Nov 18, 2022 | Adolescent Health, Inside Mount Sinai Psychiatry, Mental Health, Psychiatry
“We’re not bound by the traditional therapeutic framework where you meet in an office for a scheduled appointment,” Dr. Weller says. “We literally meet them where they’re at.”
By the time students reach New York City’s Judith S. Kaye High School (JSK), multiple systems have failed them. As a public transfer school for students with significant barriers to their education, many of JSK’s students have faced significant adversity.
“All of our students have been disconnected from school at some point and many have experienced some trauma,” says school principal Andrew Brown. Mental health disorders and substance use problems are common, but linking students to traditional mental health services is nearly impossible. “Even for students who are ready to meet with someone, once they leave the building, the obstacles are frequently insurmountable,” Brown says.
Thanks to Mount Sinai’s UPRISE (Use Prevention Recovery Intervention Services & Education) program, students no longer have to leave school to get the care they need. “Rather than trying to get students to come to us, we provide services on-site,” says Rachel Weller, PsyD, an assistant professor of psychiatry at the Icahn School of Medicine at Mount Sinai and project manager and clinical supervisor for UPRISE.
The partnership, launched just before the COVID-19 pandemic, is helping students address their mental health problems and substance use, often for the first time. “Having access to this high-quality care, within the school building, is a game changer,” Brown says.
Youth Mental Health: An Unmet Need
JSK, which serves about 145 students at their Manhattan site, is co-located within the School of Cooperative Technical Education (Coop Tech), a career and technical school that serves about 1,500 students. Students from both schools are offered access to mental health and substance use treatment through the UPRISE program.
UPRISE is an offshoot of the Comprehensive Adolescent Rehabilitation and Education Service (CARES), a program of the Addiction Institute of Mount Sinai that has served adolescents and young adults for more than 20 years. CARES provides a therapeutic high school environment that includes a range of targeted services for youth with complex mental health, substance use, and educational problems. While CARES has seen great success, the need for services among New York City youth remains significant. UPRISE is a new model that shows how mental health services can be integrated into a public school setting.
Both Coop Tech and JSK serve historically marginalized populations who have long been subject to systemic racism and discrimination, says Shilpa R. Taufique, PhD, director of the psychology division for the Mount Sinai Health System and director of CARES. “These students and their families have all had the experience of not being seen or heard, and of having institutions impose what they think is best for them,” she says. “There’s such a deep mistrust of the systems that are supposed to be helping them.”
As a result, students have often struggled for years with mental health problems — even before the COVID-19 pandemic made youth mental health a national crisis. “We see many kids present with PTSD, complex trauma, major depression, anxiety, and difficulty with substance use,” Dr. Weller says. “What’s most striking is the number of students who have a longstanding history of mental health difficulties, yet have never received any type of treatment.”
A New Model of School Mental Health
UPRISE aims to give adolescents the tools to help them develop into healthy, functioning young adults. The clinical team is small but mighty: Dr. Weller is on-site in the school most days, along with part-time clinical staff including two postdoctoral fellows and a graduate student extern. They currently provide services for about 30 students, but Weller and her colleagues hope to double that number in early 2023.
UPRISE offers a range of services, including:
- Psychoeducation
- Individual therapy
- Group therapy
- Family therapy
- Milieu therapy
- Substance use treatment
- Medication management
In addition to counseling and therapy services, the team helps students connect with prescribing providers via telehealth for medication management. All of these services are billed to students’ insurance companies, making it a model that is both sustainable and replicable, Dr. Taufique says.
Flexible Approaches to Teen Mental Health
Plenty of schools have experimented with embedding social workers or mental health providers in school settings. But UPRISE goes further. Before launching the program, the team spent a year learning about the schools and their students’ unique needs. “People make a lot of assumptions about teenagers, especially young people who have been disconnected from school or who are in treatment,” Brown says. “[The UPRISE team] didn’t come in with any expectations about who these kids are.”
That open-minded attitude has led to several innovations. URPISE takes a novel approach to family therapy, incorporating school staff into students’ treatment plans much like parents or other family members might be included. “The school setting is a surrogate family for most of these students. The teachers, guidance counselors, and social workers are very involved in their students’ lives — these are the people students call in the middle of the night if they’re in crisis,” Dr. Taufique says. “We want to highlight the roles they play in students’ lives and also give school staff some therapeutic framework to draw on so they don’t get burned out.”
