Psychiatry's Most Controversial Topics: Dr. Mark Mullen's Season 4 Retrospective with Dr. Preston Roche

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Preston Roche: And welcome back to Psychiatry Boot Camp. I'm your host, Preston, and I'm really excited to do a recap episode. Now, this isn't something that we do very often here on Psychiatry Boot Camp. Well, personally, I don't ever do this because this is my first time hosting a review episode of Psychiatry Boot Camp or an episode of Psychiatry Boot Camp.

But I'm excited to introduce our guest today, Dr. Mark Mullen, who I believe is a little bit more familiar with this podcast. 

Mark Mullen: Preston, thank you so much for having me. 

Preston Roche: Oh, thank you for being here. And [00:02:00] now you have had a very productive season. I believe we had 14 episodes. 

Mark Mullen: I don't actually know. I didn't count.

It might be. It could be. I'm not sure. 

Preston Roche: Okay, so our producer Rob just checked it. He said there's 13 episodes. You know, here's, the thing. not everything that counts, that can be counted matters, and not everything that matters can be counted. You know what I mean? and it's not really the number of episodes, but what is in those episodes, and that ultimately is what we are here to talk about today.

So I'm gonna kind of walk us through the journey of your most recent season, if you will. and r- and as we kinda glean along the surface, there's a couple things that I, really wanna get from you. So this is to kind of prime your brain a little bit as you reflect. So I, wanna know what your biggest takeaway from each of these episodes are a- and if there's a way that we can condense these into a clinical pearl.

But that's enough of my yapping. I, think we [00:03:00] actually have a whole list of audience-driven questions, and I imagine you probably had hundreds, if not thousands of questions sent in from the audience. So before we even start, how did you pick these and narrow them down? 

Mark Mullen: Yeah. So I work with a lot of medical students, and I said, "Why don't you scrape TikTok, Instagram, Spotify comments and design an outline?"

And then all the emails that I got during the season, I forwarded to my medical student producer, U- Ameena. She's just wonderful. So she put together a list for me, and then I sort of pared it down to things that I thought would be the most entertaining. 

Preston Roche: See, when Margaret and I do that, with our hundreds of thousands, if not millions of comments that we have to deal with, we actually prioritize Spotify comments.

I think we see those as, gold-tier comments, Patreon comments too, then TikTok, then Instagram, 'cause people just be saying anything on Instagram. So for any listeners of How to Be Patient and, Psychiatry Boot Camp, if you will, a Spotify comment is worth 10 Instagram comments [00:04:00] in my opinion. As we kinda go into the season, let's work backwards.

And I wanna start with this sports psychiatry episode that you did with Dr. David McDuff So surely we all can't be professional basketball players, but we can be the psychiatrist on the professional basketball team that travels with them on the bus. So s- maybe, who knows? But, that's my question. What does a day in the life of a sports psychiatrist look like?

That was the question from the listener. 

Mark Mullen: Yeah. I think for Dr. McDuff, and he really started... It's funny, he started his career more at the professional level and now works with, like, high school students, but started as the team psychiatrist for the professional sports teams in Baltimore. for him, he said that he took, like, a military-based approach.

So he talked about how being a military psychiatrist was a very pastoral approach, so you're not practicing psychiatry one-on-one in a private space in an office with scheduled appointments all the time. You are moving around [00:05:00] the base dynamically, starting conversations with people. Maybe you're having important conversations one-on-one.

Maybe you're having important conversations in a group, so it's sort of like an ad hoc individual or group therapy session. I thought that was fascinating. It's not-- That therapeutic frame is not like anything that I learned in residency, and I feel like it would make the hair on the necks of m- some of my psychotherapy supervisors stand up, right?

'Cause when you think about, like, boundaries and frames and all of those things. So I thought that was interesting. I thought the pastoral approach was interesting of being a sports psychiatrist. But I think most people who are practicing psychiatry with athletes are not professional sports team psychiatrists and don't have such a flexible contract that just sort of pays you to exist and to practice however you want.

Like, I think most people working with athletes are in a more traditional fee-for-service model. So I think the day-to-day for a typical sports psychiatrist is actually more like a typical outpatient practice. It's just that you would specialize in that patient population. And of course, like, we can't all be psychiatrists for professional sports teams, but there's a lot of college and high school athletes out there that need [00:06:00] access to psychiatric care and do need their treatment plans tailored for elite athletes.

So I think that, actually, and I've been surprised too. I feel like as a psychiatrist, every now and then you get a text from a family member or from a friend that's like, "Hey, I know so and I need a referral for this." And I've been really surprised how many of those have been athletes that are like, "Hey, this so and so's really struggling with...

And they're an athlete in this sport, and it might be performance anxiety, it might be this. And do you know anybody who specializes in this population?" So I think the day-to-day for most sports psychiatrists is less pastoral, more traditional psychiatry. But I think as you move up the ladder, and work with those higher level programs, that pastoral approach is really interesting to me.

Preston Roche: You become like the concierge attached to the team in a way. Yeah. th- this actually resonates with me, as a college athlete. We had, a physician who was attached to our team. He wasn't a psychiatrist, so he was just kind of, he was a general practitioner, but I remember he went to clinic during the day, and then when we had practice from 3:00 PM to around like 6:00 PM, that was like our practice window, [00:07:00] he would just sh- He had a, clinic room in the, like, trainers, like recovery area, and he would just go chill in there.

Like he would be, you know, chit-chatting, s- in the military, we call it smoking and joking with, the trainers and the nurses and stuff. But if you had a problem, you literally had a doctor you could see within five minutes. So I remember even coming back one day and like I wanted to get started on Accutane 'cause I was having problems with acne.

So I just told the trainer, "Hey, I wanna see the doctor about like getting acne treatment." And she was like, "Oh yeah, he'll be ready f- in five minutes." And he's like, "Oh, someone needs to see me?" And he walked over and I was-- it was like right there. And it was nice because I had a longitudinal relationship with this doctor over the course of the four years What's, funny, thinking about it from the perspective of a psychiatrist, actually we-- For context for everyone, I'm actually in the military, so we do a lot of military psychiatry, you'd hope, right?

And when I talk to my attendings that have been deployed in that kind of sports or, like, military psychiatry setting, [00:08:00] they essentially are doing family therapy at the individual level with each person in the unit because a lot of the stress comes from, like, the interpersonal dynamics. So they would say, you know, like, your eleven o'clock is the private who's, like, pissed off at his sergeant for riding him all day, and your one o'clock's the sergeant, and the sergeant's pissed off because the major has been putting a ton of pressure on him.

And guess who your three o'clock is? It's the major. So, so you, like, have, everyone in the line down there and, you're also, trying to manage their meds and make sure everyone's doing okay. So it's-- I guess it's more-- That, that feels more like confession than, than therapy. So it's still the, pastoral approach, I guess, in a way.

I guess coming back to this pastoral approach or the, different dynamics between high school, college, professional level, what would you say the biggest clinical takeaway is for you from this episode? 

Mark Mullen: I thought, I guess two things. One, when he talked about his psychotherapy approach, it's very common factors based.

So he talked about a lot of things that come [00:09:00] up in Persuasion and Healing, which is this book that I always talk about by Jerome Frank. and part of it is Basic common factors of healing, like reaching out to your support system, notifying them that you need help. Like that sounds small, but especially for an athlete, someone who's so successful, so strong, able to do it all, right?

I think it can be really difficult for that person to say to people that love them, respect them, look up to them, "I'm really hurting right now and I need help." So it felt like he spent a lot of his energy trying to get over that hump to reach out for help and then maybe to get better. And then I thought he gave some really common sense clinical pearls about medications in athletes, and basically what he said is, "You need to start extra low on the dose and go extra slow."

