From left, Honoree David Sanborn, Shantelena Mouzon, administrative coordinator at the Louis Armstrong Center for Music and Medicine, and musician Paul Shaffer
The 17th annual “What a Wonderful World” gala benefiting the Louis Armstrong Center for Music and Medicine, was a festive evening of jazz and expressions of gratitude to three honorees for making the world more wonderful through their contributions to music and music therapy.
The event, held Monday, October 24, at the Angel Orensanz Foundation and hosted by the Wonderful World Friends of Music Therapy Inc., honors the legacy of the Louis Armstrong Department of Music Therapy and their commitment to music therapy at Mount Sinai hospitals.
The event recognizes a dynamic group of individuals chosen from a variety of fields including music, medicine, and patients who have benefitted from receiving music therapy at Mount Sinai hospitals.
This year’s honorees were Grant Mitchell, MD, Chair, Department of Psychiatry, Mount Sinai Beth Israel; David Sanborn, the multi-Grammy Award-winning saxophonist, who was presented the Phoebe Jacobs Award by Paul Shaffer (pianist of the former Late Night with David Letterman); and patient Rosemarie Greene.
From left, Honoree Grant Mitchell, MD, Joanne V. Loewy, DA, LCAT, MT-BC, Prameet Singh, MD, and Daniel S Safin, MD
The gala was hosted by Mercedes Ellington, dancer, choreographer, and granddaughter of Duke Ellington, and Bill Daughtry, the retired radio and TV host. The co-chairs were Karen and Doug Seidman from the Louis Armstrong Center for Music and Medicine’s Steering Committee. The event featured performances by Rema Webb from the Broadway production of The Music Man; Antoine Smith from the Broadway production of MJ: The Musical; saxophonist Erik Lawrence, Lou Marini, a saxophonist and an original member of The Blues Brother, and jazz pianist Garry Dial. Mr. Shaffer and Mr. Sanborn, along with Will Lee (bass), performed jazz and Louis Armstrong’s ‘Wonderful World’.
“We are proud to bring together members of the music, medicine, and patient community who through the gala learn of the breadth and scope of patients we serve and our research projects with doctors and nurses, from neonatal care to oncology, Alzheimer’s disease and psychiatry,” said Joanne V. Loewy, DA, LCAT, MT-BC, Founder and Director of the Louis Armstrong Center for Music and Medicine, which provides music therapy services throughout the Mount Sinai Health System.
The Department of Music Therapy, with support from the Louis Armstrong Educational Foundation and other grants, provides a range of clinical services for infants, children, and adults, and day treatment at the Mount Sinai-Union Square clinic and within the community. Its music therapists are licensed and board certified to provide care that complements medical treatment, assisting with sedation, pain management, and neurologic and respiratory function.
“With substance use disorders, there’s a huge issue of stigma that prevents a lot of women, and thus their children, from getting the care they need. If we want healthy children, we need healthy moms.” — Yasmin Hurd, PhD
Addiction is an all-too-common problem among pregnant people, with devastating results for parents and their children. Now The Bridge Program, a new initiative at Mount Sinai, is providing integrated prenatal care and substance use treatment.
Launched in September 2022, The Bridge Program is the first program of its kind in New York City, and it addresses an increasing need. “Until now, there was no place in all of Manhattan where a pregnant person with an addiction disorder could go for prenatal care or consultation. It’s a really overlooked area, and it’s so important for the health of pregnant people and their newborns,” says Joanne Stone, MD, Chair of the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai.
“With substance use disorders, there’s a huge issue of stigma that prevents a lot of women, and thus their children, from getting the care they need,” adds Yasmin Hurd, PhD, Director of the Addiction Institute at Mount Sinai. “If we want healthy children, we need healthy moms.”
Prenatal Care for an Overlooked Population Nearly 10 percent of pregnant women use substances during pregnancy. “This problem is just as common as many of the other issues that we test for during routine prenatal care, yet there are limited programs specifically targeting this population,” says Leah Habersham, MD, an Assistant Professor of Psychiatry and Obstetrics, Gynecology, and Reproductive Science at Icahn Mount Sinai. “And overdose deaths are steadily increasing among women of childbearing age.”
Dr. Habersham aims to use her dual training in obstetrics and addiction medicine to turn those trends around. She is currently the sole provider for The Bridge Program, offering varying levels of care depending on a patient’s needs. If a patient has already established prenatal care, Dr. Habersham will offer consultations or provide treatment and support for substance use disorders. Other patients may choose to come to her for both addiction services as well as obstetrical and gynecological services, including the full range of prenatal care. She also works closely with a social worker to provide additional care and psychosocial resources to her patients.
