Feb 20, 2020 | Psychiatry
Dr. Yehuda’s interest in MDMA-assisted psychotherapy represents the culmination of her 30-year career spent investigating the pathophysiology, treatment, and prevention of PTSD.
MDMA, the psychoactive drug sometimes known as ecstasy, is poised to become a powerful tool in the treatment of PTSD. In 2017, the U.S. Food and Drug Administration (FDA) designated MDMA-assisted psychotherapy as a breakthrough therapy. Although MDMA itself is not officially legal or approved for clinical use, phase III trials are underway, and expanded access status was granted in 2020 in the United States and Israel. The results of preliminary clinical studies are extremely promising, and the FDA could approve MDMA-assisted psychotherapy for PTSD as early as 2023.
Rachel Yehuda, PhD, Director of Mount Sinai’s Traumatic Stress Studies Division, has completed the clinician training for MDMA-assisted psychotherapy sponsored by the Multidisciplinary Association for Psychedelic Studies (MAPS). She plans to launch a Center for Psychedelic Psychotherapy and Trauma at Mount Sinai later this year that will focus on MDMA-assisted psychotherapy and other psychedelic-assisted psychotherapies with compounds such as psilocybin. Below, she breaks down the top five things psychiatrists need to know about MDMA-assisted psychotherapy.
1. The backstory. MDMA was first synthesized and patented by the German pharmaceutical company Merck in 1912, but it wasn’t until the 1970s and 1980s that psychiatrists began using it in therapy to enhance communication and introspection. Because MDMA was also used recreationally in ways that could potentially lead to abuse or harm, the U.S. Drug Enforcement Administration banned this compound in 1985, and the FDA designated it as a Schedule 1 controlled substance.
2. How it works. The pharmacologic effects of MDMA involve the release of neurotransmitters such as serotonin, dopamine, and norepinephrine, with a subsequent increased secretion of several hormones such as oxytocin, prolactin, cortisol, and vasopressin. “But these properties do not fully explain the sense of empathy towards self and openness to engage in self-reflection,” said Dr. Yehuda. “People taking MDMA report feelings of energy, well-being, empathy, transcendence, and sensory pleasure, and these are optimal conditions for engaging in processing of difficult or traumatic material.”
3. How it’s administered. A typical MDMA-assisted psychotherapy session involves ingesting 120 mg of MDMA, followed by an optional half-dose of 40 mg administered about two hours after the initial dose to extend the therapeutic effects. The effects can last as long as eight hours, during which the patient has the opportunity to revisit important past events and emotions with two trained therapists. Preparation and integration sessions help the patient consolidate therapeutic gains. Generally, patients receive two or three sessions within a 12-week period.
4. What to tell patients. Patients wishing to try MDMA-assisted psychotherapy should do so within the context of a clinical trial until the treatment is approved by the FDA. Taking MDMA recreationally will not produce the therapeutic effects associated with MDMA-assisted psychotherapy because the goal of the treatment is to provide an opportunity for processing painful emotions under the guidance of trained psychotherapists. There are some contraindications for taking MDMA, so patients must undergo a physical clearance process. However, MDMA has an acceptable safety profile if administered according to the protocol. Patients interested in participating in the study should visit mdmaptsd.org.
5. The evidence. “MDMA-assisted psychotherapy has demonstrated greater therapeutic efficacy than any other psychotherapy or medication for PTSD,” said Dr. Yehuda. Unlike with many other therapies for PTSD, symptom reduction can be maintained after a single course of treatment by most patients. And the effects last—more than two-thirds of patients receiving MDMA-assisted psychotherapy no longer had PTSD when measured one year later. Researchers attribute these outcomes to MDMA’s unique ability to allow patients to examine traumatic experiences without experiencing the attendant pain, which enables them to work through the issue with their therapist.
Dr. Yehuda’s interest in MDMA-assisted psychotherapy represents the culmination of her 30-year career devoted to identifying biological alterations in PTSD and resilience, and developing novel treatment approaches for the prevention and treatment of PTSD. Her Center for Psychedelic Psychotherapy and Trauma Research uses clinical trials, computational genetics, molecular biology, blood samples, and neuroimaging to accelerate understanding of how MDMA and psilocybin work. The center also holds clinical trainings for therapists in anticipation of FDA approval and leads public and scientific education, including a monthly lecture series.
