Dr. David Feifel, Professor Emeritus of Psychiatry at UC San Diego and founding president of the Kadima Neuropsychiatry Institute, joins the JCP Podcast to kick off the new "Psychedelics in Psychiatry" theme. A pioneer in the field who established the world’s first ketamine infusion program for depression, Dr. Feifel sits down to discuss the paradigm shift currently reshaping mental health care.

In this installment of the Behind the Manuscript series, Dr. Feifel breaks down the findings of his recent JCP paper: “Results From a Long-Term Observational Follow-Up Study of a Single Dose of Psilocybin for a Treatment-Resistant Depression”. He explains the significance of the 25mg dose in preventing relapse over 52 weeks and offers a critical look at why traditional SSRIs are no longer enough. Beyond the data, the conversation delves into the nuances of "set and setting," the controversy of microdosing versus "heroic" doses, and the practical challenges clinicians face as the field moves toward interventional psychiatry. Dr. Feifel also challenges the traditional medical view of the placebo effect, arguing that harnessing expectation may be the key to the next generation of healing.

Episode Highlights:

00:00 - Dr. David Feifel and His Breakthrough Career

02:13 - How Early Curiosity Led to Psychiatry Instead of Neurology

07:33 - Balancing Clinical Practice With Research Innovation

11:41 - Psychiatry Entering a Transformational New Era

13:51 - Why SSRIs Fall Short and TRD Demands Better Solutions

17:27 - What Makes Psilocybin the Leading Psychedelic Candidate

20:25 - Why the Psychedelic Renaissance Is Surging Now

25:42 - Microdosing Myths and the Power of Expectancy

33:55 - How Set and Setting Shape Psychedelic Treatment Outcomes

39:51 - Do Psychedelics Really Need Psychotherapy to Work

48:58 - Inside the Phase 2 Study and How TRD Patients Were Enrolled

56:04 - Why 25mg Psilocybin Delivered the Strongest Clinical Results

1:05:39 - What Long-Term Follow Up Reveals About Relapse and Durability

1:11:38 - How Clinicians Can Prepare for Psychedelic Medicine Adoption

1:16:53 - Why the Future of Psychiatry May Rely on Harnessing Placebo Power

Key Takeaways:

"Psychiatry is in the midst of a golden age revolution... I feel like every day I was going to war with Godzilla with a peashooter. Now I feel like we've got some real tools."

"We’re in the midst of what I call the Cambrian explosion of treatments... a massive explosion of life forms after a long time of stagnation."

"The concept of 'one and done' with psychedelics is dead. We aren't going to have patients come in one time and say, 'You're good for life.'"

"Doing ketamine is like doing psychotherapy, but you're both the psychotherapist and the patient at the same time."

Links:

Journal of Clinical Psychiatry: psychiatrist.com/jcp/

Dr. David Feifel: https://www.linkedin.com/in/davidfeifel/

Kadima Neuropsychiatry Institute: https://www.kadimanp.com/

“Results From a Long-Term Observational Follow-Up Study of a Single Dose of Psilocybin for a Treatment-Resistant Episode of Major Depressive Disorder”:

Dr. Michael Asbach, Associate Director of Interventional Psychiatry at the DENT Neurological Institute and a nationally recognized educator, joins The JCP Podcast to discuss the critical and expanding role of Advanced Practice Practitioners (APPs) in behavioral health. With a background that spans from sports medicine to leading interventional psychiatric programs, Dr. Asbach offers a unique perspective on how the medical model training of Physician Assistants (PAs) uniquely positions them to address the growing psychiatric workforce shortage.

In a nuanced discussion, Dr. Asbach tackles the headlines and controversies surrounding the profession, including the recent British Medical Journal rapid review and the UK’s "Leng Report." He dismantles the concept of "scope creep," arguing instead for a model of "autonomous collaboration" that respects physician expertise while maximizing patient access. From the history of PAs emerging after the Vietnam War to the modern "Build, Baby, Build" approach to healthcare staffing, this episode provides a roadmap for how interdisciplinary teams can alleviate burnout and improve outcomes in the golden age of biologic psychiatry.