The Bridge Program sees pregnant patients who use or misuse any substances, including nicotine, alcohol, opioids, and other drugs. Dr. Habersham also welcomes patients who are not currently using substances but are at high risk, such as those with a history of addiction or those who may live with a partner who has a substance use disorder. “If there’s any concern, patients can be referred to this program,” she says.
A Nuanced View of Addiction in Pregnancy
While interventions are tailored to each patient, Dr. Habersham often uses motivational interviewing to meet patients where they are—and begin to move them toward accepting treatment. “There’s often a lot of ambivalence from patients who aren’t ready to take that next step toward recovery. Harm reduction is important in this setting,” she says.
As a specialist in addiction medicine and obstetrics and gynecology, she brings a more nuanced view to her care of pregnant patients. During pregnancy, for example, patients who receive medication for opioid use disorders (MOUD) will often need increases in their MOUD regimens to prevent cravings. She makes sure patients are aware of that possibility, and not afraid to speak up if they notice changes in how they are feeling. “Someone without an addiction background may see that as a sign the patient is going to go out and use opioids, though it’s not necessarily the case. Often, patients just need an increase in their doses,” she says. “A lot of times, patients withhold that kind of information from general providers.”
When it comes to prenatal care, Dr. Habersham also does things a little differently with this population. “A lot of patients with substance use disorders have trauma in their backgrounds, and many have distrust for their providers. It’s really important to build a strong foundation of trust in the doctor-patient relationship,” she says. That means she may not do a vaginal exam during the first visit, for instance, but wait until the second visit when the patient feels a bit more comfortable. “There are many biopsychosocial aspects involved,” she says.
Substance Use Screening & Methadone During Pregnancy
Because of stigma and stereotypes, there are often inequities in who is screened for substance use disorders during pregnancy and how they are screened. Even before The Bridge Program was conceived, Mount Sinai’s OB-GYN department began screening all pregnant people for possible substance misuse and addiction. “The implications [of substance use during pregnancy] are profound, and it’s important to make sure that screening is done in an unbiased way and in a manner that leads to better health care for pregnant people and their babies,” Dr. Hurd says.
She and her colleagues hope The Bridge Program will be a first step on that path to better and more inclusive health care. Initially, the program will be available to patients one day a week. Eventually, the team hopes to expand the services to reach many more patients in need. “We have all the parts of the toolbox here at Mount Sinai—a detox unit, rehabilitation, residential living, even a female-only methadone clinic. I hope we can become a center of excellence for women throughout the city with substance use and substance use disorders, and not just during pregnancy,” Dr. Habersham says.
The Opioid Treatment Programs at the Addiction Institute of Mount Sinai offer medications and a suite of services to help thousands of people with opioid use disorder reclaim their lives each year.
In 2021, drug overdose deaths in the United States surpassed 100,000 annually for the first time, according to CDC data. The vast majority — 75,673 —were caused by opioids, up from 56,064 the year before. One factor in those lost lives is fentanyl, a powerful opioid that is increasingly prevalent in the illicit drug supply.
Yet deaths due to opioid use disorder (OUD) are preventable, and effective treatments are available. The Opioid Treatment Programs at the Addiction Institute of Mount Sinai provides medications and other services to more than 3,500 patients with OUD at eight clinics in New York City.
“We treat the entire person. The first step is helping them to stop using opioids, then we start to work on recovery of all life areas,” said Teri Friedman, Senior Director of Addiction Services at Mount Sinai Beth Israel. “We try to help patients reach the highest level of functioning in all areas of their lives.”
Buprenorphine and Methadone Clinics Are Just the Beginning Mount Sinai has a long history of treating substance use. Its predecessors, Beth Israel Medical Center and, before it, Manhattan General Hospital, were pioneers in addiction treatment. Harold Trigg, MD, Marie Nyswander, MD, and Vincent Dole, MD, launched the Methadone Maintenance Treatment Program in 1965. More than half a century later, the program is now known as the Opioid Treatment Programs at the Addiction Institute of Mount Sinai, and it continues to help patients with opioid use disorder reclaim their lives.
Medication is the gold-standard treatment for OUD. Methadone and buprenorphine/naloxone are FDA-approved and able to decrease cravings and relieve withdrawal symptoms. Mount Sinai’s outpatient Opioid Treatment Programs provides those medications at outpatient clinics in Manhattan and Brooklyn.
Yet medications alone cannot restore lives. “As we embrace recovery, we come to an understanding that every recovery path is different from the next. We meet patients where they’re at,” said Cheryl Marius, Director of the Opioid Treatment Program clinics at Mount Sinai Beth Israel.
