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Florence Jaguga, MBChB, MMed, Brittany McCoy, MD, Leading Progress in Mental Health Care in Kenya

We are currently in the midst of a global crisis in child and adolescent mental health. The COVID-19 pandemic put a spotlight on the significant barriers youth and their families experience to accessing quality, evidence-based mental health care in all settings, including those that are otherwise considered to be resource-rich. In Kenya, the 2021 National Adolescent Mental Health Survey found that 12.2 percent of Kenyan adolescents (10-17 years) met criteria for a psychiatric disorder. However, of those, only 11.1 percent had accessed any form of support for their mental health concerns in the prior year, in part because of a lack of available services.

Mental health plays a critical role in the development and overall well-being of young people, which is why efforts are being undertaken at the MTRH-Rafiki Center for Excellence in Adolescent Health to improve the availability of mental health services for youth in western Kenya.

Florence Jaguga, MBChB, MMed, and Brittany McCoy, MD, are working together to lead progress towards the mental health-related care, research, and education priorities set out by the AMPATH Adolescent Working Group at the AMPATH Adolescent Summit earlier this year.

Brittany McCoy, MD

Dr. McCoy is the new Adolescent Mental Health Team Lead for AMPATH, a T32 Postdoctoral Research Fellow in Psychiatry, and an Instructor in the Departments of Psychiatry, and Global Health and Health System Design at the Icahn School of Medicine at Mount Sinai. She is a recent graduate of the Mount Sinai Triple Board Residency Program, where she trained in general pediatrics, general psychiatry, and child and adolescent psychiatry, and completed the requirements of both the pediatrics global health and global mental health residency tracks.

Dr. McCoy has a long history of engagement with AMPATH Kenya, starting in 2016 when she served for a year as the Indiana University School of Medicine Pediatric Global Health Research Scholar working with Rachel Vreeman, MD, MS. She has completed AMPATH clinical rotations at MTRH and continued to work with Dr. Vreeman and her team on research projects related to the mental health of youth living with HIV throughout her subsequent medical education and residency training.

More recently, she completed a study funded by an Pediatric Research Scholars Award at Icahn Mount Sinai to adapt a battery of mental health measures culturally and developmentally for Kenyan youth living with HIV. In her new position at AMPATH, Dr. McCoy hopes to use the unique skillset she has gained as a “Triple Boarder” to inform research, care, and education initiatives aimed at increasing adolescents’ access to evidence-based, culturally and developmentally appropriate mental health services in western Kenya.

Dr. Jaguga is a psychiatrist at MTRH and Head of the Alcohol and Drug Abuse Rehabilitation Services. She is co-chair of the AMPATH Adolescent Health Working Group. Dr. Jaguga has conducted research projects to evaluate the feasibility of a peer-led substance use screening and brief intervention program for youth at Rafiki. Her research findings support the feasibility of this program.

Florence Jaguga, MBChB, MMed

Dr. Jaguga has worked to integrate mental health and substance use screening for youth into the AMPATH electronic medical records system. The tools included in the screening are the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7) scale, and the Substance Use Screening to Brief Intervention (S2BI) tool.

Next steps include training peer counselors to conduct screening for mental health using the tools. Youth screening positive will be referred to the psychologist that is currently stationed at Rafiki Clinic. Rafiki now also runs a weekly mental health clinic led by an MTRH psychiatrist, and youths who screen positive for a mental health concern will also be referred to this weekly clinic.

Over the coming months, Dr. Jaguga and Dr. McCoy will work together with others in the adolescent health and mental health initiatives at AMPATH to continue to grow the mental health services offered by the Rafiki Center and support adolescents’ mental health.

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Mount Sinai Researchers Publish First Genome-Wide Analysis of Binge Eating Disorder

Binge eating disorder is the most common eating disorder in the United States, thought to affect as many as 3 percent of people during their lifetimes. Yet it remains poorly understood.

Now, researchers from the Icahn School of Medicine at Mount Sinai have made important progress with the first genome-wide analysis of binge eating disorder (BED). The study, published in Nature Genetics in August, identified genes that appear to be associated with BED risk. The study also found evidence that iron metabolism may play a role in the disease.

