Hey, how's it going? We've got an exciting podcast for you today. We're talking about the future of psychiatry, and we're talking about interventional psychiatry, and we're joined with Dr. Owen Muir. Dr. Muir is a huge ambassador for TMS. He's really at the cutting edge of treatments that we have in mental health. Some of the treatments that he offers and that we'll be talking about in this podcast are TMS and advanced TMS protocols, prism neurofeedback, external trigeminal nerve stimulation, and non-invasive vagal nerve stimulation.
He also writes an awesome blog called Frontier Psychiatrists, where he shares humorous insights and updates on the latest in the field. So, let's get to it. Your clinic has, it truly feels to me like a clinic that is in the future. And you probably have experience with things that most people have never seen. Can you talk about, you know, the vagus nerve stimulation, the trigeminal nerve stimulation?
Can we go one at a time? Yeah. So the GammaCore NVNS non-invasive vagus nerve stimulation. What does that look like? Who does it help?
So the vagus nerve, right, cranial nerve 10, goes from your brain down to your heart and to your viscera and controls things like heart rate, slowing it down, not speeding it up, and a bunch of sensory and other. It's controlling a lot. It's input to the brain and it's output from the brain in that same nerve bundle. So the gamma core device is handheld. It fits in your brain.
It's about the size of an iPhone, essentially, a little thicker. And it's got two electrodes on it. You use a little bit of gel, and you put it on your neck. You put gel on the electrodes, put it on your neck, and there's a little rocker on the side where you turn the power up. And so for two minutes at a time, you're turning the power up until you just barely feel it.
You'll see maybe the edge of your mouth pull down. It's in that line on the side of your neck with your mouth. And you hold it there. And it's doing a pattern of stimulation using a waveform that doesn't mess with your heart rate. And so that was the magic, is we can stimulate the vagus nerve, but not change your heart rate and have you drop on the floor from syncope.
Because if you drop someone's heart rate abruptly, that's bad. This is right now an FDA cleared treatment for migraine, hemicrania continua, that half of the headache that really sucks. And I know because I get them and cluster headache. And it's both in some people can work as an abortive treatment, but mostly it's used as a prophylactic treatment. So you're using it for about eight minutes a day.
You hold it to your neck for eight minutes a day, two minutes, four minutes in the morning, four minutes at night. And that's a preventative treatment for very serious headaches. Like cluster headache is horrible. And the fact that we can abort hemicrania continuance, by the way, only has one drug, endomethacin, that works. Migraine, which is the bane of many people's existence. And cluster headache's a big deal.
And it's going through the FDA pathway right now for the breakthrough pathway for post-traumatic stress disorder. Now, I published last year a paper on a case report of a person who had failed multiple other treatments. She failed accelerated transcranial magnetic stimulation with the left side target, with the dorsomedial target. Nothing was working. Medicines, medicines, nothing, nothing, nothing. And I gave her this because she also had a history of migraine and said, look, I don't know if it's going to help, but at least your headaches will get better.
Three weeks later, she said, well, I've got some news for you. My depression's over. And this is someone where I had no placebo response I was expecting in that I had, you know, all these fancy things that didn't do anything. And this was the treatment that worked. And so we published that in the journal Transcranial Magnetic Stimulation this year. So that's what it does. It's a handheld device that you use every day for about eight minutes, and that may treat depression, we'll find out, is going through a regulatory pathway to treat post-traumatic stress disorder, and we'll find out.
I suspect is useful for those things, but if you happen to have headaches, it may make sense to use this and get an additional benefit, not just less headaches, but maybe less depression, less anxiety, et cetera.
Now, this is completely non-invasive then. There's no need for a surgery, an installation of something. This is so futuristic compared to what we used to think of as vagus nerve treatments.
And I mean, the vagus nerve treatments haven't done as remarkably well as we would have liked as an implantable stimulator in depression. However, we just had a paper in the American College of Rheumatology demonstrating that vagus nerve stimulators reduced both pain and inflammation.
Hmm.
So we have neuromodulatory treatments for inflammatory markers and pain from a general medical condition, which is rheumatoid arthritis. Okay. Cool. Yeah. So that's, yeah, it's non-invasive. You hold it to your neck. You know, you have to remember to do it, but that's about it. You do it every day. It builds up over time. It's like a, you know, a dose of a medicine, but instead of taking a pill, you hold the thing to your neck.
Awesome. Let's move to the next nifty thing that you do, the Monarch ETNS, which is external trigeminal nerve stimulation.
Right. And so the Monarch device has a sticky pad, goes on your head, your forehead, and that sticky pad hooks to an AI stimulator with a battery pack that you sleep with on your head. So you go to bed for eight hours. This is FDA approved, not just cleared. In kids seven through 12, the approval was for epilepsy and treatment refractory seizures. So it's a treatment for kids with epilepsy.
It's also a treatment for ADHD. And it's on label, approved by the FDA for kids seven through 12. And there are additional studies happening in adults and kids. I prescribe it routinely in adults because off label, it works enough in ADHD and it doesn't have the side effects of stimulants. So there's no appetite suppression. There's no insomnia. It actually helps many individuals sleep a little bit better.
And if it works, the risk is low and the benefit is really high. And when I say benefit is really high, a lot of these neuromodulatory treatments have like responder groups and non-responder groups, right? So some people works great and other people doesn't do anything. When you average them out, it's modest, but it's probably more likely that you should like try to figure out who the responders are gonna be.
