Dan Simon (Host): Hello everyone. My name is Dr. Daniel Simon. I am your host of the Science at uh, podcast sponsored by the University Hospital's Research and Education Institute. This podcast series features university hospital's cutting edge research and innovations. Thank you for listening to another episode today. I am happy to be joined by my guest, Dr. Molly McVay.

The Rocco Elma Professorship in Child and Adolescent Psychiatry in the Child and Adolescent Psychiatry Division at University Hospital's Cleveland Medical Center, and she is also an associate professor of Psychiatry at Case Western Reserve University School of Medicine. Thanks for joining me today.

Molly McVoy, MD: So glad to be here.

Dan Simon (Host): I wanna just start off by saying Dr. McVay's work combines cutting edge technology with behavioral interventions, aim to understand and improve the mental health of young people. So, Molly, before we begin, perhaps you could set the stage for us to really talk about, the challenge, that we face right now.

I mean, this has been a time of the greatest need for someone like you. Tell us a little bit about that.

Molly McVoy, MD: Absolutely. I mean, it's both an overwhelming and amazing time to be a child psychiatrist and a researcher. In the last 10 years, as an example, more 10 to 17 year olds have died of suicide. Then if you combine heart disease, cancer, infectious disease, and inherited rare diseases, if you put all of those together, more kids have died by suicide.

So, I mean, it's a, crisis we've seen, but it's also an opportunity. And I think that the hospital and the at large community is recognizing the need, which makes it both, exciting and a little bit overwhelming.

Dan Simon (Host): So let's talk just for a sec. I know that of course we all think about the influence of the pandemic. Social isolation and other things that spanned the 2020 to 2022 timeframe. But you mentioned in fact that this precedes that it was really in the past decade. So tell me, what do you think are the main factors that you think are contributing to this?

Molly McVoy, MD: It's a good question and the number one new quote, unquote factor is social media. And I sound a little bit like a broken record, but the advent of a phone that was connected to the internet and social media and a camera, which is about now 11, 12 years ago, has coincided with the spike in specifically anxiety and depression, and then exacerbated, just like you said by the pandemic and all of the things that.

Contributed to the social isolation that teens especially felt

Dan Simon (Host): So it's a, great observation that you've been able to isolate that to what we would think would be a, a communication tool, for good or for bad. But tell me a little bit. About what is it in particular, that leads to, you mentioned anxiety especially, and we hear a lot of that.

There's also been an explosion of individuals on A DHD drugs, millions and millions of children on A DHD drugs. How does that all factor in in your mind?

Molly McVoy, MD: so I think the smartphone and anxiety issue are very interwoven. The A DHD thing is slightly different, which we can talk about, but the anxiety is driven by the need for immediate reassurance and worries about things you can't control. Smartphones are designed to feed on just that. So they are designed to keep you hooked on said device by convincing you that there's all this stuff other people are doing and you need to check repeatedly to engage and understand that what people are doing and what the world is doing that you might be missing.

So they are designed to keep you engaged. The way to keep humans engaged is to feed on that worry and that. I'm so old, but that fomo, that fear of missing out and teenagers are wired specifically to, that's developmentally what they're doing. So they're interested in what their peers are doing, and social media feeds on that and creates an anxiety loop.

And we see that, you know, you don't have that in any other part of your world where you can get second to second information We can't say that correlation is causation, but there is a lot of data that increasingly is overwhelming. That attachment to a phone that has a camera and the internet is.

Exacerbating, if not causing the huge rise in anxiety. which then if left untreated leads to depression. Right? So it's not that necessarily social media is causing depression, but it's everybody's wound up and then if you leave that untreated, they're at higher risk for depression. I'm gonna pause and the A DHD issue I think is slightly different.

So there's been in the last seven to eight years in kids, so an under 18. There has not really been a measurable increase in the diagnosis of A DHD in older adolescents and young adults. That's a different story. and that partly has been. Fueled or facilitated, or whatever you wanna call it, by the telemedicine that was, needed and now expanded from the pandemic.

So prior to COVID OVID, it was really unusual. Like some of our trainees would do telemedicine 'cause we're so underserved. But it was a production and there was so much regulatory things around it that it was really difficult. The pandemic removed all those. So now everybody does telemedicine, which has allowed and or expanded those that are able to get a diagnosis for A DHD mostly in the older adolescent and young adults, which then leads to all the challenges we've seen around access to stimulants.

but in the school aged kids and in early teenagers, that's really stayed. Similar to what it was pre pandemic. That rate is similar. It's the older kids and young adults that have access in a way that they didn't before.

