Psychiatry Boot Camp

In this episode of Psychiatry Boot Camp, Dr. Mark Mullen speaks with Dr. Owen Muir, psychiatrist, entrepreneur, and Chief Medical Officer of Radial Health, about the growing role of transcranial magnetic stimulation (TMS) in psychiatric treatment.The discussion explores how TMS works as a form of noninvasive neuromodulation, using focused magnetic fields to influence neural circuits implicated in depression and other psychiatric conditions. Dr. Muir reviews the evidence supporting TMS for treatment-resistant depression, explains the FDA clearance pathway for neuromodulation devices, and discusses how stimulation parameters, coil positioning, and treatment protocols affect clinical outcomes.The conversation also addresses the broader implications of neuromodulation in psychiatry, including emerging indications, technological innovation, and how clinicians can integrate TMS into modern psychiatric practice. This episode provides a practical and conceptual overview of one of the fastest-growing treatment modalities in mental health care.

Takeaways:

TMS is a noninvasive neuromodulation technique that uses magnetic fields to induce electrical activity in targeted cortical regions.The primary FDA-cleared indication is treatment-resistant major depressive disorder, though research continues for other conditions including OCD and PTSD.Treatment protocols depend on stimulation parameters, including frequency, location (often the dorsolateral prefrontal cortex), and session scheduling.The FDA device clearance process differs from pharmaceutical approval, relying heavily on device equivalence and clinical safety data.Neuromodulation represents a growing frontier in psychiatry, complementing pharmacotherapy and psychotherapy in the treatment of complex mood disorders.

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In this episode of Psychiatry Boot Camp, Dr. Mark Mullen speaks with psychiatrist and medical ethicist Dr. Mark Komrad about physician-assisted suicide and euthanasia, focusing particularly on their implications for psychiatric practice.

The discussion reviews the terminology, legal frameworks, and international trends surrounding assisted death, including developments in Belgium, the Netherlands, Canada, and multiple U.S. states. Dr. Komrad outlines concerns regarding capacity assessments, the expansion from terminal illness to psychiatric suffering, and the ethical tensions between autonomy and the physician’s role as healer.The episode also examines countertransference, projective identification, and the clinical dynamics that arise when treating chronically suicidal patients in jurisdictions where assisted death is permitted. Position statements from the American Medical Association and the American Psychiatric Association are reviewed, along with questions of conscientious objection

Takeaways:

Terminology matters. Major professional organizations continue to prefer the term “physician-assisted suicide,” reflecting ongoing ethical debate about whether these practices are distinct from suicide prevention work.Capacity assessment standards remain variable. In many jurisdictions, evaluations are left largely to physician (or provider) discretion without standardized psychiatric frameworks.Expansion beyond terminal illness is occurring internationally. Countries that initially limited eligibility to end-of-life conditions have broadened criteria to include chronic disability and, in some regions, primary psychiatric diagnoses.

Borderline personality disorder and mood disorders are disproportionately represented in psychiatric assisted death cases in some European jurisdictions.Countertransference and projective identification are clinically relevant. Physicians must remain vigilant about how therapeutic fatigue and induced hopelessness can influence decision-making in chronically suicidal patients.Key professional organizations in the United States maintain opposition to physician assisted suicide. The AMA and APA have articulated clear ethical boundaries regarding the role of physicians and psychiatrists in assisted death. 

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In this episode of Psychiatry Bootcamp, Dr. Mark Mullen is joined by Dr. Mark Ruffalo for an in-depth examination of complex post-traumatic stress disorder (C-PTSD), a construct widely discussed in academic and public discourse, but not currently recognized as a distinct DSM diagnosis.The conversation situates C-PTSD within the historical and theoretical landscape of psychiatry, tracing its origins to Judith Herman’s work and examining its proposed relationship to borderline personality disorder and classical PTSD. Dr. Ruffalo explores core questions of diagnostic validity versus reliability, drawing on foundational psychiatric theory, communication models such as the double bind, and contemporary critiques of the DSM’s proliferation of categories.Listeners will gain a framework for understanding why diagnostic labels matter, how trauma-informed care can coexist with diagnostic rigor, and the potential clinical consequences of adopting constructs without clear discriminant validity. The episode emphasizes careful formulation, treatment matching, and ethical responsibility in an era of expanding diagnostic language. 

