Introduction: A Visionary's Path to Transforming Mental Health Care

Dr. David Feifel's (MD, PhD) journey into psychiatry began with a fascination for consciousness and quantum physics, leading him to envision a "golden era" of psychiatric treatments. However, his early career was marked by disappointment as the field seemed stagnant, with pharmaceutical companies pulling out of CNS R&D and a looming "pipeline crisis" in psychiatry.

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Despite these challenges, Dr. Feifel's determination to drive innovation in mental health care led him to pioneer groundbreaking treatments and establish one of the nation's first ketamine infusion programs.

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

• How Dr. Feifel's fascination with consciousness and quantum physics sparked his interest in psychiatry

• The challenges he faced in introducing innovative treatments like TMS and ketamine in an academic setting

• Why the right environment is crucial for effective ketamine therapy, and how a change in setting led to breakthrough results

• How Dr. Feifel is expanding access to cutting-edge treatments globally, including his work in Rwanda

• The complex interplay between innovation, regulation, and economics in bringing new psychiatric treatments to patients

• Dr. Feifel's vision for the future of psychiatry and the potential for transformative treatments to reshape mental health care
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From Optimism to Disillusionment

‍Dr. Feifel entered psychiatry in the 1980s with high hopes for the field's future. He recalls, "I just felt that psychiatry was going to have a golden era during my career... This was in the eighties and scans, new technology, brain scans were opening up the brain and we were able to research and elucidate the workings of the brain in ways that were unimaginable before."

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However, this initial excitement gave way to disappointment as the promised breakthroughs failed to materialize. "A decade into my career, I started to question whether I was right about that because I found myself still prescribing things that my mentors in medical school had been prescribing when they were residents," Dr. Feifel admits. This realization sparked a determination to seek innovative solutions.

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Pioneering Transcranial Magnetic Stimulation (TMS)

Dr. Feifel's first major breakthrough came with Transcranial Magnetic Stimulation (TMS). Recognizing its potential to revolutionize psychiatric care, he convinced UCSD to invest in TMS equipment in 2008, making it one of the first institutions in the country to adopt this technology. He explains:

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"It was just very exciting. It was like, okay, psychiatry is actually a procedure. We're not just prescribing pills. And it was one of the first things that were designed deliberately rather than found by serendipity, as the medications were."

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The Ketamine Lightbulb Moment

Shortly after embracing TMS, Dr. Feifel's innovative spirit led him to explore another groundbreaking treatment: ketamine for depression. His journey with ketamine began when he stumbled upon early studies showing promising results.

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"After the 2006 paper came out, I was still very skeptical, but I said, you know what, we need something. And if this is half as good as these results in these papers, it's a game-changer," Dr. Feifel recalls.

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However, implementing ketamine treatment at UCSD proved challenging. Initial attempts in the Post-Anesthesia Care Unit (PACU) yielded no benefits. Dr. Feifel quickly realized that set and setting was the missing fulcrum to making ketamine treatment work.

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"This was a horrible context, PACU, it was noisy, stressful, and the anesthesiologists were grumpy... And nobody's really enjoying the experience and nobody's getting better," Dr. Feifel notes.

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Unwilling to give up on the potential of ketamine, Dr. Feifel approached the pharmacy and therapeutics committee with a request to conduct the treatments in a more conducive environment. In an unexpected move for a psychiatrist, he was granted permission to use the outpatient cancer center for ketamine infusions.

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This change proved crucial. The cancer center offered more privacy and a dedicated infusion nurse, creating a calmer, more supportive environment for patients. The results were remarkable: "Things started to change and people, I saw things I had never seen before. And people with chronic depression, severe suicidality after, you know, sometimes after one infusion, just feeling like for the first time in their lives, they didn't have depression and I was like, wow, there really is something to this."

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From Cancer Center to CATMAD: Challenging Conventional Set and Settings

The success with ketamine treatments in the outpatient cancer center led Dr. Feifel to a profound realization: psychiatry was on the brink of a revolution. He saw psychiatry as "this big ship on the Atlantic and there's no wind and we're not going, there's no land in sight and we're stuck." But now, with the promise of innovative treatments like TMS and ketamine, he saw a way forward.

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Inspired by these breakthroughs, Dr. Feifel proposed a bold idea to UCSD: a specialized center for advanced treatments. "We need a center where people can come who aren't responding to the conventional things and they can get these advanced treatments," he explains. This concept, which he now recognizes as an early version of "interventional psychiatry," was ahead of its time.

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To his surprise, UCSD was supportive of the idea. This led to the creation of the Center for Advanced Treatment of Mood and Anxiety Disorders (CATMAD). CATMAD quickly gained recognition, attracting patients from across the country and even internationally. This center represented the culmination of Dr. Feifel's vision for psychiatry, combining innovative treatments like TMS and ketamine under one roof.

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Combining TMS and Ketamine: A Synergistic Approach

‍Dr. Feifel's innovative approach didn't stop at exploring these treatments separately. He soon realized the potential benefits of combining TMS and ketamine.

