Episode 47: Understanding the DSM V TR with Dr. Michael First

• Episode 47: Understanding the DSM V TR with Dr. Michael First

  Alex: [00:00:10] Welcome to PsychED, the Psychiatry Podcast for Medical Learners by Medical Learners. This episode covers all you need to know about the new DSM five TR. I'm Alex Raben. I'm a staff psychiatrist at the Centre for Addiction and Mental Health in Toronto, and I'm also a lecturer at the University of Toronto. I'm joined today by my co-host Saja Jabri. She is a international medical graduate and a psychiatry enthusiast and this is her first episode. So welcome, Saja.

  Saja: [00:00:44] Thank you. I'm very happy to be here.

  Alex: [00:00:48] This was also such as brainchild. I should say so. Thank you, Saja, for picking a wonderful topic. We're also very pleased to be joined by our esteemed expert, Dr. Michael B first, and he is a professor of clinical psychiatry at Columbia University. Dr. First is also a internationally recognised expert on psychiatric diagnosis and assessment issues as a private practice in New York City and also conducts expert forensic psychiatric evaluations in both civil and criminal matters, including the 2026 trial of Zacharias Moussaoui.

  Dr. First: [00:01:29] Sorry. Moussaoui.

  Alex: [00:01:31] Moussaoui. Thanks, Doctor. First. And then especially important to this episode, Dr. First is the editor and co-chair of the DSM five Text Revision Project, the editorial and coding consultant for DSM five, the chief technical and editorial consultant of the World Health Organization ICD 11 Revision Project and was an external consultant to the NIMH Research Domain Criteria Project or RDOC. Dr. First is also the lead author of the Structural Structured Clinical Interview for DSM five, known as the SCID. More broadly, and this is a widely used or the most widely used structural diagnostic instrument for DSM five diagnoses and in research and in the clinical setting. He has also authored and co-edited a number of books, including a research agenda for DSM five, the DSM four TR Guidebook, the DSM five Handbook for Differential Diagnosis and Learning, DSM five by Case Example. So we could not be more pleased to have you here, Dr. First on the show to talk about this topic, which you are clearly a leading expert on. Welcome to the show.

  Dr. First: [00:02:42] Thank you. A pleasure to be here.

  Alex: [00:02:45] Now I'm going to just quickly talk about our learning objectives today, and then I'm going to hand it over to Saja, ask the first question. So by the end of the episode, the listener will be able to, number one, understand the rationale for undertaking a DSM five TR revision, as well as how that revision process looks. Number two, become familiar with disorders, the text and the symptom code additions and modifications to the DSM five TR. And number three, understand the purpose and function of the DSM generally and be able to contemplate what future directions are going to look like in this area. All right, Saja, I'm going to hand it over to you to take it away.

  Saja: [00:03:33] Okay. So without further do, I'll jump into things to start with, Dr. First. Could you briefly describe to our listeners in simple words, what is the DSM and where did it come from and how did we get to the present edition?

  Dr. First: [00:03:48] Okay, so the DSM that stands for the Diagnostic and Statistical Manual of Mental Disorders and the version that the subject of today's presentation is the DSM five. Tr So that means it's the fifth edition of the DSM, and the TR is the latest version, which is a version that focuses primarily on revising the text. So the DSM is basically a dictionary, so to speak, of all of the psychiatric diagnoses which are accepted as valid by the American Psychiatric Association. The fifth edition when the first edition came out in 1958 and the second 62 and DSM three, which is the one that is it's the first one to have diagnostic criteria for every disorder. That was the 1980, and then DSM four was in 1994, and now we're up to DSM five, which is in 2013. So we're now 11, eight years past the release of DSM five. So we felt that a revision was needed and that's what the DSM five text revision is.

  Alex: [00:04:53] That's terrific. Thanks so much, Dr. First. No, we live in Canada. You live in America, but we have listeners from all over the world, certainly in North America. We turn to the DSM quite frequently in our clinical practice, as you said, as a dictionary for diagnosing. But our international listeners, I'm guessing they might use some other sources. So there's the ICD. So how do we differentiate the ICD from the DSM five? And could you take us through that?

  Dr. First: [00:05:24] Sure. So the it's a little complicated. So the the version, the DSM, the ICD 11, which is the 11th revision, just got finished a couple of years ago, but no country is yet implemented yet. Eventually, every country in the world will have to use ICD 11 codes in the same way. Right now, the United States, Canada and all the countries of the world are using ICD ten codes. The DSM uses the ICD code. So when you open up the DSM and make a diagnosis and write down the code, you're actually fulfilling the obligation to use the ICD codes. But the definitions in ICD and DSM are very, very similar, but they're different. There's been attempts over the years to harmonies them, and I've been involved in that process. So they're pretty close. But there are still differences that have to do with some different historical traditions between the United States and other parts of the world and different levels of detail, different types of disorders. So they're pretty much the same, but not identical. It really depends upon where you live. Even though the DSM is produced by the American Psychiatric Association, there are a number of countries around the world which also use the DSM. It's been translated into different languages, and that got started basically after DSM three came out in 1980. DSM three had introduced diagnostic criteria for every disorder. The basically the rules you need what needs to be present in the patient duration and symptom wise in order to make the diagnosis at the time. The system which is affected in the rest of the world was ICD nine, which did not have those kinds of definitions. So a lot of countries decided to use the DSM three as their main system, mainly because of the sense that the diagnostic criteria were so useful. It was they preferred using the DSM. Since then, ICD has caught up. The ICD 11 does have something called clinical descriptions of diagnostic requirements, which are like criteria. So both systems now have criteria. So I think the usage of the ICD 11 has greatly increased over the years, and in many countries that's the only system that's used.

  Alex: [00:07:31] Interesting. I didn't realise there was that sort of practical difference between the manuals historically and caused a lot of uptake of the DSM three. For that reason. It's quite interesting.

  Saja: [00:07:43] Okay. So, Dr. First, thank you so much for that. Could you tell could you briefly describe to our listeners and tell us more about why was the DSM five are needed? What was the rationale behind it?

  Dr. First: [00:07:56] Okay. So the as you can imagine, the DSMB is an amalgam of what we currently know about the mental disorders. And we luckily live in a world where what we know keeps changing as we learn more things. So know, like any textbook, you would not use a textbook of medicine from ten years ago. You would assume that a lot of things there would be out of date. So the same thing is kind of true too. There are two components to the DSM. There's the criteria which defined the disorders, but actually 95% of the words in the DSM are the text. That's the information about the disorders. It includes things like prevalence, sex ratio, familial pattern, all those aspects about the disorder, which are very important. And in more recent years we include things like risk factors and diagnostic markers. So this information, it's really become an authoritative source of information so that information could get out of date. As we know things happen. So the the version, the DSM five from 2013, all the texts there was based upon what we knew about mental disorders in 2012. So in the intervening eight or nine or ten years, a lot of the information in the DSM is really no longer up to date. So this is an attempt, since we don't know when the next big DSM six will be. We wanted to take the opportunity to revise the text to make it up to date. Now, one thing that's a little new this time around is in the previous DSM's, in between DSM editions, there were no changes, so you had to wait till the next big DSM to make changes.

  Dr. First: [00:09:28] We finally got rid of that way of doing it, which is kind of bad to have to wait for some artificial period of time and changes can be made on a rolling basis. There's a process by which people could submit proposals for changes to the DSM five website, and then there's a whole process by which the proposals are evaluated. They have to be empirically based. You can't just write in and say, I think it would be a good idea to have this kind of disorder. You would say, I think we'll give you an example. A disorder that is becoming more and more popular around the world is Internet gaming disorder. People who have basically kind of like a gaming addiction. ICD 11, when they came out, has actually a disorder called gaming disorder, and DSM five doesn't yet. It's in the appendix. But it's very possible that in maybe the next ten years there's more and more data is collected. They'll feel that there's enough data to justify going into the DSM five. So new disorders could be added when there's enough data. There was one new disorder since DSM five came out that has been added, and that's prolonged grief disorder, which that's been much discussed already also in ICD 11. But the DSM group finally felt that there was enough data to justify being added to the DSM. So it is now in the text revision.

  Alex: [00:10:46] I see. So a lot of years have passed. There's progress in science taking place all the time. And so there was this need to update the the DSM clearly, but it needs to be data driven. You can't just make an arbitrary change, as you were saying. You mentioned one of those changes, prolonged grief disorder. We are going to get into the meat of what these changes are very shortly. But I did want to talk about the process because you've been directly involved in that. So I was hoping with your personal perspective on that, what does that look like? How do these changes get approved? Who's sitting on these committees, how many committees, that kind of thing.

  Dr. First: [00:11:27] So when the DSM five came out, that was the preparation for the DSM five was about seven or eight years. So that was a big process with different work groups working over that period of time to make all of the proposals. And once we've changed over to DSM five, post DSM five, this new ongoing revision model, we now have a different process. Now, for the first time, we have a website open up for proposals, and when a proposal comes in to the website, the website is very specific about what a proposal has to include. So for example, if you want to add a new disorder, which is probably the hardest thing to do, you have to show a lot of data about things like its validity and different kinds of validity. It's clinical utility, it's reliability, all the kinds of things you would want to know about before you make the decision to add a disorder. So a lot of data has to be collected, and it's pretty clear on the website what kind of data it needs to be. So this website has been open since 2013 and proposals have come in and some of the proposals are for tiny changes, but there have been a number of proposals that have been evaluated and have gotten through the process and that prolonged grief disorder is one of them.

  Dr. First: [00:12:39] So now for that process, there's a steering committee that is the first line of when when a proposal comes in, they evaluate and see whether it looks like there's enough data in the proposal to even spend time considering it. If somebody just writes it, this should be this and. My data is I did a study of five people or whatever that would clearly not not immediately get sent back and say we need a lot more data. But so you would outline the proposal, kind of say what kind of data they're planning to give in. And then the committee would decide, okay, if they're in the ballpark of getting in, they would actually send it to a special committee that had expertise in whatever area it is that somebody had a proposal for a new mood disorder, the Mood disorder group would look at it and they would review a proposal and decide whether the data was sufficient, and if not, they would send it back to the submitter and say, you know, this is really good, but we still need more about this kind of validity, and then would go back to them and then it would be up to the person who submitted the proposal to provide that data.

  Dr. First: [00:13:39] Then it would go back to the committee again. And if the committee feels like there's sufficient data, then the next step gets posted on the website for public comment for 45 days and then know notices are sent out to organisations saying there's a new proposal for such and such on the website. And then after 45 days we look at what comes in and then they get analysed and then that goes back to the steering committee to see whether or not any of the concerns that were raised by the public comments need to be addressed. And if everything's sort of taken care of and everybody's satisfied with how it looks, then it goes through the APA approval process. The APA has a board of trustees and an assembly. They also get to look at it and give a thumbs up or thumbs down on it. So by the time it's in there, it's got going through many, many layers of approval and the not so easy gets up at the end basically.

  Alex: [00:14:31] Doesn't sound like it. So just to summarise that for our listeners, because it's harder to do visually, this would be, I think, a little bit easier, but it sounds like it goes to the steering committee first. If it passes a threshold, then it goes on to the individual committees that are experts in those areas or review committee. And then from there there's a public appraisal.

  Dr. First: [00:14:55] Let's say it goes back to the steering committee first, because the steering committee has to approve. So the review committee would say, we think it's good. Then the steering committee debates whether to put it in. And when they're satisfied, like, okay, we really think it's solid and then it goes for public review and then then we'll see what the public has to say. And and hopefully it happened. It's been you know, the big one was the prolonged grief disorder. We got lots of very helpful comments. And the criteria that were proposed actually were changed after the public comments came in to address some of the problems that they pointed out.

  Alex: [00:15:28] Interesting. And I think that's something. Yeah, Really? No, because I don't think a lot of people, myself included, realised there's this public component to it and and then after that back to the steering committee and then ultimately kind of APA for the final signoff. Okay.

  Dr. First: [00:15:42] And that's what this is the first time we ever did that. There was never such an all the previous DSM's while people would write things into the APA and whenever there was never a formal process by which the public could make a proposal, that's that's new since DSM five.

  Alex: [00:15:59] Gotcha. Okay. Very cool.

  Saja: [00:16:01] Wonderful. Dr. First. Can I submit a proposal, let's say? Or who can submit these proposal for changes to the DSM? Is it open to the public?

  Dr. First: [00:16:11] Well, the the hard part is fulfilling the requirements for the data. I mean, a regular person, a psychiatrist in practice might think there's a good idea for new disorder, but to get it in, a lot of data would be collected. And that's what that's what's laid out on the website, what that data is needed. So generally most of the people are either organizations or researchers or groups of researchers who can present all the data that is required to at least submit the proposal. But you're right. Theoretically, if an enterprising clinician collateral that data available, then then sure, you know that absolutely would be appropriate.

  Alex: [00:16:53] Great. So I wonder if maybe we should go to the case now as a entryway into some of the changes in the DSM five, if you want to read that out.

  Saja: [00:17:04] So for today's episode, we have a case presentation. Mariyam, she's a 56 year old female, married her daughter, completed suicide more than two years ago. She often feels depressed but does not think that she feels depressed most of the time, and she's unsure whether she feels depressed most of the day. Her appetite is normal. She sleeps very well. She often experiences fatigue and anhedonia. She experiences recurrent involuntary dreams and memories associated with her daughter's suicide. She used to avoid places and things that reminded her of her daughter outside the home rather than inside the home. But this is no longer the case. Her beliefs about the world have become negative and very pessimistic, and she struggles with substantial guilt associated with her daughter's suicide. She has invested. A great deal of time and effort to investigate and try to find answers and reasons for her daughter's suicide. She's not particularly angry, or hypervigilant, and she does not engage in reckless, self-destructive behaviours. She thinks about her daughter very frequently and longs for her daily. Since her daughter's death, she feels as though a part of herself has died. She has struggled to engage with friends or interest and experiences life as meaningless and feels intensely lonely and emotionally numb. So I don't know. Should we take a minute to think about the possible diagnoses?

  Dr. First: [00:18:44] Yeah, I mean, you want me to comment on it.

  Alex: [00:18:46] That'd be Great.

  Dr. First: [00:18:47] So if you if her mother, Miriam, if you saw her mother one month after her daughter's suicide and she gave that story, you would say to her, you're going through a normal grieving process. It's painful, but there's then maybe counselling to help you get through the grief. But you would not consider her having a disorder because, you know, that's normal for people to grieve the loss of especially a child. The fact that it's two years later is what suggests that might be pathological. Another thing that's in the differential there. So normally when when there's a death like that, the two most common besides this, a grieving and abnormal grieving process could be depression. Major depression can be triggered by grief reaction, like any life stressor. But certainly if you're predisposed, have a family history of depression, you have a past history of depression that could trigger a depressive episode. But as was described in the case, she doesn't have the symptoms that would justify a diagnosis of major depression. The depression wasn't every day didn't include many of the required symptoms. So that was sort of ruled out. The only other diagnosis that sounds possible could be PTSD, avoiding things, you know, feeling nightmares that that's a symptom. So one of the questions which wasn't in the case was what was the nature of the suicide that the mother let's say the the she found her daughter had killed herself with a shotgun and the mother finds the body in the bedroom.

  Dr. First: [00:20:19] That exposure to that traumatic experience could actually be enough to go for PTSD. But it doesn't sound like from the description that the typical symptoms of PTSD were, they're like things like re-experiencing the trauma. The only one that was a little bit like that were the dreams. But the doesn't sound like a picture of PTSD, but that would be in the differential. So and all three of these could happen together. So the three diagnoses I've mentioned in the differential would be major depression, PTSD, And then this new diagnosis, which has recently been added, which is called prolonged grief disorder. And the concept is simple. There's certain a certain amount of grieving. And some people, when they're grieving, become non-functional for a month or two after the death of a loved one. They really can't do anything but the normal grieving process. People at different paces slowly get over it. At a certain point in time, most people will have gotten pretty much back to normal, at least somewhat, and for that reason. So this the idea here, this is a diagnosis reserved for that subgroup of people who experience a loss, who never get over it. Now, that's a tricky state. When I use phrases like get over, a lot of people would say, Nobody, you never get over the death of your child, which is true.

  Dr. First: [00:21:36] That's why getting over it is not the right word. But there's the way you get. If your grief is stuck at such a high level two years later, where it's preoccupying your life and it's interfering with your functioning, then we could say that that's not a normal grief reaction. When this diagnosis was put on the website for comment, there was a contingent of people who are very upset about the idea of labelling grief of any kind as disorder. And we're very we're very sensitive to that. We want to make it very clear that there's a normal grief and then there's abnormal prolonged grief disorder. And what made it even more compelling to add this diagnosis to the DSM is there's a treatment that has been shown to work. It's a cognitive therapy type treatment. There's no medication for this condition. It's a therapeutic therapeutic edition. And theoretically, you're supposed to wait a year until the death has occurred to be able to say you have prolonged grief disorder. So, I mean, I'm sure you could start the therapy earlier if you wanted. But as far as getting the label, you really need to wait a full year before you can conclude that the reaction to the grief and the person's life change is beyond what we would consider normal.

  Alex: [00:22:50] That's really interesting to me that the way the public commentary kind of played into thinking about this as a disorder. And thank you for outlining your differential in the case. I couldn't agree more. And then you also let us nicely into this prolonged grief disorder discussion. You kind of outlined a bit of it for us, including even treatment. But I'm wondering, can we get a bit more specific? Like what are these criteria that clinicians will be looking out for? What's the sort of DSM version of this?

  Dr. First: [00:23:24] As with the many DSM diagnoses, is symptoms which are core that are required for all cases. So for a manic episode, you must have elevated or expansive mood the rest of the symptoms, whether or not you don't need sleep, that's optional, that's variable. But you must have the elevated or irritable mood to have mania in the same way. Prolonged Grief disorder has two symptoms in particular, one of which must be present in all cases. The two cardinal symptoms. Either of them have to be present, usually both, or it's a yearning for the person and preoccupation with thoughts or memories of the person you can't get, Everything you think about has to do with the death of the person. So you have to have those. And as with many DSM definitions, you have to have it's not just every once in a while. It's got to be nearly every day for 12 months, very long period of time. That's the first part of it. So if you don't have either of those, you're not even in the ballpark. But once you have either the yearning or the preoccupation, then there's a bunch of other symptoms that you need. At least I believe it's three. There's a list of eight symptoms and three out of the eight are required. And let me tell you what the first is called identity disruption, which means that you feel like as though a part of yourself has died.

  Dr. First: [00:24:48] A lot of people in right after the death of a level. And they feel that. But again, months later and again, that's why that itself would not be enough to make the diagnosis. That's why it's you need a whole cluster. It's a combination of the symptoms together. So that's one of them. Some one another one is a more sense of disbelief about the death. You really can't believe the person has died. Avoidance of reminders that the person is dead. Intense emotional pain, which includes anger or bitterness, difficulty reintegrating into one's relationship. So it's very common to kind of withdraw into yourself when you're grieving. But the part of the normal grieving process, you get back to your old life, you reconnect with your friends. In this condition, you really have a real hard time integrating with the way your life used to be. Some people are emotionally numb. They feel like they don't have any emotions at all. People will feel life is meaningless and there's an intense loneliness as a result of the death. So any one of these on their own may not be pathological. It's the three together, plus the yearning or preoccupation. All of that together is required. And like most DSM diagnoses, there's a requirement that that all of these symptoms together have to be severe enough to cause distress or impairment in occupational or social functioning. All that together is what makes it a disorder.

  Alex: [00:26:14] Thank you so much for taking us through that doctor. First and looking at the list. I'm also kind of struck by, as you were mentioning before, like the overlap with PTSD, for instance, or some other conditions. Right. Identity disruption. You can think of that in other conditions, emotional numbness, avoidance. But to me, it seems like it's very oriented around the person you're grieving. That seems to be a very distinct difference here. And then the timing, as you were saying as well.

  Dr. First: [00:26:41] That all of the symptoms, the identity disruption is as a result of the death. So, you know, people can have these symptoms chronically before the death happened. So you couldn't count that as part of prolonged grief disorder unless you could attribute it to as a result of the death of the loved one.

  Alex: [00:26:59] It makes sense. Makes sense. Great. Thank you for taking us through that. I think now we'd like to turn to the other changes because prolonged grief disorder, that's the only new disorder added to DSM five TR. But there have been a number of other changes. Could we maybe go through?

  Dr. First: [00:27:18] Well, actually, there are a couple of other new new in quotes. They're not completely I mean, this is the major one. There's no question. This is the one of the most clinical interest. It's three other disorders or conditions which have been added. One is something called unspecified mood disorder, which sounds it's a technical thing of sorts, but it's for real. When DSM five got rid of, you know, all of the categories in the DSM have an unspecified sort of a wastebasket for individuals who have presentations that don't meet the criteria for any of the disorders. And that actually is fairly common. A decent percentage of people who come for treatment don't actually meet the full criteria. So you really can't give them a diagnosis of one of the disorders in there because you don't meet the criteria. So you have to use one of these unspecified categories. So for someone who has like a subthreshold depression or subthreshold bipolar disorder, they would get a in the DSM five, bipolar, unspecified bipolar disorder or unspecified depressive disorder. But what is the mood category like something like irritability? Is that a depressive thing or is that a bipolar thing or agitation? Those certain mood symptoms aren't specific to either depression or mania. So one of the questions was what if somebody comes in and their main problem is irritability and agitation, but they don't meet the criteria for any of the disorders? What do you call that in the DSM five, you'd have to pick between decide whether is it really depressive or is it really bipolar.

  Dr. First: [00:28:49] But the arbitrator, if you don't know anything, you have to pick like flipping a coin. The problem with that is then the person ends up having that wrong diagnosis stuck on their chart. So the solution is to take a step back and and reintroduce something which used to be in the DSM, which is an unspecified mood disorder. So we're now allowing the clinician to just say, hey, this is a mood problem. I'm not going to commit myself to whether it's bipolar or unipolar as of yet. So it's mood. So as you know, with all of these unspecified, there's more information comes in. You hope to be able to rewrite the diagnosis based upon new information. So you have to start somewhere. So this is sort of like a place to start for some unspecified general mood problem without committing yourself to bipolar versus unipolar. So that was one. There's a category called No Diagnosis. Believe it or not. So what? You know, when you work in a hospital, you have to write down a diagnosis or your practice. So sometimes you're going to get somebody who comes in, says, you know, I need to have a doctor's note saying I'm ready to go back to work.

  Dr. First: [00:29:55] I've been on disability, everything's gotten better. So what would the diagnosis be for that person? There was really nothing in it. So we reintroduced another category that used to be in the DSM called No Diagnosis or Condition. So for somebody getting a wellness exam or sort of a duty to work thing that's been reintroduced for that reason. So these two are a little bit administrative, but they have real world implications. Another new thing was in the in the neurocognitive section, substance induced neurocognitive disorder. So that's a section of conditions that could cause dementia. Mostly dementia Drugs like alcohol, inhalants and sedatives can lead to a dementia that is very, very severe. The DSM five got rid of dementia, interestingly, and replaced it with a category called neurocognitive disorder. That comes in two levels of severity major, which is really the same as dementia. And this new thing that was added to DSM five, which is mild neurocognitive disorder. So it turns out the three drugs which cause dementia, which is inhalants, sedatives and alcohol, also cause mild neurocognitive to, I mean, the severity of the symptoms. If it's going to cause dementia, it should also cause less severe cognition.

  Dr. First: [00:31:16] But it turns out there's one substance which only causes milder neurocognitive care, but not severe, and that's amphetamines. So amphetamines can present with a prolonged cognitive impairment that's not severe enough to call it a major neurocognitive disorder that was by accident, left out of the DSM five. So that's been now a new diagnosis, which is basically stimulant induced mild neurocognitive disorder. And the other new addition, which is a new thing for the DSM, which is to have codes for symptoms that are not disorders. And you can now add and the two that were added to DSM five was a code for suicidal behavior and non suicidal self injury. If suicidal behavior can occur in a wide variety of conditions that it's clearly very, very often it's going to be a focus of attention. It's something you really want to know. It's present and be able when you're referring the person to another clinician, know that that's on the table. So there was no way to indicate that suicide was part of the picture before. Now there's a special code that you can now write down the chart, which basically is for either current suicidal behaviour or past history of suicidal behaviour, and the same thing for non suicidal self injury, current and history. So those are all, those are new to.

  Alex: [00:32:31] So is that diagnostically sort of agnostic in terms of the suicide behaviour and non suicidal self-harm behaviour, You could apply that to anything.

  Dr. First: [00:32:43] You can apply to any diagnosis. You can also apply with no diagnosis. I mean there are people who make suicide attempts and you can't find any diagnosis at all. So you could write, you could use the code for that. But so there's so basically this categories for two uses. One, when those behaviours occur in the absence of a condition, but we expect that most cases of suicide or non suicidal self-injury will have a co-mental disorder diagnosis like depression, schizophrenia substitutes or whatever, they're usually going to use the codes that are code with an actual diagnosis.

  Alex: [00:33:15] Right, Right. Makes sense.

  Dr. First: [00:33:17] So that's those are the big changes with respect to new things. Some of that we've corrected some definitional problems or things that were unclear. Probably the biggest one is persistent depressive disorder. So persistent depressive disorder, which used to be known as Dysthymia in DSM five, is now any depression which lasts more days than not for at least two years, is now called persistent depressive disorder. So that includes the old dysthymia, which was. But if you have a major depressive episode every day for two years, that's also a persistent depressive disorder. If you have what used to be called double depression, there are chronic mild depression with occasional intermittent, serious depressive episodes. That's also if it's last at least two years. That's also called persistent depressive disorder. So you can indicate what waiver it is by using one of the subtypes. But the question was, do you also write down a diagnosis of major depressive disorder and persistent depressive disorder? So somebody, the double depression, get two diagnoses or just the the persistent depressive disorder. And the problem was that depending the two different spots of the DSM, which had the exact opposite thing, so it was really unclear what to do.

  Dr. First: [00:34:30] It turns out that the actual it was supposed to be that you're supposed to use both diagnoses. You're supposed to use major depressive disorder and persistent depressive disorder. And the reason that's important, it's a little bit of a technical thing. It's a coding. So, for example, the coding for major depressive disorder allows you to see if the person's psychotic or mild, moderate, severe and psychotic are available in the diagnostic code. So if you write if that shows up in the chart, you could see immediately this person had a psychotic depression. The persistent depressive disorder, the code is is has nothing, nothing of severity, no anything. So if we only use the persistent depressive disorder code, you would have lost the information of the person had a psychotic depression. You need to use a code for major depression to get the psychosis in there, not plus the severity, which could also be relevant. So kind of technical reasons. We really want both codes there. And in a sense, the persistent depressive code really is used to say this is a chronic type of depression. And then the major depressive disorder codes indicate what the episode looks like.

  Alex: [00:35:29] Makes sense.

  Saja: [00:35:32] Okay. Shall we move on to the next question? So, Dr. first, as everybody knows, there are changes in regards to the terminology as well that's used in the manual. Could you briefly highlight the most important ones our listeners should be aware of?

  Dr. First: [00:35:47] Sure. Some of them are extremely technical, which I won't even go into. It has to do with the most has to do with the people may have noticed that some of the diagnoses have parentheses next to them, which gets their alternate name. We kind of change some of the alternate names. The two most important ones are the use of the word neuroleptic. So Neuroleptic is a word from the fifties. I believe that's how the antipsychotics were referred to, and that word is still around. Neuroleptic malignant syndrome is still there. But through the DSM it appears in a number of different places that were term is really going out of disfavour and neuroleptic. If you look at the history of the word, basically focusing on the side effects of antipsychotics, that's what a neuroleptic is. So we decided to change it and get rid of it. Accepted in one spot. Neuroleptic malignant syndrome has been entrenched so much we sort of allow it there. But whenever we refer to the class of drugs, we call them antipsychotics and other dopamine blocking agents. Now, if in the text we refer to it as this is a drug for schizophrenia, we would call antipsychotic. The problem is that class of drugs is sometimes used for other medical uses, like nausea. You know, some of the dopamine blocking agents neuroleptic could be used to treat nausea. So we don't want to call them antipsychotic when they're not being used for that purpose. So we basically made the terminology throughout the whole book consistent. And we also got rid of the word neuroleptic wherever we could. The other area where there's significant changes of terminology was, perhaps not surprisingly in the gender dysphoria section, terminology about gender.

  Dr. First: [00:37:22] If there's one area of the terminology, it's changing very, very rapidly. That's one of the a lot of terms become both. I don't say old fashion exactly, but they're just I guess they're let's let me tell you. So the key ones in in the gender dysphoria section, we used to say that the person you had your gender and the desired gender was the terminology that was original use. That's been changed now to the experienced gender, which is much more accurate. It's not just that you want it, you experience yourself as being that gender. Another the word phrase cross-sex as in the terms of a cross-sex medical procedure. That's another term, which is you can understand why the term was there. But that term is also going out of favour and it's been replaced by gender affirming medical procedure. And the other big one is the issue of being assigned Natal. So if you're considered a natal male, that means you were born male. That's, that's, that's also replaced because it's been replaced by assigned male at birth. It's really emphasizing the gender is what you were assigned with the doctor and the family thought you look like at birth. That's what gets you started. It's not that you're actually a male at birth, so it's really kind of highlighting the fact that gender is a social construct. And so the words have been changed to reflect that gender is not just a biological phenomenon. So they're basically basically bringing the text in line with current usage of these concepts.

  Saja: [00:38:59] That's great. So just to summarise it, we've changed. Instead of saying desired gender to experienced gender and instead of saying cross-sex medical procedures, we use gender affirming medical procedures. And the third one would be instead of saying natal at birth, natal male at birth or natal female at birth, we say an individual assigned male at birth, and the fourth one us retiring the term neuroleptic and using antipsychotic. Amazing. Should we move on to the next question?

