Episode Transcript
[00:00:00] Speaker A: It's still very early in academia because funding agencies are still sort of getting comfortable and up to speed.
[00:00:06] Speaker B: It sort of allows us to work hand in hand at times with industry to think about solutions for patients that are not readily apparent right now.
[00:00:20] Speaker C: Well, Jerry Sharman, thank you so much for taking the time to have this conversation. I've been looking forward to this for quite some time, so I really appreciate you carving out the time to have this.
[00:00:27] Speaker A: Good to be with you.
[00:00:28] Speaker B: Thank you for having us.
[00:00:29] Speaker C: Of course. Now for the audience at home, Jerry has been the Chair of psychiatry at MGH for 20 years now, psychiatrist in Chief Emeritus and Professor of Psychiatry at Harvard.
Sharman is the Director of Cognitive Neuroscience at the center of Neuroscience of Psychedelics at MGH and a psychiatry instructor at Harvard Med. So today we're going to be diving into the incredible work that the two of you are leading on the front lines in psychiatry and in psychedelics. Maybe as just a, a starting point, would love for you to talk to me about what drew you both into this intersection of psychedelics and psychiatry.
[00:01:01] Speaker A: So I was, as you alluded to, I was serving for a long time as a psychiatrist in chief at Mass General, had an interest in treatment resistant mood disorders and had been struck by the patterns in thinking that a lot of patients who continue to suffer an array of psychiatric disorders, not just depression, manifest.
And I was not particularly expert in the area, but, you know, was observing this phenomenon of stuck thinking or rumination that seemed to drive a lot of the anguish that people, you know, with depression, ocd, ptsd, anxiety disorders, substance use disorders manifested and was sort of also aware that it was poorly or incompletely represented in our diagnostic criteria. And so was casting about to figure out how to pursue that in the waning days of my leadership and convened a meeting of colleagues who I thought had an interest. And, and I was fortunate that I reconnected with someone I had known as a trainee and early career psychiatrist who had done meaningful work in the area as a PhD student, as an MD, PhD student. And so we reconnected at this meeting of colleagues to figure out how to explore rumination.
Fast forward to the first publications or the first presentations I'd seen about psilocybin's influence on brain connectivity.
And it struck me that this was something that we should pursue as a potential means of both studying and assessing therapeutic impact of psychedelics on severe ruminators.
I'll let Charman take it from there.
[00:03:07] Speaker B: The person who pursued their MD PhD with a focus on rumination was me.
So Jerry Reached out and said, you know, I want to convene these folks. Can you put together, Because I done graduate work on rumination, kind of an outgrowth of my interest in both philosophy and neuroscience. And rumination was a way to look at a phenomenon that was affecting patients that relates to how we understand ourselves and make sense of ourselves. I was already engaging in work looking at rumination in other populations because the focus had been for the longest time, really on patients just with depression. And so we convened this meeting, and it turns out other colleagues agree that this was a. This was a process or a feature of illness that was the cause of a great deal of suffering. We didn't have great treatments for it. And so we set out to sort of better measure it and study it in actual clinical populations as opposed to subclinical populations.
But we also, of course, wanted to think about how could we treat this, given that our armamentarium didn't seem to really do well with it. One of the things that had come out around that time was that mindfulness leads to a decrease in a network of brain regions called the default mode network.
And that sort of subserves our concept of self and how we think about self.
But also, not surprisingly, it's involved in rumination.
And the research was coming out that mindfulness decreases activity in the default mode network. Initially, I said, hey, Gerry, maybe we should look at mindfulness for rumination.
Applied for a grant, as these things go. Didn't get the grant, but that idea was ceded. And Jerry happened to go to this talk and saw about how psilocybin affects the default mode network.
Came back and said, sharmini, do you know about this?
I said, no, I'll go read about it and see.
Read some of the early papers and said, this is worth exploring and looking and looking at.
We didn't get into it thinking, oh, this is psychedelics. We kind of just got into it as, oh, this is another possible solution for something that is really affecting our patients.
That was the beginning of our journey into psychedelics.
[00:05:30] Speaker A: Then we reached out to source psilocybin for a study that Charman would lead a neuroimaging study looking at depressed patients who ruminate a lot in the process of sourcing psilocybin. Got into a conversation with the person that we were connecting with, and she wondered whether at a place like Mass General, which is, although you might think of it as a hospital, it's actually the largest research institute that's attached to a hospital with now about $1.7 billion a year, of research funding, with neuroscience one of the jewels in the crown. And so she was aware of that and said, at your center, could you think of something bigger than just the one study?
