THE FUTURE OFF PEDIATRIC MENTAL HEALTH

scott shannon, md faacap

wholeness center

DISCLOSURES

• I have published four books on integrative mental health.

• I receive royalties from these books

• I am a PI/researcher on The Phase III MDMA Assisted Psychotherapy in

PTSD study and receive support from Multidisciplinary Association for

Psychedelic Studies (MAPS), a 501(c)3 non profit through MAPS Public

Benefit Corp

• I have no other conflicts or financial relationships to disclose

AGENDA

• Where we are now

• A new model of care

• Gaming and VR

• Q EEG and neurofeedback

• Mindfulness

• Telepsychiatry

The Adolescent Mental Health Crisis

HALF of all lifetime cases of mental illness start by

age 14

75% start by age 24

79% don’t access care

The Incidence of Disease Across the Lifespan

MENTAL HEALTH AMERICA 2020 REPORT

37% of students with

mental illness age 14

and older drop out of

school

This is the highest

drop out rate of any

disability group

ADOLESCENC

EAGES 12-18

National Institute of Mental Health. Mental Health by the Numbers. 2015.

MENTAL HEALTH AMERICA 2020 REPORT

YOUNG PEOPLE DON’T SEEK OR GET PROFESSIONAL HELP!!

Only 13% of young men and

31% of young women access

professional mental health

care

Young men aged 16-24 have

the lowest professional help-

seeking of any age group

SUICIDE RATES ACROSS THE US, CDC JUNE 2018

A NEW MODEL OF CARE

What would teens use?

EXPANDING EARLY ACCESS TO MENTAL

HEALTH CARE FOR YOUNG PEOPLE

School health/

mental health

programs

Early

psychosis

programs

A Public Mental Health Continuum for Youth

• Early Mental Health Support

• Primary care

• Supported education and

employment

• Early Substance Use Treatment

• Peer support

INTEGRATED YOUTH MENTAL HEALTH ACROSS THE GLOBE

Growing around the world: headspace Australia- 130 sites, growing to 150 soonheadspace Denmark- 8 sitesheadspace Israel – 2 sitesJigsaw Ireland- 16 sitesFoundry, BC, Canada- 8 sites open & new funding for 8 moreYouth Hubs Ontario - 8USA – plan to open first 2 in 2020!

Integrated Youth Mental Health Center

Components

●Stand alone one stop shop youth mental health

centers for young people ages 12-25

●Accessible (location & short appointment wait time)

●Low to no cost; serve everyone

●Provide 5 core components in youth developed and

friendly environment:

Mental health, including mild-moderate issues

Primary care support

Alcohol and other drug early intervention

Supported education and employment

Peer and family support

HOW IS THIS MODEL UNIQUE?

• Low to no cost

• Early intervention focus

(a public mental health care model)

• Youth-centered design; Informed by youth

• Youth advisory board

• Stigma-free / normalizes mental health

• Youth-friendly, engaging, upbeat staff

• Strong youth outreach & marketing

• A consortium of youth serving agencies

• Integrated care (no wrong door)

CORE SERVICES

MENTAL HEALTH SERVICES

PRIMARY HEALTH

CARE

SUPPORTED EDUCATIO

N & EMPLOYMEN

T

SUBSTANCE USE

SERVICES

PEER & FAMILY

SUPPORT

SOCIAL SERVICE

REFERRALS

INSTAGRAM DESIGN WALK THROUGH

https://www.instagram.com/p/BnJdlUng73r/?utm_source=ig_web_copy_link

VIDEOGAMES AND VR

Not just for fun anymore

In the U.S. and UK, the best-selling video game title of 2010, “Call of

Duty: Black Ops,” amassed more revenue in its first day of sales than

the biggest-ever first-day sales of any book, record album, or movie,

including all Harry Potter and Star Wars titles

VIDEOGAMES: ENGAGING

• US Teens: 99% of boys and 92% of girls regularly play VGs

• Average time spent: 13 hours/wk for boys and 8 hrs/wk for

girls.

• One billion people on the planet play at least one hour per

day

• 40% of players are female and 26% over 50 years old

Pew Life Internet Study, 2014

June 18, 2018: The World Health Organization classified "gaming disorder" as a

diagnosable condition, giving mental health professionals a basis for setting up treatment and

identifying risks for the addictive behavior.