  Alex: [00:39:34] I'm really curious to get your thoughts on this one Dr. First, for the DSM, as we've been talking about, used very widely, very highly regarded, and especially in North America. But I guess we're also wondering from your opinion, what does it do well, clinically and where where there's still some blind spots or weaknesses in your opinion, either from your own experience clinically or from what you've heard from other clinicians? And also you could speak to the research world if you feel there are pros and cons there to.

  Dr. First: [00:40:06] Well, absolutely. The DSM has gotten an immense amount of criticism over the last 30, 40 years. There are very high hopes when the DSM in 1980, when DSM three came out, that these conditions actually were like diseases and that they were closer to medicine than they turned out to be. So it's turned out, for example, that it would have been nice if all if you had a diagnosis of depression, that drug that antidepressants would be the drugs to use and only they would work. But it's turned out that the relationship between a diagnosis and treatment is many to many. So many treatments work for the same diagnoses like SSRIs, work for like anxiety disorders, a compulsive disorder, and given a disorder that's many, many different treatments. So we were hoping it would be a better fit between making the diagnosis and knowing what the treatment is. And that didn't quite work out. So that in that sense the utility has been a problem. So when some people say, well, why use, you know, what's the point of using the DSM if it's not going to help me practice? Certainly one use of the DSM that I think everybody would agree on as a as a getting back to the dictionary term, that's the way we communicate with everyone, coalitions, family members, newspapers, everybody uses this terminology. And if you use the word major depression, the person hearing you, if they know how depression is defined, well, understand that I'm giving you I'm going to refer you a patient with major depression. If the person is using it correctly, you can expect when that person walks into your office what that person you'd expect to look like.

  Dr. First: [00:41:40] You'd expect them not to have manic episodes, because if they had manic episodes, you would have said they were bipolar. So the terms both indicate what they have and what they don't have. So the terms are powerful as a communication. Beyond that, that's where it gets more controversy. The fact is that all of the treatments that have been developed in the past 50 years have been geared to some DSM diagnosis, like all of the medications on the market. To get approved for use in patients, you have to pick a drug indication to say this drug is indicated for depression. All that means is the studies have been done on patients with that diagnosis and it's been demonstrated that the medicine works better than placebo for that diagnosis. So as a clinician, if you're looking if your patient that you're seeing has a presentation that meets the criteria for social anxiety disorder, then if a drug is indicated for social anxiety disorder, you would expect it to work for that patient because that's where they date. So that all the treatment data and all the studies have been geared to the DSM system. So that's another. So it does tell you something, if we didn't have it, any system at all, you really be hard to get to get started about how how to think about how to plan the treatment. So it's been the framework for psychiatry for the past 50 years.

  Dr. First: [00:42:56] It's far from perfect and people point that out all the time. You have this lack of specificity. The the other hope was, I think when DSM three came out that once we defined when we really didn't know the causes of any disorders and I'm I was in practice back then and I and I the belief was that now that we have a system of criteria that makes it clear what the patient's conditions look like and we do the work and the studies will find out what the causes are now that we at least have a language we all agree on. You know, here we are 50 years later, we still don't know what the cause of virtually any of the mental disorders are. That's been a really big disappointment. In fact, some researchers have blamed the DSM for our not being able to find the cause. I think that's a little over, but I could see they make some points. It's the DSM drives research funding and drives drug development, and the system itself is has no validity. Then you're really in a hole. I think there's some problems with validity, but I still think it does. Have a considerable amount of validity, enough validity to make it useful, but it's far from what we would have liked it to be. So I think that I'm I'm the first to admit that it's an imperfect system. But when people start harping on I said, Well, what should we replace it with? And then nobody has an answer.

  Alex: [00:44:15] All right. An imperfect system is better than no system. As you were saying. Okay. So I think that that leads us in nicely, though, to Saja's, I think our last question for today. And so I'll hand it over to Sasha.

  Saja: [00:44:30] Yeah. So when thinking about the DSM and this whole system, if we are to replace it, what can we replace it with? And there has been increasing, increasing evidence about the Rdoc framework that the APA is working on. Could you tell us if it's going to replace the DSM and what are the differences between those two systems?

  Dr. First: [00:44:55] If Rdoc is not really a replacement. I mean, the ICD ICD is the only system in existence which is trying to do the same thing the DSM does. So, I mean, you know, you could argue maybe they really should only be one system, but I think it's safe to say that the ICD and the DSM will continue to co-exist indefinitely. But the other newer hopes, like Rdoc is basically a framework for doing research. That was an attempt. It kind of got started with the idea you should you shouldn't be doing a study looking recruiting patients for major depression because there's no doubt and schizophrenia is the same way that the people who have major depression probably have many different things going on biologically. It's a huge amount of heterogeneity. That's the big problem you have to people who meet the criteria for major depression, they're completely different, nothing in common other. Then you even have depressed mood in common necessarily because either depressed mood or loss of interest. So there's a huge variability for all of these diagnostic categories, which is a real problem. So Rdoc partly said, you know, if we're going to try to find the cause, the underlying biological cause of mental disorder, we should be recruiting patients based on whether they meet the criteria for a DSM disorder. We should be recruiting patients because they have some biological factor or pathway in common.

  Dr. First: [00:46:08] And that's what Rdoc. Rdoc has broken things down into domains of functioning. And so and they they break them down into they're based on known neurocircuitry. For example, there's a whole group of domains which are called negative valence systems, and they correspond to symptoms that people have that are negative like fear, anxiety, loss. These correspond to actual brain circuitry. So the idea is if we recruit somebody, a group of patients that all share in common the same domain, which is linked to the biology, we're much more likely to be able to have a homogeneous group of patients to be studied. So that's another one called Positive Valence, which is where mania and stuff comes in and substance use disorders as a cognitive one. And so so these are broken down, not diagnostic. And that's the whole idea that Rdoc it's cross diagnostic. It kind of ignores the entire DSM system and recruits patients based upon these common symptom factors which are connected to the neurobiology. It's a sensible approach. So it's almost like, say, the the DSM, we know we're not going to find the cause of mental disorders if we just use the DSM. I think everybody would agree very strongly. The question is what would help us find the cause? And Ladakh was a proposal by the NIMH for a completely different approach, much more tied to the biology.

  Dr. First: [00:47:36] And since a lot of the treatments they were looking for a biological and since we all know there is a biological basis for most mental disorders, that was very promising and continues to be a very promising approach. It's you can see it's not ready to replace anything. I mean, I think the reality is it will help us improve the DSM and the ICD as information comes in, we maybe will be grouping the categories differently. For example, once we determine that OCD and anxiety disorders have the same neuro circuitry. So we would reorganise maybe the disorders by the neuro circuitry, That approach is very appealing, but we're still far from getting there. So I don't think we see the Rdoc as a very, very useful replacement for basing science on a system, but it's also completely not practical for clinicians. That's the other thing. I mean, the DSM having a system which is symptom base that corresponds to the symptoms you see, that's very valuable. And also the Rdoc approach doesn't do well with things like delusions. What, what neurobiological is a delusion. I mean, the circuits, it's way too complicated. So it really works really well for anxiety, depression, addiction, not so well for a lot of the psychotic disorders.

  Alex: [00:48:51] That's super interesting. And I know I said that was our last question, but that discussion that just now raised one more for me, if that's okay with you Dr. First, which is that you said and I think nice line why Rdoc is not a DSM replacement. I know you don't have a crystal ball, but where do you see the future of the DSM going, like in DSM six, for instance, and beyond?

  Dr. First: [00:49:15] That's I think there's been a push on the DSM five. When they started work on DSM five, there was this hope for a paradigm shift, partly because of the frustration with the DSM. And that was not very I think it was very clear during the DSM process that we weren't ready to get rid of the current approach. One thing that another criticism of the DSM is the fact that it's a categorical system. You either have a diagnosis or you don't know which is not the world. Everything is not. Yes, no, it's like the shades of things. So everything's dementia, like blood pressure. One of the best examples of hypertension is a category. You either have hypertension or you don't. But in fact is it's a continuous measure of blood pressure. So any place you cut it, that's where you could call hypertension. So the same idea could work for mental disorders where you could have different possible cut points across the spectrum. And then and there's some reflection of that in the DSM five itself. So, substance, in fact, what I mentioned earlier, they got rid of dementia that was replaced by this neurocognitive impairment spectrum and autism. They got rid of Asperger's and autistic disorder, and that's now been replaced by an autistic spectrum disorder. And they did that with substance use and dependence. Now it's substance use disorder. So they're trying to move towards having some broader dimensions with cut points within them to define. So that's certainly a very, very important direction and that's already been started. And I think it will continue as we move forward. I'm not sure if this what the next big paradigm shift is, because if I knew that, I would have to know what's going on. I mean, I have a really amazing crystal ball to know that.

  Alex: [00:50:59] Or what proposals might come through that. The new website.

  Dr. First: [00:51:02] Yeah, right.

  Alex: [00:51:03] Well, thank you so much, Dr. First, for joining us today. We really appreciate it. I know I learned a lot. And so thanks for being here. And Saja, thanks so much for the great first episode and this idea. And I hope you come back for another. Take care, everyone, and we'll see you next time.

  Dr. First: [00:51:24] Okay. Thank you.

  Saja: [00:51:25] Thank you.

  Alex: [00:51:29] Psyched is a resident driven initiative led by residents at the University of Toronto, where affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Saja Jabari and myself, Alex Rabin. The audio editing was done by Alex Raben. Our theme song is Working Solutions by all live music. Special thanks to our incredible guest, Dr. Michael B, first for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at PsychED Podcas.org Thank you so much for listening.

Episode 46: Antisocial Personality Disorder and Psychopathy with Dr. Donald Lynam

• Episode 46: Antisocial Personality Disorder and Psychopathy with Dr. Donald Lynam

  Dr. Chase Thompson: [00:00:12] Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. This episode covers the development of antisocial or psychopathic personalities and features our guest expert, Dr. Donald Lynam. Dr. Lynam is a clinical psychologist by training and professor at Purdue University, where he heads the Purdue's Developmental Psychopathology, Psychopathy and Personality Lab. He has written extensively on the topic of antisocial and psychopathic personalities. The learning objectives for this episode are as follows one Develop a basic understanding of what is meant by antisocial or psychopathic personalities two be aware of some of the core characteristics and traits of these personalities. Three Describe the theoretical basis for the development of these personalities, as well as their clinical trajectory over time. I just want to make a note to our listeners that we will be referring to the DSM five criteria for antisocial personality, as well as a psychopathy checklist or PCL. Dr. Lynam, is there anything you would add to that or anything you want to clarify?

  Dr. Lynam: [00:01:21] No, that sounds about right. I mean, I also work on sort of just personality disorders more generally and personality more generally, but that's a pretty good description.

  Dr. Chase Thompson: [00:01:31] Dr. Lyneham Since is kind of an interesting area, we don't always ask our expert this, but I'm just curious how you how did you get interested in this area of personality and psychopathy more in general?

  Dr. Lynam: [00:01:43] Sure. Well, I started my graduate training with Terrie Moffitt at University of Wisconsin, and her her main interest was kind of the longitudinal study of antisocial behaviour and folks who would become kind of severely antisocial later in adult. I mean, that's a huge issue kind of in that sort of research is that all adults who were antisocial were antisocial as kids, but not all antisocial kids grew up to be antisocial adults. So a lot of her work was about how can you identify kids who are at greatest risk for continuing kind of their delinquent or their antisocial behaviour into adulthood. So I kind of started there looking at early risk factors like IQ and neuropsychological deficits and problems. And while there, her husband, Aslam Caspi, also worked some with him, and he was more interested kind of in personality. So I added this kind of personality layer. And then I took several classes with Joe Newman, who's a psychopathy researcher. So I became very interested in psychopathy at that point. And so those those kind of interests began to merge. And my earlier work was sort of on trying to identify can you identify in early adolescence kids who look psychopathic and who might go on to become to be psychopathic in adulthood? So that was kind of my my earliest work. But then I was at University of Kentucky, and I began working or hanging out more with Tom Whitaker, who was a big five factor model of personality fan. And it's sort of at that point that I began thinking of psychopathy the way I do now as sort of this collection of personality traits that that if you're extreme enough and you have enough of these, you're going to be psychopathic. And so that's kind of the history of how I got involved in this. And ever since about whatever late nineties, I've been pursuing that line of research.

  Dr. Chase Thompson: [00:03:35] I see. And I think we'll get into some of those points that you brought up a little bit later on. But I think maybe a good place for us to start would be sort of some definitions of the terminologies, because I think that's a source of confusion for myself at least. And I know some other learners in the areas of psychiatry and psychology. So maybe I'll just put it out to you. Like how would you sort of define the terms an antisocial personality, or how is that different or similar to a psychopathic personality?

  Dr. Lynam: [00:04:12] Well, I think ultimately that they are referring to the same things. I mean, there's been a distinction. So there are three terms that get used. Psychopath, sociopath and antisocial personality disorder. And I think ultimately they're all referring to the same people, which typically is sort of folks who are seriously, consistently chronically antisocial. It's sort of what it's meant to capture. The distinction between APD and psychopathy was really about how they were operationalized. So so in DSM three, this distinction really began to emerge. DSM three adopted these very behavioural criteria that came out of Leigh Robins work. And so it was really just a series. It was like a behavioural checklist, right? And you just sum those up and check the things they had done and that was how the diagnosis of of APD or antisocial personality disorder was arrived at. Psychopathy was about was a bit different. It kind of grew out of work. It was more closely aligned with kind of beckley's clinical description. And it had a direct line through Bob Hare who was trying to take collect these description. He had this in-depth, in-depth descriptions of 16 folks that he thought were psychopathic, and he had a set of criteria. And Bob Hare was interested in using those criteria in prison settings, maybe to identify this this kind of very chronically and consistent antisocial group of folks.

  Dr. Lynam: [00:05:45] And so he built the psychopathy checklist in that kind of forensic setting or that prison setting. And it was a bit more focused on sort of traits. Right. So callousness, lack of remorse, lack of guilt, irresponsibility. So it wasn't just this behavioural checklist. And so that was the initial big distinction between antisocial personality disorder and psychopathy across time, like DSM four DSM, four TR, the criteria for APD have moved much more much closer to psychopathy criteria, where now they're really just traits that are being assessed and rather than the close. So so APD and DSM three are used very close criteria. Right. Did they do this act? Did they do that act? Did they do this other act? The criteria now in the current DSM are much more open, like, does he does things? Do they do things that look like they lack remorse? So it's not just this like checklist of things that you had to check. And so those diagnoses are becoming much more closely aligned. And I think a big deal was made about how different they were early on, I think in part Bob Hare and colleagues, to try to highlight how good the psychopathy diagnosis was and why you might want to use that. Their big line was like virtually 90% of people in prisons will receive antisocial personality disorder diagnoses.

  Dr. Lynam: [00:07:16] But but only a subset of those 20% will get diagnoses of psychopathy. So but but all psychopaths, also all individuals with psychopathy, will get diagnoses of APD. And that, I think, was mostly about threshold. I mean, so on the psychopathy checklist, to get a diagnosis of psychopathy, you need 30 out of a possible 40 points. And that's a pretty strict cut-off. But for APD, you needed three out of nine criteria. So so there's a huge difference in the threshold that led to that sort of subset finding or that sort of subgroup finding. And the other thing that gets used is a sociopath, and it's often contrasted with psychopath. And the idea there is that sort of there's a difference between why people got the way they did. And so there was an assumption that if you were for people who were psychopathic, they were sort of born that way or as innate or something internal to them. But the sociopath was created by his or her environment. They they grew up in a really poor environment which pushed them down that path. So they're still meant to refer to the same type of people. But there's a difference in the assumption about where it came from.

  Dr. Chase Thompson: [00:08:32] And correct me if I'm misconstrued misconstruing what you're saying a little bit, but it sounds a little bit like the DSM version of antisocial personality is sort of a an outward checklist that tries to capture the person's outwardly manifesting behaviours. Sorry for listeners who don't have the DSM criteria in front of them, but basically they're mostly outward behaviours, except for, I believe, one which is lack of remorse for, for such behaviours. But I guess there's been concerns raised by some people that one could enact those certain antisocial behaviours. Say you're, you're experiencing poverty and you need to commit a certain amount of crimes to feed yourself and or you have a substance use disorder and you're sort of caught in this horrible cycle of trying to, to obtain substances for yourself that basically an individual without sort of a core of psychopathy could, could still end up meeting criteria for an antisocial personality disorder, but may have a different underlying subjective experiences. Is that a concern in terms of differences between those two constructs or.

  Dr. Lynam: [00:09:54] I mean, it's possible. I mean, I think I think the DSM criteria have more kind of trait like things. So I'm staring at them now. So I can tell you, I mean, one is very behavioural failure to conform to social norms and so indicated by repeatedly performing acts that are grounds for arrest. Lots of reasons for for committing crimes, as you just outlined. I mean, deprivation need sort of know growing up in a culture where that's in a place where that's the only available way to get, get the things you want. But there are some others deceitfulness, impulsivity or failure to plan ahead, irritability and aggressiveness, reckless disregard for the safety of others, consistent irresponsibility, lack of remorse. So, I mean, those are a little more less behaviorally tied or less less specifically tied to the antisocial stuff. But but it is still a concern. But but it's also a concern for psychopathy. I mean, if you look at how the psychopathy checklist is scored, it's based on a semi-structured interview and a file review. Right. And there's a lot of emphasis placed on crimes committed. So so in fact, a lot of what they call factor two psychopathy is based kind of on criminal history. How much have you done? When did you start? Do you show remorse about those crimes? I mean, so so so those crimes sort of suffuse the psychopathy checklist as well. So so I do think that's a possible concern. I mean, I think it would be very hard to hit the tops of these scales just on the basis of having come from a really rough and deprived environment or disadvantaged environment. But but certainly sort of low to mid-level elevations would certainly be possible, I think, for reasons that didn't have to do with sort of the underlying personality that this person possesses.

  Dr. Chase Thompson: [00:11:48] Got you. You know, in terms of when we think about, say, psychopathic individuals, maybe I'll draw a similarity to, say, borderline personality disorder, where we think of affective dysregulation. Is this core one of the core defining features of the disorder and some of the other aspects of the disorder kind of flow out from that core. Is there a sort of core characteristic or defining features of psychopathic individuals?

  Dr. Lynam: [00:12:24] Sure. I mean, I think I think there's one big one and then sort of a fairly large secondary one. And the first is sort of this this interpersonal dimension that that if you want to talk about the negative pole, you call it antagonism. If you want to talk about the positive poll, you call it agreeableness. But this is sort of a basic measure of personality shows up in everybody's personality model. It shows up in these models of disordered personality and it's an interpersonal dimension and it's really about how you feel about other people. So it's separate from extroversion, which is like, how much do you like them, how warm you are, This is your orientation to them and you kind of at a very basic level, it's a nice versus mean dimension. Antagonistic folks are egocentric, they're lying and manipulative. They're callous. I mean, they really just don't care much about other people. And I think that accounts for almost all of the most of the symptoms that we that we use to define psychopathy. And in fact, if you take these sort of self-report measures of psychopathic personality. It's the glue that holds them together, both within an inventory and across inventory. So this is a feature that that is really shared across all various ways of assessing psychopathy.

  Dr. Lynam: [00:13:45] There's another important part which which is sort of this low conscientiousness or lack of constraint or disinhibition that also seems to be in there. And so this is that poor impulse control, this lack of self discipline, this lack of this irresponsibility bit that sort of has. And when you put those two things together, I mean, you just have a person, I think, who is free to do whatever pops into their head because they're not constrained by by what the effect their actions have on others or what other people expect. So boom, they can do whatever they want there. And and they're probably not constrained by consideration of future consequences either. And so. Yeah, they just they lack these internal constraints that most of the rest of us have. If an antisocial impulse pops into our head, we think, well, I could get in trouble. That might hurt that other person. They might be really hurt. What would that do to my social? I mean, there are all these things that we think about that kind of keep us in line. But if you start peeling those off, you get a person who's pretty much capable of doing almost whatever they please.

  Dr. Chase Thompson: [00:14:58] And along those lines, like lack of remorse is sort of one of the criteria as well. And I think, you know, when you you hear about psychopaths talked about in the media or or among just in general conversation, it commonly comes up that they don't they lack empathy. I mean, part of the reason I bring this up is because lack of empathy is a feature that occurs across numerous different disorders in psychology and psychiatry, including it's like a schizoid personality or pathological narcissism or. So on, but you don't necessarily see these like very antisocial acts among in these other sort of diagnostic entities. So are you sort of suggesting that it's this antagonism and lack of restraint that is sort of the the thing that separates them and sort of drives the antisocial behaviours?

  Dr. Lynam: [00:16:02] Or in part, I mean, I think I think I mean, narcissism and psychopathy are pretty closely related. I mean, we we do research on narcissist, I do research on narcissism as well with my collaborators. And the core feature to lots of narcissism is this very similar antagonism dimension. I mean, that seems to be what's what, why these two things are so highly correlated with each other. If you look at kind of relations between psychopathy and narcissism is they both share this sort of antagonistic core of I'm better than others. And I'm I don't really care what my what what effect my actions have on you because frankly, you're not important. Right. And so so that is a common theme there. I mean, I think what you get for psychopathy is maybe it's a little more broad. You add that deceptive Ms.. And that willingness to manipulate other people and and use them, there may be a little bit absent in narcissism. But the other big part is narcissism is not associated with this control or disinhibition. Right? I mean, it doesn't have that sort of poor impulse control piece to it. So I do think that's important for separating out psychopathy from narcissism.

  Dr. Lynam: [00:17:15] The other role it serves, too, is you'll hear people sort of talk about successful psychopaths often. And what I think people mean when they say that is they mean people who are antagonistic but can still hold it all together. Right. So they've got impulse control. I think they have enough impulse control to contain to to get advanced degrees. They have enough impulse control not to punch somebody when they feel like it. Right. And so but but that kind of callousness and that coldness and that lack of concern for other people lets them do lots of stuff that is not very nice. Right? Cheating, manipulating, using. I mean, this is where all the financial or some of the financial crimes come from, right? They don't care about the people whose money they're taking. Right. It's all about sort of them. And so those folks get called successful because they haven't been arrested. They don't have a long rap sheet. But but but they're really just sort of these incomplete manifestations of psychopathy because they've got some of the some of the traits, but not the others.

  Dr. Chase Thompson: [00:18:20] This is sort of touch on what you talking about is psychopathy being sort of a cluster of specific traits. I'll just put it to you. Like, what are the traits? Is it you mentioned antagonism and impulsivity.

  Dr. Lynam: [00:18:32] Right. So I work from this this big five model, A personality, which is sort of the current coin of the realm. And it suggests there are these five broad traits that you can use to describe everybody that are relatively universal and extroversion. So one's orientation to others, whether you really like being around others or you prefer to be alone neuroticism, which should be very familiar to anybody working with psychopathology, right. Sort of high levels of negative affect that are experienced easily, often, and take longer to subside versus kind of an emotional stability. There's this openness to experience idea that people are open or close to new experiences. And then you've got the two that I'm most interested in, which is the one is that antagonism dimension or that agreeableness dimension, which is really that other interpersonal dimension about how you are oriented to others or whether you care about them or you don't, whether you're nice or whether you're a jerk. And then the last one is this conscientiousness domain, which has a couple of pieces to it, but it's like organisation and impulse control and that's sort of what it gets at. And so I work with them. I work with a slightly bigger model because the specific five factor model that I work with has six subscales for each one of those. And you can get this very kind of well articulated profile of psychopathy across them. One of the things that comes out is they are low on every aspect of agreeableness. So they are they are distrustful, They are lying and manipulative, They are selfish, they are noncompliant, they are immodest and they are callous.

  Dr. Lynam: [00:20:11] And so across the board, that's true. And so that's a huge feature. And the other bit is you get within conscientiousness like it order doesn't matter, right? So one of the aspects of order is like, how neat is your room? That doesn't seem to be very psychopathy, but the things that are like dude awfulness like I do, what I'm supposed to do is self discipline. I finish stuff, I start and then sort of deliberation, I think things through. So those are the big pieces. And then there's this little mix of stuff on extroversion and neuroticism, the kind of up and down. So within neuroticism, they have a lot of hostility, but they don't have much self-consciousness, they're not depressed, they're not anxious. And then in extroversion, they are not warm, but they are sort of gregarious and assertive. So it's kind of this little mix profile. And that extroversion neuroticism piece gets clumped together in some inventories and it gets called boldness or fearless dominance. So those are the big three pieces of psychopathy. And I know there's debate about how important that boldness piece is. I mean, I think it's window dressing, right? I don't think it does anything really for for the kinds of stuff we care about in psychopathy. But but those are, I would say, the big three pieces. And so the more of those pieces you have, the more psychopathic you are kind of in my model because it's nothing more than just this collection of extreme traits.

  Dr. Chase Thompson: [00:21:47] Yeah. And I think going back to the impulsivity thing and talking about the high functioning psychopath versus the lower functioning or someone we might imagine is in a lower socioeconomic status group and maybe more involved with the criminal justice system. It almost seems that the the ones who do have some restraints on their impulsivity and who are of more ability to carry out their goals is maybe as aligned as they are, almost seem to be more harmful in some sense. Like, I don't know, I guess I'm thinking of people like Bernie Madoff. I think he was assessed and not actually found to have psychopathic personality by whoever assessed him because he didn't meet sort of the other external behaviours. But I guess it seems like there's like this problem of maybe overdiagnosis in people who are more, more actively involved in in criminal acts versus those who are sort of high functioning and sitting in, in a high up office downtown somewhere.

  Dr. Lynam: [00:22:59] I mean, I think that's definitely a risk. I mean, but, you know, that's an issue with white color crime anyway, right? I mean, people regarded differently than kind of non white color crime, right? It gets overlooked a lot or that's not real crime or I don't know how people feel about it, but but that's just my kind of my general sense is that people don't think of white color. Crime quite in the same way they think of other types of crime. And so, I mean, but I mean, Bernie Madoff defrauded. Tons of people out of lots of money. But I mean. But but, but, but he but he wasn't violent, right? And he didn't have a huge, you know, a long, long rap sheet, which will elevate your psychopathy checklist scores because that's a huge focus of of of what they're assessing in prison settings. So, yeah, I mean, but the other thing that happens to I mean is that people want to call Bernie Madoff psychopathic. Right? And they want to call the person who's called psychopathic because it's like a curse word, you know? You know, and it's like we don't like that person. That person's not good. But but you have to be a little careful about how you throw the label around, because it is more than just that callousness. It does include these other pieces. And sometimes people will shrink the entire idea down to just one trait, coldness or lack of empathy or fearlessness or whatever it is. But these are all just kind of sub manifestations of the much bigger construct.

  Dr. Chase Thompson: [00:24:35] Right. As in people who are not necessarily psychopaths can still do some pretty bad things.

  Dr. Lynam: [00:24:41] Right. Exactly. I mean, you know, the the the individuals of psychopathy don't have sort of the corner on the market of antisocial behaviour. Right.

  Dr. Chase Thompson: [00:24:55] Maybe just changing gears a bit. Can we talk a bit a little bit about how common is the problem of psychopathy? How how many people in broader society or kind of experiencing what we're talking about here?

  Dr. Lynam: [00:25:13] It's funny, I've had a back and forth for three weeks now with one individual wanting me to try to tie me down to, well, exactly how many are there. And I think that's I think that's hard to do, because I really do think this is something that is continuously distributed in lots of ways. So my response to this person was, well, how many tall people are there in the world? Right. And that's the problem you run into. At what point do we decide to call somebody tall? And at what point do you decide to call somebody psychopathic or give them a diagnosis of psychopathy? I mean, the psychopathy checklist has a pretty explicit criteria. It's 30 out of 40 on their scale. That'll probably identify less than 1% of the population is my guess. If you could assess everybody on the psychopathy checklist, which you probably can't because you need to file a review and it takes forever. But but they have a pretty strict criteria. So kind of if you use that criteria, it's about 1%. If you do something like I think APD criteria is 3 to 5%, something like that. But again, if you change the threshold, how many do you need? How many? What's the score on the psychopathy checklist? Well, instead of 30, let's make it 25, because those guys are pretty bad, too. Then all of a sudden your prevalence rate increases. And with APD, we'll just require a set of three of three of them or four of them require five or six, and then your prevalence will decrease dramatically.

  Dr. Lynam: [00:26:43] Mine is always about sort of I think this is this is you can you can see this as not relatively normally distributed in the population. You have some people who are basically anti psychopathic, right. They are they have great impulse control and they're really agreeable. So they're like negative, psychopathic. And then you've got most of us who are somewhere in the middle and then you've got a bunch of folks out on the far end. And how far out do you want to draw that? I mean, two standard deviations above the mean prevalence rate of two and a half percent. So something along those lines. So that's how I think about it. I mean, the really, really extreme folks are relatively rare, but it depends on what criteria and what what threshold you're going to use. So it's sort of hard to put a number on that. But if you went with the psychopathy checklist, you're going to tell you about less than 1% at the very, very, very extreme end. And that's comforting unless you think that, you know, the person with a 29 is basically as bad as the person with a 30, and so is the person with 28, that it is continuous, that there's no point at which this seems to become qualitatively different. And so that's the issue you face anytime you're dealing with something that's continuously distributed like that is prevalence depends on where you want to draw your cut point.

  Dr. Chase Thompson: [00:28:05] Right. Right.

  Dr. Lynam: [00:28:06] That may not be what you wanted, but that's all I got.

  Dr. Chase Thompson: [00:28:08] Sorry. No, fair enough. I don't know if this is known, but is it is it expected that the prevalence is sort of the same across different populations?

