The Journal of Clinical Psychiatry Podcast

Jenny Guidi, PsyD, PhD, associate professor of clinical psychology at the University of Bologna and director of psychometric and clinimetric studies at Massachusetts General Hospital, joins host Ben Everett, PhD, to discuss her new systematic review in The Journal of Clinical Psychiatry. The review examines more than 30 years of research on the Diagnostic Criteria for Psychosomatic Research (DCPR), covering all 14 DCPR syndromes across 96 studies.
Traditional psychiatric diagnosis can overlook psychosocial factors that shape the course and outcome of medical illness. Dr. Guidi explains why DCPR syndromes were found more often than formal psychiatric diagnoses in many clinical settings, how demoralization differs from major depressive disorder and why that distinction changes treatment, and how allostatic overload links a patient's lived experience to measurable biological change. The conversation closes with practical considerations for bringing the semi-structured DCPR interview into routine clinical care.

🎯 KEY EPISODE HIGHLIGHTS:
🔍 WHAT STANDARD PSYCHIATRIC ASSESSMENT CAN MISS [09:39]
“Our results suggested that the DCPR captured distinct clinical phenomena rather than merely symptomatic manifestations or attenuated forms of psychiatric disorders.”
Many medically ill patients with meaningful psychological distress meet no psychiatric diagnostic category, yet DCPR syndromes can identify them and inform prognosis and treatment.
💊 WHEN AN ANTIDEPRESSANT IS THE WRONG TOOL [20:30]
“On the other hand, if you misdiagnose demoralization as major depression, you are likely to prescribe unnecessary pharmacological treatment for what is essentially a psychological problem.”
Recognizing demoralization redirects care toward psychotherapeutic approaches such as well-being therapy rather than medication with no evidence of benefit.
🧬 BIOGRAPHY WRITTEN INTO BIOLOGY [24:06]
“The concept of allostatic overload provides a theoretical bridge between biography and biology.”
Allostatic overload gives clinicians a measurable way to connect chronic stress and life events to changes across multiple biological systems.

CHAPTERS:
00:00 – Introduction and Dr. Guidi's Path to the DCPR Review
05:00 – What the DCPR Detect Beyond DSM and the 2017 Revision
09:16 – DCPR Syndromes Across Cardiology, CL Psychiatry, and Primary Care
14:32 – Distinguishing Demoralization From Major Depression
18:08 – Recognizing and Treating Demoralization
23:03 – Allostatic Overload: Where Biography Meets Biology
29:02 – Bringing the DCPR Into Routine Clinical Practice

LINKS:
Full transcript and show notes:
https://www.psychiatrist.com/jcp/ep26-thirty-years-dcpr-psychosomatic-research-jenny-guidi/
Journal of Clinical Psychiatry
https://www.psychiatrist.com/jcp/
Publisher of peer-reviewed research discussed in this episode.
Thirty Years of the Diagnostic Criteria for Psychosomatic Research (DCPR): A Systematic Review and Discussion of Clinical Implications
https://www.psychiatrist.com/jcp/Thirty-years-Diagnostic-Criteria-Psychosomatic-Research-systematic-review
Dr. Guidi's systematic review of all 14 DCPR syndromes across 96 studies, the focus of this episode.
The Demoralization Construct in Clinical Practice and Research (de Figueiredo)
https://www.psychiatrist.com/jcp/demoralization-construct-clinical-practice-research/
Companion commentary on distinguishing demoralization from depression, discussed in the episode.
Biography Inscribed in Biology (Horwitz)
https://www.psychiatrist.com/jcp/biography-biology-diagnostic-criteria-psychosomatic-research-embodiment-lived-experience/
Companion commentary on allostatic overload and the embodiment of lived experience.
Dr. Jenny Guidi - LinkedIn
https://www.linkedin.com/in/jenny-guidi-psyd-phd/
#DCPR #Demoralization #AllostaticOverload #PsychosomaticMedicine #Clinimetrics

