Bruce Bassi#FuturePsychiatryPodcast discusses novel technology and new ideas in the field of mental health. New episodes are released every Monday on YouTube, Apple Podcasts, etc.
Summary
Arielle Radin Pulverman (UCLA PhD student in Health Psychology) and co-founder of Bruin Health speaks about their goals to, “enable measurement based dimensional, data driven, precision psychiatry through partnering with clinicians who want to do this type of care.” Ultimately in 20 yrs, she would like to make sure that “mental health care at least looks like other areas of physical health care… If we can get to the point of being like the gold standard for all things mental health, I don’t think we can really do our jobs until mental and physical health are completely integrated at the level of healthcare. That’s a very ambitious goal, but that is our North Star.”
What was the need? “So Bruin is trying to translate a lot of the approaches that we use in mental health research in terms of measurement approaches, also the constructs that we know are relevant for mental health and also the biopsychosocial model of mental health, trying to translate all those approaches into the real world. So something that I noticed being in academia is that a lot of the work that we’re doing is not translating. It’s not making its way into clinical practice.”
Why was the product so successful and engaging? “Some people don’t realize that using expressive suppression, keeping your feelings in, that is associated with both deleterious mental and physical health outcomes, whereas something like cognitive reappraisal is actually associated with better outcomes. So these are things that people don’t know about themselves, and I think that’s why they found it engaging.”
Chapters / Key Moments
00:00 Preview
01:38 Arielle Radin Pulverman’s background
05:51 Definition of Health Psychology
06:45 Inflammation & Brain Health
09:37 Inflammation Phenotype Depression
10:18 What is Bruin Health
11:12 Underlying Mechanisms Psychiatric Disorders
12:55 How does DSM Fit In?
13:36 Current Research Breast Cancer Inflammation
14:33 Patients with Pro-Inflammatory States
17:06 Difficulty Diagnosing Inflammation
19:05 Psychiatrists Become Primary Care Doctors
20:56 It’s not just “in your head”
22:01 Work at Bruin Health
27:14 First Steps w/ Bruin – Reward learning
27:48 RDoC Approach
29:56 Patient’s View of Self-Report
32:41 HiTOP
40:36 Why Some Measurements Don’t Work
42:53 Treatment Changes Are For Psychotherapy
44:30 Future Challenges
45:29 Bench To Bedside
45:52 Conditions Not Like Real World
47:52 Goal to Enable Measurements with Partnerships
48:09 Singula Institute
52:23 Why Alpha Product Helpful
53:14 Results Have Helped Pts Seek Treatment
55:07 One Goal Is Interrater Reliability.
Transcript
Episode Preview
Arielle Radin Pulverman: But things that kind of bothered me a little bit about what we do in academic medicine is that the conditions under which we are doing this research is not at all like the real world. The patients that we’re getting are not like the patients out in the real world. And so I’m really excited about being able to collect data from real people. When we ran our alpha product, I got representation from every single state and people across the spectrum of functioning, people who had never engaged in mental health care, people who are currently in treatment. There’s clearly a need for this and a desire for it. And I’m really excited by being able to conduct research out in the real world. It’s just very different from what other people in the field do. And so I’m afraid of how that will be perceived, and I’m hoping that it will be welcomed, but it’s a little bit of a renegade approach.
Introduction
Bruce Bassi MD: Hello, and welcome to the Future Psychiatry podcast, where we explore novel technology and new innovations in mental health. I’m your host, Dr. Bassi, an addiction physician and biomedical engineer. If you’re joining for the first time, I would greatly appreciate if you subscribe and share the podcast with your friend group on social media. Additional resources, a full transcript, and a group discussion can be found on our website, telepsychhealth.com. Then click podcasts in the top right corner of the screen. Thank you so much for joining us, and I hope you enjoy the show. So today we have the pleasure of speaking with Arielle Radin Pulverman, who’s a PhD student at UCLA in Health psychology and the cofounder of Bruin Health, which helps to empower researchers and clinicians with insights to understand the fundamental underlying mechanisms of psychiatric dysfunction. Welcome to the show.
Radin Pulverman: Thanks, Bruce. It’s great to be here. Can you tell us a little bit about yourself and how you got involved in this field? And then we’ll go into a little bit more depth about health psychology and that field. I think it’s really fascinating. Yeah, absolutely. So I’m currently finishing my PhD at UCLA. I have under a year left and six long years. Yes, I’m just wrapping up, writing my dissertation, so almost done. I got started in psychology, actually, in high school. I was fortunate to be able to be in the IB program, and they had psychology classes. That’s when I got introduced. And I was always fascinated by the mind, understanding why people behave the way that they do, and the fact that we’re able to actually understand our own thoughts and feelings. Metacognition has always been super fascinating to me. I think it’s a really uniquely human thing that we can do, although, of course, it’s possible that other animals can do it. But it seems like a very human thing.
Bassi: For another podcast.
Radin Pulverman: Yeah, exactly. That we know of. So I was always interested in– I knew that I wanted to study psychology in college. So I went to Columbia and I got my Bachelor’s in Cognitive Neuroscience, and my love for that really came from being able to measure the brain. So I was in an EEG lab, I took a lot of fMRI courses. I got super interested in cognition, episodic memory, executive functioning, all of that good stuff. And I was actually about to go and do my D Phil abroad, and I started to have a panic attack as I was walking to the lab. My senior year of college, realizing that all this amazing, super intellectually stimulating work I was doing was going to end up in some esoteric journal that no one would read. So that really freaked me out that I was going to spend all this time being super niche, even though I was very intellectually stimulated by it. I just really wanted to have an impact and not to say anything bad about that work. I think it’s super important to do basic science, of course, but for me personally, I wanted to make sure that I had impact, so I thought that meant that I needed to do something more clinical. So I totally switched gears and actually ended up doing postbac research in a substance abuse lab. So at Columbia Psychiatry department, the Substance Treatment and Research Service (STARS). So I worked there for a year, and I really felt for the patients. It was really nice getting to be hands on with the patient population. I also learned how great it is to collect bio samples. So, fun fact, I used to be afraid of blood, and I actually had to learn how to draw blood for that job.