If you find our research and clinical experience valuable for the field and your patients, please consider voting for The Mount Sinai Hospital via Doximity in the U.S. News & World Report Best Hospitals rankings for Psychiatry. Your vote helps make it possible for us to continue to uncover and explore paths to prevention and treatment of psychiatric disorders.
Dr. Yehuda is a Professor of Psychiatry and Neuroscience at the Icahn School of Medicine at Mount Sinai, where she is also the Vice Chair for Veterans Affairs in the Department of Psychiatry as well as Director of the Traumatic Stress Studies Division. This division includes the PTSD Clinical Research Program and the Neurochemistry and Neuroendocrinology Lab at the James J. Peters VA Medical Center in the Bronx. Her PhD is in psychology and neurochemistry, and her MS is in biological psychology.
Updated on Jun 30, 2022 | Psychiatry
From left: Dennis S. Charney, MD; Nora Volkow, MD; Yasmin Hurd, PhD; Sabina Lim, MD, MPH, Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, and Vice President and Chief of Strategy, Behavioral Health, Mount Sinai Health System; and Eric J. Nestler, MD, PhD.
Luminaries in addiction research, policy, and clinical care, led by keynote speaker Nora Volkow, MD, Director of the National Institute on Drug Abuse (NIDA), participated in an all-day conference in the fall hosted by the Addiction Institute of Mount Sinai (AIMS) at the New York Academy of Medicine.
“Today is about solutions,” said AIMS Director Yasmin Hurd, PhD, Ward-Coleman Chair of Translational Neuroscience, as she welcomed guests to the “Confronting Addiction: Science, Policy, and Care” conference. “Our objective is to start a dialogue among scientists, policymakers, and clinicians so we can create more opportunities to collaborate on developing more effective treatment strategies, support structures, and policy infrastructure for people and families struggling with addiction.” Dr. Hurd, a world-renowned researcher in the neurobiology of addiction disorders, is also Professor of Psychiatry, Neuroscience, and Pharmacological Sciences at the Icahn School of Medicine at Mount Sinai. Her remarks were followed by introductions from Dennis S. Charney, MD, Anne and Joel Ehrenkranz Dean of the Icahn School of Medicine at Mount Sinai, and President for Academic Affairs for the Mount Sinai Health System, and Eric J. Nestler, MD, PhD, Nash Family Professor of Neuroscience, Dean for Academic and Scientific Affairs, and Director of The Friedman Brain Institute at the Icahn School of Medicine at Mount Sinai.
In her speech, “The Role of Science in Substance Abuse Policy and Care,” Dr. Volkow challenged the audience: “When I first came to Washington, D.C., as Director of NIDA, one of the most frustrating things was my naïve perception that policy would be guided by science—and it’s not.” She asked: “So what do we need to do to make sure it’s not ignored? What can we, as scientists, do to increase the likelihood that our evidence-based findings are implemented into policy?”
The event also included discussions on four key topics: Taking Addiction Policy into the 21st Century; Early Predictors of Addiction; Objective Assessment of Addiction Symptoms and Treatment Outcomes; and New Frontiers in Addiction Treatment.
Updated on Jun 30, 2022 | Psychiatry
Yasmin Hurd, PhD, is currently conducting a clinical trial of CBD for treating opioid use disorder, a neuroimaging study of CBD’s effects on the human brain, and a study looking at neurodevelopmental effects of cannabis and its epigenetic regulation.
Yasmin Hurd, PhD, Director of the Addiction Institute of Mount Sinai (AIMS), has been at the forefront of cannabidiol (CBD) research for the past decade, particularly its effects on those struggling with addiction. In May 2019, she published study results from a clinical trial showing that CBD reduced cue-induced craving and anxiety in individuals with a history of heroin abuse, suggesting it could help break the cycle of addiction. Below, she breaks down five things psychiatrists need to know about the potential for using CBD to treat psychiatric disorders.