And essentially in half of kids, it's twice as effective as stimulants. So we're talking about effect sizes in the 56 range, things like that. It's like massive. Yeah. Stimulants are monster treatments in psychiatry, like 8, 9 effect sizes. And in half of kids, this is gangbusters. And the other half, it doesn't do much. Now usefully, the half of kids in which it tends to go well, the kids with more emotional dysregulation the kids who respond less well the stimulants um but i personally use this treatment now because my doctor prescribed it and uh i don't use stimulant medicines anymore so hallelujah my wife is also much happier with me when i get a good night's sleep with the monarch on i don't forget it because i have much more clarity and i'm less of a pain in the neck the next day and i get less distracted
That's such an interesting difference there because it makes me wonder about things that I've thought about clinically, whether ADHD is just too broad of a category. There are probably some types of different things causing that same output. And the difference in response there seems at least suggestive of it.
Yeah. And subjectively, what do you experience with the machine?
Everything you like about the clarity you get when you have like a great cup of coffee, but none of the jitters. So you wake up with a sense of like, I find myself getting less like derailed in conversations. And frankly, I can hold other people together better too. So it shows kind of how connected we are. Like when I have more distractible colleagues, when I've been consistent with the use of the monarch, I can hold conversations together between people.
So that there's a transitive effect of monarch treatment in my life anyway. Um, But having any ADHD treatment that can help in attention, which most drugs other than stimulants don't do a good job of and doesn't have the side effects of reduced height in young people, cardiac side effects. There's a black box warning on stimulant medications. Nobody likes tachycardia. Nobody likes elevated blood pressure. Nobody likes extra mortality, which it seems like it's the case.
There is a morbidity and mortality burden of stimulant medications. which, by the way, is second only to the morbidity and mortality burden of untreated ADHD. And to your prior point, we think a lot about our treatments based on what we're going to prescribe for them. So people argue about ADHD all day long and like to hate on it because we assume ADHD means stimulants. But if we didn't assume that, which the monarch argues we shouldn't, then maybe we think about ADHD as just, okay, we need to understand the problem.
And then we have a range of options to address it. And not all of them are addictive drugs. And then you think differently about ADHD. We stop arguing about adult ADHD because the treatment isn't something people have a bias against.
Yeah.
That's spectacular.
Yeah.
It's cool. Um, Moving on to the next cool thing you do, the prism neurofeedback for PTSD.
And so full disclosure, I am now a consultant and advisor to Gray Matters Health, who makes this device. Thank you, Gray Matters, for that gig. And I wasn't when I got the device or when I was reviewing papers about it. So this story, at least for me, goes back about three years. I went out to Berkshire Medical Center to train with Bessel van der Kolk, who's the author of Body Keeps the Score.
In EEG neurofeedback. And like for those who haven't met Bessel, he's a hoot. He's a great psychiatrist and he cares a heck of a lot about trauma and not a lot about other things.
He's a real specialist.
Because he doesn't have to. He knows a lot of the people that I trained with and his opinions of them I thought were highly accurate. Like he's got a good eye for humans. And so his take was like, look, MDMA is going to be a potent treatment at some point. But like for children, we're not going to be giving them MDMA. We need effective treatments for young people that are not invasive and not harmful.
And the early effect sizes in the studies he was looking at were big. And they were from neurofeedback. The problem was no one had productized it. Like it wasn't easy to do. It was in fact very complicated in a way that wasn't realistic. And what the team at gray matters did is they trained an EEG, which is like the brainwave reading, electricity from the brain being picked up by these electrodes.
And they trained it on fMRI changes. So they're able to sync up what is your amygdala, the fear center of your brain, calming down. What does that look like as a signal from a brainwave? And use machine learning to synchronize the brainwave reading with the change in Yeah, we use bold signals. So change in metabolism, bold signal changes in the brain when oxygen is pulled off of hemoglobin because you have more metabolically active brain.
And that changes the spin on an electron that is hanging off of a hydrogen, which is on the hemoglobin molecule. And I used to teach organic chemistry, so I'm sorry. But we're seeing that change happen and it's functionally measuring what's happening deep in the brain. And instead of having to have a multimillion dollar scanner, we now have a cap you can put on in the office. And they created a video game that lets you see what's happening with your brainwaves and represent it to you and change it.
So when you think in a certain direction or in a certain way, if you sing to yourself or if you imagine skiing down a mountain, it changes your brainwaves. And so you select from a you create some mental strategies for yourself. You try them out. You see what works in the video game. And then the one that works the best to get the people to sit down and shut up.
That's what you use and practice. And it actually calibrates to where your amygdala signal is at for every repetition. And each one is about five minutes. And so just like you're lifting weights at the gym and someone puts on just enough weights, you can barely get the bar up. And that's the threshold at which you really build muscle. It's doing the same for your ability to calm yourself down.
Now, this sounds quite different than the run of the mill community biofeedback therapies that I'm familiar with. This is completely different, right?
Yes. So it's both. I mean, it's similar in that there's an EEG.
Yeah.
And there's an output of that EEG and you're responding to the output of that EEG. But this isn't you don't need a psychologist to shepherd you through the process. It is completely automated.
Wow.
And you can imagine we have this initial treatment for PTSD where we train that signal change on the amygdala. One could easily imagine we could do that for other brain regions. And I'll let your brains run from there. But if you think brain circuits are important, the ability to isolate one brain circuit or another and then use an EEG to have your brain be its own stimulator opens up a lot of possibilities.
Now, what you speak about that happens under the use of this device from a subjective experiential standpoint, are there parallels or differences between what the patient does with the device versus what happens in a psychotherapy or mindfulness practice or anything else that we do in the field so far? Yeah.