  Dr. Lynam: [00:28:22] I think there's been some research suggesting well, some research suggesting that say the items on the PCLR don't function the same in certain groups. And so so that's a bit problematic. And that gets back to your idea about are these scores going to be elevated for people from disadvantaged backgrounds? And so there's some evidence that at least on some of the symptoms that are used in the psychopathy checklist, that that is problematic. And I think it's probably around most of the antisocial items because there are a lot there are multiple pushes to making people antisocial. And so if you grow up in an environment where you're experiencing a lot of those, you're you're going to elevate a little bit on the antisocial related facets. But but in terms of I mean, mostly men score higher than women, as you might imagine. And that's actually you can actually predict that just from the basis of what we know about the traits that are involved and the gender differences there. So that's one thing that you could certainly say with, I think, some authority, although there are some folks who disagree a bit saying, well, we should change the criteria. If you change the criteria and had different criteria, they would be more equal. That's that's possibly true. But but but in general, actually, it's interesting. Among all the personality disorders so kind of attend DSM, PDS and psychopathy if you sort of calculate gender differences on the basis of gender differences in the traits that they contribute to them, psychopathy by far has the largest sort of male to female ratio, but it should be the most male disorder of them all.

  Dr. Chase Thompson: [00:30:09] What do we know about the development of psychopathic personalities in terms of like, is it genetic, environmental and.

  Dr. Lynam: [00:30:20] Well, I think like most things, I mean, it's, you know, what is it, 40 to 40 and 50% of the variance seems to be heritable, you know, or 40 or 50% of the variation in the population seems to be due to genetic variation. And that's that's true for for lots of lots of these sorts of things. What we do know is, is that that that this adult manifestation has kind of adolescent and childhood precursors. I mean, if you look at if you look at kind of conduct disorder diagnosis in the DSM, there's a specify that is called callous unemotional traits. And that's basically Paul Frick's version of psychopathy in a lot of ways. And I had a version, too. We called it the childhood psychopathy scale, but it was much the same as kind of what what Paul's done, which is that sort of you can identify early on folks who are callous and impulsive and don't seem to care about other people and and all these traits. And there is some stability across time. And so it's not surprising that the kind of the child who's going to grow up to receive a diagnosis of psychopathy, of psychopathy, or who's going to look psychopathic in adulthood is also looking psychopathic in childhood and adolescence.

  Dr. Lynam: [00:31:33] Do we know how that comes about? Not really. Really? Well, I mean, I think Paul has done some work sort of on on on on parenting. And there seem to be some parenting styles that are associated with with those sorts of traits in kids in adolescence. But the problem with those studies, it's awfully hard to know. I mean, parents are also reactive to kids, and that's been shown again and again, right? Difficult kids who are difficult end up with parents who have certain parenting styles. And it may not be the parenting styles that come first. So it's really kind of a thorny thing to try to figure out about how does this develop. We do know there's a genetic component. We also know that 50% of the at least 50% of the variation is not genetic. And that's the hardest piece to get on. And, you know, and again, we didn't know what the genes what the what the genetics of it are at all. Anyway, These are global estimates, and our ability to identify any specific genes is really lousy. So I'm not sure that those numbers ever help us a whole lot.

  Dr. Chase Thompson: [00:32:39] Sometimes you commonly hear that, for example, an individual who has severe a personality disorder, that there tends to be some sort of contribution of early life trauma. Is that something that's relevant in psychopathic personality disorders?

  Dr. Lynam: [00:33:01] I'm not I'm not sure. I'm not sure about that. I'm not sure that's been as strongly demonstrated for psychopathy as, say it has been for some some other sort of disorders. So I would I'm not going to go out on a limb and say anything about that. Sorry, I just I just don't know.

  Dr. Chase Thompson: [00:33:17] Yeah, no worries. And you mentioned something about children showing some there being some stability of psychopathic traits over time, even from early childhood. What are some of the early signs that you tend to see in children?

  Dr. Lynam: [00:33:38] A lot of them are just sort of just the similar manifestations as what you find in in adults. So my earliest work was taking the psychopathy checklist and trying to operationalise it in a group of 13 year old boys using sort of archive data. And so so you could find things like they lie a lot, right? They're aggressive, they're in trouble a lot, but they don't seem to feel bad after misbehaving. They've got impulse control problems, you know, they steal. So it's a lot of the same sorts of traits. I mean, they're not stealing cars, right? But they are stealing food or things like that that are a little more developmentally normative. But sort of those same traits seem to be present earlier on as well, that they look slightly different, but they seem to mean the same thing. Yeah. So, you know, they seem to be they seem to be callous, they seem to be selfish. And one of the concerns was some of that stuff is, well, aren't all kids callous and selfish and and things like that. But but it's really a matter of degree, you know, like these folks are these these kind of kids who will grow up to show more psychopathic features are even more callous and even more self-centred and lie even more.

  Dr. Lynam: [00:34:55] And so it's about sort of elevations across all of those things that seems to predict higher levels of psychopathy. I mean, we did one study where we had those 13 year old boys that we had that we had assessed using this kind of childhood psychopathy scale, and we followed them up 11 years later in the young adulthood and gave them the the PCLSB, which is a psychopathy checklist screening version. And across those 11 years, I mean, the stability wasn't high, but it was a correlation of about 0.35, which is not awful when you consider it's 11 years. And these are different instruments being used. And there's mother ratings at time one and it was interviewer ratings at time, too. So there's definitely some degree of stability in all of that. And again, it's sort of like predicting like it's, it's the same sorts of behaviours, early predicting the same sorts of behaviours later on.

  Dr. Chase Thompson: [00:35:50] So what about in the DSM for antisocial personality? One of the criteria is that there's some evidence of conduct disorder behaviour in the past, and at the beginning we were talking about the concept of a sociopath or someone who might be like a it's an acquired antisocial personality. I guess I'm wondering how do you reconcile those things or is acquired sort of antisocial personality, not really a thing or or what's going on there?

  Dr. Lynam: [00:36:25] I mean, are you thinking that sort of those who acquire this antisocial personality won't show that sort of early evidence of conduct disorder? I'm not sure quite what you're.

  Dr. Chase Thompson: [00:36:34] Yeah. I mean, I guess I'm wondering, like if you have an adult who has what seems to be really antisocial behaviours, but as far as you can tell, there isn't clear evidence from, from the parents or on review of their development that there was clear conduct disorder behaviour.

  Dr. Lynam: [00:36:55] There have been a couple attempts to look at that. I mean there have been a couple this was years ago that I read on it, but there have been some people arguing that you can have kind of antisocial personality disorder in the absence of evidence of of earlier conduct disorder that you can sort of meet these other criteria and that it's still sort of meaningful and important. So I do think that's possible. I mean, I think there's a whole issue of sort of a lot of times like psychopathy checklist is used to predict future violence or it's used to predict recidivism, things along those lines. But there is an issue about the assessment being saturated with the behaviour you want to predict later on. So one of the reasons that the psychopathy checklist might serve so well as a predictor of future antisocial behaviour is because, boy, it's certainly built on past antisocial behaviour in a lot of ways because that file review just just bleeds into lots of those criteria. And so if you have lots of anti sociality in your background, in your file, you're going to elevate that psychopathy checklist purely on the basis of the past behaviour. So of course that's going to predict future behaviour very well.

  Dr. Lynam: [00:38:12] One of the ways we've tried to move away from that is trying to move to a much more pure personality assessment. And there have been some other folks too in the adult military who are working around the psychopathy checklist saying we should try to exclude antisocial behaviour so we eliminate that kind of contamination and we're getting more at sort of pure personality. There's something that's a little bit separate from the behaviour that we're interested in and care about, and that's almost what you'd be doing with the APD if you eliminated childhood conduct problems because that's the most antisocial or the most, frankly, anti-social criteria in that set. But I mean, I think it's I think it's meaningful to to have these characteristics in the absence of I mean, I think they I think a lot of times antisocial behaviour will follow from having this collection of traits because again, I think it's about the removal of of internal controls that let you do almost anything. And so I think anti-social behaviour is a pretty probable outcome if you have these traits. But, but again, doing away with previous childhood conduct problems is probably might not be a bad idea for for the APD criteria. Mm hmm.

  Dr. Chase Thompson: [00:39:28] What can we say about the prognosis or long term clinical trajectory of individuals with psychopathic personalities?

  Dr. Lynam: [00:39:38] Years ago, they thought they would talk about them being untreatable, right? You couldn't do anything with psychopathy, with individuals, with psychopathy. And they pointed to a couple treatment studies that looked just like things went terribly. There was no help at all. But but more recent scholars have looked at those and said those were crazy treatments you were trying. And sort of more recent stuff suggests that they're about as treatable as anybody with a personality disorder, which is so you can treat some, but it's not great, right? I mean, I think psychopathy may be a particularly difficult disorder to treat because there's not a lot of distress. I mean, like borderline right, individuals, borderline PD. I mean, they are remarkably distressed, right? I mean, they are not happy with how stuff's going. Right. But I think I think for folks with who are high in psychopathy or anybody who's high in antagonism generally, like they don't feel a lot of distress. They're like they're not anxious and worried and really, really sad. I mean, the pissed off and it's not their fault either. Right. I mean, it's your fault for for being so soft or it's it's the cop's fault for coming along at an inopportune time or it's the victim's fault for falling and hitting your head more severely.

  Dr. Lynam: [00:41:05] I never intended for her to get hurt that bad, You know, this sort of things like that. And so I think it may be harder to get a lever. What do you grab to try to convince somebody to change? And Reed Molloy years ago was talking about kind of what he tried to do and was try to make them understand that you are not happy now. Jail sucks. Jail is not fucking right. What can we do to keep you out of ending up here again? And so it kind of it's an appeal to a certain amount of selfishness that sort of you might be happier if you could avoid prison or if you could sustain a relationship or. And so I think I think that's an issue for for psychopathy is sort of where do you grab on to? What kind of handle can you get? Because that big handle of subjective distress and you feel terrible, let's figure our way out of this just is not as available as it is in other places.

  Dr. Chase Thompson: [00:42:06] Right. Right. I think there's also been some areas I've read around kind of like a burnout effect of antisocial behaviour as as individuals hit their midlife. Is that a phenomenon that that you recognize?

  Dr. Lynam: [00:42:23] Well, one of the things that seems to happen a lot I mean, is this sort of crime decreases, our crime changes at least. So if you chart sort of the changes in levels of the psychopathy checklist factors, they break them into two factors. One, they I think erroneously call personality and the other they call antisocial behaviour. And it's more about for me, it's more about pure antagonism and then a mix of antagonism and conscientiousness. But what you see is that that factor one stuff changes a little bit, maybe decreases a little bit, but it's really the factor two stuff that drops off. And that's probably due to the kind of the way in which it's assessed and the reliance on crime. I mean, at 50, you just can't fight as much. You can't you can't break stuff and climbing windows anymore. I mean, it's sort of I think the burnout is more about the sort of crimes that are being committed. And so so those are definitely dropping off because I think they're hard to sustain as you get older. So I do I do think that that part's definitely a real thing. We're about to start looking at, at least in an older age cohort, just sort of psychopathy assess purely on the basis of personality. So not including the really antisocial stuff to look and see what does happen across 15 year old, 15 year span from, say, 60 to 75. Are the traits themselves changing very much at that point, or is it reasonable to believe that all the change people are reporting on is really this this drop off in antisocial stuff?

  Dr. Chase Thompson: [00:44:03] So if I can try and paraphrase you it's it's it's that the outward behaviours decline, but maybe the inner subjective world remains the same.

  Dr. Lynam: [00:44:15] Yeah, I think that's fair.

  Dr. Chase Thompson: [00:44:17] Okay. Psychiatry and psychology. We always see a lot of comorbidity. And what are the common comorbid issues that people with psychopathic personalities run into?

  Dr. Lynam: [00:44:34] I mean, you know, one is, is it really a kind of a close cousin personality disorder, which is narcissism. So you end up with narcissism is highly correlated with psychopathy. Substance abuse and substance use problems are highly correlated with psychopathy as well. I mean, there are diagnoses, but but aggression is a problem. Relationships are a problem. But but again, because they tend to lack this subjective distress, it's not as comorbid with other forms of psychopathology as, say, borderline personality disorder is right, which is co morbid with almost everything, because they all have this big piece of of emotional reactivity and subjective distress. And you don't really find that in psychopathy, but it is co morbid with all the externalising behaviours. So various sorts of substance use alcohol problems, I mean all, all that sort of what gets called externalising stuff, psychopathy sits right in the middle of that.

  Dr. Chase Thompson: [00:45:38] So is it kind of protective against the internalising depressive depressive anxiety disorders?

  Dr. Lynam: [00:45:45] It is, especially if you allow that boldness component in. I mean, in fact, if you allow boldness in psychopaths, psychologically speaking, you really want to be psychopathic because you are relatively immune to those sorts of those sorts of problems. If you don't have that in there, then you can get some of the kind of depressive sorts of stuff going on. But but if you allow boldness as a piece of psychopathy, it definitely protects against against kind of internalising disorders because frankly, it's it's virtually the opposite of internalising disorders.

  Dr. Chase Thompson: [00:46:25] Right, Right. So I think we're getting closer to the end of our time together. One maybe question I have is sort of more theoretical, broader question, but sometimes thinking about personality, I wonder why is psychopathy a something that's developed in people as opposed to any other disorder? And does it we've talked about it being sort of on the spectrum.

  Dr. Lynam: [00:46:53] I see.

  Dr. Chase Thompson: [00:46:54] Is there some sort of benefit that antagonism maybe has a in a more milder sense or what is is there any sort of function of psychopathic orientation?

  Dr. Lynam: [00:47:05] Sure. So I'd say a couple of things. One, one thing I would say I think is that I'm not sure psychopathy is a natural category in the sense that sort of I think what it is, is it's a it's a presentation that is really kind of bothersome and people notice it. Right. And so you can't help but see it. These folks are like this. But but I'm not sure that it coheres like a syndrome does. So I'm not sure it's a natural category. But but the question is interesting, like, why does high antagonism exist at all? But why are we not all just kind of flat, bare and all nice to each other and stuff? And, and I do think there's some advantage to being a bit of a jerk. I mean, quite quite frankly, I think I think this is a way of pushing and getting what you want. It's a way of stepping ahead of others while stepping on others, which can be to kind of your individual advantage. I mean, these are sometimes I think of these if you think of these in evolutionary terms, different reproductive strategies, these are the cheaters. These are the folks who aren't following kind of our rules as long as there are too many of them.

  Dr. Lynam: [00:48:13] It's a very successful strategy. And so I think that sort of these folks are probably I mean, if you want to talk purely evolutionarily, these folks are having more babies, right? At least at least the men are right. If you're if you're sort of can't have committed relationships, then any relation you have is sort of uncommitted. And so you have lots of them. And and just that'll propagate your genes just quite simply. And I do think just from a subjective feeling, I mean, some of these folks are decently successful because they're the first in line and they will find their way up front if they're not there already. And so this is a manipulative they don't care what they do to you. They don't think you're particularly important. And this this this allows them to get some of what they need at the expense of others. And so so that's why I think probably, you know, there is high antagonism out in the world. But not everybody could be like that. Right. Because living in community becomes really very difficult, is my thought on it. I mean, I'm not an evolutionary psychologist, but that's me pretending to be one.

  Dr. Chase Thompson: [00:49:28] Fair enough. I know you spoke a little bit about treatment, just in the sense that there's not a lot a ton of intersubjective distress that drives someone towards treatment. But say you did have someone who is, for some reason, very motivated to get treatment. Is there any sort of modality that's been shown to help at all? Or. 

  Dr. Lynam: [00:49:52] Not really

  Dr. Lynam: [00:49:53] I mean, I don't think I mean, I don't think people have studied treatment for psychopathy in the same way they have, say, for for borderline or for depression. I mean, not what works best. I mean, so you certainly don't have these sort of cross treatments and people trying to figure out what will work. I think people have thought for a while that these folks are probably relatively untreatable. So and frankly, they don't come in a lot. I mean, you know, in your clinical practice, let's say, how many grandiose narcissists do you see rolling in of their own accord? I think the answer is very few. They get there because the spouse brings them in or court orders them there. I mean, this is what kind of brings them in. So there's not a huge population to work with. And I think a lot of a lot of clinicians find that group a difficult group to work with. And I think individuals with psychopathy are much the same because they've got that same core of I don't know why I'm here, I don't have a problem. You guys have a problem. This kind of shifting of blame. And again, what do you do? I mean, I think Reed Molloy was probably right. If I find a lover in there, that's a selfish leaver. Look, you don't like coming in to see me. You don't like being in trouble with everybody? What's something we could maybe figure out that you could do differently that would keep you from ending up in jail or would allow you to resume a decent marriage with with your spouse. Right. I mean, that's kind of the only thing I can think of. I mean, I do think I mean, I'd love to see somebody develop. There's a unified protocol for negative affects in the world today. I mean, boy, if you could come up with something like that for antagonism, that'd be great. You know, maybe it starts with this kind of motivational interviewing approach about sort of just getting them to think about change because the way they're doing stuff now is is less than optimal for them.

  Dr. Chase Thompson: [00:51:55] Hmm. Mm hmm.

  Dr. Lynam: [00:51:57] But but I mean, appeals to look at. Look at how you hurt this person are probably not going to work very well. Wow. Yeah.

  Dr. Chase Thompson: [00:52:06] Hmm. Well, is there anything that you think that we haven't touched on in terms of psychopathy that you think is important to say at this point?

  Dr. Lynam: [00:52:17] No, I think I think I've got to say pretty much everything I wanted to say. I appreciate your questions and I hope I was somewhat clear, at least.

  Dr. Chase Thompson: [00:52:24] Yeah, I think you're. Yeah, absolutely. Well, thank you very much for being on our podcast. We really appreciate it.

  Dr. Lynam: [00:52:33] Thanks for the invitation.

  Dr. Chase Thompson: [00:52:34] Okay.

  Dr. Chase Thompson: [00:52:43] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by myself, Chase Thompson. Theme song is Working Solutions by all Live music, especially thanks to our incredible guest, Dr. Donald Lynam, for serving as our expert for this episode. If you want to get in touch with us, you can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.Org. Thank you for listening bye.

Episode 44: Reproductive Psychiatry with Dr. Tuong Vi Nguyen

• Episode 44: Reproductive Psychiatry with Dr. Tuong Vi Nguyen

  Nima Nahiddi: [00:00:10] Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. In this episode, we'll be exploring the psychiatric aspects of reproductive mental health. I'm Dr. Nima Nahiddi, a fourth year resident at McGill University. And I'm joined by Arielle Geist, a second year resident at the University of Toronto, and Audrey Le, a first year resident at McGill University.

  Arielle Geist: [00:00:34] Hi, everyone.

  Audrey Le: [00:00:37] Hi, everyone.

  Nima Nahiddi: [00:00:39] We're really grateful to have our guests, Dr. Nguyen, this week to share her expertise. Dr. Nguyen, if you could, please introduce yourself.

  Dr. Nguyen: [00:00:48] Sure. So I'm a reproductive psychiatrist at McGill University Health Centre.

  Nima Nahiddi: [00:00:54] For this episode. Our learning objectives are the following to define the field of reproductive psychiatry to discuss the possible neurobiological pathways impacting mood and cognition during the reproductive cycle of women, to discuss the influence of sociocultural gender roles on psychopathology, to list the DSM five diagnostic criteria of Premenstrual Dysphoric Disorder. To recall the Epidemiology of Premenstrual Dysphoric Disorder. To describe the steps in the diagnostic evaluation of Premenstrual Dysphoric Disorder. To list lifestyle and psycho pharmacological interventions for Premenstrual Dysphoric disorder and to discuss common mental health concerns during the perimenopausal period.

  Arielle Geist: [00:01:42] So I'll start with the first question today. So before diving in today's discussion, could you briefly explain the clinical scope of reproductive psychiatry and what your work entails? Exactly.

  Dr. Nguyen: [00:01:55] So reproductive psychiatry is really about all of the mental health changes that occur in a woman's lifetime during reproductive periods, typically around puberty. You start to see changes related to hormones and you can see a significant proportion of women who start to have premenstrual syndrome, 70 to 80% with a smaller proportion that go on to the premenstrual dysphoric disorder. Another stage of life when you have these hormonal fluctuations is, of course, the pregnancy and postpartum period. And then finally you have the perimenopausal period. And there has been talk amongst us, reproductive psychiatrist that psychiatry should also include hormonal changes for men. But we'll see maybe in in ten years. For now, it's pretty focused on women's mental health.

  Arielle Geist: [00:02:46] Mm hmm. Since you mentioned hormones, my next question was, how do these hormones, especially in the field of reproductive psychiatry, where the focus is on mostly estrogen and progesterone, how do those hormones modulate mood and the neurobiological pathways that are involved in regulating mood?

  Dr. Nguyen: [00:03:06] There's no simple answer for that. I think that when you think about hormones and women hormones, you have to think about the fact that there are classes rather than just thinking about estradiol and progesterone. It's really all of the steroid hormones are linked together. And you can have up to 54 metabolites, maybe more, maybe more metabolites could be discovered. And then you have these three or even four classes. I don't know if you're aware, but it all starts with cholesterol. And then you have one branch that go on to be corticosteroids. You have one branch that go on to be the estrogens, but then you have tons of different types of estrogens, including 17 beta estradiol, the most famous one. And then you have the progesterone progestogen basically progesterone alone and all of these related hormones. And then you also have the androgens like DHEA and testosterone. So all of these hormones change cyclically throughout the menstrual cycle and then very drastically during pregnancy and the postpartum period and of course the perimenopausal period in terms of how they affect neurotransmitters, I would say again, no easy answer, but just in a very broad way, in simplified way, the estrogens tend to regulate serotonin. Well, all of the all of the neurotransmitters, it's really like they're really almost like dirty medications. So they will affect serotonin and norepinephrine, dopamine in different ways. Progestogen also and estrogen suppression tend to have opposite effects. So for example, estrogen tends to be more stimulating to, for example, up the serotonin, serotonin tone and also androgenetic tone. And then progestogen tend to act again, not all of them, but most of them act through the GABA receptor and then they will lead to inhibition or kind of downregulation of the HPA axis, for example. So the kind so more a bit more like benzos androgens, there's a lot of research that remains to be done on androgens, which are really not well studied. But the typical effect is really in terms of activity, mood, lability, competitiveness, things like that.

  Arielle Geist: [00:05:23] Thank you. I think you really were able to simplify something that that seems very complicated to. I think many trainees. Next, because of the way that we formulate things in psychiatry, going with the biopsychosocial model, I wanted.

  Arielle Geist: [00:05:38] To step away.

  Arielle Geist: [00:05:39] From the biological aspects of reproductive mental health for a second and take some time to explore its social aspect. So my next question was about how do you feel that social and cultural type of gender norms affect clinical presentations of this field? For example, how the way that it might affect the experience that mothers who have postpartum depression have?

  Dr. Nguyen: [00:06:05] I think there are still many unanswered questions regarding that. And one of the key aspects of the literature is that we still don't know enough about the social determinants of health for perinatal depression. I hope that beyond post-partum depression, we'll start to talk about perinatal mental health disorders. I think PPD has become very famous. Postpartum depression has been recognized by and large by the mainstream media. But then oftentimes we miss the anxiety disorders that present during the period of period the post-traumatic stress disorders, OCD, which is its own different beast as well. And so I think that, yes, there's a lot of advantages to to have more recognition and awareness, awareness of depression. But we must I think it would be more helpful for women if we use a broader term, perinatal mental health disorders. And I think that in the past decade or so, more and more women are delaying fertility or delaying reproduction to further career or other interests that they may have. And so more and more women will have unfortunately, more and more couples will have infertility and fertility problems. And then that kind of opens the door to a whole other area of mental challenges, which is all of the mood fluctuations related to hormonal treatments, IVF IUI, and in addition to the psychological issues of repeated miscarriages and pregnancy complications. So I think in terms of in terms of that social aspects of mainstream recognition and awareness, we've done a lot, but there's still there's still a lot of work to do because some women will still come to me and say, well, I have suffered for two years because I had no idea.

  Dr. Nguyen: [00:07:54] I thought they were suffering from postpartum anxiety, let's say, and then not want to present to not want to discuss it with their doctor because it's they felt they were obviously not depressed. So I think that's that's one aspect. I think the other aspect socially that is that is important to mention is that unfortunately, we're still, despite the fact that Hillary Clinton said several years ago that women's rights are human rights or human rights or women's rights, something like that. I don't know if I'm quoting her properly, but I still think that we are struggling to we are struggling to kind of have the political recognition that we that we need. And this is at all levels. Just to give you an example, all of the reproductive psychiatrists currently working in Quebec have really struggled to implement to have even a prenatal clinic. This in the in face of the fact that we know now that maybe one in three women around the period may have a significant period of mental health disorder with all of the uncertainties surrounding COVID, with the fact that most of the child care burden and house chore burden still falls on the woman at home, and that several of them have out of work because of that. Even so, we're still really struggling to establish these these clinics. And there's actually just one, I would say, clinic in the Quebec province that offers psychological help, an experienced nurse and a psychiatrist. Then the rest of us are basically perinatal and reproductive psychiatrists that are working with little support.

  Arielle Geist: [00:09:32] Mm hmm. Thank you for all of that wise insight. I have one last question about the social aspect that I think you kind of touched on to. So when I was reading on the literature leading up to doing this episode, some of it suggested that premenstrual syndrome and postpartum depression and such are quite seem to be a bit more culture bound because there is some literature out there that suggests that it's less prevalent outside of Western countries. So I was just wondering if you had any comments to make in terms of how those differences might be explained by cultural norms or whether that even is true, whether or not we do see it pretty prevalent in in all cultures?

  Dr. Nguyen: [00:10:13] Yeah, No, no, absolutely. I wanted to mention that too. So it's again, an example of of perhaps some of the biases that are in some of the controversy that always surround women's mental health in terms of of how long it took for the premenstrual dysphoric disorder to make it into the official category of the diagnosis instead of being relegated to the culture bound syndromes. I would say all of the evidence up to now point towards the fact that there are similar percentages, proportions of women suffering from PMDD across all across all cultures, across all ethnicities. And so I would say if you have a multiple choice question, I would say that PMDD is not the culturally bound syndrome. And it it really does seem that there is an overlap between the women who suffer from PMDD and the women who may have bad reactions like disinhibition and aggression with alcohol. So there seems to be something surrounding maybe men alone and the GABA receptor, but there's several biological and particular genetic contributions to this to this illness.

  Audrey Le: [00:11:16] Thank you for answering all of those questions. We're going to move a little bit now into premenstrual dysphoric disorder. So this is a depressive disorder that's linked to the menstrual cycle with symptoms presenting in the week before the onset of menses. Before we dive into this further, it might be helpful for our listeners to briefly talk about the DSM criteria for premenstrual dysphoric disorder to get a better understanding of what this looks like. So before asking further questions, I'm just going to run through the DSM criteria for premenstrual dysphoric disorder. So A, in the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses start to improve within a few days after the onset of menses and become minimal or absent in the week post menses, criteria B one or more of the following symptoms must be present, and these include effective lability, irritability or anger or increased interpersonal conflicts, depressed mood, feelings of hopelessness or self deprecating thoughts and anxiety, tension and or feelings of being keyed up or on edge. Criteria C, one or more of the following symptoms must additionally be present to reach a total of five symptoms when combined with the symptoms and criteria B above.

  Audrey Le: [00:12:32] These include decreased interest and interest in usual activities, subjective difficulty in concentration, lethargy, easy fatiguability or marked lack of energy, marked change in appetite, overeating or specific food cravings, hypersomnia or insomnia, a sense of being overwhelmed or out of control. And lastly, physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of being bloated or weight gain. Of note, the symptoms I mentioned must have been met for most menstrual cycles that occurred in the preceding years. And the rest of the criteria after this include D causes significant distress or interference with daily activities or relationships. E The disturbance is not an exacerbation of the symptoms of another disorder such as MDD, panic disorder, PDD, or personality disorder. F Criterion A should be confirmed by prospective daily readings during at least two symptomatic cycles, which we'll talk about more detail later in the episode and G. The symptoms are not attributable to a substance medication or another medical condition. So now that I've gone through the diagnostic criteria of premenstrual dysphoric disorder, let's talk about the epidemiology. How prevalent is this disorder and how does it evolve across the lifespan?

  Dr. Nguyen: [00:13:53] So in terms of the last estimates, they go between two, it's 2 to 8%. I think if you define it very rigorously with a two month perspective ratings, which not all women are willing or able to complete, then it maybe is 2 to 5% and that is compared to the 70 to 80% of women who have premenstrual syndrome.

  Audrey Le: [00:14:16] Thank you. And and how does this tend to evolve across the lifespan?

  Dr. Nguyen: [00:14:21] So typically, PMDD, unfortunately, tends to get worse with the years, particularly after having had children, that we we still don't know what exactly in terms of hormonal mechanisms that's due to. But that has definitely been documented in terms of it's getting worse over time.

  Arielle Geist: [00:14:40] And again, thinking about premenstrual dysphoric disorder, what's the differential diagnosis that you think about when you're seeing a patient?

  Dr. Nguyen: [00:14:48] Oh, you have to think about all of the gynaecological endometriosis, for example, PID (pelvic inflammatory disease), ovarian cysts or ovarian torsions. There's a lot of different gynaecological conditions that you have to think about. I am actually of the school of thought that I don't. I think that disorders can be co-morbid. And so even though I know that in the DSM, it says it cannot be the exacerbation of another condition. We know from family studies that, for example, MDD and PMDD coexist in these families. And so you will have several women who suffer from both. And so then it's really difficult to disentangle. Is it just an exacerbation of MDD or PMDD and MD together? So for me, it's not kind of hard exclusion criteria per se.

  Nima Nahiddi: [00:15:37] I was just wondering how realistic or easy do you find it is for people to do the prospective charts for the two months? Is that something that if you will have resources or with your smartphone, that is very doable.