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He explains: "I started to give them together. So, it made sense, right? You have patients who are, and I do that currently a lot because they have very complementary care features: one is not very fast, but more durable to late effects. One is very fast, but not as durable as we'd like." This combination approach leverages the strengths of both treatments.

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Read more: ECT vs Ketamine vs TMS vs Esketamine

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As he puts it, "I felt like I was practicing a completely different type of psychiatry than every other psychiatrist world.”

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Breaking Free from Academic Constraints into Private Practice

Despite his success in establishing the Center for Advanced Treatment of Mood and Anxiety Disorders (CATMAD) at UCSD, Dr. Feifel found that academic medical centers were not always conducive to innovation. He explains:

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"Academic medicine has become very, very risk-averse... It's gone from physician-led, or scientist-led, to administrator-led places. The number of administrators has just ballooned, and you really start feeling like you're working for the administrators."

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This realization led Dr. Feifel to make the difficult decision to leave his tenured position and start the Kadima Neuropsychiatry Institute, where he could continue to innovate without institutional constraints. He still maintains a Professor Emeritus position at UCSD, keeping one foot in academia and one foot in private practice.

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Expanding Impact: Ketamine Therapy in Rwanda

Going beyond clinic walls, Dr. Feifel found himself drawn to lend his skills in Rwanda, a country still grappling with the mental health aftermath of its 1994 genocide. This project not only brings cutting-edge treatments to a trauma-affected population but also tests the adaptability of these therapies in diverse cultural settings.

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"I can't think of anything more gratifying than to have these exciting revolutionary treatments get spread to places that really need them, but don't have them," Dr. Feifel shares.

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The team faces unique challenges in implementing ketamine therapy in Rwanda, including intergenerational trauma, cultural stigma, and suspicion toward breakthrough treatments. These factors necessitate a careful balance between clinical efficacy and cultural sensitivity.

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The Future of Ketamine Treatment and Insurance Coverage

Despite the proven efficacy of ketamine in treating depression, insurance coverage remains a significant hurdle.

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Dr. Feifel discusses the paradoxical situation: "It's so paradoxical, you know, we have one of the biggest breakthroughs in psychiatry, and efficacious. And because of these very dogmatic sort of structural things, well, it's not covered by the FDA for the indication of depression. So insurance companies will not cover it."

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He contrasts this with the approval of Spravato (esketamine), highlighting the complex interplay between innovation, regulation, and economics in healthcare. While Spravato is covered by insurance, including Medicare, Dr. Feifel notes that it's "certainly not more efficacious than intravenous or intramuscular ketamine." However, because it's a patentable formulation, it was economically viable for a pharmaceutical company to pursue FDA approval.

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This situation underscores a fundamental challenge in bringing innovative treatments to patients. As Dr. Feifel explains, "It's a very counterintuitive and paradoxical system... It just creates unintended consequences like having this blockbuster drug that very few people can access because it's not covered by insurers."

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Part of the solution lies in providing real world evidence. Read further: The State of Innovative Mental Healthcare.

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Conclusion: A New Era in Psychiatry

Dr. Feifel's journey embodies the evolution of psychiatry from a field dominated by traditional pharmacology to one embracing innovative, targeted treatments.

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His journey offers invaluable lessons for clinicians:

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1. Embrace interdisciplinary thinking to drive innovation.
2. Persist in exploring and advocating for promising new treatments.
3. Consider the crucial role of treatment context and patient experience.
4. Be prepared to challenge institutional inertia when necessary.
5. Adapt approaches to serve diverse populations and global needs.
6. Understand and navigate the complex regulatory landscape to improve patient access.

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He reflects: "This is an exciting time to be in our field. It is completely changing. And I think it's going to be unrecognizable from those of us who kind of started when we had, you know, monoamine drugs and that was it. And with talk therapies like CBT, it's going to be unrecognizable in a good way. We're going to have a lot more options, a lot more powerful treatments."

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As psychiatry continues to evolve, the field promises to offer more effective, personalized treatment options for patients who need it most.

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About Dr. David Fiefel:

Dr. David Feifel earned B.Sc., M.Sc., M.D., and Ph.D. (Neurobiology) degrees from the University of Toronto. After an Internal Medicine internship, he completed a Psychiatry residency at UC San Diego, becoming outpatient Chief Resident.

Joining UCSD's School of Medicine faculty, Dr. Feifel rose to full Professor in Psychiatry and Neuroscience. He directed the Neuropsychiatry and Behavioral Medicine Program, founded the Adult ADHD program, and created the Center for Advanced Treatment, pioneering TMS and Ketamine Therapy.

In 2017, he established Kadima Neuropsychiatry Institute while maintaining a Professor Emeritus position at UCSD. Dr. Feifel has authored over 130 peer-reviewed papers and is recognized in 'Best Doctors in America' and Castle Connolly's "Top Doctors" list.

He's an elected member of the American College of Neuropharmacology, sits on the Clinical TMS Society Board, and is on Osmind's Community Advisory Board. He holds certifications in General Psychiatry, Psychosomatic Medicine, and Behavioral Neurology and Neuropsychiatry.


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