And so it's a lot like if you knew just the right thing to say in psychotherapy, right? A lot of psychotherapy is like advice on average for what's likely to help you calm down.
Mm-hmm.
It's not customized to the person. It's what's in the manual for that therapy. Yeah. And because all therapy is neuromodulation is my argument. The nice thing here, there are two really nice things. One, nobody has to talk about the trauma.
Wow.
Not the therapist and not after the initial intake, the person getting the treatment. So trauma therapy is, absent talking about your trauma awesome because you know what it's traumatizing to hear about people getting traumatized it's traumatizing to relive your trauma and a lot of people don't want to do that for really good reasons yeah so not having to do that like trauma therapy without the talking about your trauma part's pretty sweet i mean when i was hearing about mdma assisted therapy which frankly i'm happy and it's at least that the form it was submitted to the fda didn't get approved because it's questionable at best yeah but i've treated people who are mdma therapists in my practice as patients and they will tell me it's really awful to watch people on mdma relive their therapy their trauma and like doing that as the only thing you do all day long because that's what you're a specialist in takes a special kind of person but there's vicarious trauma there oh yeah no thank you no bueno If I can do something else that isn't bad and, you know, we have an oven mitt essentially for the trauma.
And that's what I feel like prism is for the therapist. And it lets the person engage in a therapeutic activity that isn't talking about their trauma, which is awesome. What people report to me is actually I don't really know how to fit it in my brain yet because it's weird. I have a patient who's actually a trauma therapist herself, a different one. I have a number of trauma therapists who see me.
And she told me that she was singing. The thing that works best in the treatment, the prism treatment, was silently singing a gospel song to herself. And she was able to, when woken up by a nightmare at home, in keeping with her trauma, sing that gospel song to herself, immediately calm down and go back to bed. She was out in the world and something stressful happened and she just hummed quietly in her own mind a gospel song.
And lo and behold, she was able to get through an otherwise impossible experience. She was able to get a massage for the first time in her adult life in a way that wasn't triggering her trauma because she just sang the gospel music in her head. So it's a little bit like a discovery probe to find out like what the absolute best coping skill for you is.
Yeah. Have there been, so for that particular treatment, does that co-occur with other treatments in the studies so far? And how far out do we see outcomes so far in terms of long-term?
And so we have, we're going to have more outcomes data soon because whenever anyone does this treatment, they get follow-up rating scales with it just as part of it. But in the initial studies, the nice thing about this kind of treatment is we have within subjects comparisons. Right. So we know what you look like on session one in your brain. And we know what you look like at session 15 and thereafter.
And so part of it is we're able to really more linearly measure over time how someone is changing with respect to themself, which is a powerful statistical approach. Um, but long and short of it is it's, it's the clearances is an adjuvant treatment. So in addition to other stuff, and that could be a medicine, it could be psychotherapy, it could be supportive care, it could be any number of other things.
That's a regulatory thing. So, uh, Many of these treatments are approved as an adjuvant treatment first, just like Spravato just had this happen. It was approved as an addition to antidepressants, and that's an ethical concern in trial design. And then it was approved as a monotherapy subsequently. So the initial approval is an adjuvant treatment. We will see if there will be a subsequent label expansion to monotherapy.
I want to go back. Oh, go ahead.
Yeah, you got it. You got it. Okay. I want to go back to what you were saying before. You know, with the TMS treatment for depression, you, you, you point to hope, but you also say after this, there are going to be changes. You have a long. view of the road ahead for these patients and you tell the patients about it i suppose what i am worried about is that if we begin to have targeted treatments for targeted problems that the efficacy of the treatments will go down because not everyone will be doing the proper long-term work with patients and they may just simply be dispensing treatments rather than working with patients long term what do you think about that yeah
Yeah, we shouldn't abandon our patients just because we have a whiz bang tool. But some of us are surgeons and some of us are internal medicine doctors and some of us are family medicine and some of us have careers with longer relationships with people and others are interventionists who do a thing when the person needs it. Don't follow up with your trauma surgeon quite as often as you do with your primary care doctor, because we want trauma surgeons to save your life when a car hits you.
And we want primary care doctors to prevent you from dying early from a heart attack. And those are different jobs.
Right. So probably then what might be practical is much more split treatments, rather different professionals providing different things.
Teamwork.
Yeah.
Teamwork is great. Like nobody goes to a job and is like, it's just going to be me and I'm going to work with nobody else and get everything done or one person. Like I have some people, but most large undertakings involve a team. Medicine is no different. And the more teamwork, the better.
Now, within your specific sub area with the neuromodulation, are societies working to get with things like the ACGME to make sure the education is getting to the residencies? That's something that worries me as an educator that, you know, you guys are doing incredible work on the research end. Do you even have time to talk to the educational bodies in the way that you need to? Is there a need for liaisons?
What's the situation?
so you know part of this happens at national meetings right uh and so i present every year at the american academy of child and adolescent psychiatry on something or other often that's psychotherapy actually um i do kind of a i'm a professor at a clinical assistant professor at the meninger department of psychiatry at the baylor college of medicine i did six months at mayo clinic last year uh i have me at ground brands at your institution i'd be thrilled i just did conway medical center I love going and giving talks about this stuff.
And I think ongoing education matters. A lot of what ends up in the residency training curriculum has to do with ADPERT. Some of that has to do with what ABPN values and Jeff Linus, who's the president, was actually my mentor in medical school. But I do think building educational and training curriculums matters. There's a problem. I work for medical device companies, so I can't create continuing medical education, right?