Those clinics also provide:
One-on-one therapy
Group counseling
Peer counseling
Case management
Educational and vocational counseling
Annual physicals and general medical care
Psychiatric evaluation and medication management
Referrals for mental health treatment
HIV counseling and testing
Hepatitis C testing and telemedicine
As part of Mount Sinai, the programs are well connected to help patients access the care they need, said Annie Levesque, MD, Medical Director of the Opioid Treatment Program at the Addiction Institute at Mount Sinai West. “We’re embedded in the Addiction Institute, so our patients have access to a greater level of care. We can easily refer them to other services as needed, such as more intensive group therapy or inpatient detox for other substances.”
Addressing Disparities in Addiction Treatment Methadone has been prescribed to people with OUD for decades. Buprenorphine/naloxone is a newer treatment, with a better safety and side effect profile than methadone, Dr. Levesque said. And because there is less regulation around buprenorphine, it can be prescribed in more settings, including doctor’s offices. Yet in many treatment programs, there are sharp racial and socioeconomic disparities in treatment. Patients with private health insurance are more likely to receive buprenorphine prescriptions from their doctor, avoiding daily visits to a methadone clinic.
At Mount Sinai’s opioid treatment clinics, all patients are given the option of treatment with either methadone or buprenorphine. Many patients who have been on methadone for some time prefer to continue with that medication, Marius said. But counselors and patients take many factors into consideration when determining the best path forward. “We provide individualized treatment for each patient,” Dr. Levesque said.
The frequency of a patient’s clinic visits depends on their progress through the program, regardless of which medication they choose. Early in the process, patients come to the clinic daily for their medication, which ensures that they are in regular contact with their counselor. Patients who are stable for some time and not using illicit drugs may progress to coming less frequently to pick up their medications, perhaps as infrequently as once a month. “Your recovery determines your schedule,” Marius said.
Rethinking Treatment for Opioid Use Disorder Treating OUD remains an uphill battle. Both the disorder and the medications prescribed to treat it are subject to significant stigma. “More people need to accept that this is a medical disease,” Marius said. One common misconception within the medical community is that patients who take methadone have just swapped one drug for another. “Methadone is a medication, just as insulin is a necessary treatment for diabetes,” Friedman says.
Another mistaken belief is that patients with OUD should be referred for short-term detox, or that they should eventually taper off treatments like methadone. “In fact, long-term maintenance treatment is considered the best quality of care,” Dr. Levesque said.
Dr. Levesque and her colleagues at the Opioid Treatment Program are pushing back against the stigma, training others in the medical field and conducting research to improve access to treatment — and save more lives.
“Despite the high number of deaths, opioid use disorder is highly undertreated,” Dr. Levesque said. “As physicians we need to be referring patients to treatment and making sure we connect them to these treatments that work.”
Suicide is a serious public health problem, one that affects a broad segment of the population, according to the Centers for Disease Control and Prevention. But it can be hard to talk about.
In fact, there is one suicide death every 11 minutes, and that does not reflect the number of attempts. The suicide rate had been rising dramatically prior to the pandemic, which is one reason why the federal government in July launched the 988 National Suicide & Crisis Lifeline, an upgraded hotline for those in crisis.
At the same time, it’s important to remember there are ways to mitigate the risk of suicide and specific things you can do if you are concerned about a friend of family member. In this Q&A, Marianne Goodman, MD, Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, offers some guidance on this sensitive topic.
“If we can help people identify suicide risks, limit access to ways that they could die by suicide, and use the crisis services that are now much more available, including the national 988 hotline, we can make a big difference,” says Dr. Goodman, acting director of the Mental Illness Research, Education and Clinical Centers at the James J. Peters VA Medical Center in the Bronx, who also co-leads a new initiative to help concerned family members speak to veterans about safely storing firearms and reducing the risk of self-harm.
How serious is the problem of suicide in the United States?
Suicide is the 12th leading cause of death. There are about 130 suicide deaths every day, and that’s one about every 11 minutes. In 2020, almost 46,000 Americans died by suicide, and this is twice as many as those who die in homicides. There were also 1.2 million suicide attempts. White males account for about 70 percent of the suicide deaths, and firearms are involved in more than half of these deaths. Unfortunately, in the past 20 years, the age adjusted suicide rate has increased 30 percent. This is a national crisis prompting a tremendous amount of research and clinical programming developed to target this elevating rate of suicide.
Who is most at risk, and why?
Certain populations have a particularly heightened risk. These include those encountering chronic stressors such as the elderly, veterans, lesbian, gay, bisexual, transgender, and queer populations, those with debilitating physical and mental illness, and especially those with a previous suicide attempt. Other risk groups include people with acute stressors such as a recent job loss, having been stigmatized, victimized, or traumatized, or who have experienced financial or relationship problems. But there’s not an equal risk at all times. It turns out that the rate of suicide is higher on Mondays and lower on the weekends; rates are higher during the spring and summer and after midnight.
