as I prepare for them — Why, I, in this weak piping time of GOP dominance, Have no delight to pass away the time, Unless to see my manly shadow in the sun And be impressed by my physique. And therefore, since I cannot prove a lover To entertain these fair, well-spoken days, I am determined to prove a villain, and hate the regulations that might limit my consumption of supplements and medicines to enhance the idle pleasures of these days. Plots have I laid, regulations dangerous, By drunken prophecies, libels, and appointments to agencies that I have no business running, To set my friend Donald and Elon In deadly hate, the one against the other; And if Elon be as Bold and Ambitious As I am subtle, false, and treacherous, This day, should Donald be held up About an Infowars story, reposted on Breitbart and OAN, that says that “RFK” Of JFK's heirs, the most important appointment, shall be. Dive, thoughts, down to my soul. Here Donald Comes!  This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The path from xanomeline to the brand name treatment named Cobenfy was a long one. Cobenfy is FDA-approved for the treatment of Schizophrenia. Here is the literal label:COBENFY is a combination of xanomeline, a muscarinic agonist, and trospium chloride, a muscarinic antagonist, indicated for the treatment of schizophrenia in adults.To people who haven't yet read my book Inessential Pharmacology, (Amazon Affiliate Link), I will highlight that this is approved as a monotherapy. That means it can be prescribed as the only drug for people with Schizophrenia.It has a completely different mechanism from every other antipsychotic. All the others block or modulate dopamine to some degree. Those are the variety of drugs I have written about, in less than glowing terms, in some cases.These are medicines that lead to obesity and early death (particularly in youth on Medicaid). I have argued they should never be used as augmentation agents.I argue, in fairness, a lot of things. One of the things I have argued about regularly is that individuals, particularly those suffering from devastating illnesses like schizophrenia, deserve treatment that works. That same treatment best if it doesn't harm the person also. The problem with antipsychotic medication is that they regularly harm the people who take them.Finally, we have a new drug that is helpful for individuals with schizophrenia and less harmful in terms of catastrophic adverse events like massive weight gain and tardive dyskinesia.What are the adverse effects for Cobenfy? Yes, those used to be called side effects.It's overwhelmingly causing problems related to nausea or other predictable anticholinergic side effects in the peripheral nervous system, especially the G.I. tract. I'm not saying it doesn't suck. I'm not saying it doesn't have side effects. But what you don't see there is massive weight gain. What you don't see there is permanent movement disorders. Does it work? In short, yes, it works. Nothing works fabulously well in schizophrenia yet, but it's not a slouch treatment, and it's not worse than existing drugs at least in the people they already studied (again, from their submission to the FDA):It's the first not me-too for schizophrenia, since clozapine. It's got a restricted range of side effects that are annoying, but not life-threatening. Will we discover more at large scale? Probably.Bristol Meyers Squibb is not done yet. They are going to be bringing this drug to bipolar disorder, and other conditions. Let's reduce the risk of early death from dopamine blocking medications for everyone for whom that would be beneficial.I'm at a conference, so I'll keep this one concise, because I'm writing it on my phone. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

I was at AACAP and sat down with Dr. Sood, a colleague, and we had a chat about investing, goal setting, venture scaleable businesses, and private equity, and we had some fun at the expense of Red Lobster in the process. I hope my colleagues enjoy the listen!Prior articles on the topic include What If We Didn't Blow The Horn, Private Equity Sucks at Running Business of Medicine, and more. Thanks for reading and listening, and Ashwin for joining me! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

This Podcast is a recording of departmental grand rounds presented at the Medical University of South Alabama pre-pandemic on burnout. It references a long legal back and forth I'd put up with. That has led to, last year, our legal team filing a defamation lawsuit and, this week, a request for an injunction. It's more burnout than when I did the talk. I hope it's still a source of sassy wisdom about what physicians must do to keep their heads in the game, care for patients, and respond with sense and compassion. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists is a daily health-themed newsletter. My dear friend Courtny —who recently penned an awesome guest post— reminded me that Fall is here. And with it, seasonal changes in mood for those with Bipolar Disorder. I've written about having bipolar disorder before, in a letter to that disorder. I've written about how important sleep is to not die. I've even written about this specific topic—circadian rhythm changes in bipolar illness, in a prior article here. But who has the time to read anymore? Isn't there a video or podcast I can view without having to read all those linked articles? Yes, now there is. It's here, now, for you, my dear subscribers. I've got music on Spotify! I even have a book on Amazon…(affiliate link). Oh, and another book of poetry. And a therapy manual. Thanks for reading, viewing, and listening. Oh, and…50% of subscriptions to help you cope with depressing changes in lighting.A special discount is available to celebrate fall by clicking here!The Frontier Psychiatrists is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

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. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

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. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

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. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

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. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

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?PrazosinThe ICU is Traumatic For EveryoneAs well as a whole… Saga… on MDMA:Can MDMA-AT Be Saved, Part ICan MDMA-AT Be Saved, Part IIShould MDMA-AT Be Saved, Part IIISaving MDMA from AT: Part IVBad Touch!: MDMA Part VSaving MDMA (and other psychedelic therapies), Part VISaving MDMA VII: This Isn't The First Drug to Have Problems Getting ApprovedIt'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 DecisionRegister 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, OsmindYou 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 This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

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. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

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:DepressionPharmacologyHumor: Doctors and MedicineAnd 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) This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

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. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists started as a room in on the clubhouse app. One of the enduring pleasures from that era is my friendship with (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 hypothesisThe 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. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