“By applying machine learning to the study of binge eating disorder, we’ve gained important insights into this poorly understood condition, and a new tool for exploring other underdiagnosed diseases,” says Panos Roussos, MD, PhD, Professor of Psychiatry, and Genetics and Genomic Sciences at Icahn Mount Sinai and Director of the Center for Disease Neurogenomics, who is a co-author of the study. “By combining Neuroscience with genomics and big data analysis, we can discover more about how the brain works and ultimately prevent psychiatric disease.”

A Fresh Look at Binge Eating Disorder

Binge eating disorder has significant impacts on a person’s health and well-being. “It can cause substantial distress and impairment in quality of life,” says Trevor Griffen, MD, PhD, a psychiatrist and neuroscientist who collaborated on the recent study while he was a fellow in child and adolescent psychiatry at Mount Sinai. “BED often co-occurs with other psychiatric disorders, such as depression, ADHD, and substance use, and seems to be a nexus of metabolic dysfunction, with associations to conditions like diabetes and high blood pressure.”

Trevor Griffen, MD, PhD

Yet it took a long time for the scientific community to recognize BED as a distinct disorder. It was first included as a new diagnosis when the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in 2014. As a result, the diagnosis is all but absent in the electronic health records and large biobanks that researchers tap into for large-scale genetic analyses. Luckily, the Mount Sinai team developed a workaround.

“A big part of this study was using machine learning to figure out the people most likely to have BED,” says lead author David Burstein, PhD, a data scientist at Mount Sinai who works in the labs of Dr. Roussos and study co-author Georgios Voloudakis, MD, PhD, Assistant Professor of Psychiatry, and Genetics and Genomic Sciences.

Using electronic health record data from more than 767,000 people through the Million Veterans Project, Dr. Burstein and his colleagues applied machine learning approaches to sift through medical diagnoses, prescription medicines, body mass index (BMI) data, and other factors, looking for patterns that would predict if a person had BED. Applying their model to smaller cohorts of people with diagnosed BED, they showed the approach could meaningfully predict the disorder, even in the absence of a formal diagnosis.

Genes Point to New Binge Eating Disorder Treatments

Applying the machine learning model to some 362,000 people for whom genetic information was available, the researchers zeroed in on several genetic loci that appear to be associated with BED risk. One of the genes implicated in the new study is MCHR2, which is associated with the regulation of appetite in the brain. Two others, LRP11 and APOE, have previously been shown to play a role in cholesterol metabolism.

David Burstein, PhD

Another gene identified in the study, HFE, is involved in iron metabolism. The identification of HFE aligns with recent research suggesting iron metabolism may have an important role in regulating overall metabolism, Dr. Griffen says. In particular, iron overload seems to be associated with binge eating, the team found. Interestingly, iron deficiency has been implicated in pica, a disorder that drives people to eat non-food items such as soil or hair.

“There have been hints that iron is a player in the eating disorder world,” Dr. Burstein says. “This new study is more evidence that the mineral deserves a closer look.”

The findings also point toward new directions for treating BED. So far, treatment has mostly focused on repurposing therapies used for other disorders, such as depression or ADHD.

“This study identifies genes and systems that could serve as potential targets for treatments that finally address the underlying biology of BED,” Dr. Griffen says. “It also continues to build evidence that there are biological and genetic drivers of binge eating behaviors. The more we get that message out there, the more we can decrease stigma associated with binge eating.”

A New Tool for Eating Disorder Research

Dr. Griffen is continuing to collaborate with Dr. Roussos and Dr. Voloudakis to expand on their findings, with plans to develop mouse models and dig deeper into the mechanisms. Ultimately, their goal is to develop new treatments that target the underlying biology of BED.

Meanwhile, the researchers are eager to apply their new computational approach to other diseases such as bulimia nervosa—another common eating disorder for which no genome-wide analysis has ever been done.

“Being able to infer a diagnosis from medical records is really significant, not only for BED but for other eating disorders, which are often extremely underdiagnosed” and therefore challenging to study using electronic health records, Dr. Burstein says.

The approach can also extend the science into populations that have been overlooked in past research. Most research on eating disorders has focused on white females. Using machine learning, researchers can more thoroughly study eating disorders in males and populations with other racial or ethnic backgrounds.

“This is exciting work, with so many potential future directions,” Dr. Burstein says.

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Is Physical Activity Always Good For Us?