And so one of the problems is now that we have a frontier of a new medical subspecialty, the people who know the most are most likely to be working with industry and thus excluded from creating educational materials. And so we need other educators to at least sign off on that educational material and work with the ACGME to update and modernize its... criteria for what is responsible and reliable education materials but there's some nice starting places like can we include articles as part of the continuing education pathway for board recertification that would be great and jeff linus has said yes please submit articles on neuromodulation and i plan to do so all right very good um jeff is a is a relentless educator for his entire career as evidenced by teaching me to be a teacher and uh I was a Kaplan teacher before I was a medical student, so that's good.
It does take educators doing their thing, professional societies doing their thing, and journalists like myself some of the time telling a story so that everyone can understand it. But continuing education is one of the fun parts of medicine. We get to keep learning stuff. That's awesome. And I would argue that this is a great opportunity for all of us to keep learning in a way that's fun and enriching.
And does it have to get baked into residency? Heck yes. Because if it's all pills all day long, you're not prepared for the future. But if you happen to be a training director, awesome. And I'm more than happy to come and talk to your trainees. All right.
That's awesome. I want to splice something back because we only have a few minutes and I do want to touch on all the things that I feel like you have clinical experience in. Can you talk a little bit about your experience with Spravato?
Yeah. So Spravato or esketamine is a, is a, uh, one half of the like left and right-handed molecules is the racemic mixture of ketamine. Esketamine is just the left-handed version. Uh, it's a nasal spray and it, goes in your nose and it happens. It's eight times over the course of the first month and then weekly or less thereafter. And it's a treatment approved for treatment resistant depression or major depressive disorder with suicidal ideation.
And very recently as a monotherapy, for treatment-resistant depressions. You can use it on your own without a medicine that didn't work for you, mandatory added. It works. It doesn't work remarkably well for everybody. I tend to use it as a second-line treatment after TMS because practically the durability of TMS, like you get a course of TMS and you can go to Japan on vacation and you don't have to worry that you're going to crash and burn because you missed a week of Spravato.
And bravado does require for many people more consistent treatment over time, like every week, something like that. And if you miss a dose, it goes badly. Many people can space it out, but not everybody. But what you choose first matters. And so I think it is an open question as to what we should choose first and for whom. But I tend to start by thinking what's going to be the least disruptive in the person's life if it works.
Mm-hmm.
And so having something like accelerated TMS, which can be done in a week and you get to go on vacations for a year and not have them be interrupted seems better to me than having to worry that you can't go abroad for a week because if you do, you'll miss your dose and things will go bad.
Absolutely.
But again, more options that don't cause permanent movement disorders, metabolic syndrome, et cetera, better than less options.
what are the things that you are the most excited about? And, you know, what do you see as the really important things that you think are going to be around in five years?
Getting treatment paid for.
Not terribly exciting, but key.
So I, look, I have, I have gotten right with God about the fact that if we don't do as good a job on the business side, as we, can on the clinical or science side, these will not be here for our patients, right? We've done a tremendous amount of research around TMS and it can do a bunch of exciting things, but insurance companies have coverage criteria that we have not successfully changed that say it's only for major depressive disorder and only once a day over 36 days.
And none of that rewards us for doing it better or for caring for people who need it or for any of these things. And that's not acceptable. So if we want great innovations to have as treatments for people who are suffering, they need to be sustainable businesses also. And we go through medical school and do rotations in internal medicine, in surgery, in OBGYN, so that we'll know something about the other parts of medicine.
If we don't know something about the business of medicine, we will get crushed and our patients will get crushed. So I think the innovation and some of this is measurement. And I'll talk more about how I think AI is going to revolutionize measurement. But if we're not measuring our outcomes and we're not understanding the business case that those measurements help make, we will fail our patients. And that is not acceptable.
You know, it is unfortunate that business money, it almost feels like for some people, it seems like a virtue to not think about. But it's an unfortunate reality that it's the gate to making change and to making things happen at all.
I don't know that it's unfortunate. I think if you... If we didn't have the ability to measure, like the motor threshold, that ability to make the thumb move with TMS, that was a way we could measure an effect on the brain. And thank God we had that way to measure because that allowed us to have a way to calibrate a treatment and a way to deliver a reliable treatment.
Measurement is the soul of science. Number of dollars is a scalar variable. And it's another tool for measurement. So if we think about in a world of limited resources, how are we going to use that tool for measurement to advance what's good for our patients? I think we can do a good job. And if we abdicate a responsibility to use all the measurement tools at our disposal, well, go do wellness.
Like get another job. If you just want to be nice, go start a nonprofit, which still has a budget, by the way. You're always going to have a master, and sometimes it's going to be money. And if you're not good at it, well, okay, fine. Find someone who is. Get a teammate. None of us are going to be great at everything. But I don't think it's axiomatically unfortunate.
I think it's unfortunate when we let people who don't have at their heart the like a ruler isn't ethical it's it's not you know measurement isn't ethical but what we use those measurements to advocate for can be yeah so i don't think anyone would argue that like we shouldn't oh the world war ii is going to cost a lot let's not go fight the nazis right no it's going to cost a lot well how do we possibly do that let's measure our way to success And so the ability to use money as a measurement and to have more of us be more familiar, like we feel hopeless because we don't understand a thing because it's complicated.
Yeah, but we're physicians. We can probably knock that out of the park. It's a group of very smart people who measure, you know, blood oxygenation and, you know, changes in renal function all the time. Well, just extend that to the hospital budget.
