Residents are required to engage in scholarly activity throughout the four years of training. The core of scholarship is the learning of critical thinking, evaluation of basic science and clinical research, and the development of a scholarly project by the middle of the PGY-4 year. Some examples of scholarship are research studies, review articles, case studies, theoretical writing, development of curricula and teaching materials. Residents are encouraged to participate in regional and national academic meetings.
The research portfolio at the Department of Psychiatry at Cambridge Health Alliance (CHA) includes cutting edge behavioral health research that aligns with the CHA mission to improve the health of our communities, and aligns and informs the clinical objectives of promoting equitable and quality care to the area's residents and patients from underserved neighborhoods.
Across the four research centers (see below) the Department of Psychiatry has been successful in receiving grants from NIH (NIDA, NIAAA, NIMHD, NIMH), the Agency for Healthcare Research and Quality, private foundations such as the Robert Wood Johnson Foundation and Blue Cross Blue Shield of Massachusetts Foundation, and industry partners. Approximately 75 grant-funded projects cover the core research areas including disparities in access and quality of healthcare, improving treatment for gambling, opioids and other illicit substances, tracking trajectories of infants raised in under-resourced environments across the lifespan, and in using mindfulness to enhance psychiatric treatment.
The grants provide funding to large research teams, as well as cover training of HMS students, residents, and fellows, varying widely in terms of funding amounts, and ranging from postdoctoral fellowships to NIH R01 and Center grants.
The research portfolio predominantly resides in four research centers, the Center for Multicultural Mental Health Research (CMMHR), the Division on Addiction, the Family Studies Lab, and the Center for Mindfulness and Compassion (CMC). Together, these research centers identify gaps in behavioral health treatment, test and promote novel interventions to improve access and quality of care, and provide intensive mentorship to trainees in multiple disciplines. This work shares a focus on understanding and promoting equity in behavioral health care treatment for underserved and disenfranchised individuals, extending and improving the mission and practice of the Cambridge Health Alliance. The following are examples of the larger research efforts.
1. Center for Multicultural Mental Health Research (CMMHR)
The Center for Multicultural Mental Health Research (CMMHR)/Health Equity Research Laboratory, directed by Benjamin Lê Cook, PhD MPH, is an interdisciplinary group comprised of health services researchers and clinicians. The CMMHR is a research center dedicated to conducting research to improve physical and mental health in diverse communities. The CMMHR mission is to promote equity in health and well-being in the hopes of improving social and economic opportunity for individuals from racial/ethnic and sexual minority groups and impoverished backgrounds. To accomplish this goal, the CMMHR identifies and reduces health care disparities in underserved populations by developing and rigorously evaluating clinical and policy interventions, leveraging community assets and mobilizing system transformation.
The three primary focus areas of the CMMHR are:
Tracking trends in behavioral health and behavioral health care disparities through the analysis of large, nationally representative datasets
- Mentoring young investigators interested in pursuing research to close health equity gaps
- Assessing innovative disparities reduction strategies through evaluating interventions at the hospital and in area community-based agencies
In the first focus area, CMMHR applies a wide range of expertise including health services research, disparities, evaluation and clinical experience. Funded by an R01 grant from the Agency for Healthcare Research and Quality (AHRQ) (PI Cook), the CMMHR investigates trends in disparities across racial and ethnic groups and their use of psychotropic medication among adults and adolescent populations. Published articles include studies identifying structural, community and individual-level determinants of access and utilization of behavioral health services; assessing and identifying geographic “hot spots” of racial/ethnic disparities in behavioral health care access, and tracking the preliminary impact of the Affordable Care Act on substance use and mental health treatment access and utilization. Other papers under review track trends in mental health care disparities over time, assess the differential diffusion rate of antidepressant black box warning for youth across racial and ethnic groups and monitor overuse of psychotropic medications among white and racial/ethnic minority adolescents.
Second, the CMMHR supports early-stage investigators interested in pursuing a research career in health and health services equity. Through work with the New Connections project, funded by Robert Wood Johnson Foundation (PI Cook), the CMMHR has ten years of experience mentoring a diverse group of investigators in research methods, grantsmanship, publications, and career navigation. These investigators are predominantly from underserved communities in institutions with little research infrastructure. Dr. Cook and Research Scientist Dr. Nicholas Carson also have experience mentoring psychiatry and psychology fellows and residents at CHA interested in
pursuing research projects, with success in leading these projects to peer-reviewed publication and conference presentations.
