Brain Trust: Conversations in Psychopharmacology

7: The Role of Psychopharmacology in Pediatric Care: Discussing Strategies With Melissa DelBello, MD

Joseph F. Goldberg, MD, in this installment of "Brain Trust: Conversations in Psychopharmacology," sits down with child and adolescent psychiatrist Melissa DelBello, MD, to discuss the role of psychopharmacology in pediatric mental health treatment. Their conversation emphasized early identification and intervention for mood and related disorders in young patients. DelBello addressed common concerns regarding medication safety in children, noting that when prescribed by clinicians with appropriate expertise, psychotropic medications “can be life-saving” and used in ways that minimized adverse effects while maximizing efficacy. She cautioned against excessive polypharmacy and inadequate duration of therapeutic trials, which could undermine optimal outcomes. DelBello also underscored the developmental consequences of untreated psychiatric illness. She explained that childhood and adolescence represent critical periods for achieving social, academic, and interpersonal milestones. The onset of major depression, bipolar disorder, psychosis, anxiety, or attention disorders during these years could disrupt developmental trajectories, with enduring functional sequelae. She drew parallels to untreated medical conditions affecting growth, arguing that failure to address early psychiatric symptoms could similarly alter long-term outcomes. Goldberg raised the question of whether earlier intervention might mitigate chronicity and comorbidity, echoing the sentiment of many practitioners wishing they could have seen a patient just in time to prevent a disorder worsening. DelBello supported a positive view on early intervention, suggesting that timely treatment could prevent abnormal neurodevelopment and reduce downstream complications. She emphasized that early-phase intervention was often more effective than treatment initiated after recurrent episodes and accumulated morbidity. The discussion also highlighted substance use risk in youth with bipolar disorder, particularly in the context of family history. DelBello described proactive psychoeducation targeting adolescents before college transition. She advised candid discussions about biological vulnerability, for example, letting particular patients know that vulnerability is part of their “genetics and neurochemistry, and if you start using substances, you’re more likely to get addicted faster.” Framing risk in neurobiological terms appeared to enhance insight and facilitate harm-reduction strategies. Goldberg and DelBello advocated for developmentally informed, longitudinal care models that prioritized early recognition, individualized risk assessment, and judicious pharmacotherapy to improve long-term psychiatric and functional outcomes.

6: The Complex Psychopharmacology of Personality Disorders: Prioritizing Symptom Management With Michael Gitlin, MD

Joseph F. Goldberg, MD, in this installment of "Brain Trust: Conversations in Psychopharmacology," sits down with Michael Gitlin, MD, to discuss psychopharmacologic options for personality disorders. They highlighted the dimensional nature of personality disorders, contrasting them with the categorical DSM model. “The relationship between treating personality disorders and the use of medicines is not as natural as it would be for classic symptom-based disorders, such as mood disorders, anxiety disorder, and psychotic disorders. Because, when we describe symptom-based disorders, we have symptoms, we have time frames, and it fits the medical model. The DSM is categorical, meaning there are allegedly boundaries around all of the disorders. The problem is all of psychopathology, but most of all personality pathology, is dimensional, not categorical,” said Gitlin. Gitlin emphasized the importance of treating specific symptom complexes like impulsive aggression and affective liability rather than the entire disorder. He suggested using anticonvulsants, low-dose antipsychotics, and serotonergic drugs for different symptom profiles. “Instead of saying, do I know how to treat borderline personality disorder with medicine, what we should do is take a step back say, what are the symptom complexes that dominate the features of that personality disorder? And then say, do I know how to treat that?” said Gitlin. They also discussed the role of therapeutic alliance and placebo effects in enhancing treatment outcomes. A collaborative approach, where the patient is an active participant in the treatment plan, can enhance adherence and treatment outcomes. Overall, the conversation underscores the need for personalized, goal-oriented approaches in managing personality disorders.

5: Pharmacogenetic Testing in Psychiatry: Exploring Personalized Medicine With John J. Miller, MD

Joseph F. Goldberg, MD, in this installment of "Brain Trust: Conversations in Psychopharmacology," sits down with Psychiatric Times' very own editor in chief, John J. Miller, MD, to discuss the current state and future directions of pharmacogenetic testing. According to Goldberg, pharmacogenetics is almost like a Rorschach test in the eyes of many practitioners and patients: “It is thought to be a projective that you sort of identify in various ways. It is going to tell me things about myself. It is going to make predictions. It is going to help me guide treatment. It is going to override clinical factors, patient specific features that influence outcome, and really get to the heart of things.” Miller also shared his initial reactions to the introduction of this testing: "When pharmacogenetic testing first became available about 12 to 14 years ago, I was excited. And then, as I learned more about it, read the literature, and became aware of the institutions that exist to vet genes and whether or not they are clinically actionable, I became very frustrated by how overly adoptive pharmacogenomics has become when really the evidence base is not there. In fact, as we have learned more, it has become less evidence based in terms of clinical applications." Recently, the International Society of Psychiatric Genetics published a review article on genetics and psychiatry, and they concluded that there are 4 genes that are evidence based and actionable: CYP2D6, CYP2C19, HLA-B*1502, and HLA-A*3101. "I think there is a mythology that all you have to do is do the gene testing, and you can choose a drug based on the results," shared Miller. When it comes to testing, Miller believes we need to alter the thinking around testing in psychiatry: "We are very selective, and we do it for a reason, because we have a hypothesis. Maybe there is atrophy. Maybe we have some neurological sign. It really should spark the curiosity of the clinician to think, would a test—any test, for that matter—be informative to answer a question. That is how I always think about any test in medicine." Together, Goldberg and Miller stress the importance of therapeutic drug monitoring and personalized medicine, while acknowledging the limitations and ongoing evolution of pharmacogenetic testing. "We have a common goal. We want to do a test that is scientifically informative for you. If there is a test out there that I think will help us answer a question, I promise you, I will order it, but not everything comes down to a particular test, right? There are certain clinical impressions we have in medicine. How do you diagnose migraine headaches? There is no test for that. How do you diagnose your bowel syndrome or tinnitus? There is no test for that. So we look for tests to someday enhance or augment what we think is an observation that we would like some corroboration for," said Goldberg of speaking to patients about testing. Miller agreed, concluding that, "We do not want to put the car before the horse, and so let's stick to the what the experts who really know this stuff are guiding us, and then incrementally use what becomes clinically actionable or evidence based."