Yeah, it does seem to some degree volitional, willful, right? Yeah. We're used to looking at all kinds of measurements, price, dollars, money. That's a type of data, as you say. And if we can get used to looking at as part of the system of care, which I agree needs to happen, I think people will stop categorizing as this other separate thing that we leave in the hands of somebody else.
And physicians can get a little bit more direct with it, which I think it's going to really benefit patients and the system as a whole.
We're in a less good position to make a strong argument to the counterparties on the other side of the table if we don't understand their language. And we wouldn't abdicate our responsibility to have a translator when someone speaks Spanish or sign language. And we may need a translator when someone speaks money. But you should still be an effective communicator. So I'm joking when I say payment model, but not too much, right?
So how do we get there? And there are some innovations that I see that are gonna help that be the case. So I'll give you an example. The new technology add-on payment under Medicare has brought every major innovation to the hospital setting. since 2000, right? So the biventricular pacemaker, extracorporeal membrane oxygenation in the ICU. These are innovations that exist because industry worked on them, brought them to the hospital setting.
And there was a law that under Medicare, if these things were new, better, and more expensive, those are the criteria for the new technology add-on payment, that a hospital could be paid more in the tiny value-based milieu of a diagnostic reference group based payment, and you had the opportunity to make more money. Hey, we just talked about how making more money can sometimes be good. So I'll give you an example, SAIT, Stanford Accelerated Intelligent Neuromodulation Treatment, a branded version of accelerated TMS by Magnus Medical.
That got a new technology add on payment for inpatient psychiatry. Unfortunately, most inpatient psychiatry couldn't utilize it because the law said you only get the extra money if you have this DRG like bundle payment contract, not if you get paid per day. And so the reason inpatient psychiatry sucks is because there's no payment model to make it better. In most units, you get paid per day and they fight about how many days you get.
And you want the patient to stay more because you make more money, maybe, or less because you don't want to pay for it. And that's the wrong fight to have. We should probably have a system where getting the patient well is the only thing that matters. And we're willing to go at risk on using something new. We get paid a little bit more upfront. But if we can get the patient out sooner or faster, everybody wins.
The patient wins. The hospital wins. The doctor wins. The med device maker wins. Wow, that would be great. And that's what the new technology out on payment let us do in cardiology, in the ICU, in pulmonary critical care. And it hasn't come to psychiatry yet, except it just did. Right. So now we have the ability to have psychiatric treatments, get a new technology out on payment. And now we need innovation and contracting to be able to make use of it.
But that could open the doors open really wide to the inpatient setting. And there's a bill coming through Congress this year again called the Breakthrough Treatments Act, which I really, really hope gets passed. And if that's the case, then it could be the law that if something gets an FDA breakthrough status, it has to be paid within three months by Medicare and commercial payers follow Medicare. And that would be amazing.
So let's have innovation come not just to drugs, but to diagnostics, to medical devices, to treatments. And we're getting closer to that. The open comment period in any year, there's a physician fee schedule and you can leave an open comment. And look, not that many people leave open comments.
It's like those matter. I mean, yeah, no, I do.
But not not only do they matter, they matter tremendously.
Wow.
So a new technology add on payment got signed off on for the Sarah Bell system. So Sarah Bell is a is an AI guided, really lightweight headband that detects seizure. And so you slap it on someone's head in the ER and we can tell if they're having a seizure while they're sitting there, even if you don't have an epileptologist on hand. You don't need a fancy EEG.
The company makes like a thousand bucks per thing and you get to pick up seizure in at-risk patients in the hospital. That company went for an upsized IPO because of that one payment mechanism. And that's awesome. So now everybody can have their seizures monitor with less expertise. Who isn't excited about that?
Epileptologists?
I mean, maybe, but it's not like they don't have plenty of other work to do. They don't want to be screening. They should be diagnosing people who screen positive. Similarly, this past year, I created a technology with colleagues at Videra Health and a company called IRX Reminder where we enrolled hundreds of patients in a study where we measured their tardive dyskinesia with multiple independent raters on the aims and then trained an algorithm to detect those involuntary movements, which we call tardive dyskinesia, a late developing movement disorder that is sometimes the side effect of antipsychotic medications, better than any human has ever done.
So the area under the curve, and this is a measurement in AI studies, was 98, which is really, really, really good. One is the best number that can be. And the sensitivity and specificity when set equal to each other was 81%. The best prior trials were in the 76% range when humans were doing it. So in 90 seconds, an algorithm did a better and frankly less racist job because humans are reliably racist at this particular measure.
We underrate TD in people of color and we overrate it in white people. So the algorithm wasn't biased in that way. compared to the human raters and it was more accurate than any of the human raters so we built a better tool in 90 seconds to screen for a crippling adverse event for which we have effective treatments and under prescribe them that's hot oh yeah oh yeah yeah and that was done with nih funding i think we had like
4 million nih funding to get that done and we did it huh And so there's a revolution in diagnosis, in assessment, and it's coming. That's like one example, but we're going to have a safer, better, faster world. And what I hope for is there are going to be tools that can capture data from someone's behavior and use it to target a treatment. So the robot assistant in my intake is helps me understand which brain stimulation approach for your depression is going to work for you.
That's the future I see. And it also leads to less money burned if you're a payer that cares about that. Or if you want to make it more expensive, it's not up to me. I guess you could just charge. And we have psychedelic medicines. It's just a couple of years down the road. And those look like they have large effect sizes and are really potent. And so when brain stimulation doesn't work or you need a change that's different than that is able to provide, well, we may have those options.