1. What it is. CBD is one of 140 components—known as cannabinoids—in the cannabis plant. Tetrahydrocannabinol (THC) is the most prevalent cannabinoid and is the main psychoactive agent of the plant (causing the cannabis “high”). CBD, on the other hand, does not cause intoxication, and is not “medical cannabis,” which generically refers to THC-containing products. However, each state has its own distinct medical cannabis program, and some include CBD-only treatments. The full mechanism of CBD’s pharmacological actions is still being investigated, but it’s clear that unlike THC, CBD is not an agonist at cannabinoid receptors.
2. Conditions it may help treat. CBD has been studied for various disorders including anxiety, cannabis use disorder, Crohn’s disease, diabetes, epilepsy, graft versus host disease, Huntington’s disease, opioid use disorder, Parkinson’s disease, and schizophrenia/psychosis. Several open label studies have also been conducted in relation to autism, cancer, pain, and sleep. To date, the U.S. Food and Drug Administration (FDA) has only approved CBD for the treatment of Dravet syndrome and Lennox-Gastaut syndrome, two rare and severe forms of childhood epilepsy. CBD has not been FDA-approved to treat any disorders in adults.
3. The evidence. In limited clinical trials—many related to psychiatric illnesses—CBD was found to reduce social anxiety, PTSD, and cue-induced craving in opioid addiction. It was also found to lessen the activation of brain areas altered by emotionally fearful conditions. CBD can have anti-psychotic effects primarily reducing positive symptoms and may be effective as an adjunct to current FDA approved anti-psychotic medications. Pretreatment with CBD may also block the induction of psychosis induced by THC. Most of these clinical studies have been small; to make conclusive decisions regarding treatment for specific psychiatric disorders, large-scale double-blinded trials are needed.
4. What to tell patients. Many individuals are using CBD despite the lack of definitive clinical insights or FDA approval for any psychiatric disorder. Because of this, it is critical for clinicians to have an open rapport with their patients to document any CBD use. This rapport will also be important to guide patient education about the potential for CBD to interact with medications they are currently taking. Additionally, it is important to have patients keep a log of their daily activity including aspects of any change in physiological state, mood, and sleep. Patients should be educated about the source of their CBD, as many products sold as “pure CBD” contain THC and other adulterants that can affect overall health such as lead, mold, and psychosis inducing synthetic cannabinoids.
5. The dose range and side effects. The typical daily dose studied ranges from approximately 100 to 600 mg and is normally taken orally. However, doses up to 6,000 mg have been investigated in healthy subjects, resulting in no severe effects. Although CBD has been implicated in a large spectrum of biological effects, a consistent finding in clinical studies is that it is safe, generally well tolerated, and lacks toxicity in adults. The most notably adverse events are gastrointestinal including diarrhea, but with low severity. Additionally, an increase in liver enzymes has been reported in combination with anti-epileptic medication in children. We still lack systematic studies to determine whether general safety extends beyond oral routes of administration or how CBD may interact with medications like benzodiazepines, which are metabolized by the same cytochrome P450 enzymes as CBD. It is possible that this could affect the therapeutic levels of each drug. The therapeutic dose range is also still unclear for psychiatric illnesses given the limited clinical studies for most of these indications.
Dr. Hurd is currently the principal investigator on a clinical trial of CBD for treating opioid use disorder, a neuroimaging study of CBD’s effects on the human brain, and a study looking at neurodevelopmental effects of cannabis and its epigenetic regulation.
If you find our research and clinical experience valuable for the field and our patients, please consider voting for The Mount Sinai Hospital via Doximity in the U.S. News and World Report Best Hospital rankings for Psychiatry. Your vote helps make it possible for us to continue to uncover and explore paths to prevention and treatment of psychiatric disorders.
Dr. Hurd is Professor of Psychiatry, Neuroscience, and Pharmacological Sciences and Ward-Coleman Chair of Translational Neuroscience at the Icahn School of Medicine at Mount Sinai. She is also the director of the Addiction Institute of Mount Sinai, and director of the Hurd Lab.
Updated on Jun 30, 2022 | Psychiatry
Tom Hildebrandt, PsyD, Associate Professor of Psychiatry, and Director of Mount Sinai’s Center of Excellence in Eating and Weight Disorders.