Third, CMMHR dedicates a significant portion of its work to rigorous evaluations rooted in community engagement in the Cambridge and Boston area. As an example, Dr. Cook, Associate Director Dr. Andrea Ault, Dr. Carson and other CMMHR staff work closely with the Cambridge Safety Net Collaborative, a collective project to prevent the school-to- prison pipeline by Cambridge Police Department, Cambridge Public Schools, CHA, and the Cambridge Department of Human Services. The project’s purpose is to assess the efficacy of an intervention that pulls together a team of a social worker, police officer, and psychologist to provide treatment and case management to at risk youth. CMMHR also works with the Psychiatry Department in measuring the impact of the Health Integration Program, a behavioral health home model that integrates physical health care into a clinic working with patients with schizophrenia and bipolar disorder. Both evaluations use mixed-methods research technique combining electronic medical record and qualitative interview data. [See appendix at end of section III for research publications]
2. Division on Addiction
The mission of the Division on Addiction is to alleviate addiction-related social, medical, and economic burdens through research, education, outreach, and training. The Division’s mission is reflected in every aspect of its activities, explained further in the scope of work that follows. The Division on Addiction is responsible for its funding, which derives entirely from gifts, grants, and contracts; Division staff develop proposals for funders that range in size and scope from the National Institutes of Health and private industry to the Commonwealth of Massachusetts and Harvard Catalyst.
During the past five years, the Division on Addiction (Division) had 59 new publications. These include four books, six book chapters and reviews, and 45 original research articles. These publications include the two-volume APA Addiction Syndrome Handbook, which won the American Library Association CHOICE award as an Outstanding Academic Title. Division articles can be found in a variety of topline journals including: Psychiatric Annals, Psychology of Addictive Behaviors, Annual Review of Clinical Psychology, Psychological Assessment, and European Journal of Public Health. Books include Change Your Gambling, Change your Life: Strategies for Managing your Gambling and Improving your Finances, Relationships and Health, and Responsible Drinking for Women. The Division research represents worldwide collaborations, including research with colleagues from South Korea, Demark, Switzerland, Hong Kong, Iceland, Canada, and Australia. The Division’s primary areas of interest include psychiatric comorbidity of DUI offenders, psychiatric comorbidity and addiction, epidemiology of gambling- and gaming- related problems, substance use disorders, addiction treatment and treatment outcomes, relapse, and addiction among vulnerable populations. The Division supports open science through its innovative Transparency Project data sharing repository.
The Division has developed evidence-based public health screens and self-help guides (i.e., Brief Biosocial Gambling Screen; Your First Step to Change) for alcohol, marijuana, shopping, and smoking. For 20 years, the Division has published The BASIS (Brief Addiction Science Information Source) a free weekly addiction science review that many thousands of people access each year. The Division created and leads an international initiative to promote screening for Gambling Disorder. The Division is completing a 5- year project that has created a software system for mental health screening and assessment (CARS) that includes a guided diagnostic interview and a report generator permitting lay interviewers to identify psychiatric disorders, complete an assessment report, and refer patients to treatment providers.
Recent funding for the Division includes support from the National Institutes of Health (e.g., NIAAA, NIGMS/IHS), Foundation for Advancing Alcohol Responsibility, The Foundation for Alcohol Research, Digital Entertainment, Alcohol Beverage Medical Research Foundation, State of Florida via Spectrum Gaming, St. Francis House, Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Office of Juvenile Justice and Delinquency Prevention (OJJDP), Commonwealth of Massachusetts via Massachusetts Gaming Commission, Commonwealth of Massachusetts via Office of the Sheriff – County of Worcester Jail and House of Corrections, Heineken USA, the Harvard Catalyst program, National Center for Responsible Gambling (NCRG), and the Danish Council for Independent Research. In addition, the Division now hosts the Morris E. Chafetz Professorship in Psychiatry and the Behavioral Sciences; we anticipate that this chair will begin to distribute funds during 2019.
The Division of Addiction builds innovative teaching and training programs for a diverse set of learners. The Division has provided education to professionals seeking continuing medical education, visiting scholars, undergraduate interns, residents and fellows, postdoctoral researchers, and graduate student trainees. During the past 5 years, the Division has offered many educational opportunities, including an annual Addiction Medicine live CME course; 3 online CME courses; CHA seminars (CHARGE, the Addiction Syndrome model, and a Research Methods for Healthcare Professionals); didactic research experiences with HMS residents; guest lecturing; invited conference presentations; and webinars for national and international audiences. [See the appendix at end of section III for research publications by the Division on Addictions.]
