The FDA has a new clearance for TMS.

It hasn't made many headlines, but some think it changes the game for adolescent depression.

Welcome to the Carlet Psychiatry Podcast, keeping psychiatry honest since 2003.

I'm Chris Agen, the editor-in-chief of the Carlat Psychiatry Report.

And I'm Kelly Newsom, a psych NPn-p, and a dedicated reader of every issue.

I've always wished I could practice psychiatry in 1963,

because that's around when insulin coma therapy and frontal lobotomies were on the decline, rapidly

being replaced by safer and more effective treatments like psychopharmacology.

I say more effective because there was a small signal that those older therapies worked,

at least in terms of reducing symptoms, at least worked enough that psychiatrists

argued for their utility well into our current age. The last paper that argued for frontal

lobotomy in schizophrenia was a case series from 1997. By that time, the name had been changed to Lucotomy. And as late as 2013,

we find a case report on the efficacy of insulin coma therapy and refractory depression.

With hindsight, these changes are dramatic. They're revolutionary. But for practicing psychiatrists, the changing of the

guards was a gradual process, quietly hashed out in the back pages of medical journals and sporadic

conference debates, which means we could be in a revolution right now and not even know it. Here's some contenders.

The first is antipsychotics in delirium. This year, the APA updated the practice guidelines for delirium, and they downgraded antipsychotics to a treatment of last resort.

The changing of the guards came on top of numerous meta-analyses

and large controlled trials that show no discernible benefit with antipsychotics in delirium,

and some well-known risks. So far, the reaction on the professional level has been mixed,

with some accusing the APA committee

of being out of touch with the realities of everyday practice, and others retorting that

...