Clinicians provide services to students in school during the school day, but they also reach out to them in the community. If a student has a phobia of the subway or anxiety about coming to school, for instance, providers might arrange to travel to school with them to provide a form of exposure therapy. “We’re not bound by the traditional therapeutic framework where you meet in an office for a scheduled appointment,” Dr. Weller says. “We literally meet them where they’re at.”
Services Without Stigma
In addition to services for patients, UPRISE offers psychoeducation and outreach to the entire school community, such as school-wide presentations on topics related to substance use and mental health. The program is also open for a drop-in hour five days a week, so any student in either school can come in to talk whenever they need. “With the drop-in hour, we discuss things that are going on in students’ lives, provide some psychoeducation, and sometimes link students to services or provide referrals,” Weller says. “We want to make this accessible, even to kids we’re not directly serving.”
At a time when most of the news about teen mental health is bleak, UPRISE is making a positive difference in his students’ lives, Brown says. “We have students who are seeing counselors for the first time. They’re showing up to appointments, connecting with counselors. They’re more connected to school.”
“Students look at this as a tool to help them get better and help them transition into adulthood. There’s no stigma attached to it,” he adds. “It’s just become a part of our community.”
Learn more about The Comprehensive Adolescent Rehabilitation and Education Service (CARES) program at Mount Sinai.
Updated on Nov 18, 2022 | Inside Mount Sinai Psychiatry, Mental Health, Psychiatry
“Many patients think that being hospitalized is the worst thing that can happen to them,” Dr. Vora says. “But sometimes it actually ends up being the thing that turns their life around.”
Stigma remains a big problem for psychiatry. Inpatient psychiatric care, in particular, has long suffered from unfair portrayal. The mere mention of an inpatient psychiatric unit conjures up images of Jack Nicholson in One Flew Over the Cuckoo’s Nest. This stigma is present not only among the public, but also among many doctors and medical providers. “There’s a certain amount of stigma and fear around the idea of being hospitalized in a psychiatric unit, but it’s a very different quality of care and treatment than what is typically portrayed in the media,” says Rajvee Vora, MD, MS, Associate Professor and Vice Chair of Clinical Affairs for the Department of Psychiatry at the Icahn School of Medicine at Mount Sinai.
Forget the stereotypes, Dr. Vora says. The inpatient psychiatric facilities at The Mount Sinai Hospital are bright, welcoming, and beautifully designed, and patients receive high-quality care. “Patients are up and walking around, encouraged to be up and about, attend groups and sessions, and play basketball in our indoor court.”
Above all, hospitalized patients receive a range of evidence-based treatments to help them manage their mental illnesses. “Many patients think that being hospitalized is the worst thing that can happen to them,” Dr. Vora says. “But sometimes it actually ends up being the thing that turns their life around.”
An Interdisciplinary Approach to Inpatient Mental Health
In recent years, the field of psychiatry has moved most treatments to outpatient settings. Yet for some patients with severe mental illness and acute psychiatric needs, inpatient care remains critical. In fact, the need for such care has increased recently. “During COVID, many outpatient providers switched to remote services, which aren’t always accessible to people with serious mental illness,” says Danielle Campisi, LCSW, director of social work for the inpatient psychiatry service. “Now we’re seeing a big uptick in the number of patients that had been chronically well-managed, but lost access to care during the pandemic.”
The team at Mount Sinai’s inpatient behavioral health unit treats a variety of psychiatric illnesses, including:
- Mood and anxiety disorders
- Personality disorders
- Psychotic illness
“Treatment isn’t something that happens to the patient. It happens with the patient,” says Dr. Rosenthal.
Patients don’t need to be severely incapacitated to benefit from hospitalization, says Blake Rosenthal, MD, Assistant Professor of Psychiatry and Inpatient Unit Chief at The Mount Sinai Hospital. “Sometimes our patients have developed psychotic symptoms for the first time. They may have a change in their ability to perceive reality or are developing hallucinations,” Dr. Rosenthal says. “They can come in without having a complete decompensation and loss of function, and we’re able to meet those needs really well.”
