Department of Psychiatry

WINTER 2016 CHAIR’S REPORT www.icahn.mssm.edu/psychiatry Deep Brain Stimulation Yields Positive Results in Patients with Obsessive-Compulsive Disorder

For more than a decade, Sara Gordon experienced the debilitating effects of obsessive-compulsive disorder (OCD), which had her constantly washing her hands and taking showers that lasted four hours. “I never felt like I was clean enough,” says Ms. Gordon, a recent graduate of Harvard University. “I had tried every treatment and nothing worked.”

Last summer, Ms. Gordon turned to Wayne K. Goodman, MD, Chair of the Department of Psychiatry and the Esther and Joseph Klingenstein Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai. Under Dr. Goodman’s care, Ms. Gordon underwent deep brain stimulation (DBS), a procedure in which an implanted device delivers electrical stimulation directly to the brain and modulates the abnormal patterns of neural activity underlying OCD.

Over the last 12 years, Dr. Goodman has used DBS to treat more than 20 patients with Bilateral VC/VS stimulation using 0-/Case+. The orientation is from posterior (back of head) to anterior, with left hemisphere on the left, and right hemisphere on the right. The MRI shown is an axial plane at the continued on page 2 › level of the base of the ventral striatum.

How Adaptive Rewiring Protects Against Bipolar Disorder

Individuals whose siblings have bipolar disorder bipolar disorder is genetic and can be traced to and are at high risk for developing the mood genes that affect brain function. Studies show disorder themselves may have a natural ability that close relatives of a person with bipolar to rewire their brains, which enables them to disorder are up to 10 times more likely than a remain unaffected and healthy. These findings, typical person to present with a range of mood led by Sophia Frangou, MD, PhD, Professor of problems within the bipolar spectrum. Psychiatry at the Icahn School of Medicine at Mount Sinai, were published in the January 5, The new study examined patterns of brain 2016, issue of Translational Psychiatry. connections in individuals with bipolar disorder and the patients’ healthy (resilient) Most of the risk (up to 80 percent) of developing Sophia Frangou, MD, PhD siblings, then compared them to unrelated continued on page 3 ›

Icahn School of Medicine at Mount Sinai | One Gustave L. Levy Place, Box 1230 | New York, NY 10029-6574 | www.icahn.mssm.edu/psychiatry Mental Health Services for the LGBT Community

Transgender individuals who experience charged with implementing profile of health risks and clinically significant distress or impairment its recommendations. He is disparities, increased rates due to the lack of congruence between their also on the editorial boards of of depression, anxiety experienced gender and their natal sex meet the Journal of Homosexuality, disorders, suicidality, and DSM-5 criteria for the diagnosis of gender the Journal of Gay and substance abuse have been dysphoria (GD). Some individuals will seek Lesbian Mental Health, and found across all of these treatment through hormones and surgery serves as editor-in-chief groups and have been linked while others will socially transition and of LGBT Health. He works to minority stress. benefit from assistance to cope with stigma nationally with the Veteran’s and connections to community support. Health Administration to Dr. Byne says, “A similar train VA staff in the provision pattern of mental health In 2014, Medicare lifted its ban on coverage of culturally competent health disparities is seen in for gender-transition-related-health care care to transgender veterans. William Byne, MD, PhD stigmatized racial and ethnic and subsequently, many private insurers minorities, and is even more have followed suit, as have some state It is essential, he says, that clinicians accept pronounced in sexual and gender minority Medicaid programs. and affirm their patients’ sexual orientation individuals who are also racial or ethnic and gender identity when providing mental minorities.” “This increased insurance coverage health services to sexual and gender underscores not only the recognition by the minority individuals. An affirmative stance For GD patients, he says, mental health medical profession and insurance carriers of reflects the therapist’s respect for and professionals have many tasks. These hormonal and surgical transition treatments validation of the patient’s sexual orientation, include assessing GD; providing information as medically necessary, but also the increased relationships, and gender identity. regarding options for gender identity social acceptance of gender transition,” and expression and possible medical says William Byne, MD, PhD, Associate “The therapist’s affirmative attitude is interventions; assessing and diagnosing Professor of Psychiatry at the Icahn School of meant to offer LGBT patients a contrast to coexisting mental health concerns, Medicine at Mount Sinai, and staff physician the social denial and denigration they may discussing treatment options and making at the James J. Peters VA Medical Center. have experienced in the past, or continue to appropriate referrals for care; assessing “The generally positive public response to experience outside the consultation office,” eligibility and preparedness for hormonal Caitlyn Jenner’s recent transition is another says Dr. Byne. and surgical treatments, and providing indicator of increasing public acceptance.” necessary referrals; and engaging in Psychiatrists should also consider the psychotherapy with the goal of finding Dr. Byne chaired the American Psychiatric impact of such stigmatization, sometimes ways to maximize a person’s overall Association’s Task Force on Treatment of referred to as LGBT minority stress. While psychological well-being, quality of life, Gender Dysphoria and chairs the workgroup each LGBT population experiences a unique and self-fulfillment.

