Hope for Young People at Risk of Developing Psychosis

Updated on Aug 2, 2022 | Inside Mount Sinai Psychiatry, Mental Health, Psychiatry

“We can’t always prevent psychosis. But the earlier someone gets treatment, the greater the likelihood that they’ll recover and do better in the long term.”

A college student often hears her name in the wind. A teenager starts to believe they have a special relationship with God. Another is worried that strangers are watching him. Yet they all retain insight and skepticism about the strange beliefs and perceptions they’re experiencing. They wonder: Is it just a trick of my mind?

These symptoms may indicate clinical high risk for psychosis (attenuated psychosis syndrome). In addition to suspiciousness, grandiose thoughts, and perceptual disturbances in what they see and hear, people at clinical high risk often experience social withdrawal, worsening performance in school, anxiety, and suicidal ideation. About 20% will develop psychosis within two years.

The symptoms of clinical high risk often develop in adolescence or early adulthood, and they are, unsurprisingly, alarming. “We see a lot of functional impairment and suffering in these individuals. They’re often afraid, and their families are often afraid,” says Cheryl Corcoran, MD, associate professor of psychiatry at Icahn School of Medicine at Mount Sinai and co-director of Mount Sinai’s Psychosis Risk Program. She and her colleagues are there to help.

“The goal is to catch people early to provide treatment,” says Shaynna Herrera, PhD, a clinical psychologist and instructor of psychiatry and project director at the Psychosis Risk Program. “Through education and cognitive behavioral therapy, we help them learn about the symptoms and how to manage them. We can’t always prevent psychosis. But the earlier someone gets treatment, the greater the likelihood that they’ll recover and do better in the long term.”

Interventions for Attenuated Psychosis Syndrome
The Psychosis Risk Program works with teenagers and young adults at clinical high risk for psychosis, providing evaluation, treatment, and psychoeducation to reduce the risk of psychosis and help patients manage symptoms.

For patients with high clinical risk, anti-psychotic medications aren’t recommended as a first-line therapy (though patients may take medications to address comorbid anxiety or depression). The Psychosis Risk Program offers a variety of interventions to help patients and their families. These include a structured five-session psychoeducation program that educates patients and family members about psychosis risk, called BEGIN: Brief Educational Guide for Individuals in Need. The program also offers cognitive-behavioral therapy for psychosis (CBT), which aims to decrease symptoms, provide coping skills, and prevent the development of full psychosis.

This type of CBT is adapted for people with clinical high risk, and research has shown that it can delay the progression to psychosis for at least four years, says clinical psychologist Yulia Landa, PsyD, MS, assistant professor of psychiatry, Director of Cognitive Behavioral Therapy for the Treatment and Prevention of Psychosis research and clinical program, and co-director of the Psychosis Risk Program. “We will need much longer longitudinal studies to know if CBT can really prevent psychosis, but we can delay it, and maybe prevent it,” she says.

Because most patients are adolescents and young adults who still live at home with parents, the Psychosis Risk Program also provides family-based programs. “Our group- and family-based CBT teaches family members how to interact with their loved ones who are beginning to experience psychotic-like symptoms and learn how to support them in using CBT skills at home,” Dr. Landa says.

Schizophrenia and Psychosis Research
In addition to clinical work, the Psychosis Risk Program is active in research, from mechanistic studies of biomarkers to research that evaluates diagnostic and clinical services. One recent project aims to improve early identification of patients at clinical high risk. “[Attenuated psychosis syndrome] is a newer concept, and not all clinicians recognize there is this population of people at clinical high risk who don’t meet the criteria for a psychotic disorder,” says Rachel Jespersen, LMSW, a clinical social worker and coordinator of the CBT for the Treatment and Prevention of Psychosis research and clinical program. “What’s more, these are types of symptoms people don’t spontaneously disclose, so it can be difficult to identify patients at clinical high risk.”

To improve identification, she and her colleagues recently conducted a pilot screening program in Mount Sinai’s outpatient clinics. They asked providers to use a brief screening tool for all patients between 12 and 30. Those who screened positive received further evaluation, and patients identified as clinical high risk were referred to the program for symptom monitoring and adjunctive treatment. The screening pilot identified 3.5 times as many patients at clinical high risk of psychosis compared to the standard referral model, Dr. Landa says.

She and her colleagues are also evaluating interventions such as CBT-based programs for individuals, groups, and families. “Eventually we want to establish solid interventions that could be disseminated across Mount Sinai and integrated into community practice,” Dr. Landa says.

Meanwhile, Dr. Corcoran and colleagues are actively involved in research to better understand biomarkers for schizophrenia. The Accelerating Medicines Partnership: Schizophrenia, spearheaded by the National Institutes of Mental Health, is collecting information on biomarkers such as MRI and EEG data, cognition, fluid biomarkers such as inflammatory and genetic markers, daily diary studies and biosensors that may predict behavioral patterns, even subtle patterns of language and facial expression that could predict the transition to psychosis. Mount Sinai is one of the study’s data processing centers, responsible for collecting and analyzing data from across the consortium. “We’ve identified a number of biomarkers that are predictive of psychosis,” Dr. Corcoran says. “We want to understand how they relate to each other, to better understand the causes of psychosis and ultimately to develop new pharmacological treatments.”