3. The Family Studies Lab
The Family Studies Lab, led by Karlen Lyons-Ruth, PhD, Professor of Psychology at Harvard Medical School, is conducting translational research to better understand the contributions of early relational risk, trauma, and genetic factors to social adaptation in infancy, childhood, and adolescence. One central aspect of the lab’s activities has been the conduct of the NIMH-funded Family Pathways Project, one of the few prospective longitudinal studies of infants from adverse environments. The repeated, and now replicated, finding emerging from this 30-year longitudinal study is that infant disorganized attachment behavior and disrupted communication on the part of the parent in the first two years have long-term implications for depression, suicidality, borderline psychopathology and antisocial behavior in young adulthood even with subsequent risk factors controlled. These results raise the possibility of an early sensitive period for the development of effective emotion regulation capacities.
Recent funding from Harvard Catalyst allowed the Family Studies Lab to extend the work to identifying associations between these findings and young adult brain volumes. This work is in collaboration with Dr. Martin Teicher’s MRI lab at McLean, with two papers reporting on infancy and childhood predictors of amygdala volume in adulthood. Under current funding from NICHD, Dr. Lyons-Ruth and her collaborators have returned to the study of infants and are exploring differences in volume and connectivity of the infant amygdala at 1 year of age, in collaboration with Dr. Teicher and Dr. Ellen Grant at Children’s Hospital. The Family Studies Lab is currently evaluating the relations between infant brain development and maternal brain morphology, maternal maltreatment, maternal low basal cortisol, maternal disrupted communication, and dis-regulation of infant stress responses over the first year of life. The Family Studies Lab also trains researchers internationally in attachment-related assessments developed in our lab, including the AMBIANCE assessment for atypical forms of parent-infant interaction and the RISE scale for assessing indiscriminate infant attachment behavior.
4. The Center for Mindfulness and Compassion
The Center for Mindfulness and Compassion (CMC), directed by Dr. Zev Schuman- Olivier, aims to enhance the health and well being of CHA patients, staff, trainees and our local communities by integrating mindfulness and compassion into healthcare. The CMC aims to cultivate mindfulness and compassion in five major mission areas: 1) patient care; 2) clinician and staff well being; 3) professional education and training; 4) our communities; and 5) scientific research.
Through its core program, MINDFUL-PC, the CMC integrates mindfulness training for staff and patients across Patient-Centered Medical Homes throughout CHA. As part of this implementation program, the CMC has trained 28 primary care providers (PCPs) in mindfulness-based stress reduction curriculum during 2014. The Center has offered 10 consecutive months of Mindful Communication to these PCPs in 2015; 21 of the 28 PCPs attended at least 1 session. The CMC has offered a 60-minute “Mindfulness at Work” introduction to mindfulness to hundreds of PCMH staff across 6 primary care sites. These trainings support the referral-based clinical program for patients at CHA. MINDFUL-PC aims to integrate referral-based, insurance-reimbursable mindfulness training for primary care (MTPC) for patients across 6 PCMH sites. These 8-week MTPC patient group sessions are designed to be delivered by CHA clinicians who complete rigorous training to lead mindfulness groups at CMC. These groups provide high quality evidence-based mindfulness training for primary care patients with anxiety, depression and trauma/stressor-related disorders. Overlaid onto the implementation program is a randomized controlled trial investigating the effects of mindfulness training on patient health outcomes (as measured by self-report scales on depression, anxiety and stress), the patient/provider relationship (as measured by self-report scales on health care climate, patient/provider communication and patient/provider relationship), chronic disease self-management (as measured by initiation and maintenance of action plan goals, patient activation, self-efficacy of chronic disease management and perceived control) and neuroimaging targets of self-regulation using fMRI imaging. The program has received over 150 referrals in the first four months, has completed patient groups in two PCMHs and plans to expand to an additional two PCMHs in Spring 2016. This work was initially funded by pilot funding from the CHA Department of Psychiatry, the CHA Executive Leadership team, the Arthur Vining Davis Foundation, and the Arnold P. Gold Foundation. More recently, the MINDFUL-PC project has been funded by the NIH Science of Behavior Change Initiative through NCCIH. The CMC is currently translating our MTPC program into Spanish and Portuguese with support from a Harvard Catalyst Disparities Research award. This PCMH co-located, insurance-reimbursable, referral- based program is designed to reduce inequities in evidence-based mental health care for diverse population, and is designed to be ready for national dissemination.
Through the CMC trainee/education arm, CMC and its Chief Mindfulness Residents support the mindfulness curriculum for psychiatry residents, and integrated mindfulness projects for psychiatry and medicine residents. Finally, CMC has supported the annual family medicine resident retreats. CMC also supports the intern orientation curriculum for medicine, psychiatry and transitional year interns.
