Good afternoon. The Youth Anxiety Center is a novel program of some of the most highly talented child and adolescent clinicians and investigators in the country. It is focusing particularly on people with great needs, which means people with mental health disorders in general and also people with very little resources who need mental health help. The world of youth anxiety disorders has captured public attention because its scope is so wide and the number of people needing help has increased so much. Also, the illnesses, if not attended to appropriately, often lead to even more distressing developments, which can go as far as school failure, family disruption, youth suicide, and other similar disturbing developments. This center, consisting of child mental health psychologists and psychiatrists, is a result of a clinic that was launched at the suggestion of Anna Winter and her close friend, Dr. David Schaffer, who is head of Child Psychiatry Columbia per year. The problems are many. The volume of people with anxiety disorders in youth is rapidly increasing. In addition, the number of treating clinicians or clinical entities to address the problems is well below the necessary numbers of personnel needed to address these multiple problems. The problems include how to help particularly under-resourced and underserved populations find ways of accessing good treatments. It also includes the need to train more people and help therapeutically. It focuses on the transition from high school to college and post-high school and college for people who have had an impact from the COVID treatment, for example, which can be devastating. Thus, it is not surprising that youth suicide is higher. Schools are concerned about the volume of young people they have to assist. There also is a broad-based concern in the society that the necessary talent pool of young, outstanding people to add to the society's strength and diversity is undercut by these disorders. Aside from providing clinical care, training for people who can help with child mental health problems and also can work on innovative ways to make the treatments more effective and more widespread are issues of great concern for the entire population, and certainly for the victims as well as the families of people who have such disorders. Our program will describe many of the components of the Youth Anxiety Center, which has been functioning now for about six years and has treated tens of thousands of young people as well as helping families, trainers, and the like. Youth Anxiety Center has injected innovation in its efforts, which we feel will be informative to all people concerned about these issues. The fact that, as in other areas, the undeserved populations are lacking in adequate treatment is an important national concern. We're trying to improve equity and improve social justice. Those ideas apply here as well as throughout the society. We will have several presentations and then an opportunity for interaction between the several panelists. Thank you very much. It's my great pleasure now to introduce our first speaker, Dr. Christiane Duarte, who is a Professor for the Implementation of Science for Child and Adolescent Mental Health at Columbia University, New York State Psychiatric Institute. Dr. Duarte. Thank you, Dr. Pardes, for this introduction. So, I will speak today about anxiety disorders among low-income Latina young adults. I'm using the term Latina to signal both Latinos and Latinas. Some people use Latinx. The more academic community is preferring this term Latina. And to tell you about the activities of the Youth Anxiety Center that we have been pursuing. Just to give you a picture of where we are located, you see here the different clinics that are part of the Youth Anxiety Center. I'm going to call your attention to the Northern Manhattan Clinic, where we see bilingual and bicultural young adults. I'll tell you more about it, but I will start by telling you why we decided to focus on young adulthood. So, young adulthood is a critical developmental stage where important skills are acquired, important strengths are developed so that you can have a successful transition into young adulthood. However, what we noticed was that most studies that existed were either focused on children, therefore below the age of 18, or post age of 18 with adults. Any young adults were part of the adult group, but not necessarily looked at as a specific group. So, that's what we are trying to do at the Youth Anxiety Center. To focus on this, that is an important developmental period, was recognized by this report in the Institute of Medicine. And so that we can understand what are the needs of this specific group. These needs were first recognized by Arnett in 2000, when he coined the term emerging adults for what he called this age of in between, if you will, where there is a search for identity possibilities, but it's also a time of instability and self-focus. So here, basically, what we used to have was a transition that was much faster. So from high school, one would, if you will, jump into career, marriage, and would, you know, move forward from there. Now, the pathways that can exist between those two, being an independent adult and finishing high school are multiple. And that period has been stretched quite a bit. So we live a different situation at this point, in which we have several developmental milestones that young adults need to meet. So we used to think about milestones as being what is our toddlers or, you know, infants need to go through. But there are actually very important developmental milestones during adulthood. And you see here, some of them listed grouped by different domains of, for example, milestones related to self-care, one needs to be able to cook for yourself, or to, in terms of relations, have maintained, make and maintain long-term relationships. In terms of independent tasks, schedule your own doctor appointments and other appointments. And also this period where your personal values are solidifying who you're going to vote for, who you self-identified from a gender perspective, from a racial ethnic perspective. So all of those milestones, they need to be completed during young adulthood so that an independent adult life can pursue. The question is what, how do those milestones are reached if anxiety appears? And this becomes really a problem. As with the anxiety symptoms, there is a fear of new experiences, a way of coping with experiences that could be challenging by avoiding those experiences. And by doing that, those developmental milestones are not properly developed. And then that creates more anxiety that also further impairs the development of those milestones. And what happens is that those young adults fail to launch as independent adults. So that's the problem that the Youth Anxiety Center tries to tackle. And if you look here, what you see is the lifetime prevalence of anxiety disorders. So these are conditions you see in red. Those are the anxiety disorders compared to in green, for example, mood disorders. They are a lot more prevalent. About almost 35% of 18-year-olds would have had an anxiety disorder when they reach age 18. So these are not rare conditions in any way. And something that also people fail to appreciate, they tend to be quite impairing. So what you see here is impairment due to anxiety disorders in three domains, health, finances, and interpersonal personal domains. And what you see is that independently for all types of anxiety disorders, there are impairments across these domains. So that really emphasizes how important it is that we are able to treat those disorders and how this can make a difference in how things continue. So here, we see lots of numbers, but I will translate them to you. What we were curious about was if the determinants of having an anxiety disorder in young adulthood were different from the determinants of anxiety disorder that we know in other periods of life. So this is the analysis of