In addition, one of Dr. Corcoran’s abiding research interests involves collaborating with physicists, engineers, and computer scientists to use artificial intelligence to analyze speech, language, and face expression. Language disturbance (particularly complexity and coherence) is common in psychotic disorders, and often appears at the initial onset of symptoms. Using natural language processing, Dr. Corcoran and her collaborators were able to predict psychosis onset in clinically high risk patients with an 83% accuracy rate—that is, more accurate that clinician predictions. The implications of this field of study can potentially help prevent psychosis by initiating the development of treatments that address the problems with cognition that are at the root of language disturbance. Her team has focused on this as a biomarker for mechanistic studies (several currently in recruitment), and are working to include this “natural language processing” approach for services as well.

Patient Care at the Psychosis Risk Program
Running throughout all clinical and research efforts at the Psychosis Risk Program is a commitment to the well-being of patients, whose symptoms are often misunderstood and stigmatized. “We have been contributing to research on stigma and interventions to reduce stigma,” Dr. Herrera says. “And we’re committed to involving patients and their families in our work. We conduct qualitative interviews and get their feedback so that we adjust our practices and make sure that they are meeting peoples’ needs.”

The program staff also takes time in caring for patients with a challenging and frightening diagnosis. “In mental health care, there’s often not enough time to provide psychoeducation and do lengthy feedback sessions” where the evaluating therapist sits down with the patient and their family members to discuss the diagnosis, Dr. Herrera says. “One thing that makes Mount Sinai stand out is that we take our time to do thorough assessments, give feedback and write detailed reports so that families and clinicians have the information they need to seek care.”

Schizophrenia and psychosis remain challenging conditions, for the people affected and for their clinicians. But Mount Sinai’s Psychosis Risk Program is providing hope and health to the young people at clinical high risk. Learn more about their services and research, including language-based studies, at www.mountsinai.org/psychosis-risk.

 

Suicide Prevention Website: A New Resource for Families

Jul 15, 2022 | Inside Mount Sinai Psychiatry, Mental Health, Psychiatry

“Many family members don’t know much about firearms,” Dr. Goodman says. “We’re trying to empower those individuals, who can make a difference if we give them the knowledge, tools, and skills.”

Each day, approximately 17 veterans die by suicide, according to the 2020 National Veteran Suicide Prevention Annual Report. Of those lives lost, 68% die from a self-inflicted firearm injury. Clinician-researchers at the Mount Sinai Health System are working to lower that number, through a new initiative that aims to help concerned family members speak to veterans about safely storing firearms and reducing the risk of self-harm.

The project is led by Marianne Goodman, MD, Professor of Psychiatry at Icahn School of Medicine at Mount Sinai and acting director of the Mental Illness Research, Education and Clinical Centers (MIRECC) at the James J. Peters VA Medical Center in the Bronx, a program affiliated with Mount Sinai, along with New York Governor’s Challenge team members.

The MIRECC is a national network of 10 research hubs within the Veteran Integrated Service Network. “The MIRECC is basically a research think tank within the VA,” Dr. Goodman says. “We take a bench-to-bedside approach, conducting genetic and neuroscience research, through clinical trials, and into services research.” Each MIRECC site has its own research focus. At the James J. Peters VA Medical Center and its academic affiliate, Mount Sinai, the program’s faculty and fellows conduct research and outreach focused on severe mental illness and suicide prevention.

Empowering Veterans’ Loved Ones
Dr. Goodman’s latest effort is a website, WorriedAboutAVeteran.org, directed towards the loved ones of service members. The website grew out of the New York State Governor’s Challenge to Prevent Suicide among Service Members, Veterans and Families, with funding support from the New York State Health Foundation. Their working group, including team members from the Veteran Integrated Services Network (VISN) 2 Center of Excellence in Suicide Prevention and New York State Office of Mental Health and Counseling on Lethal Means (CALM) consultants, met for close to two years before launching the site in the spring of 2022.

Though the premise is simple, the site addresses an important unmet need, says Dr. Goodman, an expert in suicide safety planning interventions. “A lot of instructions have been developed to help clinicians counsel patients about firearm safety. But there’s nothing directed toward the families who are living with a veteran and their firearms,” she says. She hopes the site will be a resource for families, and a tool that clinicians can share with patients and their families.

The website shares information on the safe storage of firearms, how to limit access to firearms during times of distress, how to start conversations with loved ones about suicide and safety, and resources for seeking help and support. Much of the site’s content is based on the stories of other veterans and their family members who have been in similar situations. “Many family members don’t know much about firearms,” Dr. Goodman says. “We’re trying to empower those individuals, who can make a difference if we give them the knowledge, tools, and skills.”

Even when family members are concerned that a veteran might be having suicidal thoughts, raising the topic of firearm safety can be challenging. “Discussing safe storage of firearms can be a thorny subject. Veterans often associate their firearms with rights, values, and personal service experiences,” says Robert Lane, PhD, a clinical psychologist and MIRECC postdoctoral fellow. “What makes our site unique is focusing on the significant people in a veteran’s life and helping them facilitate conversations about practices that can increase the safety of a veteran and a veteran’s family during a time of heightened risk, while being mindful of these rights, values, and service experiences.”