Future direction for research in the CHA Department of Psychiatry
All four research centers have sustainable plans for continuing to understand and promote equity in behavioral health care treatment for underserved and disenfranchised individuals such as those that receive care at CHA. The CMMHR intends to pursue its three objectives of tracking quality and access of mental health care treatment in the US, mentoring the next generation of equity researchers, and engaging in rigorous evaluation of local interventions that have the potential to be scaled up nationwide. Grant applications are pending at the National Institute on Drug Abuse, the National Institute of Mental Health and PCORI. Future quantitative data research projects include:
Examining how state and local tobacco cessation and tobacco cessation coverage policies have impacted tobacco consumption and related health consequences among individuals with mental illnesses.
- Assessing the impact of Affordable Care Act-initiated health insurance exchanges on insurancecoverage and service utilization for racial/ethnic minorities and individuals with severe mental illness
Future interventions include:
- Developing machine learning / natural language processing algorithms to predict and alert clinicians to patients with high risk for suicide and readmissions, and clinical processes to act upon alerts;
- Identifying interventions to improve health, education and criminal justice outcomes among adolescent offenders; and
- Evaluating how different implementation components of behavioral health home interventions impact the mental health service and mental health outcomes of patients with a schizophrenia diagnosis.
During the next ten years and beyond, the Division of Addiction will look for funding opportunities from the National Institutes of Health and other federal sources such as the National Science Foundation, SAMHSA, and Indian Health Services, state departments of mental and public health, the National Highway and Traffic Safety Administration (NHTSA) and private sources, including, but not limited to the Robert Wood Johnson Foundation, DraftKings, National Center for Responsible Gaming, and the Patient Centered Outcomes Research Institute (PCORI).
The Family Studies Lab will continue to pursue their longstanding support from NIH for their Family Pathways Project, with continued submissions to NIMH and NICHD. Their expansion of the longitudinal family study to understanding relationships between infant brain development and maternal brain morphology, maternal maltreatment, maternal low basal cortisol, and dis-regulation of infant stress responses holds great promise for connecting social adversity with neurobiological mechanisms and is closely aligned with the NIMH strategic plan.
The CMC recently submitted a PCORI grant through the Improving Healthcare Systems RFA. In addition, through collaboration with the Center for Integrative Pain Neuro- Imaging at the Martinos Center for Biomedical Imaging, the CMC has submitted three pilot grants to support research on mindfulness, self-compassion and chronic pain. The CMC has created international collaborations with University of Zaragoza in Spain and the Mindfulness Center in Sao Paulo, Brazil, through a Spanish training grant. The Center is currently writing a collaborative R01 focused on adaptation of our mindfulness training intervention for Brazilians in the US and Sao Paulo. In addition, the CMC has had a contract with Harvard Work/Life and Wellness programs, provided mindfulness and wellness offerings for CHA and other local organizations, and offered continuing education programming.
Clinical Research Program for DUI
As part of the mission of Cambridge Health Alliance to improve the health and wellbeing of our communities, Dr. Mark Albanese, Medical Director of the Department of Psychiatry's Addictions service, has initiated a DUI Program with both a clinical and research component, to treat both first-time DUI offenders and repeat offenders. Dr. Albanese and his colleagues have considerable experience in addressing the complicated issue of driving under the influence.
The Department of Psychiatry values research as the foundation for improving the quality of clinical care. Research is essential for determining the efficacy of methods of care and for disseminating these methods to the larger professional community. The Department has developed a center for research initiatives in clinical psychiatry, including health services, clinical trials, quality improvement, and multicultural research.
Residents are encouraged to join in ongoing research in any of these areas or to develop their own projects. Residents may choose to pursue research intensively in their final year of training. Examples of our Residents' research projects include mindful meditation group therapy for psychosomatic disorders, acupuncture for anxiety, family interventions in early onset schizophrenia, mother-infant attachment studies, forensic research at the Maudsley Hospital in London, neuroimaging in patients with addictions, clinical drug trials, and a NIH funded naturalistic study of treatment outcomes in patients with bipolar disorder. Residents have also participated in studies of the treatment of obesity, metabolic effects of antipsychotic medications, and outcome studies for the treatment of victims of violence. Residents receive a yearly educational stipend to help defray the cost of attending conferences and other educational activities.
The Center for Mindfulness Based Treatment
Cambridge Health Alliance has a growing Center for Mindfullness Based Treatment that will include clinical, research and training components. Co-directed by Faculty and Trainees, the Center currently provides Mindfulness Training for patients and staff, and hosts regular sessions open to the CHA community and patients. Projects under way include researching the effectiveness of Mindfulness Based Treatments for symptom management and stress reduction. Residents in Psychiatry have developed a curriculum on MBT that has been incorporated into the didactic schedule and part of the Resident Retreats held during the year.