Scrolling, Stress and the Teenage Brain: How EEG Biomarkers and Self-Management Can Change the Story

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Daniel Simon, MD: Hello, everyone. My name is Dr. Daniel Simon. I am your host of the Science@UH podcast, sponsored by the University Hospitals Research and Education Institute. This podcast series features University Hospitals' cutting-edge research and innovations. Thank you for listening to another episode.

Today, I am happy to be joined by my guest, Dr. Molly McVoy, the Rocco L. Motto Professorship in Child and Adolescent Psychiatry in the Child and Adolescent Psychiatry Division at University Hospitals 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.

Daniel Simon, MD: I want to just start off by saying Dr. McVoy's work combines cutting-edge technology with behavioral interventions aimed 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 than 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.

Daniel Simon, MD: 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 to 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.

Daniel Simon, MD: So, it's a great observation that you've been able to isolate that to what we would think would be 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 ADHD drugs, millions and millions of children on ADHD 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 ADHD 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 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 then 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 it untreated, they're at higher risk for depression.

I'm going to pause, and the ADHD issue, I think, is slightly different. So, there's been, in the last seven to eight years in kids, so in under 18, there has not really been a measurable increase in the diagnosis of ADHD. In older adolescents and young adults, that's a different story. And that partly has been fueled or facilitated or whatever you want to call it by the telemedicine that was needed and now expanded from the pandemic. So, prior to COVID, it was really unusual. Like some of our trainees, they would do telemedicine because 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 ADHD, 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 age 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.

Daniel Simon, MD: 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, 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 going to do? Yeah.

Molly McVoy, MD: No, 100%. 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 8th or 9th grade. So that's my recommendation to families - is make it till 8th. There's a whole campaign around that. And so if you can get to 8th or 9th 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.

Daniel Simon, MD: Wow. Okay, so now I'm going to 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 have 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, the 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 want to 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.

Daniel Simon, MD: 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 now 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 those 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, its 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 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.

Daniel Simon, MD: So, all right, I'm a cardiologist. You know, an EKG's got a bunch of leads. You put it on, it 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 within 4 minutes. So, there's people that do both resting, which is just what I do, which is with their eyes closed, but they can't fall asleep, which they can do. And then there's other researchers that do tasks where they have them do things, and they measure that. But we can use the 4 to 5 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 4 or 5 minutes of EEG data.

Daniel Simon, MD: So, you have an EEG. It shows that you don't have connection between the right and the left brain. Let's say that I'm going to jump ahead here...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, because 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 going to 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 to see 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.

Daniel Simon, MD: All right, so let's shift gears for a moment because you have developed specific programs called SMART and CAE ADHD, 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 because 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 disease learn how to be effective patients. It sounds really crazy, but having been a family member and a patient, it's a different skill set 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 and whatever disease that you're living with. We have tons of data on 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, I wish I had this when I first got diagnosed. And so, we've modified at least the CAE for individuals with ADHD 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 because you're going to live with this illness probably for decades, if not for the rest of your life. And we know, if you can help people, and 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.

Daniel Simon, MD: 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 going to 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 pleasant surprises, I was going to be a pediatrician, and then I discovered child psychiatry and was worried everyone was just going to 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 going to 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 them 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 is mood disorders...if they have a strong family history, they're still going to 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 done 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.

Daniel Simon, MD: 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 going to sound so self-serving, but we don't have a personalized way to pick what's going to 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. 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.

Daniel Simon, MD: 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, they know way more, right? So, 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 in 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 six-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 ability to understand and prescribe what's going on.

Daniel Simon, MD: 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: 100%. 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 we know so little about the evidence around pediatric mental health and I like to write and I like to learn. So, I 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 going to, again, sound self-serving, but what little it takes to make a difference. So, you spend an hour at a school, and they see the mental health providers' care changes the tenor of how they approach every mental health interaction in the future. And so, you know, most of the time I err more on the hopeful side... and on anyone who would like to fund any of this, please come talk to me side...but there are certainly days where it feels like it's such a big problem.

Daniel Simon, MD: Well, thank you for taking the time to speak with us today.

To learn more about research at University Hospitals, please visit UHhospitals.org/UHResearch. Thank you, Molly, as always.

Molly McVoy, MD: Thanks, Dan, so much.

Daniel Simon, MD: Thank you.

Dr. McVoy receives research funding from the State of Ohio, the Department of Defense, Case Western Reserve University, a private foundation funder, University Hospitals Cleveland Health Services Research Center, Neurelis Inc., receives royalties from American Psychiatric Publishing, McGraw Hill, and creates CME for the American Physician Institute.

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