These conversations do not necessarily have to result in a veteran giving up access to firearms, Dr. Lane adds. “They’re about considering the safe storage options that are most effective for that Veteran’s lifestyle and needs and the veteran’s family.”

Before developing the website, Dr. Goodman and her colleagues conducted interviews with family members of veterans, including family members who have lost a vet to suicide. “We found that they don’t want to hear statistics or see a presentation about the research. They want to connect with others who they feel understand them,” Dr. Goodman says.

Their finished product is based on the experiences and suggestions of real people in close relationships with veterans, including tips on starting a conversation about firearm safety or when and why to call a crisis line when you’re worried about a loved one.

The website is specific to New York, with links to resources such as counseling centers within the state. However, the team hopes to expand it nationally so that it can be used by families of veterans anywhere in the U.S., connecting people to local resources and services as needed.

One message they hope to send is that suicide prevention isn’t just for families of veterans with a history of mental illness. “In an emotional crisis, people can be at heightened risk of self-harm whether or not they meet diagnostic criteria for prior or current mental illness,” Dr. Lane says. “Our focus is about overall safety and applying that focus to all veterans and their families.”

Through efforts such as this website, the MIRECC team also hopes to normalize conversations around suicide prevention. “We want this to be like any other public health conversation, like conversations about the risks of smoking or diabetes,” Dr. Lane says. “If we can take away the mental health stigma surrounding these conversations, we can save veterans’ lives.”

 

Student-Run Free Mental Health Clinic Provides Care for the Uninsured

May 25, 2022 | Diversity and Inclusion, Inside Mount Sinai Psychiatry, Mental Health, Psychiatry

Student providers are trained in CBT and psychodynamic therapy, which has been shown to be an effective treatment for anxiety, depression, and other mental health concerns.

In the East Harlem neighborhood of New York City, residents without access to health insurance are receiving free outpatient mental health care, thanks to an innovative project at the Icahn School of Medicine at Mount Sinai. Part of Mount Sinai’s East Harlem Health Outreach Partnership (EHHOP), the student-run clinic offers no-cost, evidence-based mental and behavioral health treatments to patients in need.

Mount Sinai experts created the program from scratch more than a decade ago to meet the needs of the local population. “There was no model for this,” said Craig Katz, MD, Clinical Professor of Psychiatry, Medical Education, and System Design and Global Health at the Icahn School of Medicine and Faculty Director of EHHOP’s mental health clinic.

In 2021, the clinic served 75 patients, treating them on an outpatient basis for conditions such as anxiety, depression, and alcohol use disorder. Patients, medical students, and psychiatric residents are all benefiting from the program. As the clinic grows, it also serves as a model for other student-run health clinics to follow as they address the mental health needs of uninsured and underinsured communities.

Providing Mental Health Services for the Uninsured
EHHOP was launched in 2004 as a student-run free primary care clinic for uninsured adults in East Harlem. It has grown to incorporate a variety of services including women’s health, ophthalmology, and cardiology. The free mental health clinic was founded in 2009.

Patients are first enrolled in EHHOP primary care services. If they are identified as having a mental health condition not readily managed in primary care, they are referred for a consult at the mental health clinic. Trained medical student volunteers provide medication management as well as psychotherapy. The student providers also help connect patients to the on-site pharmacy, social workers, and an emerging alcohol use disorder buddy program, as needed. The majority of patients speak Spanish as their first language, and services are offered in Spanish, either by fluent medical students or through medical interpreters.

Overseeing the services are senior residents, who review each case and treatment plan with student providers. Patients are seen at least once a month, while those receiving psychotherapy and those who recently began medications have more frequent visits, either in person or through telehealth.

Early on, Dr. Katz and his colleagues made a decision to offer psychotherapy, even though it requires a greater time investment than psychiatric medications alone. “EHHOP is committed to offering care that is on par with the care patients with insurance would receive, to the best of our ability,” he said. “Research shows that for conditions like depression, medication plus psychotherapy tends to convey a more robust and lasting recovery, and our goal is to offer psychotherapy to any patient that wants it.”

Dr. Katz is also the founder and director of Mount Sinai’s Program in Global Mental Health, and he drew on practices from global mental health to train medical student volunteers in the principles of cognitive behavioral therapy (CBT). “Early on we wanted to offer individual therapy but didn’t have the person power. But global health research shows us that non-specialists can be trained to provide specific forms of psychotherapy,” he said.

Student providers are trained in CBT, in part because it’s manualized and relatively easy to train, said Cassandra Pruitt, a fourth-year medical student at the Icahn School of Medicine and a student provider active with the free mental health clinic. “There’s also a lot of excellent data about the efficacy of CBT for treating anxiety and depression, which are things we often encounter in EHHOP,” she said. Recently, the program began training student volunteers in psychodynamic therapy as well, an additional modality that’s been shown to be an effective treatment for anxiety disorders, depression, and other mental health concerns.