Bassi: Wow, that’s tough.
Radin Pulverman: Luckily, a lot of my colleagues were super nice and allowed me to practice sticking them. I bet you never thought you’d be doing that from your pathway. No, not at all. But I think that that’s what actually introduced me to medicine and kind of learning more about the way that we approach illness from a biomedical model, which was so different from anything I had done in psychology. So I really loved that. I learned pretty early on that I didn’t want to necessarily do my PhD research in substance use, so I knew I needed to kind of shift gears before applying to grad school to get relevant experience in an area that I would want to spend six years researching. So I actually ended up working at NYU’s Medical School in a microbiome lab. So I went fully the other way, totally leaving psychology. From what I understood at the time, I had never heard of a microbiome. I had never heard of inflammatory bowel diseases. I was working in Crohn’s and Colitis, trying to understand how the microbiome plays a role in treatment response and disease pathophysiology. So I went very far into medicine.
Bassi: Well, if you want an impact, you got it there. I mean, that’s going to impact millions of people.
Radin Pulverman: Yes, and it was super revolutionary. I was working with Martin Blaser, who is one of the leading experts in microbiome research. I was working with gastroenterologists translational scientists. I learned how to dissect mice. Yeah, it really got my hands wet. And I thought that I discovered health psychology, so I didn’t know what health psychology was. I think at the time it was really mostly on the West Coast. On the east coast no one had talked about it in New York.
Health Psychology
Bassi: I never heard of that term before. And admittedly I had to look it up and I copied it down: it studies how patients handle illness, why some don’t follow medical advice and the most effective ways to control pain or change poor health habits. And the first thing that came to mind was doctors and therapists and everybody who knows the right things to do but doesn’t do them basically because it’s one thing to know something and another thing to put into action. And I think that’s a pretty cool field because that’s what a lot of what we do in behavioral health sciences we’re trying to figure out, OK, we’re giving this knowledge, but now what’s the next step? How does it apply to this person’s life?
Radin Pulverman: It even goes broader than that or I mean, I guess it’s more of an umbrella term. So within health psychology I’m in to get even more niche and weird, I’m in psycho neuroimmunology. So this is the connection between the immune system and the brain. And so I studied, for example, how inflammation impacts brain function. So you can think of like this became much more relevant during COVID with long COVID, thinking about how inflammation resulting from the infection impacted the brain. So we had a lot of people dealing with cognitive problems, brain fog, fatigue so that’s kind of like a bottom up approach. And then the top down is how to stress impact our immune system and our physical health. So that’s kind of like how mindfulness can reduce inflammation, for example. So it’s really this recognition that there is a mind body connection and that everything going on up here isn’t necessarily separate from everything going on down here. So that’s what I thought that I discovered. So I noticed that the patients that I was working with who had inflammatory bowel diseases, when they were stressed, their diseases would flare and when they were flaring, they would be experiencing brain fog, fatigue, all this cognitive disturbance. So I thought that I had discovered this whole field and then a very quick Google search made me realize that no, there’s a whole group of people that practice this and that’s actually how I discovered UCLA. So very long story, I’ve had a very winding path. But I think the common thread throughout has always been a love of science, understanding, measuring, modeling the brain, understanding how it impacts our health. And really the thing I think that I started to learn more as I transitioned into medicine is that it’s bizarre that we treat mental health and physical health separately. I don’t understand why we have different approaches or even different expectations of what care should look like and different systems. And I think, obviously, being at HLTH right now, which is like a major health tech conference, everyone’s talking about how you can’t treat physical health without perhaps the mental health. And health psychologists have been saying this for decades at this time. So, yeah, I’m really excited to be in the field. And that’s kind of how I got here.
Bassi: As clinicians, when somebody has CFS or some other fibromyalgia, very much pro inflammatory psychiatric state, we’re always defaulting to saying we need more research. And when we say that, we can now point to we’re actually talking about you. This person right here.
Inflammation and Depression
Radin Pulverman: Yes, exactly. My advisor, she actually studies specifically how inflammation induces fatigue in psycho neuroimmunology. We call it sickness behaviors. So if you think about it, something that I think is really interesting is if when you get a cold or the flu, what are the main symptoms? You feel malaise, you’re fatigued. You want to socially withdraw from other people. You want to be alone. A lot of the symptoms are the symptoms of depression. And so there’s this entire field right now looking at the inflammatory phenotype of depression. And there have been trials that have looked at things like what I thought was interesting, like infliximab which is what we were using in IBD patient treatment, because it’s a biologic. There have been clinical trials looking at whether or not we can use anti-inflammatories as depression treatments. Turns out, no main effects. Not surprising. But for those who were higher inflammation at baseline, we do see symptom reduction. So there’s this idea that there might be an inflammatory phenotype of depression, and that really comes from psycho neuroimmunology.
Bassi: And before we— I have a lot of follow up questions on that. Yeah, there’s a lot I have a lot of patients who struggle with this, and so it’s nice to have this conversation with you, who knows the research.
What does Bruin Health do?
Radin Pulverman: So Bruin is separate from my PhD research, really, by design, because I really shouldn’t have overlap there for various reasons. But a lot of what I’m doing at Bruin was inspired by the work that I’ve been entrenched in for about a decade now. So Bruin is trying to translate a lot of the approaches that we use in mental health research in terms of measurement approaches, also the constructs that we know are relevant for mental health and also the biopsychosocial model of mental health, trying to translate all those approaches into the real world. So something that I noticed being in academia is that a lot of the work that we’re doing is not translating. It’s not making its way into clinical practice. I think I’m preaching to the choir here with you on that.
Bassi: Can you give me a specific example? I think the listener would be really be like, yeah, that’s totally true. Is it with EEG? Or what were you seeing?