  Dr. Nguyen: [00:15:54] It is doable. I just find that this is this goes back to the social determinants of health, I guess, but it's just very special to me that it's the only disorder which you require. Two months perspective ratings for all of the other disorders are not it's not that hard to to meet the criteria, basically. And I think that for some of our some of our population it is quite difficult. You know, like you have three children, you're trying to get diagnosed with PMDD, you just don't have the time. So it can be challenging for some people. So at least we have the option of being of giving a PMDD provisional diagnosis until the person kind of hands in the two months perspective readings. But typically I really try to encourage them to do it either like you said, on the smartphone or some people just like hard paper copy. So it's it's doable. But I think maybe in ten years there may be changes again to that specific criteria.

  Audrey Le: [00:16:55] And thinking of those rating scales. What are some rating scales that are typically used in diagnosing premenstrual dysphoric disorder that you use?

  Dr. Nguyen: [00:17:05] They're quite widely available now, particularly given that a lot of women are trying to track their fertility. So you just there are several apps like Overview and several other new apps as well. It's called Fertility. I don't remember, but there are several for both iPhones and Google Samsung phones now. And even if you just do, you don't even have to download an app. You can just do a Google search and you'll see like all of these paper forms, you just have to make sure that the big categories, like the effect of symptoms, cognitive symptoms, physical symptoms are all properly listed, but they're widely available and free.

  Nima Nahiddi: [00:17:42] Now that we've reviewed the diagnosis of premenstrual dysphoric disorder, what is your approach to the treatment once you've diagnosed someone?

  Dr. Nguyen: [00:17:51] It really depends on the patient. I think most of I think most of reproductive psychiatry is. There's a lot of joint decision because it's such a it's such a personal decision. For example, for PMDD, it depends whether the woman is willing to consider contraception, in which case you could try something like Yasmin for three cycles with four days off. It's important to mention, though, because I see this very commonly, is that you cannot just throw any oral contraceptive pill at PMDD and hope that it works. Several pills, particularly the ones that have more androgen potency, actually can make PMDD worse. One common culprit is alesse, for example, which is quite commonly prescribed. So even though if alesse has very low levels of hormones and so some GP's or some other health care practitioners may think that this is going to be helpful for someone who's suffering from PMDD. It actually is not about the levels of hormones but about the potency and which direction, which of the different classes of the steroid hormones that I mentioned earlier, which the oral contraceptive is offering. And the other thing that people often forget is that you have to prescribe it really three cycles and four days off, which is not the typical regimen for oral contraceptive pills. Usually it's like three weeks on and then you have like a week of sugar pills or placebo pills. But you need to do this to disrupt the cycle and to help in terms of the PMDD symptoms. Another aspect I would say is some women actually come to me already on SSRI, And then I think in that case, it's easy to consider, okay, why don't you try to increase your SSRI during your luteal period? And so the week before menses, this is depending on their perspective tracking this.

  Dr. Nguyen: [00:19:39] This can be useful in terms of knowing. Does the woman start to have symptoms right after ovulation, which some women do, unfortunately. So they have like a full two weeks of symptoms that then only start to improve slightly when menses start. Some women only have like three days of symptoms before their period occurs. And so depending on the timing that you can tell them to increase, bump it up a little bit. For example, if the person is on escitalopram, they could go up to 25 or 30 just for that period. What's important to remember is that the mechanism through which the SSRI work for PMDD is not the same as how it works for depression, for depression and anxiety. You have all of these changes at the synapse or occurring the changes in auto receptors 5HT1A But for PMDD, it's really thought to occur through a disruption in the way that the hormones are being metabolized. So again, because there's this communication between the serotonin and just overall neurotransmitter systems and the hormones, basically the if you administer SSRIs or an increased dose of SSRI during this period of time, perhaps it's changing how fast the hormones are being self-rated or converted to different metabolites in a way that then helps women. So there's still a lot of research, kind of more fundamental research that needs to be done in terms of how that occurs. Exactly. But there are now several studies showing that the SSRI are quite effective for PMDD when administered in this fashion.

  Nima Nahiddi: [00:21:11] So to clarify for pharmacological treatments, there's oral contraceptive pill and SSRI. And so can you explain in which situation would you choose one or the other or would you recommend one or the other?

  Dr. Nguyen: [00:21:27] I think I've touched a bit on that in terms of, you know, depending on the on the patient perspective and what they what they want to priorities. Some women may be in the midst of trying to conceive and so the Yasmin wouldn't be the right choice for them. Some women might have a family or personal history of stroke, pulmonary embolism, deep vein thrombosis and other and have other risk factors such as being over 35 years old and smoking, etc. And in that case, Yasmin and Yaz, that whole category of oral contraceptives actually are associated with an increased risk of stroke and deep vein thrombosis, etc. So there are some exclusions in some cases where I tend to shy away from the Yasmin or Yaz, oftentimes. Also, it may be easier for women who are already on SSRI to just continue on and just change their dosages that way. And then it's less stressful for them in terms of changing medications. I just want to mention also that if SSRI and oral contraceptives don't work, then you can help. GNRH agonist or antagonists are kind of like basically surgical or medical menopause. So this is really a last resort, though. And I would say 70 to 90% of women actually respond to Yasmin or SSRI. And in terms of the study. It does seem that the contraceptives have a slightly higher rate of success. It may be 80 to 90% versus the SSRIs, which are more like 70 to 80%. So like a highly treatable condition.

  Nima Nahiddi: [00:23:03] You had mentioned that we should avoid certain contraceptives like Alesse, What is the specific reason why you would avoid that? Just to clarify.

  Dr. Nguyen: [00:23:15] So some contraceptives have more androgen activity like you remember, Like the difference, like there's androgen activity, progestogen activity and estrogen activity. So each pill actually has different balances or mixes of of that similar to, I guess, the antidepressants in the different neurotransmitters. So if you have one that acts more on androgen and not so much on the drospirenone or basically it's the metabolite that is in the progesterone category that is part of Yasmin and Yaz, then it's not going to be effective. So some some contraceptives will just be neutral. It will neither help nor worsen the PMDD and then some others will make it worse if they have the wrong mix, if they have too much androgen activity, for example. And then that's why we think that it's Yasmin or Yaz, that has that is efficacious because of that drospirenone metabolite specific to those medications.

  Nima Nahiddi: [00:24:12] Thank you so much for clarifying that. Are there any lifestyle interventions that can help with the treatment of PMDD?

  Dr. Nguyen: [00:24:19] Unfortunately, there's very weak evidence to support that. Some women will say, I've tried calcium, I've tried B vitamins, I've tried exercise. And I'm not saying like in lots of cases, add on CBT, add on light therapy even could help. There's a lot of different conditions, but it's just that the the evidence behind those complementary therapies is still quite weak.

  Nima Nahiddi: [00:24:46] So I'd like to finish our discussion by going to another topic. Mental health concerns during the perimenopausal period. Can you clarify? First, the definition of perimenopausal?

  Dr. Nguyen: [00:24:58] Perimenopausal is again, difficult to define because you have so you have menopause, which is one year after the cessation of the complete cessation of menses. So you can basically only define menopause retrospectively because you never know if you're going to have another period at perimenopause. In most of the studies are is thought to represent the whole period of when the ovaries or the follicles are starting to decline up until menopause, which is one year after the last period. And then you have early perimenopause and you have late perimenopause. I feel like for your learning, you don't need to know all the details of that, but just know that the changes of hormones are different in early versus late perimenopause. Menopause in early perimenopause, you can see a lot of erratic changes in estradiol and other hormones, too. I don't want to get too much into the complexities of that. And in the late period menopause, that's when you start to see a profile that is more similar to menopause. So a lot of ups and downs and fluctuations throughout that whole period. And just to mention that some women can start to enter the early menopause around age 40, 45 years old. So it can be quite much earlier than than some of us would expect.

  Nima Nahiddi: [00:26:20] And what are some mental health concerns that arise during this time period?

  Dr. Nguyen: [00:26:25] It's typically anxiety and depression, but you will also see exacerbations of schizophrenia and exacerbations of bipolar disorder, for example. So again, if you have a patient with bipolar disorder or schizophrenia and suddenly you have treatment resistance, you have to think about asking those questions about the menstrual, the menstrual history and reproductive history in terms of the more common disorders like anxiety and depression. And so what we see is that these perimenopausal mental disorders tend to be more persistent and more comorbid. So instead of just seeing a classical picture of depression, you will see a lot of anxiety, kind of depression with anxious features, difficult to treat, a lot of insomnia. And sometimes the women will describe it as the worst, the worst mental breakdown that she's had during her entire life and accompanied accompanying these mental symptoms. You have, of course, the physical symptoms also. So the hot flashes, the vaginal dryness, there's a lot of discomfort physically that occurred during this time as well.

  Nima Nahiddi: [00:27:27] Can you speak about the incidence of depression specifically in the perimenopausal period and perhaps what effect estrogen has in the treatment of depression?

  Dr. Nguyen: [00:27:38] I think other than the fact that the depression is often comorbid with anxiety in terms of presentation, I don't see any remarkable features of the depressive symptoms that are different from an MDD at another period of life. It's possible, though, that in terms of psychological and social contexts it's even harder because it's like a woman ageing, her children leaving. There's a lot of life changes also that are different from other periods of life in terms of the hormonal treatment. So I mean, we do consider transdermal estradiol as one of the useful add ons to antidepressant treatment. I don't tend because I'm not a gynaecologist, I don't tend to start with the transdermal estradiol, Some gynaecologists will, and I guess it's for them to comment on how the how they think, how they consider it first line versus second line. For me, I consider it more second line because there are several antidepressants. All of the antidepressant categories have been shown to be effective for perimenopausal depression and anxiety. Maybe with the SNRIs being a little bit more effective, we think because of all of the hypothalamic changes and dysfunction in the noradrenergic  nucleus in the hypothalamus that happened with hot flashes. And that may also be may also cause some of the mood fluctuations that occurred during this period. So perhaps a SNRI a little bit more effective, but SSRI is also effective. Mirtazapine is also effective. I wouldn't go so much with bupropion though, because it's too activating and it can increase the anxiety that is often comorbid with perimenopausal depression.

  Dr. Nguyen: [00:29:21] And then if that doesn't work, then you can consider something like transdermal estradiol. I think Raloxifene at some point was also discussed. It tends not to be very effective, maybe mildly effective sometimes a bit like how we use Pregabalin for for GAD like it can be effective, but oftentimes more like an ad as an add on. It actually has been studied in schizophrenia. I don't know if you're aware, but in terms of schizophrenia for cognitive and effective symptoms of schizophrenia and Raloxifene, which is a selective  receptor modulator, seems to be effective for those symptoms in schizophrenia. And so that's why sometimes we also use it for perimenopausal depression. If someone, for example, has contraindications to transdermal estradiol, I always make sure to have a family doctor or a gynaecologist who is my partner in prescribing these medications. Typically, I've had no issues with people kind of collaborating and getting back to me quickly. And usually it's like at least it takes six weeks of transdermal estradiol and sometimes a bit more six weeks to six months. I would say after that I would be reluctant to continue to prescribe unless I have like an ultrasound or a really good follow up by the the other either family doctor or gynaecologist to make sure that endometrial thickness is not has not change, etc..

  Nima Nahiddi: [00:30:46] And these other side effects that you've spoken about, like hot flashes that occur during menopause, do you find that these contribute to having increased mental health concerns?

  Dr. Nguyen: [00:30:59] So just like the co-morbidity between PMDD and MDD, sometimes it's hard to disentangle. However, all of the prospective studies have shown that even when you control for hot flashes and all of the physical symptoms of menopause, you still have a peak. So the mental health symptoms do seem to be independent, although of course, the worse, the more anxious you are, the more you can suffer from hot flashes also. So so so there's a bidirectional kind of exacerbation that can occur. But even in a woman who would have very little physical symptoms of perimenopause, you can still have an increased risk of perimenopausal depression, anxiety, as well as exacerbations of bipolar disorder and schizophrenia.

  Nima Nahiddi: [00:31:41] Thank you so much for that overview of reproductive mental health. Before we leave, do you have any specific clinical pearls you'd like to leave our listeners with?

  Dr. Nguyen: [00:31:52] Oh, I would say I mean, I hope that everyone who listens to this podcast will remember to ask about menstrual history, because that's what I kept repeating throughout the podcast and then strong sexual history. I think these are really key and this is something that we often as psychiatrists feel uncomfortable to talk about and at any life stage, as you can see. So even a woman who comes to you 55 years old. So I have to ask about reproductive history, sexual history as well.

  Nima Nahiddi: [00:32:18] Thank you so much, Dr. Nguyen.

  Dr. Nguyen: [00:32:20] You're welcome.

  Arielle Geist: [00:32:27] Site is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode is produced by Dr. Nima Nahiddi, Dr. Arielle Geist, Dr. Audrey Le and Dr. Rebecca Marsh. The episode was hosted by Dr. Nima Nahiddi, Dr. Arielle Geist and Dr. Audrey Le. The audio editing was done by Dr. Audrey Le and the show notes were done by Dr. Arielle Geist. Our theme song is Working Solutions by All Live Music, and a special thanks to the incredible guests we had today, Dr. Nguyen, for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

Episode 43: Psychedelic-Assisted Psychotherapy with Dr. Emma Hapke and Dr. Daniel Rosenbaum

• Episode 43: Psychedelic-Assisted Psychotherapy with Dr. Emma Hapke and Dr. Daniel Rosenbaum

  Nikhita Singhal: [00:00:14] Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners. This episode covers an introduction to psychedelic assisted psychotherapy, an exciting and rapidly developing area in the field of psychiatry, which has been receiving growing attention in the scientific community and among the general public lately. I'm Nikhita, a third year psychiatry resident at the University of Toronto, and I'll be co-hosting this episode alongside a few of my colleagues who I'll pass it along to so that they can introduce themselves.

  Chase Thompson: [00:00:43] Hi, I'm Chase. I'm a fourth-year resident at the University of Toronto and I'll be hosting along with Nikita.

  Annie Yu: [00:00:49] Hi, I'm Annie. I'm a fourth-year medical student at the University of Toronto, and I'm really excited to join in on this conversation.

  Jake Johnston: [00:00:56] And I'm Jake Johnston, a fourth year medical student at UBC. Also very happy to be here.

  Nikhita Singhal: [00:01:02] Thanks. We also have two experts among us. Our guests for this episode are Drs. Emma Hapke and Daniel Rosenbaum. Dr. Hapke is a psychiatrist, psychotherapist and psychedelic researcher at the University Health Network in Toronto and is co-founder and associate director of the Nikean Psychedelic Psychotherapy Research Centre at UN. She's also a lecturer at the University of Toronto. Her specialty is Women's Mental Health and the treatment of developmental trauma, sexual trauma and complex PTSD. She has extensive training in multiple modalities in psychotherapy, as worked clinically with ketamine assisted psychotherapy. She also has a growing interest in psychosocial oncology. Dr. Hapke works with MAPS as the principal investigator for the Montreal site of the Phase three trial of MDMA assisted psychotherapy for PTSD, and is MAPs trained to deliver MDMA assisted psychotherapy. Dr. Rosenbaum is an attending psychiatrist at UHN, as well as the Inner City Health Associates (ICHA) in Toronto. He's also a clinical lecturer in the Department of Psychiatry at the University of Toronto. He works on an assertive community treatment team serving people with severe and persistent mental illness, as well as a palliative education and care for the homeless team through ICHA. Dr. Rosenbaum is interested in psychosocial oncology and palliative care, especially end of life issues for marginalized populations.

  Nikhita Singhal: [00:02:20] He's a certified CALM therapist managing cancer and living meaningfully and has received training in ketamine, assisted psychotherapy and completed the MAPS MDMA therapy training program. He's also co-founder of the Canadian Climate Psychiatry Alliance. Dr. Rosenbaum has published articles in peer reviewed journals on psychedelic assisted therapy and palliative and cancer care and on psychedelic microdosing. He's also a co-founder and faculty member of Nikean Psychedelic Psychotherapy Research Centre. Now the learning objectives for this episode are as follows. By the end of the episode, the listener will be able to briefly describe the history of psychedelics and psychiatry. List the four classes of psychedelic drugs and their mechanisms of action. Summarize the evidence regarding psychedelic assisted psychotherapy for various psychiatric disorders. Discuss patient selection considerations for psychedelic assisted psychotherapy. Describe the safety, tolerability, and possible side effects of psychedelic assisted psychotherapy, and understand how psychedelic assisted psychotherapy session is practically carried out. I'll hand it over to Annie to get us started and it's great.

  Annie Yu: [00:03:25] Thanks, Nikhita. So just to start off with some basic definitions - Dr. Hapke and Dr. Rosenbaum, can you tell us what the definition of psychedelic is and how these psychedelic drugs differ from other classes of medications that are already used in psychiatry?

  Dr. Emma Hapke: [00:03:42] First of all, I just want to say thank you guys so much for having us. It's a real pleasure to be with you today.

  Dr. Daniel Rosenbaum: [00:03:48] In some ways, I think it might be most helpful to start by categorising the various medicines that might be discussed at a psychedelics conference. And then I think from there, we'll be able to effectively answer the question of in what ways they're different from conventional pharmacotherapies that are used in clinical psychiatry. So I know one of the learning objectives for the episode is about the different categories of medicines, and I'll start by talking about the so called classic psychedelics, and I think that will take us towards a definition as well. Pharmacologically, the classic psychedelics are so called or defined by their action at the serotonin 2A receptor. And so some examples of the classic psychedelics include psilocybin, which is the psychoactive component found naturally derived in about 100 species of mushrooms, which can be found all over the world. In fact, there's also lysergic acid diethylamide or LSD along with mescaline, as well as dimethyltryptamine or DMT. And then there's also 5-methoxy-DMT (or 5-MeO-DMT). And together these comprise the category of classic psychedelics, the five HT2A receptor. Maybe we'll talk about this more a little bit later, but it's really key to understanding the subjective effects of the classic psychedelics. And there's plenty of evidence that points to the specificity of that receptor in particular, and serotonin 2A receptor mediated signaling in governing the profound and at times quite unusual subjective effects of psychedelics. So one piece of evidence is that the receptor occupancy after someone is administered a psychedelic at the 2A receptor has been shown to correlate with the subjective effects and then also serotonin 2A antagonists, including a medicine called ketanserin blunt or basically abort the psychedelic experience. I'll turn it over to Emma to talk about a different category of medicine.

  Dr. Emma Hapke: [00:06:00] Sure. Maybe I'll just add a little bit about some of the subjective effects that you can experience with the classic psychedelics. In general, psychedelics induce a non ordinary state of consciousness. And so with higher doses of psilocybin and LSD, for example, you'll hear about this phenomenon called ego dissolution. So that typical sense of self starts to melt away, and parts of the brain that don't normally communicate start to communicate. So we'll probably go into the mechanism of action in more detail later on. But there's a part of the brain called the default mode network (DMN). And we think that that that's sort of the conductor of the brain. So it kind of controls which parts of the brain are communicating, and it's active when you're just at rest and letting your mind wander. And some people have wondered, is that equivalent to our sense of self or ego? I think that's an open question. But what we do know is that with these classic psychedelics, the default mode network is quieted and therefore you get these pretty profound changes in perception and emotion and thinking as a result of that and other things that are going on. Those are the classic psychedelics. I think the second big category is empathogens, of which the most well known one is MDMA, 3,4-methyl​enedioxy​methamphetamine. And this class is different in the sense that with your classic psychedelics, chemically they resemble serotonin, so they bind those serotonin receptors, whereas with MDMA, it actually causes a massive release of your own stores of serotonin.

  Dr. Emma Hapke: [00:07:44] So it's a serotonin release, but it also releases dopamine and cortisol as well as norepinephrine in the brain and oxytocin. So it really does a number of different things in the brain. And one of the effects of it is this sort of heart opening effect, this increased sense of empathy, both for yourself and for others. It's also been called an entactogen, which means "to touch within." And part of that's getting at its ability to allow the person to become really self reflective and gain a better understanding of their own inner state in addition to sort of the empathic effects of it. One of the things that I think is interesting to note about MDMA is it's quite anxiolytic, meaning it reduces anxiety and it reduces activity in your limbic system. And the amygdala, for example, which is sort of the smoke detector of the brain and a lot of other medications in psychiatry that reduce anxiety also cloud the sensorium, so they lead to this state of greater confusion. But because MDMA also increases cortisol and dopamine, it's both anxiolytic but increases alertness. And I think that's part of what facilitates trauma processing and makes it a good catalyst for psychotherapeutic work. Dan, do you want to take it away with some of the other categories?

  Dr. Daniel Rosenbaum: [00:09:12] Yeah, pleased to. I also wanted to come to a definition of psychedelic. It's different from the pharmacologic action of the various medicines that Emma talking about, empathogens and relating that to the nature of the effects or the experience among people who take them. The word psychedelic etymologically derives from Greek words psyche and delos, psyche, meaning "mind" and delos, meaning "to manifest." So putting them together, we get mind manifesting. And that's really what the word psychedelic means. And it comes from an exchange of letters between two quite famous figures in the world of psychedelic science and history, one of whom is Aldous Huxley, the English philosopher and writer, and the other of whom is a psychiatrist named Humphry Osmond, who was working in Weyburn, Saskatchewan and was interested in LSD and doing trials for people with alcohol use disorder, what was called alcoholism, I suppose, at the time. And Osmond was very influential as he gave Aldous Huxley mescaline for the first time. And mescaline can be found in the peyote cactus as well as the San Pedro cactus. And Huxley's experience with mescaline turned into his famous book, The Doors of Perception. And after that, these two men struck up a lifelong dialogue. But I do also want to say that before this word was created, these medicines were called and classified or understood quite differently.

  Dr. Daniel Rosenbaum: [00:10:55] So when LSD was initially synthesised, it was distributed mostly to psychiatrists, actually. And psychiatrists were encouraged to take LSD so that they could better understand the psychotic experiences of their disturbed patients. This is quite interesting. And as a result of this understanding of what LSD was and how it might be useful, it was classified as a psychomimetic. In other words, that it mimed or brought about psychotic experiences. And it's probably not the most useful term. I think probably a lot of people are also familiar with the term hallucinogen, which is still sometimes offered as the classification of these medicines, which is to say that they bring about hallucinations. That's probably also not quite accurate. It's sort of rare for people to have frank hallucinations with these experiences. The nature of the subjective, psychedelic state or experience I think we should get into a little bit more later, but Emma's done a good job already introducing that. And then the one last term I'd offer as a potential substitute for psychedelic is this term entheogen, and entheogen refers to or means revealing the God within.

  Dr. Daniel Rosenbaum: [00:12:11] And so entheogen is often used when referring to the use of these same medicines in their plant medicine form by indigenous cultures. And so I think maybe we'll get into some of the history of Indigenous use of psychedelics as well, but shifting to a different category of broad psychedelics or again the things you might hear discussed at the psychedelics conference, we come to ketamine and I'm aware that the podcast has covered ketamine in a different episode, but I'll just say briefly that ketamine, which acts at NMDA receptors as an antagonist, is a rapid acting antidepressant medication which can be administered either intravenously, intramuscularly, sublingually, or also orally and at high enough doses, still sub anaesthetic doses, but at high enough doses, people can have experiences on ketamine that resemble in terms of the subjective experience, a psychedelic state. And for that reason, sometimes ketamine can be paired with psychotherapy, so called ketamine assisted psychotherapy, in a similar way that the classic psychedelics or MDMA are used in conjunction with psychotherapy. But I think that's all I'd like to say about ketamine for today is I think we should leave the focus of our conversation to the classic psychedelics and MDMA.

  Dr. Emma Hapke: [00:13:28] One other category of psychedelic that has its own complex pharmacology that we'll just mention very briefly is iboga. And iboga is this root bark that comes from Gabon in Africa, and it's one of the most potent psychedelics on earth. And it seems to have this possible effect around the treatment of specifically opioid use disorder. It's a molecule that can induce a rapid detoxification from opiates, which is really interesting. And then it also induces these profound mystical states, which may be linked to how it's plays a role in the healing of addiction.  It's used typically in a ceremonial context. It's the tradition from Gabon that uses iboga. And I think that it's an interesting area of study. There's a higher death rate with iboga than other forms of psychedelics. So it may have some form of cardiotoxicity that we need to research. And I know there's a number of companies that are looking at extracting parts of the molecule to see what elements of it are healing.

  Chase Thompson: [00:14:43] Thanks so much for that overview. Dan and Emma, I just had a question about a points that each of you raised. Emma, you talked about the psychedelics being causing the effect of ego dissolution. And Dan, you kind of went through the etymology of the word and how it means to manifest the mind. So I'm kind of wondering, like these might seem maybe contradictory sort of effects where you dissolve the ego or maybe the self, but also revealing the mind. I'm just wondering if you guys have any thoughts about whether that's a contradiction or how that occurs?

  Dr. Emma Hapke: [00:15:21] When I think about psychedelics, I really think of them in some ways as like non-specific amplifiers of the psyche. And sometimes it's our ego structures and our defences that actually keep stuff from our past down. Sometimes Carl Jung would talk about the shadow - when I think of the shadow, I think it's the part of our psyche that we're not typically conscious of in our normal waking consciousness. And often things get pushed into the basement of our mind that were difficult in the past or that we were unable to process. We're still carrying them around and they're still affecting us. And so as the normal sense of self starts to dissolve away, you will often see some of that other psychic content come up for processing. And it's not always that the person's actually trying to consciously process it in the psychedelic state. It's more about experiencing it in the psychedelic state. And then after, in the integration phase, when they're no longer in the non ordinary state of consciousness, that's when we try to make meaning and interpret what came up. And I think the other piece that happens to as the ego dissolves, in addition to sort of the mind itself manifesting and coming up, is there's also these connection to these expanded states of consciousness. So people will talk about having these mystical experiences where they feel connected to everything or connected to something greater than themselves. And that also seems to be profoundly healing. Do you want to add anything, Dan?

  Dr. Daniel Rosenbaum: [00:16:57] You've got a great answer. It's a great question too Chase. I've never really noticed actually that potential contradiction in terms. So I mentioned that the term psychedelic was coined or emerged out of this exchange between Huxley and Osmond before they arrived at Psychedelic. Huxley suggestion was a term called phanerothyme. I'm not quite sure about the etymology with phanerothyme, but it means soul revealing. So before they arrived at mind manifesting, Huxley, who was a deep mystic, thought that this word soul revealing best captured the nature of the experience, that that the mescaline or LSD was a kind of medium through which the soul was revealed to itself.

  Jake Johnston: [00:17:52] Dr. Rosenbaum, you've sort of beautifully set us up to go into the history by talking about Huxley. You also mentioned psychedelic youth and indigenous cultures in the past. I'm wondering if you could sort of - I know it's a massive topic to go through in a short podcast - but an overarching overview of the history of psychedelics as medicines.

  Dr. Daniel Rosenbaum: [00:18:12] Yeah, thank you for that. I'm glad you prefaced it that way because it is an enormous question that I will not be able to do justice to, nor am I an expert on this particular topic. But I do find it interesting. And I would also say - I mean, to your point, Jake, there are hundreds of ways to tell the story of psychedelics even before we come to the biomedical story in the West in the fifties and sixties. But we can say a few general things about what we know regarding indigenous use of psychedelics. And again, I'll use the term psychedelics. But in different cultures these would be understood and referred to as very different things, perhaps plant medicines, and perhaps we could apply a different term like entheogens, as I mentioned earlier. But one thing that's interesting to note is that indigenous cultures in various regions of the world for centuries or probably even millennia, have been using these plant medicines with psychoactive properties in healing and spiritual rituals and ceremonies. And I have a wonderful quote here from the Canadian ethnobotanist and anthropologist Wade Davis. And just to give a sense of the different frame or context or the kind of setting and the purpose that these medicines or plant medicines would have been used. And so he's referring here to ayahuasca and just to provide a brief orientation. Ayahuasca is an Amazonian brew, which contains a number of different psychoactive plants. One is Psychotria viridis, which is a shrub from the coffee family that contains dimethyltryptamine. Dimethyltriptamine is orally inactive, which means that it has to be combined with a different medicine, a monoamine oxidase inhibitor to inhibit the enzyme that would otherwise break down DMT.

  Dr. Daniel Rosenbaum: [00:20:12] And somehow this occurred in a variety of different settings, in fact, which is remarkable in and of itself. People learned which combinations of plants to include in this brew to bring about these transcendent experiences. And so Davis, in describing the use of ayahuasca, says that these preparations, the ayahuasca preparations allow people to invoke some technique of ecstasy to soar away into the realms of trance, a higher state of consciousness, if you will, that allow them to achieve their medical, mystical acts of healing, but also, in the case of communities, a kind of annual or monthly reaffirmation of the connection between human beings and the natural world, a balancing of the energetic flows of the universe. And in that sense, the substances and the rituals become a prayer for the well-being of the entire Earth and the cultural continuity of the society itself. So there's obviously a lot to that quote, and I offer it only as I think a quite radical juxtaposition to some of the ways in which psychedelics are being studied and offered in a more narrow biomedical way, which I think will be the focus of our conversation. But just to kind of frame the history, I think I find that resonates so deeply. I mean, it's so powerful, right? So coming into the popularisation of psychedelics in the West, one version of the story goes that a Western banker named Gordon Wasson, who was working at J.P.

  Dr. Daniel Rosenbaum: [00:21:46] Morgan, visited the Oaxaca region of Mexico, where a quite famous medicine woman, or Curandera named Maria Sabina, who worked with psilocybin mushrooms, welcomed Wasson and his wife and allowed them to participate in a mushroom ceremony. And upon returning to the States, Wasson wrote an article for Life magazine called, "Seeking the Magic Mushroom." And this became the most widely read edition of the magazine in its history. In parallel, a Swiss chemist named Albert Hofmann was working on the ergot fungus, which is a fungus of the rye plant, and he serendipitously discovered lysergic acid diethylamide or LSD. I say serendipitously, because he was not seeking to create or discover a psychedelic medicine, but he did, and he took some of it as a kind of test on himself. And without knowing exactly what would happen, he took a very, very low dose on the order of a couple of hundred micrograms, thinking that it might not do a lot. He didn't know that LSD is tremendously potent. And so after taking a very what he thought was a very low dose, he then bicycled home. And this was April 19, 1943, which is an infamous date now in this world, which has since become referred to as Bicycle Day, because what occurred on that bike ride home was a rather peculiar and probably disturbing experience for him. I mean, he tripped and discovered that there was something significant going on with this medication. And so the pharmaceutical company that he was working with at the time, Sandoz, began synthesising lysergic acid diethylamide.