a national database, the NSERC, where we had young adults between the ages of 18 to 24. And we looked and we found, as we have known about in adults, that being a female, being white, having a low income, being unemployed or not in training, all these conditions that we knew were common to adults with anxiety disorders, also we observed among young adults. But we found something that was very unique, which was we found that young adults who are married were also more likely to have an anxiety disorder. And here, our interpretation is that this is just illustrating what I just mentioned to you, that this period of young adulthood has been extended. And for now, being married before the age of 25 may signal some problems with some of those developmental milestones that we mentioned that could be motivated for by anxiety disorders. So interesting. And also, again, justifying the need to focus on this specific period if we want to learn the specificities. But really, the most important issue that we think needs to be tackled, and you'll hear more about that in the presentations by Drs. Monhatt and Lee, is how access to mental health care is a problem for young adults, how we have a big gap between those who need treatment and those who receive treatment, which is an issue that the Youth Anxiety Center is trying to tackle. And you see this illustrated here. So if you look at the red line, the red line is showing the percentage of youth who receive mental health care if they have a need, meaning they have a psychiatric disorder. So if you look here on the left, what you see is that 50 to 60 percent of youth, when they were children, meaning before the age of 18, they received care, which is not great, but we want 100 percent, but it's 50 to 60. But look what happens here when this youth transition to young adulthood. There is what many have called the transition cliff. So the mental health service utilization goes down quite starkly, and particularly if we think and look here in the dotted blue and green lines are the disorders, psychiatric disorders, at the same time are going, if anything, up, and then the use of services are going down. So really signaling that that's something that we need to think about and address, and particularly for youth, Latina adolescents who tend to use services for mental health problems four times less than white adolescents. We don't have this information about service uses specifically by race, ethnicity for young adults, but we have it for adolescents, and that's the number I'm giving you here. So with that in mind, with some colleagues, we try to understand and at least conceptualize what were the main barriers to mental health service use among young adults, and what we identify are barriers that go span from individual-level barriers all the way to system-level barriers. So for example, for young adults, when they are trying to be independent and self-efficacious and perceive the need for mental health services, that sometimes may not happen, and so that could prevent the use of services. Stigma about mental disorders, unfortunately we have this across all developmental periods, but also very important in young adulthood, and also the complexity of the mental health care system during this transition period is a very important issue. So there is a lack of continuity between the services that were received by children and adults, and the really important lack of coordination, and also we have insufficient professionals who have an expertise in young adulthood, and that may translate into youth perceiving services as not being as effective. So with all of that in mind, the good news that I would like to convey also is that, however, we do have treatments that work for anxiety disorders in children. What you have here are the results of one of the largest actually studies done for anxiety disorders in children, and what you see here is that CBT, cognitive behavioral therapy alone, or medication, or the combination of both, they are effective to treat most children, if you will. However, when researchers actually followed those children that they treated into young adulthood, what they found was almost 50 percent relapsed. They were back with their anxiety disorder, and the question was, so but what happened? How did this happen? And the conclusion was that the problem was that development. So those milestones that we were talking about were not addressed, and so we were very much focused in symptom improvement, but not necessarily in improving functioning, and that could make a big difference. So with that in mind, Dr. Anne-Marie Albano, one of our members of our center, our leader in our center, she created a program called the Launching Emerging Adulthood Program, or LEAP, which incorporates empirically supported cognitive behavioral treatments for anxiety with those developmentally informed components that would be so important to fill this gap and make treatments effective in the long term and sustainably for young adults. So that's a very important part of our treatment. However, it does leave, there is a question that we still have, which is, do low-income ethnically diverse youth benefit equally from evidence-based treatments? And the answer, unfortunately, is that it looks like sometimes they do not. So there are two examples here that I list for you, the two big studies, one of anxiety disorders and the other one of depression among adolescent children and adolescents, in which we have some indication that the treatment was not as effective for low-income or racial ethnic minority youth as for other youth. So therefore, and getting us to what we do in the Youth Anxiety Center at the Washington Heights Clinic, where our mission is to bring to underserved youth who have anxiety disorder, not only the most novel approach into treatment that we are developing at the center, but also taking into consideration the role of sociocultural influences. So including that in the work that we do. Here you have a picture of our team. And so who are the patients that we see at the Youth Anxiety Center? So we see adolescents and young adults between the ages of 16 to 28. Most of our patients, about half of our patients are below and half above the age of 18. 60% are women. You have the racial ethnic distribution, about three-fourths of our adolescents are, our young adults are either Latina or African American. And we receive referrals from external sources, from internal sources. They go through a centralized intake process, and then they go undergo a comprehensive evaluation in our clinic that directs them to any type of intervention that we deem most appropriate. During this period, they also are asked for informed consent so that they could, if they allow us to share their data for research purposes, because one of the missions of the center is really to learn from what we are doing so that we can disseminate what we are doing. And with all of that in mind, to close, I'm gonna tell you a bit about cultural competence and how we see it in the Youth Anxiety Center. So basically, most of our young adults, as they transition to adulthood, they need to negotiate what we call bicultural identity. So we have some young adults who are recent immigrants, even DACA patients, but most are second generation or even third generation. They are trying to negotiate different cultures. And so we have an example here that our young adults, they share in their growing up views of independence with their other white young adults, but they also favor views of obligations to others, specifically family, as being more important sometimes than that is for other young adults. So this is very much part of their experience and their treatment and needs to be incorporated. The other thing that we pay a lot of attention is to incorporate into treatment, their experiences of racial and ethnic discrimination and also experiences of structural racism that could be part of very much of them growing up. And I'll tell