› Deep Brain Stimulation Yields Positive Results in Patients with Obsessive Compulsive Disorder continued from page 1 intractable OCD—patients who fail to implanted electrodes bilaterally in respond to selective serotonin reuptake each side of Ms. Gordon’s brain and inhibitors (SSRIs), augmentation with placed a neurostimulator in her chest. antipsychotics, or cognitive behavioral He used intraoperative imaging and therapy. In a 2012 literature review tractography to guide the DBS lead in the Annual Review of Medicine, placement, two advances pioneered at Dr. Goodman showed that more Mount Sinai. than 60 percent of participants experienced clinically significant Two months after her initial surgery, relief from symptoms following DBS. Dr. Goodman worked with Ms. Gordon The procedure was successful for Ms. to determine her emotional and Gordon, as well. behavioral reactions to the device and adjust the settings using a handheld During her case, Dr. Goodman worked programmer to optimize her response. closely in the operating room with neurosurgeon Brian Kopell, MD, “Making it through the day is no longer Associate Professor of Neurosurgery, an accomplishment—I don’t brood over Neuroscience, Psychiatry, and who touched the doorknob or faucet, and Neurology at the Icahn School of my repetitive reassurance questions are Medicine at Mount Sinai. Over the From left: Brian Kopell, MD; Sara Gordon; and Wayne nonexistent,” says Ms. Gordon. “I finally course of three surgeries, Dr. Kopell Goodman, MD feel like I have a future ahead of me.”

2 › How Adaptive Rewiring Protects Against Bipolar Disorder continued from page 1 Substance Use and Adolescent healthy individuals without family history of the disorder. Siblings selected to Brain Development participate in the study were in their mid- 40s, an age when the chances of developing The Icahn School of Medicine at Mount Sinai the disorder are very low. recently received more than $4.7 million from the National Institutes of Health to Functional Magnetic Resonance Imaging study the effects of adolescent substance (fMRI) results revealed that compared to use on the developing brain. The Adolescent healthy unrelated individuals, patients with Brain Cognitive Development (ABCD) study bipolar disorder and their resilient siblings will follow approximately 10,000 children showed similar brain abnormalities when beginning at ages 9 and 10, before they initiate asked to perform tasks that tap into brain drug use, through the period of highest risk functions known to be affected by bipolar for substance use and other mental health disorder. However, the resilient siblings disorders. Scientists will track exposure to Rita Goldstein, PhD showed additional changes in brain wiring substances (including nicotine, alcohol, and within these networks that were unique marijuana), academic achievement, cognitive skills, mental health, and brain to them and therefore likely to represent structure and function using advanced research methods. adaptive rewiring that has helped them remain well. Mount Sinai’s portion of the ABCD study will include following 500 teens and specifically focus on predictors of early onset use and how these substances alter “So far in the field of psychiatry we have the developmental trajectory of the brain in the short and longer terms. focused on risk, and on brain changes that contribute to illness instead of looking for “The standardized, multisystem big-data framework approach that we will use to brain changes that can be protective,” says study a large number of young study participants represents a paradigm shift for Dr. Frangou. “The fact is, the majority of the addiction and mental health fields and will yield valuable insight about the people at ‘high risk’ for bipolar disorder impact of substance use and abuse on young people,” says Rita Goldstein, PhD, remain free of any psychiatric disorder. Chief of the Neuropsychoimaging of Addiction and Related Conditions (NARC) and Recognizing the factors that promote the Brain Imaging Core (BIC), and Professor of Psychiatry and Neuroscience in the resilience in the presence of significant Icahn School of Medicine at Mount Sinai, who is leading the study at Mount Sinai. genetic risk is very important as it shifts the focus from illness to well-being.” She says, “Integrative multimodal neuroimaging studies to uncover the brain mechanisms that could predate and potentially contribute to risk for substance The research suggests “that it is possible abuse and addiction and related psychiatric comorbidities have not been conducted for some individuals to develop adaptive at this scale before, so this project is both exciting and crucially important.” changes naturally, and we can promote these connectivity changes in other high- Dr. Goldstein will work with collaborators from the University of California, risk people,” Dr. Frangou says. San Diego, and Weill Cornell Medical College of Cornell University and Columbia University to collect mental and physical health information, including data Ultimately, Dr. Frangou expects to develop from high-resolution brain scans and genetic material. They will also collect an automated algorithm able to reveal the information about sleep patterns, diet and exercise, social media use, and other likelihood that a person at high risk for environmental factors. bipolar disorder will actually develop it. “The close collaboration with BJ Casey, PhD, the principal investigator of the study She also wants to extend her research at Weill Cornell, and her team, will allow us to study the cortical-subcortical to include relatives of people with pathways that may predispose some individuals for developing impulsive behaviors schizophrenia, and to develop computer- that could contribute to drug addiction and other disorders,” says Dr. Goldstein. based cognitive training interventions to “Such early identification of risk is crucial for the development of effective and evaluate whether mental exercises can help individually tailored intervention and prevention efforts. We will also be able promote resilience. to identify the brain circuits and pathways that may provide protection against developing addiction; identifying mechanisms underlying resilience has been an “Looking for biological mechanisms that important focus at Mount Sinai.” can protect against illness opens up a completely new direction for developing In addition to creating a comprehensive informational database and birds-eye view new treatments,” says Dr. Frangou. of this potentially turbulent time in a person’s development, the ABCD study aims to “Our research should give people hope apply these findings to help inform public health and prevention strategies that can that it is possible to beat the odds at the be designed to protect young people when they are most vulnerable. genetic lottery.” For more information about the ABCD study, please visit: http://addictionresearch. nih.gov/adolescent-brain-cognitive-development-study