And I do want to say, oh, go on.
You got it. You got it.
Well, let's say these big changes happen. The technology advances in the way it looks like it's going. Do you have any thoughts about how the culture around mental health and psychiatry will change?
I can't wait till we stop using the term mental health. What a useless term. It's a great way for, cause people don't know what any of it is anyway. They're embarrassed. Like everyone has mental health. That's my favorite. Like, uh, okay. Um, the lack of ability to differentiate one thing from another would like, ah, you have a broken bone. Yeah, no, but which one? bones are important.
I agree, but you know, if it's a leg or an arm or a toe or a femur, like it, it does matter, right?
Yeah. I'm taking a bone health day today.
I'm taking my bones or bones are so important. Yeah. And I agree. Um, and, and so the ability to, to have something meaningful to say, to be able to differentiate one thing from another is the role of specialists probably. Um, And just thinking, I mean, we think of these diseases as essentially chronic incurable conditions. Ah, my depression is really bad today and forever. I live with depression.
Well, I don't think people should have to live with depression. I think people should have their depression. There's a word we don't use, but cure, which is defined as no signs or symptoms of a disease. And I think we should cure things in the future, not just make them half as bad. so world where we get we we are healers and we should lean into that the culture of psychiatry should be one of of taking the underlying biology seriously and taking the psychosocial justice seriously and pursuing wildly efficacious cures that i can hope dearly are safer than our prior round of less safe interventions right so
perhaps just better understanding of the line between What comes from what both on the clinician side and the patient side, you know, I see a lot of, especially in trainees, they get a lot of despair. And I do suspect this is related to what you mentioned in that as clinicians, we can. knowingly or unknowingly take in the despair of patients and live it too, which is a problem in treatment.
But they confuse and they're not experienced and they don't know what they can change or what they can't change in the state. I can't help this person at all. They have a bad life and it's never really that simple. Most people have something going on psychologically, psychiatrically and socially. I do hope that this would change how people identify with their illness. I think especially with mental health, no one says I'm a person with a broken bone.
That's who I am. But it's so natural to identify with mental health. I'm sorry, I'm going to keep using the terminology, mental health conditions and say this is who I am rather than something that is happening to me that I can make some changes about.
Well, we don't. I mean, when you have a cold, you know, the cold's going to end.
Yeah.
And so, like, I'm living with cold. But long COVID, like, God, that's a disabling thing, right? People have a disability and they want to feel understood. And so we want nomenclature for it. We want to have a way to understand our experience. And also, if we could do a better job of communicating that there's a good reason for hope.
Yeah.
Well, let's do that. Like, you know, no one's like, gosh, I'm just never going to get anywhere in life. And they're talking about their inability to pull out their phone and call an Uber.
Yeah.
Like, no, you can probably call an Uber to get there. It's just, you know, we're actually like, if you go to a place that doesn't have ride sharing apps, like I get frustrated that we mean I have to call a cab.
Yeah.
What is this? I got to find the cap stand.
That's ridiculous.
Stone ages. And so we take for granted when we have these great things that can make our life easier, that they're going to work. And I would just love it if we could take for granted that, yeah, you got your depression again. Yeah, good thing that's going to be over the next weekend. Great. I got a brain guy. My brain guy's coming after the pool guy comes and he's going to touch me up.
Yeah, that'll be good.
Change out the filter. But I think it's like we have a one day treatment for depression that will get you to remission in at least one study, open label, early, whatever, but 90% of people. So maybe you will have a brain guy and you'll have to figure out how you schedule him and the pool guy around each other. to fix the filter and fix your brain and then go about your day.
Like that would be a wonderful world to live in where these things just weren't the major problems in people's lives.
Yeah, and I think kind of, we talked about this a little bit earlier, but how much treatment dictates how we view mental illness and how we view, you know, like because of our treatments, our medications, we think of depression as low or high serotonin or you have low serotonin. Like the treatments dictate how we think about the disorders and how we think about getting better. If we're able to actually integrate modern brain science into treatment, because right now, you know, in residency in med school, I learned all these brain areas.
I learned about the dorsolateral prefrontal cortex, the anterior cingular cortex, all these things. And I don't think about them ever in my private practice with medications in that if I didn't know a single brain area, I would be providing almost the exact same level of care. Yeah. The future that Dr. Muir envisions will change all that and that those things aren't fun curiosities of, you know, almost a completely different science.
Those will be part and parcel of psychiatry. And that'll be part and parcel of how we understand mental illness and diagnoses.
And so when I see a patient, I'm thinking about where in the brain, I'm like a neurologist localizing the lesion. Where's the functional problem? in your brain. Is this a PTSD circuit problem? Is this an amygdala problem? Is this a subgenual problem? Is this a dorsal anterior cingulate problem? And I use that to create a rank order list of targets for a stimulation approach and then decide on how we're gonna stimulate that, et cetera, et cetera, et cetera.
But the most important change isn't any of that. I think it's understanding that people can have their suffering end. And having the end of suffering be a goal, not a reduction in suffering only. And it's a big deal to end suffering. And you should be prepared with other thoughts, feelings, and humility around what that's like. And that may mean ritual. That may mean, you know, making sure you go and...
visit the grave of the person you couldn't when you were so depressed. It may mean rethinking the job you took as a hedge against the bad state of the world when your depression ruled your life. You may do something different with your time. But I am routinely amazed by my patients and their ability to grab a hold of their life and do something wonderful with it. And having that same hope for everybody.