you a bit how we do that in a second. So our culturally competent treatments, they are informed by different types of frameworks. And I'm putting here two, one more, the first one in the adult world, the APA Cultural Formulation Interview that is part of DSM-5 and was actually developed in our department by our colleague, Robert Louis Fernandez. And also, but we are also very much informed by approaches like that by Dr. Pumar-Yega in child psychiatry, which have also developed, incorporate the developmental component really nicely. And I just wanted to end by giving you this example. This is an adaptation of the cultural formulation interview by a group of clinicians in our NYP Child Clinic. And as you can see, there is a conversation, is helping clinicians to have this conversation and to be open and exploratory about someone's background or identity and telling, we know that those sometimes can impact the problems that you are describing. And I would like to talk a bit about the various parts of your identity. So I'm just showing you here the questions and conversations about race, ethnicity, but there is also a piece about sexuality and gender identity, which are really, really very well done. But just to have an idea, so can you tell me a bit about where you were born and raised? Where were your parents born and raised? I want to ask about also some experiences of discrimination that they may have had of immigration trauma if they were the immigrants themselves or that their parents have told them about, about racial trauma. As we know, violent, life-threatening encounters with the police are not rare. So how do you describe your racial identity? This is a really important piece because we call people groups, we label groups of people as Latinos, Hispanics, Latinas. But the way that one sees him or herself may be very different and we need to be able to know what that language is. And finally, just the last question, if you will, are there ways in which your identity as whatever word one is using, impacts your current problems? Because sometimes we may make an assumption that they do, but this is not the experience that the person is having. So really having those conversations is so important. And as you see here, this is an attempt to summarize it all. So we try to provide a cultural competent assessment and treatment that includes all these different components, but it's very important that we keep our fidelity to the core CBT components so that we can be effective. And we integrate the developmental framework as you've seen in the leap example that I gave. And this is a way that we can provide the best treatment to low-income racially ethnic diverse young adults. So just to conclude, the Youth Anxiety Center provides novel solutions for the treatment of young adults with anxiety disorders. And the Washington Heights YACC adapts the highest excellence treatments offered by YACC to the needs of low-income racial ethnically diverse youth. And I wanna finish with a poem, which was written by, at the time, a young adult woman, Aurora Levins Morales, that describes her experience of being a bicultural youth. And even though this was written in 1986, I think it's still very much reflects the experience of many of our patients. So if you bear with me, it's called Child of the Americas. So I'm a child of the Americas, a light-skinned mestiza of the Caribbean, a child of many diaspora born in this continent at a crossroads. I am a U.S. Puerto Rican Jew, a product of the ghettos of New York I have never known, an immigrant and the daughter and granddaughter of immigrants. I speak English with passion. It is the tongue of my consciousness, a flashing knife blade of crystal, my tool, my craft. I am Caribbean, island grown. Spanish is in my flesh, ripples from my tongue, lodges in my hips. The language of garlic and mangoes, the singing in my poetry, the flying gestures of my hands. I am of Latino America, rooted in the history of my continent. I speak from the body. I'm not African. Africa is in me, but I cannot return. I'm not Taina. Taina is in me, but there is no way back. I'm not European. Europe lives in me, but I have no home there. I'm new. History made me. My first language was Spanglish. I was born at the crossroads and I am whole." So that's where we try to meet our youth, in this crossroads. And thank you very much. First, let me say, Dr. Duarte, that was superb. Thank you very much for an excellent presentation. And now it's my very great pleasure to introduce Dr. Justin Mohat, who is Vice Chair for Faculty Practice in Child and Adolescent Psychiatry at Weill Cornell and an Assistant Professor. Dr. Mohat, happy to have you. Great. Thank you, Dr. Partas, and thank you, Dr. Duarte, for a fantastic introduction and overview of the work you're doing at the Washington Heights Clinic. I'm gonna pivot a little for my presentation and talk about the last year and what we know so far about the impact of the COVID-19 pandemic on our young adult population and transitional youth in general. We also recognize that there are many factors that have impacted our youth in the last year, not just the COVID-19 pandemic, but our national reckoning with regards to racial injustice and racial equity. But today, what I'm gonna be speaking primarily about is what we know with respect specifically to COVID-19 and how we at the Youth Anxiety Center have tried to impact the impact of that for our youth through clinical interventions, but also through sort of larger scale national educational outreach and dissemination efforts. So before I get started, here are my disclosures. I really have none that pertain to this particular topic. And I think a good starting place is to say, where were we before the pandemic? Which is to say, and I think Dr. Duarte already spoke to this, we weren't necessarily in a good place for our young people in this country. We know that between 2008 and 2018, the rate of anxiety disorders, and this is, I believe, past month prevalence, rose from 8% to 15%. We also know that during that same timeframe, or frankly, in 2017, the rate of major depression and past year prevalence for young adults was approximately 13% across the board. And we also know that pre-pandemic, and for some time now, suicide was the leading cause of death for people in this age group. So things were not great before the pandemic. And so where are we now? And unfortunately, the news is concerning. So this is from the COVID-19 States Project. This is a large four-wave survey that has many components to it, but we're gonna talk specifically about this mental health piece. It is a partnership between Northeastern, Northwestern, Harvard, Harvard Medical School, and Rutgers University. And they began surveying in May of 2012 on a variety of items, and with respect to young adults and mental health. As you can see in this graph, back in May of 2012, we were seeing reports of symptoms of at least moderate depression in 45% roughly of young adults responding to depression. So this is a graph that we put into the survey. And sleep difficulties were ubiquitous, close to 75% of young adults reporting difficulties with sleep. There was a little bit of a reprieve in the summer, and then we've seen a linear increase steadily since then in rates of at least moderate depression and anxiety in parallel with that. And then as you can see as well, we've seen an increase in reported suicidality among this population. And suicidality for these purposes was defined as essentially any positive answer to the suicide question in the PHQ-9. And this is drilling down a little bit more into that suicidality piece. And what I wanna have you take home from the circled portion of this graph is that the rates of suicidality among young adults in this very large survey population are quite high. Approximately 36% of respondents reported suicidality at the time of the survey. Interestingly, across all of these psychiatric symptom groups and suicidality, there was