And I think that has to do with like fluid balances and just how hard these athletes are working. So you never know how a medication's going to affect them, their autonomic nervous system, et cetera, et cetera. So you wanna just be extra cautious. 

Preston Roche: Yeah. Managing someone's ADHD with a stimulant when they're running [00:10:00] a marathon is a whole different game.

Mark Mullen: Exactly. 

Preston Roche: Yeah. Much more likely to, Like your risk of r- of like rhabdo or, cr-- myocardial infarction just goes way up. 

Mark Mullen: And the list goes on, right? Metabolic side effects of hyponatremia with SSRIs, like et cetera, et cetera. 

Preston Roche: Yeah. I mean, instead of a geriatric population where their body's been pushed to the limits by their life, they are just pushing their body to the limits for the purpose of sport.

Mark Mullen: And I wondered how much of that too is in these athletes. 'Cause I always think sick versus not sick, and I think this, phrase that gets a little, bit of flack, worried well, we call it, right? Worried, but doing well enough to compete in, you know, high level sports versus severe and persistent mental illness in and out of the hospital frequently.

I think most athletes are probably on the worried well side, and so do they get better at low doses when they're engaging with psychotherapy? I think the answer is probably mostly yes, because we're mostly treating generalized anxiety disorder, performance anxiety, depression, ADHD, and not treatment-resistant schizophrenia.

So just sort of a different way of thinking about [00:11:00] things. 

Preston Roche: Yeah. There aren't too many NFL players with treatment-resistant schizophrenia. 

Mark Mullen: Not that I know of. 

Preston Roche: there was a baseball player on the Dodgers actually who developed schizophrenia, and they keep him on the payroll. 

Mark Mullen: That's awesome. 

Preston Roche: his salary is zero, but he's on the payroll because it means he gets the team's insurance.

Mark Mullen: That's so cool. 

Preston Roche: So moving on to meaningful psychotherapy with, Jonathan Shedler. For this one, I'm gonna read off an email and then ask for your thoughts. So this is someone writing in, "Hi-" I'm a psychiatry residency program director, and I love your show. Sorry to be writing to you for the first time with a negative comment, but I just listened to the Schedler episode and I wanted to share feedback.

I was excited to see that you were interviewing him, and I was imagining sending this episode to all my rising PGY-3s as an introduction to starting psychotherapy. I've used Schedler's paper for this in the past and to my psychotherapy supervisors as well. But I found his tone denigrating of trainees, practicing clinicians, and the [00:12:00] institutions where we work.

To write off institutions as providing substandard care is demoralizing for trainees wh- who are learning to work in the medical center, and it's dismissive of the important work that happens outside of the private practice settings for underserved people in-- who are in most need of care. He could have made his teaching points and lifted up trainees and educators and hospital-based clinicians rather than denigrating the state of psychotherapy practice and training.

Only at the very end did it seem he was aware of a trainee audience since most of the rest of the episode seemed to be the mold of social media-- seemed to be in the mold of the social media blog, where the point is to be proactive and garner attention for your ideas. Thanks again for all your incredible work with the podcast, and I hope you accept this feedback in the constructive way I am intending 

Mark Mullen: So I'll say as a, as an attending, providing constructive feedback is the worst part of the job.

Actually, we talked about this in my episode on your show, Preston. Giving formative feedback stinks. so I really appreciate this and I know that this was not written [00:13:00] lightly. And I did pass it along to Dr. Shedler 'cause he emailed and said, you know, "Thank you. I'm getting good engagement on my channels about the episode."

And I said, "Me too." I, and I did. I got a lot more engagement on this episode than most other episodes. And about 95% of the comments were exceedingly positive. And then I got this one email that just kind of stuck with me. And it's not from no one. It's from a East Coast residency training director which thank you for, you know, supporting the show and sharing with your residents.

And I'm sorry that, some of the tone was not particularly encouraging for residents. When I passed it along to-- Well, I just said to Shedler that I got a critical comment from a residency training director and he replied, "If we didn't piss off one residency training director, what was even the point?"

So I think, you know, he's, coming in to help us ask hard questions and I think that hopefully trainee... You know, the, tone of this show, it was invented for trainees. I, started it because I was in residency and I felt like there were things that I wanted to learn about that were not readily accessible to me.

And so I'll just start a podcast and learn about it there. Like, it's for trainees. [00:14:00] But especially this season, I have moved away from some of the in-the-room, day-to-day clinical nuts and bolts and starting, started to have more abstract conversations about where are we as a field, where do we wanna go, and what should we be?

And I'm hoping that we can strike a balance between supporting trainees and, helping to give them information to help their patients and criticizing institutions. And I do think there's a lot to criticize about the United States healthcare system. I think there's a lot to criticize about the graduate medical education training system and the way residents are treated and the system that we have developed for residents to practice in.

And so, you know, this podcast is not affiliated with any institution and so we're gonna have some difficult conversations and my hope is that trainees can hear Shedler's criticism of most residency clinics and say, "I am gonna work as hard as I can and get what I can get out of this experience for my training.

I'm gonna do my best to do right by my patients. And [00:15:00] then when I've completed residency, I'm gonna build a practice environment either at an academic institution or in private practice that gives me as much flexibility as possible to have meaningful psychotherapeutic interactions." And for Shedler that is, and he was very clear about this, his minimum dose is basically one hour a week.

And he says even that it's really hard to do meaningful psychotherapy when you're only seeing people that frequently. And that's really the genesis of this comment, is that some of these residents can only see patients once every month or so. And I personally don't necessarily agree with Dr. Shedler on that.

I mean, he's a legend in the field of psychiatry, and who am I to disagree with him? But I'm-- I, work in a CL setting, you know, and I've had conversations with professionals that I feel like have led to meaningful psychological change and behavioral change for me in just a couple of sessions. And my overall role model in the field of psychiatry is Allen Frances, and when he came on the podcast, he made, I think, what a lot of therapists would regard as a wild comment.

He said, "Psychotherapy for me is everywhere all the time." Basically meaning we can [00:16:00] have meaningful interactions with other people, we can learn things about ourselves and the way the world works that can change the way we see things, change the way we interact with the world. And that can really have, you know, can lead to positive spirals that can lead to major positive changes in our life.

And I do believe that can happen in a brief encounter with a patient. I, don't have any data to support that. Dr. Shedler has a lot of data to support his assertion that meaningful psychological change takes about six months before you start to see it. So that's where I'm coming from, trying to have conversations.

I'm sorry if the conversation made anybody feel unsupported, but I hope it helped us all to expand our brains a little bit. 

Preston Roche: Mm-hmm. Gotcha. So as someone who's, not-- kinda coming to this conversation as a, newcomer m- and is also a trainee, I'm hearing that the denigrating comments that this listener might be referring to is a- assuming that, you know, because of residents have such a limited schedule or the frequency of which they're seeing patients leads them to [00:17:00] providing substandard care.

Was that, like, kind of the tone? 

Mark Mullen: That's the tone, and then also he made a comment about how in our eight years of post-undergrad training, almost none of it is relevant to the practice of psychotherapy. And that hurt, but it's not completely untrue. I mean, we hardly covered psychotherapy at all in medical school, and then even in residency, it's less than a half of the content that you're covering.

And so I think we have to hear that and appreciate it and also know that Dr. Shedler lives in psychotherapy land. Dr. Shedler is a psychologist, and he's probably-- he may be the best psychologist in the world as far as I'm concerned. But the job that he's doing day to day is different than the job that most psychiatrists are doing every day, where we are embedding medication management, and we're practicing in different settings, right?

So I think we have to take what he says about the practice of psychotherapy and take it really seriously, and I know he knows a lot more than that than-- about that than I do. But then I have to take what he said and apply it to my consultation liaison setting and apply it to the residency training clinic setting, and it may not be a one-to-one comparison.