4: Psychedelics for Depression and Other Mental Health Conditions: The Way Forward With Guy Goodwin, MD

Joseph F. Goldberg, MD, in this installment of "Brain Trust: Conversations in Psychopharmacology," sits down with Guy Goodwin, MD, to discuss the potential of psychedelics in treating depression and other mental health conditions. Goodwin, who is the chief medical officer at Compass Pathways, highlights psilocybin's ability to induce profound experiences that can lead to long-term improvements in mood and anxiety.  "I got the opportunity to go full time into a new position with Compass Pathways to develop psilocybin. I'd been interested already, I'd advised a little bit on how to design the phase 2 clinical trial. At the time that I did that, I was a little pessimistic about whether there was really a future in this, because it looked quite hard to raise money and quite difficult to do the studies. There were a lot of things that seemed to me potentially difficult, but many of these obstacles have become overcome by the people at Compass. That was the beginning of a new life," Goodwin said of his research evolution in psilocybin. LSD, the first psychedelic, discovered in 1943 by Albert Hofmann,1 "was the stimulus to understanding serotonin metabolism and function, both in the brain and to a lesser extent, in the peripheral nervous system," shared Goodwin.  Together, Goldberg and Goodwin evaluate the challenges of developing psilocybin, including regulatory hurdles and the need for careful clinical settings.  Goodwin notes that psilocybin's effects are immediate and can be more effective than traditional treatments for some patients. They also touch on the potential for psilocybin to treat posttraumatic stress disorder (PTSD) and substance abuse, and the importance of understanding its pharmacodynamic properties and potential combinations with other drugs. For example, in an open-label, small study of 22 patients with PTSD, Goodwin and investigators saw an approximate 80% remission rate in symptoms.2 In the follow up interviews with patients, Goodwin found a few details very striking: "One is that patients can have the trauma recur—the actual index trauma can be something that recurs in the experience under the influence of psilocybin—and it seems to be something that is tolerated by the patient. They kind of find an indirect route to feeling better about the trauma." As to future directions, Goodwin believes we should start carefully: "We're advocating for very careful use. We're advocating reimbursement so that access is fair and equitable. Our objective is not to get this widest possible use of the drugs; Our objective is to get the proper use of the drugs in the right patient population."

3: The Intersection of Psychotherapy and Psychopharmacology for Mood Disorders: Optimizing Patient Outcomes With Holly A. Swartz, MD

Joseph F. Goldberg, MD, in this installment of "Brain Trust: Conversations in Psychopharmacology," sits down with Holly A. Swartz, MD, to discuss evidence-based psychotherapies for mood disorders, emphasizing a nuanced approach to treating depression.  If a patient prefers to start with psychotherapy, they should be given 6 to 12 weeks to see if it works before considering augmentation or switching to another modality, shared Swartz. The approach is similar to starting pharmacotherapy and considering augmentation or switching if there is no response. For less severe depression, Swartz recommends utilizing psychotherapies like cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT), as they are comparable to pharmacotherapy.  For patients with severe depression, Swartz finds combining psychotherapy with antidepressants to be more effective; however, patients with severe depression alongside cognitive rigidity and melancholia may benefit more from pharmacotherapy, whereas patients with moderate depression and interpersonal or cognitive issues may benefit more from CBT or IPT. "The way that I think about it is you have got to have stuff to work with in order for the treatments to be effective. We have seen that differential response to IPT and CPT," said Swartz. Additionally, patient preference significantly impacts treatment success, with those receiving their preferred treatment being 4 times more likely to respond. "Getting what you think is going to help you feel better, get better actually matters a lot," said Swartz.  The conversation also explores the integration of psychodynamic principles in pharmacotherapy, the role of psychotherapy in neuroplasticity, and the concept of deprescribing in psychotherapy. "We always want to tailor our treatments for the individual. Some people might feel that they need a little bit less because they really get it, and they are able to use other coping strategies, whereas there may be others who struggle a bit more and need more frequent help. Our modal frequency would be monthly, with the capacity to flex that based on on patient needs and tailored treatments," concluded Swartz.