Cutting-Edge Psychiatric Treatments
Inpatient treatments typically include medications and intense psychotherapy, including individual, group, and milieu therapy. As a cutting-edge research institution, Mount Sinai offers access to new and emerging treatments, including interventions such as electroconvulsive therapy (ECT) and esketamine for treatment-resistant depression. Patients also receive additional services such as art therapy, music therapy, dance/movement therapy, and substance abuse counseling. “Inpatient treatment is so much more than medication management,” Dr. Vora says. “The core of the work we do is ‘milieu therapy’ — what being in this environment does for patients.”
Patients are treated by an interdisciplinary team that includes an attending psychiatrist, psychiatric residents, nursing staff, creative arts therapists, assistive staff, and social workers. The team develops a comprehensive treatment plan for each patient, which describes the interventions and services they will receive as well as the plan for transitioning to outpatient care. That transition is important, since patients typically stay in the hospital just a week or two before being discharged to outpatient services or to higher levels of care, such as assertive community treatment (ACT).
Social workers work closely with patients to understand their psychosocial needs, connect them with appropriate services, and teach them about their illnesses. “When patients come in, they’re sometimes resistant to being treated. We do a lot of psychoeducation to improve patients’ understanding of their illness, the potential need for medications, and the importance of outpatient follow-up,” she says.
It’s a collaborative effort, Rosenthal adds. “Treatment isn’t something that happens to the patient. It happens with the patient,” he says.
Inpatient Mental Health at Mount Sinai
While Mount Sinai provides access to the latest evidence-based treatments, its biggest asset is the people delivering those therapies, Dr. Rosenthal says. “What really distinguishes Mount Sinai’s inpatient program is our team. Our treatment team almost functions as a single provider,” he says. “It sounds cliché, but everyone on the unit cares deeply about how patients are doing.”
Mount Sinai has leading experts in schizophrenia, depression, and other psychiatric illnesses, who often consult on treatment. The team mentality extends to treating a patient’s non-psychiatric medical conditions as well. The inpatient psychiatry team collaborates closely with other service lines such as OBGYN and neurology to ensure all of a patient’s healthcare needs are met during their inpatient stay.
While caring for patients is a top priority, Mount Sinai’s inpatient behavioral health team is also committed to reducing stigma and improving care for all patients with psychiatric illness. Experts from the department recently held a symposium to discuss the management of clinical challenges in inpatient psychiatry.
Most psychiatric inpatients are transferred from the emergency department, but individual cases are considered. Learn more about Mount Sinai’s Inpatient Behavioral Health Services, or contact the inpatient behavioral health admissions coordinator at 212-241-5675.
Updated on Nov 18, 2022 | Community, Featured, Inside Mount Sinai Psychiatry, Mental Health, Psychiatry
From left, Honoree David Sanborn, Shantelena Mouzon, administrative coordinator at the Louis Armstrong Center for Music and Medicine, and musician Paul Shaffer
The 17th annual “What a Wonderful World” gala benefiting the Louis Armstrong Center for Music and Medicine, was a festive evening of jazz and expressions of gratitude to three honorees for making the world more wonderful through their contributions to music and music therapy.
The event, held Monday, October 24, at the Angel Orensanz Foundation and hosted by the Wonderful World Friends of Music Therapy Inc., honors the legacy of the Louis Armstrong Department of Music Therapy and their commitment to music therapy at Mount Sinai hospitals.
The event recognizes a dynamic group of individuals chosen from a variety of fields including music, medicine, and patients who have benefitted from receiving music therapy at Mount Sinai hospitals.
This year’s honorees were Grant Mitchell, MD, Chair, Department of Psychiatry, Mount Sinai Beth Israel; David Sanborn, the multi-Grammy Award-winning saxophonist, who was presented the Phoebe Jacobs Award by Paul Shaffer (pianist of the former Late Night with David Letterman); and patient Rosemarie Greene.
