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.”
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.
Jul 28, 2022 | Mental Health, Psychiatry, Your Health
Growing up is never easy, and adolescence has often been a difficult time for kids. But the ongoing pandemic has made life even more difficult, especially combined with the always growing influence of social media.
Nearly one in three adolescents will experience some form of anxiety disorder, according to the National Institutes of Health. Kids who are uniquely vulnerable include lesbian, gay, bisexual, transgender, Black, and female students.
Experts say there are steps families can take to address these issues, especially when it comes to use of social media.
Findings regarding the impacts of social media on adolescent health are nuanced and sometimes in conflict, though many clinicians and researchers agree that there are some adolescents who are more vulnerable to the effects of screen time than others. Families can intervene by monitoring for possible problems and helping kids determine how much they should use social media, how to balance that with other activities, and the drawbacks of taking away the smartphone entirely.
Stacey Lurie, PhD
“The good news is that parents can play a positive role and help their kids navigate screen use and social media,” says Stacey Lurie, PhD, a psychologist at the Mount Sinai Adolescent Health Center, who, along with her team, see more than 25 young patients each week. She is also the Director of the Center’s Psychology Training Program, which trains the next generation of psychologists in comprehensive mental healthcare for adolescents.
The Center is one of the leading centers of adolescent health care, training, and research in the United States. Mount Sinai experts report a significant uptick in teen anxiety, stress, and depression among the adolescents and young adults they treat. The uptick emerged during the pandemic and is consistent with a nationwide pattern described by the Centers for Disease Control and Prevention, which found that between 2009 and 2019, the experience of sadness or hopelessness among high school students had increased by 40 percent.
Many kids were struggling with virtual learning at home instead of in class due to the pandemic. Even as they began returning to the classroom, the experience of the pandemic had left a mark, which will be something experts will watch as kids prepare to return to school in the fall.
“As kids returned to in-person instruction, they have been experiencing social anxiety,” says Dr. Lurie. “The shift to a virtual environment was challenging. Shifting back was tough to handle all at once. Additionally, we are seeing more students struggling with attention difficulties, brought on in part by the virtual training model and the short-term feelings of reward brought on by social media apps and gaming apps.”
A key aspect of mental health care, says Dr. Lurie, involves getting families to come together to address screen use in a productive and collaborative fashion. Dr. Lurie works closely with families to address this. It’s all part of a process she calls “media planning.”
“The reality is that most young children these days have smart phones and it’s a whole new territory for parents,” says Dr. Lurie. The Pew Research Center reported in 2018 that 45 percent of teens say they are online almost constantly, up from 24 percent of teens in 2014-2015; they similarly reported that a majority of parents, 71 percent, are concerned that their child might spend too much time in front of screens.
Here are some of Dr. Lurie’s suggestions for parents:
- Kids are experiencing greater anxiety and depression these days. Keep an eye out for signs your child is not acting like themselves and keep the lines of communication open so you can help.
- Parents need to find the right balance for screen time. This is no small task, but it does help to bear in mind the new role of smartphones in kids’ lives today as lifelines to their entire community. Parents should have a conversation with their children. Finding a middle ground is key—so is being collaborative, and not controlling. For example, taking a phone away as a form of discipline for poor performance in school, or something else the parent is not happy about, is not recommended. Parents can set new limits if they think their child is going overboard with screen time, but taking the phone away is akin to removing that lifeline.
- Families need to come together and decide on their goals; there needs to be agreement on how much screen time is okay.
- Recognize that kids, like adults, see everyone on social media seeming to have the time of their lives. Help them to understand that’s not always true. Parents can help their children become informed critics of what they are seeing on social media.
- Parents need to be good models on screen time. So, for example, if the family has agreed that phones will not be a part of the family dinner, then parents should refrain from phone use at this time.
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.”
Updated on Sep 16, 2022 | Psychiatry
About the study
Mount Sinai researchers Xiaosi Gu, PhD, and Daniela Schiller, PhD, designed two games measuring how we make decisions to answer questions such as:
- How do we handle social situations?
- How do we perceive fairness and social influence?
Social interactions correlate with mental health, so the app also has mental health questionnaires. By playing our games and answering questions within the app, you will become a part of a massive online study that will allow us to take a whole new approach to the way we conduct research on social behavior.
All data is anonymous, and those who participate will be part of the first National Institute of Mental Health (NIMH)-funded study of its kind looking at social interaction and mental health.
The key to this study is scale, so the more people who participate, the more information we’ll have to understand behavior and work on solutions to the mental health crisis worldwide. Researchers hope you will share it with your friends and family.
Dr. Gu is one of the foremost researchers in computational psychiatry. Her research examines the neural and computational mechanisms underlying human beliefs, emotions, decision making, and social interaction in both health and disease.
Dr. Schiller’s line of research focuses on the neural mechanisms underlying emotional control. Understanding the neural mechanisms that make such emotional flexibility may shed light on the impairments leading to anxiety disorders and may also promote new forms of treatment.
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.