  Dr. Daniel Rosenbaum: [00:23:30] It was fully legal at the time, as I mentioned earlier, it was then distributed to psychiatrists, which was initially thought to be its value, helping the psychiatrist understand the experiences of their patients. And from there it it was recognised that it had potential therapeutic value. So it began to be used in some cases in conjunction with psychotherapy and in other cases more in isolation for the treatment, principally of alcoholism, as well as to help people prepare for death and dying, or to help treat anxiety and depression associated with serious illnesses like cancer or the terror associated with death and dying. And so in the fifties and sixties, there were tens of thousands of patients treated with LSD, another couple of thousand patients treated with psilocybin. Many thousand articles written. A lot of the studies did not have the same methodological rigour or ethical standards that the clinical research today does. But the results were intriguing and for the most part, research participants that the treatments were safe. Unfortunately, there was a large political backlash that occurred, which led to the scheduling of these medicines and the almost total banning of research involving psychedelics by the 1970s. And the political backlash followed basically from the associations between psychedelics and the counterculture movement of the sixties. So that infamous figures like Timothy Leary, who then President Richard Nixon called the most dangerous man in America because of his psychedelic evangelism, the famous phrase "Turn on, tune in, drop out." The use of these medicines outside the lab and I guess even inside the lab was thought to be too terrifying for the establishment, essentially.

  Dr. Daniel Rosenbaum: [00:25:27] And so all research was halted. I'll just mention briefly, there is a dark side, if you will, to the psychedelic history that I think it's important that we don't gloss over and people may be familiar with or have heard at least something about the CIA's use of an investigation into LSD. And this was part of the MK-ULTRA program. Canada also has a dark history to play here. There was a psychiatrist at McGill, in fact, named Ewen Cameron, who was part of the LSD experiments involving LSD. And in general, in a number of different places, people were frankly tortured in conjunction with the use of LSD. So people were put together in groups forced to take very high doses of LSD repeatedly. They were naked. They were fed through straws from a hole in the wall. I mean, really, really horrific kind of stuff. And for people who are interested, there's a great CBC podcast series called Brainwashed, which covers this history. And skipping ahead a few decades, there was the beginning of the so-called psychedelic renaissance, or the resurgent interest in psychedelic research, at least in the States, began in the nineties and into the early 2000s. And some of that work was done in California with Charlie Grob, a psychiatrist at UCLA, but also at Johns Hopkins, Roland Griffiths and his group. And maybe I'll leave it there because I feel like I've been talking for a while.

  Jake Johnston: [00:27:09] That was a terrific answer. And you've really sort of synthesised a complex, broad history down into a very nice narrative for us.

  Nikhita Singhal: [00:27:18] Yeah, it's certainly had a very turbulent course, both in medicine and in politics. And it seems like we're arriving now at an era where things may be showing promise and improvements in terms of a lot of the errors and things that happened in the past. You mentioned there's many exciting ongoing trials within the field of psychedelics. Now, what do we kind of know about psychedelics so far in terms of their efficacy and clinical potential for various psychiatric disorders?

  Dr. Emma Hapke: [00:27:51] So I think in terms of psychedelics moving through the drug development process, mostly in the United States, the one that's furthest along is MDMA assisted psychotherapy for the indication of post-traumatic stress disorder. And so that's in the second half of the phase three trial. So that trial has 16 sites, 12 in North America, there's two in Canada and one in Israel. And so they've published the first half of that in Nature Medicine, and the second half is recruiting and underway right now. Psilocybin is the next furthest along. So there's sort of two main groups that are moving it through the drug development process. So we have Compass Pathways, which is a for profit company that's moving psilocybin assisted psychotherapy through the drug development process for the indication of treatment resistant depression. And they've recently published their Phase two data. And I believe they'll be moving on to conversations with the FDA to start phase three trials next and then Usona Institute, which is a non-profit player, is also moving their formulation of psilocybin through the drug development process for the indication of major depression. And they have yet to publish their phase two results, but those should be coming soon. So that's sort of those two are the furthest along. And there's an emerging and fairly strong evidence base for psilocybin assisted psychotherapy at the end of life, which maybe I'll let Dan talk about in a moment, I'll tackle MDMA first, because that's sort of the literature that I'm most familiar with. So I think what we're seeing with MDMA assisted psychotherapy is at least for a significant portion of patients that take this treatment, that it is both a safe and effective treatment.

  Annie Yu: [00:29:43] So if you look at our phase three results, 88% had a clinically meaningful response to the treatment and 67% lost their diagnosis of PTSD by the end of the trial, and 33% went into complete remission, which means they lost their diagnosis of PTSD and they had something called a Caps five score under ten, which means very, very low symptomology for PTSD. And so that's at the end of an 18 week protocol, which includes three MDMA sessions. And what I think is important to note that these are people with severe and treatment resistant PTSD. So the average number of years that they had suffered in the trial was 15 years. They had high degrees of comorbidity, so comorbid childhood trauma, dissociation, history of substance use disorder. So this is a difficult to treat population that had failed other treatments. So failed pharmacotherapy that has been unable to gain benefit from some of the other evidence based psychotherapies for PTSD. So that's one thing. And what's also interesting is that we saw good results as well in people with those comorbidities. So they're also responding to the treatment. And in addition to the reduction of PTSD symptomology, we also saw reduced incidence of depression in the MDMA group and improvements on something called the Sheehan Disability Scale, which looks at sort of people's functional abilities and sort of domains of work in general life.

  Dr. Emma Hapke: [00:31:19] So it's interesting it seems to work in a significant proportion of patients that take the treatment. There's definitely still a group that don't respond that I think we need to study better and understand. And then the next question is, do these results last is are they durable? We don't have the long term follow up data yet from the Phase three study. But what we do know from Phase two is it does seem that the results are durable. So the phase two data, if you look at it a year later, again, 67 or 68% of people are showing that response. So it seems that with MDMA anyways for PTSD that what we're seeing is the results seem to be durable for the vast majority of patients. So it seems that it catalyses this process of healing and resilience that then allows people this ability to perhaps have greater resilience in the face of future stress or continue to their own self healing journey that's catalysed by the MDMA therapy. Things are less clear with the treatment of psilocybin assisted psychotherapy for depression, especially treatment resistant depression. So the Compass Phase two results were recently published, and what we're seeing is about 25% response at the 12 week mark, which is not insignificant for a population with treatment resistant depression. But there's still a significant subset that are not responding at 12 weeks. Now, in that trial, they just did one high dose session in one low dose session.

  Dr. Emma Hapke: [00:33:03] So I think one of the unanswered questions is, is  do people actually need more sessions with psilocybin assisted therapy to get a more prolonged and endurable response?  Also, I think what's important to note in the Compass trial is there was a higher incidence of serious adverse events around suicidality in the group that got the high dose psilocybin. Not statistically significant, but more than in the group that got the low dose. And so I think that's important to note because it brings up a lot of questions around the safety of this, especially since in most cases people have to be taken off their SSRI to participate in these trials. And that's another unanswered question is can people stay on their SSRIs and take psilocybin? And I think the jury's still out on that one. So we're taking people off of their treatments in order to participate. And  is there a risk involved there? And I think that, again, getting into that sort of hype disappointment cycle in the Compass results, it's the people that had those adverse effects were  typically the non responders to this treatment and so going off of their typical treatments to participate in this and then not getting a response I think has a potential to be harmful for people or at least there's some risk involved that people really need to consent to and to understand before they participate.

  Dr. Daniel Rosenbaum: [00:34:29] I wanted to make a comment or, you know, a plea for restraint is maybe one way to put it, just to call attention to the tremendous amount of hype that exists around psychedelics, a lot of which is driven from the commercial, corporate, for profit sector. And we've come to a place where it could be fairly argued, I think, that the hype has outpaced the state of the clinical research. So in terms of what we know for sure, what I feel most comfortable hanging my hat on is that results from the preliminary research in the contemporary clinical trials are promising enough clearly to warrant greater study. Again, well designed, methodologically rigorous study with a greater number of patients proceeding into phase three trials and so on and so forth. But I think we want to be careful not to say at this point, psychedelics are going to be the next breakthrough, revolutionary treatment, silver bullet, panacea that's going to fix mental illness.

  Dr. Emma Hapke: [00:35:46] Just add to that. I think that the hype is actually a really big challenge for researchers because there's so much coverage in the lay press about psychedelics and it's often not factual and the effects can be exaggerated. So people come in with these very high expectations that this treatment is going to work. And these people often feel very desperate because they've failed many other treatments. So they can be really set up for significant disappointment if it doesn't work. And that can actually present a number of really challenging ethical dilemmas for the field. And the other big challenge is - gets into some of the challenges in the field - is I think we clearly have enough of a signal that this is worth continuing investigating, but it's also a treatment that's very hard to study with our traditional methods of double blind RCTs because of this big problem in psychedelic research of blinding. So it's usually pretty obvious to the patient for the most part, whether they've received a psychedelic or not. And so that creates a whole host of methodological issues that the field is grappling with. And I think some people are even questioning, like, can we even conclude that this works when with some of these methodological challenges? So we need to be very cautious as we proceed. And I think we need to really educate our patients that this remains an experimental treatment, that it's not for everybody.

  Dr. Emma Hapke: [00:37:18] And the other thing that I say is that know what I was when I'm coaching people who are considering being in a clinical trial for PTSD with MDMA, it's a piece of work. I think it's harmful when people think that they're going to go into this trial and aim for a complete cure. I really think of the MDMA as a catalyst for your own psychotherapeutic process, and it's for people who are ready to go in and go deeper because we're starting to see the medicine and the container can start to strip away some of your defensive mechanisms like dissociation and numbing, for example. And if you're not ready to start facing what's coming up and you don't have adequate support internally and externally, that can be really challenging. And especially in a clinical trial which is not flexible, you can only have three treatments and then it's illegal. So you can't actually access it legally. So what if you find that you're starting, but then there's more work to do. That can be a real challenge for people. And we've noticed that at the termination phase of the study that some people feel there's more work to do. So these are things that I think we're all grappling with and there's no easy answers to them.

  Nikhita Singhal: [00:38:31] Thank you so much for mentioning those really important considerations. I think being cautious and aware of some of the risks is really key. And you've mentioned that another of the indications is end of life care. Could you tell us more about that?

  Dr. Daniel Rosenbaum: [00:38:47] The greatest area of clinical interest for me personally in this field is the application of psychedelic assisted psychotherapy in palliative and cancer care to help people prepare for death and dying, to help mitigate some of the distress associated with life threatening illness. And there's an interesting history to these research programs, again, at least as far as the US based research is concerned. At Spring Grove, the Maryland Psychiatric Research Institute in Maryland, of course, there was a program of LSD assisted therapy research for the treatment of alcoholism in the sixties, and one of the nurses involved with that was diagnosed with cancer. And I believe the story goes that she asked her fellow researchers to receive LSD to help her manage the distress associated with her condition. And from that emerged a series of research trials and a whole research program, including luminary psychiatrist Stanislav Grof, who initially did a lot of his work and Czech Republic before coming to the states, but also people like Bill Richards. And there's a wonderful book about this research program for people who are especially interested called The Human Encounter with Death, which Stan Grof wrote with his then wife, Joan Halifax. But what I can say is that between the mid sixties and up to about 1980, there were six open label trials of psychedelic assisted psychotherapy for end of life distress, existential distress, that sort of thing. Most of the participants had advanced cancer or terminal cancer. More recently in terms of the contemporary clinical trials, there have been four randomised controlled trials done since 2011, one of which included LSD and three of which used psilocybin. All of the psilocybin randomised controlled trials were done in the States and they were all based on the Spring Grove program developed by Grof and colleagues.

  Dr. Daniel Rosenbaum: [00:40:57] In all of the contemporary clinical trials, what we see is rapid, robust and sustained improvements in cancer related psychological and existential distress. Then in terms of the robustness, the effect sizes, these are relatively small studies, so the biggest of which was done at Johns Hopkins. A landmark paper published in 2016 by Roland Griffiths and colleagues had 51 patients, so not huge. But in terms of psychedelic clinical trials, this is quite a large study and the effect size in terms of reductions in cancer associated depression and anxiety are massive like really blows something like an SSRI or more conventional pharmacologic treatment for depression among cancer patients really out of the water. Again just highlight as a point of caution. This was not a head to head trial. It was not comparing a psychedelic to an SSRI, but just to highlight the really robust effect sizes associated with this intervention in these patients. Importantly, the intervention has been shown to be safe for people even with serious illness, which is very important because we're talking about people with potentially significant medical issues approaching end of life and so forth. So the two most important studies that have been done in this area thus far, both published in 2016, in the Journal, the same edition of the Journal of Psychopharmacology, one was the Johns Hopkins study that I mentioned. The other was conducted at New York University. The lead author is Stephen Ross. They're quite similar in terms of the study design, the patient population, the results, the NYU study.

  Dr. Daniel Rosenbaum: [00:42:41] It was really useful because it came along with a couple of qualitative research papers, one of which I always recommend to people who are interested in this area. It's called Cancer at the Dinner Table. It's a 2017 paper published in the Journal of Humanistic Psychology and the lead author there is Thomas Swift. And so in this paper, transcripts of participant interviews, which were done with the researchers using a semi-structured interview kind of questionnaire, were coded and distilled into themes. So this was a kind of interpretive, phenomenological analysis, and I'll just say, just will highlight the ten themes that emerged from participant reports about their experiences in the trial. Because this is I find always I find so moving and the language is so evocative. So first of all, participants experience the psilocybin session as very distressing. This is an immersive experience. It's not always ecstatic or it's not the same kind of use that you might that people might use recreationally for fun. I mean, Emma's already spoken about the fact that high dose psychedelic therapy is work and it can be really, really distressing. And so this emerged from the participant reports in this trial. Participants also reported that the psilocybin helped them reconcile with death. It helped them acknowledge the place of cancer in life. Uncouple emotionally from the cancer and to reconnect to life or to reclaim presence in the face of cancer or possible cancer recurrence. And one last thing I'll mention about this is that there is a lot of the participants had a spiritual or religious interpretation of the experience, and I think that opens a whole other door of conversation potentially.

  Dr. Emma Hapke: [00:44:34] I would just add that what we're seeing in the psilocybin literature, especially for the treatment of end of life distress, but also for depression, is that having a mystical experience which is measured on something called the MEQ, the mystical experience questionnaire, seems to mediate positive therapeutic benefit in the psilocybin literature. And so I believe it's approximately 70% are having a complete mystical experience in those end of life population using psilocybin. What's interesting in MDMA, it's closer to 40% are having a mystical experience. So it's lower and it doesn't seem to connect to positive therapeutic outcomes. So we think that the MDMA may facilitate more an ability to process trauma as opposed to connect to the mystical, although that element and the transpersonal element is very much still present with MDMA.

  Nikhita Singhal: [00:45:29] Thank you both so much for that. I think we've kind of covered some of the what the evidence has shown so far. Maybe to give our listeners a better idea, maybe hand it over to Annie for our next question, what this actually looks like for sure.

  Annie Yu: [00:45:45] So in our discussion around some of the evidence and literature around psychedelics, the term that popped up was psychedelic assisted psychotherapy. So it sounds like aside from just the psychedelic treatment itself, it's generally paired in both clinical and research settings with more guidance using psychotherapy. So can you maybe walk listeners through what the components of psychedelic assisted psychotherapy looks like and what a typical session session looks like in your respective practices?

  Dr. Emma Hapke: [00:46:21] Sure. So when I think about psychedelic assisted psychotherapy, I like to think of a triangle. So at the top we have the therapeutic modality and there's research going on into like what is the best type of therapies to pair with different psychedelics for different indications, but you have the actual therapy itself. Another point on the triangle would be the therapeutic relationship, which we know for any psychotherapeutic process, that is a really important mediator of a successful outcome. And then on the third point of that triangle, we have the drug effects, which I really see as a catalyst, catalysing the psychotherapeutic process, and then inside the triangle, I imagine the patient's own inner healer. So in some of the models that I've been trained in that come from Stan Grof and other sort of pioneers in the field, they talk about this idea of the inner healing intelligence. And you think about it just as the body moves towards healing. For example, let's say you cut your arm, you go to the emerg. The Emerg doc might clean it out, even suture it. But it's your body that heals that from the inside out. And similarly, your psyche wants to move towards wholeness. And sometimes what we're doing in the psychedelic state is we're removing some of those blockages to allow your own natural inner healing intelligence to work. And so really in this model, we're really trusting the patient's inner healer and the patient to allow up the thoughts, feelings, memories, sensations that are most in service of their healing. And especially in the integration phase. It's the patient's inner healer that's the has the ultimate authority on interpretation and meaning making, and we're really following that.

  Dr. Emma Hapke: [00:48:10] So as a therapist, you're following the patient's lead. A typical course of psychedelic psychotherapy would typically have two therapists and involves three main phases. There's a preparatory phase, there's the dosing or the medicines administered, and then there's an integration phase, and you'll hear these terms set and setting. And I think they're really important to be aware of when we're understanding psychedelics. So the setting is the physical environment in which the person takes a psychedelic, but it also includes the psychotherapeutic environment that's created by the therapeutic relationship and the entire container in which the experience is going to unfold. And we pay a lot of attention to that. In psychedelic therapy, we want people to feel at ease so that they can trust the process, trust the therapist, trust themselves. And so you'll often see psychedelic therapy rooms look less clinical. There's dim lights, there's art, there's plants, and there's a bed. The patient in the dosing session will lie down. They'll typically have eye shades on. There's music played throughout, which also supports that setting for the person. And part of why the setting is so important is because psychedelics induce a greater state of neuroplasticity. So we're really seeing this especially in the psilocybin literature, but also for MDMA. So it's inducing these states of neuroplasticity, which is why the setting in which you take it is so important. And that's happening both while you're being dosed with the medicine, but also in the time that follows. And that's when the integration phase is also really important because the brain is more changeable.

  Dr. Emma Hapke: [00:49:54] And so what you do in that time after really matters in terms of set. What that refers to is sort of the mindset of the person going into the experience. And so it includes things like their intention, how they're feeling that day and what work they've done to prepare. And so the preparation phase, it varies, but typically would be at least three sessions that are 60 to 60 minutes to 2 hours long, where the therapists are really getting to know this patient, they're getting to understand their life history to connect with them. You're beginning that process of trust building and you're providing a lot of psychoeducation on the effects and what they might what they might experience in the psychedelic state. And one of the things that we really encourage people in the preparation phase is to trust and surrender to the experience as much as possible. So the more that you're able to surrender and open up in the psychedelic state, they're more able to access these expanded states of consciousness that can be really healing. And so we also encourage people to move towards things that are difficult and to adopt the stance of curiosity towards the darker elements that might come up. And there's something very transformational that comes from moving towards something that's difficult and working through that and coming through the other side of it. And that's one of the mechanisms that we're learning seems to be facilitated by psychedelic therapy, is overcoming experiential avoidance, which can often maintain a lot of psychiatric disorders. The integration phase then is a, I think, there's two main things that are happening in integration.

  Dr. Emma Hapke: [00:51:38] One is meaning making. So the person is continuing to process what came up and connect the dots and understand how might this apply to my life. And often some lessons will emerge that then they want to then try to implement to make change in their life. And then the second part of integration I think of as practices to maintain that sense of connection that they felt in the psychedelic state. So really encouraging people, especially in the days and weeks that follow, to take time to go inward, be it journaling or art or time in nature, meditation, whatever works for them to reconnect to themselves and to try to continue to maintain that sense of connection. And I think the sense of connection is, again, one of these what we're learning is sort of one of the mechanisms of action when I think about trauma in particular, but really a lot of psychiatric illness, a state of disconnection from yourself, from others, and then from something bigger than yourself are really, I think, predominant themes that we see in a lot of psychiatric illness. And I think the psychedelic state has the potential to help people feel more connected. But then in the integration phase, it's like, how do you maintain that? I think communities of practice and communities of patients who have received this kind of treatment that can connect to each other in an ongoing fashion after is going to be part of what really increases the chance that people can maintain the gains that they're seeing in the immediate post session phase.

  Dr. Daniel Rosenbaum: [00:53:08] Emma mentioned set and setting. Set as having to do with someone's degree of preparedness heading into the experience, the intention they bring to it and so forth, and setting being for the most part synonymous with environment or the surrounding influence of the environment. So you can imagine if someone takes a handful of mushrooms at a music festival and they're surrounded by thousands of screaming people, and there's lots of stimulation in the form of loud noises and flashing lights and so forth that they might be more likely to have a challenging experience, to have a bad trip, so to speak, even if their intention is to have a good time with others. On the other hand, if someone takes the same dose of mushrooms with a loved one who they trust very much and who will be taking care of them in an idyllic setting like a meadow, and their intention is to connect with nature and have a peaceful experience then the kind of experience they have will likely be quite different even though it's the same medicine at the same dose that they're taking. So I think that's a helpful illustration of the importance of setting in terms of set, the mindset, the preparation. Think about the same meadow, the same couple, let's say, and someone comes across some mushrooms in the meadow and they decide to take the mushrooms because they figure they're edible mushrooms. If they don't know that they're psychedelic mushrooms and within an hour they start to trip out, they're liable to go to the emergency department because they're not prepared, they're not expecting, they don't have the intention to take a powerful psychedelic, to have an experience of connection with nature or whatever. And so I think that's been a helpful way for me regarding the importance of those factors.

  Dr. Daniel Rosenbaum: [00:54:54] And why that's important is that the quality of the acute drug experience has been shown across human studies in various indications to predict, be correlated with or mediating the long term outcomes. So the acute drug experience is key. And one of my favourite findings in the field of psychedelic science comes from regarding the nature of the acute drug experience and how it leaves people afterwards is a healthy volunteer study from Johns Hopkins. So this was one of the early studies that constituted the psychedelic renaissance and really, I think, kindled people's interest in this. So researchers at Johns Hopkins offered people synthetic psilocybin under blinded conditions. So they told people that they might get a variety of drugs. And under blinded conditions in a hospital room with guides and in the same kind of setting that I described with eyeshades and the headphones, and in a comfortable living room like environment, people who took a high dose of psilocybin reliably reported that it was either the most or among the top five most personally meaningful experiences of their lives. If you stop and consider that for a moment, I think you'll find that it's remarkable. It's incredible. The same is true that the researchers always used readings of spiritual significance, and people also reported these experiences were among the most spiritually significant of their lives. And so both in terms of personal meaning, meaningfulness and spiritual significance, people talked about them as being akin to the birth of a child or the death of a parent. So clearly something profoundly moving is happening for people in relation to these experiences of taking a high dose psychedelic under the appropriate set and setting.

  Dr. Daniel Rosenbaum: [00:56:45] The only other thing I'd add to that is, you know, in a clinical context, it's still common for parts of the experience to be quite distressing or challenging. And it's just that I think one of the differences in a clinical setting is that the person has support and feel safe to actually work through those challenging experiences, which can then lead to this feeling of resolution, which can then often lead into these transcendent and ecstatic states. And so people will also describe them as some of the most challenging experiences of their lives. But it's the resolution of that that also seems to be healing.

  Chase Thompson: [00:57:25] I think that leads to an important question that I have, which is, you know, in that study that you mentioned, and it sounds like people are describing some of their experiences with psychedelic psychotherapy experiences, some of the most important in their lives. I think some people might hear that and think about ethics. Whether that's something that should be happening in a medicalized setting with patients, doctors versus friends and colleagues. And I think from the psychedelic community, there's been some pushback that psychedelics should not be administered in a medical setting and should be kind of more available in the community for people to just do given that they're very physiologically safe and that there's a low risk of harm from medical causes. I'm just wondering if you have any thoughts on kind of the movement of psychedelics into a more clinical setting? And what are the ethical implications of having this really significant or profound experience with your doctor, say, versus your friend or partner?

  Dr. Emma Hapke: [00:58:36] Yeah, I mean, I think one thing that comes to mind there is that for people with psychiatric distress and psychiatric illness, such as trauma, having somebody who's trained in trauma informed psychotherapy, who's bound by a regulatory college, who has training in psychedelic assisted psychotherapy, I think can increase the chance that this is a healing experience and it can increase the safety of the experience. So for people that are really suffering with these treatment resistant conditions, I think there are certain risks when taking them outside of a clinical setting. So I think that's one thing. I think that you bring up an interesting question, which is sort of what is the role of spirituality in modern medicine? It's been largely divorced from and when we're taught to formulate us in psychiatry, we're taught the biopsychosocial model. But I've also wondered what about the biopsychosocial spiritual model? Because it's often those things that are greater than ourselves and doesn't necessarily need to be a specific religion, but it could be meaning and purpose or a sense of connection to nature. Or just connecting to something that's bigger than you is fundamentally really healing. And I think thinking about that in the context of healing as psychiatrists is actually important, but it brings up a question of training and exposure. And I think that there's a real role in psychedelic medicine for interdisciplinary teams. Like on one of our teams, we're bringing on spiritual care providers, for example, who can really help us in the preparation integration phase with patients who've had these complete mystical experiences, which can be paradigm shifting for people who have previously had no sense of that kind of connection. So I think training and interdisciplinary teams in our ways to address some of these ethical issues and I think it's also a really important area of study. So those would be some of my initial thoughts. Dan, do you want to add anything?

  Dr. Daniel Rosenbaum: [01:00:47] Yeah, I'll add a couple of things and I'll just say it. It's a great question and it brings to mind quite a lot of considerations, a few of which Emma's already touched on the study that I was referring to with the healthy volunteers at Hopkins and the personal meaning and spiritual significance that people derive from the psychedelic state. I think there's a way to take those results and come away with the view that the psychedelic experience is itself intrinsically healing. And I think that's a partial misread because again, talking about the critical importance of context, the people in the study were offered a high dose psychedelic in the presence of trained guides and therapists. They had been prepared for the experience extensively, and in the end, following the experience, they had opportunities to process challenging material and to. There was a clear and explicit invitation of frame to make meaning from the experience. So I think it's probably more helpful to think of the psychedelic experience. I mean, setting aside for a moment the awesome, literally awesome and profound kinds of subjective things that might go on for someone but the experience opens a window of change. And this is the sort of recently proposed terminology about psychedelics as psychoplastic, meaning that you're opening up a critical window for change and that that window itself is outcome agnostic and that we can expect a greater potential for healing.

  Dr. Daniel Rosenbaum: [01:02:40] And I'm not saying that that has to be done in a hospital with a psychiatrist per se, but with people who are trained to work with the medicines, who are trained psychotherapist, as Emma was alluding to, that that's where a greater potential for healing can come and where harm can be reduced, I think to a greater extent. I don't know that bio psychiatry has yet to come to a good, doesn't know exactly where to place this treatment paradigm. It's a complex intervention and clearly it kind of straddles a number of perspectives. It's not a pure pharmacology. It's not pure psychotherapy. It seems to invite this this marriage of the two: the psychological, the biological. It invokes the spiritual. I mean, words like mystical experience appear in the German Journal of Psychopharmacology, and it rests on a great deal of indigenous traditions and wisdom. So there's really a lot of paradigm and perspective straddling going on that it's just  key that we recognise all these perspectives being brought to bear and that we're thoughtful about offering these treatments to people. And that sets aside altogether the question of decriminalisation, legalisation, recreational use and so on, which I hesitate to get into too much at the moment.

  Chase Thompson: [01:04:04] I think one of the things that you've also mentioned is having a challenging experience and and that's the so called "bad trip" can sometimes arise and whether that occurs can be influenced by the setting that one uses psychedelics in. And so  I'm wondering, in a more clinical setting, how common is it for people to have challenging or bad trips and and does that lead to a poor outcome for people? I think many in the general population may have a notion that's having a bad trip, for example, could produce lasting psychological damage or even trauma.

  Dr. Emma Hapke: [01:04:45] So I think that in some of the trials, they see something called anxious ego dissolution, which is when as the psilocybin is coming on and the sense of self is starting to soften, that can be really terrifying for some people and can induce this these states of terror and panic. And I've seen rates around 30% in some of the trials. So it's not insignificant, but that doesn't necessarily mean that it's going to negatively impact the outcome. And it's very often that as people work through those really intense, challenging moments of a trip, that that in of itself is actually healing. And so, one, I could draw your attention to the Zendo Project because they have these principles of harm reduction that they use at festivals for people. And this idea that there's no bad trip, that no matter what happens, this is data that's coming up. And if the person is able to work through it in the integration process, though, it can be challenging. It still has the potential to be healing. And so I think that's something that's really important for people to keep in mind, especially if they've had their own difficult psychedelic experience and they're not knowing what to do with it. Finding an integration coach or somebody that's experienced with psychedelic integration can be really helpful because even if you're still feeling like something's opened and it hasn't closed or I have so many questions or I'm feeling really unstable, there's work that can be done and integration can go on for months or even years after a psychedelic experience for people.