Preston Roche: So [00:18:00] what would you say is your biggest takeaway of the Shedler episode? 

Mark Mullen: I thought it was super interesting that he, pointed out that the most important thing for patients when they Are receiving psychotherapy is not symptom reduction. It's basically what he described as meaningful psychological change, changing the way that we think about ourselves and our role in the world, and the way that we understand our interpersonal interactions and understand our own mind and coping mechanisms, et cetera.

And that is drastically different than symptom reduction. And I don't think that's a conversation that we're having in psychiatry residency, and I think it's a conversation that we should be having. So I, think that when we're especially studying psychopharmacology, we are gonna have to use symptom scales because that's the best thing we have available to us when creating evidence.

But I think thinking that the only thing patients care about is reduction in their symptoms when they come see a psychiatrist is really misguided, and I think we probably should do a better job of discussing what our role as [00:19:00] psychiatrists needs to be beyond symptom reduction and then discussing that the evidence we have actually doesn't give us a whole lot in that regard.

Preston Roche: Mm-hmm. A lot of people go to the psychiatrist hoping to almost like anesthetize their anxiety or their sadness away. But what if you could reframe your life in a way that, you know, you are sad, but it's meaningful and ready to lean into that sadness? that wouldn't be reflected on a PHQ-9. It's interesting.

Mark Mullen: And he talked about how depression is a non-specific symptom like a fever. And so when you're treating a fever, right, you might treat a fever. And for him, that would be like giving an antidepressant to reduce your score on a Hamilton Depression Inventory or a PHQ-9 or a MADRS. But just because you've treated the fever then, you also need to look further at is there anything causing this, right?

Are there relationship patterns that we need to talk about here? Are you having difficulty being empathetic for yourself for the way that you are or the things that you've [00:20:00] done? And all of that goes way beyond symptom reduction in medications, and I think that we have to be really careful not to throw it out the window and think that reducing your score on a PHQ-9 is our only goal.

Preston Roche: taking it to the next level, something, that's hard for clinical medicine to do sometimes. That kind of wraps itself into a clinical pearl, which is to look beyond the psychometric screeners. So I guess we can then move on to the next episode, which was Problematic Screen Use with Justin Romano.

To kind of recap for everyone, Dr. Romano, he, draws this direct parallel between screen addiction and substance use disorders and uses like nearly identical clinical, language to describe them. I've also seen that used with like things like exercise addiction too. At what point do you think psychiatry needs to formally treat problematic screen use?

And should we give it the same diagnostic seriousness or weight that we give substance use disorders? 

Mark Mullen: I think we're there. I mean, I think Dr. Romano made a pretty compelling case that [00:21:00] we're already there. But I also feel like Preston, having listened to your podcast, you guys have done more on this technology screen time thing than I have even.

I mean, what do you think? You know, does a behavioral addiction to screens belong in the DSM now? 

Preston Roche: yeah, I would agree. And we should have, like, a couple different criteria for it. I think to have a addiction to screens, you actually have-- sh- should probably have to demonstrate that you have an unreasonably high screen time.

So I think it's, reasonable to say, you know, something like greater than twelve to sixteen hours a day or something of screen time would be like criteria A. And then criteria B is, like, excessive screen time use is interfering with interpersonal relationships or ability to execute duties. They're distressed if they're not able to, like, achieve their screen time, so, like, some kind of, like, withdrawal or relapse symptoms.

In looking at actually some, like, brain interconnectivity studies, people with excessive screen time have-- they have impaired default mode network deactivation. It's [00:22:00] harder for them to essentially direct and focus their concentration after being exposed to, extended periods of especially short form videos and with doom scrolling, so to speak.

That's a really interesting, like, new body of research that's coming out. But what's fascinating is that when they go a month off of their screen and they repeat the studies, the interconnectivity of those attention networks starts to reconstruct, starts to bounce back. So I think that entire dynamic sets us up pretty well to consider this a disorder that can be treated, that has biologic substrates that are detectable in the ways that we analyze the intraconnectivity of our brain.

So I think that's how I'd put it. And then, and we already have, like, some different therapies that people are trying. Like, there's a whole industry now about how to, keep your phone smart while also not subjecting yourself to all of the modalities that are designed to steal your attention. Like, people [00:23:00] use this thing called the Light Phone.

Have you heard of that? So it's basically like a smartphone that has it, it has, maps, it has email, I think Spotify, and calling and texting capabilities, but it won't let you download any other apps. It's like a dumb phone that can do, like, smart-ish things, so you can use it effectively because it's almost impossible to function in daily life without a phone anymore.

So people are trying to kind of split that difference. And then another one is to just find ways to lock yourself out of your phone and use it effectively for the, things you're trying to be productive with. So things like the Brick, which Margaret and I have, used on and off. It's a physical device that you put on your fridge that you have to tap with your phone to say, like, "I'm in work mode" and like, "Hey, I'm not in work mode."

Because if, you know, you wanna go on Instagram or TikTok or some kind of social media, you have to physically go, like, unlock that thing. Those are, like, different solutions we have. But I imagine that there's a world where even using stuff like, [00:24:00] naltrexone or SSRIs or GLP-1 agonists, things that might actually, disrupt the reward pathway, disrupt the, like, operant conditional behavioral feedback loop that people generate, like, may be indicator or at least, like, worth exploring if it has any effect on it outside of just, like, behavioral therapy because the screen time, use is...

It's out of control. There was a grand rounds we had where they were looking at adolescent screen time use, and they would like to enroll in the study. They just download an app on their phone, and they just tracked how often they picked up their phone, how often they checked it. And there was a subset of teenagers, I think like 10%, that checked their phone every single hour in a 24-hour period.

Like, they, like, to the point where, like, they weren't getting, they weren't getting periods of uninterrupted sleep. 

Mark Mullen: Oh, that makes me sick. 

Preston Roche: You know, they're, you get 45 minutes and I'll check your phone, then go back to sleep or something. Yeah. 

Mark Mullen: 10%, that's [00:25:00] crazy. 

Preston Roche: Yeah. And then it has... I, and I don't wanna quote 10%, but it w- I just remember it was, like, a substantial number.

And, those kids all had like much worse outcomes on, you know, stress, anxiety, depression scales. Like, it's all directly related. So I think I'm, pretty much there. Like, I agree, DSM-6, get ready for the remix, guys. It's gonna include doomscrolling. What were your biggest takeaways from that episode?

Mark Mullen: Biggest one was, and maybe this is just that I'm a parent now for the last year, I think communicating to children and adolescents that you as a parent or as a trusted adult are a safe person to come to when they run into weird or scary things on the internet, or aren't sure what to do about something that they see on their device, et cetera, et cetera, et cetera.

'Cause there's a lot of stuff out there, and it's can be really heavily associated with shame. And when the shame comes in and the, you know, the, child doesn't feel safe to fully discuss it and be themselves, or [00:26:00] fears punishment or fears that they're gonna get yelled at, and so they can't be honest about it, I think that's where we really get into trouble.

So for me, the biggest takeaway was as a parent, as a trusted adult, really clearly and deliberately communicating to my child, "I will always love you. There is nothing that you could ever do that would ever jeopardize that. And the internet can be a really scary place. And so if you find yourself somewhere on the internet or run into something on the internet or wanna talk about something that you've seen on your device or someone that contacted you on your device, I'm always a safe place, person to come to, and I'd be honored if you'd come to me with that because I don't want you to ever feel like you're in over your head."

That was my number one takeaway. 

Preston Roche: So y- your takeaways were stronger as a parent. 

Mark Mullen: Well, and maybe some of that's just avoidance and denial, but yeah. Yeah. But 

Preston Roche: yeah. Yes. The e- easier thing to focus on. We can always be better parents, said Preston, who has zero children and two cats So moving on to, rethinking decisional capacity with [00:27:00] Dr.