no real racial or ethnic difference found. However, this is not necessarily consistent with what we understand now. And I'm hoping that when we get to a discussion section at the end, Dr. Duarte can talk a little bit more about what we understand now about the impact of COVID-19 on racial and ethnic minorities and in particular the Latinx communities. We also should speak about loneliness because this is a population that is at risk for loneliness anyway. We know from prior to the pandemic in a very large BBC led survey, the BBC Loneliness Experiment, which had 46,000 participants in 237 countries, that 40% of 16 to 24 year olds reported feeling often or very often lonely and they were the most at risk group. Additionally, young men in individualistic cultures like ours here in the United States were the most vulnerable for loneliness in the survey. And this is pre-pandemic. We do have data in the last year, however, which is equally concerning in that this already vulnerable population is reporting much elevated levels of loneliness. So the Making Caring Common group, which is a pilot, is a project out of the Harvard Graduate School of Education, did a survey of 950 adult Americans and found that overall 36 reported feeling frequently or almost all of the time lonely. And that rate was 61% for young adults. And then 43% of that same group of young adults reported that their loneliness had been increased since the onset of the pandemic. A statement that I found particularly poignant from this is the following, about half of lonely young adults surveyed reported that no one in the past few weeks had taken more than just a few minutes to ask how they are doing in a way that made them feel like the person genuinely cared. So this already vulnerable population is struggling even more than they were before the pandemic. And in a multitude of ways, and in here I'm gonna focus primarily on the school closure, school and university closures, and their switch to both work from home and learn from home and remote learning. Although you can see there are many ways in which our young people have been challenged during this time. We know before the pandemic, that relocation is a significant stress for anybody. And we have essentially a mass experiment in relocation this year for our young adult population. 96% of US News and World Report surveyed schools shifted to remote learning or canceled in-person classes in the spring of 2020, impacting 26 million US college students. And we've fortunately been able to look at the impact of this. The CARES study in 2020, surveyed 791 students in the college years. A third of these students were forced to relocate in the spring of 2020. And 86% of those were in a week or less. And about 40% of them had to leave behind valuable belongings when they were forced to relocate. And the CARES study found that relocation was associated with increased COVID-19 grief, loneliness, and generalized anxiety symptoms. In addition, if you drill down a little bit further, they found that certain populations were even at greater risk. Patients, I'm sorry, subjects or participants who identified as gender non-binary, patients who were on financial aid, and the patients, I'm sorry, I keep saying patients. The participants who were forced to relocate and leave behind valuable items, all reported elevated levels of anxiety, depression, and PTSD symptoms relative to other populations. Also gender non-binary youth and financial aid receiving youth were at higher risk of relocation compared to the other participants. Which brings us to where we were in New York City in the spring of 2020. It was truly a community in crisis and I don't need to tell anyone how ugly it was. It's something that will live with all of us for the rest of our lives. That was through it, it threw medical services up in the air, services were closed that weren't related specifically to take care of the very ill COVID patients flooding our hospitals. And in the context of that, our outpatient psychiatric services also had to transition to telehealth and there was a period of time where we were figuring out how to do that, how to do it efficiently and access to all kinds of mental health services was even more hampered than it usually is. And we all know the state of access for child mental health services nationally to start with. So in the context of that, we started getting urgent calls from our colleagues in pediatrics. And fortunately we have a very close relationship with our colleagues in pediatrics due to our work in kind of mental health integration over the last several years. So they knew who to call, they knew we would be responsive. And they called saying, we have all these families calling us every day, parents are dying, grandparents are dying and we don't know what to do. There's nowhere to send them, can you help? And so we put our heads together to try and figure out what we could do and decided that we would take advantage of many of the loosening of regulatory restrictions and the general sense within the medical community in New York at the time to just do whatever you could do to help and we'll figure it out later. And decided to launch essentially a free crisis counseling service for all of the families in our New York Presbyterian pediatric clinics that would provide short-term evidence-based treatment founded in the principles of psychological first aid. And that this was a way we could deploy care very quickly. So we did this in April of 2020, it took approximately a month to get this up and running. We did trainings for the volunteers and I wanna sort of speak to the volunteer aspect of this. At the time, many of our services in psychiatry were shut down and our faculty said, we wanna help. We can't run vents, we can't be on the critical care units. Many of our faculty are psychologists, not psychiatrists, so they weren't able to be in the medical role in quite the same way anyway. And so they offered their time to do this, which I am still so grateful for and will be forever. And when word got out that we were doing this, we also got volunteers from Child Life, we got volunteers from pediatrics, including a pediatric resident that asked to be part of this. We opened the referral to all pediatric clinics at New York Presbyterian within Manhattan and Queens. And these sites serve primarily low income immigrant and BIPOC communities on public insurance, which was very important to us since these are the communities that have less opportunity and less access and who often don't come to our clinics. And we felt if we can go to them where they are and with their pediatricians who they trust, that we're gonna be more successful. So who did we end up serving? We found that we served a broad age range. We're still waiting for IRB approval, so I can't get into analyzing all of our data specifically, but just speaking to trends, broad age ranges, gender was roughly equal. It was largely referrals from pediatricians, though some people self-referred. And the acceptance rate was almost universal in terms of taking advantage, even though they weren't necessarily the ones making the initial call, it was the pediatrician making the referral. So all families were contacted by a clinician the same day that we received the referral. This was really important when we were planning this, that it be quick and that we be very responsive. And people were offered a session within 24 hours of the referral being made. All the families we reached were open to services and were very receptive to what was being offered. And almost 100% of people had their first appointment within five days of the referral going in to the system. And we offered between one and five sessions. We additionally sort of did evidence-based or validated screening measures at the outset to identify what was going on. By far anxiety was the most common referring reason followed by behavioral disorders and then depression. The anxiety and depression were primarily