  Dr. Daniel Rosenbaum: [01:06:14] The qualitative study that I mentioned out of NYU, in their cancer psilocybin trial, they said almost everyone referred to the immersive and distressing nature of the psilocybin experience. There are a few quotes from that cancer at the dinner table paper about people being being brought right to the brink of what they can tolerate. And what I think what that experience is like is, as I mentioned, sometimes terror, anxiety. People can even have transient experiences of paranoia during the psychedelic session. This again speaks to the trust and presence of trained guides so that during the experience the participant can seek support if needed, whether that's gentle touch in the form of hand-holding or to say, I'm really scared, I'm having a hard time. And the response that they would typically be met with is, You're safe, we're here with you. Everything's unfolding the way it should be. And people are encouraged to go into that experience and to be curious about it. There's a story which I hope I won't misrepresent too much in Buddhist psychology about encountering one's demon and one's demons and inviting them, welcoming them. And to the extent that you can tolerate it, being curious about it. And I think that's where, as Emma was alluding to, a lot of the healing can happen, going through the challenging material and going all the way back to one of the initial questions about the ways in which psychedelics may be different from conventional pharmacotherapy is a lot. In a lot of ways, pharmacotherapy is like SSRIs for the treatment of, say, depression or anxiety disorders can be understood as suppressive, which means that they suppress some of the distressing symptoms of those illnesses. And there's a great paper from Robin Carhart-harris and David Nutt about it's called A Tale of Two Receptors, and it examines the differences between SSRI mediated serotonin 1A receptor signalling which governs this sort of suppressive response compared with the psychedelic mediated, serotonin 2A receptor signalling, which has to do with working through. That distinction, is maybe helpful.

  Chase Thompson: [01:08:40] Yeah. Just to note, I would direct our listeners just to our previous episode with Dr. Carhart-harris. We actually talked about some of those differences with him for overview. If you're interested on the differences between the more suppressive effects of SSRIs and the activating effects of psychedelics, and it's episode 27, just for reference.

  Dr. Emma Hapke: [01:09:02] I think the other thing that this brings up is the question of how to train therapists to hold space for people in psychedelic states. So I think an unanswered empirical question is whether having your own psychedelic experience as the therapist gives you a greater competence or confidence or ability to hold space for people. And that's a question we hope to maybe start to address empirically at the Nikean Centre that we're developing. And, you know, as as I said, it's an unknown question. But what I will say is that things can look really rough from the outside of when you're watching somebody on a psychedelic, it can look terrifying. It can look like they are in so, so much distress. And there can be a very strong urge to want to help and try to get them through that and try to stop what's going on. Or a guide who's not experienced with, you know, not necessarily psychedelics themselves, but just psychedelics in general could really think there's a problem here when actually everything is unfolding just as it's meant to. And when the guide trusts the psychedelic state and the person and the medicine and the container and doesn't get too worked up about what they're witnessing, I think that really creates a greater state of trust in the patient. And so that's one possible reason why having your own experience may allow you to better hold space. But like I said, we need more research on that.

  Nikhita Singhal: [01:10:33] Thank you both so much for for walking us through that. And I think we've touched on a lot of the challenges, the risks and and you mentioned some of the upcoming work. So I guess I'm curious to hear what what do you see as kind of the future of this field moving forward? What are you most excited about investigating and what are what are you working on now?

  Annie Yu: [01:10:52] So I think, you know, one of the things that I'm really curious about is how is this how are these treatments going to be integrated into the public health care system in Canada and down in the States, of course, into their more complex health care system with all the different insurers? The last I heard, MDMA could be regulated by the FDA in Q4 of 2023. So this treatment is coming down the pipeline very soon. And in Canada, we recently had the government open up something called the Special Access Program, which potentially creates a route for a physician to prescribe MDMA for a patient with severe and life threatening PTSD. And I think we're going to see in Canada a lot of for profit clinics potentially trying to provide these treatments. And I think one of the things that really concerns me is how are we going to create equitable access? I would hate to see this treatment only be available to the elites and those who can afford it. And I think in Canada we really need to watch this creep of privatisation in our health care system where we have a universal health care system. So I think some of the work that we hope to do at the Nikean Centre over time is collect data both on patient safety and quality improvement, but also to create a cost benefit analysis for OHIP, which is our provincial insurer here in Ontario, really create the business case of why the government insurer should cover these treatments. That's a stage once we really are confident that the treatment works. So that's one piece that I've been thinking about.

  Dr. Daniel Rosenbaum: [01:12:41] As I said earlier, the area of interest that most excites me in this field is the potential application of psychedelic therapy and palliative and cancer care. And in that regard, actually, maybe first I'll mention that a great paper that was published in 2021 by Yvonne, a palliative care physician in the States, who, with his colleagues and after convening a conference of experts and soliciting opinions and so forth, set out a research agenda for psychedelic assisted therapy among patients with serious illness. And they highlighted it as actually four areas of opportunity. And I think our research group here at UHN, which has developed a psychotherapy intervention called Pearl, which stands for Psilocybin, Assisted Existential Attachment and Relational Therapy. Which I can say more about in a moment. But we're trying to operationalise these four opportunities in terms of advancing research in this area. So one of which is clarifying indications. Is it important, for example, that someone carries a diagnosis of major depressive disorder in addition to their advanced cancer in order to qualify for or benefit from a course of psilocybin assisted therapy, these researchers identified the development of clear therapeutic protocols as important. So in response to that, that's part of how we and why we developed Pearl therapy. Investigating the impact of set and setting.

  Dr. Daniel Rosenbaum: [01:14:23] This is key. One major element of set and setting, which we haven't talked about and which I think again is a big open door that we can spend a long, long time on is the role of music in psychedelic therapy. And so we have a wonderful PhD music therapist on our team, and we might begin to pose some questions about the role of music and psychedelic therapy for people at end of life. And then finally continuing to further the understanding about mechanisms of action. So thinking about at the biological level, the psychological level, so what kinds of psychotherapeutic processes are at play over the course of psychotherapy, not just in the psychedelic session? And then of course however you might characterise or whatever language you might bring to bear on the psychedelic experience itself, which often leads into the terrain of the spiritual. And so in this regard, we're also planning collaborations with spiritual care providers and chaplains, both to help in the spirit of training and making sure that our therapists are most well equipped to work with people who are experiencing these profound states. Also thinking about in terms of the mechanism of action, what is going on? How can we best understand this so that we can best help people in the future?

  Dr. Emma Hapke: [01:15:34] I think a lot of those questions also apply just more broadly in the field. So figuring out what indications are best treated with which psychedelics in combination with which types of psychotherapy. So for example, people have combined access ACT, which is Acceptance and Commitment Therapy with psilocybin for depression. There are studies that are going to be happening in Toronto that combine cognitive processing therapy with MDMA for the treatment of PTSD. So what existing psychotherapy is best combined with which molecules for which indications I think is going to be really interesting work. And then, as Dan said, a greater understanding of the mechanism of action and biomarkers both biologically, also psychologically and also spiritually, and really trying to understand how this treatment works. And I think moving eventually to personalised medicine, which I think the entire field is going to hopefully move in that direction. So can we actually scan somebody and interview them and figure out where what type of psychedelic is best? Where do we start? I think down the line you may actually see like a menu of psychedelics. Maybe you start someone, for example, with PTSD, with some ketamine, which can allow them to feel good in their body again, which can help them get used to being in a non ordinary state of consciousness. Then they might move on to processing with MDMA or psilocybin. So I think really understanding the person's unique makeup, both genetically and psychologically, will help us better figure out which psychedelic in which treatment is going to help them the most. So just a couple other things that I think we're really interested in at the Nikean Centre. One is this question that I mentioned earlier of how do we train therapists and studying experiential training through things such as whole entropic breathwork, which is a form of breathing that can induce a non ordinary state of consciousness and may provide a way for therapists to have some experience of both holding space and being in a non ordinary state without having to take a psychedelic.

  Dr. Emma Hapke: [01:17:42] And then also potentially what is the role of having an actual psychedelic as part of your training? And that's being used in the ketamine model of training pretty commonly is therapists will receive their own dose of ketamine when they're training for that, but hasn't been studied. So that's, I think, something that's really interesting to us. I think another question that the field is grappling with that I think is really important to keep on the forefront, is remembering that using substances to induce a non ordinary state of consciousness comes from indigenous cultures around the world. And this question of how do we incorporate indigenous worldviews into the training of therapists without appropriating their cultural practices and with making it suitable to our own setting and culture while also honouring what they've learned, including their their knowledge and working in the unseen and working with spirit. So these are really important questions to grapple with in this. You have indigenous reciprocity that we're not just taking something and potentially capitalising on it in a for profit model, but actually giving back and working with Indigenous healers and indigenous teachers. When we think about the design of curriculum and also when we think about the actual treatments and especially when we're treating patients from an indigenous background. So that's just something I wanted to mention as well.

  Nikhita Singhal: [01:19:07] Thank you both so much. It's been an incredible episode and I think our listeners have learned so much and we have as well, I guess, tying things up. Do you have any recommendations for people in terms of learning more like a favourite book, podcast movie in this field? And are there any last thoughts that you want to leave our listeners with?

  Annie Yu: [01:19:29] I'll do a little plug for our research centre. So we've co-founded the Nikean Psychedelic Psychotherapy Research Centre at the University Health Network in Toronto, and so we're Canada's first non-profit academic research centre, and we're really hoping to develop an academic and innovation hub for psychedelic assisted psychotherapy in Canada and abroad. So you can check out our website. Nikean is spelled "N I K E A N," and you'll find us and you can learn more about the work that we're doing and we're always accepting donations as well. So if you're looking to donate to psychedelic research in Canada, we of course would welcome that. In terms of training, we are going to be developing a training program through the Nikean Centre that will launch in the fall. I think you're going to see a number of trainings popping up all over. So I think it's really important that you do research on the training program that you're considering, too. If you're really keen on being a psychedelic therapist and you're already part of a regulated health profession or in training to do so to programs that have a really good reputation would be the certificate in Psychedelic Therapy and research at the California Institute of Integral Studies. So I'd recommend checking them out. And then MAPS is also doing a lot of training, specifically around MDMA assisted psychotherapy. And both Dan and I have done their training program and it's really good. So those are a couple really reputable ones. There's going to be a lot popping up, so make sure you do your due diligence and ask questions about what they're offering and who's teaching.

  Dr. Daniel Rosenbaum: [01:21:11] Yeah, and I'd just like to add, I'd like to start by expressing my gratitude for the invitation to be here and to participate in this podcast series. I think it's wonderful that you're covering this area, of course, being a researcher and someone interested in the field. Nikhita, you talked about a favourite podcast. I mean, if I'm right, this is one of what will become a series around psychedelics, and I look forward to listening to future episodes of this podcast around psychedelics. And I would also direct listeners, as has been done already today, to the episode with Dr. Robin Carhart-harris. But thank you so much for being here and directing the conversation.

  Annie Yu: [01:21:51] Yeah, thank you guys so much for your interest in this area. You know, it's exciting in mental health to have a new treatment and really a new treatment paradigm on the horizon. And so I think we all owe it to ourselves and our patients to learn more about this area. So thank you so much.

  Nikhita Singhal: [01:22:10] This concludes our episode on Psychedelic Assisted Psychotherapy with Dr. Mahaffey and Dr. Dan Rosenbaum. And we hope it may be the first, as mentioned, of a series of episodes that focus on this topic. Psyched is a resident driven initiative led by residents at the University of Toronto. We're affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Chase Thompson, Jake Johnston and you and Nikhita Singhal. The audio editing was done by Nikita Singhal. Our theme song is "Working Solutions" by All of These Things. Special thanks to our incredible guests, Dr. Emma Hapke and Dr. Daniel Rosenbaum, for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com Or visit us at psychedpodcast.org. Thank you so much for listening.

Episode 42: Interpersonal Psychotherapy (IPT) with Dr. Paula Ravitz

• Episode 42: Interpersonal Psychotherapy (IPT) with Dr. Paula Ravitz

  Jake Johnston: [00:00:15] Welcome to PsychED, the Psychiatry podcast for medical learners by medical learners. This episode covers Interpersonal Psychotherapy or IPT for short. I'm Jake Johnston, a fourth-year medical student at UBC, and I'll be hosting this episode. I'm joined by my colleague Sena, who will be co-hosting. Sena why don't you introduce yourself?

  Sena Gok: [00:00:36] Hi. I'm Sena Gok, a doctor with international training and huge passion for pscyhiatry. I'm really excited to be here!

  Jake Johnston: [00:00:44] Awesome! Thanks. And last but not least, we have the privilege of hosting Dr. Paula Ravitz as our guest expert for this episode. Dr. Ravitz is an associate professor of psychiatry at the University of Toronto and senior clinician scientist at the Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital. She was the director of Psychotherapy, Humanities and Education Scholarship Division, the University of Toronto Department of Psychiatry. Dr. Ravitz is also one of three authors on the latest Canadian Psychiatric Association position Statement on Psychotherapy in Psychiatry, just published in November 2021. The last position statement was published in 2003. Dr. Ravitz, would you like to introduce yourself?

  Dr. Paula Ravitz: [00:01:27] Sure. First of all, thank you so much, Jake and Sena, for inviting me to participate in this. And it's my pleasure to be able to share some ideas about Interpersonal Psychotherapy. IPT I have been involved in teaching and practising and also researching IPT for the last 20 years or so, and I'm delighted to be able to share some of the ideas about the core principles of IPT in this episode for interested learners.

  Jake Johnston: [00:02:09] Thank you so much for coming on to this episode, Dr. Ravitz. We are truly lucky to have you. Without further ado, I will launch into our learning objectives. By the end of this episode, you should be able to one define Interpersonal Psychotherapy to describe the core principles and phases of IPT. Three become familiarized with some psychological theories underpinning IPT. Four, List some patient selection considerations for IPT. Five, describe the efficacy and evidence base for IPT. Six, understand how IPT is practically carried out. Seven, briefly compare and contrast IPT to other common psychotherapies. Now the learning objectives are out of the way, Dr. Ravitz will take us away. We'll start off with the question; what is IPT?

  Dr. Paula Ravitz: [00:03:05] Well, first of all, I think IPT is predicated on the centrality of relationships in our lives. Relationships matter in health and disease and resilience, in coping with stress and in recovery from illness. So this is the rationale for IPT, which is a time limited psychotherapy model that focuses on relational aspects of experience and mental health. And there's a strong evidentiary base. I know we're going to get into that a little bit later, but there are both phase and focus specific tasks of IPT. So there's a beginning, middle and end phase. Generally it is anywhere from 4 to 16 sessions. In my clinical practice and teaching, I use a 12 session model of IPT and in many low and middle income countries we use a briefer version of IPT. So for example in an implementation project we did a number of years ago in Ethiopia, we used a 4 to 8 session model of IPT. Generally. I know there are a number of questions, but the beginning phase of IPT is similar to what we do in psychiatry and an assessment. So we begin to establish an alliance with the patient. We learn about what they're struggling with. So that's what we do in the diagnostic assessment and in the history of presenting illness. So we learn both about symptoms about, but as well in the story of the context of what's going on in their lives right now.

  Dr. Paula Ravitz: [00:05:05] And IPT focuses on these universal life events of loss of change and of conflict and relationships that are often associated with the onset or worsening of symptoms. And so there are therapeutic guidelines for the middle phase, for grief, for what we call role transitions, which has to do with large life changes. And that happened to us all. We all have multiple social roles which kind of determine what we expect from one another, depending on kind of the social roles. And social roles change inevitably in a lifetime, and sometimes the changes are planned and wished for and sometimes they're unplanned and I've wished for. And these can be associated with distress or symptom onset or worsening. And then of course there are conflicts or non-shared expectations that can unfold in relationships and that are often kind of the salt in the wound and IPT is predicated on this idea that what happens in our relationships and what might unfold in terms of symptoms or distress are bi-directionally linked. So it's when people are in a state of depression, it's often more difficult to engage or utilize social supports. And similarly, when there are difficulties in relationships or people are more disengaged or in conflict or they've experienced losses in their social network, that can also exacerbate or contribute to symptoms.

  Jake Johnston: [00:07:00] Thank you so much for that eloquent overview of IPT. It sounds like it's somewhat of a feedback loop where relationships feed into mood and mood feeds into relationships. With that, I'll pass the mic over to Sena for our next learning objective.

  Sena Gok: [00:07:19] Thank you, Jake. So, Dr. Ravitz, could you please tell us further about the core elements of IPT?

  Dr. Paula Ravitz: [00:07:28] So in terms of the core elements, first of all, I want to emphasize common factors in psychotherapy that I think apply to every therapeutic engagement session, whether we're providing follow-up psychiatric care, doing a psychiatric assessment or delivering any of these evidence supported psychotherapy models. So these are included in the core elements. So first and foremost, it's really important to establish a therapeutic alliance in which there is a trusting bond. And we need to earn our patient's trust and we need to actively listen, use empathy, engage with our patients with positive regard, seeing them for their strengths, for their healthy wishes to recover and to find their way to feeling and doing better and for receiving care and help in a time of need. The core elements as I mentioned, there are three phases of IPT. So in the beginning phase of IPT, in addition to conducting an assessment of symptoms, getting agreement on the patient's goals and at a very high level, the goals of IPT are the same as we have for all medical care to help our patients feel and do better. And the way we do that is by helping them to connect with support of others. We try to identify one of four interpersonal problem areas or focal areas of IPT. The four focal areas have to do with what I've already alluded to. Grief is one of them related to loss of a significant other.

  Dr. Paula Ravitz: [00:09:39] Role transitions, which has to do with life changes, for example, becoming coupled or becoming separated, becoming a new parent, moving, migrating, whether it's chosen migration or forced migration, graduating from a training program and starting your new role as a practising professional. So starting a new job. Losing a job. So life changes, as I say, are kind of very common. There's lots of literature of IPT in perinatal depression for people who are becoming new parents and a very strong evidentiary base as well. There's lots of evidence for IPT, for different age groups. So in adolescence there's lots of life changes as as young people begin to affiliate more with peers and get a sense of their identity separate from their families of origin. And in adjusting to a medical illness that might be disabling or life shortening or disfiguring and in in late life, right. Adjusting to retirement or the loss of some of a functioning or certain social roles. There's also role disputes where there's non shared expectations and then there's a default focus that in earlier manuals of IPT was called interpersonal deficits. I think many of us see that term is somewhat pejorative. And so what I tend to use is the more 21st-century term of interpersonal sensitivities, and that's for individuals where there doesn't seem to be any clear life event associated with onset or worsening. But oftentimes as we dive into the work, we will learn of smaller life events.

  Dr. Paula Ravitz: [00:11:43] But it's for individuals who have difficulties with forming or sustaining relationships and as I said, in the middle phase, we are guided by those focal areas which each have a set of therapeutic guidelines. For example, with social world transitions, we will explore the change. What do people miss and what are they grappling with? There's a sense of grieving, if you will, over positive aspects of what was and struggling with some of the challenges or negative aspects of the new role. And I like to divide the middle phase into two parts. Early middle is about deepening understanding. In the late middle phase, patients often become more emboldened, regain a sense of agency, begin to connect with support of others as they problem, solve and find ways to manage the new role. We focus very much on what happens in communication. So communication analysis is something that we do a lot of in the middle phase where we understand I like to think of it as way more than fact finding. We understand problems with understanding, with empathy, with non-reciprocity. We might brainstorm and do role plays or marginal role plays in order to help our patients clarify what their expectations are, how they might express them. And in the process of doing communication analysis, we often use principles of mental sizing, right? This idea of that, we all have thoughts and feelings and expectations of one another. These thoughts and feelings are not necessarily known. They're sometimes opaque. And sometimes what we assume in terms of what's happening in others may or may not be true. Right? So this is where I might intersect with some of the principles of cognitive therapy. Excuse me, in the early phase, I forgot to mention we really focus on what we call the interpersonal inventory. Getting a sense of who are supportive, others and which relationships and which focal area we want to work on. We try to limit the focus to two areas. Even though all there might be salience in all four areas because it is brief and it is structured so we mark time. I like to use validated measures such as the PHQ-9 and the GAD-7 and of course in research studies we'll monitor those symptoms week to week. But in usual clinical care you want to have repeat measures, so you want to do it at least three times beginning, middle and end. Or if you're doing a 12 session model, you might want to do it at least monthly or every few sessions. Remembering that there's a whole literature on self-report versus clinician rated symptoms, there's going to be a subset of patients who continue to endorse high. And you might notice as the clinician that they seem to be getting better, in which case you might want to do a HAM-D on them, a clinician rated, and see if there is a mismatch. There's also a subset of patients that seem to under-report, but you get a sense that they're suffering in functional.

  Dr. Paula Ravitz: [00:15:41] Their struggles with functioning are more profound. So, we use measurement-based care, but we also want to use our clinical judgement. And then in the final phase of IPT, again similar to the beginning phase, which I think can be used in any therapeutic episode of care, right? It's about kind of doing an assessment, getting a sense of what's going on, where the problems are, where we might help our patients to find resolution to those problems. In the ending phase. I find that the termination phase tasks of IPT are very much generalizable to any episode of care, such as discharging someone from an inpatient stay or from a course of treatment in a day hospital program and in the termination phase we try to consolidate gains. So we look back and we'll ask patients thinking back to when we first started and now what are you taking away and what's your sense of kind of how you're feeling or doing differently or how things have changed? And so if I was a fly on the wall and I was doing competence ratings with my IPT hat, I could tell whether you were in a beginning, middle or ending phase. The ending phase is we need to be very deliberate in our practice in order to consolidate gains.  There's going to be a subset of patients who struggle more chronically. Treatment works for 100% of patients, but there's still value in marking efforts and gains that might not result in full recovery or significant reduction in symptoms. So the other thing that we do in the end is we think about what next, what more, what else might make sense. In terms of sequencing care episodes it's very important to be able to have a good goodbye. So Winnicott wrote about how we have to navigate a gazillion separations in a lifetime and how you don't want to leave things unsaid. Right? The ending phase can be evocative of the termination phase of of any treatment. When we say goodbye, we might feel some emotions, some sadness in parting. And again, we it's helpful to differentiate what is normative sadness from full on clinical depression. So sometimes people might feel alarmed that they're feeling depressed again or feelings of sadness and IPT is focussed. And it's not that we want to make sadness go away. Sadness is an important, useful marker in the face of loss, right? That's the core emotion. So we want to help our patients for those who have recovered to be able to differentiate, tease apart normative sadness, who they might talk to, who else they might connect with and get support from, and when to recognize if depression is returning and have a contingency plan, for example, of connecting with their family physician or seeking reassessment.

  Jake Johnston: [00:19:30] Thanks Dr. Ravitz, for walking us through the core principles and phases of IPT. We're curious to learn more about some of the psychological theories that underpin IPT. Our preliminary reading indicated that attachment theory is one of them.

  Dr. Paula Ravitz: [00:19:48] Yeah. I mentioned earlier that at the time of Bowlby's work on attachment theory was very much kind of in academic discourse. And I think it has remained very central a relationships. This is based on Bowlby's work are critically important for survival and for thriving and that we need to have a secure base in order to explore, in order to manage now. Early relationships might shape these attachment patterns of relating because it's about survival. So for example, in individuals where attachment figures are generally unavailable, it's adaptive for individuals to become more self sufficient. Right? Remember that attachment patterns are only evident in times of stress. Otherwise, they might not be so evident when patients come in with symptoms of mental illnesses. They're in a state of distress, I mean this is true of medical illnesses. Right? And so that's when we might see these attachment patterns of relating, whether it's someone being somewhat kind of avoidant or dismissive of care or the other insecure attachment pattern is anxious, preoccupied. And again, if you think back, it might have been adaptive for someone to be signalling their attachment needs very loud and frequently in the face of others being inconsistently available. So the other theory that I draw from is contemporary interpersonal theory by the late Don Kiesler and Timothy Leary that talks about these universal needs that we have for affiliation or connection in our relationships, along with a sense of agency or power or influence in our interactions. They have developed what they call the interpersonal complex, where individuals can be mapped based on kind of our patterns of expectations of others.

  Dr. Paula Ravitz: [00:22:30] And again, this intersects with attachment theory, right? Bowlby talked about these internal working models based on early life experiences of what we tend to expect from others. And contemporary interpersonal theory is interesting because there are some predictions about the polls that we have that might be distancing or might be silencing of others and lead to individuals being kind of inadvertently authoring distance or perpetuating this sense of being disconnected or disempowered in their relationships. And we did some process research at a number of years ago. I'm happy to share the article where we looked at both attachment, self reported attachment and mapping on the interpersonal complex and looking at changes with treatment. And we found that in IPT patients with depression and this is patients with depression tend to be disempowered and with chronic forms of depression tend to be disconnected. And so one way of conceptualising recovery and IPT is that we help patients regain their sense of agency and to become less disconnected in their relationships. And we found that patients who recovered fully from depression in a course of IPT, whether or not they were on medication or not, tended to regain their sense of agency and become less disconnected as well. They moved away from dimensions of attachment insecurity towards security. So we did find some validity to these models. However, in terms of movement towards attachment security, we only found that in patients who fully recovered from depression. So you might wonder about how the state of depression also might interact with these self reported experiences of attachment in relationships.

  Jake Johnston: [00:24:41] Thanks, Dr. Ravitz, for touching on and contextualising some of the psychological theories that are important in IPT. One thing you had mentioned was that no treatment works in 100% of patients, which is something we all know is true in medicine. With that in mind, are there any characteristics that make people better or worse candidates for IPT? Specifically, we're curious if there are any indications or contraindications for IPT and some patient selection considerations.

  Dr. Paula Ravitz: [00:25:10] So based on this idea that IPT has these therapeutic guidelines for grief, for social transitions and parole disputes, it makes sense that especially for depression, where there's the strongest evidentiary base and the most IPT studies, that if an individual is presenting with depression and in the timeline in the history of present illness, it's clear that the depression, the onset of worsening depression seems very much linked to the death of a loved one, to disagreements in important close relationships, or to big life changes. Then for sure, IPT is likely to be a good model. Right? And then I started doing clinical research where the inclusion criteria was depression in not acutely suicidal because of course, then we need to move to kind of acute crisis care or higher level in order to ensure safety. It might require admission for patients who are not psychotic. So there really haven't been a lot of studies showing that. There's only one study that I know of that shows that IPT can be helpful for patients with affective psychosis. This was done at CAMH years ago and there was a poster presentation with Janice Harris who used to work at the Effect of Psychosis Clinic at CAMH. So depression, not acutely substance abusing or functionally impairing substance abusing, I should say. Not acutely psychotic and not acutely suicidal. So I started in the context of doing research studies with  inclusion and exclusion criteria, found that patients who intuitively I wasn't so sure that IPT was going to help, that I started discovering that the IPT model actually helped patients who even in this fourth category of interpersonal sensitivities or whether there was no clear precipitating or triggering life events.

  Dr. Paula Ravitz: [00:27:51] So I would say for your first training cases to try IPT because the middle phase therapeutic guidelines are so useful and can be applied. However, I think that IPT is really a good depression treatment. It's very powerful and it has sustained effects, sustained improvements. For a depression treatment, Ellen Frank and Holly Swartz. Ellen is a professor emeritus from University of Pittsburgh, has done a lot of the landmark IPT studies, including for patients with more chronic and recurrent forms of depression, and has adapted IPT for individuals with bipolar disorder. Holly Swartz is doing an NIH study looking at comparing IPT and Quetiapine IPT as a monotherapy for patients with bipolar disorder. It includes kind of a behavioural element with what they call "using a social rhythm tracking" where they find that if they can stabilize social rhythms, it actually significantly extends the period of wellness. Like not only does it aid recovery, but it delays relapse. Originally, it was in combination with mood stabilizing medications for Bipolar 1 Disorder for sure. As well, IPT has been researched for eating disorders, particularly for Bulimia in a group format.

  Dr. Paula Ravitz: [00:29:27] Earlier studies were done by Chris Fairburn and Denise Wolf showing that compared to IPT, compared to CBT. That. Actually, it's interesting. It's kind of the turtle and the hare, the horse race that if you look long-term that IPT actually surpassed CBT. But in the short-term there were CBT seemed to work better in the kind of short-term follow up, but they're both powerful models. IPT has been extensively researched in adolescence for adolescent depression. This has been led by Laura Mufson and Jami Young has looked at group IPT as a preventative treatment and is doing work in high schools in the US. Using her model, a family-based IPT model has also been shown to be helpful by Laura Dietz. And again, for people who are interested in learning more about these models, there are many publications. We did a 40-plus year scoping review of IPT, looking at trends and themes over time and looking at all the different clinical populations including in low and middle-income countries. IPT for PTSD, I suspect, will be in future guidelines. As you know, in these guideline panels you have to have a minimum of two randomised controlled trials conducted by different groups of researchers in order to control for kind of allegiance or bias of the research group and the original gold standard study conducted by John Markowitz compared to the prior gold standard which is exposure based CBT and shown this was the first non-exposure based structured treatment to be as effective as exposure based CBT. Since that time, others are kind of have done studies in other settings, including in Brazil. What's interesting about the adaptations of IPT is that the model is generally the same in contrast to some other models of therapy that have been adapted for specific patient populations that differ quite a bit like exposure-based or exposure and response prevention for PTSD or OCD in CBT. Whereas with IPT, the model is essentially kind of preserved. So there's a bit less variation in the adaptations of IPT. As I mentioned, there's very strong evidentiary base of IPT for postpartum and perinatal depression, and many of us have been numerous studies, including one that was led by Cindy-Lee Dennis and Sophie Grigoriadis and myself were the clinical leads where we supported nurse therapists in the delivery of telephone IPT. This was published back in 2020 and found that 85% of our patients who started out meeting full criteria based on skid with 12 sessions of telephone IPT remitted. Again, there were no differences in patients who were on medication versus not on medication and with sustained improvements over time.

  Jake Johnston: [00:33:17] Thank you very much for that thorough answer. Dr. Ravitz. So just to sort of summarise and reiterate, you're saying that IPT has the best evidence for major depressive disorder. According to the CANMED guidelines, IPT is a first line treatment for acute depression, second-line maintenance treatment for depression. And as you were saying, according to the can guidelines is a first-line treatment for depression in several special populations, including children and youth, mild to moderate, major depressive disorder in pregnancy and mild to moderate postpartum depression during breastfeeding. It's such a strong treatment that it is recommended before medications even in these populations. Dr. Everts, you had also mentioned that there's evidence for use in some other disorders, including Bipolar Disorder, Bulimia Nervosa and PTSD. One clarifying question I wanted to ask was if you could comment on IPT's use in anxiety disorders.