Omar Mirza. So Dr. Mirza draws this provocative parallel between capacity assessments and colonialism. How do you personally sit with that framing as a physician who's conducted these assessments? You're a CL psychiatrist, and do you think that metaphor changes anything about how you intend to practice going forward?

Mark Mullen: Yeah. Dr. Mirza's parallel between colonialism and capacity assessments was a bit shocking as a CL psychiatrist, and it really made you think. So when I think of colonialism, I think of this idea that we are more civilized than you, more advanced than you, we know better than you, and therefore we should get to exert our control over you.

And I think it's a totally reasonable comparison to compare colonialism to capacity assessments. I also think though, that when we think about colonialism and all of the violence, that's associated with that over the years We also have to take a beat and say, well, there's pretty clear clinical guidelines about assessment of [00:28:00] decisional capacity, and there's pretty clear legal precedent out there about the duty of a physician in making sure that a patient has decisional capacity before going through with the procedure.

So I think it's a provocative thought, and it certainly made me sit up in my chair, but I do wanna be careful that a lot of the images that come to mind when thinking about colonialism don't apply very neatly to practicing evidence-based medicine, and certainly following the APA guidelines requires assessing decisional capacity based on the Applebaum-Groszer criteria.

So how has it changed what I do? Now when I-- A couple things. Now when I get a capacity assessment, before I were to make a determination that a patient doesn't have capacity to accept or refuse a certain intervention, I stop and ask myself, "Is this a situation where I need to break the glass and take the really extreme step of saying that this person does not have the capacity to make this decision for themself?"

I think I give that more weight now, and I really see it as, like, an emergency thing. I [00:29:00] work really hard to avoid that by seeing if there's a third outcome or there's something that we can do creative to make sure everybody's on the same page and we're not having to do any treatment over objection. So I think I just give it a little more weight.

The big clinical takeaway for me was when I get a capacity consult now, I make sure to think about who are all of my stakeholders. Obviously, it's the consulting team, obviously it's the patient, but it's also whoever the surrogate decision-maker would be, and then sometimes there's other stakeholders as well.

So what is the optimal outcome for everybody? And sometimes when you have that conversation first, you end up not even needing to do a capacity assessment because you come to a better outcome. As an example, if the primary team says, "Does the patient have capacity to refuse," I don't know, "valve replacement surgery?"

And we ask the vascular surgery team, "Hey, if we find that the patient doesn't have the capacity to refuse this, would you go ahead and do the surgery over the patient's objective-- objection?" And they say, "Well, no, we wouldn't do that." Then it's like, what's the point, right? So we're happy to help you solve this problem, but us doing a decisional capacity [00:30:00] assessment and saying the patient can't decline this treatment and you wouldn't offer it anyway is kind of a waste of all of our times.

And I, hadn't really thought about it that way before, so I try to do a better job now of saying, "Who are the stakeholders? What are the possible outcomes? And is there a common sense approach that we can take?" 

Preston Roche: Yeah. It-- 'Cause it's different when someone's delirious and you kind of against their will hold them down and give them some antibiotics But, you know, cutting someone's leg off or going into a major, heart surgery that like, yeah, even if they don't have capacity, no one's gonna touch that.

Mark Mullen: And you think about the things that lead to someone needing amputation, a lot of it is pretty closely linked with capacity, right? Poor self-care, et cetera. That question comes up a lot, "Hey, should we cut this person's leg off without their consent?" And usually the vascular team says, "Well, we wouldn't do that."

And then it's like, well, we need to rethink this whole paradigm. So that was helpful for me. 

Preston Roche: I think that would be helpful for me too. I'm-- I don't do a ton of CL, but when I'm on call, I'll get that question often and, it would probably save everyone a lot of heartache if I just said, "The answer is [00:31:00] no.

What would you do anyways? Okay. Gotcha." So this next episode, it's a double feature, so we have the six suggestions for DSM-6 and scientific pluralism. So this is with Dr. Aftab, and Dr. Aftab makes this case that the DSM is actually too conservative, that it underdiagnoses rather than over diagnoses. it's almost the opposite of what Allen Frances argues in Saving Normal, which is a book that you hold in high regard.

How do you reconcile those two positions? 

Mark Mullen: So I was not exaggerating when I said that I think Awais Aftab should chair the DSM-6. I'm obsessed with his work. I think the lens through which he examines critical issues, philosophical issues in psychiatry is just spot on and, it's very hard for me to disagree with Awais Aftab and I guess I'm probably wrong.

However, the idea that the DSM is too conservative-- and I'll agree with him too that I'm sure he's correct that we could identify additional patterns of behavior that tend to run [00:32:00] together, that share validators like response to treatment, genetics, course of illness, et cetera. I'm sure he's right that we could find some additional disorders that are validated on those levels and that academically speaking, they deserve to be added to the DSM as much or more than some diagnoses that are currently in there.

However, I personally think that at the end of the day, more diagnoses are gonna lead to more diagnoses. I think if we put more diagnoses in the DSM, there's gonna be more diagnoses written on charts because of course you can give a patient more than one diagnosis and we do regularly, routinely. And I think that just giving more diagnostic labels is not necessarily going to lead to better care.

I have a lot of concerns about over-treatment in psychiatry and, as a clinical psychiatrist, I'm pretty comfortable living in the unspecified territory. I always take diagnostic labels with a grain of salt, but I do have to admit that to Aftab's point, if we were to create more specific diagnostic categories and sort of [00:33:00] shrink the number of patients, which is a lot, that fall into these unspecified categories, maybe we could have better studies generate better data, through which to address these validated illnesses.

Preston Roche: Mm-hmm. So- Even having stuff like depression related to driven by social factors with treatment resistance to medication being a specific one. Or like, like are you talking about adding more like modifiers Or like specifiers, but lit- literally different illnesses or disorders. 

Mark Mullen: Yeah. Like, so, you know, we have unspecified, you know, I'm using unspecified depressive disorder- Or other specified

a lot on consults. Yeah. Yeah. And I think that's his point, is that there's actually, like, in other specified, there could be- You could specify the others ... actual, you could specify it. Right. Exactly. 

Preston Roche: Yeah. 

Mark Mullen: Yeah. 

Preston Roche: Yeah. Gotcha. Okay. In using that, what would you say your biggest clinical takeaway is? do you think you'll spend more time in unspecified [00:34:00] territory or less time in unspecified territory?

Mark Mullen: I'm gonna spend the same amount of time in unspecified territory. I think on CL, I gotta be spending a lot of time in unspecified territory. I think it's honest, I think it's humble, and I think that when we-- I, talk about putting your cape on a lot in CL. You know, you'll see a patient come in and you'll read the medication regimen, and you'll think- what is this person thinking that's writing all these meds?" Or you'll read the diagnoses in the chart and they're contradictory, and you'll think, "Gosh, I'm so smart. I know so much better than all these previous treatment providers. I'm gonna, you know, put my cape on and I'm gonna fix this person."

And guess what? You know, you get to know the person for 48 hours, and then they're somebody else's problem. And so I think you can do a lot more harm than good when you put your cape on consults. I think it requires- Yeah ... being really patient, taking a deep breath, being very humble about what we know and about how much we should intervene in this person's life during the brief time period through which we are honored enough to serve the patient.

So I ch- I try... I talk about putting your cape on a lot on CL, and I try to avoid that and not be a hero because sometimes the harms of being a hero [00:35:00] aren't as easy to see as the perceived benefits. but to answer your question, I think that my big takeaway from this one is when Aftab talks about the word disorder and what patients think of when we use the word disorder, I think when a patient hears that you have major depressive disorder, it's easy for that patient to interpret this as, "Oh, I have a medical illness that I'm always gonna have, and I therefore am going to require lifelong treatment for this chronic illness."