in our young adult referrals, as you can imagine. And these are the interventions that were used. I'm not gonna go through all of them. You can look at it yourself. But to say that we did it in a modular way, we could meet people where they were and within those one to five sessions kind of do what seemed most important at that point in time for that given patient. It was also very important to us that we be able to provide adequate care for those patients that our one to five sessions were not going to be enough for. And so either at the outset at triage or at any point during those crisis counseling sessions when it became apparent that someone's needed more, we prearranged to have a rapid access evaluation clinic within our child psychiatry outpatient clinic and our adult psychiatry outpatient clinic. And we did utilize that referring many of our young adults to the adult clinic as well as parents of some of the kids to the adult clinic. Those were the more common referrals than actually into the child psychiatry clinic. The feedback from clinicians was universally very strong about the experience of delivering care this way and the process of being trained and getting going in it. We didn't hear from families, but this is feedback from the clinicians about what they heard from families who were still waiting to be able to actually survey families on this. And then the clinician's experiences in free text form also were very positive and I'm not gonna sort of dwell on these. We learned a number of lessons, particularly around the high acceptability of these services, bringing it to families within pediatrics, things we knew and we talk about at meetings, but actually doing it and seeing the dramatic difference between the number of people that actually took advantage of this versus if we said, please come to our clinic for an appointment and the number of people we lose between the pediatrician's office and ours. We learned the value of technology and how much it helped us in terms of no shows and access to break down geographic barriers, but also the limitations with respect to privacy and high speed broadband internet connectivity for many families, particularly low income families. Though we were generally able to find workarounds for that. The other thing that's important to say is that the presenting concerns were almost universally COVID-19 specific related when they called. They weren't calling for my kids been having disruptive behaviors since they were two. It was, there's been this dramatic change since COVID. And then pairing with pediatricians was a very effective way to do this. We're working on models for sustainability and integrating a youth cope type approach into our stepped care model within the department and looking at this as an opportunity for training for all of our trainees in different disciplines. We have an integrated training program for mental health for pediatric residents and child psychiatry fellows. And this is part of why I think this worked as well as it did. In addition to youth cope, we did a series of youth anxiety center webinars in the spring of 2020. You can see all of the topics here. These were free webinars open to the community. They remain on the youth anxiety website and I've got the link here so that people don't have to hunt for them. And they are free and available to anyone who wants to watch them. And they have, the traffic has been much more substantial, I think, than even we hoped that it would be. In addition, we did local partnerships with schools in the New York City region, working with the staff in schools and their teachers, as well as working directly with the students on coping with stress and anxiety. And then I wanna spend a little bit more time talking about a novel partnership that we've been able to develop with the Western Interstate Commission for Higher Education. And this has been led by Dr. Shannon Bennett and Anne-Marie Albano, our two clinical site coordinators for Columbia and for Wow Cornell. So what is WICHE? WICHE, which is the Western Interstate Commission for Higher Education, and specifically the Mountain Plains Mental Health Technology Transfer Center. The transfer center is one of 10 SAMHSA funded centers around the country. Their focus is on HHS region eight, and you can see the states that are included in that here. It's a collaboration between WICHE and the University of North Dakota. And they have two primary goals, which is to help Western states serve the behavioral healthcare needs of their residents, to develop, prepare, and continuously improve the behavioral health workforce. And while it's not on this slide specifically WICHE is a partnership with the University of North Dakota to provide training opportunities and enhance availability of evidence-based practices for underserved populations. So this started as them asking us to help develop a webinar for them, specifically for campus mental health providers. And so we developed an initial 60 minute webinar on clinical strategies to promote emotional with the idea that this would be primarily for campus mental health providers in the Western region. It was open to anyone though who knows about WICHE and was looking at what they were doing and was capped at about 500 participants. It ended up being fully subscribed, which was fantastic. And I think one of our big goals in doing this was to take what we're doing at the Youth Anxiety Center to help meet the needs of transitional age youth with significant depression and anxiety out beyond the local New York City area and to populations with need and underserved areas not just in the upper kind of Eastern part of the country but across the country and internationally ultimately. What we found with this initial webinar was that we had people from all parts of the country not just that Western region. We had people from Puerto Rico, India, Canada, Australia and other countries that attended the webinar. And we had everything from campus mental health workers to clinicians in the community, clergy. We had police detectives that attended. We had sort of every walk of life in terms of people who interact with our youth on a daily basis and have an opportunity to have that be a more positive and therapeutic experience for them. And so we were very happy with this and we decided that we should do more. And so the next step was a series of intensive workshops over the fall of 2020 on understanding and supporting the mental health needs of faculty, resident assistants and staff, assessing and treatment strategies for mood and anxiety disorders and promoting resilience, wellness and coping skills for the campus community. These were smaller intensive workshops, 90 minutes long and capped at 50 participants. And following that, the decision was made that we should sort of drill down further and do something even more intensive for people who wanted something more. And so the most recent thing which was just completed was a series of communities of practice programs. So communities of practice are essentially small groups of people with shared challenges, interests or topics that they are intensely focused on coming together with shared goals and working together. So these were, this was a four series, I'm sorry, a four session series capped at 25 participants and it was a committed group. So it was the same 25 that attended each of those four sessions. And the focus for this based on the feedback that we received in the original series of webinars and intensive workshops was actually on self-care and wellness for the campus mental health providers who are dealing with the young people who are either working, I'm sorry, studying remotely or back in attendance. And we're gonna be doing more of these as well as some additional work with WICHE to come and hope that this will continue to be a way to get the word out there about the needs of our young adult population and what we know about how we can help them through the sort of