That led us to begin talking to a number of colleagues, fundamental scientists, neuroimagers, clinician, teachers, and others, to explore whether there was a critical mass of people interested in the idea of starting a center to explore how psychedelics work in the brain and potentially lead us to novel therapies.
And it was remarkable how either we were lucky or there was a lot of hidden enthusiasm and interest that hadn't surfaced yet. But it seemed like the majority of people we talked to were very excited about coming together to create a program like this.
[00:07:04] Speaker C: Now, I imagine creating a program like this at an institute like MGH could have been an uphill battle, maybe. Talk to me about the kind of journey to establishing it.
[00:07:13] Speaker A: Mass General is an interesting place.
One of my mentors used to say that great thing about the Mass General is, no matter what you want to do, they might not help you, but they don't stop you. As, as long as I wasn't asking for money, there was no, you know, and.
And it was an area of, you know, emerging scientific interest. I mean, the question got asked not by leadership, but by others, the same question you're asking. I remember the first conversation with this, the president of the hospital, when I first told him we had done this, you know, one of these situations of. Of being asking for forgiveness but not permission. He. He simply said, you know, that's fine, but, you know, why, you know, it was not something he was aware of. So there was never any pushback.
Occasional questions telling, you know, to tell you more or, you know, what are you planning to do? But never any negative reaction.
[00:08:14] Speaker C: So maybe catch me up on the. We're talking about the center of neuroscience, of psychedelics here. Catch me up on kind of the journey that that center has been on and where. Where is it today?
[00:08:24] Speaker A: I'd say initially our. Our. Our main impact is that we came into existence that seemed. That seemed to capture a lot of attention in. In the media and press. We had, for a time, a very distinguished advisory board. We had a launch meeting that was on the web and hundreds of people joining. And then we began a process of seeking support, mainly philanthropic support, which I'd say we had mild to modest success.
It's sort of another topic, I actually imagine, given the frenzy of investment in this space, you know, the hundreds of millions of dollars of, for a while anyway, valuation of new cos in the Space. I really anticipated that some of the passionate wealthy people who were involved in that would be interested in supporting a scientific enterprise that would help validate the field, and that really didn't happen. We did get some support in terms of sponsored research agreements and foundation grants and individual gifts that help us launch our initial studies. It's really been in a way a collaboration or I don't know if you'd say virtual, but certainly a distributed center until recently where we actually have obtained some space and some unique resources for one element of what we're doing. But it's become really a connection of several different investigators, from basic science to clinical research, to neuroimaging to actually ethnobotanical studies. So it's really, it's a whole concatenation of activities that fall under the umbrella of the center now.
[00:10:06] Speaker C: So I spoke to Dan Carlin over at MindMed before this conversation and he was eager to ask, where do you think the balance will lie between academic research and industry research as we progress towards hopefully a regulatory approval and kind of a change in the landscape there? How are you thinking about the kind of balance between academia and some of the work that industry is pursuing?
[00:10:29] Speaker A: It's not really balanced. It's like parallel play. I mean, I think in a way it's still very early in academia because the funding agencies are still sort of getting comfortable and up to speed and grants are starting to be available. You know, most of the investment has been in advancing a handful of very well known psychedelics in various forms and formulations to FDA approval. That's where most of the investment has gone. And to some extent academics might be involved in that as clinical trial sites, but it's really parallel play. I mean, I think academics are, are more interested in what's happening in the brain and understanding these mechanisms. Now I'll let Charmin take it from here.
[00:11:14] Speaker B: Generally, academics are supposed to be kind of visionaries, right? It's supposed to be at the long goals.
And towards that end, like for instance with the center for the Neuroscience of Psychedelics, the thought is that a better understanding of mechanisms will help us think about how to better utilize these compounds, how to potentially derive new compounds, how to make these safer for some people. And I think and very fundamental questions of how it works in the brain, I think that's different from trying to obtain regulatory approval, but at the same time it allows us to work hand in hand at times with industry to think about solutions for patients that are not readily apparent. Right now.