And I think that's a totally reasonable conclusion, and I think that we as psychiatry as a field are responsible for creating that understanding. But I actually think that when we say someone meets criteria, and those are the words that I would use, meets criteria for major depressive disorder, that doesn't necessarily mean that they're gonna be on, an SSRI for the rest of their lives, and it doesn't necessarily mean that they have a specific neurochemical imbalance in their brain that's going to be particularly corrected by a certain class of medications.

And I think that there's some disconnect between what we as psychiatrists understand. And we have a lot of data on this, right? Like, we know when [00:36:00] you can taper an SSRI after a major depressive episode remits, et cetera, et cetera, but patients don't have that same understanding, and how could they? So my big takeaway is making sure that when I use the word disorder or when I communicate a diagnosis to a patient, trying to make sure we're on the same page, that I'm basically just saying they meet this list of criteria And I have tools that have been shown to help people who meet the same list of criteria, and I'm offering them to you.

And it may be that in the future you no longer meet criteria for this disorder, and it very well could be in the future that you will no longer need to be engaging with this treatment, whether that's psychotherapy, interventional psychiatric treatment, or psychopharmacology. I don't think we're having that conversation.

I think we need to do a better job as a field. 

Preston Roche: Yeah. I've noticed that, like, we only have an on-ramp for psychiatric diagnoses. we don't have a good exit ramp. And, even, like, depression, like you can go through a depressive episode and then achieve remission, sometimes spontaneously. But we just say like, "Oh, past psych history of depression," as if they, like, [00:37:00] always have it.

So we, reinforce it to ourselves and to any other doctors that see it. And even for things outside of depression, like, PTSD doesn't-- even if you're not on medication, doesn't necessarily follow you for the rest of your life. It will gradually t- in most people will gradually taper on its own after the course of a couple years.

So you may have met criteria for PTSD at one point, but then we have like no off-ramp for PTSD. It's like, "Oh, you're diagnosed with PTSD at age 20. Well, now here I'm doing your intake at age 50," and I'm like, "You don't meet criteria at all for PTSD," but I keep it on. Do I just remove PTSD from your diagnostic chart?

Like the, like those kind of things don't have a, like a clear cut, like procedure and most, people I'd say just leave them on. 

Mark Mullen: Exactly. 

Preston Roche: It's like a policy at the VA, you know? You can only add new ones on. You can't ever take one off. 

Mark Mullen: Been there. 

Preston Roche: All right. So speaking of PTSD, we have some interesting episodes in the second half of this with complex PTSD with Dr.

Mark [00:38:00] Ruffalo, physician-assisted suicide with Dr. Mark Komrad, and TMS for treatment-resistant depression with Dr. Owen Muir. So after these quick messages, we'll be back to talk about those.

Mark Mullen: Do you ever feel like technology was invented to make your life easier, but it actually just made things more difficult? Like now you have multiple systems to juggle. I spent twenty minutes in a department meeting with faculty recently discussing the differences and advantages between email, WhatsApp, Microsoft Teams, the cloud, etc.,

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Preston Roche: So, in the first half, we, talked a lot about screen time and psychotherapy and how our residency training could be better, but let's, get a little bit more into the fun interventional sci-fi feeling stuff to me, which is transcranial magnetic stimulation. So, this episode with Dr. Omer, you actually got your first negative review on this episode, [00:40:00] and it asks, for more skepticism on TMS claims.

Or, and I guess I'm assuming that you're very pro-TMS in this episode. Do you wanna respond to that? that, you should have had more skepticism towards TMS? 

Mark Mullen: My bad. 

Preston Roche: That's the response? 

Mark Mullen: Yeah, I think, it's, totally well taken, and I apologize to the listener for that one and to the listeners for that one.

I, As the show has grown and I have tried to make it more sustainable- Mm-hmm ... I have stopped, like, pre-planning the curriculum and then trying to find an expert to teach the curriculum, and now I'm finding the expert, and we're talking about what that expert wants to talk about, which makes the podcast a lot more sustainable for me.

But I'm having trouble sort of deciding how much should I, as a, someone who's been attending for less than two years and is not an expert on these topics, you know, what's my responsibility to my audience? I think I'm understanding more now that I really do need to have a [00:41:00] critical lens. I really do need to push back on guests when I feel like they're overstating the case.

And, you know, when Dr. Meurer was talking about TMS, we talked about it in pretty, We were not, like, citing particular studies and rates, I don't think, and I'm not familiar with those studies and rates. I didn't come into the episode with all that data in front of me, and so I'm gonna try to do a better job on that in the future, and I appreciate the constructive feedback.

Preston Roche: Yeah. I, think it's, something you learn in middle school or high school that you always have to have a counterclaim whenever you're writing an essay. And the thing is, a good counterclaim makes the argument for even stronger. So, yeah, I try to, do that too. also something that I think, like, we could benefit from more on How to Be a Patient when we do, like, episodes about different treatments is, like, bringing up the, skepticism for it.

I think the only one we did that [00:42:00] well with was with, some of our, like, different psychotherapy modalities, where, like, the existential psychotherapy, we, like, really brought up, like, okay, you know, you can use this form, but Here's what the haters are saying. And I'm not necessarily a hater, but I just know what they're saying and I can, say it's valid.

Mark Mullen: And just especially now we're gonna have CME on the podcast, I need to be able to have the studies in front of me and cite some specific numbers when we're talking about like treatment outcomes for something like this, which those numbers are pretty easily available. So I just, you know, I gotta take that one on the chin.

Preston Roche: that's the right way to do it. I would say, but I'm not an expert on taking stuff on the chin. So what's your biggest clinical takeaway from that TMS episode? 

Mark Mullen: I think just generally speaking, TMS is probably the next big thing, TMS and psychedelics. I, despite what I just said, I'm pretty encouraged by the efficacy and especially the safety data with TMS.

So I'm just gonna leave it at that. I think that it's gonna continue to expand and, continue [00:43:00] to help the field of psychiatry have more tools to help our patients. 

Preston Roche: You know what I would like is, it's a backpack With a TMS magnet on it. So you know how people have those, like, portable ultrasounds that you can plug into your iPad?

Mm-hmm. 

Mark Mullen: Oh. 

Preston Roche: Picture this. You have the machine on your back- 

Mark Mullen: Mm-hmm ... 

Preston Roche: on rounds or on a med student's back or somewha- something, and then we're like, "Okay, we're gonna do some bedside TMS." Walk over to the patient, hold it up, you know, do the motor threshold, and then spend the next 20 minutes just zapping them, then move on to the next one.

Mark Mullen: Patented. Yeah. Someone's gonna steal that idea. 

Preston Roche: That'd be pretty cool. 

Mark Mullen: Mm-hmm. 

Preston Roche: Or maybe, it could be a cart that you could push. That'd probably be a little bit easier, but, you could ru- you could use your rucking steps in while being in the hospital. Mm-hmm. So- You could run and do TMS ... 

Mark Mullen: just an idea.

Yeah, I like that. 

Preston Roche: Yeah, that would be awesome. Y- you're literally running the TMS service. So moving on now from magnets, let's talk about, a pretty taboo topic, physician-assisted suicide. This was with Dr. Mark [00:44:00] Komrad. This is, cannot be overstated as one of the more controversial episodes on the podcast so far.

and the listener commented, "There's no rational, moral, or ethical argument that adequately justifies any medical professional that engages in facilitating physician-assisted suicide." What are your thoughts about that comment? 

Mark Mullen: So I would say I try to be careful with always or never statements or statements that include the word only, et cetera.

I tend to agree with that statement. I do think we need to paint the picture, though, here of what we're talking about when we talk about being against physician-assisted suicide but for palliative care, right? So the standard of care in palliative care is to treat symptoms to make someone more comfortable while they are suffering from whatel- for whatever illness it is that they're suffering from.