And there are still problems like some cancers are really bad and are going to kill you. Some brain problems are really bad and will end your life. So, yes, we have to think about the brain more than we might have to if we're thinking about neurotransmitters. But we learned that stuff for a reason because we might need it someday. I'm just arguing that today is that day.
Well, I certainly hope so.
It's here. I'm seeing patients today, later, and I'm going to try to work out which part of the brain is the problem. And I'm going to do something that's going to work or it's not, which is clinical medicine. But at least the way that's gotten me to think about it is thinking about the combination of personality, psychosocial factors, where in their brain that becomes more important than what's the receptor profile.
Okay, well, I have more data to guide the decision-making in one regard than another. But like, This is not super complicated. Someone comes to the ER and they don't have a leg. You're not going to be like, you should run. Or first, maybe you get a replacement leg and then you can get more running in. But absent one of your legs, sprinting is not your first line recommendation.
And we just got to meet people and their brains where they're at.
This is a great conversation, and I'm glad that you aligned with us in regards to... a lot of the hard work is actually like the therapeutic relationship and the, um, understanding the person and that it's not just give, give treatment, fix person, uh, leave like, and that's how a lot of, uh, you know, a lot of psychiatry is treated today, especially as you see these online things pop up, hymns, all those ones where you fill out a survey and you get sent the medication as if that's how getting better looks like.
Um,
Payment models too, right? If you don't find something specific that you've approved treatment for and you don't apply that treatment, you don't get paid necessarily, depending on the situation.
I don't want to hate on systems of care because I do think they're tremendously important and for some things are great. But I'm a healer by training and healing is the goal, not prescribing. Sometimes prescribing is a path to healing, but often it's not. And all of us know that people keep secrets. And they do that for very good reasons because they don't trust the person they're talking to yet.
And so you may have to wait a long time to realize why the person actually came to see you. That may be a secret they're holding deep inside their heart. And you have to show up enough and be a person they want to talk to so that when they're ready to tell you the secret, you're ready to hear it and then do something useful with that. But I mean, the thing I love about psychiatry is the surprises.
Like, oh, it was that the whole time. Huh. I mean, there are weights on our hearts, right? And we can't forget how heavy it is to be a person and how much our patients and our colleagues and ourselves can go through in that process. Like, these are heavy. So I hope. More powerful tools means, A, we get to show up with more hope, and we can also be a little bit more patient when it comes to hearing people out because we know by the time we work it out together, we'll actually have something we can do.
Awesome. We only have five minutes left. Before we kind of close out, anything else you want to talk about? Any pitches? Yeah.
Yeah, I think the crucial thing for my clinician colleagues is to not forget that we're healers and that our patients have things to say that matter. And really listen, as we're learning what these new treatments can do, the people who are going to teach you that are your patients. So spending a little bit of extra time to learn from them is crucial. And... You know, being involved in industry, being involved in, you know, professional societies, being involved in committee work, all helps you understand how the sausage gets made and helps you more successfully advocate for your patients.
And it's easy to kind of pigeonhole people working at payers as bad guys or the devil or only caring about money. And that I think is both a disservice to our understanding and doesn't help us move the needle in a way that's collaborative because everybody wants to get through the day and do their job and not get fired. And if we can understand what helps someone not get fired and get through the day and do their job, maybe we can offer them an argument that can help them get our patients what they need.
So I think it is working together and not denigrating each other for the very challenging work we're doing in shepherding an extraordinarily complicated system to be something more just. It burned my heart to hear people cheering for the murder of Brian Thompson. He was, by all accounts, a decent man who worked in a very complicated company with tremendous forces beyond his control. And I'm not saying he was a saint.
I don't know the man. I am saying nobody should cheer for the murder of anybody else. And if you don't like a policy, you don't like an auth, that's what lawsuits are for, not bullets.
That's right. So, you know, I love your recommendations there and your hopes for the future. Let's say the average clinician who has listened to these couple hours here becomes very interested now. Where should they go next? What do you recommend? Where do they go now to learn more about this, get involved?
So I have an awesome newsletter. Yeah, plug it, man. The Frontier Psychiatrists, but it's also a podcast. So that's true. But what I do with that is actually pretty simple and other people can do it too, which is I set aside a little bit of time to write every day. And I let other people read it. You don't have to do that if you're embarrassed. I don't think it's that bad.
You have probably things to say. But like I look up papers and I try to understand them and I write up my understanding and that's an article. And now I learned something new and so can you. And the more we do that for ourselves, I just happen to publish it. But setting aside even five minutes every day to try to learn something new or tackle a new piece of information and see what you can make of it, that's really valuable to become a better clinician.
So just like going through that process. um try to write try to explain it try to come up with a way to explain it to somebody else even if it's just one other person have an email pen pal um join a listserv join a professional society be taught something teach something etc and and it's very rewarding for me to do and my readers give me ideas all the time like hey can you explain this i'm like yeah i guess like i guess i could try um you don't have to do it every day i'm kind of a you know, I don't know that I would do that again if I had to go back in time because it's a lot of work.
But I certainly got to be a better writer real fast by doing it. Right. So.
Yeah. And I want it. The newsletter is spectacular. We'll put it in the show notes. Frontier Psychiatrists. Highly recommend it to all our fellow listeners.
It's literally daily.
Yeah. Which is crazy. I don't know. You're nuts.