From left, Honoree Grant Mitchell, MD, Joanne V. Loewy, DA, LCAT, MT-BC, Prameet Singh, MD, and Daniel S Safin, MD
The gala was hosted by Mercedes Ellington, dancer, choreographer, and granddaughter of Duke Ellington, and Bill Daughtry, the retired radio and TV host. The co-chairs were Karen and Doug Seidman from the Louis Armstrong Center for Music and Medicine’s Steering Committee. The event featured performances by Rema Webb from the Broadway production of The Music Man; Antoine Smith from the Broadway production of MJ: The Musical; saxophonist Erik Lawrence, Lou Marini, a saxophonist and an original member of The Blues Brother, and jazz pianist Garry Dial. Mr. Shaffer and Mr. Sanborn, along with Will Lee (bass), performed jazz and Louis Armstrong’s ‘Wonderful World’.
“We are proud to bring together members of the music, medicine, and patient community who through the gala learn of the breadth and scope of patients we serve and our research projects with doctors and nurses, from neonatal care to oncology, Alzheimer’s disease and psychiatry,” said Joanne V. Loewy, DA, LCAT, MT-BC, Founder and Director of the Louis Armstrong Center for Music and Medicine, which provides music therapy services throughout the Mount Sinai Health System.
The Department of Music Therapy, with support from the Louis Armstrong Educational Foundation and other grants, provides a range of clinical services for infants, children, and adults, and day treatment at the Mount Sinai-Union Square clinic and within the community. Its music therapists are licensed and board certified to provide care that complements medical treatment, assisting with sedation, pain management, and neurologic and respiratory function.
Oct 27, 2022 | Inside Mount Sinai Psychiatry, Psychiatry
“With substance use disorders, there’s a huge issue of stigma that prevents a lot of women, and thus their children, from getting the care they need. If we want healthy children, we need healthy moms.” — Yasmin Hurd, PhD
Addiction is an all-too-common problem among pregnant people, with devastating results for parents and their children. Now The Bridge Program, a new initiative at Mount Sinai, is providing integrated prenatal care and substance use treatment.
Launched in September 2022, The Bridge Program is the first program of its kind in New York City, and it addresses an increasing need. “Until now, there was no place in all of Manhattan where a pregnant person with an addiction disorder could go for prenatal care or consultation. It’s a really overlooked area, and it’s so important for the health of pregnant people and their newborns,” says Joanne Stone, MD, Chair of the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai.
“With substance use disorders, there’s a huge issue of stigma that prevents a lot of women, and thus their children, from getting the care they need,” adds Yasmin Hurd, PhD, Director of the Addiction Institute at Mount Sinai. “If we want healthy children, we need healthy moms.”
Prenatal Care for an Overlooked Population
Nearly 10 percent of pregnant women use substances during pregnancy. “This problem is just as common as many of the other issues that we test for during routine prenatal care, yet there are limited programs specifically targeting this population,” says Leah Habersham, MD, an Assistant Professor of Psychiatry and Obstetrics, Gynecology, and Reproductive Science at Icahn Mount Sinai. “And overdose deaths are steadily increasing among women of childbearing age.”
Dr. Habersham aims to use her dual training in obstetrics and addiction medicine to turn those trends around. She is currently the sole provider for The Bridge Program, offering varying levels of care depending on a patient’s needs. If a patient has already established prenatal care, Dr. Habersham will offer consultations or provide treatment and support for substance use disorders. Other patients may choose to come to her for both addiction services as well as obstetrical and gynecological services, including the full range of prenatal care. She also works closely with a social worker to provide additional care and psychosocial resources to her patients.
The Bridge Program sees pregnant patients who use or misuse any substances, including nicotine, alcohol, opioids, and other drugs. Dr. Habersham also welcomes patients who are not currently using substances but are at high risk, such as those with a history of addiction or those who may live with a partner who has a substance use disorder. “If there’s any concern, patients can be referred to this program,” she says.
A Nuanced View of Addiction in Pregnancy
While interventions are tailored to each patient, Dr. Habersham often uses motivational interviewing to meet patients where they are—and begin to move them toward accepting treatment. “There’s often a lot of ambivalence from patients who aren’t ready to take that next step toward recovery. Harm reduction is important in this setting,” she says.
