Psychiatrist Develops Treatment for Kids With Comorbid Illness

When child psychiatrist Eva Szigethy, M.D., Ph.D., refers to the accomplishments of her “kids,” it is with the pride of a parent who has seen them overcome life's hardships and cheered them along as they reach important milestones.

Only these are not her own children. They are hundreds of children and adolescents who are all too familiar with adversity—they are living with inflammatory bowel disease (IBD) and co-occurring depression.

Szigethy's job is to care for and study these youth as she uncovers the links between the brain, digestive tract, and immune system with cutting-edge research.

In her position as an assistant professor of psychiatry and pediatrics at the University of Pittsburgh and clinical director of the Medical Coping Clinic in the Department of Gastroenterology at Children's Hospital of Pittsburgh, Szigethy has been able to study the associations between mind and gut and, in doing so, to help her young patients lead better lives.

Szigethy majored in neuropsychology at Princeton University and studied brain regions controlling positive reinforcement. “My undergraduate experience sparked an awareness that the brain was one of the last unchartered horizons of the human being,” she told Psychiatric News.“ It fascinated me.”

Following her undergraduate studies, Szigethy attended McGill University in Montreal to pursue a Ph.D. in neuroanatomy and trained at the Montreal Neurological Institute. Her studies led her to medical school at the University of Rochester, with the goal of becoming a neurosurgeon.

It was in her fourth year of medical school that she realized that psychiatry was the medical specialty that might be more aligned with her professional interests. “I began to realize that much of the day-to-day practice of neurosurgery doesn't necessarily involve the brain,” she recalled, but often dealt with peripheral nerve and spinal-cord dysfunction, while psychiatry provided much more access to the mind.

After completing her psychiatry residency at Case Western Reserve University in Cleveland, Szigethy embarked on a child and adolescent psychiatry fellowship at Case Western and Children's Hospital Boston, where she treated and studied medically hospitalized youth.

Research Tests Specialized Form of CBT

After joining the psychiatry faculty at Harvard University in 1999, she began researching depression in medically ill youth. By the time she joined the psychiatry faculty at the University of Pittsburgh in 2005, she had gained valuable experience on the link between physiological mechanisms and emotional problems.

Some of her preliminary work involved the study of children and adolescents with IBD and mild or moderate depression.

In some of the subjects, she tested a form of cognitive-behavioral therapy (CBT) she developed for medically ill children and adolescents that incorporated the children's “illness narrative,” or perception of their illness, into the therapy. She also recruited the children's parents or guardians as CBT “coaches.”

She adapted the specialized intervention from a type of CBT developed by Harvard-affiliated psychologist John Weisz, Ph.D.

According to Szigethy, William Beardslee, M.D., of Harvard University and John March, M.D., of Duke University were also influential mentors in this work, which was funded by a National Institute of Mental Health Career Development Award.

Said Szigethy, “I wove in certain principles related to coping with medical illness and utilized relaxation techniques, which are meant not only to help the children deal with anxiety, but also to help them cope with the pain associated with IBD.”

In her 2007 study, one group of children received the specialized form of CBT and the other received treatment as usual, which consisted of parents receiving an educational sheet about signs and symptoms of major depression and being asked to call her team if they saw these symptoms in their child.

Szigethy found that the CBT intervention reduced depressive symptoms by the end of treatment, and the youth experienced significant reduction of severity in IBD symptoms at six months following treatment, suggesting that improved coping skills can influence disease course.

The findings spurred her to write a grant proposal, which was recently funded by the national Institute of Mental Health. Szigethy will be randomizing more than 200 children and adolescents who are patients at Children's Hospital Boston and Children's Hospital Pittsburgh, and she, along with her Boston co-principal investigator David DeMaso, M.D., will be examining the interaction between improvement in depression and IBD symptom severity.

In September 2007, Szigethy became one of 29 recipients of the National Institutes of Health Director's New Innovator Award.

With the award, she plans to use functional magnetic resonance imaging to study regions of the brain that process emotion and thought in depressed youth with IBD before and after treatment with her modified CBT.

Medical Illness and Depression Linked

Szigethy noted that patients with IBD have higher rates of depression and anxiety than do patients without the disease. various mechanisms may be at work that cause a heightened risk of depression in IBD patients.

For instance, cytokines, which are chemical compounds released by the immune system at disease sites, may play a role in symptoms of mental illness. In those with IBD, the compounds are released at the site of the inflamed bowel. Research has shown that cytokines may affect the brain in some cases, Szigethy noted, and have been shown in animal models to induce depression-like conditions.

In addition, prednisone, one of the medications used to reduce IBD's inflammation, can cause depressive symptoms. And some patients with IBD may have endogenous depression caused by a combination of genetic liability, social factors, and the stress of having a chronic medical illness.

With her research, she is hoping to develop an approach in which mental health care is integrated into the treatment of chronic medical illnesses.“ We also hope to develop predictive models based on this research that will enable us to understand which kids [with medical illness] may develop depression,” she said, so that depressive symptoms can be prevented with proactive treatment such as CBT.

“I think we need to educate pediatricians about the risk of depression in kids with chronic medical illness,” Szigethy said.

In addition to her role as a researcher, Szigethy is president-elect of the Association of Women Psychiatrists (AWP). One of the main focuses of the organization, she noted, is to help women psychiatrists strike a balance between work and a fulfilling personal life.

Leah Dickstein, M.D., second AWP president and a professor emerita of psychiatry and behavioral sciences at the University of Louisville, praised Szigethy as an “extraordinarily gifted and creative human being. She's a role model for everyone.”

In her own life, Szigethy has achieved a balance between work and leisure that suits her well.

She is part of a competitive rowing team, and last fall her women's team quad boat placed second in the Head of the Charles race in Boston. In Pittsburgh, she trains on the three rivers that converge downtown. “I use rowing both to relax and escape,” she noted.

Though she has no children of her own, Szigethy speaks of the youth with whom she works as her “kids” and encourages them to develop a hobby or pasttime to add another dimension to their lives.

In addition, she said, “In some ways, my research is my surrogate child. This is the mark I am hoping to leave on the world.” ▪