I can see he's one of those, you know, people, amazing people who have a lot of energy, drive, ambition. And The answer that you gave is so good, too, right? Lots of people will give a recommendation that's passive. Go here and consume this. But it's greater than that. You see, you can go here and you can engage with yourself and other people in this new way. I think it's a reflection of your amazing powers as a clinician there.
if you want to write a letter for the frontier psychiatrist, like write your own article, like great, I'll publish it. I publish a bunch of people's stuff. Uh, it's a great way to build community and to get to know your colleagues and peers by, by writing together and learning together. So I encourage anyone who's interested to reach out and I've, Published a bunch of my peers' opinion pieces on things, and I'm happy to do yours, including patients.
I have a patient who wrote an amazing five, not one of my patients, but a five-parter. He's on lithium, lives in the UK. He's a physicist. And under a pseudonym, he wrote a five-part epic on when we should measure lithium levels that led to a collaboration and a publication we're doing together. It's him, Awais Oftob, who I know through Substack Writing also, and myself with a patient first authored article on how we should denote when we drew a lithium level, which was really important to have.
Awesome.
And a gap in the literature. So everybody can read science and make something out of it. Go for it. listen to a lot like indie rock jazz folk electronica etc if you look me up on spotify like you can hear the music i make which is like if if modest mouse and sufian stevens had a child but wasn't as good as either that might be the my the best thing i've ever heard um i uh i did a full-length album in the pandemic at tiny telephone in san francisco with john vanderslice who's a very dear friend um so i ended up recording the last album recorded at tiny telephone where like death cabs transatlanticism was done oh my god let's go and yeah it's i mean so it's a it's john's backup band and he was the engineer so it's like actually a decent record um i got a horrible cold so my voice sounds like garbage but um he he mostly saved it so owen muir on spotify you can play play that on repeat when you go away you mentioned um somewhere that you like
messaged steve albany uh which is really cool oh yeah yeah a million years ago i
messaged steve and i was like hey how do i be an engineer he's like don't um yeah steve was a really good guy uh just to so many people he was just he was like you know want to pick up the phone and give you advice if you're a kid like yeah Yeah. Real giant of our age and a bummer that he passed.
Yeah. Yeah, I'm a mega Modest Mouse fan.
Yeah, I've seen them 20 times. I saw them the week before Jeremiah died.
Oh, really?
Yeah, I opened for them in college. I did sound for the show. We got to throw this in the podcast. 97. Save these kids. I mean, I can talk all day about... the role of music and in my, uh, thinking about stuff, but like between modest mouse, Sufjan and, and, uh, flaming lips, I think you cover most of psychiatry.
Fantastic. Huge fan of all of them.
Yeah. Uh, so it's, it's mostly that stuff like on a day to day basis.
Nice. For, for modest mouse, I've put together, uh, like a little compilation of all their like unreleased stuff. I can send it to you afterwards. And I named it, I made a little mock album.
Love it.
Yeah, I did. One of the things I started doing in the in the pandemic was I did recordings of songs where I would give myself one take for any part. And so the record, The City of Woe, which is like all live to two track or 24 track mostly. It was like one take first take. So I think like one one song we did a second take.
But like the rule I made for myself is if I fuck up the part, I have to write a new part.
What made you decide to do this? That's very unusual.
Well, because I'm a perfectionist and I needed a bulwark against the perfectionism.
Oh, I see.
And it turns out I'm vastly better creative when I don't allow myself to be a perfectionist. And so I wanted to create like the highest barrier. We should probably like click and record and go from there. But perfectionism is the death of being good at stuff, I think. or at least depending on the kind of stuff you're doing. There's some disciplines where just doing more of it gets you better.
And I think writing is one of those things. At least for me, music is one of those things. And you need practice. And I tend to, as an engineer, be kind of obsessed with getting it right. But that can kill the creative spark. And so as an engineer, I'm a perfectionist. And as an artist, I try to be an imperfectionist.
That's cool. Right. I mean, I feel like you have to have... taken some inspiration from clinical treatment, right? All the patients who don't act or get better because they feel like they have to be a certain way or perform to a certain level based on their values about themselves.
Well, it's a scam that you tell yourself that's very, it's comforting to think that you have to get it perfect. But it also turns out like the hundredth thing you do is better than the second thing you do and edit to perfection. So, um, learning how to fail frequently, I think it's probably the most useful thing in the lives of people with, uh, these kinds of problems.
I, my example of this is, um, sorry. Okay. Um, do you know, OKRs is a framework objectives and key results?
No.
So there's a book by John Doerr, D-O-E-H-R. I'm going to spell it wrong. It's called Measure What Matters. It's a really good book. He's the one who brought this from Intel to Google. And essentially, it's a goal setting philosophy that also is a treatment in my brain for narcissism. So the approach is you're supposed to set an audacious goal as measured by something measurable. And here's the hook.
If you, you know, I'm going to record a podcast and it's going to be great as measured by 100 listeners in the first hour. And I'm going to do that every week. However, if here's the catch, if you exceed your goals by seven, more than 70%, like they're going to be a hundred listeners and they're going to be a thousand downloads in the first month. But if you actually make a hundred, you were under ambitious.
And so doing it perfect is doing it wrong because you weren't striving hard enough. It's a framework to learn how to set ambitious and audacious goals, and perfection is failure.
And for myself and the listeners, can you repeat the name of the book?
It's called Measure What Matters by John Doerr.
Okay.
I have a bunch of articles in The Frontier Psychiatrist about this. So if you go to the newsletter, com, and you search OKR, literally O little K, letter R, you'll see the articles on this where I kind of describe it in more detail.
So thanks a lot for listening.