Radin Pulverman: Yeah. So, for example, currently, the way that we assess or diagnose mental health conditions, it’s really categorical. So we do this, like, symptom checklist. Do you have five out of the seven of these? Is it causing impairment or whatever it is, and then we call you depression or anxiety or whatever human made construct we decided this constellation of symptoms is. And we know that that’s not actually reflective of the underlying pathophysiology of this disease or this illness. So in mental health research and a lot of the work that I do and others, there’s a ton of people I’m standing on the shoulders of giants. Like, it’s not something that I created who are taking more of a dimensional approach. So there’s a recognition that there are these underlying biopsychosocial mechanisms that are transdiagnostic that cut across what we call depression or anxiety, and they can explain why there’s so much heterogeneity within these diagnostic classifications. Also why there’s so much shared symptomatology across conditions and why there’s so much comorbidity because they’re being driven by the same underlying factors. So I’ve always struggled with we know this or we have a decent amount of empirical and clinical evidence now to support that approach to looking at mental health conditions as dimensional as these processes that cut across these diagnoses that we call depression, anxiety, schizophrenia, whatever it is. And yet that approach isn’t making its way into the real world. So I think the reason why that is because there aren’t technologies or ways to assess people in this dimensional, trans-diagnostic way. And that’s what we’re trying to bring with Bruin.
How does DSM still fit in?
Bassi: Right. I mean, the DSM is driving a large part of that clinical interview where we have these categories. And while I think a lot of clinicians know about these biopsychosocial models, transdiagnostic models, it still hasn’t changed our interviewing with the patients because the DSM is just kind of still there and lingering.
Radin Pulverman: Yeah, we’re not trying to replace DSM. I think that’s really important. I think some of these terms, like depression, anxiety are helpful for clinicians. These terms were made really for clinicians because they’re observable signs and symptoms. It’s a helpful heuristic similar to how, like– an example I use because I actually work in breast cancer right now, my PhD research. So I look at how inflammation impacts cognitive functioning and breast cancer survivors specifically. But because of that, I’ve learned a ton about breast cancer treatments. And something that I think is really cool is that right now in breast cancer, having breast cancer doesn’t really mean that much in terms of clinical approach anymore. What actually matters is what type of breast cancer you have. Is it HER2 positive? Is it triple negative? What types of receptors are on the tumor itself, and that dictates what types of treatments are going to be targeted for your specific breast cancer. And so I think that’s kind of the way you can think about it. We’re more of like an oncotype DX for mental health, not trying to change depression per se, like her two positive or triple negative breast cancer is still breast cancer. It’s just a deeper phenotyping to better understand how do we treat it.
Someone with one underlying chronic condition will be labeled with many “diagnoses”
Bassi: Let’s talk about the patient who does have some underlying pro inflammatory genesis that’s contributing to their symptoms. And they feel malaise, fatigue, anedonia, not enjoying anything, depression, occasional anxiety about upcoming medical treatments. And the psychiatrist, we classify them into these numerous categories, and they probably feel even more dysfunctional because they carry these artificial constructs of these diagnosis that we made up, when really, there’s probably just one state or underlying reason. A cause for their symptoms that they’re experiencing, but yet they feel more broken because they have all of these issues that they’re going to the psychiatrist now with insomnia, obsessive thoughts, anxiety, panic attacks. What would you like to say to those people and the people who approach those patients?
Radin Pulverman: I love this idea of it feeling more broken. Is there one crack or are you like 100 cracks within the vase or whatever? Yeah, I think that’s a really great way of thinking about it. It’s like there you’re not broken beyond repair. There are these, like, very specific underlying processes that are probably driving a lot of the symptoms that you’re experiencing. And if we had ways to just want to assess that and recognize it and then target our treatments to the underlying pathophysiology of what you’re experiencing. Just like in any other physical health condition, you know, when you go to your doctor because you feel ill, they take your temperature, and that’s kind of like doing a PHQ, right? It’s like we take your temperature to see how severe you are, but they don’t stop there. They try to understand what’s causing the fever. Why are you feeling sick? And I think psychiatrists in particular, really good ones, are trying to get those root causes. It’s just taking forever. It takes lengthy clinical interviews over weeks, months to try to collect all of this information to better understand all these multifactorial causes that are leading to all of these symptoms. And what if we could just run a lab test like you do in any other health condition where it’s expected that of course I’m going to get tested? That wouldn’t happen in any other health condition.
Bassi: Right. I think what can make research go so quickly is if there’s fewer variables. But when you look at the field of immunology and inflammation, if you open up a textbook and from my limited immunology background experience from about ten years ago now, there’s so many interleukins and cytochromes that don’t really have that much interpersonal consistency there, and they’re not very specific. Meaning when one person is high doesn’t necessarily always translate to that particular disease state. And that’s what makes it so difficult to point our finger at, okay, this is the process here. This is what we have to target.
Radin Pulverman: Yes, that work is definitely evolving. So it depends on the disease indication. There are certain markers that are more relevant for certain populations. For example, I know that for depression, it seems like IL-6 and CRP are the most robust, reliable indicators of inflammation within depression. Breast cancer is different. When we look at breast cancer patients, those who have elevations after treatment in what we call inflammation, we’re really seeing it in, like, STNF-2, which is the soluble tumor necrosis factor receptor type two or TNF alpha. So it depends on the disease indication. So unfortunately, I know that, for example, there was this whole uproar around the serotonin hypothesis getting debunked in depression. I know we want to find one biomarker or one really simple, easy way to diagnose these conditions are like, oh, this is the inflammatory marker that’s going to tell us whether somebody has an inflammatory phenotype of depression. I think we’re working on it, but it’s just much more nuanced than that. And again, mental health is not like a broken bone. You’re not going to just find a specific fracture within a specific bone in your arm. It’s much more complicated than that. And I think what we’re trying to do is embrace that complexity and leverage all the tools that we have in science to better understand, model, measure and communicate these processes to people, as opposed to just overly simplifying for the sake of ease.