In this bonus episode, host Ben Everett, PhD, reconnects with Ilan Melnick, MD, chief medical officer of Passageway, a South Florida forensic community control program, who also maintains a private concierge practice. Dr. Melnick chaired a JCP consensus panel of early adopters of xanomeline-trospium chloride (XT), and nearly two years after approval, he shares what clinicians have learned putting this first-in-class muscarinic agent into everyday practice.
Unlike dopamine D2 blockers, XT activates M1 and M4 muscarinic receptors to lower presynaptic dopamine, while trospium limits peripheral cholinergic effects. The conversation covers EMERGENT trial findings on positive, negative, and general psychopathology symptoms; early use in first-episode psychosis; titration to maintenance doses; prophylactic ondansetron and empty-stomach dosing; distinguishing cholinergic from anticholinergic adverse events; class-specific cross-titration; and antipsychotic dose sparing. Dr. Melnick also reviews two new Psych Congress posters: a real-world prescriber survey and a post hoc analysis of EMERGENT-5 examining GI side effects and treatment retention.

🎯 KEY EPISODE HIGHLIGHTS:
💊 ONDANSETRON BEFORE NAUSEA STARTS [31:00]
“One of the things we know about ondansetron is that it's a better preventer than it is a fixer.”
Prophylactic ondansetron at initiation is a simple step that can prevent early GI-related discontinuation.
⚖️ CHOLINERGIC OR ANTICHOLINERGIC? [36:00]
“If they're cholinergic in nature, go up to the one twenty-five. But if they're anticholinergic in nature then we have to see what other medicines are causing that extra anticholinergic effect.”
Identifying the type of adverse event determines whether to titrate up or review concomitant medications such as OTC sleep aids.
📈 STALLING AT 100 MG AND DROPOUT [49:41]
“So those that stay there and don't move up to the 125 milligram dose ended up usually dropping out due to higher GI issues.”
A post hoc EMERGENT-5 analysis suggests that titrating to the higher dose may support retention rather than threaten it.

CHAPTERS:
00:00 – Introduction: Revisiting the XT Consensus Panel
02:04 – Forensic Community Care and a Concierge Practice
05:26 – From Postsynaptic Blockade to Presynaptic Modulation
08:34 – M1/M4 Agonism and the Role of Trospium Chloride
13:03 – EMERGENT Trial Results and Early Cognitive Benefits
18:17 – Inside the Panel: Early Adopters and Experiential Evidence
22:35 – Early Use in First-Episode Psychosis and Dose Titration
28:28 – Patient Selection and Prophylactic Ondansetron
31:47 – Empty-Stomach Dosing and Cholinergic vs Anticholinergic Effects
37:15 – Cross-Titrating From Dones, Pines, and Partial Agonists
40:33 – Antipsychotic Dose Sparing, the ARISE Trial, and LAIs
44:17 – Psych Congress Poster: Real-World Prescriber Survey
49:07 – EMERGENT-5 Retention Data and the Future of Muscarinics

LINKS:
Full transcript and show notes:
https://www.psychiatrist.com/jcp/ep25-lessons-early-adopters-xt-schizophrenia-ilan-melnick/
Journal of Clinical Psychiatry
https://www.psychiatrist.com/jcp/
Publisher of peer-reviewed research discussed in this episode.
Real-World Implementation of Xanomeline-Trospium in Schizophrenia: A Consensus Panel Report
https://www.psychiatrist.com/jcp/real-world-implementation-xanomeline-trospium-schizophrenia-consensus-report/
The JCP consensus panel report chaired by Dr. Melnick and discussed throughout this episode.
Dr. Ilan Melnick - LinkedIn
https://www.linkedin.com/in/ilan-melnick-516b4468/
#Schizophrenia #XanomelineTrospium #MuscarinicAgonist #FirstEpisodePsychosis #Psychopharmacology