Dan Simon (Host): So you know what's fascinating about. talking to you about this is that, it, just brings on all these other amazing questions. And so of course, as we would say, talk therapy, counseling is extremely important. Medications have a role, but of course as a parent, well, my, kids are older now, so it's not, an issue where I would have that control is Okay.

So what about removing the social media device? is that part of. controlling and treating this anxiety depression cycle. I mean, I'm sure a lot of parents are listening and going, what am I gonna do? Yeah.

Molly McVoy, MD: Oh, a hundred percent. And I've actually seen, so I do work with schools and I was there this morning and they have changed. So in the last year and at the end of last school year, there's now a policy in most Ohio schools that they either have to lock up or remove smartphones during the day.

That's made things better. and there are recommendations. That you should have smartphones only in common areas. so certainly limiting access to smartphones during times when you should be doing other things. And then I think it's very instructive that Steve Jobs and all of those that created social media won't let their kids have smartphones till they were in eighth or ninth grade.

so that's my recommendation to families is make it till eighth. There's a whole campaign around that. And so if you can get to eighth or ninth grade. Without a smartphone, you've let the kid's brain develop in such a way that they're better able to cope and they have a better sense of who they are in the absence of being connected to this sort of worry thing that they're carrying around in their pocket.

Dan Simon (Host): Wow. Okay. So now I'm gonna ask you, a question about something that I know you're very passionate about, which is this biomarker idea that you've developed to help with the, diagnosis subtyping of depression, and that relates to your EEG coherent studies. Tell us a little bit about. how does one diagnose depression in general, and then how is this helpful in you categorizing and treating, that person in front of you?

Molly McVoy, MD: So depression's a really broad category is one of the challenges. So when I've seen one teenager with major depressive disorder, I've seen one teenager, one can come in angry and yelling at me, and another one can come in crying. And so it's really variable in how it shows up and it's relatively difficult for a teenager to describe how they're feeling.

Currently, the state of the art is an assessment with a specialist, an assessment with someone like me. We're the most underserved specialty in all of medicine, so it's super difficult to get in to see a child psychiatrist. Teens are often been depressed for at least a year before they can get in to see someone, if they can get in.

And so the challenge of it being a somewhat vague diagnosis. Access is really difficult to get in to see someone like me. And so then teenagers show up in their pediatrician's office or the emergency room because they're in crisis, to individuals who are not specialized in how to diagnose this.

And families are really confused about what's going on. So if we had something. That is more objective. That is a biologically based indicator of what's going on in a kid's head. It could be incredibly helpful. For both the families. So this is the one where my research participants all wanna take their pictures of their brains home.

It's just really validating that there's something that I can measure that looks different and it would help, especially in a field like mine, where it's such a shortage that we could add an additional tool for schools or emergency rooms or primary care offices around how to diagnose and classify depression.

Dan Simon (Host): So you went on this very nice thing, which is okay. The adolescent, the child is going to their pediatrician. The pediatrician is doing the best, assessment that a general pediatrician can do for this and how they come to you. How do you use this quantitative EEG coherence to help you?

what exactly is it?

Molly McVoy, MD: So it's a great question. So, Anyone who's ever been to like a neurologist or to do any kind of sleep assessment, EEG or electroencephalography is common. It measures the electrical activity on your scalp, basically, which then is a translation. It's really not great about location, but it's a translation of what's happening in the deeper areas of your brain.

And what adult research had discovered that I then was able to look at in kids was that adults with depression. This part of their brain, which is chugging away, was less connected to this part of their brain. in individuals who are depressed, and that's what I'm talking about with coherence.

It's a measure of connectivity. So it's just a measure of how one part of the brain is marching, it's electrical signals marching similarly or differently than another part. And I've seen that teenagers with depression are less connected, especially in the frontal part of their brain, which is like the key area in adolescent development.

they've got different measures of coherence than their healthy peers. And that's super exciting and it's really available. So I, that's where I got interested because I'm not really at my core, a neuroscience researcher, but it's available, it's affordable. The teenagers don't hate it. and so it's promising that I think it could be usable in some of these locations where kids are showing up.