Psychiatry can become primary care for chronically ill
Bassi: I can think of numerous patients who have had ill described intermittent physical symptoms. Numerous patients. And I’m always becoming their primary care doctor in a lot of ways because I’m accessible. I communicate very well and very quickly to my patients. And they often are going to doctors who are in large hospital systems and maybe can’t reach the doctor directly. These individuals often find that they can’t find somebody who diagnoses them appropriately. And I come after building trust with the patient and talking to them and getting to know them and their symptoms. Even though I can’t come up with an answer, they trust me. And I told them, and I’m trying to help guide them through the medical process of getting the work up done. And oftentimes numerous people with the pattern is that they are ruled out by a particular specialty. Like this is not a neurologic issue. They do a couple of routine neurologic tests, then they go to physiatrists, and then they go to rheumatologists, and then maybe they’ll start something. But like, there’s a few large centers that do this well now, but that’s not common throughout the United States. What do you think we need to do to get there so that these individuals do feel like they have a place where they can get treatment?
Radin Pulverman: Yeah. So you’re not the only psychiatrist who said that to me, I think this is becoming more and more common, is that psychiatrists are becoming the primary care providers for individuals who have psychiatric illness or mental health symptoms, because, again, your brains are not separate from your body. Of course there are going to be physical symptoms. It’s almost crazy to think that there wouldn’t be.
“It’s in your head”
Bassi: They default to saying, “go to psychiatry.” That’s how they end up with us. And I like to help them see the balance there so that they know that it’s not all in their head, because I think that can be very intimidating for people to say, I just need to control this with my mind, and it’s not actually the case. Maybe there are some components to, like, working on sleep and trying to learn acceptance, but it’s not the underlying pathogenesis of their symptoms.
Radin Pulverman: The phrase it’s all in your head irks may be on belief your brain is an organ in your body. It’s an artifact of this really antiquated dualistic view of the brain and the mind somehow being separate from your body and not having any biological basis. So even if things are in your head, it doesn’t mean they’re not a medical problem. So it’s so disheartening for a patient to hear that and invalidating as if they’re making this up or they have control over it. So, yes, I completely agree. I think we at Bruin have very strong opinions around these things. So, yeah, you’re speaking to the choir on that.
Bassi: So let’s switch gears a little bit and talk specifically about Bruin health and where you’re going with that. And it sounds like you have so much time in your day to be able to balance a PhD and a startup company. So it’s very impressive. And tell us a little bit about how because I feel personally, I didn’t get trained very well in the business aspects of a start up company. Tell us what your experience has been.
Beginnings of Bruin Health
Radin Pulverman: Yeah, it’s been fascinating. So luckily, something I didn’t mention is that throughout my PhD, I’ve always been consulting for Digital Health. So I’ve had my foot in the industry world for a while. I actually met a founder at a conference when I was working at NYU in IBD, and he was looking to build a patient support app for individuals with chronic illness, and he wanted to start an inflammatory bowel diseases. So I was actually his first hire because he liked the fact that I had direct patient experience. I understood the disease. I had no idea what I was signing up for. I’d always been in academia, so I find that working in industry, for me, because I’m not clinically trained, I should say that straight up, I’m purely a psychologist, not a clinical psychologist. So for me, I’ve always really enjoyed having my feet both in academia and research and science, but also working in industry because it allowed me to feel like I was making direct impact to patients anxious at scale. I think if you don’t have clinical work, it’s really hard to feel like the work you’re doing means anything to people, sometimes directly in the world. So I have always been a part of startups and I kind of watch that startup go from conception all the way up through funding. And during that process, I actually met the CTO of that company. His name is Andrew DiMichele and he’s now my co founder. So he was the former co founder of Omada Health, which was a prediabetes digital health intervention program. And so he had a ton of experience and way more experience starting startups than I did. So I really learned from him, otherwise I would never have been able to do this because as you said, we don’t really get any kind of business training in academia or in medical school unless you do like an MD-MBA. But for PhD is definitely not there. I don’t know of any PhD MBA joint programs. That’s kind of how I started. And then when Andrew sort of approached me about the idea of starting a company, I thought that was crazy. I never thought that a PhD could start a company.
How Graduate School is Like Entrepreneurship
Radin Pulverman: I never considered being an industry or being an entrepreneur. And then the more and more I thought about it and the more and more I read, it turns out that PhD training really does train you to be an entrepreneur. So if there are any other grad students listening to this podcast, I would love to encourage you to consider that as an option. Because if you think about it, when you’re a PhD student, you’re learning how to one deal with rejection constantly. We’re always applying for grants, submitting manuscripts, getting desk rejected, constantly dealing with rejection. So you’re building this resilience of dealing with rejection and persisting in that face of getting no’s. That’s very much prepared me for fundraising. So that helped. The second thing is dealing with working on the edge of what is known. You’re constantly trying to bring something new into the world with your research. So that really prepared me for working with the ambiguity and not knowing if things are going to work out. And then in terms of fundraising, we’re constantly pitching the NIH for grant funding and trying to communicate why our research matters. And so I think a lot of people don’t realize that you are being trained to run a company. Because when you run a lab, it is like a startup and you never know if you’re going to die or if you’re going to get that grant or if the research is going to work out or are the results going to turn out the way you thought they would. So that uncertainty and that tolerance for getting rejected really helps. So yes. So all of that to say, I did not see myself becoming an entrepreneur. It was definitely something that I warmed up to over the last two years. But I’m really happy to be doing it because it feels like I’m going to be able to have much more impact with my work, and I still get to do this cutting edge science. It’s just within the context of on a larger scale, essentially.
Bassi: And an entrepreneur also has to be very self motivated too, like a PhD student. There’s nobody who’s going to be, like, telling you what to do and when to do it. So you really have to have an inherent love for that field forward.
Radin Pulverman: Paul Graham, who is the founder of Y Combinator, wrote something like, there’s nothing more dangerous or motivated than a PhD student who is procrastinating. And I totally agree because we’re constantly just having to, like, do this work and wake up every day. No one tells me what to do. And that actually when I was thinking about what am I going to do after the PhD, like, the idea of getting a job, I mean, it kind of freaked me out because I’m so used to just owning my time. And that’s one of the beautiful things about academia, is that you really do get to own your time as long as you have the grant funding. I definitely think there’s a lot of transferable skills. So you see this huge need with Bruin Health and where do you go from there? Yeah, so it’s funny how it evolved, actually. So we started because during the pandemic, I couldn’t run my research, so I do a lot of behavioral testing. So I use behavioral tasks like cognitive tests, looking at reward learning, things like that. So they’re computer-based assessments, and those are great because they come from cognitive neuroscience literature, and they were originally developed for use in fMRI to look at which brain regions are involved in something like episodic memory or cognitive control. And I was also learning a lot throughout my PhD about the RDoC approach from NIMH. Are you familiar with that? I’m not familiar with that, no. Yeah, so this work is really cool. It’s what inspired Bruin, a lot of it. So I think in 2009 or 2010, the NIH rolled out what’s called the Research Domain Criteria, or the RDoC, and it’s basically a research framework to help support the dimensional mechanistic study of mental health conditions.