I think the work of academia is just Somewhat, slightly different, other than serving as a trial site or for one of the larger clinical trials or something like that, or beginning to think about novel uses for the same compounds that aren't necessarily a good return on an investment in the way that it needs to be for industry, just because there might be more steps to bringing it to fruition.
[00:12:23] Speaker A: Yeah, industry sort of playing the game of the hikers and the bear. I mean, they have all these compounds that are well known and wide, you know, widely used outside of therapeutic settings. You know, whether it's LSD or psilocybin or other compounds, you know, ibogaine, TMT and so forth. And they're all finding ways to manipulate it to get intellectual property and are not likely to be able to show any differences in efficacy. But what they'll try to do is show minor differences in the economics of delivery or the cost of delivery and try to win the race. The hikers in the bear is that you don't have to outrun the bear, you just have to outrun the other guy. And so, you know, they're picking up on all. I mean, there, there are companies doing innovative research trying to identify novel molecules and whether they're psychedelics or, you know, really new types of antidepressants or psychopatholytics is unclear, but it's, it really isn't innovation yet coming from industry. I mean, I think there are. There are some companies that are trying to come up with new molecules that work somewhat differently and might be more like medications, let's say, and less like procedures.
But it's really just a.
A gold rush in some ways, and trying to be, you know, first, first to clinic or have a marginal advantage that allows you to be a successful second or third mover. I think that's what's happening in that space. I think it's, you know, it'll be interesting to follow. I mean, I think we're looking for, as clinicians, we're looking forward to having these tools. How they'll roll out, be paid for and provided is. Is going to be an interesting challenge.
[00:14:16] Speaker C: Yeah, certainly. I'd love to maybe just drill in a little bit there. Like, from an academic perspective, you're certainly pushing the thinking in terms of mechanism, understanding, kind of like the fundamental questions about how it's working and how it's impacting the brain. Take me into the latest thinking here. How do we currently understand how psychedelics are impacting the brain and why there potentially is a positive therapeutic outcome here?
[00:14:38] Speaker B: I think there are different levels of explanation right there's the preclinical work that points to certain things. There's work in humans that would suggest other things. The important thing to realize is that, that and most, sometimes there's been one study or two studies done, like we're early, right? And so these are potential mechanisms.
Probably what you've heard a lot about is the plastic, you know, increasing capacity for plasticity and how that might be, you know, because that's a real boon if we're able to do that. Because all of our treatments work by causing changes in the brain. So increasing the potential for change seems quite, you know, seemed a great way to be able to optimize and really take advantage of our current treatments as well as making new therapeutics. But the thought is that it's partially, it's catalytic in conjunction with psychotherapy because of this potential plasticity that's been shown in preclinical models.
With the thought that with a window of plasticity that's, that's greater, you're actually able to affect more change. Because we do know that neurotrophic factors and other elements that are important for plasticity are decreased, especially in patients with treatment resistant illness. Part of the thought is that it increases that way, you know, increases the potential for change to happen in a positive way. So, you know, and then there are complex theories about how we think human brain networks are working. You know, so for instance, one of the popular ideas is that you've increased entropy. Maybe there's a, a decrease in top down processing that allows us to change prior conceptions or notions that free us up from old patterns of thinking and may allow us to, in that way, may allow people to get better, to adopt new ways of thinking that are healthier.
But you know, some of that is, some of that research is very preliminary. I don't think we have a really good handle on how these work, which means that there's a lot of fun work ahead for us to try to figure that out.
[00:16:40] Speaker C: Maybe take me into the clinic a little bit here. A patient shows up that you're working with and you're considering this as an option, how do you explain it to them?
[00:16:48] Speaker B: Well, right now I don't think about it much as an option for patients that I see in the clinic.
But let's say I'm thinking about somebody for a trial. Well, they've tried other things and they haven't worked. So like. Well, what we know is that this works, seems to work for some patients. Not all patients can be quite transformative. For some patients, we don't quite know how it works. It seems like it may increase your brain's ability to change and heal. And, you know, it's worth a shot if you're, if you're within the right, you know, parameters. And there aren't the same certain risks that we have to avoid.