  Dr. Paula Ravitz: [00:34:19] Yeah. John Markowitz and the late Joshua Lipsitz did a review looking at the evidentiary base for IPT and anxiety disorder. At present we don't really have sufficient evidence for it to make it into guidelines. But what I can tell you is that depression and anxiety are often comorbid. As mentioned in all of the depression studies that I've participated in, we monitor both GAD- and PHQ-9 and in our perinatal in our postpartum IPT telephone IPT study, we found that the patients who had comorbid levels of depression and anxiety seemed to benefit even more. In all the clinical trials that I've participated in, including a current clinical trial that I'm a clinical lead on using behavioural activation for women with perinatal depression the SUMMIT Trial. Interestingly, in the back channels I'm noticing that the anxiety scores are also going down significantly. So I think for patients who have comorbid depression and anxiety, both symptoms often decrease significantly. And perhaps surprisingly, because we're not directly targeting anxiety. But IPT is not only interpersonally focussed, it's affect focussed.

  Jake Johnston: [00:35:56] Okay. Thank you for the information on the indications for IPT. Are there any contraindications?

  Dr. Paula Ravitz: [00:36:08] I think if patients are kind of acutely suicidal, we need to provide kind of crisis support and we need to assess safety. So I think that clinically you need to just shift your focus and not necessarily proceed regardless of what their therapeutic model you might have in mind to be rendering. There really isn't evidence for a patients with psychosis. There's been some really important and helpful modifications of CBT for psychosis, and there is some evidence of the adaptations of that model. That work hasn't been done in IPT. It might be eventually over time, but in our thus far, over these last 40 years, there haven't really. There really isn't evidence for it. So I don't think it's indicated. And for patients who are struggling with functionally impairing substance misuse, it's really important to address the Concurrent Disorders and see if we can kind of help our patients with that. It doesn't mean that you can't still integrate some of the principles of these other useful evidence supported therapeutic models such as CBT or MI or IPT. I think they can still be integrated, but there really isn't research showing that it's helpful.

  Jake Johnston: [00:38:09] Thanks, Dr. Ravitz, for walking us through some of the patient selection considerations for IPT. You've already touched on the some of the evidence base behind IPT. I'm wondering if you would be able to take us and our listeners through a brief history of sort of how IPT was developed and maybe a deeper dive into the evidence base behind IPT.

  Dr. Paula Ravitz: [00:38:35] The first controlled study for depression was published over 40 years ago and originally there was a study conducted by Gerald Klerman and Myrna Weissman and others that compared IPT to medication. So this was, as I said, over 40 years ago, and what they tried to do was operationalize what effective, well-respected community-based therapists were doing. So in a way, it was a descriptive study of kind of good psychotherapy where they discovered that patients were coming in with these universal relational life events. So it was kind of a life events based model. At the time of IPT's genesis, Bowlby seminal work on Attachment Theory was kind of in in academic discourse as well. Brown and Harris studies on the associations between bereavement and depression were being published, and the etiological links between biological and psychosocial factors were becoming influential in discourse on illness and recovery. Since that time, the importance of relationships for health, coping and resilience has been well established. And in the very first study, to Gerald Klerman surprise and he was a pragmatist, he found that patients who received this structured psychotherapy and at that point in time it was a 16 session model. And partly the reason for the dose was because they also wanted to compare it to pharmacotherapy over time, they found that IPT worked as well as medication as pharmacotherapy. Now remember back then it was the tricyclic antidepressants, but that led to IPT being included in what still stands as a landmark study, the TDCRP study with Irene Elkin that was published long ago in which IPT-CBT pharmacotherapy and a kind of comparative, just supportive response to when patients requested it was conducted.

  Dr. Paula Ravitz: [00:41:12] It was the first multi-site RCT that compared IPT and CBT. And in that study Lester Luborsky wrote a paper that quoted the Dodo bird from Alice in Wonderland that said "all must have prizes and all have won". So in the initial analysis, they found that everyone seemed to improve even the low-contact patients. There have since been multiple analyses of that study looking at process factors, looking at moderating factors, and they looked at baseline patient severity and when they examined that, the patients and pharmacotherapy did best, followed by IPT, then CBT and then the kind of low contact model. And subsequent to that study, there have been many studies of both IPT and CBT in particular showing that both models are highly effective, thus included in many international consensus guidelines as a depression treatment, especially including the World Health Organization here in Canada, the Canadian Association of Mood and Anxiety Treatments. It's amongst a very short list of three first-line treatments for depression based on many effectiveness and efficacy studies. And for people who are interested, there's Pim Cuijpers in the Netherlands has done many well conducted meta-analyses and the most recent one published in 2016 was a transdiagnostic meta-analysis of IPT showing that IPT is is helpful in the horse races. Comparing IPT and CBT in particular, they're both shown to be highly effective treatments, thus both recommended in consensus treatment guidelines here in Canada, in the US and in other parts of the world, including the World Health Organisation. So it's long been included in the mental health gap and guidelines of the World Health Organisation.

  Jake Johnston: [00:43:32] Thank you, Dr. Ravitz for that comprehensive answer. You mentioned the IPT being cited as one of the three most effective psychotherapies in the CANMED guidelines. And I'd just like to point out that I noticed your name on the author list for that paper and just for our listeners, all of the papers that Dr. Ravitz has mentioned, we'll make sure to include in the show notes. So Dr. Ravitz, you've sort of gone through and given us a really good idea of what IPT is. The principles behind it are some of the patient selection considerations and some of the evidence behind it. And I'm curious, can you go through some of the more practical elements of going through a course of IPT? You know, you mentioned that it's usually sort of 12 ish sessions. There's a beginning, middle and end phase. And I'm curious if you could sort of paint a picture for our listeners what it's like to actually go through and maybe experience each of those phases and what type of things happen in each of those phases.

  Dr. Paula Ravitz: [00:44:39] So, first of all I think that the provider needs to be aware of the structure. So a number of sessions. So when I first meet with a patient, if I'm doing IPT, I will orient them to the different phases and explain to them the rationale. I might say, "thank you for coming. Today is our first session of 12" and I explain the phases. So, "in these first few sessions, I am going to learn more about you as a person, about what's been going on in your life that's associated with you feeling worse. I am also going to ask you about important relationships so that we together can decide on which relationships and which focus we want to pursue in the middle phase of our work together. I'm going to be monitoring your symptoms as we go along using these two questionnaires, the the physician health questionnaire, which is nine items, which asks you about the last two weeks, how you have been feeling and to what extent it's affecting you, along with another short questionnaire about anxiety symptoms. The reason I do this is because the goal of our work together is to help you feel and do better. So this is one way I can track how you're feeling and doing in order to lessen the symptoms of depression and anxiety. And in the middle phase of our work together, once we decide which relationships in which focus I, we will go through a process of, first of all, deepening our understanding of what's been going on with respect to changes or losses or conflicts in your relationships that are linked to the moments when you're feeling worse or better. Then in the final 1 to 2 sessions, we'll try to consolidate our gains and what you've taken away if necessary. Think about next steps. Again, as I mentioned, I'm going to be tracking your symptoms over time so that if you're feeling worse or not feeling better, we're not going to wait for 12 sessions to think about what next. I might, depending on your symptoms, make recommendations".

  Dr. Paula Ravitz: [00:47:40] In my mind, I'm also monitoring for the need for medication and safety monitoring. So then I proceed similar to what we do in psychiatric assessments to getting their identifying data. Chief Complaint History of present illness and a symptom review along with family, psychiatric and medical history, their past psychiatric history, medications, they are on. And then in the psychosocial history, the interpersonal inventory is kind of it happens in the beginning session and I usually begin with a genogram, but I ask them using the interpersonal inventory to tell me more about the important relationships where I learn about kind of maybe 6 to 10 closest relationships. I like to use questions from the adult attachment inventory, some of them. So I'll ask "Who raised you?". I love that question because it doesn't assume that it was biological parents. Sometimes people will say, "I raised myself or it was my big sibling or my neighbour or a teacher or a religious leader". It gives me, again, similar to doing communication analysis, data about their back story about whether there might be unresolved developmental trauma. I also watch and listen very carefully. If there are lapses in narrative coherence and I watch for affect, when do they become flushed with emotion or when do they tear up? Because again, this is data for me to revisit most important relationships in the middle phase. That's how I might introduce IPT. I track time. And at three points at the beginning when I'm kind of contracting and this is again, there might be times when you are post call or a crisis comes up and you have to reschedule or it could be just a word conflict or a personal conflict, and the same might be true for them. So you want to kind of set some ground rules. "I will let you know ahead of time but I understand that emergencies come up and you can let me know". I try to reschedule in the same week, where possible. And again, "I don't think we have time today, but there's going to be a subset of patients that it's it's hard for them to come within a period of time".  Or they keep cancelling that they there's this might signal problems in the alliance of a tendency to kind of withdraw or be reluctant to trust or to engage. And that's a topic for another conversation. But I then in the middle so it's session six, say "we're halfway through".

  Dr. Paula Ravitz: [00:50:51] People are often surprised, but do you want to mark time and you also want to get a sense I will sometimes work it as a middle session, but I'll also ask like what more else? Like thinking back to kind of where we are right now and that we have six more sessions including today. "What more else do you think would be helpful and important for us to focus on that seems to be linked to your distress?" and as I mentioned, the homework that I assigned in IPT has to do with paying attention to their emotions, to their affect both times when they feel more upset or distressed or annoyed or disconnected or sad or angry or scared. So any negative emotions but also positive emotions are really important for us to mark and track the times when they feel better, because hopefully it's linked to times when they feel more connected or understood or a sense of belonging or a sense of having begun to master some of the interpersonal problems that brought them in. Then in the last 10 minutes of the third from last session, so if I'm doing 12 sessions last 10 minutes of the 10th session, I'll say something like, "We have two more sessions after today". Again, that's a very different homework assignment. I'll say "Between now and when we meet, I'd like you to give some thought, and I will as well give some thought to this thinking back to when we first started and now what are you taking away? And also thinking back and this is again of a bit of a pre-post, what's changed? How you feeling different or what's changed in terms of your life or your relationships?" So one has to do with kind of of all the things that we've done and talked about.

  Dr. Paula Ravitz: [00:52:55] This is such great data for learners and for therapists because sometimes the things that we think are the most salient or most important in terms of kind of supporting change and recovery are not necessarily what our patients report. So I think it's iterative discovery, joint discovery, and you want to also give some thought to that such that if I was a fly on the wall or I was doing a competency rating in the final two sessions, the first, maybe third of the session, 15, 20 minutes, you want to unpack whatever they bring again? I often I ask from session two onwards, How have you been since we last met? If they report events, I'll ask. And how did that affect your mood or symptoms? If they affect if they report motor symptoms? I want to ask and how did that and what's been going on? So again, we begin to socialise our patients to making those bidirectional links. Over time, patients just spontaneously report both right and so. You want to give some thoughts to those same questions that we ask our patients? And when you begin to ask those questions to say, okay, this is our second from last session, as I mentioned last week, we want to take some time today.

  Dr. Paula Ravitz: [00:54:24] So it's similar to agenda setting that we might do in more highly structured therapy like CBT. "Thinking back to when we first started what are you taking away or thinking back to when you first started? What's changed?" You want to use therapeutic communication 101. So open-ended questions, empathic, paraphrasing or summarising what your patient tells you and not parroting, but paraphrasing. So this is part of the skill set that I think in all therapies our clinicians can improve over time and that will help them in all their clinical interactions, regardless of what kind of medicine you're going to practice. Actually, sometimes questions pop up in your mind that are like, yes, no questions that I often invite trainees. It's a good question. So how can you rephrase that to be more open-ended questions such as or prompts such as "Can you say more about that?" or to paraphrase. So, "You had an argument with your partner last week and it was really upsetting to you". Full stop. Don't even ask the question. Just paraphrase. Nine times out of ten, when our patients feel like we're really with them in that moment, they'll just elaborate spontaneously. There will be a subset of patients where it's like pulling teeth. And you actually have to ask, "Can you say more?" or "I'm not sure I quite understand."

  Dr. Paula Ravitz: [00:56:08] And I want to just go back to communication analysis, because oftentimes when patients come in, they'll just give us the tip of the iceberg, the most heated moment of the argument or the way that they were feeling or the resentment that they experience from feeling kind of misunderstood or mis misinterpreted or responded to in ways that felt just kind of really empathic or miss a tune. And you want to roll the tape back. You get "Hang on, so this is what happened at the end and how you were feeling." So. "Where were you" and "What time of day" and "What day of the week" and "How did this start", "What was going on just before the interaction started?" And you want to get what words did you use or what did you say and how did they respond and how will you feel and what do you think they were thinking and what do you think they were feeling or what do you think they thought you thought. So you begin to draw kind of this figure eight linking of kind of two people in an interaction. And again, that gives us data about misunderstandings, about difficulties with empathy or with mental sizing and whether expectations or wishes are both reasonable and realistic. Sometimes we need to lower expectations, considering limitations of others. Sometimes we need to be more clear in our communication, right? In being in the way we give voice to things.

  Jake Johnston: [00:57:57] Thanks. I'm sure of it. So that communication analysis sounds a lot like chain analysis, DBT for Borderline Personality Disorder which is actually a good segue way into our last learning objective. But all parking lot that for now, that was a beautiful way you took us through sort of how IPT is practically carried out in the focus of the various phases. A couple of more pointed questions. You mentioned it's about usually about 12 sessions in total. How long does each session last?

  Dr. Paula Ravitz: [00:58:31] There's variability. Generally, I think the shortest sessions are 30 minutes and depending on kind of whether what practice setting you're in and also patients, they may or may not have time ideally, I think 45 to 60 minutes. So psychologists tend to do 60 minute sessions and psychiatrists do, like 45, 46 minute sessions. I think this is partly been driven by funding plans, but that's been my practice and that seems to be a good amount of time to really kind of cover a good amount of material using the IPT model, both phase and focus specific guidelines. Generally, it's once weekly, but for example, 12 sessions can take as long as four months because of holidays or interruptions. But you want to probably complete it. You want to complete it with them, 4 to 5 months or 4 to 6 months, I would say if it's 16 sessions within six months.

  Jake Johnston: [00:59:53] And could you comment on maintenance IPT? Is that something that you practice?

  Sena Gok: [00:59:59] Yeah, so I do. I was very much influenced by Dr. Alan Franks studies, I've showed that what gets you well, keeps you well. IPT alone can be very helpful. So if our patients, we have a more a history of chronic depression have gotten well with IPT rather than just kind of concluding with no follow up at the end of 12 or 16 sessions, what I do instead is the last few sessions I increase the time frame between. So it's a tapering, right? So let's say they've recovered by session ten or 12. I might then schedule sessions every other week for the next few sessions, then every third week and then offer monthly follow up for because they're at higher risk of relapse as well in the event that they become ill or severely symptomatic. We have a good alliance, so they're more likely to accept medication if I think it's indicated based on severity, functional impairment. So, they may have said no to pharmacotherapy in the past, but agreed to it in the future. And I find that there's a subset of patients who actually recover and then they just naturally taper off because they enter into their lives and no longer feel the need for mental health care and support. I usually keep my door open in the event that they're in crisis or feeling unwell that they can call. And I'm happy to reassess or sometimes I'll do some booster sessions with them. And again, having already had a relationship and know a little bit about their back story and their relationships, we can move into kind of therapeutic action pretty quickly. Right? In just a few sessions I can help to stabilise them. So that's in my clinical practice how I tend to work and with the residents that I provide supervision to the guidance that we give for patients who recover but who have a history of more longstanding struggles with depression. I suggest you kind of extend those 12 to 16 sessions over a longer time period, especially.

  Jake Johnston: [01:02:30] Towards the end. I love that you call them booster sessions. It's like extending our immunity on the assaults on our mental health.

  Sena Gok: [01:02:39] Yeah, that's a that's a beautiful metaphor.

  Jake Johnston: [01:02:41] Yeah, absolutely. Thank you, Dr. Ravitzt. So that was a really helpful overview of the practical aspects of IPT. Just wrapping up now with our last learning objective, I'll pass the mic over to Sena.

  Sena Gok: [01:02:58] Thank you, Jake. So Dr. Ravitzs, you mentioned earlier that IPT might have some advantages when compared to CBT. Could you explain these further, and are there also other advantages to other common psychotherapy methods?

  Dr. Paula Ravitz: [01:03:13] So I think that we as clinicians need to have a repertoire of approaches because no one treatment works for everyone. I think as well that clinicians have models that just feel like a better fit, right? And so I think that just like is as medical students, you will kind of have preferences or things, areas, clinical populations or therapeutic tasks that are more appealing and feel like a better fit in terms of your motivation to gain expertise. The same is true in these different psychotherapy models, but what is also true about these psychotherapy models is that there are factors that are common to them. All right. And that are included right in the teaching of them and I think if you only learn one, you might not know that. Right? You might think this is IPT or this is CBT, when in fact it is an important common element for people who are interested in that. John Norcross and Bruce Wampold have done some wonderful work and looking at common factors and in fact in the most recent can that guidelines, we include a list of the common factors. We got permission from John Norcross who vetted it to include that run across such as the therapeutic alliance, use of empathy, positive regard, presence. These are very important having agreement on the goals and the tasks of whatever treatment you're doing.

  Dr. Paula Ravitz: [01:04:58] So being explicit, being collaborative, being authentic and being non-judgmental, using open-ended questions and empathy and using paraphrasing and summative comments really go a long ways. No matter what you're doing, no matter which brand or guilt of practice you identify with, CBT is highly effective. And I think CBT has been shown to be effective diagnostically more. So there's been more studies but IPT the evidence is that the jury is out. It's the effect size is like compared to a cholinesterase inhibitor that has an effect size of over 30. The effect size of in terms of number needed to treat in IPT is over 30 for cholinesterase inhibitors and it's three for IPT and something like seven or eight for for CBT. But again, it depends on the practitioner, your preference, your style. As I mentioned, I think IPT is particularly helpful in the context of existential life events, right, in which one's appraisal might have, you know, a degree of accuracy. S,o I also think that it's helpful to actually have more than one model in your therapeutic repertoire. You don't want to be to have kind of a one size does not fit all. Procrustes was a famous innkeeper in Greek mythology that used to the idea of a one size fits all, because he used to cut the legs of long-legged people or stretch the legs of short-legged people in order to fit the one-size bed.

  Dr. Paula Ravitz: [01:07:01] So one size does not fit all. And so that's why I really encourage people interested in having kind of these powerful psychotherapeutic approaches. And again, we've used we've trained nurses, we've trained family medicine residents and family physicians and into professional providers of social workers. It's not just for mental health specialists, because we know from the work of Martin Prince and Vikram Patel and those landmark articles that were published in the Lancet that there is no health without mental health, and it's incumbent on us all to be alive to struggles with mental health, which can help our patients in their recovery and in their functioning. So IPT focuses on clinician, on thoughts, CBT focuses on relationships, they are both affect focused, they're both structured, they're both time limited, they're both evidence supported. Jake, you mentioned comparing communication analysis to chain analysis in DBT. DBT has strong evidence base for our patients with Borderline Personality dDisorder. A handful of studies of IPT would be PD, but I think that right now, mentalising based therapy and DBT  have the strongest evidentiary base for our patients with Borderline Personality Disorder. But communication analysis and chain analysis are not dissimilar and in behavioural activation, we look at helping our patients in a more kind of concise and simple way with communication of feelings or asking for help or being assertive, you know, by kind of starting with facts, feelings, a request or expression, but also thinking about impact which is important in thinking about sometimes we say things that aren't understood or aren't clear or don't land well with others for all kinds of reasons.

  Dr. Paula Ravitz: [01:09:15] And so I think that there's lots of intersection and some of the things that we describe in these different models. It's a matter of semantics. And if you train and I have trained and taught and edited books on kind of multiple models of therapy, including through one series that learners might be interested, it might be in the library collections of the different schools where you go called Psychotherapy Essentials to Go that have both videotapes, and they're kind of learner's guides for some of the key principles of IPT for depression, CBT for depression, CBT for anxiety, affect regulation, skills from DBT and Motivational Interviewing along with a book on Common Factors and Improving Alliances and Outcomes. So I encourage learners to  peruse these different models and make sense of them. You know that sometimes it's a matter of semantics and there's lots of similarities. But I also think that these different models of therapy give us different frameworks that are really useful to make sense of patients experiences and to give us kind of a roadmap for fostering reflection and exploration that will then lead to patients kind of finding their way in problem solving and adjusting to new roles or resolving disputes or processing grief through bereavement.

  Jake Johnston: [01:11:01] That was a beautiful comparison, Dr. Ravitz, and a great way to sort of wrap up the learning objective part of this episode. I think we better let our listeners off the hook here pretty soon. It's been a ton of information and you've shared a lot of your expertise with us. Do you have any closing thoughts before we wrap up?

  Dr. Paula Ravitz: [01:11:20] First of all, I think that psychotherapy has a role in the armamentarium of especially mental health specialists in both the training and provision of care. A group of us, Gary ChaimoWitz, Weerasekera and myself, recently published a position paper on psychotherapy in psychiatry with the Canadian Psychiatric Association, reaffirming the role. And I think that as mental health specialists, we are the ones who see patients who are at higher risk, who have higher levels of severity, chronicity, comorbidity, functional impairment. So it's really important that we have a full armamentarium of therapeutics, both to establish alliances, to understand, to monitor and to provide care and treatment to people who maybe have failed treatment from multiple first trials of either therapeutics or self-help or pharmacotherapy.  I think the good news is  our Mental Health Commission of Canada has done a really wonderful job of decreasing stigma and raising awareness of how common struggles are and with mental health and how we really need to scale access and treatment to mental health care. And there are apps and online treatments and lower intensity treatments that are being studied and offered. But when those aren't sufficient, I think that we as for those of you who want to become mental health specialists, I really encourage you to get training in a number of these evidence supported psychotherapies. They're powerful treatments. And for those of you who are going to become other kinds of specialists, I think it will really serve you and your patients and the teams that you work on well to. It's easily accessible to get more training and learning, including through these terrific podcasts that your group is hosting on these evidence-supported psychotherapy models.

  Jake Johnston: [01:14:07] Thanks, Dr. Ravitz. Those are some beautiful closing thoughts and I really like the way how you framed it within the broader context of psychotherapy and within the broader context of our healthcare system. Before we wrap up the episode, Dr. Ravitz, you had mentioned a website that you're currently developing that could be useful for learning more about IPT.

  Sena Gok: [01:14:30] Thank you Jake, for reminding me of that. So with IPt experts and instructional designers and learning management system programmers, we've developed what I think is a really exciting learning resource for people interested in kind of taking a deeper dive into learning about IPT. It's called www.learnipt.com. At present we're just at the tail end of completing an educational research study and we're in conversations about extending access to medical learners at different levels across the educational lifespan. So for people who are interested in doing the course, where we have all kinds of videotaped demonstrations that are captioned and transcribed so it can be translated into different languages, interactive case based learning exercises and brief segments of different experts talking about therapeutic aspects of IPT, including a welcome message from Myrna Weissman, who is the founder of IPT and John Markowitz, who has done more IPT studies than anyone I know. They're both at Columbia University. A brief segment from Holly Swartz, from Ellen Frank. So I've mentioned some of these and from  Wanda McGinn along with psychologist Giorgio Tasca, talking about kind of colonic common elements and the therapeutic alliance. So I know I'm biased, but I think it's terrific learning resource. We've gotten wonderful feedback from learners and people can email me directly. So it's not open access at this point, but we hope there will be. We will find ways to open access over time. So I'm at Paula Ravitz at Sinai Healthcare and you can probably kind of put that in the resources for people who want to contact me or who want for the readings as well.

  Jake Johnston: [01:16:50] Sounds great. We'll do. Well, Dr. Ravitz, on behalf of the entire team, we thank you very much for coming to speak about IPT on this episode. And we would also like to thank our listeners for your continued support and dedication to our podcast. Until next time!

  Dr. Paula Ravitz: [01:17:06] Thank you so much, Jake and Sena for your interest and for this really enjoyable conversation about IPT.

  Jake Johnston: [01:17:21] PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Jake Johnston. The episode was hosted by Jake Johnston and Sena Gok. The audio editing was done by Jake Johnston. Our theme song is Working Solutions by All Live Music. A special thanks to the incredible guest, Dr. Paula Ravitz for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

Episode 41: MAiD and Mental Illness with Dr.Sonu Gaind

• Episode 41: MAiD and Mental Illness with Dr.Sonu Gaind

  Dr. Alex Raben: [00:00:10] Welcome to PsychEd, the psychiatry podcast for medical learners by medical Learners. This episode covers medical assistance in dying and mental health or MAID and mental health. We're going to be covering this topic mostly from a Canadian perspective, although we hope our international listeners will gather some important general points that can apply to their jurisdictions as well. I'm Alex Raben. I'm a lecturer at the University of Toronto and a staff psychiatrist at the Centre for Addiction and Mental Health. I'll be the host for today's episode. This episode will be using a slightly different format than our general episodes, because today's episode is not just a podcast, it's also a grand rounds. It's Dr. Urvashi Prasad's Grand Rounds to be specific. For those who are not familiar with what Grand Rounds are, this is a time honoured tradition in medicine, not just in psychiatry, where a physician, a learner and allied health member will deliver a presentation to a live audience in a hospital on a medical topic. However, now, with the pandemic and with technology what it is, we're really happy that the PsychEd podcast is able to act as a platform for grand rounds. We'd also like to thank the University of Toronto for allowing this to be possible and to fulfil Dr. Prasad's Grand Rounds requirements. So let me introduce Dr. Urvashi Prasad, who is a PGY3 at the University of Toronto to the show. Hi, Urvashi. Welcome.

  Dr. Urvashi Prasad: [00:01:46] Hi, Alex. Thank you for that introduction. As Alex mentioned, my name is Urvashi Prasad. I'm a third year psychiatry resident here at the University of Toronto. I am very excited to be here today and also super eager to share with you today's topic of discussion, which was one that piqued my interest not too long ago. Some months back, as a member of the American Psychiatric Association, Ontario branch, I remember sitting in on a brief discussion on Maid and Mental Health, which was led by Dr. Sonu Gaind. At the time, it was the first time I became formally aware of this topic. Fast forward a couple months from there, I was introduced to a patient during my SPMI block or Severe Persistent Mental Illness who had been requesting for made for primarily their psychiatric disorder. My appointments with her always left me with several questions on this topic, some practical as to what would be the eligibility criteria for MAiD for mental health. Is it legal to some of the more challenging questions around some of the ethical dilemmas around this topic? And so putting all of that together, this has brought me to here today where I decided to do my grand rounds topic on this on on made for mental health with the hopes of both educating myself and also perhaps educating others within the field. So to our listeners, whatever your reason might be for tuning in to our podcast today. Thanks for being here and we hope that we can make your time here with us worthwhile.

  Dr. Alex Raben: [00:03:36] Well, thank you Urvashi for being here and for leading this episode today. We're really excited to learn more. You mentioned Dr. Sonu Gaind and he is actually our topic expert today who will be joining you in educating us on this important subject. And I'd like to just briefly introduce him as well. So Dr. Gaind is a professor at the University of Toronto, as well as the chief of psychiatry at Humber River Hospital and works clinically as a psycho-oncology consultant. He's been a past president of the Ontario Psychiatric Association, the Canadian Psychiatric Association and PARO. His experience in this topic is quite big. And I won't be able to, I think, list all of these things he's been involved with. And he can certainly add to this, but I'll mention just a few. He has testified, for instance, at the Federal External Panel on the options for a legislative response to legislation around this issue. He's also chaired the Time Limited Canadian Psychiatric Association Task Force on MAiD, and he has given talks both within Canada and internationally on the subject, as well as written papers on the subject. So, Dr. Gaind, we want to welcome you to the show as well. Thanks for joining us.

  Dr. Sonu Gaind: [00:05:06] My pleasure to be here, and thank you for inviting me.

  Dr. Alex Raben: [00:05:09] And then last but not least, we are also joined by David Eapen-John, who is a third year medical student at the University of Toronto who is eager to learn more and want to be part of the show as well in order to give the medical student perspective. So thank you, David, for being with us as well.

  David Eapen-John: [00:05:30] Thank you so much, Dr. Raben. Very excited to be here.

  Dr. Alex Raben: [00:05:34] Great. So I will briefly go through our learning objectives for this episode and then I will hand it over to Urvashi to take us through a background on the topic and to go through the topic with our expert guest. So by the end of this episode, you, the listener, should be able to, number one, briefly summarise the history of MAID in Canada. Number two, define the present policies of medical assistance in dying and mental health in this country and how that might apply in your jurisdiction. Number three, evaluate the arguments in support of and against the implementation of MAID in the mental health context. And number four, discuss the possible impacts of MAID both on the profession of psychiatry and on our patients. So without further ado, Urvashi, please take it away.

  Dr. Urvashi Prasad: [00:06:36] Awesome. Thanks, Alex. Before we jump into the topic at hand and hearing from our expert guest speaker today, I'd like to take a few minutes to provide our listeners with some definitions and a bit of background on the history of MAID in Canada. This will hopefully help orient ourselves and help put things into a bit of context as we later focus our discussion on Maid and mental health specifically. So let's get started and maybe we can begin by some definitions. David, do you want to take this one on?

  David Eapen-John: [00:07:11] Thanks so much, Dr. Prasad. So first to according to the government of Canada MAID itself describes the administering by a physician or nurse practitioner of a substance to a person at their request that causes their death or describes the prescribing or providing by a physician or nurse practitioner of a substance to a person at their request, so that they may self administer the substance and in doing so cause their own death.