Evidence-Based Mental Health Services
The EHHOP free mental health clinic is an evidence-based program. Mental health clinic staff and volunteers collect data to monitor patient progress and ensure that the program improves outcomes. At each visit, student providers measure the magnitude of patients’ depression and anxiety symptoms using the Patient Health Questionnaire-9 (PHQ-9) and the General Anxiety Disorder-7 (GAD-7) scale.

In a paper pending publication, co-lead authors Alexandra Saali and Samuel K. Powell, both medical students and clinic volunteers, and colleagues found that the clinical service performance of the free mental health clinic was similar on most measures to outcomes for patients with Medicaid or private insurance. While HMOs in New York state had higher rates of acute-phase antidepressant medication management, the authors found no differences in performance in continuation-phase antidepressant management. What’s more, the free mental health clinic outperformed New York state commercial and Medicaid plans on optimal provider contacts for depression and follow-up care after emergency visits related to alcohol or drug use.

Outcomes data shows that patients in the free clinic get better with treatment. In addition to improvements in mental health symptoms, they also report improvements in various psychosocial domains, such as handling social situations, dealing with problems, and accomplishing goals. Patients also report high satisfaction with their clinic sessions.

Student volunteers, too, gain a lot from the program. “In a hierarchical structure like the medical school system, it’s incredible to have a place where we can be autonomous, and receive training in these psychotherapy modalities,” said Ms. Saali. “This has been such a rewarding experience. It’s a way to give back to the community by establishing long-term relationships with patients and serving people who otherwise couldn’t receive care.”

A Model for Free Clinics
Building on its successes, the free mental health clinic is launching new projects, including a CBT for diabetes program in which students trained in diabetes-specific didactics help patients with disease management, medication adherence, problem-solving skills, and managing the stress of a chronic illness. The program is also partnering with the humanitarian aid organization International Rescue Committee to provide EHHOP student providers to offer CBT sessions to Afghan refugees and asylum-seekers.

Meanwhile, Dr. Katz and other clinic contributors hope the free mental health clinic will serve as a model for other student-run free clinics to follow in offering mental health treatment to patients.

“The intention is for the design of our clinic, and the tools we use to measure outcomes, to be adopted among the hundreds of other student-run free clinics in the country,” said Ms. Saali, who brings experience to this effort as a former health care consultant with McKinsey & Company, the management consulting firm. “We also have an EHHOP consulting group that works with other programs interested in beginning or ramping up their student-run free clinics.”

The program is currently grant-funded, but it’s a relatively low-cost program since it relies largely on volunteers. “With the exception of medications, we’re extremely low-budget, and that’s because everybody gets something out of this: Patients get care they would otherwise not have gotten. Students get an opportunity to be primary mental health clinicians. And residents have a chance to play a supervisory role,” Dr. Katz said. “It’s a perpetual motion machine fueled by energy and need, and everybody is happy.”

Craig Katz, MD, is Clinical Professor of Psychiatry, Medical Education, and System Design and Global Health at the Icahn School of Medicine at Mount Sinai and Faculty Director of EHHOP’s mental health clinic.  

 

Samuel K. Powell is a medical student at the Icahn School of Medicine at Mount Sinai and a volunteer in the EHHOP clinic.

 

Alexandra Saali is a medical student at the Icahn School of Medicine at Mount Sinai and a volunteer in the EHHOP clinic.

 

Cassandra Pruitt is a medical student at the Icahn School of Medicine at Mount Sinai and a volunteer in the EHHOP clinic.

 

 

The Department of Psychiatry’s New Vice Chair for Community Engagement

Mar 4, 2022 | Diversity and Inclusion, Inside Mount Sinai Psychiatry, Mental Health, Psychiatry

Sidney Hankerson, MD, MBA, holds two new leadership roles at the Icahn School of Medicine at Mount Sinai: Vice Chair for Community Engagement for the Department of Psychiatry, as well as Director of Mental Health Equity Research for the Institute for Health Equity Research (IHER) in the Department of Population Health Science and Policy.

Mount Sinai’s Department of Psychiatry is pleased to welcome Sidney Hankerson, MD, MBA, to our faculty. Dr. Hankerson holds two leadership roles at the Icahn School of Medicine at Mount Sinai: Vice Chair for Community Engagement for the Department of Psychiatry, as well as Director of Mental Health Equity Research for the Institute for Health Equity Research (IHER) in the Department of Population Health Science and Policy.

Dr. Hankerson has received several prestigious awards, including the American Psychiatric Association’s Nancy C.A. Roeske, MD, Certificate of Recognition for Excellence in Medical Student Education, and he was chosen as a 2021 Emerging Leader in Health and Medicine by the National Academy of Medicine. Last year, New York City Mayor Bill de Blasio appointed him Chair of the Community Services Board of the New York City Department of Health and Mental Hygiene. In that role, he identified two priorities. The first is addressing behavioral health care needs in children and adolescents, given the rise in suicide attempts—particularly in Black and Latinx youth. The second is addressing the workforce shortage to meet the increased demand for mental health care. “Figuring out how we address the shortage and demand for these vulnerable populations is crucial,” he said. “Ideally, we can bring in early-stage clinicians and researchers to be on the ground and develop new models of care and engagement and delivery models.”