[00:17:25] Speaker A: I mean, there's some controversy, for example, about whether the trip, the entheogenic experience or ego dissolution or the challenging experience is essential to the benefit or not. And there are companies looking to see whether they can develop psychedelic like therapeutics that eliminate that, which obviously make it easier for deliveries. But that's controversial and many people believe it's very much that challenging experience or that, that, that loss of sense of self or the feeling of oneness with, you know, the, the, the universe that, you know, is part of the therapeutic effect or whether there are reopening of critical periods that were, you know, closed in development. I mean, there are lots of speculation, but as Charman says, you know, they're, they're all interesting thoughts, but they're. They. We don't have a way to, to know specifically. I mean, we don't know even that much, you know, about the Calhol cascade of, you know, neurochemical change, let alone network changes that beyond the, you know, the initiation or the, the first minutes or hours of treatment. So that makes it fun for an academic in a way.
[00:18:51] Speaker C: So hypothesize with me for a moment here. Where do you sit on the, on the balance of. Does the subjective experience, like, need to happen with the neuroplastic experience or is it just the neuroplasticity that matters? Like, where do you sit on the, on the debate?
[00:19:05] Speaker A: Sharmin? There was one study, right.
[00:19:07] Speaker B: A small study by Franz Valenweider. Yeah. Out of Switzerland, where they used a medium dose, sort of a moderate, moderate dose, about 15 milligrams. I believe this is going by memory. I think it was 15 milligrams of psilocybin, where the extent of the experience as measured by the altered states of consciousness measure didn't necessarily correspond to benefit.
I think it's very much an open question whether it's. Especially whether it's necessary. Right. Whether it helps. I mean, we, we know that patients who have profound experiences not using psychedelics are sometimes altered by them.
So the possibility of a profound experience from a substance also contributing to change is not a far fetched idea. Right. But whether it's necessary is an open question.
[00:20:01] Speaker A: And we certainly know there are treatments that are profoundly efficacious in which the patient Is, is not really a participant at all.
Like electroconvulsive therapy. You know, there's no awareness, no psychological insight, no, no psychotherapy component.
It's presumed to work again by, in, you know, inducing change in state and, and increasing neuroplasticity.
And people have profoundly positive, sometimes quite durable responses to it. So to say, more broadly, you know, do you have to have a certain kind of experience to change? Clearly you don't. So my, my best understanding is that for some conditions and for some people it matters, and probably for other disorders or conditions and people it doesn't.
And some of the interesting work ahead is sorting that out. It may be for conditions that were caused by a life experience quite clearly, like PTSD after trauma or, or traumas. Processing those in some conscious way might be essential to treating the ptsd, but maybe not necessarily the depression associated with it. Depression may be different. That may be a state that you can change, especially in those who are predisposed to it profoundly by genetic predisposition, who may or may not have had a challenging or traumatic or emotional poverty associated early development experience.
[00:21:46] Speaker C: I'm fascinated to pull on that thread. So Jordan Smoller, who connected us here, is leading some interesting work in precision psychiatry, but maybe with more traditional therapeutics.
Think about the matrix of psychedelic options per se, and indications that they could be a good fit for, or kind of maybe patient profiles that could be a good fit for. How do we start to reason through what could be good for whom and why?
[00:22:12] Speaker B: Well, it's interesting you bring up Jordan, because I was going to say we've got a ways to go for precision psychiatry, let alone precision psychedelic psychiatry. There's still an art to psychiatry as we practice it. You kind of, you know, because we don't have precision psychiatry and we still have to exhibit a little bit of like a hunch, like, hey, you know, I think this therapist or this kind of therapy would really help this patient. Or like they need to.
I have a sense that they could use a little bit more to calm their nerves or do something.
And I don't, at least for right now, I don't see that art quite going away yet. And it's hard to say with psychedelics not having had much experience with giving it to patients to have that same facility or that same intuition.
[00:22:56] Speaker A: Yeah, I mean, they're certainly not precision therapeutics. I mean, I think of them as more broadly psychopatholytic.
We do know, or we do believe there are some subgroups of patients who really should not be exposed to psychedelics. Or at least there's an association between exposure to psychedelics and onset of a schizophrenic spectrum disorder or schizophrenia or bipolar mania use. So we know we operate as if there is a subgroup of the population who should not be exposed to it. But in general, in psychiatry, the outcome of what I guess you'd call both the genome and the exposome is variable. For some people it's pretty strongly genomic, and other people it's pretty strongly exposomic. And for most people it's a mix.
And the exposome is complicated. It can be early deprivation or trauma, it can be air pollution or head injuries.
