Each year, providers involved in UConn Health’s Mood and Anxiety Disorders Program treat more than 500 patients with the skills of a psychiatric SWAT team, using diagnostic tools that epitomize the 21st Century.
The team is comprised of seven psychiatrists and four psychologists who have taken the treatment of psychiatry to a near-unprecedented level, using such innovative applications as smart phone apps and nasal spray mood elevators.
The program – launched four years ago by Dr. Jayesh Kamath, associate professor of psychiatry and immunology at UConn Health – distinguishes itself by tailoring treatments to patients with specific disorders, ranging from extreme depression and mood swings to suicidal tendencies.
“We see patients with mood and anxiety disorders who can benefit from specialized treatment approaches,” he says. “In founding the clinic, I wanted to create a program that would provide evidence-based care.”
Dr. Kamath says mood patients can primarily be divided into two extremes: those with depression, and those with mania or hypomania. The latter, he says, are frequently on a roller coaster ride of emotion from feeling low to feeling euphoric, “while patients with depression swing between feeling normal and feeling depressed.”
He says the needs of these patients are different from those of people with psychotic disorders. “Patients with schizophrenia, for example, experience paranoia and hallucinations.” While they may also have mood and anxiety symptoms, they’re only a part of their symptomatology. “The first target for their treatment is usually those psychotic symptoms, like hallucinations,” he says.
The clinic has refined its treatment program by using a triage-like approach to direct patients to specific providers based on patient needs and provider expertise. This process begins when patients in need call the clinic and report their symptoms to Razan Jazeh, the clinic’s coordinator.
“I handle the process of interacting with patients via phone and, after hearing their concerns, I select the appropriate [physician] provider for them,” says Jazeh, a four-year employee of the anxiety program. She’s become so attuned to her role that “I can pretty much predict when patient activity will increase – especially around the holidays or during bad weather, winter versus summer, or even when TV news is depressing. Every day, I’m impressed with the faculty here and the way they deal with each and every patient.”
Many of the patients in the program suffer from debilitating anxiety as a result of physical, sexual and, in some cases, military trauma.
“We also see patients who have, unfortunately, been subjected to other horrible traumas during their childhood or early years, and they can’t carry that baggage any longer,” says Dr. Kamath.
One of the features that make this program unique is its focus on both medication and psychotherapy, unlike those that focus only – or primarily – on medication management.
“In our program, we have psychiatrists who have expertise in psychopharmacology, so if a patient needs medications to manage their problems, they are assigned to these providers,” says Dr. Kamath.
“But we also have psychiatrists who have expertise in integrating medication management with psychotherapeutic treatments, and that is really one of the unique natures of this program. I would say most of us provide supportive psychotherapy with medications, and then there are psychiatrists in the clinic who provide specialized psychotherapies such as cognitive behavioral therapy.”
In terms of psychotherapy, that’s where someone like Karen Steinberg, PhD, comes in. Dr. Steinberg, a 20-year UConn Health employee, is a psychologist who conducts research in the areas of psychotherapy and child attachment; oversees programs aimed at reducing risk factors for child maltreatment and supporting new families in fostering positive relationships and child development; and teaches within the medical, graduate, and residency programs. She enjoys teaching mind/body skills and psychotherapy for psychiatry residents and fellows, helping them to cope with managing the stress of medical school.
She also sees individual patients throughout the week. “In the clinic, many of the people I see are struggling with work. They may be having challenges with a supervisor or coworker,” she says. Other patients may be students who are feeling stressed as they try to balance the demands of life, work, and school. Many have experienced traumatic stress that continues to interfere with their lives, and their ability to feel joy and happiness.
One approach she finds to be particularly helpful involves the cultivation of positive moods that can counteract the negative states of mind.
“We’ve known about these ideas for a long time,” she says. “But it’s almost like competing responses. It’s hard to be really tense and relaxed at the same time. Relaxation approaches are sometimes very helpful. A lot of them involve breathing techniques – slowing down breathing or progressive muscle relaxation. Guided imagery is an approach that uses the mind and imagination to try to reduce stress and create peaceful images, and we know this can [lower] blood pressure and heart rate. So, if you can teach people things that actually turn on the relaxation response, it can counteract a stress response.”