Episode Highlights:

00:00 – JCP Podcast Kickoff and Introduction to Dr. Asbach

01:34 – Expanding PA Engagement and Education in Psychiatry

03:22 – Career Origins and Choosing the PA Path Over Medicine

05:11 – Discovering Psychiatry and the Appeal of Interventional Innovation

08:46 – Mentorship, Research Culture, and Advancing Psychiatric Treatment

12:28 – Understanding PA Training Models and Evolving Clinical Competency

16:44 – Addressing Psychiatry Workforce Shortages Through Advanced Practitioners

20:36 – Evaluating PA Outcomes and Challenges in Measuring Quality of Care

29:24 – Rethinking Workforce Assumptions and Challenging Medical Dogma

32:37 – Regulation, Role Clarity, and Key Takeaways from the Leng Report

41:25 – Navigating Scope Creep Concerns and Physician Training Protection

47:51 – Building Effective Interdisciplinary Psychiatric Care Teams

56:44 – Supervision Ratios, Access Disruption, and Real-World Patient Impact

1:00:04 – Burnout, Non-Clinical Career Paths, and Retaining Expert Clinicians

1:08:09 – Future of Advanced Practice Providers and Closing Reflections

Key Takeaways:

"I think the future of advanced practice providers is going to be one that is collaborative, autonomous, and interdisciplinary."

"We are blessed to be able to play such an important role in people's lives... and have this front row seat to their life longitudinally."

"I’m very much a ‘build, baby, build’ approach to housing... Healthcare is very similar where the more people that we bring in as helpers, the better."

"Psychiatry is... in this golden era of kind of firmly returning back to biologic origin... and the PA medical model means that PAs have taken pathophysiology, gross anatomy, fundamentals of medicine."

"The absence of evidence is not the evidence of absence."

"It’s not about replacing physicians... but rather adjusting regulations to reflect the modern healthcare environment."

Links:

Journal of Clinical Psychiatry: psychiatrist.com/jcp/

Michael Asbach: https://www.dentinstitute.com/michael-asbach/

White Coats of the Round Table:

Fluctuating ADHD Across the Lifespan with Margaret Sibley, PhD

Dr. Margaret Sibley, Professor of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine and a clinical psychologist at Seattle Children’s Hospital, joins The JCP Podcast to discuss the evolving understanding of the trajectory of ADHD across the lifespan. The recipient of the 2024 Paul Wender Best Paper Award, Dr. Sibley shares her journey from political science to clinical psychology and offers a behind-the-scenes look at the landmark Multimodal Treatment of ADHD (MTA) study.

Challenging the traditional binary view of ADHD persistence versus remission, Dr. Sibley details the findings of her award-winning paper, revealing that for the majority of patients, ADHD follows a fluctuating course into adulthood rather than a static one. The conversation explores the critical role of "environmental fit," the complex interplay between anxiety and symptom management, and the distinct clinical profiles of those with persistent versus fluctuating ADHD. Today’s thoroughly enlightening episode offers vital nuances on how patient environments and comorbidities shape long-term outcomes beyond childhood diagnosis.

Episode Highlights:

00:00 – Introducing Dr. Margaret Sibley and the Paul Wender Best Paper Award

02:41 – From Political Science to Psychology: A path to public health

04:55 – The importance of engaging with patient advocacy groups like CHADD

08:06 – A historical look at the Multimodal Treatment of ADHD (MTA) study

11:59 – Why childhood treatment doesn't always predict adult outcomes

20:17 – Challenging the myth of permanent remission vs. persistence

24:53 – Defining the "Fluctuator": The most common ADHD profile

28:15 – The "Gas and Brakes" analogy: The role of comorbid anxiety

29:48 – Understanding comorbidities in severe, persistent ADHD

31:45 – Clinical Pearls: Environmental fit and rising to the occasion

34:09 – What’s next for the MTA study

Key Takeaways:

"The fluctuators are really kind of like your bread and butter people with ADHD."

"We should be thinking about environmental fit as a potential way to help people manage their ADHD better.”

"Make sure that you read the Reddit threads about what people are saying that have a condition that you're working with."

"Most people were looking at persistence as a finality, a single outcome... But it seems very dynamic."

"The persistent ADHD group have many more comorbidities... and are much more impaired in their daily lives. And so this is sort of our severe ADHD profile.”

"People do better in behavior therapy for ADHD if they have comorbid anxiety."

"Parental psychopathology was a strong predictor of being in that 10% stable ADHD group."

"When environmental demands were higher, people were more likely to be experiencing remission."

“Make sure that you go out there and try to be non-judgmental about the lenses people see aspects of mental health through, even if it's different than what you were trained in or even what the science says.”

Links:

• Journal of Clinical Psychiatry: psychiatrist.com/jcp/
• Dr. Margaret Sibley: https://www.margaretsibley.com/
• Dr. Sibley’s Award-Winning Paper: https://www.psychiatrist.com/jcp/fluctuating-adhd-multimodal-treatment-of-adhd-mta-study/