After a young patient died by suicide, many psychiatrists might retreat to safer, less complex cases. Dr. Matthew Bernstein took a different path, choosing to treat our field's highest-risk patients in their communities rather than behind hospital walls. His journey from McLean Hospital's acute unit to pioneering community-based care offers valuable insights into balancing clinical risk with recovery potential.

‍

In this episode of the Psychiatry Tomorrow podcast, you'll learn:
‍

• How community-based psychiatric care evolved from the PACT model to modern private practice
• Why psychiatry's approach to risk differs from other medical specialties
• The role of measurement-based care in managing complex cases
• How integrating metabolic approaches can enhance traditional psychiatric treatment
• Practical strategies for balancing risk and recovery in clinical practice
• Insights on building sustainable community-based treatment programs

‍

Listen to the full episode here or read on to explore how community-based care is transforming outcomes for complex psychiatric patients.

‍

The Evolution of Community-Based Care

In the late 1970s, as state hospitals began closing their doors, clinicians in Wisconsin developed the Program in Assertive Community Treatment (PACT).

‍

This model assembled the same personnel found on inpatient units—psychiatrists, nurses, social workers, and counselors—but deployed them in outpatient settings. Scientific studies validated PACT's effectiveness in reducing hospitalizations and improving independent living outcomes. However, when the program proved as costly as inpatient care, most states abandoned it.

‍

This created an opportunity for private sector innovation, leading to programs like Ellenhorn. At Ellenhorn, Bernstein and his team work with individuals experiencing severe mental illness through a comprehensive community-based approach.

‍

"What we find is that when we can get people connected psychosocially out there in real jobs or school or relationships, those experiences can reduce symptoms and take the place of medications in many respects," Bernstein explains. The same person who needed high doses of medication during acute stabilization often requires less once they establish meaningful connections and activities.

‍

The Challenge of Risk in Psychiatric Care

"Somehow in psychiatry, things are different," Bernstein observes. "We're a little less data-driven than other parts of medicine." While other medical specialties have clear metrics—tumor size, blood pressure, cardiac function—psychiatric assessment relies heavily on clinical judgment. This creates a unique vulnerability in risk management.

‍

"Somehow there's always this sense that people have that the person could always be saved if it's psychiatric," Bernstein explains. "There must be some error because someone died by suicide... something went wrong with that individual psychiatrist." This perception often leads clinicians to practice defensively, turning away complex cases to avoid potential blame.

‍

But the reality of mental illness must be confronted with compassion. "These are illnesses that have a mortality rate," Bernstein states. "If someone dies, it doesn't mean that something did, someone did something wrong. In fact, sometimes someone dies and everyone did everything exactly right. They were in the place where they were doing their best to have the best chance of having a life."

‍

A Framework for Clinical Decision-Making

At Ellenhorn, Bernstein has developed a nuanced approach. The team uses comprehensive measurement-based care to support clinical decisions, combining standard symptom tracking through the PHQ-9, GAD-7, and DSM Cross-Cutting measure with functional assessments like the PROMIS-10 and WHODAS. These tools help evaluate what truly matters: a patient's ability to work, maintain relationships, and engage in meaningful activities.

‍

This data-informed framework doesn’t replace conversations but sparks them. Data enables more confident risk management decisions. "As clinicians, you know, it's really important who's really taking the risk here," Bernstein says. "If the individual is okay with the risk, if their family is okay with the risk, and this is the best setting that they have or the best chance they have to get the right care to get better, that's a compelling case from my point of view."

‍

Integrating Innovative Approaches like Metabolic Psychiatry

Building on this foundation of community-based care, Bernstein began incorporating metabolic treatments three years ago. Starting with basic interventions like reducing processed foods and implementing intermittent fasting, the results led to the creation of Accord, a residential metabolic psychiatry program. This program combines ketogenic diet implementation, exercise programming, circadian rhythm alignment, and comprehensive metabolic monitoring alongside psychiatric care.

‍

Outcomes have reinforced Bernstein's belief in the connection between psychosocial engagement and biological improvement. Many patients who achieve better metabolic health experience significant psychiatric symptom reduction, often allowing for decreased need for medication.

‍

Looking Forward

"It's a great time to be working in psychiatry," Bernstein reflects, noting the expanding landscape of metabolic psychiatry, rapid TMS, and ketamine-assisted therapy. His experience at Ellenhorn and Accord demonstrates a crucial insight: innovation in psychiatry isn't just about new treatments—it's about creating frameworks that allow us to use them effectively.

‍

This means challenging traditional risk assessment paradigms that lead psychiatrists to turn away complex cases. "We would do a great service to ourselves and to our patients and their families," Bernstein argues, "to push back on this idea that someone could always be saved or there must be a problem." Instead, we need to acknowledge psychiatric illnesses as conditions with mortality rates, while maintaining hope for recovery through comprehensive care.

‍

For clinicians working with complex cases, the path forward requires both courage and careful consideration. Data-driven assessment tools support clinical judgment, but equally important is the willingness to engage patients and families in honest discussions about risk and recovery. As Bernstein's work shows, when we move beyond defensive practice to thoughtful risk management, we open new possibilities for healing—not just in innovative treatments, but in the fundamental ways we deliver psychiatric care.

‍

Ready to stay ahead of Psychaitry's next era? Connect with thousands of forward-thinking clincians and access live events and free templates inside the Osmind Psychiatry Collective

---
‍

Episode Show Notes and Timestamps:

[00:00:00] - Introduction: After a young patient's death by suicide, Dr. Bernstein chose to focus on high-risk psychiatric care in community settings.

[00:01:00] - Host Dr. Will Sauvé introduces his background in military psychiatry and interventional approaches.

[00:02:00] - Overview of Dr. Bernstein's career trajectory from McLean Hospital to pioneering community-based care.

[00:03:00] - Early career at McLean Hospital
- 8.5 years on Schizophrenia and Bipolar Inpatient Unit
- Experience teaching residents
- Transition to longitudinal care focus

[00:05:00] - The PACT Model and Ellenhorn's Evolution
- Origins in 1970s Wisconsin
- Design as "hospital without walls"
- Transition from public to private sector implementation

[00:08:00] - Ellenhorn's Comprehensive Approach
- Holistic treatment model
- Integration of psychosocial rehabilitation
- Focus on real-world functioning

[00:11:00] - Discussion of Risk Management in Psychiatry
- Comparison with other medical specialties
- Role of clinical judgment
- Impact on treatment decisions

[00:13:00] - Development of Metabolic Psychiatry Program
- Introduction to ketogenic approaches
- Implementation of fasting protocols
- Creation of Accord program

[00:16:00] - Measurement-Based Care Strategies
- Standard clinical measures
- Functional outcome assessments
- Digital phenotyping implementation

[00:20:00] - Family Engagement and Risk Assessment
- Shared decision-making approach
- Balance of clinical liability and treatment access
- Case example of successful risk management

[00:28:00] - Future Directions
- Integration of innovative treatments
- Expansion of metabolic approaches
- Vision for community-based care

Key Quotes:
- "What we find is that when we can get people connected psychosocially out there in real jobs or school or relationships, those experiences can reduce symptoms and take the place of medications."
- "These are illnesses that have a mortality rate... sometimes someone dies and everyone did everything exactly right."
- "It's a great time to be working in psychiatry because of these options that we didn't have even ten years ago."

Resources Mentioned:
- Program of Assertive Community Treatment (PACT)
- Ellenhorn Community Treatment Program
- Accord Metabolic Psychiatry Program

‍