treatment models that have been developed at the Youth Anxiety Center. So with that, I'm gonna wrap up. Thank you to everybody at the Youth Anxiety Center. It's fantastic working with this group. And then these are just some references from my talk today. So again, thank you. I first want to compliment Dr. O'Had on a superb presentation. You kept the high quality tone that Dr. Duarte started and we will, I'm sure, have a continuation of that as I introduce the chair of the Department of Psychiatry at Weill Cornell. He is the Mortimer Sackler Professor of Molecular Biology and Psychiatry. And Frances S. Lee is an outstanding person in the middle of the psychiatric role in life at Weill Cornell Medicine. My pleasure to introduce Dr. Lee. Thank you so much, Dr. Partes, for that wonderful introduction and also I'd like to thank Dr. Duarte and Dr. Mohat for so elegantly laying out the challenges and also the very creative solutions that you have come up with. What I wanted to spend the next 15 to 20 minutes talking about is the translational research that is going on at the Youth Anxiety Center. We have this amazing opportunity where we have basic translational and clinical researchers at Columbia University and Weill Cornell Medical College working together to try to accelerate the pace of research in this area. And I just want to give some examples of it. I just want to give my disclosures first. And what I will want to do is sort of highlight what Dr. Duarte first began with when she noted that there's a critical developmental period between childhood and adulthood in which actually 75% of all psychiatric disorders emerge, this sort of period between 10 and 20 years of age. What is most striking is that anxiety disorders, as she noted, 35% of American teens have a diagnosable anxiety disorder and has been so well articulated by the previous speakers that there are significant challenges that we need a better understanding of the underlying mechanisms of how these disorders emerge. And then just as, even though we do have very effective evidence-based treatments, but 50% of the population does not stay well. And ultimately we also have a need to increase access. It's only 18 to 25% actually have access to these evidence-based treatments. So at the Youth Anxiety Center, we've really been thinking over the last several years of how to really have this type of patient-oriented translational research, where we try to have basic scientists interact with translational researchers as well as clinical researchers. And so on the basic side, we've been working on mouse models of fear and anxiety. On the translational side, we've been working with human neuroimagers and on the clinical side, we've been working with clinicians that have been trying to do clinical trials on new medications, as well as novel implementation strategies as Dr. Duarte had mentioned. And I think our goal is that we want to have not just the basic science studies inform clinical studies, but actually the opposite too, that the clinical studies would actually inform what questions we want our basic scientists to ask. And in this way, we hope to be able to make the fastest progress for this field. I want to just now spend the rest of the time just giving you two discrete examples of research projects within the Youth Anxiety Center. The first one is something we refer to as translational therapeutics. Can we conduct bidirectional translational research with the goal of identifying novel treatment? And in this case, for obsessive compulsive disorder and to use both mouse models as well as human clinical trials. And the one disorder we decided to focus on initially with my co-research director, Blair Simpson, was obsessive compulsive disorder. And this is the DSM-5 criteria for it. But what I wanted to highlight is that the treatments have been effective, but that there are still a certain significant subset that does not respond to SSRIs or the type of cognitive behavioral therapy that's been optimized for OCD and that there's always need for novel treatments. And it has been well known for a long time that the circuitry underlying obsessive compulsive disorder has been somewhat well mapped out compared to many other disorders. There's enhanced activity between the cortical striatal thalamic loops, in particular, the orbital frontal cortex projecting to the striatum, and also the form of CVT use called exposure and response prevention seems to require activation of the prefrontal cortex suppressing the amygdala. So the hypothesis we had is, can we come up with novel pharmacological agents that actually alter the synaptic plasticity in these two circuits? And we decided to focus on cannabinoids for a variety of reasons, mainly because the receptors are ubiquitous and are present in both circuits. And there's one class of cannabinoids, which I will not be talking about, called endocannabinoids, for which we've done studies studying anandamide in both mouse and humans showing that we can accelerate fear extinction. What I wanted to focus on is the work that Blair Simpson, along with Meg Haney and Riley Kaiser have been doing studying tetrahydrocannabinol, also known as THC, on either the core symptoms of OCD or also its response to cognitive behavioral therapy with exposure and response prevention. So what they were able to do, even in this very creative study, is give us, in this pilot study, give a synthetic TCH analog on nabalone over four weeks and basically monitor OCD symptoms through the Y-box scale and was able to show that while nabalone had no effect of changing the core symptoms, that when combined with EXRP, it was able to significantly accelerate the effectiveness of EXRP-based CBT. So in summary, they were able to show that if you gave nabalone alone, it had no effect on OCD symptoms, but that in combination with CBT or with EXRP, that they were able to essentially enhance the response rate. And I think this is one of the, something that I think is sort of core to what the Youth Anxiety Center is able to do. These are sort of out-of-the-box type of novel pilot projects that will ultimately lead to external federal funding, but it really sort of helps us sort of refine our hypotheses much better. So we now know that in humans, that it seems to be that targeting these receptors through this mechanism will probably be affecting the extinction process much more so than the core OCD symptoms. And we're now proceeding with studying these exact same molecules in studying goal directive versus habitual behavior in mouse models, which we hope to then translate into human studies also. So I want to now just move to just talking about how we want to optimize treatments for the developing brain using digital tools. And as Cristiani mentioned, that we have already been thinking that by using a developmental framework, we would want to find things that would be optimized for adolescents and young adults and based on the state of the developing brain. And this is one of the reasons of why Anne-Marie Albano, one of the other clinical leaders developed the LEAP program. But what we wanted to do is see whether we could use digital tools to sort of see whether we challenge some of the traditional assumptions about treatments. And one was that essentially for most of psychiatry, we have a one-size-treatment-for-all sort of approach where basically this, that essentially whether it be a pill or behavioral therapy, it is basically given to all patients despite their age. And I think what Anne-Marie's studies have shown is that you can develop sort of very personalized types of treatments for the adolescent age. And what we wanted to know is that one of the barriers to truly understanding what is so different about the adolescent brain than others is that we actually have to go back about 10 steps and do some studies in basic mouse models. And so what we did is we actually were able to look at what is so different about the adolescent mouse brain across adolescents. And