She then picks up her cell phone and taps an app titled ‘Instant Heart Rate.’ A few seconds go by as she places a finger over the small camera window on the back of the phone, which can measure a person’s heart rate and track the measurements over time.
Dr. Steinberg shares tools like this with her patients as a way for them to become more aware of how the body experiences stress throughout the day. These apps are like miniature “biofeedback” tools, and can often be obtained free of charge on mobile devices.
In a session, patients might use an app to measure their heart rate and think about how stressed they feel. “Then maybe we would do some kind of breathing exercise or relaxation technique and see if that had any effect,” she explains.
Another app, called “Breathe,” helps patients learn how to relax. It might tell the patient to “Stop, Breathe and Think,” and guide the patient through a 10-minute relaxation session or provide some information on stress. “It might give the patient a little quiz, after which it could say, ‘Tame your anxiety.’ There are even things about [improving] your sleep.”
Although it can be exciting to incorporate some of these advances into treatment, Dr. Steinberg does not feel they can replace one of the most important ingredients of psychotherapy – a positive connection between the therapist and patient, where the patient experiences the therapist as understanding, compassionate, and genuinely interested in their welfare, and in the improvement or resolution of their problems.
And that’s when the subject turns to one of the most innovative psychiatric approaches of the 21st Century. In short, the cell phone has replaced the 1975 mood ring.
For the past five years, Dr. Kamath has been collaborating with Professor Bing Wang, an associate professor of computer science and engineering and an artificial intelligence (AI) expert at the University of Connecticut Storrs campus. Both are leading a study funded by the National Science Foundation, using Smartphone technology to detect the worsening of depression, even without questioning patients.
“The cell phone is part of our body now, and with the patient’s consent, we can get data from these phones that can really tell us a lot about what’s going on with them,” says Dr. Kamath.
Using an app developed by the study team, Dr. Kamath and Professor Bing followed two groups of students, with and without depression. The app enabled them to track how quickly or slowly the patients moved, their mobility, their sleep, and how many places they visited during the day.
“We can even measure the intonation of their voice when they make a phone call. The app can track their activity on the cell phone, and even their Internet activity, or how many calls they make. Every two weeks, we send them a questionnaire asking a number of questions regarding their level of depression,” says Dr. Kamath.
The study clearly showed that as patients became depressed, they moved and talked more slowly, visited fewer places or remained in their home, and reduced their Internet activities. Through a Fitbit that patients wear at night, provided by the study team, “we can also tell if their sleep was disrupted.”
“It’s fair to say that their cell phones can be tattletales,” Dr. Kamath quips.
During the first phase of UConn Health’s study, involving 68 patients, the doctor and the professor found good correlations between the data and patients’ depression questionnaires. “By the second phase, among 120 patients, we were able to predict depression without even knowing the questionnaire outcome,” he says. Dr. Kamath believes they will soon be able to predict which patients are going to become depressed in the future.
Just when you think the cell phone’s AI represents psychiatry’s zenith, Dr. Kamath announces yet another innovation in the field of treating mood and anxiety disorders – a novel medication based on ketamine.
Ketamine is a medication often used as an anesthetic and pain reliever. UConn Health is one of 55 worldwide sites testing esketamine, a derivative of ketamine, as a mood elevator that acts quickly, potentially reversing the threat of suicide.
“It’s no secret that antidepressant medications take as much as four to six weeks before they can help a patient feel better,” says Dr. Kamath. “The field of psychiatry is on the verge of changing that, and we are proud to be part of it. Esketamine in a nasal spray form seems to be very effective. It works to reverse suicidality within hours or days, instead of weeks.”
Dr. Kamath said the FDA is close to approving this product, which is currently in a study phase. Its potential side effects include increased heart rate and blood pressure, possible disassociation, dizziness, nausea and headache, but there is no threat of overuse.
“The patient will have just a one-time use of the nasal spray at a physician’s office, after which the product container is disposed of,” he says. “If it gets approved within the next year or two, it can be a game changer in the field of psychiatry.”