Takeaways:

Complex PTSD lacks consensus diagnostic criteria, raising concerns about discriminant validity when compared with borderline personality disorder and PTSD.Diagnostic reliability is not the same as validity, a central limitation of DSM-based classification systems.Borderline personality disorder encompasses heterogeneous pathways, including, but not limited to, trauma exposure.Mislabeling can lead to mismatched treatment, particularly when trauma-focused approaches obscure underlying personality pathology.Thoughtful diagnosis strengthens, rather than harms, therapeutic alliance when delivered with empathy, dimensional framing, and attention to prognosis. 

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In this episode of Psychiatry Bootcamp, Dr. Mark Mullen speaks with Jesse Bogan, journalist with The Marshall Project, about a profound and often invisible failure at the intersection of psychiatry and the criminal legal system: the prolonged incarceration of individuals found incompetent to stand trial without access to timely psychiatric treatment.Using Missouri as a case study, the conversation traces how defendants with severe mental illness can spend months to years in jail awaiting competency evaluations and restoration, despite legal mandates requiring prompt assessment and care. Jesse shares detailed reporting on systemic delays, limited forensic bed capacity, underfunded community mental health services, and pilot programs that have failed to meet the clinical needs of profoundly ill patients.The episode examines ethical and constitutional implications, including potential violations of the Sixth Amendment right to a speedy trial, and highlights the human cost of untreated psychosis, mania, and depression in carceral settings. This discussion challenges clinicians to confront how structural failures transform jails into default psychiatric holding facilities and asks what role psychiatry must play in reform.

Takeaways:

Incompetency to stand trial creates legal limbo. Defendants may be jailed for years while their criminal cases are paused, awaiting psychiatric treatment that is legally required but operationally unavailable.Jails are not treatment settings. Severe mental illness often worsens during prolonged incarceration, reducing the likelihood of competency restoration and increasing morbidity and mortality.Systemic underfunding drives criminalization. Gaps in outpatient care, involuntary treatment mechanisms, and forensic infrastructure funnel untreated patients into the justice system.Competency restoration programs have limits. Jail-based and mobile models often fail for patients who are too psychotic or disorganized to engage meaningfully in treatment.This is a national problem. While Missouri is highlighted, similar backlogs and constitutional concerns exist across the United States and internationally.

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In this episode of Psychiatry Bootcamp, Dr. Mark Mullen is joined by Dr. Dinah Miller, psychiatrist, writer, and author of Committed: The Battle Over Involuntary Psychiatric Care, for a rigorous examination of civil commitment and involuntary treatment in modern psychiatry.

The conversation explores the legal structures underlying involuntary hospitalization, medication over objection, and outpatient civil commitment, while highlighting the profound ethical tensions between patient autonomy, public safety, and clinical responsibility. Dr. Miller traces the historical evolution of involuntary care, examines why state systems vary so widely, and explains why outcomes data remain limited and difficult to interpret.

Listeners will gain a framework for understanding the competing advocacy groups shaping policy, the real-world consequences of emergency department boarding and bed shortages, and the psychological impact involuntary care can have on patients long after discharge. The episode also addresses language, stigma, and how psychiatrists can practice humane, ethically grounded care even when coercion is unavoidable.

This is a sober, thoughtful discussion of one of psychiatry’s most challenging responsibilities.

Takeaways:

Civil commitment is distinct from forensic commitment, yet often conflated in public discourse and policy discussions.

Evidence linking involuntary treatment to improved public safety is limited, in part due to ethical and methodological constraints on research.

System failures (bed shortages, ED boarding, lack of housing) amplify the harms of coercive care, even when clinically justified.

Outpatient commitment models vary widely, with New York’s AOT program offering one of the most studied but resource-intensive approaches.

How psychiatrists communicate, document, and set boundaries during involuntary care profoundly affects patient trust and future engagement.

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