we were very fortunate to form a collaboration with Carl Deisseroth at Stanford University to basically put in indwelling microprisms across childhood and adolescence to essentially monitor the circuit formation and circuit refinement in the adolescent brain in many regions related to fear and anxiety. In particular, the prefrontal cortex as well as the hippocampus. And this is just one example of the type of studies that were done by this collaborative group is essentially they put a microprism to look at synapse formation in the prefrontal cortex. And data that I'm not showing here is that the spines that are shown here in this red arrows were actually synapsing onto from projections from the hippocampus. So what's not shown in this figure is that this increase in spine formation is due to increased connectivity of the hippocampus with the prefrontal cortex. And I think this is a sort of a major breakthrough we made a couple of years ago because it suggested that while during adolescence, the prefrontal cortex might be underdeveloped or still developing, the hippocampus seems to be far more plastic than we thought and forming many more connections. And this gave the mouse researchers the sort of insight that possibly we could enhance certain forms of learning that are sort of the bedrock of cognitive behavioral therapy, which is fear extinction. Can we accelerate fear extinction by taking this knowledge about this enhanced capacity of the hippocampus? And so what they were able to do is show that by using a hippocampally activatable sort of context, so essentially using the hippocampus's traditional roles in spatial memory, if you added context in addition to cue in a traditional fear learning paradigm, can you accelerate or enhance extinction occurring during this period of time? So in many ways, this is sort of akin to what was going on with the studies with Riley Kaiser and Blair Simpson, where they used nabalone to accelerate extinction in OCD populations. Can we use interventions that stimulate the hippocampus during adolescence to actually enhance fear extinction? And as you can see, this is a very complicated slide, but the main point is that if you do this type of contextual extinction intervention during adolescence, and even shock the animals later on in life, that they basically show very low fear, suggesting that you're able to significantly attenuate the fear memories if you're able to do this. And what I don't show here is that if you don't use this type of context extinction, you will not get this type of, actually this is here in the second column, that you will still get very high levels of fear. So I think this has sort of allowed us to think that during adolescence, much more so than later on in life, that the hippocampus might be particularly a target for these types of fear attenuating interventions. And what's so great about the Youth Anxiety Center is that I could then go across the street and talk to Anne-Marie Albano about this in terms of what she could do within her clinics at Columbia, and what she immediately jumped on the idea in partnering with someone at Cornell is to come up with an initiative to look at whether we could add in virtual reality to augment the cognitive behavioral therapy for our patients with anxiety disorders. And in this way, to see whether or not this, again, contextually rich type of intervention might be something that would be appealing to adolescents, and also probably tap into some underlying neurobiology about the enhanced plasticity of the hippocampus during this time period. And these are ongoing studies now being done at both campuses with Michelle Pelkovitz, Shannon Bennett, and Anne-Marie Albano using a variety of VR interventions in order to try to enhance the effectiveness of cognitive behavioral therapy. But I think this is a great example of how information that was found in mouse models in 2016 could be rapidly translated into sort of human pilot studies that could be done very quickly in clinics specifically targeting adolescents with anxiety disorders. And finally, I just wanted to talk about another assumption we've always made in psychiatry and psychology about how we treat our patients, that treatment always involves seeing a provider. And I think this is a particularly difficult assumption given the significant access needs that have been brought up by the two previous speakers. And then we began thinking in the Youth Anxiety Center whether we could come up with ways of using digital tools to essentially expand the access in this way. And what we ended up doing was building our own therapist-free cognitive behavioral app which we are currently doing clinical trials with. Just to sort of take a few steps back, if you go to the iTunes store or the Google App Store, there are thousands of mental health apps created by industry. And most of the apps there, over 95% lack efficacy and effectiveness research. And also the vast majority of them have significant dropout rates within 24 hours, suggesting that there are certain barriers to success for using digital tools. So what we did was we basically were able to leverage the clinical expertise of clinical psychologists at Columbia and Cornell to build sort of a full cognitive behavioral therapy app that does not require a therapist, but has all the key components of cognitive behavioral therapy and that has been optimized for youth, in particular adolescents and young adults. And we've run a pilot study already where we first of all, normally CBT takes 12 weeks. We basically accelerated the timeframe by allowing the subjects to do two sessions a week, essentially having the vast majority of the CBT modules be presented within the first four weeks. And we were able to show that we were able to get significant improvement in both decreasing general anxiety as well as depression symptoms. These effect sizes you're seeing here are equivalent to what has been seen with in-person cognitive behavioral therapy. So we were very encouraged by these pilot studies, but we are continuing to do larger scale studies. It does give us hope that we have developed a form of CBT that seems to have some effectiveness. We are so concerned that we're, even though we were able to get 70% of our subjects to complete the six weeks of CBT, that we're concerned that we're, whether we can maintain this level of engagement. And so what we decided to also now do, and we're in the midst of developing, is developing a symptom tracker that will basically allow the subject to actually monitor their own symptoms. And what we hope that the symptom tracker does in terms of increasing engagement is do sort of an attitudinal shift in them, where they will take their mental health in sort of maintaining their own mental health and tracking it the same way they are with their physical health. So for example, if they have hypertension or diabetes, they would have a tracker to monitor blood pressure or blood glucose. We hope that they were able to basically check in every two weeks or so on their symptoms of anxiety and depression. And what we've used sort of machine learning algorithms to, so that this can be all done within five minutes. But we've, what we've also done, because we want to be able to continue to do research in this, is that the symptoms that are in the symptom tracker have been aligned to basically symptoms that align to brain circuits that have been established by our group to be involved in symptomology related to anxiety and depression. And that we will hopefully be able to, in addition to gaining data about which symptoms clusters exist within our patients, we'll be able to do reverse inference to try to identify the specific brain circuits and networks that basically sort of predict the various clinical symptoms that we will see in the tracker. And that hopefully we can then iteratively refine modules within our app to target these various brain circuits and symptoms. So this is the final slide. What I