GAME STRATEGY

• Be flexible

• Take action

• Recruit allies

• Manage identity

• Learn from mistakes

• Acknowledge and face

challenges

VIRTUAL REALITY IN PAIN

• Recent Review: Looks at all studies on VR games and pain control

• Pain of medical procedures

RESULTS: “VR has proven to be effective in reducing procedural pain, as

almost invariably observed even in patients subjected to extremely painful

procedures, such as patients with burn injuries undergoing wound care,

and physical therapy. Moreover, VR seemed to decrease cancer-related

symptoms in different settings, including during chemotherapy. Only mild

and infrequent side effects were observed. “

Indovina, P et al Clinical J Pain 2018 September 34(9):858-877

VIDEO GAMES AND HEALTH OUTCOMES

• Literature search and review

• 1452 articles; 38 included-RCTs

• VG improved 69% of psychological health outcomes

• VG improved 59% of physical therapy outcomes

• VG improved 46% of clinician skills outcomes

• Few were worse. Reaches all demographics. Low cost

Primack, B et all Am J Prev Medicine 2012 42 (6): 630-38

OPINION

•VR and Video Game formatting will

allow us to engage, educate and

treat a much broader population

than we now reach.

QEEG AND NEUROFEEDBACK

biopsy the brain and then train it

Thatcher, R.W. (2012). Handbook of QEEG and EEG Biofeedback, Anipublsihing, Florida

Electrical Neuroimaging –

Assessment and Treatment

Advantages of Electrical NeuroImaging:

1. Spatial Resolution – 1 cm to 3 cm

2. Temporal Resolution – 1 msec

3. Imaging of Current Sources

4. Imaging of Network Connections

5. Integration with DTI & fMRI (Brodmann Areas)

6. Inexpensive ($10,000 vs $3,000,000)

7. Dry Electrodes & Wireless Caps

8. Portable

9. Integration with Smart Phones & Tablets

10. Can Assess & Treat in Real-Time1

TOPOGRAPHY & LORETA

QEEG AND ADHD PATTERNS

NEUROFEEDBACK

train the brain

ADHD AND SUSTAINED NEUROFEEDBACK EFFECTS

• Most current meta-analysis

• 10 studies with 256 subjects

• Assessment of durable effect

• Impulsivity/hyperactivity: medium effect sizes

• Attention: Large effect sizes

Measured at 6 months post treatment

“Compared to non-active control treatments, NF appears to have more durable treatment effects, for at least 6 months following treatment.”

Van Doren et al. European J

Child Adolescent Psychiatry.

2018. Feb 14th. 1121-24

Examples of Surface EEG Changes After EEG Neurofeedback

Pre-Treatment Post – 10 Treatments

TBI Subject #1

TBI Subject #2

OPINION

• We are moving towards a network and hub view

of the brain as a complex plastic ecosystem

• Chemicals and medications do not offer targeting

• Neurofeedback does

• Is is better to train than to treat

THIS ONE SEEMS OBVIOUS

Who has a phone?

TELEPSYCHIATRY

• Annualized growth rate of 22.5% from 2016 to 2021

• CMS supports TP for underserved communities

• AACAP supports TP for improved access and innovative engagement

“The evidence indicates that patients are satisfied, telepsychiatry is comparable to FTF

delivery of mental health interventions, and telepsychiatry can be a cost-effective

approach to increasing access to mental health care.”

Hubley, S World J Psychiatry 2016, 6 (2): 269-82

MEDITATION AND MINDFULNESS

train the mind

MINDFULNESS AND EXECUTIVE FUNCTIONS: YOUNG CHILDREN

• 91 children in Kind, Grade 1 and 2 (mean age= 78 months)

• Mindfulness program of 8 activities delivered over two terms:

Calmspace

• 8 brief exercises given 1-2 per day on average.

• Waitlist control

• Measured Executive Function skill pre and post (Flanker Test and

DCCS)

• Significant benefit: Cohen’s d of 1.33 and 1.10 respectively

Janz, P et al Front Psychology 2019 10: 2052

TEACHER REPORTS OF ADHD SCALES

MINDFULNESS IN PEDIATRIC MH

• Review and meta-analysis

• 33 RCTs and 3, 666 children

• All positive with small to moderate effect sizes

• Active control group RCTs: depression: 0.47

Dunning, D et al J Child Psychol Psychiatry 2019 Mar; 60 (3): 244–258.

MEDITATION: GOOD FOR EVERYTHING?

• Boosts immune function

• Decreases inflammation

• Reduces pain

• Improves mood

• Reduces anxiety

• Decreases stress

• Increases positive emotions

• Improves memory and focus

• Increases frontal lobe and hippocampal vol

• Makes you more compassionate

• Makes you less lonely

• Improves your introspection

• Increases emotional intelligence

• Improves emotional self-regulation

• Enhances attention and self-control

• Improves multi-tasking

DEFAULT MODE NETWORK

our sense of self

• On-going resting demands

• The brains operating system

• Consumes 70 to 90% of the brain’s energy demands

• DMN is by far the largest player

• Specific tasks add very little to energy demands

• Other related networks are also present

INTRINSIC BRAIN ACTIVITY

• Network of interacting brain regions

• Functional hubs: posterior cingulate, precuneus, medial prefrontal cortex,

temporal cortex and pole, etc.