Bassi: Okay, yeah, I should have known about that. Well, it’s interesting.
Radin Pulverman: It’s not surprising to me because a lot of clinicians who have been out of academia or out of training, even just in the last five to ten years, just aren’t up on this. It’s pretty new, so don’t feel bad. A lot of people don’t know, and it’s because it’s not making its way into clinical practice. It’s still very much within academia, but I think it’s really promising and a super cool way to think about mental health conditions as opposed to these categories like we were talking about. So I was running. A study looking at the role of cognitive control and emotion regulation in different dimensions of depressive symptoms. And so I was all set to go, ready to run the study. And then the pandemic hit and all of the software that we use to run those types of studies are super old. I think they’re like from the 90s or early two thousands and they’re on desktops. There’s nothing cloud based. So the ability to do this virtually is like disaster. Yeah, disaster. And no wonder why it doesn’t make its way into the real world, right? So I was telling at the time, Andrew and I were just kind of thinking about what our company should be and I was telling Andrew about this and he was like, this is such a low hanging fruit, I could easily build you something that allows you to do these types of assessments virtually. And so we did that and then we started rolling out self report and learning more and more about it’s amazing that nobody is really taking these approaches and bringing them into the real world. And we could be that technology platform that allows for that. So that was kind of the genesis of us.
What Data Is Collected?
Bassi: What does the patient see in that self report? What kind of questions are they?
Radin Pulverman: Yeah, so we like to ask, and I should mention this, so we are completely agnostic to the data type. So there are all these different ways we can measure things in mental health, right? There’s self report behavioral tasks. There’s like level two data, like zip code for social determinants of health, for example. There’s also passively collected things from voice, there’s some cool companies doing voice data right now. Some videos like facial features, GPS, your accelerometer, fMRI, EEG, I can go on forever. There’s so many different ways to measure things. What we care about is what are we measuring? So whatever the best way is to measure the construct that matters for mental health, we don’t care. We measure things like, basically, what are these biopsychosocial mechanisms that we know are relevant for mental health conditions? Things like emotion regulation, cognitive control, how you cope with stress, your health behaviors, your physical activity, your sleep. These are the types of things that we’re measuring, or even like threat reactivity, how you respond to rewarding information. So these are the processes that we’re measuring. And we’re now trying to figure out where we have recently, we’re just coming out of R and D actually. We figured out how to measure these things, how to score them in a way that’s comparable. But of course, they’re all on different scales. All these measurement approaches are different. So we have to figure out how do we actually combine this information in a way that’s intelligible and clinically actionable? How do we actually communicate this information back to patients in a way that’s almost therapeutic, like psycho education, helping people understand why they might feel the way that they do and then also trying to figure out how do we communicate these things to clinicians. So imagine if you, as a psychiatrist, had that amazing top level, high level summary chart that a primary care physician has when you go into the room with a patient. Of course, it’s not meant to replace rapport building therapeutic alliance like trying to dig in deeper, but just something to start with as opposed to waiting for months to get to all of this information. So that’s what we’re trying to do.
Using Tests to Guide Treatment
Bassi: Gotcha. I do know some clinics that use a personality test of some type to start off with that and go over neuroticism and impulse control and all these other types of elements in frame that in terms of the recovery and basically try to figure out where some of the addictive behaviors have come from. But it sounds like yours is much more comprehensive than that, perhaps.
Radin Pulverman: Yeah. I think for us. Are you familiar with HiTOP? No. Okay, so HiTOP is a really interesting dimensional approach to categorizing symptoms. So it’s a hierarchical taxonomy of pathology. I think I got that right. So that is kind of similar to what you’re talking about. It’s like across all these diagnoses, what are the relevant sort of symptom profiles or symptom dimensions that we should be assessing for? And they all load on to different factors that we think might be relevant for treatments. So we are bringing that in. Neuroticism, of course, is important, but it’s not the end all, be all. And I think that if you don’t get the actual psychosocial context to help understand why somebody might be exhibiting those types of symptoms, it’s really hard to use them within the context of treatment. So, yeah, I would say that we’re definitely taking a more comprehensive approach, but it’s definitely a balance, trying to figure out how do we do this in a way that’s not too burdensome to a patient.
Bassi: Right, that’s a good question. I think a lot of the resistance that we get in terms of filling out our forms is that they just feel burdensome, time consuming, and not all that helpful for them. And so we have in big, bold letters, we actually read this form, and it’s important to us.
Radin Pulverman: Well, imagine if your patients were doing those types of assessments at home and immediately getting feedback and learning about themselves. So one of the biggest surprises that I’ve learned through this process so we created our alpha products. We put it on the web just to see, 1: am I able to get data that’s consistent with the literature? And 2: can I get anyone to engage with us? And I was shocked. We were overwhelmed by how many people wanted to understand their mental health.
Bassi: What would somebody have to search for, on Google?
Radin Pulverman: Yeah. So the search terms that most likely ended up going to our crappy little ad that I spent, like, no money, where things like, what’s wrong with me? Do I have depression? Why do I feel the way that I do? The ads aren’t running right now if you’re trying to look for it. I turned them off because I couldn’t handle all the demand is on the health website, though. I’ve turned it off mainly because the demand so we had an overwhelming number of people came to the site and sat through a very long, horrible survey experience. Surprisingly, people were saying that they liked how comprehensive it was. It wasn’t just a quick and dirty PHQ and then learning, like, yeah, of course I feel depressed. Like, I could have told you that. They actually were filling out assessments about things that they didn’t know about themselves. For example, like emotion regulation. Some people don’t realize that using expressive suppression, keeping your feelings in, that is associated with both deleterious mental and physical health outcomes, whereas something like cognitive reappraisal is actually associated with better outcomes. So these are things that people don’t know about themselves, and I think that’s why they found it engaging. So we’ve learned that people are willing to do assessment, and they want to do assessment as long as they’re getting insight back that’s actually meaningful and helpful to them.