hope you can get from our research is that we really are trying to do sort of novel cutting edge research that really challenges the traditional assumptions of psychiatric treatment, and that we will try to develop personalized treatments that basically sort of treat the person, treat adolescents based on the state of their brain, and develop novel interventions that leverage digital technologies, and hopefully take advantage of this enhanced plasticity that we know that exists within the adolescent brain, so that this will be not only providing treatment options that are at the time when symptoms emerge, but where interventions might be the most effective. And finally, I'd just like to thank, like everyone else, Dr. Partes and everyone, all the other leaders within the Youth Anxiety Center. This has been an amazing collaboration across three institutions, and it suggests what's possible when you are able to get clinicians and researchers together. Thank you so much. I want to thank everybody for superb talks. And I'd like to hear some exchange about what those talks produced in you, thinking about the areas you were working on, or the things you're working on. Christine, you want to talk to that? Sure. Let me start just by saying how stimulating it is to hear from my colleagues. And one thing we are very concerned at Washington Heights is obviously to try to understand what is the impact of COVID-19 in our population. As we all know, the rates of death and hospitalization among racial ethnic minority groups have been higher than in other groups. So we are very concerned about how that could translate into increasing anxiety among our patients, which we are seeing. But I think the good side of this is that by hearing Dr. Monhatt and Dr. Lee speaking, it does look like there are many potential solutions or things that we could do in order to increase the outreach of our programs so that it could reach out to our patients at Washington Heights. And I fully agree that the integration in pediatric services seems to be really an important way that we could reach out more consistently, as well as the use of technology, although there are some challenges there, some that were mentioned by Dr. Lee, like the issue of privacy and when some devices are not available or connectivity and et cetera. But I think the forward thinking that I've seen here today makes me think that if we put our minds together, we can have an impact even in the most difficult situations. Commentators? I what I took away from your talk, Christiane, that I was I think we have not I think you focus on is that while technology makes so many promises of what it can do in terms of widening the circle and expanding access, what it has not done is really taken a very sort of critical look at cultural issues that basically will will be impediments to to sort of engagement with this, because I think this is going to be the how can we make these things such as symptom trackers or other things sticky so that it becomes part of their their daily routine. And it's not just sort of saying this looks really bright and shiny. You know, it is something that will appeal to them in a way that that that people in the tech industry probably don't understand completely. Absolutely. Any other comments? I'm not sure how much time we've got left. Christiane, do we have any data yet about the impact so far for, I mean, I guess, specifically the kind of Latinx community in Manhattan and the Southern Bronx? I'm thinking specifically about mental health since COVID or not yet? Not yet. Not yet. We are collecting data in this large cohort that we have. We have some national data, however, among adults. So we have national data among adults and also children. And across the board, what we are seeing, as you know, is this increase that you showed on depression and anxiety. But it does look like that among adults, we do have a higher increase among Latinos, Latinas. So we don't know exactly what that means yet. We have seen that before after some specific mass disasters, like after 9-11, we saw the same thing, particularly in the short term. After 9-11, there were elevated rates of post-traumatic symptoms, mostly among Latinos compared to other, Latinos compared to other groups. But we still don't know exactly if this is going to be sustained and exactly what it means. But it is an area of concern for us, for sure. This may be a repeat of what you just heard, but I guess the question is, why would we see different responses in Latinos than any other portion of the population? I mean, the community has been hit harder than other portions of the population in terms of deaths and also the consequences of COVID as well, in terms of unemployment and others, socioeconomically related stressors. So that would be a reason why we would expect to see higher levels of distress. I'd like to have the group gather together in front of a large audience and talk about this without fear of restriction of time. But you can ask any question you want, and we'll go on from there. Frances, I don't know where we are in time, but what could you say, does what you've done generate additional suggestions for interventions that might give an added therapeutic punch to the illnesses that you're talking about? Added therapeutic punch to the electronic entry into this field? I think with regards, first of all, to sort of the translational therapeutics, I think what Blair Simpson and Meg Haney and Riley Kaiser's study really suggests is something that there's always been a traditional assumption that marijuana or THC was somehow helpful for OCD core symptoms. And I think they have shown that that's probably not true, and that ultimately the focus should be on using or targeting during the treatment arm, not the core symptom arm, using these types of agents. With regards to the next steps about what the impact of what we've been studying in terms of the digital tools, I think what we've learned is that under controlled clinical trials types design, we can get very good engagement and effectiveness with sort of a standard cognitive behavioral therapy app that has been optimized for use. The big next step is, can we take this app into the real world and then give it to, for example, and translate it and give it to Dr. Duarte's clinicians in Washington Heights and basically have some type of program where it would not replace individual one-to-one psychotherapy, but would be something that could be added to extend or as an adjunct to help the clinician in some way, so get integrated into the system. Because ultimately, in addition to doing your psychotherapy within the app, it also gives information back to the clinician of when the patient is actually doing the exercises. And so I think that is sort of what's so exciting about the next steps. We have now within our, as Dr. Duarte presented, we have five clinics that we can do these types of iterative pilot studies to try to see whether or not what works best. And then as we are able to make a better version or more sort of sophisticated version, we can then widen the circle in many ways of who gets, how we can deliver this new types of interventions. I want to thank my superb colleagues for an outstanding presentation and one which should stimulate that much more in the way of exploration and discussion in front of all kinds of groups. It was first rate. And what I think Francis and Christian of the whole group showed is that we can pull together what might be divergent arenas of which treatment possibilities emerge and see if we can put them together in a way which will give that much more in the way of help to Latin American young people with COVID anxiety impact. It was absolutely terrific. Thank you.

Youth Anxiety Center

anxiety disorders

limited resources

child mental health psychologists

under-resourced populations

youth distress

negative outcomes

COVID-19 pandemic impact

Crisis Counseling Service

virtual counseling sessions

mental health needs