In this episode of the JCP Podcast, host Dr. Ben Everett speaks with Dr. Steven Berkowitz, Professor of Psychiatry at the University of Colorado School of Medicine and Director of the Stress, Trauma, and Adversity Research and Treatment (START) Center at CU Anschutz. Drawing on a career spanning the Yale Child Study Center, Penn, and CU, Dr. Berkowitz discusses how childhood trauma shapes psychiatric illness across the lifespan and what that means for early intervention, assessment, and treatment.
The conversation covers the neurobiology of early maltreatment, the development and outcomes of the CFTSI early intervention model, the debate over developmental trauma disorder and complex PTSD, and how trauma presents differently in autistic youth. Dr. Berkowitz also addresses treatment sequencing for comorbid substance use and ADHD, the central role of sleep in trauma care, sensory processing deficits in children in the child welfare system, and the scientific and ethical questions that would need to be answered before psychedelic research could be extended to children and adolescents with PTSD.

🎯 KEY EPISODE HIGHLIGHTS:
🌱 WE CAN'T TREAT OUR WAY OUT OF THIS CRISIS [07:00]
“I really believe in prevention, and I think unfortunately, given our current set of circumstances, we're never gonna treat our way out of what is a mental health crisis in this country.”
Dr. Berkowitz frames pediatric trauma work as prevention, noting that most adults in outpatient psychiatric care carry a history of childhood trauma.
😴 TRAUMA PSYCHIATRY IS SLEEP PSYCHIATRY [25:42]
“Trauma psychiatry in many ways is about sleep psychiatry. The goal is to get people sleeping.”
Targeting nightmares and nighttime intrusive symptoms first may make it possible for patients to engage meaningfully in trauma therapy.
🧠 PSYCHOTHERAPY IS ESSENTIAL IN YOUTH PSYCHEDELIC RESEARCH [35:32]
“With kids, feeling is it's not even a question. We should absolutely be doing psychotherapy in these sessions as well as before and after.”
Any future psychedelic trials in children and adolescents will require extensive family preparation and integrated psychotherapy, raising design questions the field has yet to answer.

CHAPTERS:
00:00 – Introducing Dr. Steven Berkowitz
01:30 – Forensic Expert Work and Delayed-Onset PTSD
05:00 – Prevention and the Neurobiology of Childhood Trauma
11:00 – Developing the CFTSI Early Intervention Model
16:00 – Developmental Trauma, Complex PTSD, and the Limits of the DSM
19:30 – How Trauma Presents in Autistic Youth
23:30 – Sequencing Treatment for Substance Use, Comorbidities, and Sleep
26:30 – The START Center, Sensory Processing, and the “Trauma-Informed” Debate
32:00 – PTSD Pharmacotherapy and Psychedelic Research in Youth

LINKS:
Full transcript and show notes:
https://www.psychiatrist.com/jcp/ep24-trauma-expert-view-psychedelic-medicine-steven-berkowitz/
Journal of Clinical Psychiatry
https://www.psychiatrist.com/jcp/
Publisher of peer-reviewed research discussed in this episode.
Dr. Steven Berkowitz – LinkedIn https://www.linkedin.com/in/stevenberkowitz/
CU Anschutz START Center https://www.cuanschutz.edu/home Dr. Berkowitz's family-centered, lifespan trauma research and treatment center.
Child and Family Traumatic Stress Intervention (CFTSI) https://www.nctsn.org/interventions/child-and-family-traumatic-stress-intervention
Brief early intervention model for children and caregivers discussed in this episode.
#ChildTrauma #PTSD #CFTSI #TraumaPsychiatry #PsychedelicResearch

In this episode of the JCP Podcast, Dr. Ben Everett speaks with Dr. Nina Schooler, a social psychologist whose career in psychiatric research spans more than six decades. Dr. Schooler began her work at the National Institute of Mental Health's Psychopharmacology Service Center in the early 1960s and has since contributed to landmark studies on antipsychotic treatment, maintenance therapy, tardive dyskinesia, long-acting injectables, negative symptoms, and coordinated specialty care for first-episode psychosis.
As the field increasingly looks toward a paradigm of meaningful functional recovery that goes beyond symptom control, this conversation traces how today's clinical standards, from dose-reduction strategies to the RAISE early-intervention model, emerged from decades of trial design, unexpected findings, and hard-won methodological lessons.