At Mount Sinai, Dr. Hankerson’s primary focus is in reducing racial and ethnic disparities in mental health treatment, particularly depression. “My overall charge is to really integrate principles of community-based participatory research—partnering with community organizations, and working in lockstep with community members to develop, implement, and test culturally relevant mental health interventions,” he said. To that end, he has launched an initiative in Harlem that trains church members as community health workers to screen for depression and provide brief evidence-based counseling. He plans to build on this to create a model for church-affiliated mental health clinics that can be replicated through New York City, as well as nationwide.

“Mount Sinai’s clinical infrastructure and IHER’s expertise in engaging communities of color will be invaluable in working toward that objective,” he said. “I think it will be a very nice fit, both clinically, because Mount Sinai serves many patients who call Harlem home, and because our churches are among the most trusted institutions in the African American community and have long been natural havens for mental health support.”

Dr. Hankerson believes his most important job is to listen and learn from the faculty. “It’s a priority for me to learn and identify the wonderful things Mount Sinai is already doing in the community, and to try to expand it to give it a bigger platform as well as to identify opportunities that are yet untapped,” he said. “One of the things that’s so exciting and novel about Mount Sinai is the DEI Committee within Psychiatry. To have such a robust committee dedicated to DEI is really phenomenal, so I am really excited to work with them.”

 

Brian Sweis, MD, PhD: A Physician-Scientist’s Approach to Psychiatry

Updated on Jun 30, 2022 | Inside Mount Sinai Psychiatry, Psychiatry

Brian Sweis, MD, PhD, logging his clinical rounds notes while keeping an eye on the mice in his latest experiment.

The past few decades have seen a surge in neuroscience breakthroughs, but translating those findings into better outcomes for patients has been slow and, in some cases, non-existent. Neuroscientists who train as clinicians can narrow that interdisciplinary divide.

Brian Sweis, MD, PhD, a second-year psychiatry resident and post-doctoral researcher at The Mount Sinai Hospital, is learning that discoveries in the lab can help inform how psychiatrists conceptualize the biology underlying complex emotions. In his most recent experiments, he investigated where in the brain emotions like regret stem from, and how this could go awry in mood disorders.

“We learned that there may be two distinct types of regret in the brain: one linked to depression, and another linked to resilience, which differ based on how people view their own mistakes and what could have been done differently,” he said. “I realized that we may even be able to access the root of some of these seemingly similar but fundamentally distinct thought processes if we structure psychiatric interviews with patients more precisely. This could help us identify which type of regret a patient is experiencing—either an emotion that is healthy and adaptive (and should be reinforced) versus one that may be pathological (and targeted for treatment).”

Dr. Sweis anticipates that as he continues to grow as a budding psychiatrist, the connections between his research and clinical experience will help him better bridge the worlds of science and medicine.

An indirect path to psychiatry
Dr. Sweis was first introduced to neuroscience as an undergraduate at Loyola University in Chicago, where he worked in a research lab studying how stress can affect the body and brain in rodents. At the same time, he was drawn to a psychology professor who was studying similar concepts in humans. He realized that neuroscience lay at the intersection of the two. “I fell in love with neuroscience when I learned that something as intangible and abstract as a psychological concept could have concrete biological underpinnings,” he said.

He decided to double major in psychology and biology, and minored in neuroscience and philosophy. “I was a total nerd about everything neuroscience,” he said. “I remember thinking at one point that I definitely didn’t want to go to medical school. Instead, I wanted to be a professor, run a research lab, train my own students, and be a full-time scientist.”

He was most interested in areas of science where multiple fields overlapped. “That’s where the most exciting innovation happens,” he said. Towards the end of college, he learned he could pursue his research passions while in medical school and work at the intersection of two often separated career paths as a physician-scientist.

Dr. Sweis enrolled in the dual degree MD-PhD program at the University of Minnesota Medical School (UMN), which splits the four years of medical school and adds a four-year PhD program in the middle. For his PhD in neuroscience, he explored the complex cognitive processes around how the brain makes decisions. “I was fascinated by how we could take abstract concepts like thought, memories, and imagination, and boil them down to the physical properties of a brain cell that you can touch and directly measure,” he said.

Most of the breakthroughs in basic neurobiology occur in animal studies because the technologies available in that space are more advanced, but this is often far removed from affecting patient care. However, Dr. Sweis set out to work across species with rodent and human subjects in parallel in order to accelerate the “bench to bedside” process of translational research.

At UMN, Dr. Sweis was part of the first group of researchers to discover that humans are not the only species that are capable of experiencing regret. Combining elements from decision neuroscience with behavioral economics, he found that even rodents are sensitive to the mistakes they’ve made when realizing that alternative actions could have led to better outcomes. He also found that avoiding future regret can be a strong motivator for learning—mice will even sacrifice food to do so.