Bassi: Gotcha. So the way it is actionable is by seeing, okay, this person’s weakness is that they don’t do very good cognitive appraisal of their underlying feelings. We have to work on that while some other aspect is very strong.
Radin Pulverman: Yeah, I like that you said that, because we also take a strength based approach. So we’re also assessing positive psychological constructs. Things like mastery, social support, self esteem, grit, flow, mindfulness. These are things that if you’re high on some of those, that’s incredible, and you should know that you’re doing really well. And these are things that you can rely on, and they’re in your toolbox, and you should use them because you’re already doing a great job. So I think a lot of times people doing these assessments that are all symptom based, it’s like, yeah, I feel shitty, and I don’t want to be reminded that I feel shitty, and I don’t need you to quantify that for me. I can just tell you I think it’s invalidating. I got to interview some of the patients who took our assessments, luckily, and a lot of them said things like, this was better than talking to a therapist, which was shocking to me. And I think it’s because it’s nonjudgmental and safe from the comfort of your home and you’re learning about yourself as you go. I think it’s a big misconception that people don’t want to do assessment.
Trait vs State
Bassi: How do the results actually differentiate between state and treat? Because I know a lot of people who can have certain symptoms, and I’m guilty of this myself. It will be very high one day, depending on how hungry I am, how I slept, the good news that I’ve experienced recently, I’d be extra happy and less impulsive versus something that’s a little bit more personality oriented, that’s consistent, long term. Do the results actually show that and delineate that? Yeah.
Radin Pulverman: So the way that I think about it is what are things that we conceptualize as like, moderators or individual differences? So, for example, experiencing adverse childhood events, that’s not going to change. So we assess for that. Things like how you cope with stress is conceptualized to be a treat level factor, although I do think with therapy and with treatment, that can change. So I’m really reluctant to call anything trait unless it’s literally an event that you cannot go back in the past and change. But things like executive functioning have been shown to be pretty stable. The way I understand it is it’s like a window of functioning. And so depending on time of day, sleep, food, you might fluctuate between your window, but your window is traced. Yeah. So I think that it’s really helpful to in terms of communicating to patients, I think it’s really helpful to make it clear that these aren’t things that you can’t change. A lot of the processes that we’re assessing for are the things that should be changing as a function of treatment. That’s why they’re clinically relevant. They’re things that are targeted by specific treatments. So I think from a communication standpoint, it helps patients get buyin into the treatments. Like, these are the things that we want to actually help you with, and that can change. And these things can change even before you see symptom reductions. So I think that that’s actually really encouraging as well. Like, you might not feel it yet, but we are making progress here. And not to get too in the weeds, but I think this is super cool changes. If you take like an experimental medicine approach, changes and mechanisms, the extent of that, the magnitude of the change actually predicts, the magnitude of clinical change and the duration, because you’re actually targeting this like, pathophysiology as opposed to treating symptoms, which, you know, is like a band Aid. So I think that helps. In terms of communication.
Bassi: Well, I like that how you pointed that out, because that was actually one of my next question. You mentioned why doing measurement based care is important to patients. It seems like it’s very engaging. They learn from it and it’s actionable for them. And from a clinician perspective, it sounds like it elucidates the subclinical improvement or worsening of symptoms. So that gives you a little head start. If there are worsening to make changes earlier versus and also if they’re getting better to provide a little bit more encouragement because they’re not seeing it themselves in terms of outcomes, maybe they still don’t have a job and they’re still not doing the things that they want to do. But subclinically there is change there that we can measure. And what other reasons do you think that measurement based care is important for clinicians?
Nuances of measurement based care
Radin Pulverman: So I do want to distinguish or like, make it clear that because there are a lot of companies right now that are saying they do measurement based care, and they are. It’s interesting, actually. I think that there are studies that show that doing measurement based care actually results in better clinical outcomes. The extent to which people do measurement based care right now is essentially using PHQs and GADs. So they are measuring symptoms over time, even though we know that that’s clinically effective. Less than 30% of clinicians do measurement based care. And I think the reason why is because, again, just measuring symptoms actually doesn’t really help too much with treatment planning or decision making. And it doesn’t really tell a clinician or a patient anything that they wouldn’t already surmise just by talking. So having the numbers helps because I think it does show like, you know, you might not feel it, but yes, your symptoms are reducing even though you still feel terrible right now.
Bassi: This doesn’t really matter to me if my number is getting better, but I feel that helpful.
Radin Pulverman: I don’t want to crack on the measurement based care companies because it is clinically effective. I think the problem is engagement with that, both from the clinician and the patient standpoint. And so what we’re doing is trying to use measurement based care with measures that actually help with treatment. So these are things that we know help with treatment selection, treatment planning, getting buy in from patients, understand why these treatments are the ones that they should be engaging in, because it’s much more targeted. It’s essentially data driven precision psychiatry as opposed to just tracking outcomes over time. Of course you need to track outcomes over time, but I don’t think it’s enough.
Bassi: And it almost seems like you are getting a more precise understanding of how the person is improving while the treatment is almost the resolution is even lower on the person’s treatment because the meds don’t always target some of those components. Like grit. I can’t give you a med for grit.
Radin Pulverman: Yeah, that would be nice, right? Well, yes, I do want to distinguish between pharmacotherapy and psychotherapy. So when I say treatment planning, I mean more around psychotherapy. So there’s some really cool work being done right now in clinical psychology where people are taking CBT, ACT, DBT evidence based therapies and reducing them into their active ingredients. It’s called a process-based approach. And the reason for this is we know that clinicians don’t just do CBT, don’t just do DBT. You can look at these evidence based therapy. Yeah, no one’s just doing those things.