🎯 KEY EPISODE HIGHLIGHTS:
🔍 THE ACCIDENTAL DISCOVERY IN THE FIRST PLACEBO STUDY [12:30]
“the patients who'd been treated with placebo seemed in some ways to be doing better than the patients who had been treated with drug.”
A counterintuitive early finding shows how unblinding and differential attention, not the drug itself, can distort perceived treatment effects in psychiatric trials.
🚧 WHY THE SICKEST PATIENTS ARE MISSING FROM NEGATIVE SYMPTOM TRIALS [1:04:00]
“the patients we most want to include will not be included in the trial because participating in a clinical trial requires effort”
A structural recruitment paradox helps explain why decades of negative symptom trials have struggled to enroll the patients most affected by the condition.
🤝 SCHIZOPHRENIA CARE AS “A TEAM SPORT” [1:19:30]
“My sense of schizophrenia as a treatment target is that it's a team sport, and that it requires a team of people to engage with patients offering a range of treatments for which I see medication as the absolutely essential platform on which other things, can indeed build.”
After six decades in the field, this framing captures why no single intervention, medication or psychosocial, succeeds alone in treating schizophrenia.

CHAPTERS:
0:00 – Introduction: Six Decades of Schizophrenia Research
2:30 – Joining NIMH's Psychopharmacology Service Center in the 1960s
9:00 – Shifting Terminology and the Boundaries of a Schizophrenia Diagnosis
11:30 – A Social Psychologist's Lens on Early Treatment Outcomes
16:00 – Open Questions on Lifelong Treatment and Parallel VA Research
18:30 – The Hogarty-Goldberg Studies and the Two-by-Two Trial Design
27:30 – Expressed Emotion and the Camberwell Family Interview
32:30 – Controlled Trials Versus Real-World Adherence
34:00 – Tardive Dyskinesia and the Push to Lower Antipsychotic Doses
36:30 – Designing the Treatment Strategies in Schizophrenia Study
40:30 – Results: Medication's Value and a Young, Family-Involved Cohort
45:00 – Long-Acting Injectables: Adherence Myths and the PROactive Study
51:30 – Research Diagnostic Criteria for Tardive Dyskinesia and the AIMS Scale
56:30 – Negative Symptoms, Cognition, and the Risperidone Question
1:02:30 – The FDA Workshop and Consent Challenges in the CONSIST Study
1:06:00 – Digital Interventions, EMA, and Smartphone-Based Treatment
1:09:30 – Designing RAISE: A Cluster-Randomized Approach to First-Episode Care
1:15:30 – RAISE Results and the Challenge of Personalized, Team-Based Care
1:21:00 – From RAISE to SAMHSA: Scaling Coordinated Specialty Care
1:25:30 – Has RAISE Changed Community Practice?
1:28:00 – Toward Meaningful Functional Recovery: What Must Change Next

LINKS:
Full transcript and show notes:
https://www.psychiatrist.com/jcp/ep23-six-decades-schizophrenia-care-nina-schooler/
Journal of Clinical Psychiatry
https://www.psychiatrist.com/jcp/
Publisher of peer-reviewed research discussed in this episode.
Dr. Nina Schooler – LinkedIn
https://www.linkedin.com/in/nina-schooler-11022870/
NIMH – Recovery After an Initial Schizophrenia Episode (RAISE)
https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/recovery-after-an-initial-schizophrenia-episode-raise
NIMH overview of the RAISE initiative and coordinated specialty care model discussed at length in this episode.
SAMHSA – Early Serious Mental Illness Treatment Locator
https://www.samhsa.gov/find-help/locators/esmi
Locator for coordinated specialty care programs, funded through the SAMHSA block grants described in this episode.
#Schizophrenia #TardiveDyskinesia #LongActingInjectables #FirstEpisodePsychosis #Psychopharmacology