Working consistently in an occupation with medium or high occupational physical activity was linked to an increased risk of cognitive impairment, according to a new study by the Norwegian National Centre of Ageing and Health and Columbia Mailman School of Public Health and the Butler Columbia Aging Center. The results show the importance of developing strategies for individuals in physically demanding occupations to prevent cognitive impairment. The findings are published in The Lancet Regional Health – Europe. “It is critically important to understand how workplace physical activity levels relate to cognitive impairment and dementia,” observed Vegard Skirbekk, PhD, professor of Population and Family Health at Columbia Public Health. “Our work also highlights what is called the physical activity (PA) paradox – the association of leisure time physical activity with better cognitive outcomes, and how work-related physical activity can lead to worse cognitive outcomes.”
Until now prior studies on occupational physical activity and dementia had been limited.  Earlier studies have typically assessed occupation at a single time-point in the individual’s career — often close to retirement — and have mainly been self-reported.
“Our findings extend those from previous studies by incorporating a life-course perspective into research on occupational physical therapy and cognitive impairment,” said Skirbekk.  “Whereas previous studies have also mainly focused on a single measurement of occupation, we include occupational trajectories from ages 33-65 to give a broader picture of the occupational histories of the participants and how these relate to risk of cognitive impairment in later adulthood.”
Skirbekk observes that the preclinical period of dementia may start up to two decades prior to symptom onset, therefore, a life-course approach where different occupations during the working life course are taken into account could provide more accurate information on the complex relationships between occupational characteristics and cognitive impairment.
Using one of the world’s largest population-based studies of dementia, the HUNT4 70+ Study, researchers assessed the association of occupational physical activity at ages 33–65 with risk of dementia and mild cognitive impairment at ages 70+. Included in the analysis were 7005 participants, 902 who were clinically diagnosed with dementia and 2407 diagnosed with mild cognitive impairment. Skirbekk and colleagues assessed the association of trajectories of occupational physical activity at ages 33–65 with risk of dementia and mild cognitive impairment at ages 70+. Of the 7005 participants half were women. Risks for dementia and mild cognitive impairment among the 70 year-old and over population were 15.5 percent among those with physically demanding work in the latter part of the working life, but only 9 percent among those with jobs that had low physical demands.
“Our results particularly underscore the need to follow up on individuals with high lifetime occupational, physical activity as they appear to have a greater risk of developing dementia,” noted Skirbekk. “Future research should assess how occupational physical activity and interventions to reduce occupational physical activity or technological changes leading to altered activity, in combination with other characteristics of the job, relate to dementia and mild cognitive impairment risk in older ages. This will further our understanding of the association between occupational histories and cognitive impairment.”
Co-author is Ekaterina Zotcheva, Norwegian National Centre of Ageing and Health.
This work was supported by the National Institutes of Health (R01AG069109-01) and the Research Council of Norway (296297, 262700, 288083). 

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Why it Is Important for Men to Get Tested for Prostate Cancer

Prostate cancer is the second most common cancer among men in the United States, after skin cancer, and the number of cases has been rising yearly. About one man in eight will be diagnosed with prostate cancer during their lifetime, according to the American Cancer Society.

Prostate cancer comes in many different forms, which is why Mount Sinai offers a wide variety of treatment options while conducting research to find new and innovative treatments and expanding care to those communities most at risk.

“The most important thing people can do is find this cancer early, when it is easier to cure. That starts with understanding your own risk, and talking with your doctor before there are any symptoms,” says Ash Tewari, MBBS, MCh, FRCS (Hon.), Professor and Chair, Milton and Carroll Petrie Department of Urology and Director of the Center of Excellence for Prostate Cancer at The Tisch Cancer Institute.

Click here to learn more and register for a special event Wednesday, September 27 featuring Dr. Tewari discussing the latest in prostate cancer screening and research and free on-site PSA tests at the Mount Sinai Robert F. Smith Mobile Prostate Cancer ScreeningUnit.

One key message remains unchanged: Prostate cancer screening is critical to detecting this cancer early, before you have any symptoms, when you have more treatment options.

In this Q&A, Dr. Tewari, who is also Surgeon-in-Chief of the Tisch Cancer Hospital at The Mount Sinai Hospital, explains when men should be tested for prostate cancer and what options are available to those who may be diagnosed with prostate cancer.