Dan Simon (Host): So, all right, I'm a cardiologist. You know an Eek G's got a bunch of leads. You put it on, takes, 10 seconds and you take it off. How long is an EEG though?

Molly McVoy, MD: So we do it for 20 minutes. In my research, really though, you get meaningful information with four minutes. So there's people that do both resting, which is just what I do, which is kids are eyes closed, but they can't fall asleep, which they can do. and then there's other researchers that do tasks where they have 'em do things and they measure that.

But we can use the four to five minutes of resting data they get before the tasks and get meaningful. I mean, every 10 seconds you get data points that are meaningful. So you get thousands of data points from like four or five minutes of EEG data.

Dan Simon (Host): So you have an e, EG. It shows that you don't have connection between the right and the left brain. Let's say that, I'm gonna jump ahead here and I'm only a cardiologist, so if I'm wrong, you start an antidepressant. Does the coherence and connection of the brain by EEG improve with therapies either?

Cognitive therapies, behavioral therapies or medications.

Molly McVoy, MD: So that's exciting. We have new research that shows it does. So I've just been collaborating in the last, and it's not even published yet. We presented it, we haven't published it yet, that we watched kids over time. They all got treatment 'cause I'm the first one that's done this, so they all got treatment.

So we can't tell you. What works better or who's gonna respond better, but that there was a change in the kids who got better in their connectivity, in their coherence. what we haven't yet finished analyzing, I'm interested what those kids look like in comparison with the healthy ones, and so we haven't yet analyzed that, but we have seen that the connectivity normalizes again in a little sample, but that it does seem to change over time.

Dan Simon (Host): Alright, so let's shift gears for a moment. Because you have developed specific programs called SMART and CAE, A DHD where you empower teens to manage their own care, more effectively. And this is good because now you're engaging and empowering and that sounds good 'cause you're really involved in your own outcomes.

So tell us a little bit about what is this smart program?

Molly McVoy, MD: Sure. So, all of the research that I do in collaboration with my colleagues over in the psychiatry department is around the concept of self-management. And this comes from really the field of diabetes has done this the best. And this is where a lot of the work comes from, is helping people with chronic.

Learn how to be effective patients. It sounds really crazy, but having been a family member and a patient, it's a different skillset than everything else in your life. And what the idea around self-management is you practice the skills you need to manage a really convoluted medical system. You learn how to take your meds, you practice and learn how to talk to all the healthcare providers.

You understand how routines impact you and it's personalized to you. Whatever disease that you're living with, we have tons of data in smart, which is self-management for individuals with epilepsy. and then CAE is an adherence, a customized adherence program, and there's lots of data in adults. Not surprisingly, many of our participants were like, oh, I wish I had this when I first got diagnosed.

And so we've modified at least the CAE for individuals with A DHD who are young. I just thank you to the Health Services Research Consortium. I just got some funding to modify it for teenagers for smart to modify that and try it out in teenagers with epilepsy. Which is fantastic.

and the idea being learn these skills that you need 'cause you're gonna live with this illness probably for decades, if not for the rest of your life. And we know if you can help people, and you know this as a cardiologist, I mean that engaging in the things that impact the quality of your life, the earlier you do it, the longer and healthier you live.

Dan Simon (Host): So let me ask you this. I think, from the sense of trying to be hopeful when you meet a family that has a child, an adolescent with anxiety and depression is there. A significant developmental component so that you can say to them, you are likely to either not outgrow this, but learn how to adapt and be effectively treated, and your likelihood of depressive episodes is gonna go down.

Or do you say that this is going to be a lifetime problem?

Molly McVoy, MD: This is such a psychiatrist answer, but it depends. So yes, this is one of my like pleasant surprises. I was gonna be a pediatrician. Then I discovered child psychiatry and was worried everyone was just gonna be a mess. I have been so surprised, and it's why I keep going to work, how many of the kids and families get all the way better and don't need me anymore and go back to their pediatrician with anxiety for sure.

So that if you can get somebody better, well in remission with anxiety, and that's a combination of therapy and sometimes medication. They're gonna be, well, depression, it depends on their genetics. So if this is a 16-year-old who comes in with no family history, something has happened, they're depressed, their likelihood is less than 50% of having another episode.