What are some of the most common causes of suicide and suicidal thinking?
Suicide and suicidal thinking is prompted by many factors. In addition to the known risk factors, suicidal symptoms can be triggered by intense feelings of failure, shame, and being a burden to others. A deep sense of isolation, helplessness, and hopelessness leads to the belief that taking one’s life is the only answer to the misery they are feeling. However, there are also protective factors that actually lower the risk of suicide. These include bolstering coping abilities, having a purpose and reason for living; possessing a strong cultural identity; and a connection to others. If we can increase our protective factors, it actually mitigates some of the risks.
There are growing concerns about suicide among younger people. Why is that?
There is a tremendous and growing concern about suicide in younger people. Suicide is now the second leading cause of death among people aged 15 to 24. The highest rate of suicide death in youth are American Indians and Alaska Natives, with about 23 deaths per 100,000 people. White youth are second with about six suicide deaths per 100,000 people. While these numbers are certainly concerning, there’s a lot of recent evidence that suggests that youth suicide is a growing problem. A recent study that looked at just the past year found that 20 percent of high school students reported serious thoughts of suicide, and 9 percent made an attempt. Those are astronomical numbers. It’s not just high school students at risk; other concerning emergency room data of pre-adolescent children 10 to 12 years old document an increase in suicidal ingestion of substances, up four and a half fold in the past two decades. Also, reports of firearm use in youth is the highest in the past 20 years. During the pandemic, there was an increase in firearm suicide deaths of about 2 percent in adults, but 15 percent in young people. So clearly life stressors are affecting youth, and it’s being expressed through suicidal expression.
What has been the impact of the pandemic?
Suicide rates peaked in 2018. During the pandemic, suicide rates actually declined 3 percent in 2020. Pandemic related decreases could be explained by the notion that people pull together during a crisis. Some stressors were lessened during the pandemic, such as no longer needing to endure long commutes to work. The pandemic did draw attention to the importance of mental health. So while the pandemic was stressful, some of those forces were mitigated with the suicide rate coming down since 2020.
Has the new 988 National Suicide Prevention Hotline helped?
The 988 hotline is the 911 for mental health crises. The national hotline, accessed through calling 988, now connects people to the National Suicide Prevention Lifeline. This lifeline then connects individuals to various resources, including the Veteran’s Crisis Line, and a network of more than 200 state and local call centers services through the U.S. Department of Health and Human Services. The Biden administration invested a tremendous amount of money into this infrastructure. In fact, funding increased from $24 million to $432 million to address our mental health and suicide crises. In the year before the hotline, there were about three million calls, chats, and text to these centers. That’s expected to double within the first year of the national hotline.
What are some signs that someone may be in need of help?
Suicide prevention is everybody’s responsibility. There are warning signs that signal that someone is struggling. These include a preoccupation with death, comments about feeling trapped or a burden to others, or suggesting that people would be better off without them. Look for reckless behavior and impulsivity, such as driving at high speeds or enhanced use of alcohol and mind-altering substances. Mood swings, irritability, and worsening anger are concerning signs, as are changes in behavior including pushing people away, turning off phones, excessive sleep, or inability to sleep.
What should you do if you are concerned about a loved one or friend?
If you are concerned about a loved one or a friend, it’s important to reach out to that person. Talk to them and listen carefully. Encourage them to tell you what’s going on. Ask some difficult questions, such as: Are they feeling so bad that they want to think about ending their life? Do they have a plan to end their life? Don’t pass judgment about what they’re saying. Just be there to hear what they have to say. It’s important to empathize with the pain that they are going through. Help them to connect to either friends or support. If they are in crisis, use the 988 hotline, or seek professional help in a local emergency room. It’s very important to reassure the person that that they will not feel this bad forever and that negative feelings do get better over time.
What resources are available?
There are tremendous resources available. You can call the 988 hotline line 24/7. There are many organizations that offer assistance, including the American Foundation for Suicide Prevention, which has a website with lots of information. Another website, Means Matter, offers information about the importance of restricting access to a means to die by suicide, such as firearms. The Suicide Prevention Resource Center is another valuable resource.
Why is the issue of firearms so important?
When firearms are used, more than 85 percent of suicide attempts end in death. All other methods average about a 2 percent likelihood of death. More than 50 percent of people who die by suicide use firearms. If we can limit access to firearms, especially for those who are vulnerable, during high-risk times, we can meaningfully bring down suicide death rates. Promoting safe storage of firearms, and involving family in these decisions, is key. Pulling a trigger can happen so quickly with firearms—that urge, that impulse, once it is acted upon, you can’t take it back.
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.”
“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.
