mental health

Unraveling

By Kim Krieger | Illustrations by Yesenia Carrero

illustration; two silhouettes, one with a scribble pattern overlayed over top. looks to scribbled circular dot between them

PTSD can undo a sufferer’s life. MDMA may help patients untangle their trauma and find their way back to mental health.


When lasting trauma is caused by callous acts of violence, the key to recovery can be making meaning from meaninglessness.

This year UConn Health will host a phase 3 FDA trial that tests whether the drug MDMA, known on the street as ecstasy or molly, is a safe and effective treatment for post-traumatic stress disorder. The disorder is difficult to treat, and many people have a tough time handling the treatment. MDMA not only might make therapy more tolerable but it also may help open a window for patients into their own mind. The insight allows them to process a shattering, horrific event into something that makes them stronger.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders defines post-traumatic stress disorder, or PTSD, as when a person is traumatized in some way and then continues to reexperience the trauma through flashbacks, nightmares, or unwanted intrusive memories. The person with PTSD avoids people or places associated with the trauma; becomes overly negative in thoughts and speech about themselves and other people; and has heightened arousal that can include a hair-trigger startle reflex, inability to sleep, hypervigilance, irritability, and aggression. At its worst, people are unable to cope with everyday life and may even become suicidal.

Often the source of the trauma is a shocking event involving interpersonal violence, such as rape, combat, or sexual abuse. Racial discrimination and harassment, particularly when it is shocking or pervasive, can also cause PTSD. UConn psychologist Monnica Williams began focusing on race-based trauma when she was at the University of Pennsylvania and had a very successful, high-achieving, black client come in with PTSD stemming from racial discrimination she’d suffered on the job. Williams was taken aback and began studying the link between racism and post-traumatic stress disorder.

Deconstructing the Trauma

But no matter what type of trauma causes the PTSD, the most effective treatment for it is exposure-based therapy, such as “prolonged exposure.” Essentially, the therapist has the patient discuss the traumatic event in excruciating detail, over and over again, until it ceases to cause overwhelming fear and anxiety.

Prolonged exposure works — indeed, it has the most evidence behind it. But it’s terribly difficult for the patients, who often get visibly upset during sessions, and many quit therapy because the experience is too much like the original trauma.

The MDMA-assisted therapy session was utterly without the distress, tension, and fear PTSD patients typically show during prolonged exposure treatment.

MDMA-assisted psychotherapy could be one way to change that. The drug stimulates the release of neurotransmitters that promote a feeling of trust and well-being and might also help the brain rewire itself. But when Williams first heard of it, she was skeptical.

“It sounded weird, like junk science, and I didn’t want to be part of that,” she says. But she agreed to take a look at an article in Psychopharmacology. She was fascinated to see that researchers had used MDMA as an adjunct to psychotherapy for PTSD and had gotten really good results. She was pleasantly surprised again when she first watched a video of an MDMA-assisted therapy session.

“People were sitting in a chair, relaxed. They’re processing it on their own, and would sometimes share new insights with the therapist,” Williams says. It was utterly unlike the distress, tension, and fear PTSD patients typically show during prolonged exposure. “They would say things like, ‘Wow. Now I understand the trauma didn’t happen to me because I’m a bad person — I was just in the wrong place at the wrong time.’ And we’re like, ‘Yes! Yes! They finally get it!’” she recalls. The MDMA helps them look at the big picture, to understand that the violence against them didn’t mean what they thought it had.

‘It’s got to come out’

It takes a while for psychoactive drugs to work their way through the FDA approval process. MAPS has been testing MDMA-assisted therapy for PTSD for more than a decade. Many of the early participants experienced lasting improvement.

Rachel Hope, who experienced a cascade of abusive events as a child that left her with severe PTSD, “did 20 years of psychotherapy” prior to participating in an MDMA-assisted therapy session. “When I got into the outer limits of the really hardcore stuff, I’d start to destabilize and get sicker … I’d start vomiting or have to leave the room. I knew that I had to tell it — the story has a soul of its own. It’s got to be seen, got to be known. It’s got to come out. But I couldn’t get it out,” she says.

Hope had had good therapists and managed to run a real estate development company, but eventually the PTSD got so bad she couldn’t leave the house. Finally her personal assistant threatened to quit if she didn’t go back into therapy. And that’s how she came to participate in an MDMA-assisted psychotherapy trial in 2005. It was a revelation.