In November, Mount Sinai’s Center of Excellence in Eating and Weight Disorders launched its new Intensive Program in an integrated clinical and research space at 53 East 96th Street. What began in 2002 as the Division of Eating and Weight Disorders has since grown into a leading multidisciplinary center that provides innovative, evidence-based treatment to patients suffering from a range of feeding, eating, and weight disorders. In 2019, the Center treated more than 300 patients, making it the largest non-residential specialist clinic in New York City.
Despite the large population base in New York, expert care for eating and weight disorders is scarce. The majority of treatment centers offer programs that are cost-prohibitive for many patients, and offer little to no insurance coverage. Mount Sinai’s Center of Excellence in Eating and Weight Disorders, led since 2010 by Tom Hildebrandt, PsyD, Associate Professor of Psychiatry, has implemented a number of initiatives that aim to remove that barrier. Since 2011, the Center’s training program has provided low or no-cost care to patients through advanced psychology externs and through participation in research studies. By 2019, the Center had treated about 2,500 patients, with more than two-thirds classified as low or no-cost care. “Community impact is central to our program,” said Dr. Hildebrandt. “We continue to learn from the science, and our patients, to make sure that we’re providing the best care possible.”
Continuing the Center’s mission to expand its community impact, the Intensive Program will provide care for patients of any socioeconomic status, with the availability of insurance-based programs and a supported transition from the intensive setting to regular outpatient and maintenance visits. Unlike other programs in New York, the Center provides treatment that combines advanced medical and psychiatric expertise, and includes a fully integrated research program. Led by Eve Freidl, MD, Associate Professor of Psychiatry, and Jeneane Solz, PhD, Assistant Professor of Psychiatry, the Intensive Program focuses on family-based therapies that are tailored to each patient’s needs. Together, families learn how to manage the recovery process and cope with the complexities of eating and weight disorders. The program saw its first intake of patients this month and is expected to be at capacity in early 2020. “We’re excited that the Intensive Program will fill what we currently see as a gap in the treatment of eating and weight disorders,” said Dr. Solz. “Our aim is to ensure that our patients have the family and clinical support they need to achieve long term recovery.”
Nov 27, 2019 | Psychiatry
The 2019 NARSAD Young Investigator grantees from the Brain and Behavior Research Foundation include six faculty members from the Icahn School of Medicine at Mount Sinai. Their research aims are listed below.
Jessica Ables, MD, PhD, seeks to determine the effect of increased blood sugar on vulnerability to stress, gene expression, structure and function of neurons in the striatum, habenula and midbrain in a mouse model of diabetes. These brain areas have been shown to be key in regulating mood and anxiety. Dr. Ables will look at specific cell types within each area, which is more informative than analyzing gene expression in the region as a whole, hoping that by sequencing and targeting specific cell types, it may be possible to identify a vulnerable population or specific pathway that may be targeted to develop new treatments for depression and anxiety.
Magdalena Janecka, PhD, is exploring the theory that risk for ASD is partly influenced by changes in DNA methylation, an epigenetic process in which molecules (methyl groups) bind to DNA, effectively switching particular genes on and off. This project seeks to discover and understand the functional significance of rare “epimutations” in ASD—changes in DNA methylation that have severe effects on genes that influence autism risk. After discovering epimutations, the team will explore whether they are linked to changes in the genetic code; and investigate the characteristics of the genes with the epimutations, which will highlight the impact they may have on a developing baby
Philipp Mews, PhD, is exploring the hypothesis that permanent changes in chromatin structure—the complex bundle in which our DNA is packaged in the cell—underlie the dysregulation of gene activation patterns characterizing drug addiction. There is currently no direct link between drug-induced alterations in chromatin and the aberrant gene regulation observed during relapse. Dr. Mews seeks to determine which neuronal subtypes are responsible within the nucleus accumbens, which is composed of two opposing types of medium spiny neurons, the D1 and D2 dopamine receptor-expressing subtypes. These exhibit dramatic differences in activity and effects on drug reward. This project aims to identify the precise epigenetic mechanisms that establish and preserve the molecular pathology in these distinct striatal subpopulations.