And the genetic risk profiles of people, even with identical symptoms and diagnoses are widely different.
So it's a complicated mix. And, you know, it's a, you know, everybody has a share of each and contributing to, you know, who they are as a person and who they are as a patient.
[00:24:24] Speaker C: You, you kind of mentioned some of the potential safety considerations with regards to psychedelics and schizophrenic episodes. Do we know why that happens?
[00:24:37] Speaker A: I think the short answer is we don't know why.
You know, of interest in this space is that psychedelics, particularly lsd, were once thought to be a way to study psychosis, that it was a way to induce a state similar to, and allow us to study potential therapeutic interventions. So, you know, there's some elements of the experience that mimic psychotic experiences, like, you know, to heal hallucinations and other misperceptions.
Whether that overlap in experience explains anything as far as risk, I don't know.
[00:25:14] Speaker C: As we think about maybe the future for the center, I'm curious, what are the questions that you're most excited to ask?
[00:25:20] Speaker B: Sure. So a couple of things. One, there's been a real focus on the period of time when patients are under the influence as opposed to afterwards. And there's been a focus on imaging them acutely or just within a day or a week. But especially if we're interested in the neuroplastic potential, we're going to need longer term studies.
In fact, our first study is trying to do that by doing imaging all the way out to 12 weeks. We're going to need even longer to get a better understanding of what's happening, not just during the trip, but in the days after the trip. How is change happening?
I think that that's a really exciting avenue of research.
I think the other thing is really understanding and probing some of what people say about what happens by understanding experience and tying it to actual changes in behavior and Also using behavioral paradigms to look at how brain activity has changed over time for particular behaviors because people's narratives are not to be disregarded, but they don't always correspond to what the brain is actually doing. There's a really exciting opportunity here to be able to better understand what's changing that's resulting in clinical benefit for folks as time goes on.
[00:26:36] Speaker C: As you talk about the kind of long term effects, one of the things that has come up a lot, I think, in the industry circles and some of those conversations we've had is how to think about treatment resistance developing kind of like a resistance to these drugs. Given seemingly patients stay in remission for quite some time. Curious. How do you start to think about that?
[00:26:58] Speaker B: I don't think we have great data on how long patients stay in remission. Right. I mean, there haven't been very.
Patients haven't been followed for very long and often they end up in a crossover design. So they're getting the.
We don't have a placebo control to see how people actually do long term.
That said, people will say that it's changed them forever, but other people say it only lasted for a little while. Right.
So the story is always more complex than we'd like it to be. You know, there is this question of like, you know, as we know, psychedelics have phenomenon known as tachyphylaxis. So you can't just keep taking more and more of it and getting the same effect. But that's true for a certain period of time.
Over longer periods of time, people can become sensitive to it again and use it again.
You know, I think that it's very much an open question, can you get repeated benefits? Does it have a role in maintenance or not?
Is it like a tune up kind of idea where you go like, you know, some people get maintenance, ect.
Is that what this is going to be like?
Is it going to be coupled with other therapies so that, you know, this helps you get out of the episode and then something else helps you manage better? You know, we don't. Those are all open questions because those studies haven't been done a lot.
[00:28:12] Speaker C: We don't know yet. Joe, you were about to suggest something from a slightly different perspective. I'd love to hear it.
[00:28:17] Speaker A: Just sort of following up on the question about some of the activity in the center. One thing that is, I think unusual or unique that we're doing is combining a basic science laboratory that has long experience, both with neuroplasticity, but also with IPS cell derived organoids mini brains from both patients and normals to be able to study psychedelic molecules in this humanized non animal context. The investigator PI of that lab, which he calls the eye psych lab is Steve Hagerty. Steve had a long standing interest, came out of the Department of Chemistry at Harvard, same department as Richard Evans Schultes, the Amazon explorer slash Harvard chemistry professor who explored Amazon plants and recorded a lot of the indigenous populations, experience those plants and what they were used for and had always wanted to pick up that thread and study. And so we're able to obtain access to several thousand square foot set of greenhouses and labs and office space on the top of our research buildings that have been basically being used as storage for many years because the original investigator who was not studying psychiatric things but looking for other medicinals and plants had built and used that he and his team are now growing plants that he believes from, you know, deep reading of ethnobotanical literature and might contain novel molecules that have psychedelic properties. Although not interested in the current scaffolds, the same, you know, structures that, that, that were, that we referred to earlier that everybody's studying and you know, has some plants or that have been associated with other perceptual altering, perception altering experiences, but not necessarily the same like in some cases auditory hallucinations. So that project is one where he is looking to study those plants, you know, understand what molecules they contain, fractionate them, study them in the lab I referenced and see whether they have properties similar to, different from known psychedelics as potential scaffolds for novel therapeutics. So that, that's one kind of cool wing of the, of, of the center.