“The MDMA was a terrific antianxiety medicine,” she says; it didn’t make her fuzzy-headed like most antianxiety meds had. “It amplified access to memories and, really, I had access to everything, and I wasn’t terrified. I could actually tell someone, for the first time in my life, what had happened to me. I had so much access to my own mind.” She describes it as the perfect tool to help work through the trauma. “I was rebooting my mind under my own directive,” Hope says.

“They would say things like, ‘Wow. Now I understand the trauma didn’t happen to me because I’m a bad person — I was just in the wrong place at the wrong time.’ And we’re like, ‘Yes! Yes! They finally get it!’”

Williams agrees that the MDMA seems to help patients rapidly make connections and breakthroughs in a single therapy session. Typically, a patient in psychotherapy might have just one such realization every few months.

The participants in the phase 3 trial at UConn Health will have a total of 20 therapy sessions, three of which will include MDMA. Each session will have two therapists present. The MDMA-assisted sessions will be six to eight hours long, after which the participant will stay overnight in the hospital to rest, supervised by a night attendant. And as part of the effort to involve participants from communities of color, all but one of the therapists at UConn Health identifies as an ethnic, racial, and/or sexual minority.

“In Singapore, I was part of the majority, but I was curious how it felt to be Malay, Indian, or one of the other minorities,” says Terence Ching, a clinical psychology doctoral student involved in the study. Ching has also lived in Australia, New Zealand, and Kentucky, where he was not part of the majority ethnic group. “That led me to critically introspect my place in society as someone with many different identities. Having that multifaceted perspective allows me to experience a lot of empathy for people from marginalized groups in the U.S.,” Ching says.

To get a better understanding of what the MDMA-assisted psychotherapy would be like for study participants, Ching participated in a session himself as part of his training.

“It felt like a lot of insights happening constantly,” Ching says. “It’s been a year since the session, and every now and then I have a moment where I remember an insight from it, and/or have another one. It’s a wonderful thing.” Ching hopes that the participants benefit from their MDMA-assisted psychotherapy in the same way he did.

“For someone who has experienced trauma, MDMA-assisted psychotherapy might help them be able to make meaning of it. I really believe in this work,” Ching says.

For Anxiety, Single Intervention Is Not Enough

illustration on the concept of anxiety. Features a male with hands held to forhead in slumped possition. Mans face is scribbled.


No matter which treatment they get, only 20 percent of young people diagnosed with anxiety will stay well over the long term, UConn Health researchers report in the Journal of the American Academy of Child and Adolescent Psychiatry.

“When you see so few kids stay non-symptomatic after receiving the best treatments we have, that’s discouraging,” says UConn Health psychologist Golda Ginsburg. She suggests that regular mental health checkups may be a better way to treat anxiety than the current model.

The study followed 319 young people aged 10 to 25 who had been diagnosed with separation, social, or general anxiety disorders at sites in California, North Carolina, Maryland, and Pennsylvania.
They received evidence-based treatment with either sertraline (the generic form of Zoloft) or cognitive behavioral therapy or a combination of the two and then had follow-ups with the researchers every year for four years.

The follow-ups assessed anxiety levels but did not provide treatment. Other studies have done a single follow-up after one, two, five, or 10 years, but those were essentially snapshots in time. This is the first study to reassess youth treated for anxiety every year for four years.

We need a different model for mental health, one that includes regular checkups.

The sequential follow-ups meant that the researchers could identify people who relapsed, recovered, and relapsed again as well as people who stayed anxious and people who stayed well. They found that 20 percent of patients got well after treatment and stayed well, rating low on anxiety at each follow-up. But about half the patients relapsed at least once, and 30 percent were chronically anxious, meeting the diagnostic criteria for an anxiety disorder at every follow-up. Females were more likely to be chronically ill than males. Other predictors of chronic illness were experiencing more negative life events, having poor family communication, and having a diagnosis of social phobia.

On the bright side, the study found that young people who responded to treatment were more likely to stay well. The study also found no difference in long-term outcomes between treatment types. This means that if there is no cognitive behavioral therapist nearby, treatment with medication is just as likely to be effective.

The study also found that kids did better if their families were supportive and had positive communication styles. Parents should talk to their child and ask the therapist questions: Why do they suggest this treatment? (It should be supported by evidence.) Have they been trained in cognitive behavioral therapy? How can we reinforce what was learned in therapy this week?

But parents should also be aware that a single intervention may not be enough.

“If we can get them well, how do we keep them well?” says Ginsburg. “We need a different model for mental health, one that includes regular checkups.”

Bridging the Health Care Gap

Q&A with Wizdom Powell, director of the UConn Health Disparities Institute

Q

What are your top priorities for the Health Disparities Institute (HDI) at UConn Health as you begin your second year as director?