Bassi: Patients come to me there, who does CBT here?
Radin Pulverman: Yeah, exactly. I look at all those things outside of clinical trials, no one does, like, manualized protocolized talk therapy. That’s just not realistic. Who knows, maybe one day. But I think what actually is happening is clinicians have all these tools in their grab bag and depending on the moment or depending on the information they have, they’re pulling from their grab bag of evidence based tools. And so there are these mechanisms of change or these processes or these ingredients across CBT, ACT, that we know are evidence based. And so those things are actually targeting the specific mechanisms that we are measuring. So that’s what I mean by helping with treatment planning and selection and also helping with educating patients around why those processes or those treatments are actually relevant for them. I think one day we’ll get there with pharmacology, but we’re not there quite yet. There are some really interesting clinical trials happening right now in that world, but it’s not there yet.
Bassi: Awesome. So what kind of challenges do you foresee moving forward with Bruin health?
Radin Pulverman: On a personal level, I’m obviously pretty terrified to be making this leap. I’m going to be leaving my PhD program in the spring, and the safe, although still rocky, route is to go to a post doc and become a professor. And that’s the expected path that I should take. And I’m definitely taking a leap and doing something that’s not what most people do after their PhD. So I think that I’m most afraid, to be honest, of the perception or the not judgment, but, you know, I’m doing something risky. I’m trying to take these approaches that for the longest time have been really relegated to the lab and bringing them out into the real world. And the reason why I want to do that is because I kind of look at what we’re doing more as like a deep tech, almost like I don’t want to call us a pharma company because we’re not, but almost like a bench to bedside approach to mental health treatment. And the reason why I say that is because we’re collecting so much data. I’m still doing research. It’s just collecting real world data in real world treatment settings. Things that kind of I don’t want to say irk me, that’s too strong. But things that kind of bother me a little bit about what we do in academic medicine is that the conditions under which we’re doing this research is not at all like the real world. The patients that we’re getting are not like the patients out in the real world. You have to be living next to an academic medical center. A lot of times that means you’re on the west or the East Coast, in major metropolitan areas. You’re a very specific kind of person. And so I’m really excited about being able to collect data from real people. When we ran our alpha product, I got representation from every single state, which really excited me. Yeah, every single state. And people across the spectrum of functioning from a PHQ of zero all the way up to 27 people who had never engaged in mental health care, people who are currently in treatment. There’s clearly a need for this and a desire for it. And I’m really excited by being able to conduct research out in the real world. It’s just very different from what other people in the field do. And so I’m afraid of how that will be perceived and I’m hoping that it will be welcomed. But it’s a little bit of a renegade.
Bassi: It sounds like we actually have a lot in common because that’s one of the underlying reasons why I started this podcast, is because I feel when I go to clinical or national conferences, there’s so many clinicians that are like, I want to be in on the conversation in the tech world, how do I do that? And we would have seminars to tell people about how to connect more with the tech world. It’s almost like they’re not talking to each other. Like there’s the tech titans that just kind of want to take an idea and run with it. And it doesn’t have maybe as much clinical utility or it’s not really thought out as to what the patients and providers actually need. And so you’re doing that when you’re bridging that divide. So in a way, a lot of your clients are the people who would be listening to this podcast.
Looking for Psychiatry Partnerships
Radin Pulverman: That’s why I’m on here. Yeah, I know when I saw your podcast because I’m looking for psychiatry partners. Another reason why we’re different from measurement based care is we’re not trying to sell fast to providers. I’m not trying to sell software to providers. That is a really hard business model to do, not trying to do that. I’m trying to enable measurement based dimensional, data driven, precision psychiatry through partnering with clinicians who want to do this type of care. I know that they’re out there. I already have some that I’m working with I’m really excited about. One of these types of clinics out there, if you’re curious, is Singula Institute in New York City. They’re a great example of people who are taking this approach to trying to measure biopsychosocial mechanisms that data drive care. I know that this is happening outside of academia. It’s just that those physicians are doing it manually. And I want to help them do this with our platform and also potentially drive patients to them because we have this direct to consumer sort of relationship with patients. We’re not charging patients for assessment, but once they get this information, it’s like, okay, now what do I do with this? Well, here are providers who actually practice this way and will use your data to help inform your care. So any psychiatrist out there who want to partner with us, we’re totally open to it.
Advantages to this model
Bassi: I see a few advantages to your model here. The main one I think that clinicians are going to be hesitant about is validation. And you guys have already have the data that’s validated because you’re taking it from the bench to the bedside and then the other pieces. How is this going to help me? Is this going to be of any clinical utility? And it sounds like that’s what one of your main missions is.
Radin Pulverman: Yeah, it’s not ready to show yet, but maybe like on the side, you and I could talk about it. I’m really, really excited about this kind of provider view that we’ve been developing. So there’s what we sort of patients, which is a couple of the psycho education and all this great information about themselves. That’s very different from what a clinician needs to see. Clinicians need to see like boom, boom, boom. One of the top things that I need to be focusing on right now. So how do we take all this complexity and surface up the most important stuff that a clinician would get to eventually? And it fits. The way that we want to present it needs to fit their mental model for how they already treat. So that’s why I’m partnering with clinicians to make sure that what we’re building actually is clinically relevant and helpful. So it saves them time and helps them get buy in from their patients around what these processes are and why they’re important.
How it informs the clinical picture
Bassi: One other way I think it informs the clinical interview with a patient is that when I talk to a patient, I’m really seeing the tip of the iceberg. This one small snapshot. If I talk to them for 30 minutes every three weeks, that’s what, like less than 0.5% of their life. And so I don’t see them in the other aspects of their life outside of the interview. And so we’re fighting recall bias. And so they’re going to remember the most salient negative or positive aspects of their experience over the last two weeks since their last appointment. And it’s almost like a white coat hypertension. But for psychiatry, they have this bias that comes into play when recalling their experiences and maybe they’re in a different state while kind of getting revved up talking to a psychiatrist or mental health therapist. And so I want to kind of see them in more of their natural habitat and to do a survey or some sort of data input while they’re in the confines of their home or in a more relaxed state perhaps. I think that would be more informative for us and kind of augment my decision making during the appointment.