If we get 'em better, someone with the family history of a mood disorder, because it's really a genetic, that's one of our major genetic. String of disorders as mood disorders. If they have a strong family history, they're still gonna function way better, but they're more in the 50 to 75% likelihood of having another episode down the road.

but almost all kids were able to get them then off medicine after about a year. You're doing great. Let's give it a try. Let's stop. See how you do. and it's remarkable. I mean, they're so resilient. So I, really, it is a very hopeful story that if you get somebody early with the right tools, they get better.

Dan Simon (Host): So you hear this term and I, just saw it the other day. I think it was in an article in the New York Times related to. The cascade of medications that there tends to be this pile on it. In fact, you can't turn on the television without hearing that.

If you have, depressive symptoms, try Rexulti. I think that's the commercial So tell me, is that a problem? are there too many meds? And, how do you counsel patients and parents to avoid this cascade?

Molly McVoy, MD: it is definitely a problem and we don't have too many meds. What we have is not enough meds that are effective enough, and we don't, this is gonna sound so self-serving, but we don't have a personalized way to pick what's gonna work for which person. And so some, if you find.

The medication that works for Joe. That's it. We're done. He's on it. It's great. But we don't have any tools other than, oh, well, his dad was on this and his uncle was on this. So we don't have tools yet, like in oncology, for example, which is remarkable that, okay, of these 600 options because of X, Y, or Z, we know you're most likely to respond to this.

And so we don't have that. So it's a little bit of a trial and error. and because specialists like me are so unavailable, it ends up that you're not able to get to somebody who's comfortable saying, no, we're not adding another one. Give it another couple weeks. Or, we need to do this or that therapy intervention.

And that's a much more difficult thing for someone who's not a specialist to counsel, a family or a patient on, to avoid being on three or four medications.

Dan Simon (Host): So you've talked about the shortage, and the weight and access being an issue. Tell me a little bit about, Extenders. So everything from advanced practice providers, nurse practitioners, PAs, social workers, psychologists, what's the solution here?

Molly McVoy, MD: For sure. So I think about it sort of in two camps. We have the prescriber shortage and then we have the mental health therapy and access shortage. when we think about. Accessing therapeutic services. That's where social workers, psychologists come in and they're amazing and often know way more, right?

So I'm not trained in, I'm trained in cognitive behavior therapy, one kind of therapy, that's it. But my colleagues that do therapy are trained in all kinds, and so we rely on them to do that kind of work and we need more. Of all levels of training of the therapy arm of mental health, and that includes school, social workers, school psychologists, that whole group.

We need more of them around medication prescribing. We have lovely, we have these fabulous nurse practitioners in our department that I love that a lot of them have come from being inpatient nurses within our inpatient child unit and then come to work with us. Again, fabulous. I think one of the things that I'm most excited about is primary care.

So these awesome pediatricians and with not a ton, right? So if they spend a little bit of time with me or with Mary Gabriel, for example, my colleague that does this, they can get incredibly more comfortable. Using what they know, right? They know normal development. They know what a 6-year-old is supposed to look like.

That's the key. I think that is the most untapped resource is us in mental health, better supporting pediatricians in having more nuanced stability to understand and prescribe what's going on.

Dan Simon (Host): Wow. It's just every time I hear you speak, I get inspired, and then at the same time, a little overwhelmed.

Molly McVoy, MD: A hundred percent. that's why I keep doing what I'm doing. I mean, I just can't not, I had no intention of doing research. I did bench research in medical school and don't have the temperament, not surprisingly, for basic science research, but there we know so little about. The evidence around pediatric mental health and I like to write and I like to learn.

So it was like, okay, how can I not, how can I not try to do these things that these kids need? And what's been cool among many things is this is gonna, again, sound self-serving, but what little it takes to make a difference. So, you spend an hour at a school and they see that mental health providers care changes the tenor of how they approach every mental health interaction in the future.

So it, you know, most of the time I err more on the hopeful side and on the, anyone who would like to fund any of this, please come talk to me side. but there are certainly days where it, it feels like such a big problem.

Dan Simon (Host): Thank you for taking the time to speak with us, today. To learn more about research at University Hospitals, please visit, uh hospitals.org/uh, research. Thank you, Molly, as always.

Molly McVoy, MD: Thanks Dan so much.

Dan Simon (Host): you.