During my first nine months, HDI underwent an internal, strategic refocusing process. This process involved conducting an organizational 360-degree assessment and reviewing state-level data on health disparities outcomes and populations. It resulted in the identification of four complementary strategic focus areas: health systems change, utilization, and finance; behavioral health; chronic disease prevention and control; and neighborhoods, housing, and health.

HDI is committed to advancing health equity and works explicitly to connect, support, and serve populations at greatest risk for poor health and social outcomes. These goals are accomplished by generating rigorous evidence for action, building multisector coalitions, translating data for policy impact, and accelerating community-sourced innovations. We apply an explicit racial equity lens to our work. We value social justice, youth engagement, and the power of art to amplify community voice and disrupt single stories about the truly underserved.


Q

What initiatives has HDI put in place or advanced in the past year, and how are they helping people?

Boys and men of color (BMoC) in our nation are uniquely underserved across a number of health indicators. Currently, HDI is developing several initiatives designed to address social determinants of health, well-being, and health equity among BMoC. Recognizing this critical gap, the HDI has established a multisector alliance composed of private, public, academic, and community leaders to provide high-level strategic guidance and accelerate systems change for BMoC in Connecticut. HDI recently launched a series of overlapping research, policy translation, and programmatic initiatives focused on advancing health equity for boys and men of color in the state.


Q

What can physicians do to better serve men and boys?

I think it is important for health care providers to be aware of the gendered help-seeking barriers men and boys experience. Such barriers include shared cultural norms and values that discourage men from disclosing vulnerability and distress. These norms may lead some men to avoid health care altogether or “watch and wait” even when health symptoms are present. It is important for health care providers to maximize appointments with men and boys, for example, by screening for behavioral health symptoms during a primary care visit.


Q

Recently, public figures like Jay-Z and NBA star Kevin Love have spoken out about mental health struggles and the stigma surrounding them. Are we on the verge of a sea change? What more needs to be done on a cultural and policy level?

It is always encouraging when public figures leverage their influence to promote mental health awareness. They have a bigger platform than scientists and far fewer structural constraints on their media engagement. In my more than a decade in the men’s health space, I have witnessed ebbs and flows in the scientific and public discourse about these issues. We are definitely in a flow period. To achieve a sea change, we also need to change systems, culture, and policy.

We certainly need mental health parity in the way we pay for services. A lot could be accomplished by the systemwide integration of behavioral and primary care services. We would also benefit tremendously from changing norms. Men and boys (and the women and girls who love them) would be healthier if they had fewer social sanctions around displaying emotional vulnerability. We encourage men and boys to be strong, stoic, and silent. If we are going to have a real sea change, those norms have to be disrupted.

Summer Breaks Help Prevent Burnout, Especially Among Physicians

Young man jumps into a body of pristine water on a summer day


It’s summertime, and you need a break! The U.S. has a culture of working too hard, and physicians are some of the worst offenders. Don’t let Labor Day pass without spending at least one afternoon at the beach.

We can joke about it, but there’s rising concern about burnout and depression among physicians. One recent study of 7,000 residents found that 50 percent showed depressive symptoms and 8.1 percent reported suicidal thoughts over a 12-month period.

“Physicians are given enormous workloads, make near-impossible life-and-death decisions regularly, and are expected to be alert and ready to go constantly. It’s unsustainable,” says Dr. Adam Perrin, a professor of family medicine and director of student wellness at UConn Health. “To enjoy life, you need balance and a break.”

Working too much can lead to burnout, or at the very least, a lack of enthusiasm. And that can be bad news not only for doctors, but for patients.

Taking care of yourself is taking care of your patients, too — even when the worst happens.

Studies show that depression and burnout make doctors significantly less likely to read about the next day’s cases, and up to five times more likely to make errors when prescribing medication.

Many doctors work too much because they don’t want to ‘abandon’ their patients. But taking care of yourself is taking care of your patients, too – even when the worst happens. Telling a dying patient that you have a vacation coming up, you regret the timing, and you wanted to tell them how much you care before you leave is very respectful, and patients are usually understanding,
Perrin says.

And while vacations are essential, your recovery and rest shouldn’t center on them. Rest and self-reflection should be a regular pursuit. For example, Perrin sings in a community choir.

“I’ve made many friends, we sing gorgeous music, and it fills the soul,” Perrin says. However you choose to take a break this summer, we hope it does the same for you.