And when you are on hospice, for example, we are often using medications that may shorten your life because they may decrease your respiratory drive, lead to cardiac depression, [00:45:00] et cetera. But we're doing that because we're treating really distressing symptoms. So I'm thinking about something like lorazepam for anxiety toward the end of life or using high doses of opioid pain medication to treat pain at the end of life.

You know, both of those are gonna suppress your respiratory drive, and when you're already near death, they very likely could contribute to hastening the end of your life. But we use them anyway because we think the benefits in terms of treating your distressing symptoms outweigh the risks given your goals of care, which are to be comfortable knowing that you're dying anyway.

So I think that we can hold space for a world in which people who are dying are allowed to have control over their bodies and be made more comfortable without legalizing physician-assisted suicide. And that being said, right, I definitely think that reasonable people can and very much do disagree about this topic, and Dr.

Komrad really is an advocate. he-- Because he's an advocate and because he feels [00:46:00] so strongly about this topic, he has written more about this topic than I think anybody else in the world, which I think made him a great guest. But- Again, in, in this episode, we didn't have a very strong counterargument. I did not invite a physician-assisted suicide advocate on, and maybe I should, but I tend to agree with Dr.

Comrade, so maybe, I think that was a difficult experience for some of our listeners that disagree with us. And we did hear from some of them. So, I apologize if the episode upset you. I think this epi- episode definitely did move into the advocacy space. And again, this is just sort of as the podcast moves into the future, I'm trying to find where my voice is gonna be.

Preston Roche: It's a hard spectrum to live along, and it actually, it reminds me a little bit of, something called the jus in bello, which is, essentially the law of armed conflict. And what, you're describing is this, distinction between act and intent. So, [00:47:00] the action, giving opiates towards the end of life, can be a death hastening tool, but the intent is to relieve pain, not to end your life.

So it's, we give with the intent of palliating someone's symptoms, and we tolerate the risk factor of them dying, but we don't give something with the intent of them dying. And it's the same thing as like with like the law of armed conflict. You can hit a target with the intent to eliminate the target and knowing the collateral damage that may exist to surrounding structures or, possible people, but you don't target people specifically.

Like, you wouldn't... You know, if, for example, if there's a, hostage who's being held with a gun to their head and you're a s- you're a sniper who's trying to, like, save the hostage, you try to shoot the attacker that's holding them, but you don't, like, shoot through the hostage, essentially. So I guess that's, kinda how I would navigate that, is think about like the act and intent there.

and I guess that whole, the whole concept of [00:48:00] legalizing physician-assisted suicide would be both the act and intent are now congruently towards ending someone's life. 

Mark Mullen: That's super sophisticated. I love that comparison. I'm gonna add too that I think there's, a, an element here that is even if we want to legalize suicide, and maybe we should We really, can't, and this is the hill that I'm happy to die on, see physician-assisted suicide as a valid medical treatment 'cause there's been some really dystopian cases where patients can get their physician-assisted suicide covered by their insurance company, but not the treatment for the underlying illness that is killing them.

And to me, we're living in a hellscape when we get to that point. So we need to make sure that we keep physician-assisted suicide out of the house of medicine as an accepted treatment because we get into some, I think, unacceptably dicey territory there. 

Preston Roche: Mm-hmm. When you abstractly or philosophically discuss it, it may be okay, but when it hits-- when the rubber actually hits the road, it doesn't hold water, and it's used more as a weapon than just a palliative treatment.

It... Would you say that's your biggest clinical takeaway? 

Mark Mullen: [00:49:00] I would say that, and then just some of the facts were shocking to me. So Dr. Comrade had said that in countries where both euthanasia and physician-assisted suicide are legal, 99% of people go with euthanasia because they prefer to outsource that final act.

That was very surprising to me because I would've thought that people who go for physician-assisted suicide tend to be more independent and are proud to be in control of their own lives and their own deaths in this way. So I just thought that was fascinating, and tells us a bit about the human relationship to death, and then also that once euthanasia's legalized, it quickly becomes commonplace.

So euthanasia is the fourth leading cause of death in Canada, which was a shocking statistic to me. And I understand that those people, you could argue, although certainly not in all cases, but you could argue that almost all of those patients were dying of something else anyway, and so this is a garbage statistic.

But I think it's, I think it's super fascinating. 

Preston Roche: That is fascinating. I don't have anything else to say about that. I think we'll just leave that there. Complex PTSD with Mark Ruffalo. Now, this episode got quite a few [00:50:00] comments about, complex post-traumatic stress disorder. Specifically, listeners felt the construct of C-PTSD was under-described.

The tone was also critiqued. It was mentioned that two males discussing the topic and not mentioning gender associations with borderline personality disorder felt a bit tone deaf. Do you wanna correct the record here at all, or what are your thoughts about these comments? 

Mark Mullen: Yeah. I, thank you guys for reaching out about this.

I think we did miss a couple of things on this episode, so I think at the very least, we need to acknowledge that we should have discussed the ICD-11 criteria for complex PTSD. We didn't discuss that, and we should have, and I'm sorry. I do think that Dr. Ruffalo and I were not exactly on the same page about the content that we were gonna cover.

Dr. Ruffalo is another one of my favorite psychologists in the world, and I maintain that he is a world-class expert on these sorts of topics. But he really has focused his clinical work on borderline personality disorder [00:51:00] and on-- well, his clinical and research work on borderline personality disorder and on psychotherapy for patients with primary psychotic disorders.

And I think that I sort of drug Dr. Ruffalo along on this conversation that I wanted to have about complex PTSD, which is not really where most of his work lies. And so probably in the future, I should have another episode that focuses more squarely on PTSD. So I think I owe Dr. Ruffalo a bit of an apology there.

I think I dragged him along for my agenda. but I also felt like in this season, I, finally was, like, secure enough in my podcast that I wanted to move into some dicey territory. Like, a lot of these topics are not neutral, and I'm proud of myself for that. Like, it was uncomfortable, but, I shoulda done a better job certainly.

Preston Roche: Yeah, you... I mean, you really went for broke this season on, controversial topics. And like - 

Mark Mullen: Yeah. Yeah, we did ... 

Preston Roche: it's like, let's change the DSM-6. What do we do about physician-assisted suicide? Like, let's make screen use [00:52:00] a disorder. So, like, I, think shoot for the moon, you'll land among the stars, and, we're doing that, and the stars are writing us back, so...

And we appreciate y'all's feedback. Another, beat about Dr. Ruffalo is that he, he has a statement that he's never had a patient reject a personality disorder diagnosis when it's delivered well. But you work in a consult setting where you often have one encounter and not a lot of established rapport.

How do you personally navigate delivering a personality disorder diagnosis under these, tough constraints? Or do you just stay away from it altogether? 

Mark Mullen: I rarely make a tag-- personality disorder diagnosis in the consult setting. I think that all of us are gonna look like we have a personality disorder on our worst day, and even when we provide a history, we're often not very empathetic toward ourselves, blaming ourselves for a lot of things, overstating the things I should have done or how much control I had over the situation, overstating the ways in which I'm a terrible person and terrible at coping and hurt so many people.

You know, when, we're really in a [00:53:00] bad mental space, the history might even be detached from reality with just how unempathetic toward ourselves the history that we give is. And so when you're giving a personality disorder diagnosis, given that this is a diagnosis that's a pervasive pattern of behavior that starts early in life, et cetera, et cetera, et cetera, we need to take it really seriously before we place that label on a patient that we're only gonna know for 48 hours.

So I rarely do it. I'll often talk about the personality organization in my assessment. I'll talk to the patient about their personality organization. We'll do some teaching about that, but I'm rarely being the first one to place the label. That said, I think there are some times when we would be abdicating our responsibility if we did not use the label, and I think there are some patients with personality disorders who maybe are only seeing a consult psychiatrist because they're coming in after repeated suicidal behavior, they're constantly in the inpatient unit, et cetera, et cetera.