Dr. Benjamin Brody, an inpatient psychiatrist who built and now directs one of the earliest hospital-based ketamine treatment programs, joins Dr. Ben Everett to unpack the regulatory maze surrounding ketamine and the psychedelics now approaching FDA approval. Dr. Brody traces how he moved generic racemic ketamine from an overlooked anesthetic sitting on the hospital pharmacy shelf to a formally sanctioned inpatient treatment, and explains why esketamine's REMS-regulated pathway looks nothing like the largely unregulated market for take-home ketamine.
As synthetic psilocybin nears a possible FDA decision and the field debates what role psychotherapy should play alongside these treatments, clinicians face fast-moving questions about safety monitoring, staffing, informed consent, and reimbursement. Drawing on his direct experience administering ketamine on the inpatient unit, Dr. Brody discusses self-escalation risk, the paradox reaction his team termed dysphoric dissociation, and what health systems should weigh before building a program of their own.

🎯 KEY EPISODE HIGHLIGHTS:
⚠️ THE NARROW LINE BETWEEN NEUROTROPHIC AND NEUROTOXIC [18:30]
“But at higher doses, it actually becomes neurotoxic and, you know, there's histopathological changes that can be seen.”
At therapeutic doses ketamine is safe and neurotrophic, but Dr. Brody warns that self-escalating doses can quickly cross into neurotoxic and bladder-damaging territory.
🧠 DEFINING DYSPHORIC DISSOCIATION [24:00]
“This is a dysphoric piece or a dysphoric reaction that is layered on top of the dissociative experience for this small minority of patients.”
Dr. Brody explains why his team coined a new clinical term to distinguish ketamine's rare, frightening paradox reaction from a psychedelic “bad trip,” and why naming it matters for informed consent.
🚫 THE CASE AGAINST TAKE-HOME KETAMINE [25:00]
“The unambiguous answer is no, I do not think this is a good idea.”
Citing self-escalation risk, a narrow therapeutic index, and a growing number of ketamine-associated deaths, Dr. Brody explains why he opposes direct-to-consumer telehealth ketamine prescribing.

CHAPTERS:
00:00 – From Creative Writing to the Inpatient Unit
02:30 – A Day in the Life of an Inpatient Psychiatrist
05:30 – How Dr. Brody Came to Believe in Ketamine
12:00 – Ketamine vs. Classical Psychedelics: A Different Mechanism
14:00 – Two Regulatory Worlds: Racemic Ketamine and REMS-Regulated Esketamine
17:30 – Safety Signals: Self-Escalation and Dysphoric Dissociation
24:30 – The Case Against Take-Home Ketamine
29:30 – Psychedelics Enter the Medical Mainstream
33:30 – What to Expect When Psilocybin Gets FDA Approval
39:00 – Staffing and Consent for Hours-Long Sessions
43:00 – Set and Setting: Lessons from Building a Ketamine Program
48:00 – Is This Psychotherapy? Defining the Clinician's Role
54:00 – What Surprised Dr. Brody About Implementation
57:00 – Advice for Health Systems and Reasons for Optimism

LINKS:
Full transcript and show notes:
https://www.psychiatrist.com/jcp/ep22-regulatory-maze-ketamine-psychedelics-benjamin-brody/
Journal of Clinical Psychiatry
https://www.psychiatrist.com/jcp/
Publisher of peer-reviewed research discussed in this episode.
How Do We Get Ketamine Safety Right? Three Questions From a Clinical Service
https://www.psychiatrist.com/jcp/how-do-we-get-ketamine-safety-right-3-questions-from-clinical-service/
Dr. Brody's 2025 JCP commentary on self-escalation, paradox reactions, and the regulatory gap between racemic ketamine and esketamine, discussed at length in this episode.
COMPASS Pathways – COMP360 Psilocybin for Treatment-Resistant Depression
https://compasspathways.com/our-work/comp360-psilocybin-treatment-in-trd/
The investigational psilocybin program discussed throughout the episode, including its phase 3 timeline and proposed psychological support model.
Dr. Benjamin Brody – LinkedIn
https://www.linkedin.com/in/benjamin-brody-md-3576bb4/
#Ketamine #Psychedelics #TreatmentResistantDepression #Psychopharmacology #REMS