Radin Pulverman: I love that idea and I totally agree. And I also think because so much of treatment planning, decision making rests on what a patient is telling you in this moment, of course, that bias is going to impact treatment. And so whatever we can do to help get patients to do this at home in a way that’s not a part of that interaction, so that when you meet with them, you can focus on rapport building and talking. About those processes and treatment planning and trying to better understand them as a human, as opposed to manually collect this data and then worry whether or not it’s even valid.
Bassi: Absolutely. What has been your biggest surprise in this journey? Sure, you’ve had a few. If you had the true entrepreneur experience that I’ve had, you probably have a surprise every 20 minutes. But generally, what do you think the coolest, biggest surprise that may have made you hopeful about the future?
Radin Pulverman:Well, I think one is the patient demand. I’ve just been shocked by just how many people want to do this. I thought I’d have to. Coming from research, we pay people to do this type of thing. So the fact that I wasn’t paying them in terms of our cost per acquisition was less than $5 for us. And you mentioned because people find it informative. Can you explain that? Yes. Things I was hearing was they felt like it was safer and better than talking to their therapist, which was interesting to me. And I think it’s because it’s nonjudgmental and it’s private. Some people said also who are currently in treatment, that these things were echoing what their therapist and provider had been telling them and that maybe they should kind of give that more attention. So it’s almost like a second opinion sort of thing. Yes, because the experience is so subjective right now with this clinical interviewing that I think when you go to your primary care provider and they’re discussing your WBC and your CRP levels, nobody’s wondering whether or not they’re just judging that from how are they coming up with this information? It’s like, no, there’s objective data to provide that information. Or one person said that our results prompted him to call a therapist. He was like, you know, I haven’t been feeling really well. I’ve been kind of putting off treatment. But based on this, it looks like I really do need to take this more seriously. So it kind of helps people, I think, in this contemplation/ precontemplation phase of behavior change who aren’t necessarily ready to take action but want to do something because they know that there’s something wrong. They just don’t know what to do. And so, of course, they go to Google and then they search, Do I have depression? And then they get bombarded with ads from companies are asking them for hundreds of dollars a month to sign up for therapy. And they’re like, I don’t know if I need that. Do I need a psychiatrist? Do I need a therapist? Is this digital health app going to work for me? Like, I don’t know what I need. I don’t know what’s wrong. So we give them something to do and a way for them to learn about what it is that might be going on.
Bassi: Right. One thing I keep hearing is that it provides a visual element that reinforces what’s going on for them. And I often have this experience where I’ll mentioned throughout the interview, maybe five plus suggestions. And then at the end I’ll kind of double back and see how much had been absorbed and I’ll say, did I mention anything that has been helpful? And they’ll say, no, you didn’t tell me anything. And I’m like, how did that happen? I’m guilty of this too. I think there’s data on this that we only absorb like 5% of an interview with a doctor. And so having this next line of reinforcement on an app or whatever device you’re going to be giving website that just kind of brings home, okay, this is like something that I need to work on. Just gives a person like another added layer of validity to it, then it’s not just something that kind of was mentioned in passing in the middle of a clinical session. So I really do like that. I think it’s very educational for the patients.
Radin Pulverman: Exactly. And I think we will know we have done our job well if the information, if the data we’re picking up on and the information we’re providing is mirroring what a clinician would have done or would have gathered, you know, I don’t want our results to be surprising to someone like you. It should be something that like, yes, this is exactly what I’m picking up on and there’s some initial evidence from the interviews I’ve done that it seems like what we’re providing to patients is echoing what they’re hearing from their providers. So that means we are doing a good job at that. I’m not trying to like, be in conflict with the provider. I would love for Bruin to just be a layer of support because I think psychiatrists, they have a really, really hard job and there are no tools and no data and nothing to support the work that they’re doing. And so that’s really what we’re trying to do.
Bassi: Well, I think this is a really cool endeavor, and I think if you just stick to your core values and reminding yourself what you said at the beginning of the interview that you want to affect as many people as possible. I think there’s such untapped need here because it’s one of those things like you mentioned, we understand how important it is, but if it’s not actionable and easy to do and relevant to the situation at hand, people aren’t going to do this measurement based care. So I really applaud your efforts and moving forward with this journey. Where do you see yourself or where do you see the company in 20 years and what do we need to do in five years to get there?
Radin Pulverman: I’m sure our investors will hope that we’re public or exited in some way in 20 years. But yeah, in terms of the field, I want mental health care to at least look like other areas of physical health care. It upsets me that there is this we talk about parity between mental and physical health. But it’s still not there. And even just the experience of what patients are putting up with and what clinicians are putting up with, I think it’s, again, an artifact of the dualism. I’ve been hearing all kinds of different things about mental health being separate from physical health or they’re not the same thing. I would love for our assessment to be in primary care. If we can get to the point of being like the gold standard for all things mental health, I don’t think we can really do our jobs until mental and physical health are completely integrated at the level of healthcare. That’s a very ambitious goal, but that is our North Star.
Bassi: That’s awesome. Arielle Radin Pulverman, thank you so much for being on the show. I really appreciate you taking the time to talk to us and the viewers here and listeners as well about what you’re up to. I’m sure we’re going to hear more about Bruin health in the future. Thank you.
Radin Pulverman: Great meeting you, Bruce.
Bassi: As a reminder, if you’d like to support the show, one way you can help us is by subscribing to the channel on YouTube and leave a comment if you’d like. It also means the world to me if you can share it with your social media network, maybe there’s somebody out there who might be interested in the podcast. Hope to see you next week. Next Monday. New episodes are released every Monday morning. Thanks a lot. Take care.
Resources
Substance Treatment and Research Service (STARS) at Columbia University:
https://www.columbiapsychiatry.org/research-clinics/substance-treatment-and-research-service-stars
Martin Blaser:
Omada Health:
NIMH Research Domain Criteria RDoC:
https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc
Hierarchical Taxonomy of Psychopathology (HiTOP):
https://www.apa.org/pubs/highlights/spotlight/issue-88
Singula Institute:
