As we stand at the crossroads of tradition and innovation in psychiatry, a pivotal question emerges: How will emerging technologies and therapies reshape mental health care? Dr. David Feifel's statement captures this moment:

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"We're in the midst of a wholesale revolution in psychiatry."

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This revolution is not just about new treatments but also about how we understand and personalize care using Real-World Evidence (RWE).

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To dive deeper, we brought together an expert panel of researchers and clinicians to discuss the future of mental health treatment and research.

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The panel includes:

• Osmind’s Chief Medical Officer, Dr. Carlene MacMillan
• Osmind’s VP of Scientific Affairs, Dr. Alison McInnes
• A sample of thought leaders from Osmind’s Community Advisory Board (CAB) including:Dr. Tobias Marton, Dr. Christy Duan, and Dr. David Feifel

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This is what they foresee…

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LISTEN: The Future of Mental Health Treatments and Research:

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Precision Psychiatry: Leveraging Big Data and Real-World Evidence

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The concept of precision psychiatry, much like in oncology, is becoming increasingly relevant. Dr. David Feifel discusses the shift towards a more personalized approach: "We're moving towards precision medicine in psychiatry, understanding individual neural networks and intervening in a directed, personalized way with technologies like TMS." This evolution reflects a broader trend in medicine towards individualized care.

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Big data is crucial in this context. Feifel highlights, "By leveraging large datasets and machine learning, we can cluster patients and predict the most effective treatments, fundamentally changing treatment prescription and sequencing." This predictive approach is key to advancing personalized psychiatric care.

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Dr. Christy Duan adds an important dimension to this discussion, focusing on the systemic challenges in realizing this vision: "We're dealing with fragmented EMR systems and a lack of cohesive data sharing. To truly embrace big data and tailor healthcare at an individual level, we need to improve our system of mental healthcare. Efficient data gathering and sharing are essential for making significant changes." Her insight underscores the need for an improved infrastructure to support the aspirations of precision psychiatry.


At Osmind, we conduct research and facilitate clinical trials to help set new standards for mental health interventions. Our goal is to illuminate how innovative mental health treatments are being used in the community and their effectiveness on patients on a large scale, via aggregate, anonymized data collected through our EHR.

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The Challenge of Treatment Sequencing

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A key aspect of precision psychiatry is deciding on treatment sequences. Dr. Tobias Marton emphasizes, "The key question is which new treatments to give to whom and when."

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He stresses the importance of RWE in this context, noting its critical role in understanding treatments' effectiveness in diverse real-world scenarios. "Industry-sponsored trials have their limitations, making RWE crucial for understanding how treatments work in the real world."


Related Reading: The State of Innovative Mental Healthcare

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Redefining Treatment Paradigms: Moving Beyond Daily Medications

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The realm of psychiatric treatment is witnessing a paradigm shift. We're moving away from the traditional reliance on daily medications towards more intermittent, procedure-based treatments. This shift is best exemplified by the increasing consideration of TMS (Transcranial Magnetic Stimulation) as a first-line treatment, reflecting a significant departure from conventional monoamine-based therapies.

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Dr. Christy Duan speaks to this evolution: "We're envisioning a future where treatments like TMS could become the norm, not the exception. This represents a move towards intermittent treatments with lasting impacts, rather than daily medication regimens."

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Dr. Tobias Marton adds, "This change is already underway. Many of our patients now come in for TMS sessions just twice a year, maintaining their well-being without daily medication."

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The larger the trip, the longer the therapeutic effect?

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Dr. Gul Dolen's work may suggest this is the case. Dolen's theory, which is fast gaining recognition, suggests that all psychedelics, from ketamine to MDMA, psilocybin, LSD, and ibogaine, act by reopening a critical period of social reward learning.

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The fascinating part? The duration of the psychedelic experience is directly proportional to the length of this reopened learning period.

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Here's how it works: Ibogaine, which has the longest psychedelic experience, also opens the longest learning period, which can have a profound effect on treating conditions such as addiction. While supervising lengthy sessions for ibogaine or LSD is challenging, the upside is that the patient wouldn't need to come into the clinic as often.

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Conversely, while short-acting, non-psychedelic compounds being developed by some companies might seem attractive for their manageability, Dolen argues that they are likely less effective due to their brief action time.

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Traditional treatments, from daily SSRIs to intermittent TMS sessions, contrast with the psychedelic model—typically 1-4 intense sessions, potentially offering relief for six months or more.

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The allure of a 'magic bullet' in psychiatry is undeniable. However, as Andrew Penn emphasizes, the complexities of the mind (and soul if we look at the latin root of “psychiatry”) require a more nuanced approach.Effective psychiatric treatment, especially with psychedelics, doesn't necessarily eliminate an ailment. Instead, it may reshape a patient's relationship with it. For example, for Penn’s patient, an MDMA-assisted therapy didn't "cure" her PTSD, but rather it transformed her relationship with her trauma. Her trauma no longer ruled over her life.

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While high doses of psychedelics can produce dramatic insights, their long-term benefits hinge on effective integration into daily life. Penn’s stance: Celebrate sustained, incremental progress over instant cures. Jack Kornfield's reminds us: "After the ecstasy, comes the laundry."

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Challenges of Integrating Psychedelics into Our Healthcare System

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The practical application of psychedelics in therapy presents logistical challenges, particularly in terms of scalability and resource allocation. Consider this: A patient occupies a room for an eight-hour therapy session, possibly with a therapist's continuous presence. Such a model raises concerns about scalability.

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Dr. Marton, shedding light on this challenge on the Psychiatry Tomorrow podcast, states, "The intensive use of resources, combined with the constraints of traditional psychotherapy, might stymie the growth of the psychedelic space."

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Tech Could Help Scale Psychedelic Treatments

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A promising solution lies in leveraging technology—a synergy between tech and psychedelic treatments. Imagine enhancing a ketamine session with computer-based training or integrating AI-coaching post-treatment. Dr. Rebecca Price’s research suggests that computer-administered implicit association tasks pre-ketamine treatments improved outcomes.

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Virtual reality can also be used as a tool for scaling preparation for psychedelic experiences. Simulating environments and exercises pre and post-treatment can aid patient readiness and reduce the need for extensive therapist involvement.

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Additionally, noteworthy advancements like Compass Pathway's NLP study are exploring the use of Natural Language Processing (NLP) to analyze preparation session transcripts. The goal is to predict the optimal state of readiness for psychedelic treatment and identify individuals more likely to respond positively. This predictive approach aims to maximize the efficiency and effectiveness of the psychedelic experience.

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Such innovations could radically expand the reach and duration of psychedelic benefits. One thing is clear: the psychedelic revolution offers transformative possibilities for mental healthcare.

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This intermittent, intensive care model could not only transform mental healthcare but also introduce significant cost efficiencies. But given that factors like set and setting influence these experiences, integrating psychedelics into healthcare at scale may require a dynamic fusion of tradition and innovation, urging us to rethink our foundational beliefs about treatment delivery and progress.

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This shift isn't just about the frequency of treatment, but also about the nature of patient engagement with psychiatrists.

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As Marton points out, "Patients might soon be visiting clinics intermittently for treatments like psilocybin, fundamentally changing their interaction with mental health professionals."

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How might intermittent intensive treatmentl reshape mental healthcare delivery? It's a question that invites us to reconsider our current models of psychiatric care.

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Integrating Neuromodulation and Psychedelic Therapies: Embracing Synergy for Holistic Psychiatry

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The nature of scientific and clinical research tends to be siloed, with a focus on the efficacy of indvidual treatment modalities. However, the next wave of psychiatry may rely on integrating modern neuroscience with proven therepeutic traditions.

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Dr. David Feifel highlights the necessity of  “psychonauts” and “neuromodulators” to come together in contemporary psychiatry, drawing from his own practice: "One day we're discussing whether to stimulate the medial or lateral prefrontal cortex, engaging in neuroscience debates. The next day, we're discussing the psychological aspects of psychedelic treatments, like setting intentions for esketamine therapy.”

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Balancing Patient Autonomy and Guided Care

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Beyond logistical challenges, novel treatments require novel paradigms regarding patient choice.

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An emerging challenge is finding the balance between patient autonomy and physician-guided care. Dr. Marton addresses this complexity:

‍"We're at a crossroads. On one hand, we value patient choice and autonomy. On the other, we need to guide treatment based on the best available evidence. It's not about offering a menu of options, but about informed recommendations."

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He further notes the importance of integrating patient preferences with clinical insights:

"The ideal approach is somewhere in the middle – respecting patient choices while using our expertise to suggest the most suitable treatment. It's a delicate balance, emphasizing both autonomy and evidence-based guidance."

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Educational Transformation Required to Foster the Next Wave of Treatments

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We're still in the midst of a wild west when it comes to education and best practices for psychedelic treatments.

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Dr. Feifel states, "The psychedelic wave is coming, irrespective of whether one is an evangelist or skeptic. It will require a rethinking of our approach to psychiatric training." Feifel points out the limitations of current neuroscience training, which often views the brain as a distinct, isolated organ.

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"Current training doesn't fully equip psychiatrists to understand and utilize psychedelic therapies, which draw on shamanistic traditions and psychodynamic theories, rather than purely biomedical models," he explains.

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This shift is not just about adopting new therapies but about re-immersing in classical psychological frameworks that have been overlooked in modern psychiatric training. "We need to re-immerse ourselves in classical psychological frameworks that have been neglected in modern psychiatric training," Feifel asserts, emphasizing the need for a broader understanding to effectively integrate psychedelics into psychiatric care.

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Dr. Tobias Marton echoes the importance of this synergy, "Neuromodulation and psychedelic therapies can complement each other, offering a comprehensive treatment model."

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The future of mental health treatment may look less stacattic, with eastern and western philosophical approaches complementing one-another rather than butting heads. An integrated gestalt may serve certain patients more than one treatment alone.

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Interventional Psychiatry: A Redundant Term in the Making

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The term "interventional psychiatry" is on the cusp of becoming redundant as these practices integrate into the mainstream of psychiatric care. Carlene MacMillan envisions a future where this distinction no longer exists:

‍‍"I hope for a time when interventional psychiatry, involving techniques like TMS and ketamine treatment, just becomes standard psychiatry."

Dr. MacMillan notes that these approaches, once seen as specialized, are garnering increasing interest among psychiatrists.

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Dr. MacMillan suggests practical ways for psychiatrists to engage with these emerging practices: "Attending conferences focused on interventional topics, moonlighting in relevant clinics, or even just referring patients for these treatments are great ways to start. It's about becoming comfortable with these tools, as they will be integral to the full functioning of future psychiatrists."

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Currently, TMS is typically reserved as a "last resort" treatment, after a patient has already tried 2-3 "traditional" treatments like SSRIs to little avail. In the future, non-invasive procedural treatments may become at least as commonplace as medication management.

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Emerging Trends in Treatment Reimbursement: The Case of Ketamine Therapy as a an Alternative to ECT for Younger Patients

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A transformative development is unfolding in psychiatric treatment reimbursement, with a particular focus on Ketamine Intravenous Therapy (KIT) for treatment-resistant depression (TRD). This shift is driven by compelling evidence that underscores the effectiveness of KIT as a viable alternative to Electroconvulsive Therapy (ECT) for certain patient groups.

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Key to this evolving narrative are the insights from two recent studies highlighted at the American College of Neuropsychopharmacology meeting on December 2, 2023. The study led by Dr. Amit Anand and his team (Anand et al., 2023) in the U.S. is particularly notable. It involved non-psychotic outpatients scheduled for ECT, who were instead randomized to receive either 6 KIT infusions or 9 ECT treatments over three weeks. The findings were significant: 55.4% of patients in the ketamine group showed a positive response, compared to 41.2% in the ECT group, indicating ketamine's non-inferiority to ECT in this context.

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Another study by Ekstrand et al. (2022) compared KIT with ECT in hospitalized patients with unipolar depression. While ECT had a higher remission rate (63% compared to 46% for KIT), the relapse rates were similar for both treatments. Notably, ECT was associated with persistent memory impairment, an issue not observed with KIT.

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These studies have led experts like Gerard Sanacora, MD, PhD, Associate Professor and Director of the Yale Depression Research Program; Sam Wilkinson, MD, Associate Professor of Psychiatry at Yale School of Medicine; and Sanjay Mathew, MD, Vice Chair for Research at Baylor College of Medicine, to suggest KIT as a suitable treatment for younger, non-psychotic depressed patients, contrasting with a preference for ECT in older, psychotic patients.

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Amplifying the importance of these findings is the REaKT-SD Trial, an ambitious initiative led by Dr. Anand and his team. This large-scale comparative effectiveness trial, involving a staggering 1500 patients, aims to study the rapid reversal of acute suicidal depression across various age groups, contrasting ECT with KIT. This trial, more than triple the size of the previous two studies combined, underscores the growing significance of KIT in the landscape of psychiatric treatment.

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The trend towards insurance coverage for KIT is becoming increasingly apparent. This shift not only marks a change in treatment approaches but also signifies a broader transformation in how these treatments are recognized and funded within the healthcare system. As the field of psychiatry continues to evolve, the inclusion of KIT as a reimbursable treatment option for TRD stands as a clear indicator of ongoing innovation and a commitment to evidence-based care.

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Conclusion:

The future of psychiatry lies in breaking down silos and embracing a more integrated, evidence-based approach. This panel was moderated by Dr. Carlene MacMillan, Chief Medical Officer at Osmind, and Dr. Alison McInnes, VP of Scientific Affairs at Osmind.

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The insights shared by Osmind’s Community Advisory Board, including Dr. Marton, Dr. Feifel, and Dr. Duan, emphasize the importance of RWE, holistic treatment strategies, and the potential of combining various treatment modalities. As psychiatry moves forward, it's clear that collaboration and innovation will be key to enhancing patient care and advancing the field.