And so when it's really clear I think there's definitely cases where the best way to serve your patient is to make the personality disorder diagnosis and connect them with the appropriate [00:54:00] evidence-based treatment. I think we'd be failing our patient if we didn't do that. But I think in the majority of cases, when I'm pretty sure this is the diagnosis, I'd rather just talk about the organization and do some psychoeducation.

Preston Roche: Yeah. The psychoeducation's, like, a key point, and it's almost like you can give them-- You, you can give them some string that they can follow to, to get themselves help. O-one thing I've noticed that my attendings have done on consults is they've said, "Have you ever thought about getting psychotherapy?"

And they're like, "I need therapy. You know, like, s- trauma-focused therapy was so helpful for me." And they're like, "Let, me put you on this one that I think is really good. It's called dialectical behavioral therapy. I want you to write this down. When you get out of the hospital, I want you to go to your, like, psychiatrist or your GP and tell them that you wanna start DBT."

And they're like, "Okay, yeah. That's awesome." So it, like, it kinda gives them an idea that, like, they may not have the diagnosis yet, and they might not even have the personality disorder at all, like, who are we to know in the inpatient setting? But they would benefit from this type of therapy that helps them regulate their emotions.

Mark Mullen: Totally. And I think the last couple years when I have a-- I'll, often say to the patient, like, "Have you [00:55:00] ever heard of the diagnosis of borderline personality disorder?" I think if I've done that 10 times, 10 patients have been like, "Oh yeah, I have it." And I'm like, "Okay, well, that makes this conversation a little bit easier."

You know, I think there's just more out there on the internet about it, and so people are reading descriptions of it and being like, "Oh, this is, my life." And so that conver-- I think that conversation has changed in the last five years. And then I just wanna add too that I'm talking about borderline personality disorder here, not other personality disorders.

I would never diagnose narcissistic personality disorder on the consult setting. I think it would be contra-therapeutic because when we do-- And we get a, good amount of consults for patients who are struggling in the hospital because their narcissistic personality organization does not match the w-conditions that they're in as a patient who is completely at the will of other people, whose schedule's at the will of other people, whose diet's at the will of other people, who have no control over their circumstances.

And our role as a CL psychiatrist in that case is often supportive psychotherapy and to sort of help the patient to maintain their ego [00:56:00] functioning even if they're not functioning at the healthiest level in terms of their personality organization. So I would not personally-- have not diagnosed NP-- narcissistic personality disorder on consults.

Preston Roche: I don't think I've ever seen that done either. 

Mark Mullen: But you've seen it be the primary diagnosis. 

Preston Roche: Yeah. 

Mark Mullen: Yeah. 

Preston Roche: Yeah. 

Mark Mullen: Yeah. 

Preston Roche: Certainly have. What would you say your biggest clinical takeaway is? 

Mark Mullen: I would say biggest takeaway is that mislabeling can lead to mismatched treatment, and I think that was Ruffolo's whole point, is that when we see a patient with borderline personality disorder and we have not just dialectical behavioral therapy, but also other psychotherapies that have been shown to work for borderline personality disorder.

We have a lot of good treatments out there for it now- When we don't make the diagnosis or don't connect them to the evidence-based treatment for the diagnosis, when we just say, "Oh, this is complex PTSD," they might get the wrong treatment because what they might end up getting and probably will end up getting currently when cPTSD is not in the DSM is some sort of trauma-focused therapy that's really helpful for PTSD but is less helpful for borderline personality disorder.[00:57:00] 

And so I think-- And this, I guess this is just Medicine 101, knowing the right diagnosis so that you can create the right treatment plan really is the point. 

Preston Roche: Yeah, y- you gotta be aiming at the right thing. Up next is severe mental illness behind bars, and this is with a journalist, Jesse Bogan. You said personally you treated patients who came to you after, languishing for a while in jail, and they're awaiting a competency restoration.

What has this clinical experience taught you about the months of incarceration without treatment, what that actually does to someone's psychiatric trajectory, and how does that change what's possible once they finally reach you? 

Mark Mullen: Yeah. So what we know is that when psychiatric illness goes untreated for extended periods of time, the longer it goes untreated, the more severe the symptoms become and the harder the symptoms are to treat, especially when talking about things like psychosis, which is common in the incarcerated population.

Often it is people's psychosis that gets them into trouble in the first place. [00:58:00] And then in the state of Missouri, we are a fiftieth out of fifty states in the nation in terms of how long it takes patients to get into competency restoration treatment. And so what we have is jails where people with severe persistent mental illness and active florid psychosis are basically languishing in restraints, smearing feces all over the wall, being relegated to solitary confinement, not eating their food, and then by the time they come to me, they are catatonic and they haven't eaten in two weeks.

And so I tend to take a really aggressive treatment approach for patients who are going to go to a carceral setting because I feel like I stand a chance at helping to control their symptoms so that they are safer when they are incarcerated and awaiting that competency restoration treatment. I'm really aggressive with this population, and then I do a lot of teaching with our students when we do get these patients that have decompensated from jail.

I mean, they, pretty much-- they o-often come in catatonic and with, you know, electrolyte abnormalities and pretty severe, very severe medical and psychiatric illness. I tend to do a lot of teaching about how I feel like we as a society have failed, and certainly we [00:59:00] as a state of Missouri have failed.

And so while we're taking an aggressive treatment approach, we're doing this because if we had done this earlier, the patient may not be in this situation in the first place. 

Preston Roche: Yeah. And, sounds like you're taking this more paternalistic approach too, because these are patients that not only do they, they don't have competency, that's why they're getting, restored, but also they don't have capacity to refuse any of these treatments, so they're almost being probably force-fed INSUREs and ECT and, benzos at this point.

whi-which I think is a-- it's a good segue into the next episode on involuntary psychiatric tr-treatment with Dr. Dina Miller. I'm kind of blending these two here, but I think they, they sit well with each other. Can you talk more about the tension between psychiatry's therapeutic role and its social control function?

Do you think that these jails that people are in, like, does it have a role to keep dangerous people off the streets? Is that how we're viewing these psychiatric patients? personally, I think a lot about how there's a conversation about returning [01:00:00] asylums or returning the, institutions of asylums, but I would say they never really left.

They just turned into jails. So do you think those-- these two roles are, ultimately reconcilable within a single profession? Does asking a psychiatrist to serve both functions compromise both, being both the, treater and the one delivering the, forced care? 

Mark Mullen: I'm glad I'm in good company with the belief that asylums never really went away.

They just turned into jails, and that's where we have these people now. I, tend to agree with you, and not everybody agrees with that. But to answer your question, you know, about the tension between treating the patient and serving our societal function, I personally think a lot about how much I dislike the Tarasoff doctrine.

So I... And maybe this is not a hot take from a psychiatrist. Maybe it is. I, don't think so. But I really wish my duty was strictly to my patient and that I wouldn't be held legally responsible for the actions of the patient because I think that since our patients know that we're mandatory reporters, since we need to disclose to them that we do have these [01:01:00] guardrails around our confidentiality, which are guardrails that not every profession who gets to know people in this way have.

Like, I, don't think that if you-- And I guess I'm speaking out of turn here, but I think if you go to the sacrament of reconciliation with a priest and you talk about some stuff like this, I don't think they're ma- they're governed by the Tarasoff doctrine, so I don't think that they have a duty to do the same things that we do So I think that we're just asking our patients to lie to us, really, and I think that it gets in the way of progress and treatment, and it, I don't know. I wish the Tarasoff doctrine didn't exist. I don't have trouble really balancing it because I don't think that our role is to keep society safe. I think there are other agents in society whose responsibility it is to keep society safe, but that's not us. Our, job is to treat our patient, and then we have this very specific carve-out when the patient is imminently dangerous to themself or imminently dangerous to others and, really in Tarasoff, imminently dangerous to a certain other person.