As a specialist in addiction medicine and obstetrics and gynecology, she brings a more nuanced view to her care of pregnant patients. During pregnancy, for example, patients who receive medication for opioid use disorders (MOUD) will often need increases in their MOUD regimens to prevent cravings. She makes sure patients are aware of that possibility, and not afraid to speak up if they notice changes in how they are feeling. “Someone without an addiction background may see that as a sign the patient is going to go out and use opioids, though it’s not necessarily the case. Often, patients just need an increase in their doses,” she says. “A lot of times, patients withhold that kind of information from general providers.”
When it comes to prenatal care, Dr. Habersham also does things a little differently with this population. “A lot of patients with substance use disorders have trauma in their backgrounds, and many have distrust for their providers. It’s really important to build a strong foundation of trust in the doctor-patient relationship,” she says. That means she may not do a vaginal exam during the first visit, for instance, but wait until the second visit when the patient feels a bit more comfortable. “There are many biopsychosocial aspects involved,” she says.
Substance Use Screening & Methadone During Pregnancy
Because of stigma and stereotypes, there are often inequities in who is screened for substance use disorders during pregnancy and how they are screened. Even before The Bridge Program was conceived, Mount Sinai’s OB-GYN department began screening all pregnant people for possible substance misuse and addiction. “The implications [of substance use during pregnancy] are profound, and it’s important to make sure that screening is done in an unbiased way and in a manner that leads to better health care for pregnant people and their babies,” Dr. Hurd says.
She and her colleagues hope The Bridge Program will be a first step on that path to better and more inclusive health care. Initially, the program will be available to patients one day a week. Eventually, the team hopes to expand the services to reach many more patients in need. “We have all the parts of the toolbox here at Mount Sinai—a detox unit, rehabilitation, residential living, even a female-only methadone clinic. I hope we can become a center of excellence for women throughout the city with substance use and substance use disorders, and not just during pregnancy,” Dr. Habersham says.
To schedule an appointment with The Bridge Program, patients and providers can call 212-659-8557 or email TheBridge@mountsinai.org.
Sep 30, 2022 | Inside Mount Sinai Psychiatry, Psychiatry
The Opioid Treatment Programs at the Addiction Institute of Mount Sinai offer medications and a suite of services to help thousands of people with opioid use disorder reclaim their lives each year.
In 2021, drug overdose deaths in the United States surpassed 100,000 annually for the first time, according to CDC data. The vast majority — 75,673 —were caused by opioids, up from 56,064 the year before. One factor in those lost lives is fentanyl, a powerful opioid that is increasingly prevalent in the illicit drug supply.
Yet deaths due to opioid use disorder (OUD) are preventable, and effective treatments are available. The Opioid Treatment Programs at the Addiction Institute of Mount Sinai provides medications and other services to more than 3,500 patients with OUD at eight clinics in New York City.
“We treat the entire person. The first step is helping them to stop using opioids, then we start to work on recovery of all life areas,” said Teri Friedman, Senior Director of Addiction Services at Mount Sinai Beth Israel. “We try to help patients reach the highest level of functioning in all areas of their lives.”
Buprenorphine and Methadone Clinics Are Just the Beginning
Mount Sinai has a long history of treating substance use. Its predecessors, Beth Israel Medical Center and, before it, Manhattan General Hospital, were pioneers in addiction treatment. Harold Trigg, MD, Marie Nyswander, MD, and Vincent Dole, MD, launched the Methadone Maintenance Treatment Program in 1965. More than half a century later, the program is now known as the Opioid Treatment Programs at the Addiction Institute of Mount Sinai, and it continues to help patients with opioid use disorder reclaim their lives.
Medication is the gold-standard treatment for OUD. Methadone and buprenorphine/naloxone are FDA-approved and able to decrease cravings and relieve withdrawal symptoms. Mount Sinai’s outpatient Opioid Treatment Programs provides those medications at outpatient clinics in Manhattan and Brooklyn.
Yet medications alone cannot restore lives. “As we embrace recovery, we come to an understanding that every recovery path is different from the next. We meet patients where they’re at,” said Cheryl Marius, Director of the Opioid Treatment Program clinics at Mount Sinai Beth Israel.