Related to this work, Dr. Sweis was first author on a Science paper showing that rodents also tend to overvalue rewards they’ve already invested in, even when it’s clear they should cut their losses. This well-studied cognitive bias is known as the sunk cost fallacy, and it was thought to be a psychological phenomenon unique to humans. Importantly, Dr. Sweis helped craft a way to study these concepts so that they could translate to animal models of psychiatric disorders. His work in comparative biology and evolutionary neuroeconomics landed him on the 2020 Forbes 30 Under 30: Science list. He has also received best PhD awards through UMN, nationally through the Council of Graduate Studies, and internationally through the Society for Neuroscience.

As a clinician, Dr. Sweis originally planned to train in neurology. But over the course of his PhD, he learned that the applications of what he was studying aligned more with the depth of training he could gain from a residency program in psychiatry.

“I realized psychiatry was more in line with the questions I found to be the most fascinating, and tied back to my philosophy interests in undergrad,” he said. “How does the mind work? Where does motivation come from? What happens when the machinery in our brain that controls the way we make decisions starts to physically break down? Whether it’s the result of a neurological insult like a stroke or psychiatric event like trauma, I wanted to know more about the biology that causes us to behave and think the way we do. To fully unpack all of the ways a clinician can deconstruct the origins of behavior, I knew I needed to be formally trained as a psychiatrist.”

Mount Sinai’s physician-scientist residency track
Dr. Sweis chose The Mount Sinai Hospital because “the institution as a whole values research at every level, not just a certain department or an individual or two,” he said. “Mount Sinai was built around accelerating and providing robust training experiences and research opportunities, and that’s one of its biggest strengths toward innovating new treatments for patients.”

The Mount Sinai Hospital was also a good fit because the training directors, Antonia New, MD, Asher Simon, MD, and Mercedes Perez-Rodriguez, MD, PhD, wanted to accelerate his research momentum concurrent with his clinical training as a physician.

“They readily identified that my talents lie with being a scientist,” he said. “They told me they would do everything they could to powerfully launch my career as a physician-scientist because that’s where I would thrive the most.”

To that end, during his first year of residency, he split his time as an intern seeing patients (including in the ICU and ER during the height of COVID-19), and the other half initiating experiments on how regret-related processes in the brain are altered in depression.

“I began working on this experiment the first day I moved to New York,” he said. “My training directors saw the clear path forward, entrusted my vision and drive, and supported me in every way. We’re working to publish these discoveries right now.” Within the first six months of residency, Dr. Sweis was awarded third place for best research by a psychiatry resident in New York City by the American Psychiatric Association.

Finally, Dr. Sweis chose The Mount Sinai Hospital because of the faculty he wanted to work with, including Eric Nestler, MD, PhD, Scott Russo, PhD, and Denise Cai, PhD. Dr. Sweis launched his first set of experiments in Dr. Nestler’s and Dr. Russo’s labs studying how regret may be processed differently in rodents that develop depressive-like symptoms following exposure to stress (stress-susceptible individuals) versus animals that are more stress-resilient.

“Dr. Nestler and his colleagues provided a home for me to continue my research from UMN in an independent manner,” he said. “The opportunity for collaboration was obvious: I took a well-validated model of depression their labs and others developed, and combined it with my expertise in neuroeconomics, which was quite new to their labs.”

Now that he completed his first set of experiments and has hit the ground running, Dr. Sweis is expanding his research horizon and learning from other expert faculty including Dr. Cai, a leader in the field of memory research. Dr. Cai’s lab leverages cutting-edge technology that she and others developed to image the living brain in ways never before possible in order to ask deeper questions about how experiences are dynamically processed and stored.

The microscope and raw footage of a rodent’s brain. Image credit: Daniel Aharoni, PhD, and Denise Cai, PhD.

Her group developed a miniature microscope the size of a penny that can be implanted into a rodent’s brain. The microscope can record videos of individual neurons that together look like stars in the night sky, where each flickering light represents a biological event. This electrical cellular activity is engineered to be converted into a visual signal that can be captured with a camera. Hidden in this display are coordinated “constellation-like” patterns that together represent aspects of a memory distributed across a network of neurons.

“This type of work is truly incredible,” said Dr. Sweis. “Information represented this way in the brain—in networks—would have previously otherwise gone unseen without this technology. Identifying new ways in which these complex processes break down is only the beginning toward developing a richer understanding of psychiatric illnesses.” Dr. Sweis and Dr. Cai together recently published a review article on the current state of this research and where these new technologies are taking the field.

Career plans
A fundamental issue in brain research is that animal work and human work can be very disconnected, but Dr. Sweis plans to keep a foot in both worlds. He sees his translational research ultimately extending back into clinical patient populations, where he has aligned interests with another mentor: Helen Mayberg, MD, director of the Nash Family Center for Advanced Circuit Therapeutics. As a neurologist who works in neurosurgery to advance next-generation treatments for psychiatric disorders through deep brain stimulation, she emulates the type of neuroengineering approach to psychiatry Dr. Sweis is aiming to grow further into with his research and clinical background. While certain techniques and questions can only be investigated in mice, he hopes some of the insights he gains by studying animal behavior in complex ways can bring a different spin or new elements to questions being asked on the human side (such as Dr. Mayberg’s research).

