Psychiatry Tomorrow

The Interventional Psychiatry Clichés Dr. Lisa Harding Would Kill

Episode Summary

Lisa Harding, MD, trained at the top of interventional psychiatry at Yale, then left academia because a hospital is a poor way to get treatments to patients. She joins Will Sauvé and Brittany Albright to argue that the treatments work fine and everything around them, the dosing reflexes, the referral thresholds, the room, and the math, is what fails.

Episode Notes

Dr. Lisa Harding was a teenager when patients burned down the psychiatric hospital her father built in Guyana, and the care that resumed afterward happened in tents. That gap between what gets built and who actually gets treated has followed her from emergency medicine to a Yale chief residency in interventional psychiatry to the insurance-based practice she runs in Connecticut. On this episode of Psychiatry Tomorrow, she tells Will Sauvé and Brittany Albright which cliché she would erase from the field forever, why she thinks new treatments will only ever reach the top two percent of patients, and how becoming a trialist on the EQUIVALENCE comparison of IV ketamine and Spravato made her tighten her own response thresholds. She also explains what worries her about sublingual ketamine arriving at a patient's door in watermelon flavor, and why the field has no warning sign for pushing an NMDA receptor too far. The conversation ends where practices actually break, which is the money.

Timestamped show notes

Approximate.

• [00:00] Recording on Juneteenth, and why Harding calls herself a "freedom day baby"
• [03:02] Training as chief resident of interventional psychiatry at Yale, the field's one open spot
• [04:57] Two rejections from Yale, and a made-up specialty for people who wanted to do ER psych
• [05:48] From the ER to psychiatry: "I'll be the most empathetic physician you will ever meet"
• [07:59] Why she left academia: hospitals are a poor delivery mechanism
• [09:40] Sauvé on the Bethesda center of excellence that treats ten patients a month
• [10:30] The psychiatric hospital her father designed in Guyana, and the day patients burned it down
• [11:56] ECT in a bus, a detox bus, mobile TMS: bringing intervention into communities
• [13:47] The referral pipeline and the illness-perception threshold
• [15:52] "I don't think we've been successful." Harding pushes back
• [17:20] The worry: new treatments that only reach the top two percent
• [18:06] Set and setting: the broom closet and the sanitized ECT suite
• [19:11] Sauvé's Frankenstein-basement TMS story
• [21:02] The effect Harding refuses to call placebo
• [22:59] Why she does not check in with patients before ketamine
• [27:12] Building the Mood Institute: insurance-based TMS, Spravato, ketamine, yoga, four retreats a year
• [31:44] You can take insurance and not see thirty patients a day
• [32:40] EQUIVALENCE: IV ketamine vs. esketamine, and why she said yes
• [37:12] How strict the regulatory posture is on lifetime ketamine exposures
• [38:36] Subscribe-and-save ketamine, and a U-shaped response curve
• [41:04] Sublingual bioavailability and hitting a moving bullseye
• [42:16] "We don't have precision psychiatry. I tell patients that it is guesswork"
• [43:10] NMDA receptor homeostasis, overshoot, and the missing warning sign
• [46:02] Trial design: randomization, the switch option, and the observational arm
• [49:12] How becoming a trialist made her question the weighing ritual
• [50:20] Her thresholds: four weeks, 50 percent, and no dose escalation for partial response
• [52:28] The number one piece of advice for adding interventions
• [54:30] Why practices fail on economics, not medicine
• [58:42] REMS audits you can fail, and the "belly" to carry risk
• [59:40] The silent survivors of the Spravato launch
• [01:00:32] Lightning round: the cliché she'd kill ("more is better")
• [01:01:15] Why depression deserves more aggressive treatment
• [01:04:27] A pessimist who's still hopeful for science