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 DrugsTMS Should be Covered by Medicaid Depression Can Be Over in 5 Days, ReplicatedThe Science Behind the Best Outcomes In Mental HealthYour Depression Should Be Over AlreadyMy Sickboy Podcast AppearanceAnd many others!Thanks for reading, listening, and sharing. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The following is a brief explanation of an overarching point of this newsletter: The Frontier Psychiatrists, for new and old readers alike.It's mostly penned, in the Apple Pencil Pro sense of the word, by Owen Scott Muir, M.D., although I sometimes have guests. We already have a diffusion product: the series of RAMHT events! That's “rapid-acting mental health treatment,” co-created with Grady Hannah.A crisis is not just a problem.  It's not just problems—plural.  It's the admixture of problems with hopelessness.  This newsletter is written to go beyond providing “solutions to problems.” We have those already.  If we knew we had problems with solutions at the ready? That does not meet “crisis criteria.”  We need to address the crisis mentality surrounding the difficulties we face in our minds. Panic is sometimes understandable in that it can mobilize life-protecting responses in the context of imminent death by, for example, tiger maw. However, panic is axiomatically not rational. In a crisis that involves solutions that extend to payment models, policy, and complex systems? It becomes a truism that demonstrably neither panic nor crisis mentality will do anything useful.We do not have a mental health crisis.  We have a mental health crisis…crisis.   We have become so panicked by the relentless onslaught of early, preventable death, loss, and sorrow that we cannot address it.  The crisis frame creates panicked responses.  Those responses have served up more death, suffering, and isolation.No thanks, I say.  This newsletter is written to address the “mental health crisis” as something other than a crisis.  We face understandable problems with rational solutions—if we can think clearly. Some of what I have written is funny.  It might be gallows humor.  It might be absurdist.  This serves two purposes—one, it is hard to laugh and panic at the same time.  The message is the medicine.  The second is more self-serving.  I just can't stand writing the number of words that will be necessary without having some fun, personally.  I wish I could.   I can't.  Other people write deeply serious tracts. Read those, if this is no laughing matter.In my attempt to dismantle the crisis mentality, I am not stopping at one word.  I'm going after the whole phrase.  I'm a serial killer for “the mental health crisis.”  Only the article—“The”—will be left standing by the end.People use the term “mental health” more often than they mean it—by a factor of always.  One of my favorite pandemic-era malapropisms-in-waiting is the saying: “Everyone has mental health.”  What I imagine people mean to say, with the stigma baked right in, is that everyone has some degree of psychopathology.  Everyone has problems. Does everyone have a risk for mental illness?  Everyone has a mental state—it's glib. It is maximally-pointless pablum.Mental health is a nonsense phrase, and I will dispense with it as useful.  Mental Health is a state of health as it applies to the mind.  Perhaps there is an absence of problems with the brain, mind, and spirit?  It's as meaningful as saying, “Everyone has bones” at an orthopedic professional society meeting. The presence of bones are not at issue for orthopedics.  It's the fractures of said bones that matter.  “Everyone is a little bit crazy” is the kind of thing generally well people can say. This is in the same way that other generally well people can claim there is no such thing as a psychiatric illness.  Both statements are inaccurate and minimizing to individuals who are suffering deeply as a result of the very real truth that some people are very, very unwell.There are two kinds of relevant “crazy.” One is psychiatric illness—which I believe exists because I have seen it up close and personal, and I don't believe demonic possession is the only cause.  The second is often also psychopathology, but more firmly rooted in problems of personality functioning—identity, self-direction, empathy, and intimacy.  It is the kind of crazy people make true crime podcasts about.  The kind of crazy people make comedy specials about.  The kinds of crazy that lead anyone to run for political office.  Personality plus more traditional illnesses of the mind—psychosis, obsession, despair—these together create very serious problems for all of us.  We can look at crazy—in the “what do you mean 30 emails an hour” sense, from a stalker—and simply call it “crazy” without understanding why, what, and how to respond most adaptively.We have problems that impact our wellness.  We have unwell people who cause us all problems.  Every once in a while it's us—we have a psychiatric illness and find ourselves acting strangely, and worry—deeply—that we might be…you know, crazy.This newsletter strives to address both of these issues—we define mental health problems, and we will examine how brains and minds can conspire with the outside world to drive behavior over the edge for vulnerable people.It's a newsletter about solutions to problems, second, and dismantling a crisis mentality first.  Join us. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists is a newsletter and a podcast. Most people assume podcast means “recording a good enough conversation.” Yes, I do those too. I also have a sick fetish for spending way too much time crafting highly produced audio pieces that happen to be podcasts. I think these might need a different name in the future—what happens when species diverge in evolution?This story is about someone I know—Alan Emamdee, D.O. A man arrested for a crime he didn't commit. Unlike the A-Team, he didn't get to go on the run and help people unionize in an 80s TV show. He's a doctor who suffered through years of a brutal legal process till he was acquitted at trial. The road back hasn't been easy, but he had the tape. This is the first episode. It's worth the listen. Please, share with your friends. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists started as a Creator First show on the ill-fated clubhouse app. One of our favorite guests was the remarkable (Jeremy Fox, LPC), an EMDR therapist with a passion for working with men around their actual problems. One of those is the loss of normative friendships among men—15% of men report no close friendships at all. This corrosion of close relationships is an accelerating problem for both individual men and society.Today's episode of the podcast includes both the video above and pushes the audio to the podcast feed!Prior writing on the value of friendships and what we can do about that includes articles such as:It's important to have FriendsFriends: A How-To GuideMatthew Perry was ClassyA Conflict of Interest Disclosure Regarding My Picks for SXSWThe Future of Brain Health?Announcing: May 5th, 2024…Rapid Acting Mental Health Treatment NYC 2024(Eventbrite Link)It's a night of thrilling conversations about the future of mental health. It features speakers from…Videra, MDHub, Osmind, Neurosigma, iRxReminder, and…Lykos Theraputics!More info to come…but it's the second IRL The Frontier Psychiatrists event, and we could not be more excited to have you! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists is a daily health-themed publication. Your author's love of podcasting is well established, and today, another from the vaults, dating back to the pandemic. In this episode, which I called “The Wave,” I started getting a little more ambitious in production, and strange in the jagged nature of my storytelling. I interview John Samuels, of WellWorth Advisors, Sonia Patel, of Capsule, and a journalist from the New York Times, as well as folks on my team at the time. Thanks for stepping in the way back machine with me. The pandemic was strange. It shaped us, now, and in the future. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

I know how much my readers love my ongoing coverage of Change Healthcare, and sort of kind of promise to keep dissecting drugs or making fun of myself or whatever it is you find compelling about this newsletter and media empire. Today, however, I will publish a podcast. I had a conversation with this week, before the ransom was paid, by UHC, about the Change situation. Out of respect to my guest, I'm going to publish it today. I also take requests on topics for articles and podcasts, so keep them coming. Thank you for reading and listening. If you are new to the newsletter, prior coverage of the change healthcare cyber attack is available here. and here. and here. and here. and here. and here. and also here. Oh, and with an NFT, here.An overview of all the things changed as is available in this article from yesterday. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

In this Frontier Psychiatrists Podcast, Jeremy Fox, P.C., And I discuss this remarkable work, as published by Cherian Et. Al. In Nature Medicine. Always love when can pop in!We discussed the role of understanding the sample in a research trial and the remarkable potency of Ibogaine, with the additional safety of magnesium to prevent cardiac side effects, in this newly published research.Thanks for watching and listening, and feel free to share with your friends.Other excellent psychedelic-themed writers I'd highlight are at Psychedelic Week and . Prior psychedelic medicine articles here on TFPs include:Are Psychedelics at Risk of Advertising Enforcement from the FDA?A Critique of “All Therapists of MDMA Assisted Therapy Should Take MDMA”Psychedelic Medicine for Primary Care?Dear Psychedelic Exceptionalism…William Osler, M.D., for Psychedelic Medicine Key Opinion LeaderPsychedelic Medicine Obtains Category III CPT CodesPsychedelic Medicine Needs to Get More Profit-FocusedI'm Psychic About Open Comment PeriodsWhy Medical Use and Spiritual Use Are DifferentPlease spread the good word—healing is coming, and more evidence is needed to understand when and for whom. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists started as a “room” on Clubhouse, and in this podcast, I am joined by one of our favorite contributors ! He joins me today to discuss how employee assistance programs can create the on-ramp to help and what might improve that process.A sampling of prior articles about employer-based health care is available here:The Science Behind The Best In Class Outcomes in Mental Health (with Acacia Clinics)Lawsuits for Health Plans Have BegunAlcohol Use Disorder is a DisabilityA Conversation About First Responder Health With Chuck DeSmithWhat is Health Insurance that is ERISA Compliant?Have Health Benefits Become a Huge Personal Liability for Employers?How Narrow Networks Can Win for Mental Health ParityCan't Find a Psychiatrist? Now You Can Sue Your Company!Why Savings Claims Can Be A ScamWhat do Shaggy and Health Insurance Have In Common?Owen's Letters to the Healthcare HackersI want to mention that another validated vendor in the mental health arena is joining my team at Acacia Clinics to have independent validation of our claims of being the best! I'm thrilled that my friends at Spring Health have achieved the coveted “savings validation” from Validation Institute!If you have been following the news of ERISA enforcement, this is important news. Employers need to get serious about providing better healthcare at a lower cost. Independent validation takes some pressure off when selecting the right vendors to make up a high-performing health plan. Why do I care, as a doctor, about health plans? Because great health plans are better for patients! Here on substack, and are on this beat as well, and I'd recommend a read! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