Those clinics also provide:
- One-on-one therapy
- Group counseling
- Peer counseling
- Case management
- Educational and vocational counseling
- Annual physicals and general medical care
- Psychiatric evaluation and medication management
- Referrals for mental health treatment
- HIV counseling and testing
- Hepatitis C testing and telemedicine
As part of Mount Sinai, the programs are well connected to help patients access the care they need, said Annie Levesque, MD, Medical Director of the Opioid Treatment Program at the Addiction Institute at Mount Sinai West. “We’re embedded in the Addiction Institute, so our patients have access to a greater level of care. We can easily refer them to other services as needed, such as more intensive group therapy or inpatient detox for other substances.”
Addressing Disparities in Addiction Treatment
Methadone has been prescribed to people with OUD for decades. Buprenorphine/naloxone is a newer treatment, with a better safety and side effect profile than methadone, Dr. Levesque said. And because there is less regulation around buprenorphine, it can be prescribed in more settings, including doctor’s offices. Yet in many treatment programs, there are sharp racial and socioeconomic disparities in treatment. Patients with private health insurance are more likely to receive buprenorphine prescriptions from their doctor, avoiding daily visits to a methadone clinic.
At Mount Sinai’s opioid treatment clinics, all patients are given the option of treatment with either methadone or buprenorphine. Many patients who have been on methadone for some time prefer to continue with that medication, Marius said. But counselors and patients take many factors into consideration when determining the best path forward. “We provide individualized treatment for each patient,” Dr. Levesque said.
The frequency of a patient’s clinic visits depends on their progress through the program, regardless of which medication they choose. Early in the process, patients come to the clinic daily for their medication, which ensures that they are in regular contact with their counselor. Patients who are stable for some time and not using illicit drugs may progress to coming less frequently to pick up their medications, perhaps as infrequently as once a month. “Your recovery determines your schedule,” Marius said.
Rethinking Treatment for Opioid Use Disorder
Treating OUD remains an uphill battle. Both the disorder and the medications prescribed to treat it are subject to significant stigma. “More people need to accept that this is a medical disease,” Marius said. One common misconception within the medical community is that patients who take methadone have just swapped one drug for another. “Methadone is a medication, just as insulin is a necessary treatment for diabetes,” Friedman says.
Another mistaken belief is that patients with OUD should be referred for short-term detox, or that they should eventually taper off treatments like methadone. “In fact, long-term maintenance treatment is considered the best quality of care,” Dr. Levesque said.
Dr. Levesque and her colleagues at the Opioid Treatment Program are pushing back against the stigma, training others in the medical field and conducting research to improve access to treatment — and save more lives.
“Despite the high number of deaths, opioid use disorder is highly undertreated,” Dr. Levesque said. “As physicians we need to be referring patients to treatment and making sure we connect them to these treatments that work.”
Learn more about the Addiction Institute of Mount Sinai and the Opioid Treatment Program.
Updated on Aug 12, 2022 | Inside Mount Sinai Psychiatry, Psychiatry, Research
Schahram Akbarian, MD, PhD, is a recipient of the prestigious NIH Director’s Pioneer Award (DP1), a five-year award that supports creative scientists who are pursuing pioneering approaches to major scientific challenges.
Most clinical studies benefit from taking repeated measurements over weeks, months, years. Researchers studying epigenetic disease processes in the brain don’t have that luxury. “You harvest the brain, and you only get one time point,” says Schahram Akbarian, MD, PhD, Professor of Psychiatry and Neuroscience and Chief of the Division of Psychiatric Epigenomics at the Icahn School of Medicine at Mount Sinai. “In this field, most studies are cross-sectional.”
Now, Dr. Akbarian is developing a novel method — longitudinal epigenetic profiling — that allows him to study epigenetic changes in the brain over time. The innovative idea has earned him the National Institutes of Health (NIH) Director’s Pioneer Award (DP1), a five-year award that supports creative scientists who are pursuing pioneering approaches to major scientific challenges. The project, Single Chromatin Fiber Sequencing and Longitudinal Epigenomic Profiling in HIV+ Brain Cells Exposed to Narcotic and Stimulant, will use the new technique to explore dynamic changes in HIV-infected cells in the brain.