Laurel Morris, PhD, has developed an ultra-high field MRI procedure that provides much improved images of the ventral tegmental area (VTA), a brain area linked with the problem of motivation in depression. This project will consist of a randomized controlled trial to train individuals with major depressive disorder to modulate their own VTA activity during an ultra-high field MRI scanning session. Previous studies have shown that the activity of the VTA can be changed in healthy volunteers if they are trained to use certain thought patterns while watching their own VTA activity in real-time. The hope is that such biofeedback training is feasible in patients with major depressive disorder.
Agnes Norbury, PhD, wants to test new theories suggesting that people only use new information to update an older fear memory if they think that the same causes are responsible for events during Young Investigator Grant Program 2019 28 both the original fear memory and current learning episode. In other words, new learning that an object or situation is safe may fail to update an older memory of that object or situation being harmful if the individual reasons that the difference in context across these events means that is unlikely that they are the result of the same underlying factors. The team will test if this new theory can explain excessive avoidance behavior in individuals with an anxiety disorder or PTSD, using an online game to test how they learn about negative events.
Allison Waters, PhD, notes that advances in white matter imaging have provided maps of the brain whose great detail help explain the difficulty of precision-targeting a treatment like deep brain stimulation (DBS), a method that involves surgically implanting electrodes deep within specific brain areas such as a large and complex white matter fiber bundle called the anterior limb of the internal capsule (ALIC), a promising target for DBS to treat OCD. This project seeks to develop a patient-level, electrophysiological read-out of the cortical response to DBS at specific white matter targets within the ALIC. The probe is to be validated on the level of individuals, which could allow for individualized DBS “tuning.”
Nov 25, 2019 | Psychiatry
Mount Sinai’s Partial Hospital Program provides intensive, highly structured outpatient behavioral health services to stabilize patients suffering from acute mental health symptoms.
Mount Sinai’s Partial Hospital Program provides an intensive level of psychiatric care for patients with acute symptoms—without hospitalization. The program treats patients with a range of psychiatric conditions, and places them on specialized tracks based on symptom presentation and level of self-harm. Most of the patients who are admitted do so as a step down after being discharged from inpatient care. But the program can also be used as a step up for patients who have been getting regular care but are on a downward trend, as a way to avoid full hospitalization. “It’s great for patients to have this program as an option to reduce the length of their stay in the hospital,” said Joan Bell, MSW, Clinical Director of Ambulatory Behavioral Health Services for The Mount Sinai Hospital. “It’s so hard for people to stay on an inpatient unit, and this offers them an alternative.”
The program was launched in 2016 to fill a service gap of patients needing care after being discharged from inpatient treatment. The staff consists of one full-time psychiatrist, one full-time nurse practitioner, and seven master’s-level therapists, and they can support a total of 20 patients at a given time. Ivan Chavarria-Siles, MD, PhD, is the Medical Director, and Jessica Rothenberg, MSW, is the Clinical Director. Patients come for treatment 10:30 am-4 pm, five days per week, for a maximum of six weeks. The Sheehan Disability Scale, which is a questionnaire completed on intake and discharge that measures how patients’ disabilities affect their lives and functioning, indicates that patients leave the program feeling more equipped to engage in their work, social, and family lives.
“This is an outstanding, well-organized program designed to maximize participants’ understanding of both cognitive behavioral therapy and behavioral principles,” said a former patient. “The group size ensures participation and feedback, and individual group members are provided a comfortable space to confide personal issues and receive group support. The group leaders are both empathetic and goal-oriented, and the material covered provides a rich array of strategies to foster mental health.”
The program focuses on group therapy (five groups per day), supplemented by individual therapy and, if needed, medication management. Patients sometimes leave before the end of six weeks, depending on their progress, stepping down to the intensive outpatient program, which is three hours per day for three days each week, and then down to regular clinical therapy services. The decision about the next step is a collaborative one, with the patient and treatment team deciding together.
The program has helped a wide variety of patients, many of them working professionals. “We see lawyers, doctors, and architects, and most of them are on leave of absence because they’re coming directly from hospital inpatient stays,” said Ms. Bell. “And then they’re able to leave the program and return to work. So it’s a really helpful and hopeful program.”