On weekends, I tend to take a break from health policy to focus on personal writing here on The Frontier Psychiatrists. This one is unfortunate, and it is a fair warning to readers who are in no mood for something like that.My older sister,  Alison, was troubled.   She was also very gifted.   She was trained as the chef at LaVernne, which was a very serious place to do your training as a chef. Parisian chef school doesn't f- around, and she was a gifted teacher of her craft.   She landed a job that she thought would be great. Less work than teaching at a busy New York teaching school for chefs, the Culinary Institute of America. Something Downtempo.The Wexlers are incredibly wealthy people. She was a personal chef for Les Wexner. It was not an easy job. She is a personal chef for a fabulously wealthy person who is now notoriously on the list of individuals who are routine customers of Jeffrey Epstein. She wasn't just cooking for one person's family. She was cooking for their hundreds of guests. She was one person. Her body couldn't take it. She had degenerative disc disease, and doing a job where she had to stand, endlessly, to cook hundreds of meals for hundreds of guests, as if one person could do all that by themselves, destroyed her body—destroyed her back. She ended up needing surgery. The surgery did not relieve her pain.After that back surgery, she was introduced to opiate pain medication. She has been prescribed a lot of opiate pain medication. And she took that opiate pain medication for years.   She became addicted. She couldn't stop. The help wasn't there for the pain, and the fire she sent to her apartment that left her foot singed made the pain worse.Now she had chronic neuropathic pain from a fire that she sat in her apartment --the investigators told us that she had left a shoe on the stovetop. She was not well. She eventually reconnected with a friend, he became a boyfriend, he became a husband.For a while, he took good care of her. He had a problem also. In his case, it was with drinking. Her health was not excellent. This is often the case with burn victims. It's often the case with trauma victims. It's often the case with people addicted. It was the case with my sister.   She was admitted to the intensive care unit, unbeknownst to me, three weeks after my father died of bladder cancer. She returned home. The next moment, as related to me, was probably after her last. She had survived a few suicide attempts already. There are only so many lives each of us has to spare.A phone call was placed to my mother by my sister's husband, letting her know that he found Alison in the bathroom, on the floor, not breathing. It was a fair question as to why the phone call was to his wife's mother and not to 911, given the not breathing... a subsequent call was placed to 911, and about an hour and a half of CPR took place, and like most CPR, the person did not come back to life. My sister was dead.The burial of my father and the burial of my sister were, unexpectedly, on the same day, in the same hole in the ground. I had lunch with my mother, my sister's husband, and others. We spoke well of her. We were sad. We all went about our days that followed.In her blood at the time of her death were the following compounds: olanzapine, Oxazepam, temazepam--both benzodiazepines--and heroin.She was also adopted. Her biological mother gave her away for adoption at age 14. She just didn't want her daughter anymore. If I had to guess the root of her pain? The event, the lesion, was this moment. Growing up, it didn't register how messed up this was. My mother adopted her. Her father was her father the whole time, but who switches moms? My sister, that is who.She posted this photograph of her and her mother on her Facebook, commenting that it was the last time she saw her mother, “20 years ago, and she was in a blonde phase.”It's not normal for your daughter to be given up for adoption. I have another older half-sister. That one? She wasn't given up for adoption. Just Alison. Not her older sister. This woman—whose name I don't even know— gave away one child, not the other. It never mattered how much my mom loved her—my mother, who was her mother, which was a lot, frankly. How could you trust anyone wasn't going to leave you if your biological mother just dropped you from her life? It's hard for any child to understand the problem is factually with the parent. Healthy people don't do that. They are not so disconnected from their children that they pick and choose between them. That's not normal. That's not healthy. This is the kind of human Alison had as a biological mother. Our love for her? Perhaps it would never have been enough. The only thing that could fill that gaping hole was morphine, more morphine, heroin, oxycodone, Vicodin, more heroin, more Vicodin, endlessly until the end.I remember the last time we spoke—she apologized for being a bad sister. I reminded her that infinite forgiveness is what we are owed as family members, so she didn't use up anything. It was good to see her, and she was forgiven, and I loved her. This was at the funeral of my father. Three weeks later, she was dead. A few days later, both of them were buried in the same hole next to each other, in tiny boxes that held their ashes. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

I checked in with Jeremy Fox, P.C., about a new FDA-cleared device, the PRISM system by GrayMatters Health. This is a treatment modality for Post Traumatic Stress Disorder that doesn't require talking about your trauma! is one of my favorite trauma therapists, so I called him to discuss.This is now offered at four sites in the US, and Fermata in Brooklyn, NY, is one of them. I discuss the experience of having PTSD myself and the role of trauma exposure in medical training and practice.I do the quick version of explaining the Prism System in 50 seconds here…More Jeremy Fox Themed Content:Bipolar Disorder: Myths BustedLSD for Anxiety?!: A PodcastPTSD and EMDR: A PodcastPeople I Mostly AdmireSome Other Content About Trauma:The ICU is Traumatic For EveryoneThe Once-Suicidal PsychiatristSo, Someone Has Been Stalking You?What Should Parents Say About Mass Shootings?Being Shot With a Gun is the Leading Cause of Death Among Children In AmericaA special thanks to the team at Graymatters Health, who visited our offices for deployment this past week! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

This article was among my most popular. Here it is, in podcast format. Enjoy!Other articles relevant to bipolar disorder include:DepakoteIs Bipolar Disorder a Circadian Rhythm Disorder?Lamotrigine (Lamictal) dosing guide.Does Lithium Prevent Suicide in Bipolar Disorder?Lurasidone (Latuda)Ziprasidone (Geodon)Risperidone (Risperdal)Why Don't You Drink?Zyprexa (Olanzapine)The Time I Almost Set Myself on FireBipolar Disorder: Myths BustedThanks for listening, and consider becoming a subscriber. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists didn't start as a newsletter. It began as a clubhouse room, with friends like and joining myself and for audio-only conversations. Even before that, I was a bit podcast-obsessed. I won a grant to record podcasts about self-disclosure among health professionals at NYU—the Rudin Fellowship in Ethics and Humanities. This episode is built on a recording from that era—2017—with Gillian Waldorf, Ph.D. This is what I looked like way back in college:She is a classmate of mine from Amherst College, and we were both huge nerds who didn't drink. Little did we know, we also had our first stirrings of psychiatric illness in common. This podcast is not perfect. It is also only part one. But perfect, as this newsletter + associated media is fond of embodying, is the enemy of the done. This was recorded, edited, and scored by yours truly, Owen Muir, M.D.I hope you enjoy it. Please share and review on Apple Podcasts if you do! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists is a substack-hosted media empire…we have video, newsletter, dumb memes, podcasts, and music—my gosh golly! Today, I bring you a conversation with a colleague who is both humble and brilliant. We first met on Clubhouse—in 2020—when and I were hosting conversations on the weekly. Tony and I met again in the What If Ventures fellowship, and, as I have told him, we just enjoyed each other's company. We collaborated on grant writing, and one thing led to another…and now I'm the Chief Medical Officer of his company, iRxReminder. Anthony is a kind and funny person to work with, which I couldn't value more highly. He is also brilliant. He understands medication adherence problems better than anyone I've ever encountered. In this long overdue podcast, he explains the problem and how we address it with our closed-loop AI + Internet of Things cognitive prosthesis. He's a master educator, friend, and my CEO (in one of my gigs)! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists started as a room in Clubhouse, and one of the people who made that awesome was Jeremy Fox, P.C. He joins me today for this video podcast to chat about the groundbreaking phase IIb data released by Mind Med today:MM-120 100 µg – the dose achieving the highest level of clinical activity – demonstrated a 7.6-point reduction compared to placebo at Week 4 (-21.3 MM-120 vs. -13.7 placebo; p

Ramon Lizardo, M.D., and I met at least two years ago when he was an investor, and I was pitching him… something. We've become friends. In this conversation, he reveals that while he was busy building fabulously successful healthcare companies, he was also going deaf. The audio isn't great…which I am going to consider “irony” kicking my ass. But he's a fascinating human, and I'm a big fan. It ends with some remarkable insights into parenting. Thanks for joining the Frontier Psychiatrists today! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