[00:30:54] Speaker C: That's fascinating. So how wide is the aperture now as you think about all these plants that are undergoing this research?
[00:31:01] Speaker A: Well, each plant contains lots of molecules. So he started with his top 50 and currently being grown are the top 12 of the 50.
He's already started processing one or two of the plants and fractionating them and studying them in, in the models that I mentioned.
[00:31:24] Speaker C: Fascinating how like for people who are interested in following along with this work, how would they.
[00:31:29] Speaker A: There was, there was a, I guess about five months ago, six months ago, an article in the Boston Globe magazine about Richard Evans Schultes, the Amazon Explorer and then led up to a description and of the, of the, what we call the medicinal plant lab and Hagerty's vision so they can access that at the moment it's early so you know, other than describing the effort there's there, I don't think there's any publications or presentations that have emerged from the work.
[00:31:58] Speaker C: That kind of leads me to a question around like breadth of impact. So beyond, you know, the, these kind of classic mood disorders, how do you think about the kind of breadth of kind of indications, conditions that might hold promise for some of the range of psychedelic therapies?
[00:32:16] Speaker B: Well, you know, one of the, I think one of the things that's interesting about psychedelics is this is sort of the reports of these trans diagnostic benefits of people across populations. And what that makes me think about is, you know, our diagnoses are categories that are pretty helpful and you know, are the best we have, and that's what we work with.
But there are processes like rumination where it doesn't seem to respect what diagnostic category it belongs to.
But also by targeting something that's a trans diagnostic process, the potential to help all sorts of patients presents itself. You know, so I think one of the interesting things about psychedelics might be some of the transdiagnostic processes that they might, you know, address also the neuro, I mean, and neuroplasticity would be not just trans diagnostic, it'd be trans field. You know, like looking at, you know, if, if it really actually increases the capacity it has potential to help like stroke victim. You know, there are other things to explore down the road, but I think.
[00:33:21] Speaker A: It'S down the road we've seen promising data emerge across an array of indications. I mean, depression, of course, but anxiety, substance use disorders, ptsd, you know, to name a few. I, I think it's, it's, it's more about where you. Where, where there's not promise, which we alluded to earlier, where we think we have to proceed with great caution, which is the psychotic disorders. But otherwise I think there's at least enthusiastic interest in virtually everything else I can think of. I think there's even some early studies in personality disorder or at least if you think of borderline personality as a, as a personality disorder, as opposed to, you know, whether it should be on axis 1 instead of access to.
I think there's, you know, there are even early studies in that space. So I, I think that they're, they're the doors wide open across, under the whole spectrum of, of psychiatric suffering, except for caution around psychosis.
[00:34:33] Speaker C: As we think about the future a little bit here, Jerry, you've trained generations of practicing clinicians. How do you think about the evolution of training programs and how the practice of psychiatry may start to evolve given the emergence of maybe, let's call interventional.
[00:34:52] Speaker A: Psychiatry here, training programs struggle with it because their curricula are in some ways driven by central authorities about what has to be covered and it tends to leave narrow opportunities for big changes in individual programs. What we've seen in our own center is that a lot of the exposure to this area is driven by the trainees themselves and their wish to be exposed to more information than their programs are providing and you know, attending off sites and so forth. I think that's going to change. I mean, I think the whole area of interventional psychiatry has, has got to be represented differently in our training programs.
And I'm sure it varies from program to program depending on what their strengths are.
But you know, even with all the, the evolution of novel rapid and other interventional treatments, device based treatments, you know, training programs are, you know, are lagging a bit behind and you know, still focusing on what I think these central authorities think are, you know, are more core to the identity of a psychiatrist.
Like things like psychopharmacology and psychotherapy.
[00:36:07] Speaker C: If I could be a little difficult here, who are these central authorities you're talking about if, if not you in the position of chair of these departments.