What should patients and consumers know about the rise of prostate cancer?

Ash Tewari, MBBS, MCh, FRCS (Hon.)

It is likely that this perceived rise of prostate cancer is not a true rise in prostate cancer incidence but rather there has been increased awareness about testing and screening. This is a good thing because we can prioritize delivering care to those who need it and make sure they are managed appropriately.

 Who should be tested for prostate cancer and when?

The decision of when to initiate screening should be an individual one that is based on shared decision making between physician and patient. There are several factors to consider including race, family history of cancer (not only prostate but also breast, ovarian, and pancreatic cancer), and age. According to the U.S. Preventative Services Task Force, all men over the age of 55 should have this conversation with their physician about the decision to begin screening with Prostate-Specific Antigen (PSA) testing. Patients who are at higher risk, such as those with family history, should start this conversation earlier, and some as early as age 40.

 Who is most at risk for prostate cancer?

 Those who are most at risk of prostate cancer include:

  • Black men
  • Men with a family history of prostate cancer and other cancers
  • Men over 55 years old
  • Men who have done genetic testing and were found to have mutations, such as BRCA2, that are known to be correlated with a higher risk of prostate cancer

How is prostate cancer diagnosed?

Prostate cancer is diagnosed when a PSA test rises above a certain threshold, and a biopsy becomes indicated. A biopsy can be done even if PSA is not above threshold—for example if a patient has other factors that might put him at risk or has a concerning MRI This biopsy can be performed transperineally or transrectally. Sometimes, this biopsy is guided by imaging tests such as magnetic resonance imaging (MRI) and micro-ultrasound imaging to increase the sensitivity of the biopsy.

How do doctors use the PSA test?

The PSA test is a blood test that can be used for screening. It also is used as a marker to track treatment response and for surveillance to detect recurrences after treatment. A single PSA test is often insufficient to draw meaningful conclusions. A single elevated PSA during screening is followed up with another PSA test to corroborate that the rise was not due to other factors, such as the result of inflammation or infection in the prostate.

What treatments are available for prostate cancer?

If you are diagnosed with prostate cancer, what follows next would be a discussion with your doctor about next steps. The conversation depends largely on the type of prostate cancer diagnosed. There are a number of different types and grades of prostate cancer, and treatment must be appropriate for the individual patient. Some patients are diagnosed with a disease that is confined to the prostate. Options for these patients range from active surveillance for low-risk disease to radical treatments such as radiation or surgery for intermediate-risk and high-risk disease. There are also emerging experimental therapies, called focal therapies, that are being investigated for their appropriateness and safety for certain patients. For advanced and metastatic disease, sometimes hormones and other treatments that target the entire body, such as chemotherapy may be used. This is also a very active field of research. There is a tremendous effort to improve the outcomes and quality of life for patients.

What is active surveillance and why is that important?

Active surveillance is an approach that is used for patients who have low-risk and very low-risk cancer confined to the prostate. Because these cancers are usually slow growing and do not involve complications or pain, we prefer not to implement radical treatments if they are not necessary, and so active surveillance can be a good option for them. This protocol often involves periodic imaging and biopsies to monitor the disease and intervene only if necessary.

Can I reduce my risk for prostate cancer?

There is no evidence that one lifestyle choice will either cause or prevent prostate cancer. Studies show that patients who eat more vegetables and less red meat, and patients who exercise regularly, are at lower risk for prostate cancer.Overall, leading a healthy lifestyle has many wide-reaching benefits.

What steps is Mount Sinai taking to bring prostate cancer screening to the community?

In 2022, we launched the Mount Sinai Robert F. Smith Mobile Prostate Cancer Screening Unit, a state-of-the-art mobile facility equipped with advanced PSA tests and trained staff that visits predominantly Black neighborhoods across New York City. We are very excited about this initiative. We want to reach patients who cannot easily access a urologist, and we want to make it easier to screen for prostate cancer and treat them if necessary to save their lives. So far, we have screened more than 3,000 patients and of those, we have found several hundred with elevated PSAs that required further follow up. We detected cancer in 30 patients and conducted surgery to remove the cancer in half of these patients. In addition, we are following up with these patients to make sure they have the most appropriate testing and treatment.

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