Welcome to the Frontier Psychiatrist…. Podcast. It's a podcast with myself, Dr. Owen Muir, as your host, and it's a companion podcast to FrontierPsychiatrist.com, a sassy Substack about health-related things. This is a conversation between Jazz (Glastra) and me. She is the senior director at Brain Futures, which is a 501c3 not-for-profit. She got to be the interviewer in this one! I'm a big Jazz fan, as a person, in full disclosure. I also enjoy the art form of the same name, but that is a different story.We are thrilled to have BrainFutures as partners in sponsoring Rapid Acting Mental Health Treatment 2024. It's in San Fran on the 7th of January! Join us! (that is a ticket link!)In this conversation, we try to get to a shared understanding of what we actually might mean by mental health, the mental health crisis, and whatnot. This means accepting that other people's minds might not be thinking the same things that we're thinking, and so trying to get to the same understandings is a process that we have to take seriously. We need to build trust, and that's really, at the end of the day, what this conversation is about. The transcript follows…Jazz Glastra I'm Jazz Glastra, and I'm the Senior Director at Brain Futures, which is a nonprofit that advances access to new treatments and technologies in brain health. Owen Muir, M.D.I'm Owen Scott Muir. I'm a child, adolescent, and adult psychiatrist by board certification. I identify as an interventional brain medicine doctor because I don't really love... the branding of psychiatry or the expectations. Much of this goes back to me constantly thinking about the role of trust and expectations in any conversation. Jazz Glastra What is the difference between a neurological disorder, a psychiatric disorder, and a neuropsychiatric disorder?Owen Muir, M.D.In the beginning, there were only humors. And that's a little bit of a joke, but We had neurology as a medical specialty,Sigmund Freud, whom we think of as a psychiatrist, was a neurologist. Because we didn't have psychiatry as a separate medical discipline, to this day, the American Board of Psychiatry and Neurology is one board, ABPN. What ends up in what bucket in medicine has a lot of historical ness to it? Neurology used to be all of it? If it was a brain or a nerve, That was neurology, and then Freud came along with an explanatory model for problems people had that didn't involve localizing the lesion,? Neurology took over things where you could point at where it was, and psychiatry took over things where you couldn't point at where it was. If you end up having a thyroid problem, then you go to endocrinology, and you're not managed primarily by psychiatry. The accident of history is nonlocalizable Neurology ended up as psychiatry.And here I am, talking all the time about fMRI-guided treatment, so I'm getting myself in trouble. One of the people who brought this bridge back was Dr. Nolan Williams, who trained initially as a neurologist. He did neurology first, then got board certified in behavioral neurology, and that not being enough residencies, he did an entire other residency in psychiatry.And three board certifications in, he's a neurologist and a psychiatrist, and blah blah blah. It ends up being, “Who's got the most practice in their training program with whatever the problem is to own it.” It's an accident of history is the answer.Jazz Glastra So, are we in a mental health crisis?Owen Muir, M.D.Yes, in that we have no idea what that means, and we feel very crisis-y about it.Jazz Glastra I feel crisis-y about it, usually.Owen Muir, M.D.What is mental health? I have no idea. It is the worst term because it means nothing. Which is really good for charlatans and hucksters and bad for people who are suffering. I would agree we're in a mental health crisis if, in the same question, you let me say, are we in a mobility crisis?Yes. When we only fill cars with water that should have taken gas, that's a mobility crisis, and we can have the same response to the mobility crisis of filling up gasoline-powered cars with water as we do to the mental health crisis. I'd say those are similarly crisis y. The cars wouldn't move.And you could talk about what a problem it was all day long, but the car still wouldn't go because you filled it with water, not gas. That's how I think of the mental health crisis. It's a crisis of misunderstanding; the problem is you don't understand the problem, and then you don't apply the right solutions, and you act like it's a crisis, not an actual understandable and solvable problem.Jazz Glastra What do you see as the problem?Owen Muir, M.D.If you don't know what a mental illness is, or that there are different ones, and that's important, is there a problem with people who are, for example, dying by completing suicide? Yes. That is one version of looking at the problem.Is there a problem with people having tremendous suffering? Needlessly throughout their day. Yes. Is there a problem of people being disconnected from each other and hopeless? Yes. Is there a problem of death by drug overdose? Yes. Is there a problem of many people feeling anxious and worried? Yes. Is there a problem? Many people are traumatized and thus have sequelae of that problem.A lot of different problems. Schizophrenia. Homelessness. Having a poor definition for a problem creates. More problems than accurately understanding?And so my argument is for starting with understanding and saying okay, if the problem is defined as X, then what? Because the mental health crisis doesn't define anything enough for me to have an answer for you.Jazz Glastra You gotta do something!Owen Muir, M.D.We have to do something is one of the worst things for anyone who's not a huckster.If you are a huckster, it's great because just misdirected energy to do something “comma,” anything is a cash grab, and that's awesome.Jazz Glastra I think what people probably mean when they say there's a mental health crisis is like the old adage about recessions versus depressions, where a recession is when your neighbor loses their job, and a depression is when you lose your job. When people say there's a mental health crisis, they mean that my immediate family and friends are suffering. People know more people who are struggling or in crisis.Maybe the question could be, is the incidence of diagnosable mental health conditions rising? Is the incidence of completed suicide rising? Are all these things you listed before, are they getting worse?Owen Muir, M.D.Yes, completed suicide is measurable and well-tracked, and definitively, more people are dying by suicide in the United States, at the very least, now than previously. Yes.Jazz Glastra What do you think about the term death of despair?Owen Muir, M.D.I think it's an attempt at good branding. It's lumping together—death from overdose, death from suicide, and death from alcohol use disorder. Death from problems associated with psychiatric illness is an attempt to draw a circle around something in a way that.It is trying to be helpful. I appreciate both attempts to understand and define a problem. Does that definition empirically hold up? Nate Silver doesn't think so. And Nate Silver is good at numbers.Jazz Glastra What's the difference between being in remission and being cured? Why don't you ever hear people talking about cures and mental health?Owen Muir, M.D.We don't use the word cure because, essentially, the FDA won't let us. I'm a doctor, saying the word cure has a very specific meaning—definition, which is more rigorous than the dictionary definition.So, the dictionary definition of cure is having “no signs or symptoms of a disease.” I would argue many of the things I do to treat, say, depression, Stanford accelerated intelligent neuromodulation as an example, leads to what could be defined as a cure. However, because of years of hucksterism, We had too many things offered up as cures that weren't.You end up having to asterisk yourself into incoherence. Could it come back? Yes. I have athlete's foot powder that says it will cure athlete's foot. But that claim was adjudicated by the FDA a long time ago. Meconazole nitrate, a cure. That's a claim on a treatment that they would have to approve. And saying cure makes you sound like a charlatan. Until the FDA agrees with the label that says cure, I'm not going to say cure. Even though people would love that.Remission is defined as... no signs or symptoms of a disease, which is different from recovery, which I prefer conceptually, which is no signs or symptoms of a disease. And At least one meaningful friendship outside the family and meaningful work or school.Jazz Glastra You're getting more into well-being and just whole-person wellness territory there.Owen Muir, M.D.I do we need to use that many words to say human? Life anyone would want? Jazz Glastra Is that the purview of a psychiatrist or a neuropsychiatrist?Owen Muir, M.D.If you imagine the job of a physician stops at no signs or symptoms of a disease no. If you imagine the job of a physician is to help people. optimize full, rich, fulfilling lives and get and stay well, then yes. I tend to be in the latter camp. It's a little bit like trauma surgeons doing advocacy work to reduce gun violence,they got really good at sewing up bullet holes, but would rather do less of that, thanks. Because there's only so much you can do in the O. R. I trained in Rochester, for med school, where the trauma surgeons were working with the police in the community to set up shot spotter systems and educate youth about gun violence …to reduce the number of bullet holes they'd have to sew up. Trauma surgeons have been thinking about how to do this in the community better than psychiatrists have, by a lot, would be my argument.Jazz Glastra I've seen this stat bandied about that something like psychiatry hasn't had a new class of drugs in 30 years or 50 years. And we've been doing all this work and research, but the mortality and morbidity rates. are not coming down in our discipline. So I want to know what