That's when we need to violate that confidentiality and do something about it, warn or protect. [01:02:00] So I, think at the end I'm able to tolerate it, but if I could write the Tarasoff doctrine, I wouldn't. I would just delete it. what do you think? 

Preston Roche: Yeah, I'm, also frustrated with the concept of being held responsible for someone else's actions.

Like there, there's no other relationship where that's true. Even if you're-- go, you go to see your cardiologist and they're telling you to take your Lipitor and you're like, "Oh, by the way, I'm gonna go kill my neighbor," the, your, the cardiologist isn't beholden to report. Or you could tell anyone on the street.

So I don't know why it's, so different, when it's your psychiatrist. Like why, does that get pinned on us? and I think it's because the-- we're kind of saying that the mental illness and your ability to make decisions, like they're one and the same. Like our organ lives in your mind so, so of course if your mind is dysfunctioning, then that's your fault.

Just like how if you went into kidney failure because your nephrologist didn't treat it right. But it's, more complicated than that, you know? I think they kind of make it-- they, look for someone to blame and they make it their responsibility like when it's convenient for the, [01:03:00] purpose of the law because otherwise it's just a giant frustrating gray area.

Mark Mullen: And I think it gets in the way. Like if you really wanna end your life, if you wanna die by suicide, you're not gonna tell your psychiatrist, right? So if we didn't have these sort of societal duties, maybe you would tell your psychiatrist and you'd be able to receive the appropriate treatment for it without fearing that you're gonna risk involuntary commitment, et cetera.

I think there are probably cases where someone realizes, "I can't tell my psychiatrist this," and then they go do the thing and if we didn't have these societal obligations, maybe we would've been able to talk about that in treatment and had a different outcome. 

Preston Roche: Yeah. I mean, you don't have to be a mind reader to know that if someone truly wants to die by suicide, they would be aware that telling you of that desire would impede them from reaching their goal.

So I, actually-- This is just like a pearl I'll say to like med students is that the, patient that tells you that they're suicidal is not your highest risk patient. The patient that tells you they're not suicidal [01:04:00] is your lowest risk and your highest risk patient. So like you always just have to t- to take that into account and, I think, yeah, part of that comes from the Tarasoff doctrine.

Mark Mullen: Couldn't agree more. 

Preston Roche: it's hard, to know. So What would you say your, biggest clinical takeaway is? 

Mark Mullen: I thought it was interesting how she s- kind of stepped out of this dualistic debate between should we have involuntary care or should we not have involuntary care? And instead she framed it as if we are gonna have involuntary treatment, what can we do to make it as humane and healing as possible?

And I like that frame because I think we all have to be honest that inpatient psychiatry units have some room to go in terms of treating people with dignity, making people comfortable, providing a healing environment. And so I think that's a good goal for our field to reach toward. 

Preston Roche: I think it is a good goal, and I think We could borrow some stuff from, British psychiatry units that, that I've seen.

They have more of an emphasis on rehabilitation and there's, I think there's more trust in the [01:05:00] patients. So they, from the ones I've seen, I don't know if all, British inpatient psych units are like this, but they'll have the nurse's station almost be in the center like an island, and it allows the patients to like work more free-flowing.

And that way it's not like we're on this side of the, bulletproof glass and you guys are over there. And then they also have like graduated integration back into society. So they'll have like cooking classes with the patients. And I don't think there's ever a reality where someone in a American inpatient psychiatry unit would even, would give someone a spoon or a fork, let alone a knife, to participate in a cooking class as they're getting rehabilitated coming out.

but we basically say, "Okay, like goo-goo, gaga, like you're a baby as far as we're concerned. Like you can't move a muscle, you can't do anything until we discharge you, and then we're just gonna throw you back on the street where you literally have access to everything and none of the resources to practice it."

So like there, there is some middle ground there and [01:06:00] I think, and personally seeing that, that rehabilitation model has inspired me a little bit. 

Mark Mullen: I didn't know that. I wonder how much of that is that we're just a more litigious society. I got... We, should do an episode on that. That's really interesting.

Preston Roche: Yeah. I, think a lot of it probably has to come from that, or I agree with that theory. So, wrapping it up on a, positive note, artificial intelligence and the future of psychiatry, where we are going from here with Dr. Allen Frances. So we only got positive comments on this episode. No one was upset or, felt it was controversial, the future of psychiatry point, which is nice to get to know people like where we're headed.

So do you have any clinical pearls you wanna share or takeaways from this last episode? 

Mark Mullen: the only thing that I'll say about AI and psychiatry is Dr. Frances is spending his golden years obsessing over this issue, publishing about it constantly, and that's by his own admission. I mean, this is really his thing now, and he is deep into his retirement.

So I think that if someone like Dr. Frances is [01:07:00] spending so much of his leisure time, freaking out about this issue, I think that we would be very wise to listen to him. 

Preston Roche: Yeah. And only time will tell where this is going 'cause it at this point it's changing every six months. And it's, gonna be hard for...

It's hard for me to keep track of it, so it'll just be hard to reel in. Every moment of silence we see here, somewhere in the Atlantic Ocean, a data center's getting built right now. So, so let's take a moment. Okay, that was three more data centers. That is the end of the episode. 

Mark Mullen: Preston, are you gonna do our outro?

Preston Roche: Oh, I, mean, if you'll let me. I mean, just kidding. I'd be honored. I 

Mark Mullen: guess you're the host. 

Preston Roche: I'm, gonna do the outro because I'm the host. There, there's, there was never a question there. You know, all, the questions are directed at you. Me, I'm here to state facts. And well, I guess this, is a fact.

It's a statement of gratitude, which to the audience is thank you so much for [01:08:00] listening. If you are enjoying the show, we would love to know what you think. You can connect with us on TikTok or Instagram at psychbootcamp or email Mark at mark@psychiatrybootcamp.com. Visit psychiatrybootcamp.com to sign up for our newsletter.

You can always connect with the rest of the Human Content Podcast family on Instagram and TikTok at humancontentpods. 

Mark Mullen: Shout out How To Be Patient. 

Preston Roche: Shout, out Rob, shout out Shahnti, shout out Aaron, shout out Margaret, who's coming back from her break soon. I've been over there just kinda yapping by myself.

I think people are watching me, like, unravel in real time. The, fact that I'm moving's probably not helping either. 

Mark Mullen: But don't worry about that. 

Preston Roche: Worry about YouTube, which is where you can find full episodes available at Psychiatry Boot Camp. Thanks again for listening. I'm your host, Preston Roche, sitting in for Mark Mullin.

Our guest today is Mark Mullin. Our executive producers are Mark Mullin, Aron Korney, Rob Goldman, Shahnti Brook. Our season is produced by Matthew Brodeck and Amina Janjua. This [01:09:00] episode was outlined and drafted by Amina Janjua. Our editor and engineer is Jason Portizo. Shout out Jason. Jason, love all of your memes, and everything you bring into our episodes.

you really give them personality. Our theme music was generously donated by Cave Radio. Find them on Spotify. A favorite band of mine and also Mark Mullin's. Check 'em out. And our other music is by Omer Ben-Zvi. To learn more about our program disclaimer and ethics policy, submission verification and licensing terms, and our HIPAA release terms, go to psychiatrybootcamp.com where you can reach out to us with any questions or concerns.

Psychiatry Boot Camp is a Human Content production.

Mark Mullen: Hey everyone, thanks for watching. If you enjoyed the show, please remember to subscribe to the channel. If you'd like more episodes, you can click right here. I'd love to connect with you more, and I'm looking forward to talking to you [01:10:00] next