3 DEPARTMENT OF PSYCHIATRY CHIEF’S REPORT | WINTER 2016

Enhanced Training in Child and Adolescent Psychiatry

In July, the Icahn School of Medicine at art evidence- Disorders; Autism Spectrum Disorder; Mount Sinai will launch an integrated based treatments Childhood Trauma and Resilience; Eating residency as part of the Child Behavioral across a broad and Weight Disorders; Mood and Anxiety Health and Science Center Education and spectrum of child Disorders; Obsessive-Compulsive Disorder; Training Program, with 10 residents from and adolescent Substance Use Disorders; and Tics and the child and adolescent psychiatry program psychiatric Tourette’s Disorder. and the Triple Board program—which disorders,” says combines pediatrics, psychiatry, and child Barbara Coffey, Senior residents will have additional and adolescent psychiatry. MD, MS, Director protected time and flexibility to choose of the Child clinical areas of focus and develop expertise Drawing upon the vast resources of the Behavioral Health that facilitates career development. Triple Mount Sinai Health System, trainees will Center Education Barbara Coffey, MD Board residents will also specialize in have access to faculty members, clinical and Training addressing the mental health needs of material, and rotations, as well as a wide Program, Professor of Psychiatry, and medically ill children and adolescents. variety of research projects. For the first Director of the Tics and Tourette’s Clinical time, trainees will rotate through four and Research Program. “As the field of child and adolescent Mount Sinai campuses, including The Mount psychiatry continues to expand and mature, Sinai Hospital, Mount Sinai St. Luke’s, The training program offers protected we rely more heavily on developmental Mount Sinai Beth Israel, and Mount Sinai time to participate in the Department neuroscience to treat mental disorders,” says West (formerly Mount Sinai Roosevelt). of Psychiatry’s Centers of Excellence. Dr. Coffey. “As a result, a central, unifying Directed by renowned leaders in the field, theme of our educational approach is a “Our program has been carefully crafted the centers provide exposure to research developmental perspective that provides a to provide immersion in a wealth of and specialized clinical approaches within clinical neuroscience foundation drawing on in-depth experiences for trainees, from subspecialty areas, including: Attention empirically based treatments understanding comprehensive evaluation to state-of-the- Deficit/Hyperactivity Disorder and Learning human behavior.”

A MESSAGE FROM THE VICE CHAIR FOR EDUCATION Redesigning Resident Training

The Department of Psychiatry has months, and added a six-month full-time outpatient redesigned residency training to better experience in the second year. This novel program structure align new trends in clinical psychiatry reflects the changing practice of psychiatry and maximizes the with discoveries in neuroscience. In ratio of educational opportunities to service delivery. Looking preparing our graduates to become the to the future of psychiatric practice, we have added rotations next generation of academic leaders, the for our third- and fourth-year residents to learn the principles Antonia New, MD Icahn School of Medicine at Mount Sinai of collaborative care and working within other subspecialty has created the first National Institutes of medical clinics. Mental Health-funded, seven-year program that combines clinical training with a PhD. We offer this novel Psychiatry Residency + In addition, we are adapting our curriculum to integrate PhD track, in addition to the Academic Clinician-Educator (ACE) neuroscience into every year of training, so that residents program, and the Physician-Scientist Research track. can translate clinical phenomenology into abnormal brain function. Mount Sinai’s residents now train in the imaging By leveraging the Mount Sinai Health System’s outstanding laboratory, attend clinical neuroscience case conferences, neuroscience and translational research faculty, we have created participate in interactive neuroscience didactic series, and an integrated and agile learning environment with a wealth of collaborate with expert clinical researchers in subspecialty material that residents draw upon and fashion into individualized areas of their choosing. The curriculum includes elective academic and professional experiences. Mount Sinai’s redesigned time that begins in the second year and substantially residency program permits maximum flexibility within the bounds increases during the third and fourth years. of the Accreditation Council for Graduate Medical Education (ACGME) requirements and facilitates independent thinking and Our mission is to foster a level of independence and expanded research opportunities. expertise that will form the foundation for their development as leaders in clinical practice, research, teaching, and We have reduced inpatient rotations to eight months from fourteen administration.