Breaking the Cycle: How Anxious Parents Can Protect Their Kids from Becoming Anxious Adults

By Kim Krieger

Infographic showcasing logical and illogical fears oppressing a nervous child figure


A woman who won’t drive long distances because she has panic attacks in the car. A man who has contamination fears so intense he cannot bring himself to use public bathrooms. A woman who can’t go to church because she fears enclosed spaces. All of these people have two things in common: they have an anxiety disorder, and they happen to be parents.

These parents sought help because they struggle with anxiety, and want to prevent their children from suffering the same way. Anxiety tends to run in families, with 30 to 50 percent of children of anxious parents growing up to be anxious themselves. But that does not have to be the case, according to new research by UConn Health child psychologist Golda S. Ginsburg.

Ginsburg and colleagues at Johns Hopkins University tested a one-year therapy intervention as part of a study of 136 families where at least one parent had anxiety and at least one child was between the ages of 6 and 13.

The study, published in the August issue of The American Journal of Psychiatry, found that therapy-based intervention works. Only 9 percent of children who participated in a therapist-directed intervention developed anxiety after one year, compared to 21 percent in a group that received written instruction, and 31 percent in the group that did not receive any therapy or written instruction.

Children of anxious parents have up to a 50 percent chance of growing up to be anxious themselves. But that does not have to be the case.

Both inborn temperament and life experiences play a role in whether an adult has anxiety. The more negative experiences a person has growing up, the greater the likelihood he or she will struggle with anxiety as an adult. But there is also a component of anxiety that is learned, taught inadvertently by parents who model the behavior. It’s these learned behaviors and thought patterns that interventions can help change, according to Ginsburg.

“The finding underscores the vulnerability of offspring of anxious parents,” says Ginsburg. She wants to do something about that vulnerability. “If we can identify kids at risk, let’s try and prevent this.”

Most of the adults who participated in the study struggled in school and didn’t tell anyone. They didn’t raise their hands, or they got sick before exams. They might not have had any friends. As adults, their anxiety still limits their activities and sometimes those of their family members, and they are very motivated to help their children avoid the same.

Physicians can often identify children at risk before they develop an anxiety disorder. Such kids are often hyper-aware of aches and other bodily sensations, and are frequent flyers at the doctor’s office and emergency room. For example, such a child might think “my heart is racing — I’m having a heart attack!” when a less anxious individual would think “my heart is racing because I just ran up a hill.”

Other signs of children at risk for anxiety include avoidance of school, parties, and other social situations, as well as unusual worries.

“Anxiety and fear are protective and adaptive,” says Ginsburg. “But in anxious kids they may not be, because these children have thoughts about danger and threat when there really isn’t one.”

For such a child, meeting a new peer for the first time can be paralyzing. Trying an unfamiliar food might summon worries of being poisoned. To cope with this kind of debilitating anxiety, children start avoiding whatever provokes the anxious feelings. If they’re afraid of the dark they might insist on sleeping with all the lights on. If they’re afraid of failing they won’t try new things. In extreme cases, they may refuse even to leave the house.

I’d say we need to change our model of mental health to a checkup method. Like going to the dentist every six months.

One of the ways to reduce anxiety is to do a reality check. It’s a way to recognize when a fear is healthy and worth paying attention to (a growling dog) or unhealthy (a possibly poisoned birthday cake).

In the study, some of the families participated in eight, hour-long sessions with a trained therapist over a period of two months. Others were just given a pamphlet that contained general information about anxiety disorders and treatments. Still others received nothing at all.

The families who participated in therapy were taught to identify the signs of anxiety and how to reduce it. They practiced problem-solving skills, and exercised safe exposures to whatever made their child anxious.

“We taught the kids how to identify scary thoughts, and how to change them,” Ginsburg says.

If you are interested in collaborating on such a study or have patients who might benefit from a family intervention, contact Golda Ginsburg at Gginsburg@uchc.edu, or call her office at 860.523.3788.

For example, if a child is afraid of cats and encounters one in the street, the child can first identify the scary thought: “that cat is going to hurt me.” Then the child can test that thought — is it likely that cat will hurt me? No, the cat doesn’t look angry. It isn’t baring its teeth or hissing, it’s just sitting there. OK, I can walk past that cat and it won’t do anything.

In general, children who participated in the intervention had lower anxiety overall than children who did not participate in the intervention with their families.

Now the researchers have funding from the National Institutes of Health for a follow-up to see whether the effects are maintained over time. Ginsburg wonders whether there would be value in providing regular checkups for families on mental health issues. She is considering approaching insurers about offering this kind of service to families at risk, to see if it lowers their healthcare costs overall.

“I’d say we need to change our model of mental health to a checkup method,” says Ginsburg, “like going to the dentist every six months.”