“In the last 10 or 15 years, research on the epigenetics of disease has taken off, thanks to modern sequencing technologies that allow us to study genome organization in a relatively cost-efficient way,” Dr. Akbarian says. “There’s a big need for more research on HIV in the brain, and I hope to morph this new idea into something specific and exciting for HIV research.”
HIV and the Brain
At the Akbarian Laboratory of Epigenetic Regulation of the Human Brain, much of the research has focused on psychiatric diseases such as schizophrenia and depression. Several years ago, Dr. Akbarian began to extend his research to HIV, in part because so many critical questions about the virus’ impact on the brain remain unanswered. More than 38 million people worldwide are living with HIV, and 1.5 million were newly infected in 2021, according to the World Health Organization. Some 75 percent of them have received antiretroviral therapy — yet for many, brain-related symptoms remain.
HIV can infect the microglia, the innate immune cells of the central nervous system, and can also cause inflammation. People with HIV can experience a range of symptoms, including headaches, forgetfulness, mood disorders, and behavioral changes. “People are still having neurological symptoms from HIV infection, even if they take antiretroviral drugs. The question is, why? What’s causing damage in the brain?” Dr. Akbarian says.
He hopes that his longitudinal epigenetic profiling method will begin to answer that question. The technique involves differentiating pluripotent human stem cells into microglia, then introducing those microglia into the brains of mice. Using epigenomic tagging of single chromatin fibers, he and his colleagues can explore dynamic changes of epigenomic dysregulation of the cells over time. “We can switch it on and off, then months later, isolate the immune cells and see how genome organization looked four months ago,” he says. “It’s a bit like a telescope that allows astronomers to look back in time in the universe. This “telescope” allows us to look back in time in the cell.”
In this study, he is focusing on HIV-infected cells that have also been exposed to opioids and stimulants. Drug abuse is a major risk factor for HIV, because drug use increases risky behaviors that can make a person more susceptible to infection. “A brain that’s exposed to drugs of abuse and to HIV is probably more unhealthy than brains from a person with HIV but no history of drug use,” Dr. Akbarian says. “We want to see if exposure to drugs of abuse makes the brains more vulnerable to infection with HIV, or to the neurological defects that HIV can trigger.”
A third goal of the project, he says, is to contribute to efforts to rid the body of HIV for good. HIV inserts itself into the genome, an ingenious trick that allows it to hide from the immune system and makes it devilishly complicated to treat. “The big question is, does HIV do this in the brain, and if so, how can we flush it out?” Dr. Akbarian says. “If we can rid the body of HIV in every cell, people can stop taking antiretroviral medication”— and effectively be cured of HIV.
Advancing Psychiatric Epigenetics Through Collaboration
The project is in its early stages, but if this longitudinal method proves effective, Dr. Akbarian hopes it could lead to new innovations for studying other diseases of the brain. Many psychiatric conditions, such as schizophrenia and depression, emerge in young adulthood. However, many researchers suspect the disease process begins much earlier, possibly even prenatally. “There’s lots of indirect evidence, but we can’t look back in time. If we study the brain of a person with schizophrenia, we have no idea what happened in their brain earlier in life,” he says. Someday, this novel longitudinal technique may uncover some important clues.
First, though, he’s applying the method to the intertwined problems of HIV and drug use. Though Dr. Akbarian’s name is on the Pioneer Award supporting the study, it’s a project he says he could not have done without support from his colleagues at Mount Sinai. “I’m a newcomer to the field of HIV. I wouldn’t be able to do this without the exceptionally collaborative atmosphere among my colleagues at Mount Sinai, including Benjamin Chen, MD, PhD, Talia Swartz, MD, PhD, and Susan Morgello, MD, who are doing experimental HIV research and were willing to help me learn,” he says. “It’s ironic that this award is in my name, because the success of this project depends so much on teamwork with these HIV researchers, as well as stem cell scientists including Samuele Marro, PhD.”
The collaborative culture at Mount Sinai makes this kind of innovation possible, he adds. “Mount Sinai has precisely the right mixture of top-notch basic neuroscience, top-notch clinical neuroscience, and a very active hospital setting,” he says. “Together they give very fertile soil to do productive research in the fields of neurology and psychiatry.”