you think about why psychiatry has been stuck in this rut for so long…Owen Muir, M.D.2023 is a year when new things have come to market. The job of a physician is to understand first and then offer treatment help,We have an entire medical discipline called Physical Medicine and Rehabilitation, which looks to help people restore their physical functioning. And it's called Physiatry, the actual name of the discipline. Now, Psychiatry. is restoring the function of one's mind and psyche, right? And physiatry helps you move your knee.Whether it's referring you to a physical therapist, or a psychiatric therapist, or a psychological therapist, or, the right number of walks for you, or a medicine to make the walks easier, I see those as very similar. We have a real dichotomy between functional problems, like problems of how something moves over time, and kind of structural problems.And it's a lot easier to think your arm is broken, let's fix it, than the way your arm moves is broken, let's fix it. Or the way you think about something is broken, let's fix the movement of your thoughts. such that they function better in your life. And, GI gets this, PM& R is a whole discipline for this, and orthopedic surgery is not the same as physical medicine and rehabilitation, but they both deal with that back pain.Jazz Glastra Why has innovation been so hard in behavioral health?Owen Muir, M.D.We Changed the term to behavioral health and mental health. Whenever we feel uncomfortable, we come up with a new label for what we're doing. None of them are as good as feeling okay. Do you need behavioral health care? I don't know. Do you want to have a good life?Oh yeah. Are you freaking out? Definitely, I'd like that to stop. Part of the problem is, again, a lack of definitions. Dan Carlin at Mind Medicine Now would say, We spent 30 years perfecting algorithms to make drugs as safe as water. And we got a generation of compounds with the efficacy profile of water. We were obsessed with errors of commission, like we didn't want to do any harm. It's in the Hippocratic Oath. But we also didn't want to risk helping people. Not too much, anyway. Which is an error of omission. We weren't willing to call a spade and to admit that the suffering we were seeing was unacceptable.And could you do something about it? We limited ourselves only to things that were not harmful, which excluded many things that might have been helpful. Thus, our vision was narrowed. And so if your expectation is, let's pursue treatments that might get people 50 percent better, you're not going to only look at things that get you a hundred percent better. If your endpoint is remission, and that's all you'll accept, then you spend your time on different stuff. So, we spent our time on half measures because it made sense to do so given the constraints we set for ourselves, which were flawed.Jazz Glastra How unusual do you think that focus on remission is in your field?Very rare. If you don't know it's possible, then why would you do it?Jazz Glastra Do you think most of your colleagues don't know what's possible?I think they know it's possible, but they don't have it, as that's not the expectation. Look, I have drugs to prescribe. I'm a prescriber. I'm going to prescribe them. Those drugs are evidence-based, but to do what? To reduce suffering by 50%. Not studied to eliminate all the symptoms of the much less, heaven forbid, something that could get you even better.Jazz Glastra So you and I chatted a little bit this week about the prevention of mental health and substance use disorders, mostly mental health disorders, I think. I'm curious if you could talk about wanting to reduce suffering but not eliminate it. Owen Muir, M.D.One of the reasons I worry about Eliminating disorders as someone who's enthusiastic about doing so, there's a reason they had a predisposition to have that problem in the first place.It is like having a Lamborghini as your car but moving to Colorado. And it won't perform well up the hill in the snow. In the context of living in Denver in the winter, a Lamborghini is a poorly adapted car, and you are a terrible driver. And so if you imagine everyone just rags on you for how well your car performs, ignoring what car it is, then I'm a terrible driver.It happens to me because I have a Lamborghini, and there's snow, and it's not a good snow car, right? My Subaru friends will rip on me. I'm just better adapted to driving around L.A. That goes, wow, you can sit on the 405 at five miles an hour in style.It's a context issue. Some people do better in the cold; some people do better in the heat. That's what we're prepared for. Some people do better in high novelty environments. Some people do poorly in low novelty environments. Some people are very careful. Some people are very reckless.We need a variety of people around. Unfortunately, some of those people are more vulnerable in some contexts. So in a high cocaine environment, people with the predisposition to be more curious and novelty seeking which often shows up as adhd Are more likely to use and get a lot of reward from cocaine and develop a cocaine use disorder if you're Some people are predisposed to have a problem in a context, some people gain more weight from McDonald's and you put them in a high McDonald's environment, they get obese.Some people are more likely to become depressed when things get bad, and they're more likely to be depressed in a highly depressogenic environment. It's our pre-existing vulnerabilities, which are boons in other contexts. You want some people around who are more curious and look under the rock for the extra thing because they can't help themselves. We evolved together in a tribe, and when you lose track of the fact that we need each other, each of these individual vulnerabilities. Thus, I don't want to think about eliminating people with mental illness.I do want to eliminate the distress. People have, and sometimes that means environmental modifications. And sometimes, it means acknowledging that this environment is one in which you are maladapted. We need to be able to help you function better in this very difficult environment in which you find yourself.But there's a classic ad for Valium that I think makes us cringe now but should. And it's a woman in a broom closet. “We can't eliminate her drudgery; we can help the anxiety. Valium,” or some such thing. It's a woman with a rag on her head, and like a bunch of brooms, and it's super sexist.And it's just ugh. You make, you want to die, and no, stop doing that! Stop, let me, but not everyone has that option. It's about being honest with ourselves. We could eliminate anxiety or make the world a better place so people wouldn't feel trapped. And I don't know that eliminating anxiety is the goal so much as can you, can we help you be untrapped?Jazz GlastraWe don't need to eliminate people who have a predisposition to anxiety, depression, or schizophrenia, But could we prevent them from having their disorder triggered?So, I will give you one of the easiest examples of this I can come up with, which is cannabis and schizophrenia. So we have really strong data, mostly from Christoph Carell's work with other people as well, that ultra-high risk for schizophrenia individuals who smoke cannabis are highly more likely to convert to schizophrenia. And so if you wanted to prevent schizophrenia, the easiest thing to do, in quotes around the word easiest, is get young people not to smoke any cannabis. That would prevent a lot of schizophrenia. Good luck with that, by the way.Jazz Glastra I think we can have a separate conversation about public health messaging around schizophrenia and cannabis and how effective it could be. Owen Muir, M.D.You could prevent schizophrenia by reducing the rates of cannabis use.Jazz Glastra I think that would be a nice thing. —fin—Thank you for listening to the Frontier Psychiatrist podcast. Leave us five stars on whatever platform you're listening to. It helps discovery and lets other people know that it's a great podcast. I highly recommend sharing it with your friends. If you have enemies to whom you would like to send podcasts, you can do that too.If you've enjoyed hearing Jazz and I talk, there'll be more of it. , Brain Futures is co-sponsoring an event I'm hosting on January 7th called Rapid Acting Mental Health Treatment 2024. You can get your tickets on Eventbrite. It's in San Francisco, right before the JPM Health Conference. A special shout out to my friend Grady Hannah, the CEO of Nightware, whose idea it was in the first place.He and other exciting innovators will be there and talking to each other and to you at this reception. (ticket link) This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists is a health-themed media empire(!) with a newsletter as its home base here on Substack. It started as conversations on the app Clubhouse, and one of our—Owen and Carlene's— earliest friends is Jeremy Fox—a licensed professional counselor. He's a specialist in trauma, an EMDR trainer, and a great explainer of things complex. I also think he is a decent human I love talking to. In this interview, we dig into the neuroscience of EMDR—eye movement desensitization and reprogramming—for trauma and more. Please share with your friends, and give the show a follow-up and 5-star review on Spotify, Apple podcasts, etc.Here is us with the lord of Winterfell, given Winter is Coming. He needs a better coat. Advertising For Other Things Section!I work at a practice in NYC for those interested in neuromodulation-first approaches to mental health problems. That means not drugs. It's called Fermata. We are enrolling for the fMRI Guided Depression Trial: The SAINT OLO Study! If you are interested in the treatments we discuss, you can either become a patient or enroll in a research trial, depending on what is right for you. A note: Some of our trials (like SAINT) require payment from patients, and we pay you for others (like TDetect). This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