For example, deep brain stimulation doesn’t work for every depressed patient. “Why is that? Is the implanted device slightly missing the intended target? Or does this person have a fundamentally distinct sub-type of depression in which treatments would be better tailored toward a different pathway in the brain?” said Dr. Sweis. “One of the primary goals of my translational research is to be able to differentiate sub-types of a psychiatric disease by refining the way in which we understand how behaviors come about in the first place—and to be better at describing those processes.”

Scientists trained as physicians, like Dr. Sweis, are in a unique position to understand and enhance the links between preclinical research and clinical applications in humans to advance patient treatments. “During my residency interview, my program directors told me that the toolkit of a psychiatrist lies in the interview,” he said. “It’s a surgical interview—much like a scalpel is to a surgeon, so is the art of interviewing a patient to a psychiatrist.”

He hopes that his research in neuroeconomics will equip psychiatrists with a new language to dissect the multifaceted drivers of behavior and sharpen the precision of a surgical interview such that it can tap into the different circuits at play. This is one of the goals of the emerging field of computational psychiatry, and he knows his training as a clinician is making all the difference as he moves toward that goal.

“By learning how to practice psychiatry and working directly with patients, I can begin to identify what needs to change the most in this field and where to best direct my efforts as a neuroscientist,” he said.

Mount Sinai’s Department of Psychiatry is one of the largest and most prolific in the world. With our new series, Inside Mount Sinai Psychiatry, we showcase stories from every corner of our Department including our training programs, patient care teams, and scientists. We believe psychiatry and mental health are the building blocks to fulfilling lives and thriving societies; via these stories about our faculty, trainees, and staff, this series shows the myriad ways we work toward that. Whether it’s manning the front desk of an opioid treatment clinic, researching how psychedelics work in the brain, or training future clinician-scientists, our team is relentlessly pursuing the best for those suffering from mental health issues.

Learn more about research at Mount Sinai's Department of Psychiatry
Learn more about The Mount Sinai Hospital's Psychiatry Residency

Alexa Salguero-Diaz: From Trauma and Truancy to Valedictorian

Updated on Jun 30, 2022 | Inside Mount Sinai Psychiatry, Psychiatry

Alexa on graduation day with her therapist, Monica Rojas, PsyD.

 

On June 25, Alexa Salguero-Diaz joined her classmates from her laptop to deliver her valedictorian speech for their virtual high school graduation. “A few years ago, I didn’t think about my future,” she said. “I didn’t even think I had one. But now, I’m actually excited for my future, and the adventures I’m going to have.”

It had been a long and painful journey for her to get to this point.

Alexa didn’t have an ordinary childhood, and she didn’t graduate from an ordinary high school. She graduated from Mount Sinai’s Comprehensive Adolescent Rehabilitation and Education Service (CARES), an integrated program for teens who struggle with mental health and/or substance use that combines a high school education with intensive psychological treatment. Founded in 1990, CARES aims to prevent the effects of mental illness and substance use on adolescents’ brain development, the subsequent decreased academic performance, and the ripple effects on their lives. CARES is the only program of its kind in the country.

When Alexa transferred to CARES, she was 17 and had been hospitalized for the 13th time for self-harm with the intent to commit suicide. The trauma she experienced due to abuse by a family member at a young age resulted in a lifetime of depression, multiple forms of self-harm, anxiety, anorexia, and bulimia, and addiction to multiple substances including Xanax.

After two years at CARES working with her therapist, Monica Rojas, PsyD, and in various targeted therapy groups including dialectical behavioral therapy (DBT), substance abuse, and milieu therapy, Alexa is in a much better place. She hasn’t used substances for three years, and is stable with no self-harm or suicidality. She is also armed with coping mechanisms and resources to get through any lapses that may arise.

“If I feel like I want to hurt myself, I let Monica or someone else know,” she said. “I’m not scared to go back to the hospital if I need to.”

Childhood challenges

Many of Alexa’s mental health problems can be traced back to genetic vulnerabilities, given her family history of depression and trauma, and the fact that she was abused at the age of seven. She never told anyone, and believes she denied and avoided the memories because it didn’t feel safe to talk about them.

In middle school, bullying and sexual harassment became a huge issue, which led to coping through substances and other risky, life-threatening behaviors. Alexa slowly began to realize there were connections between her past and present as she worked with therapists to understand how she was trying to master the traumas by re-enacting them over and over. “That’s when the sadness started coming. I started hurting myself, and I wanted to die every day.”

As a first generation Salvadorian-American, Alexa made brave efforts to share these stressors with family. But given how taboo it is to speak of abuse in so many cultures, she was unable to receive the support and validation needed.

The trauma from her abuse haunted her, and drugs helped her forget—temporarily. “I got addicted to Xanax, molly—whatever was around, but especially Xanax. I skipped school just to do drugs.” Alexa put herself in dangerous situations in order to use substances, which further exacerbated her trauma.

“I wanted to take away all my bad thoughts and go to another world, but in reality, it made things worse. I just wanted to die,” she said.

The abuse also created a sense of worthlessness and disgust. “It all started because of that sexual trauma when I was younger. I just felt so useless and ashamed of myself and disgusted with how I am, how I look.” This led to anorexia and bulimia in her sophomore year, coupled with substance abuse and suicidality.