• Changes with cognitive development

• Activates with mind wandering or rest

• De-activates with goal oriented tasks

• The CNS equivalent of our inner context

DEFAULT MODE NETWORK (DMN)

DEFAULT MODE NETWORK

• Increased DMN activity in depression

• Meditation decreases DMN intensity

• All modes of meditation work

• Stronger connectivity in key areas for experienced meditators

Brewer, JA PNAS 2011 108 (50):20254-59.

DMN AND DEPRESSION

PSYCHEDELICS AND THE BRAIN

What does this tell us about

who we are?

PSYCHEDELICS: COMING BACK

MORE IN THE PRESENT…....

ASSISTED PSYCHOTHERAPY: CURRENT STATUS

• 8/17 MDMA: Breakthrough Therapy by

FDA for Severe PTSD. 50% through Phase III

• 10/18 Psilocybin: Breakthrough Therapy by

FDA for TR MDD. In Phase III

• 11/19 Psilocybin: Breakthrough Therapy by

FDA for MDD. In Phase II

CHAOS THEORY AND THE BRAIN

A pattern interrupt

TROUGHS AND ATTRACTORS

Simplified visualization of brain hub and network activity

Placebo Psilocybin

PSILOCYBIN: CREATES LESS RIGID AND MORE OPEN CONNECTIONS

Petri G, J R Soc Interface 2014; 11(101):20140873.

OPINION: BRAIN STATES DRIVE AND LIMIT OUR AWARENESS

•Brain states can get stuck and

lock in negative filters (patterns

of connectivity) that color

awareness and create illness.

THE CONCLUSION

the future is here, just not well distributed

WHAT OUR FUTURE MH NEEDS

• Awareness that mental health issues drive much more human

distress, chronic illness and excess cost than we have ever dreamed

• Social-emotional curriculum in elementary schools makes sense for

every child

• Apps, games and VR represent a powerful trend with potential

• Access and engagement are critical.

WE MUST OPERATE FROM A MODEL OF HEALTH

• Outreach and technology can be very helpful

• We should study and work with the brain.

• Medication can catalyze healing

• A positive model of health reinforces that healing and prevention

are possible

SCOTT SHANNON, MD

Wholeness Center

2620 E Prospect Rd. #190

Fort Collins, Colorado 80525

970.221.1106 scott@wholeness.com

www.wholeness.com

FOR MORE INFORMATIONALLCOVE

• Visit our website at https://edu/psychiatry/special-initiatives/youthwellbeing.html

• www.allcove.org• @allcoveyouth

• Contact us at stanfordyouthmh@stanford.edu

• Vicki Harrison (Program Director): vickih@stanford.edu• Steven Adelsheim (Director) sadelsheim@stanford.edu 650-725-3757

• Follow us @stanfordyouthmh (Facebook Twitter, Instagram)

RESOURCES:

• American Academy of Child & Adolescent Psychiatry

• aacap.org

• Resource centers (eg. Moving into Adulthood); Facts for Families

• AAP Mental Health Toolkit

• AAP: Addressing Mental Health Issues in Primary Care: A Clinician’s Toolkit

http://www.aap.org/commpeds/dochs/mentalhealth/KeyResources.html

• GLAD-PC (Guidelines for Adolescent Depression in Primary Care)

• Guidelines for Adolescent Depression in 10 Care: Glad - PChttp://www.glad-pc.org/

• Kognito platform

• https://kognito.com/products/at-risk-in-primary-care

• https://kognito.com/products/at-risk-for-high-school-educators

• Transitionyear.org (Focuses on mental health for graduating seniors)

• The Stanford Center for Youth Mental Health & Wellbeing:

https://med.stanford.edu/psychiatry/special-

initiatives/youthwellbeing.html

RESOURCES

• Fleming TM, et al “Serious Games and Gamification for Mental Health: Current

Status and Promising Directions.” Front Psychiatry. 2017 Jan10; 7:215.

• Multidisciplinary Association for Psychedelic Studies (MAPS):

http://www.maps.org/

• Sessa, Ben Psychedelic Renaissance, 2012

• McGonigal, Jane Super Better NY: Penguin Press, 2014

• Shannon, Scott Parenting the Whole Child NY: Norton, 2013

• Shannon, Scott Mental Health for the Whole Child NY: Norton, 2014

• Thatcher, Bob and Lubar, Joel, Z Score Neurofeedback San Diego: Academic

Press, 2018

• Grob, Charles Hallucinogens, 2002

• Hyde, Steven Ketamine for Depression, 2015

• Shroder, Tom Acid Test, 2014

• Tupper, Ken “Psychedelic Medicine”, CMAJ 2015. DOI:10.1503

/cmaj.141124

• Wolfson and Hartelius The Ketamine Papers, 2016

K, MDMA AND PSYCHEDELICS: RESOURCES

Journal of Psychopharmacology, 2015

DRUG HARM SCALE

NUTT, DAVID LANCET 2010, 376

BODY, MIND AND SPIRIT