Chuck DeSmith is a remarkable man—a King County Firefighter, innovator, and a delightful person for a great conversation. Video Version also available on YouTube channel! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

I'm Owen. This week of posts is different from the usual…it's a bit of an origin story for this newsletter, The Frontier Psychiatrists. It's a daily health-themed newsletter by Imperfectionist physician Owen Scott Muir, M.D. There is a podcast (this), videos, a therapy training book, chapters in other therapy manuals, some poetry books, a live event in January, and even a brain-stimulation first clinic in NYC where your depression can be treated in an open-label clinical trial—to remission in 79% of people—without drugs or talk therapy.How did all this come to be? That is what this week's series of podcasts are the slow-roll story of!It all started with a podcast about the pandemic. For those listening closely, the last episode was from March 22, 2020. This podcast was recorded the NEXT DAY, on March 23rd. believed in me, and we all need that. Michelle and I were working together at a practice at the time, and the pandemic hit. She is the person who taught me about the hero's journey and narrative structure. She encouraged me to keep telling a story. The story was about the pandemic at the time. This episode is based on an interview with a nurse struggling to endure the horrors of the early pandemic in New York. As it relates to this newsletter and your author, the story is about the dates. Episode 3 ended, and I was recording Episode 4 the next night. I was dropping perfectionism in the heat of the moment and striving to tell stories that didn't have to be perfect..I am, by necessity, becoming an imperfectionist. There is no perfect in a pandemic. It's chaos, and perfection stopped being an option.This week's articles tell the story of how I got to write a daily imperfectionist manifesto by showing you how I started telling imperfect stories.Your feedback, dear readers, is welcome! Thanks for listening, and stay tuned for the next thrilling episode, where I get a bit more ambitious and fall off the wagon a little. It's not a linear journey!Plug 1: I work at a practice in NYC for those interested in neuromodulation-first approaches to mental health problems. That means not drugs. It's called Fermata. We are even enrolling for the SAINT OLO Study! Plug 2: Tickets are available for the Frontier Psychiatrists live event: Rapid Acting Mental Health Treatment 2024, Jan 7th, in San Fransisco! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists is a health-themed newsletter and podcast. It's a little bit of a media empire; there is a YouTube channel, Instagram, TikTok, and music I do over on Spotify up top. This article is a bit of a meta-article on my journey, with historical audio as reference material.I'm Owen Scott Muir, M.D., and I'm prolific, if nothing else. My first pass, as it were, at content creation was more plodding because podcasts—after music—were my first love. I consider myself an imprefectionist, now. This is a maxim for me—the done imperfectly and on to the next iteration is better than the perfect. One of the perils of podcasting is my fancy taste—I love Radiolab. I have Radiolab production alumni in my life. I love craftsmanship in a production! The Frontier Psychiatrists is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.The flip side is I am one person. Who isn't perfect? Believe it. This person—the modern imperfectionist version of me—has had guides on getting more iterative things done. One is featured in the podcast attached to this very set of words. It's my friend who writes ! My mom is also in this episode.Enough preamble, now to the prologue. My journey to imperfection as a maxim began with the hero's journey. I was in the ordinary world—pre-pandemic, and then there was the call to adventure. Except there was nowhere to go and nothing to do. Cause there was a pandemic. I started getting less-than-perfect content out in the world. This is the third episode of that “body of work.”Michelle—a nurse with whom I worked at the time— and with whom I am still proud to call a friend today, taught me about narrative structure and the hero's journey. She had a very dear friend teach her the same lesson. Slowly, I began to realize the hero's journey I was on was as a storyteller myself…and the story I was telling was both about imperfectionism and in an imperfect format.Much of that story will later be told, over and over, on the Clubhouse App in late 2020…but at this point—the March 19th date on which I recorded this podcast was subsequently released on March 22nd. That is a quick turnaround.I am trying to understand the weirdness of the pandemic, yes. I am trying to understand how to communicate about public health. I am scared; you can hear it. But I also got a thing done and then another. I am starting to let go…to get going.This is episode 3. It's an origin story of a sort!Plug 1: I work at a practice in NYC for those interested in neuromodulation-first approaches to mental health problems. That means not drugs. It's called Fermata. We are even enrolling for the SAINT OLO Study! Plug 2: Tickets are available for the Frontier Psychiatrists live event: Rapid Acting Mental Health Treatment 2024, Jan 7th, in San Fransisco! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The frontier psychiatrists is a Substack written by Owen Scott Muir, M.D.—a child and adult psychiatrist. This podcast is shared from the vaults…here is the story.I live in Brooklyn, New York. For those who remember 2020, we had a pandemic! I know, right? Ancient history! This is audio archeology. I did what I like to do to calm down to cope, which is I started recording stuff. That stuff became a short-ish run podcast, which I called “Remotely Possible: Uncertainty, Anxiety, and Existential Despair.” Was it content marketing for the end of the world? Regardless, it is, in retrospect, a strange time capsule about how I was thinking about the pandemic at the time, and I think it holds up pretty well. The uncertainty of that time was defining.In retrospect, listening to these podcasts, given everything we know and all the things we don't…My bottom line? Uncertainty is hard for us as humans. We're deeply unsettled by the uncertainty. We'd rather things be sh*tty than unclear. We strive to make things bad when we have uncertainty because it's easier than sitting with it. And, frankly, this makes some sense to me. We are not completely irrational — it's avoidance behavior. People avoid things that hurt. People avoid things that suck. One of the things that hurts and sucks is uncertainty. Thus, there's some degree of predictable behavior from humans when things are uncertain. They're going to take the path of most certainty. Even if that path sucks. My issue with the pandemic response ended up being around creating a primrose path straight to hell, which may have been a trap we didn't need to leave for ourselves.We wanted the certainty of what to do—even if it was sometimes dumb. We wanted a vaccine that would be perfectly efficacious—which doesn't exist. And perfectly safe. Which doesn't exist.We are predictable. We will avoid “not knowing”— if we don't build trust first. The pandemic was a giant trust fall that went south cause we forgot about the trust building, in retrospect. With that musing…I hope you enjoy episode two of my pandemic retrospective.Plug 1: I work at a practice in NYC for those interested in neuromodulation-first approaches to mental health problems. That means not drugs. It's called Fermata. We are even enrolling for the SAINT OLO Study! Plug 2: Tickets are available for the Frontier Psychiatrists live event: Rapid Acting Mental Health Treatment 2024, Jan 7th, in San Fransisco! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

In the pandemic, I didn't know what to do with myself. One of the things I did to make sense of my world falling apart was to make a podcast. I think the questions I asked at the time hold up well enough. This is the first episode I made, just about a week into lockdown in New York City. I recorded the audio on March 13th and released it on March 15th, 2020.Frankly, the worst thing about how we handled the pandemic was how we explained things—and this lack of focus on mistrust engendered as a public health risk is an enduring legacy. I called the show “remotely possible.” This is a photo of the first recording setup on my kitchen table.Let me know what you think, with the distance we have now. There are more of these. I'll release them in this feed.Thanks for reading and listening. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

This is an interview from 2015 with Samuel Sharmat, M.D., a brilliant diagnostician. It also was an interview that, in retrospect, helped define my options as a physician. He has a traumatic brain injury as a young child, it changed him. For him, the change unlocked new ways to notice what might be wrong with patients in ways that others could not. Please listen, and share with your friends. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

I won a grant years back to produce a podcast series from NYU's Rudin Master Scholars Program in Ethics and Humanities. I am proud of that work. This episode never made it on the air. It is presented for your consideration. Suicide is discussed, frankly. Both my friend and guest, Lara J. Cox, M.S., M.D, and I discussed extensively that her name should be used. That personal disclosure was the healing element, as we understood it.I presented this work on May 6th, my birthday, in 2018, at the APA annual meeting. That morning, a psychiatric resident in a local program died by suicide. It was devastating. This is a challenging disclosure to write— because of my worries about contagion effects. This issue around contagion was the difficulty in editing these stories to begin with.These stories aimed to REDUCE suicide risk by providing stories of hope. These stories offer support for vulnerable medical trainees. Otherwise, they learn the lesson…as part of the hidden curriculum of medical training: “It's unsafe to talk about your struggles, even in the past.”We lose hundreds of physicians to completed suicide every year, and the numbers on ideation are dispiriting:A 2015 meta-analysis of 54 studies examined the prevalence of depression and depressive symptoms in resident physicians across decades and around the globe.2 They found a 15.8% increase in depressive symptoms during the first year of residency, across all specialties and countries of training. Over the course of training 20.9% to 43.2% of residents reported depressive symptoms, with symptoms increasing over time. This finding could be extrapolated to fellows, attendings, and other post-training physicians. Currently, the actual data for post-training programs is sparse. When we refuse to speak—using best practices—we are also heard. I have long argued this is not the way.The physician interviewed in my podcast above is brave, outspoken, and a personal hero. Lara J. Cox, M.S., M.D., has served on the Board of Trustees of the American Psychiatric Association and is herself a scholar of suicide prevention. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