“When I was in my original high school in the Bronx, that’s where my depression and anxiety got really bad,” she said. “I was actually hospitalized 12 times when I was there.” Alexa’s education was frequently interrupted due to these hospitalizations with an average stay of one month. Additionally, one serious attempt landed her in a coma for a week and subsequently hospitalized for two months. Because of these multiple prolonged hospitalizations, Alexa fell behind in school. At age 17, she was still in need of 22 credits and all five of her Regents exams in order to earn her high school diploma.

The path to recovery

In 2019, Alexa transferred to CARES, on the recommendation of psychiatric hospital staff. “It was really the best choice I made,” she said. “I felt so much support.”

Dr. Rojas believes falling behind in school fed into Alexa’s shame and mental health issues, and that interventions for her mental health needed to be integrated with keeping her education on track.

“CARES is the kind of place where we say ‘You can do this,’ and we will work together as a team to help you reach your academic and mental health goals,” she said. Her steady progress in therapy fostered autonomy and confidence, which influenced her academic achievements.

CARES functions as a “warm handoff,” bridging the gap between inpatient and outpatient therapy. The program’s multidisciplinary team onsite consists of psychologists, psychiatrists, social workers, a psychiatric nurse practitioner, DOE teachers, and guidance counselors, along with trainees in these disciplines.

The CARES treatment team works together to make an individualized treatment plan for each patient that includes individual therapy two times per week, group therapy five times per week, family therapy, and medication management. Additionally, students have access to milieu therapy onsite to support students during the school day. The unique support of milieu, or “therapy on demand,” is to help students cope in vivo by coaching them through crises using effective skills in the moment.

Alexa believes the intimacy of the space itself was helpful for connecting with people. “It’s very easy to socialize because it’s just one floor, in one building. It really helped my social anxiety,” she said. She also used this time to explore several aspects of her cultural and sexual identities. “It wasn’t really a big deal, people weren’t shocked. But it did help me feel more comfortable with who I am.”

Of course, COVID-19 presented problems in providing intensive care. Although CARES offered a blended learning option in the fall of 2020, Alexa attended CARES remotely from March 2020 to March 2021 because of concerns around the pandemic. “It was pretty hard because it made it easier to not go to class and group therapy sessions,” Alexa said. But she persevered with the help of her support network and CARES team.

“Alexa’s capability for deep insight and ability to share is so impressive and constantly inspiring me,” said Dr. Rojas. “Even in the substance group for teens, Alexa told her story and it was so helpful for destigmatizing substance use for the others in the group. To be able to ask for what she needs even when she doesn’t feel like it—after everything she’s been through—is really amazing.”

Graduation and the path forward

The New York City Department of Education and CARES staff unanimously voted Alexa as valedictorian, along with one other student. “I was so confused,” she said. “I really never thought that I would even be considered for that.”

In her speech, Alexa provided sound advice to her peers: “To everyone that is here or still in school, or struggling with mental health, don’t let it get to a point where you regret your choices. Instead, make the choices that will lead you to have a life that you dream of. Whatever advantages or opportunities you get in life, take it, because it could be something wonderful.”

Alexa’s love of animals and art led her to create an Etsy shop: Muffin’s Stickers, named for her dog who passed away in January.

“My life revolves around animals. When Muffin passed, I really fell into a deep void. I wanted to die, and I felt completely empty,” she said. “But once I learned how to deal with it, I realized my dog would want me to continue school.”

Art has always been an escape for Alexa, so she began painting pet portraits, which she converted to stickers based on her art as well as custom commissions. In the beginning her customers were mostly friends and family, then informal marketing via TikTok and at CARES helped her attract more customers.

“It really helps to distract me and keep my days busy,” she said. Down the road, she hopes to earn a pet grooming certification so she can open her own pet shop.

As Alexa joined her family, classmates, and care team in Morningside Park for a graduation celebration, she reflected on the last two years of her life. “I came so close to not achieving any of this,” she said. “I could be under the ground or cremated right now. But I’m glad I didn’t succeed in doing that, because the people I met through CARES are the best people ever. The friends I made in the hospital, and the connections I made with adults really helped me a lot and made me feel less alone. I still feel alone and depressed at times, but then I remember everyone I’ve met and imagine how many more people I can meet.”

Alexa will begin outpatient therapy at Mount Sinai in the coming weeks as part of an individualized continuum of care. In her free time, she stays busy with her Etsy shop and is currently applying to trade school to obtain her pet grooming certification.

Mount Sinai’s Department of Psychiatry is one of the largest and most prolific in the world. With our new series, Inside Mount Sinai Psychiatry, we showcase stories from every corner of our Department including our training programs, patient care teams, and scientists. We believe psychiatry and mental health are the building blocks to fulfilling lives and thriving societies; via these stories about our faculty, trainees, and staff, this series shows the myriad ways we work toward that. Whether it’s manning the front desk of an opioid treatment clinic, researching how psychedelics work in the brain, or training future clinician-scientists, our team is relentlessly pursuing the best for those suffering from mental health issues. 

Read more about our child and adolescent mental health services

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