[00:36:15] Speaker A: The residency, the rrc?
[00:36:18] Speaker B: I don't know, I think about like the abp, you know, the American, American Board of Psychiatry and Neurology and things like that. You know, in terms of what they think. Although they did have, they did have articles, I'm doing that. I just finished renewing my certification and doing my articles and they had an article on TMS and they had an article on psychedelics. You know, it's interesting, I think some fundamentals in a good psychiatric training though, just prepare you to be able to take on whatever new therapeutics present themselves.
Being able to think fundamentally critically and to really be able to sit with patients, understand their experience, think critically about the treatments you apply.
Those are fundamentals that don't change.
[00:37:09] Speaker A: Exactly.
I worry about the loss of the centrality of the relationship with the patient. You know, that connection has to come first and that comes with the ability to understand their, their experience and not be standing ready with a set of tools and, and, and, and just applying them. You know, for many of our patients, treatment is a journey and lots of things are, can be relevant. There are no magic bullets or really for most people it's a, it's a, just as we talked about, the exposome and the genome, you know, treatment's going to include a variety of options that are, range from, you know, learning based therapies, cognitive behavioral therapies, dynamic therapies, well, being Therapies, lifestyle changes, you know, diet, exercise, meditation, dynamic therapy, you know, efforts at various psychopharmacological interventions, considering devices. It's, it's, there's so many opportunities that it's hard to even think about what, what people define as treatment resistant depression, which they, they now say is you fail two treatments to two SSRIs or something. And yet there is this vast array of potentially efficacious therapeutics and most patients never get to try because, you know, most practitioners are kind of limited to what they, they do. You know, the old here's my treatment, now what's your problem? That may be more true of psychologists and psychiatrists than any other specialty, but it's true in general. You know, you get what I know and get what I'm comfortable doing.
And your, your healthcare system is not prepared to, to provide a comprehensive evaluation and a team based therapeutic approach that, that might include an array of these different remedies, whether they're in sequence or combined.
So most patients who get better are lucky. They happen to walk in a place that offered something that works for them. But it's not ideal in terms of pulling together all we have available and addressing the complexity of human psychopathology.
[00:39:27] Speaker B: It's also worth saying that in the absence of precision psychiatry, really it is the therapeutic relationship and sometimes holding hope for the patient that sustains them through trials of medications that don't work until you get to something that works or other therapies.
[00:39:47] Speaker C: This is an interesting closing note. We've painted a picture of the current state and where we have questions. It's often said that we overestimate how much can change in a year, but underestimate how much can change in a decade. If you look into the next 10 years and curious, what are you most excited to see or maybe paint as a vision for how you hope the practice of psychiatry to evolve 10 years from now?
[00:40:08] Speaker A: Remember that psychiatry doesn't just take care of people with serious mental illness. I do think for those people who suffer the most extremes of psychiatric disorders like psychosis and severe major depression, bipolar illness, I think in the next 10 years we'll have remedies that will mitigate the course and moderate the suffering and give us better opportunities for control. But remember, the psychiatrists also take care of the anxiety of daily living and demoralization and challenges with relationships.
And so I think do a better job at lopping off the top end of suffering. But the challenges of human experiences, there's a quality of suffering that many people experience that are not necessarily going to be solved by the neuroscience revolution. That will still require a lot of what Charman is referred to, which is understanding, relationship building and a therapeutic process.
[00:41:24] Speaker B: Yeah, I'm hopeful for a more complex and nuanced understanding of people that isn't focused on genomics or just, you know, basic biology, but incorporates all of these other factors in some meaningful way to more mirror what our practice requires.
[00:41:46] Speaker A: And psychedelics or next generation psychedelics may play a role in facilitating that, and I think there's reason to believe they could.
[00:41:56] Speaker C: Certainly feels like we're in a renaissance right now where at the very least what we'll probably see is more options to choose from and hopefully more nuanced understanding of the individuals and where and when they can be applied.
[00:42:10] Speaker A: Absolutely.
[00:42:11] Speaker C: Well, I want to thank the both of you for taking the time to have this conversation. I've thoroughly enjoyed it. I've learned a lot and I appreciate you just coming on here and educating me.
[00:42:20] Speaker A: Thanks, Brandon. It's been a great conversation.
[00:42:22] Speaker B: Thank you for having us.