I won a grant years back to produce a podcast series from NYU's Rudin Master Scholars Program in Ethics and Humanities. I am proud of that work. Here is one of the episodes that NYU “Doctor Radio” felt was a touch too edgy…I'd love to make more, but this production isn't cheap!Thanks for listening, and share with your friends—a special thank you to Lancy Levy, R.N., my guest in this episode. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

The Frontier Psychiatrists is a newsletter. It's written by one Psychiatrist, Owen Muir, M.D. It's a health-themed newsletter. It's also an exercise in imperfection. That imperfection is not an accident. Here is the story…An influential book in my life? It is not about medicine. The book is called Measure What Matters. It is by John Doerr; you can buy it on Amazon with that link! John writes about the system called objectives and key results (OKRs). Andy Grove originally developed this management and goalsetting methodology at Intel.I think it's a meaningful bulwark against perfectionism. It is a philosophy. OKRs are a system for setting measurable goals. But—there is a quirk. This quirk makes it different—and more powerful— than other goal-setting approaches. The system works as follows: * set an overarching objective, and the point is to be audacious. I'll give you a very real-world example:“I'm going to write a great health-related newsletter (all by myself) that influences people's decision-making towards a better future.”Now, here's the trick: you have to figure out how to determine if you're moving toward that goal. And it has to be measurable. When you start this process, you don't necessarily know the best way to measure things for yourself or a larger organization; this is the scaffold.There are rules: * At the end of your audacious goal, you add the statement: “as measured by:”Next, you limit yourself to between two and three (easily) measurable key results demonstrating that you are appropriately pursuing that goal. The quirk is* if you achieve more than 70% of your key results in any given quarter, you did it WRONG. Getting it perfect means you didn't get it RIGHT.My God, right?This is a system to learn how to set audacious goals! I could've set my goals for this newsletter— and did— as follows: “as measured by… publishing an article every single day.”That is a “key result.”This is not the same as a key performance indicator (KPI). Key performance indicators are measurable. Some, however, are all or never—you don't want to close 70% of surgical wounds! Many things are measurable; not all KPIs are useful tools in this OKR framework.All Key Results are KPIs; not all KPIs are suitable Key Results for your strivings.I write an article almost every single day. I will calculate that for my readers at the end of this quarter, and you can see how I did. I didn't know what key results were the best way to build an influenced audience with this newsletter. Did I get it wrong with this key result? First, I have achieved the goal more than 70% of the time! I underestimated the difficulty, and thus the audaciousness, of a daily one-person newsletter for me as a writer. By writing a daily Health-themed newsletter, I failed to be audacious enough! Or I didn't select the right tools with which to measure. I would probably want to set another key result to guide me when I revisit the original goal and its measurement. Which is very much the point. OKRs are not “set and forget”. They are set and revisited. It's an iterative process. We learn, with OKRs, that successfully striving is the meta-goal. We know if we succeed by measuring iteratively, and in failing to be perfect, we learn the right degree of stretch in any epoch.Perfection is imperfect. Striving is a learned behavior and a set of skills. Not always striving is an easy way to avoid the audacious. In my example, my daily publication schedule might not be the best way to achieve my goals.I'd have to find a better way to measure. Repeat.Perfection is poison for those who wish to strive. To succeed at striving is to fail… the right amount, over and over. OKRs are an antidote to the hopelessness of perfectionism and the fragility of narcissism. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

Do you have any idea what mental health is? I wish I did. You have permission from me to be confused. I'm Owen Scott Muir, and I'm a Mental Health Professional. I should probably have an idea. I refer to the Frontier Psychiatrists Substack as a Health-themed newsletter for all the reasons I'm going to enumerate. Subscribe. We've been told mental health is important. It is. I don't know what the word it means in this context. Or I would like to know if we have a shared understanding of the word we would accept be acceptable in any other conversation. If we ask if your car is OK, we have a general sense that the car would need to have:* structural integrity, * four tires, * the ability to move on those rolling tires from one place to another, * not breaking down constantly, and * not crashing into a wall. Working tires, wheels, and the ability to move someone from one place to another are all accepted concepts regarding the utility of anyone's car. Cars need to go… safely.Health, as a more broad term, is better understood. Are you actively dying? Are you in pain? Are you able to breathe? Is your heart beating? Can you get out of bed, comb your hair, brush your teeth, go to work, and hug your children? Activities of daily living have been defined.I fear we made a mistake by putting the word mental in front of the health. It's confused us. Because it suggests there's something different about mental health and health. Health, the state of well-being in which one can do the things they need to do in the day without significant impairment, is a meaningful way to assess whether someone's health is good enough. Being functional, you don't need the word mental in front of it.I would encourage us to consider Health on this World Mental Health Day. I would encourage us to think about the distinction between disability by any standard and what would be the ability to do life things by any measure. The brain is part of the body. The health of the brain and its relationship with the body matters. Similarly, the health of your body and the health of the bodies and brains of the people you interact with matter.I urge researchers and clinicians to look at ability and disability broadly. * Are you able to focus? * Are the things on which you can focus the things you'd like to focus on? * Can you have positive, loving relationships in your life? * Can you do meaningful work? * Can you pursue a goal? * Can you imagine feeling satisfied? * Can you work towards feeling satisfied, perhaps in an accessible educational setting?The further we get from the confusing specifier of mental before the word Health, the better. It is about addressing disability. We happen to have laws about that, at least in the US.Healthy people are mentally healthy people. Being mentally healthy doesn't do much to add relevant context, and I fear that it subtracts some from our ability to understand each other.Thanks for joining me on this World Health Day, which is maybe what we call it in the future. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe

This is an episode of the Frontier Psychiatrists Podcast. It's a conversation between my Fermata team member, Chelsey, and Myself. This conversation is about us, at work, trying to understand neuroscience together. We recorded this one! An edited version of the transcript follows.Owen Muir, M.D.: So we were chatting about the amygdala, and if you want to ask me any questions about it, I can answer them and edit it together. And that's a podcast. Chelsey Fasano, BA: There's a lot of discussion in the field right now about location neuroanatomy or chemistry neurobiology. And I'm always thinking about how the two crossover, so we're talking about the up-regulation or down-regulation of the amygdala.What are the neurochemical aspects of how the amygdala would be up- or down-regulated?Owen Muir, M.D.: Neurochemistry is a great way of selling drugs and selling explanations that are easy to understand.When we talk about neurochemistry, we're talking about a synapse between two nerves that are trying to communicate. There's a tiny little gap, and the way a nerve communicates with another nerve cell is a neurotransmitter is released from one and floats its way across a tiny little gap, and then hits a receptor on the other side, and that creates a change in that subsequent cell, which makes it either more likely or less likely to fire.What's happening next is within that cell. There are intracellular changes that lead to an increasing likelihood of reaching an action potential and itself firing and effectuating the next change in its neighbor cells. We focus narrowly on neurochemistry, because we can look at and modify it.We're getting obsessed with answerable questions— not with important questions. For example, we don't give people “hyper-glutamate,” the excitatory neurotransmitter in the brain. They'll have a seizure. Those excitatory impulses open ion channels that cause immediate depolarization and firing of neurons. Uncontrolled depolarization leads to seizure and death. GABAergic drugs do the opposite thing. So, anything binding to the GABA receptor opens a chloride channel. Chloride's negatively charged.And that changes the inside of the cell's voltage to negative, which means it's less likely to fire because you need more glycine and glutamate to increase the voltage. GABA is safe to agonize, because you're not going to get a seizure—but withdrawal is dangerous because now you're more likely to fire in the absence of the GABA drug.We're focusing on other compounds like serotonin, norepinephrine, and dopamine, which functionally regulate the internal cellular environment, making firing more or less likely. And we focused on it because it's safer. We got obsessed with what we knew we could do and not immediately kill somebody— as opposed to what might actually be effective or is happening naturally because, on their own, our cells are firing and releasing neurotransmitters and pulling them back up and regulating their voltage without us messing with it at all.For example, the chemistry argument at the amygdala level is part of the story. But when we're talking about what information the amygdala is kicking out, it's really how fast it is firing. That's my kind of argument. It's a rhythm answer. If we looked at the stage plot for AC/DC and saw they had a lot of cables and started worrying about which cable plugged into the guitar as opposed to they are going to play in time --and you can replace the strings, the guitar, the cables. You do not have a good AC/DC show if they play at a time, and if they're playing in time, even if the guitar cuts out like bass drums, Angus is still locked in, and it rocks.We've focused on what's focused-on-able, not what matters.Chelsey Fasano, BA: The primary neurotransmitters of the amygdala are precisely the ones you were talking about!Owen Muir, M.D.: The n methyl D aspartate receptor is a binding site that modulates glutamine.Chelsey Fasano, BA: So that makes sense as to why ketamine would strongly affect PTSD since it works primarily on NMDA and GABA. That would downregulate the amygdala, which would help to buffer against the overactivity associated with PTSD and subcortical areas.Owen Muir, M.D.: The firing rate functionally comes down because each nerve in the amygdala firing becomes less likely by some amount. Chelsey Fasano, BA: Is the feeling something to this whole hippie thing of vibration and vibe?Owen Muir, M.D.: It's true at the level of the neurons in the brain. Yes. I think wavelength is an accidental term. I don't know. But it's the literal truth.Chelsey Fasano, BA: We know that neural firing from some research that I've read affects motor movements and speech patterns, and so there probably is some truth to the fact that upregulation of specific circuits is going to cause speech pattern and motor movement differences that are going to be the bodily rhythmic reflection of the brain activity. We would pick up a vibe because we all sense those things about each other through our brains.Owen Muir, M.D.: We're building a model of the vibe. I propose that a firing pattern represents everything in the brain. It's click click of one nerve group, right? And in the other person's brain, it's click click.But in our brains, we build a model of our click. And then, we make a model with clicks in our neurons of the other person. We're constantly building models of other people's minds in our minds with our pattern of firing. Then, we pick up signals from their motor movements and behavior. We're resynchronizing our model. with their model, and we're constantly just getting it a little bit wrong and getting back into sync, and what humans love is feeling in sync.When we dance, we're dancing in time. Like the guy who dances badly, we find displeasure. When we dance together, we find it joyous. When we're dancing to the beat, we enjoy that because our brains all represent the beat simultaneously. We can look and see and feel with high bandwidth sensory cortex and high bandwidth motor cortex that we are together, and that lets us not bump into each other when we're dancing and emotionally not bump into each other's feelings when we're communicating.The dopamine system, for example, which profoundly regulates ventral striatal activity around motor gating, is also implicated in not just motor gating but also the gating of behavior. Some of that behavior is our feelings, how we react to the feelings, and how we talk, think, or sing.This is how we can do things like lie to each other politely and not get enraged. Because there are times when someone lies to you, and it's bad, and how dare you lie to me. There are times when someone says, thank you so much for calling. And we recognize that their thanks may not be sincere.And both of us are definitely on the same page about that, but the underlying intent we have modeled for the statement is beneficent.We're both on the same page about that metadata, which is, oh, the person's lying to me, but it's because they care and want me to feel good. And so I'm going to think this lie is kind in this context, and in other contexts, my internal model was that they shouldn't have lied as opposed to should have lied.So it's not the lie; it's the intent that we model and can reconnect to that allows human behavior and motion. To go well. If someone's a lousy dancer because they have Parkinson's, you're not going to love it, even if you don't know they have Parkinson's, and you may feel more positively inclined to them if you understand they have a reason for it.But it doesn't feel good. We feel good when we move together.Chelsey Fasano, BA: We've had some discussions about this previously about you not valuing agreeableness or not liking that quality of when people pretend to be polite, and I tend to be more like that.And I think when I do that. Often, when I attempt politeness or I attempt positivity, even in a situation where things feel pretty dire, and I don't think that way, what I'm doing, my intention, is I'm trying to slow down the dance. I'm trying to introduce something to the dyad that I'm a part of that is not necessarily totally authentic in that I'm not feeling it at that moment, but I want both me and the other person to handle it.I desire. So, I create the desired state in affect, hoping the dance will move in that direction. It often works. If you fake it till you make it, and you choose grace, and you choose to give someone calmer and more positivity than you might feel like they deserve, they often follow suit by giving it back to you.Owen Muir, M.D.: What mentalizing and Peter Fonagy would say about this is like the way to do that most successfully because some people will interpret it because their experience and trauma, for example, as a lie—an aversive lie— and that'll create mistrust, and they'll get agitated, right?Like, how dare you be polite to me, right? For those individuals and people who like politeness, you can do the same thing: mark your intentions. I'm going to be polite now. It's just that much—set it up. “I am behaving in a way because I hope it will be helpful.”You can tell me if that's different from how it comes across. You can do whatever you want, and you have the spoonful of acknowledging the rationale for your behavior that gives them the additional information that you're doing it within the intent of XYZ, as opposed to just being polite. They can assume you're scamming them with your politeness.Because they're people who've been harmed, scammed, and traumatized by polite people who wanted to abuse them. Thus, politeness for them may be a signal of risk. And so it's the ability to mark that I wonder if politeness is the right way to go, but I will try it out. That is the kind of permission slip to behave; however, you need to behave and also eat if it goes poorly… in a tolerable way.“Wow, my politeness came across badly there. I can see by the look on your face that politeness was the wrong approach,” Then suddenly, they feel understood and don't want to argue with you anymore.Chelsey Fasano, BA: We've talked before about having a mini version of the other person in your head, which, according to this conversation, the mini representation of the person that we have would be not only our conceptions of them and abstract representations but be a literal rhythmic firing of neurons, which explains sort of emotional contagion and how you can feel someone else's feelings.Owen Muir, M.D.: Mirror neurons are a metaphor for mirror patterns of circuits firingChelsey Fasano, BA: When we're looking at different schools of therapy, and some people are saying all of the feelings that you're feeling are definitely counter-transference are all coming from your past. It sounds like what you're saying is that's not accurate. What is happening is that we're getting rhythmic representations of the person that are combining with the conceptions that we previously had of what those rhythmic representations mean to create a sort of mini person inside of us that then informs both Our immediate affect as well as our ability to predict another person's behavior across time.Owen Muir, M.D.: a million percent correct. So it's yes. Therapy is neuromodulation using the sensory experience of another plus the representation they have of us and the representations we have of them, and the desync/resync on repeat —is what therapy is. If you've seen projective identification when you come across that term, the ability to invoke in another person Psychodynamically a behavior that's true because of my ability as a human to create a model of you and perturb that model and react to the perturbances. I see it in a way that's in keeping with my internal representation.It's a fish swim in schools. They're not sending a letter to all the other fish in advance, being like, okay, so in second 17 — turn left. They're modeling all of the other fish and then swimming in context with the model and then adjusting the model in each fish, so there's the constant adjustment of how much the school is moving because we're all building models of the school and checking them with each of the nodes in the network.In therapy, you have a dyad that's doing the same thing. I move left, and I expect you to move right, and you move right as far as you move right. And then that hits or doesn't hit the model I have, and then we move back to the center and do it repeatedly. That's the misunderstanding that is the neuromodulatory agent in psychotherapy. Still, it's brain rhythms in both people's brains firing and then checking, and error checking against the visual sensory interpretation as presented to consciousness and heavily edited by subcortical structures that make that dance happen. It's the getting it wrong, just like in meditation, -- we're attending, losing the attention, bringing it back to the flame. And bringing it back to the flame is why we meditate, not simply “staying on the flame.” It's supposed to be challenging.It's better if it's hard because it's a workout. -- Therapy is better if it's hard because it's a workout. But it's not just for attention regulation; it's a process of re-syncing to better inter-human and intra-personal things because when you do it in therapy, you get to do it out in the world when the therapist isn't there to help. So, being a therapist who's a little bit wrong all the time and then gets back to it is the honest answer. Ta-da! How's that?Chelsey Fasano, BA: Good.Owen Muir, M.D.: Let's see if it turns into anything. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thefrontierpsychiatrists.substack.com/subscribe