  Dr. Urvashi Prasad: [00:07:43] With that definition in mind, let's dive a little into the history of MAID in Canada, and this will hopefully also cover our first learning objective for today. So assisted suicide was illegal in Canada from 1892 to 2016 under section 241 B of the Criminal Code. During this time, anyone found guilty of counselling someone to take their own life or aiding someone to take their own life was guilty of culpable homicide and subject to imprisonment of up to 14 years. However, starting in the early 1900s, there were a series of court cases and legal proceedings which challenged the prohibition of assisted suicide as contrary to the Canadian Charter of Rights and Freedoms. Particularly, these cases argued that the law against assisted suicide violated Section seven and 15 of the Canadian Charter of Rights and Freedoms, which guarantees the right to life, liberty and security of person and equality. Some of you may be familiar with a few of these landmark cases, which include the Sue Rodrigues case in 1993, which was a case about a woman with ALS or amyotrophic lateral sclerosis requesting for physician assisted suicide. The Robert Latimer case in 1994, which was a case about a father ending the life of his severely disabled daughter. And the Carter versus Canada case in 2014, where Lee Carter assisted her 89 year old mother with degenerative spinal stenosis to assist her in planning her death in Switzerland.

  Dr. Urvashi Prasad: [00:09:19] Subsequently, in the year 2015, after decades of legal battles, the Supreme Court of Canada ruled unanimously to allow physician assisted suicide, which became legal in June 2016. According to the second Annual Report on Medical Assistance and Dying in Canada, published in the year 2020, the total number of medically assisted deaths reported in Canada since the enactment of federal legislation in mid 2016 to late 2020 was about 21,589 individuals. The average age at time of MAID being provided in 2020 was 75 years and cancer was the most commonly cited underlying medical condition, making up about 69.1% of the individuals who received MAID, followed by cardiovascular conditions, chronic respiratory conditions and neurological conditions. And these were similar trends that they saw in 2019 as well. So of course, all of that was in regards to Maid so far in Canada and some statistics to help sort of orient ourselves before we jump into MAID, specifically focusing on MAID for mental illness. Before we focus in on some of the questions with our expert guest speaker, what might be helpful is perhaps as a segue into our discussion is to introduce the patient case. And this is loosely based on the patient that I had alluded to a little bit earlier in my introduction as a means of perhaps anchoring some of our discussions around a topic around this topic.

  Dr. Urvashi Prasad: [00:11:13] I should also mention importantly that all of this information here has been de-identified to ensure that we can preserve patient confidentiality. So let's talk about Anna. Anna is a 50 year old single female who lives in a supportive housing and is financially supported on government disability supports. She has around a ten year history of schizophrenia, during most of which unfortunately she had been untreated and I was previously a high functioning individual with a husband and two children. She had her her own house and a stable job after completing four years of an undergraduate degree since the onset of her illness, likely about ten years ago now, she gradually lost her family, her employment, her housing, and was only brought to medical attention when bystanders called 911 after seeing a homeless woman engaging in bizarre behaviour at the time. Anna spent three months in hospital on a psychiatric unit where she was started on Paliperidone, an antipsychotic medication, which is which she has shown fortunately some response to. She no longer hears voices, is able to organise her thoughts and is much less paranoid of others. Since discharged from hospital, she's able to maintain her supportive housing and has never failed to miss an outpatient psychiatric appointment.

  Dr. Urvashi Prasad: [00:12:38] However, Anna still struggles with persistent delusions about being controlled by aliens, such that these aliens seem to dictate what food she eats. She also presents with prominent negative symptoms of schizophrenia, of being asocial, demonstrating a poverty of speech and a lack of motivation to do most things. She spends most of her time sleeping, waking intermittently for lunch and dinner, going on short walks and watching television. She has no interest in reconnecting with her family and has no desire to seek employment. From her perspective, Anna feels no change in medications would allow her to go back to her previous level of functioning prior to the onset of her illness. She does not feel that she is capable of leading a fulfilling life with her current illness and feels that the only answer to end her suffering is through Medical Assistance and Dying on the grounds of a mental illness. All right. Thank you all for patiently hearing me speak. I know it's a lot of talking on my end, but we are very excited and eager to hear Dr. Gaind's input on this discussion as well. So now that we've established the background of MAID as a whole in Canada, we can shift our focus on the topic of mental health. Maybe David can take this one on.

  David Eapen-John: [00:14:04] For sure. So why don't we start with the probably the most important question in the forefront of our listeners minds: Is MAID for individuals with primarily mental illness legal in Canada right now?

  Dr. Sonu Gaind: [00:14:19] So it's actually surprisingly complex answer because you would expect an answer to that question would either be a straightforward yes or no. But the history has been a bit more convoluted than that. Back in 2016, when MAID originally came about in Canada, there was no prohibition against MAID for sole mental illness conditions. However, there was a requirement. One of the safeguards that was in place in 2016 original legislation was that natural death needed to be reasonably foreseeable. And what that meant, for all intents and purposes, was that in the vast majority of cases, sole mental illness conditions wouldn't qualify because sole mental illness rarely, if ever, leads to natural death being reasonably foreseeable. And suicide was not considered a natural death that was reasonably foreseeable. Now, what's happened recently in 2021 with the new legislative changes is that initial safeguard of natural death being reasonably foreseeable is no longer there. That was removed. And in lieu of that, the government has put in what now is a temporary prohibition against made for sole mental illness, but they've attached a so called sunset clause to that, which means that within two years of that legislation being enacted, which was March 2021, that by March 2023 MAID for sole mental illness conditions is supposed to be permitted in Canada. So a somewhat convoluted answer to a fairly simple question.

  Dr. Urvashi Prasad: [00:16:12] Thank you for that, Dr. Gaind. So to sort of put that into context with Anna, the patient that we talked about, it seems like at the moment made for mental health is currently not available for individuals with so mental illness. So she would not at present be eligible to apply. But it sounds like by March of 2023, as you mentioned, that starting from that time, there may be eligible for applying for MAID in individuals with primarily mental illness. Would that be correct?

  Dr. Sonu Gaind: [00:17:05] That's correct. And part of what makes the area quite murky is that there are multiple eligibility criteria or safeguards that are in place, and you need to fulfil all of them in order to qualify for MAID in Canada. And so the question becomes that even once made for mental illness and I should clarify, by the way, that it does not mean that if you have a mental illness, you cannot apply for MAID, you can apply for MAID if you have a mental illness. However, some other condition needs to be the condition that's leading to reasonably foreseeable death or that is the basis of your application for it. So you're not precluded just by virtue of having a mental illness from getting MAID. Now, in 2023, what will change is that, as I mentioned, that sunset clause kicks in and so that temporary prohibition is removed. I should point out that when the original legislation that was passed in March 2021, Bill C-7, when that was drafted the previous year in 2020, the government had actually put in an exclusion of made for mental illness without a sunset clause. And so for that entire year from the draft legislation 2020 March to 2021 March or actually was February, the government had maintained that MAID for sole mental illness conditions would not actually be permitted pending further work and study. And then in a relatively short time, all of that changed in March where they put in this sunset clause to allow MAID for mental illness by March 2023. The question then shifts to are the other criteria able to be met for some mental illness conditions. And I'm sure that the discussion will lead into some of this. But the overarching criteria for any applicability for MAID is that somebody suffers from a grievous and irremediable medical condition. And then there are various ways that that's outlined in the legislation.

  Dr. Urvashi Prasad: [00:19:31] Yeah. Thanks for bringing that up, Doctor Gaind, we'll certainly dive a little bit deeper into the criteria in just a little bit, hearing you share some of your thoughts around that has also got me thinking about one other one other aspect of this, which is upon the some of the history that we that we heard around how MAID in Canada was established at the time in 2016, it seemed to have been driven by real people stories that resulted in landmark Supreme Court cases when it comes to MAID for primarily mental illness. Has there been any such movement from patient experiences in terms of legal proceedings?

  Dr. Sonu Gaind: [00:20:24] So for sole mental illness conditions, actually, this reflects one of the challenges we're facing that the legislation that's been drafted in response to court cases has all been drafted in response to court cases involving various degenerative or neurodegenerative medical conditions that are eminently predictable. And what has happened is that the policies have expanded to all sorts of other conditions, including now with the sunset clause, eventually mental illness conditions that were not examined by the courts. And that raises certain problems and questions, of course. There was one case back in 2016 prior to the original legislation being implemented, and this was at a time after the Carter ruling. The Carter ruling took place in 2015, and the country was given one year to come up with legislation to allow MAID in some circumstances. And during that time, prior to legislation being enacted in 2016, there were individual kind of applications to the courts that were allowed to be made. So there was one known case of a patient called EF in Alberta who did receive MAID at that time for sole mental illness conditions or a mental illness condition, I should say. And what that involved was a woman who was she was in her mid-fifties with conversion disorder and she suffered from intractable spasms, impaired mobility. And her family actually supported her application for MAID and she did receive MAID. Now, that case raised some concerns because it showed the potential problems or challenges when we don't have standards for what we're doing. In that case, the psychiatrist who opined on the case and on capacity based their entire assessment on chart review. They never saw the patient nor spoke with the patient. And they actually testified not just that they felt that the situation was irremediable, but also that the patient had capacity for the made request despite never speaking with the patient. And so it did raise eyebrows and concerns in some quarters about kind of the need for standards and what may happen when those don't exist.

  Dr. Urvashi Prasad: [00:23:05] Wow. Yes, that sounds very controversial and potentially highly problematic. And also gets me wondering whether from now until March 2023, when MAID might be available for individuals with sole primary mental illness. What can we expect in terms of some of the the legislative changes and such from now until then?

  Dr. Sonu Gaind: [00:23:34] So at this point, what's happened from the last legislative changes in March 2021 is that two pathways are now there in you could consider in a way in parallel for made one remains the pathway if death from some other medical condition is reasonably foreseeable. And in that pathway there's no longer a waiting period to receive MAID. There used to be a ten day waiting period that was required prior to getting MAID. But if death is deemed to be reasonably foreseeable under the current legislative changes, that waiting period is no longer there. But if death is not reasonably foreseeable. And so this was the big change in in March 2021 that Bill C-7 expanded MAID to eligibility for people who were not dying. And so if you have any disability. Other than a sole mental illness. But if you have any disability and you're not dying and you apply for MAID, you may qualify for it. If it can be shown that your illness is or you're suffering and condition is irremediable and you meet the other criteria and then you have a 90 day, three month waiting period. So looking forward to when to March 2023 once MAID for sole mental illness is supposed to be permitted. We don't know what the full legislative framework will be, but presumably there will be some pathway that has differences from some of the other pathways in terms of potentially waiting periods and other things like that. At this time, there is an expert panel that is deliberating on how to implement the processes for made for mental illness by 2023. I should point out that it's been made very clear that the expert panel is not deliberating about whether to provide MAID for mental illness or whether it is safe to or whether you can determine irremediably. They've been charged with essentially providing an instruction manual for how MAID for mental illness will be provided by 2023.

  Dr. Urvashi Prasad: [00:25:42] Okay. Thank you for for clarifying some of that. I'm also wondering, at the time of legislation of Made in Canada in 2016, there were a few other countries at the time being Switzerland, the Netherlands, Belgium, Luxembourg and some US states, including Vermont, Oregon and Washington, which had already legalised assisted suicide in certain circumstances prior to Canada. When it comes to MAID for primarily mental illness reasons. Do we know if there are other countries that we could perhaps look to that may have already legalised assisted suicide and mental illness?

  Dr. Sonu Gaind: [00:26:22] Yes, there are some of the European countries. So the jurisdictions that you mentioned in the states, they had and still have laws allowing assisted dying, but not for mental illness. So the ones in North America till now have all required in some way that death is either reasonably foreseeable as it had been previously in Canada or there's some element of terminality, etc. They don't allow MAID for sole mental illness conditions. The only jurisdictions that do allow that are in Europe and the Benelux countries. So the data we have is mostly from Belgium or Netherlands. We don't really have a lot of good data about the Swiss experience with this. And what we find from the data in Europe does, again, in many of us raised concerns because what it shows is that it's a different population that applies for MAID when it is sought for mental illness reasons. The data in North America till now when death needed to either be reasonably foreseeable or it was for some terminal condition, what that actually showed is that the people who would receive made here in North America under those circumstances tended to be better off. It was more affluent people who are better educated, higher socioeconomic status. And they actually had essentially, you could consider it, they had greater opportunity to live lives of autonomy. And the reason they're seeking MAID in those circumstances was to die with autonomy as well. And the dying with dignity, peace. In the European countries that allow MAID for mental illness, you actually lose that association. What you find is that when people apply for MAID outside of those conditions and for mental illness, they do have unresolved psychosocial suffering. They are not from the better off socioeconomic classes.

  Dr. Sonu Gaind: [00:28:30] In fact, they have unresolved, as I was saying, psychosocial suffering and loneliness. One of the early works that showed the kind of all of the consecutive MAID requests in the Netherlands over a period of about two or three, I think it was about three years. What it also found and looked at all of the MAID requests in the Netherlands for mental illness and it found a 2 to 1 disproportionate gender gap or ratio of 70% women versus 30% men getting MAID for mental illness. And that contrasts to a 50-50 equal balance of MAID when it's for terminal conditions in North America. So that raises some concerns as well, because even in terms of demographics that then, as you know, parallels the 2 to 1 ratio of suicide attempts that we find women to men have. In terms of mental illness driven suicide attempts. And what it also found that data that the most common condition, as you would expect that people sought made for mental illness for Netherlands was depression. And that's paralleled in Belgium as well. And you also had some conditions, including psychosis, PTSD, somatoform disorders, but also prolonged grief and autism. It found that in over 10%, I think it was 11 or 12% of cases, there was no independent psychiatric input despite these being primary conditions of mental illness leading to MAID requests. And then fully one quarter in one quarter of the situations that people got MAID for mental illness, there was disagreement amongst consultants about whether the person should get it. But eventually some or sufficient consultants felt that the person should that they did end up receiving MAID. And all of these are differences from the other patient populations that we see seeking made.

  Dr. Urvashi Prasad: [00:30:34] And just to clarify, Dr. Gaind, you mentioned that in these individuals with primarily psychiatric disorders, such as depression, that there was no psychiatric input. Just to clarify that for ourselves and our listeners, do you mean that there weren't any psychiatrists or mental health professionals that were involved in the MAID assessments and in the proceedings?

  Dr. Sonu Gaind: [00:30:58] Yes. And about 11% of them, there wasn't any psychiatric input. The other point, bearing making here is that when you look at the demographics, they're not just of who gets made, but who does the made assessments. That also changes when MAID for mental illnesses provided versus other conditions. So in Netherlands, they have what are called end of life clinics, where people can go and get MAID assessment and get MAID provision. And those are clinics where the person hasn't received their ongoing medical or psychiatric care. And what we find is that at least 75% or more of the psychiatric MAID applications go through those clinics. So more than the vast majority, more than three quarters go through those clinics. And that contrasts to less than one in ten of the general medical assessments going through those clinics. So even the and what that seems to reflect is that in many of those cases, the mental health providers who had been involved in the person's care did not want to participate in the assessments or didn't agree with.

  Dr. Urvashi Prasad: [00:32:12] Okay. That is certainly an interesting point. I'm also wondering, do these countries have specific regulations around MAID for primarily mental illness that perhaps would be helpful for our discussion?

  Dr. Sonu Gaind: [00:32:25] It's a very good question. Whatever we're doing, we want to do as safely as we can and with as much evidence and evidence bases as we can. And what they tend to have and I'm actually going to rewind for a second to point out some of the differences from their regulations and Canada's because I think that people often don't realise that, in fact, with the Canadian law as it is and where it's heading, it's actually much more expansive than what the Benelux countries allow. People often think that because the Benelux countries were providing MAID earlier and because they allow it for mental illness, that other countries that follow will have more restrictive policies. In fact, Canada will have a much more open policy because in both Belgium and Netherlands, actually anywhere else in the world, that MAID is allowed. There is also a requirement that essentially means there is an assessment from the medical team that all reasonable options at treatment have been tried and exhausted and that there is no reasonable prospect of improvement. Canada is the only jurisdiction in the world that does not have that requirement. And the reason for that is that one of the pieces in legislation says that any treatment that may relieve suffering must be acceptable to the patient. And it's interesting because, of course, we don't want to be forcing treatments on people. People have autonomy and the right to make decisions when they have capacity. But what that does in the context of MAID legislation is it says that even if you haven't had treatments, you may qualify from it.

  Dr. Sonu Gaind: [00:34:13] Now, think about what that means for someone with depression who has internalised a sense of hopelessness as part of the symptoms of depression. And I'm sure we've all had patients like this. I have one lady who, despite having been on low to moderate doses of citalopram, that each time she gets depressed actually help her relatively quickly. Every time she gets depressed, she is convinced nothing will ever help her and she doesn't want any help. And so the Canadian legislation, when you're asking about do those other jurisdictions have some frameworks that might help us, they do have some frameworks that might help us, but we don't have those in our legislation. Our legislation explicitly allows for people to get MAID despite not having received treatment. And when you have only one in three Canadians who need treatment for mental health having access to it, you can see that becomes an additional problem. And the one other piece that I think will hopefully have a chance to talk about is in terms of the safeguards and criterion, what it means to provide MAID for what purpose, meaning that if it's being provided for an irremediable medical condition, we need to be able to predict that a condition is irremediable. If it's being provided for other reasons, because we think someone has enough suffering in their lives, then that's a different criteria. But in Canada, it's supposed to be for irremediable medical conditions. And the whole question of whether you can actually predict that in mental illness, hopefully we have a chance to discuss.

  Dr. Urvashi Prasad: [00:35:53] Why don't we take a look at the current eligibility criteria for MAID in Canada? I know we've been alluding to this for quite some time now, so let's take a moment here and we will go through the eligibility criteria. And then perhaps after we go through that, we can take a look at each one and discuss how this might if and if it might have to change and how that might look like when discussing the eligibility criteria for MAID in mental illness. So the current eligibility criteria for MAID, as defined in the Medical Assistance and Dying Act at present includes that an individual must be one eligible for publicly funded health care services in Canada to be 18 years of age or older. Three Be capable of making health care decisions. Four have a grievous and irremediable medical condition, which means A, the patient has a serious and incurable illness, disease or disability. And B, the patient is in an advanced state of irreversible decline and capabilities. And C, the patient is enduring physical or psychological suffering caused by the medical condition or the state of decline that is intolerable to the person and cannot be relieved under conditions that they consider acceptable.

  Dr. Urvashi Prasad: [00:37:33] Five, Be making a voluntary request. Six, Provide informed consent to medical assistance in dying, which means one of two things; 1. For a person or a patient whose natural death is reasonably foreseeable, the patient provides consent after having been informed of the means that are available to relieve their suffering, including palliative care. And for a patient who's not or for a patient whose natural death is not reasonably foreseeable. The patient provides consent after having been informed of other means available to them, including counselling, mental health supports, disability supports, community services and palliative care. And after having been offered consultation with relevant professionals as available and applicable, and after having discussed these means with the medical or nurse practitioner and given serious consideration to these means. So maybe what we can do now is take a look at this criteria and perhaps discuss if and how some of these criteria might change or that we speculate might need to be changed or modified in order to fit the framework for MAID for individuals with primary mental illness.

  Dr. Sonu Gaind: [00:39:03] So thank you for that background and a comprehensive overview of what the current criteria are and in terms of how those may be modified. There are many different criteria there. I actually tend to consider many of those as safeguards in terms of we call them criteria. But the purpose of them also is to ensure that when people apply for made, they get it for the reasons that society thinks makes sense essentially and whatever normative and evidence based judgements we're making on that, that's the ostensible reason for the criteria. So I'm not going to comment on all of them because many of them I think are translatable. We my background is in psych-oncology and CL psychiatry and in any field in psychiatry and especially in CL, we make challenging decisions all the time, having to do with capacity, having to do with people wanting or not wanting treatment. And keep in mind that the vast majority of time our patients with mental illness has retained capacity. So it's not that they're formally incapable. They pass the criteria of capacity. But what I will do is point out a couple of challenges that that poses. And I'll end with the biggest one. But one is in terms of capacity. The vast majority of our patients can, should and do pass the capacity test when it comes to decisions about living and dying. Think about what or how mental illness can affect the person's wish to live while they still retain capacity. So the point I'm making is that capacity as a safeguard alone is a challenging one because you don't want people to not to be deemed incapable when they're capable. But we also do know that, again, for depression, the typical cognitive triad of what we get when we get clinical depression affects our view of the world, ourselves and the future in a way where we still retain capacity, but it might well influence our decision making nonetheless. And so that's one of the challenges. And how you sort that out in legal terms is really difficult because you're not going to say someone lacks capacity, but we need to be aware of those impacts. Another area is in terms and we tend not to weigh in to the motivation. Funds that people have for decisions because that's their autonomy about why they're making decisions. But when we're talking about life and death, the issue of suicidality also needs to be considered. And unlike any other medical conditions, suicidality is a symptom of some mental illnesses. It's not a diagnostic. We can have suicidality in the context of many things in life, but it's not a potential diagnostic criteria of any other medical conditions other than psychiatric ones. And so how we tease that apart also is challenging. And I don't have an answer for you for how we actually do that with criteria. And in fact, when you look at the data, you find that when people apply for MAID for medical conditions, you can see a difference between the populations that are traditionally suicidal versus those seeking made for other medical conditions. But when people are applying for a mate for mental illness, you see overlapping characteristics between the populations and shared characteristics of people with traditional suicidality for mental illness, including ambivalence, including despair about the future and other things. So those are two challenges that it's unclear to me how existing criteria would potentially address, but we'd be need to be mindful of those. But the biggest one that I said I would kind of lead to is the fundamental what I call the foot in the door safeguard, which is the need to have a grievous and irremediable medical condition. There's no doubt that mental illnesses can be grievous. They cause terrible suffering in people, and that suffering can be as bad or worse as any other suffering or medical condition. But the question of whether we can predict irremediably in mental illnesses is different. And there I would say that the evidence shows or suggests that we cannot. And people often, I think, mistakenly think that. Well. Does that mean that things that when someone has mental illness, it can never be irremediable? Remember that for assessments. That's not the question. The question is, can we predict that in this person the situation is irremediable.

  Dr. Sonu Gaind: [00:43:51] And all the groups that have looked at this have concluded that you cannot make that prediction. And I'm just going to read the quote from Camh specifically on this point. And this is in their consultation advice, policy advice on MAID. And they conclude CAMH concludes that at any point in time it may appear that an individual is not responding to any interventions, that their illness is currently irremediable, but it is not possible to determine with any certainty the course of this individual's illness. There is simply not enough evidence available in the mental health field at this time for clinicians to ascertain whether a particular individual has an irremediable mental illness. And to me, this leads to the crux of the dilemma we're currently in. And I should preface my comments by saying I'm not a conscientious objector to MAID. You know, I'm not sure if I'd mentioned previously, but I actually am physician chair of our hospital MAID team. I certainly wouldn't do that if I was a conscientious objector to MAID and I see the value MAID can provide in certain circumstances. It's also sensitised me to the potential dangers if we proceed on safely. And the fundamental lack of ability to predict irremediable and mental illness, to me, that shows that the very first safeguard cannot be met. And so now we're in a dilemma where legislation is saying you have to allow it by March 2023.

  Dr. Sonu Gaind: [00:45:26] All the science and evidence is saying we can't make predictions if irremediability. So it raises the question that if people end up getting MAID for mental illness but we can't predict irremediability; what are they actually getting it for? And so it does challenge our fundamental notion of what MAID might be provided for. And this is not to make a normative judgement even of whether it should or should not be provided. But I personally do think it is dangerous to provide MAID or death for one reason, when in fact we can't say that's the reason we're providing it for. And then it opens the door to all of the other reasons that people may be seeking death. And in fact, we've seen this. There are as we speak, there are people in Canada who have actually said with the MAID expansion that they will seek made when they run out of money. In other words, the worst case scenario that well, now what I want MAID when I have some other psychosocial suffering that society doesn't help me relieve. But if I can currently also have a mental illness, that might be my quote unquote foot in the door to apply. But if people can't even determine, my mental illness is truly irremediable, but I get MAID, what have I gotten MAID for? So a lot of things to consider and ponder.

  Dr. Urvashi Prasad: [00:46:44] Certainly a lot there for us to consider and ponder. And I think it raises a whole bunch of questions in regards to the practicality of what the criteria, what and if the criteria may need to change, but also a whole slew of ethical and moral questions that also arise from that in terms of whether MAID would disproportionately affect a certain subset of our population versus others. Moving on to address our third objective for today is a discussion around some of the support for and against MAID for primarily mental illness. Perhaps prior to jumping into this, I believe there was a recent survey from conducted by the Ontario Medical Association. And Dr. Gaind, feel free to correct me if I'm wrong, which gathered the opinion of psychiatrists across Ontario on the topic of MAID. I'm aware that you were involved in this project and I'm hoping you could share with us some of the key results from the survey to help us get a sense of the opinion of our profession on this very highly controversial topic.

  Dr. Sonu Gaind: [00:48:01] Thank you. And you're correct. It was conducted by the Ontario Medical Association section on psychiatry. So it was done just for or administered to psychiatrists in the province, and it was developed by the OMA section on psychiatry. I sit on the OMA section as an executive member, but it was developed by the entire executive, not just by one or two individuals. It was vetted by all of us. What the survey found, this was done in the fall of last year and the goal of the survey was both to ask questions, to solicit opinions of Ontario psychiatrists, but also to provide context of the expansion to mental illness, peace, and to get those specific questions of things that currently aren't in place but are predicted to be. And there were about 300 or so I think there were about 270 validated responses. So the OMA staff has a process of ensuring responses are validated, etc. and that's about how many ended up being validated. And what we found is that the overwhelming majority of psychiatrists support made about 86%. So actually let me give you the actual number. 86% said that they supported MAID in some medical situations, 11% did not support it and 3% preferred not to say. So that showed that the vast majority support MAID and are not conscientious objectors. When the question was shifted to "Do you believe MAID should be permitted for sole mental illness conditions", then it changed and there 56% did not support MAID for sole mental illness and 28% did.

  Dr. Sonu Gaind: [00:49:46] When you looked at the end of range, strongest responses, in other words, comparing the people who strongly support to those who strongly don't support, then it was an even greater margin of 3 to 1, strongly disagreeing with MAID for sole mental illness to those who strongly agreed for it. And so that was the overall result. And we did have other nuanced questions that asked about things related to irremediability, whether stances should be based on evidence which most psychiatrists did agree with, did ask question on mature minors and advanced directives. I can go into any of those if you want more details, but the one that I do want to focus on, because this again points out a difference in Canadian law. Familiar to anyone, anywhere else in the world is whether psychiatrists thought a patient should be eligible for MAID for mental illness if standard best practice treatments have not been tried. Because again, as I mentioned, in Benelux countries and everywhere else, standard best practice treatment is a fundamental safeguard before applying for MAID, not in Canada. And here, as you'd probably expect, the overwhelming majority of psychiatrists thought that if standard best practice treatments have not been tried, then MAID should not be offered. And it was about over 90% felt that with.

  Dr. Urvashi Prasad: [00:51:16] So if I were to apply that to or in other words, perhaps it sounds like the overwhelming majority of psychiatrists greater than 90%, as you point out, would likely not be in favour of MAID for mental illness as the legislation is currently laid out at present. Would that be a reasonable understanding of the statistics?

  Dr. Sonu Gaind: [00:51:49] You know, I think it's a reasonable kind of conclusion from that, but with a caveat, because we don't know what additional potential safeguards might be coming into play. And so right now, based on the absence of that safeguard, I think that's a reasonable understanding because if it was simply MAID is allowed for mental illness, even if you haven't had standard, best practice standard, best practice treatment attempts or access. Right. It goes both ways then, yes, 90% of psychiatrists would think MAID should not be allowed in those circumstances.

  Dr. Urvashi Prasad: [00:52:35] Okay. I'm also wondering what might we foresee as a field some of the challenges in supporting MAID for mental illness.

  Dr. Sonu Gaind: [00:52:48] You know, it's something where there are different approaches to suicide prevention. But one of the commonalities is that in many of the approaches, we have tried to keep patients alive and think about our certification laws so somebody comes in to emerge. And if they're suffering from a mental illness and they say that they want to end their lives, in many cases they may end up being certified and hospitalised with MAID for mental illness on the horizon. How all of that plays out is unclear because then you may have somebody who comes in who is saying that and they end up being certified and they're beside someone in a stretcher who is saying something slightly different, who ends up then going down a MAID pathway. And so it does raise questions about what our role is, what will be our response to how we carry out other parts of our mandate as well. Is legislation aligned in a way that actually makes sense across the spectrum, not just MAID, but all of the other legislation do?

  Dr. Urvashi Prasad: [00:53:57] And certainly, Dr. Gaind, you point a very vivid picture in my mind in terms of what as a resident where we frequently do work overnight on call, interfaced with some of these decisions around suicidality being in a scenario in the near future, perhaps of varying a suicide assessment based on whether a patient may be eligible for MAID or not does certainly seem to pose its challenges. I'm also wondering, for the sake of and for the sake of rounding out our conversation and also I think perhaps this might be important for us to touch up upon, is that what might be some of the reasons for supporting MAID for mental illness?

  Dr. Sonu Gaind: [00:54:48] So, you know, I think that is not just an excellent question. I think that is the fundamental underlying issue we need to think about in terms of both how have we gotten to where we are and where do we think we should be going? Again, I'll present some that I think have led us to here and also provide some counterpoints, because I think some of them are based in a little bit of a myth, actually. But one of the fundamental ones in terms of mental illness is, look, we are the people who have advocated for those with mental illness. People with mental illness have been discriminated and stigmatised for decades, centuries. And so how can we now say that mental illness is treated, quote unquote, differently? So one of the fundamental arguments has been that it would be discrimination to treat mental illness differently. Now, my view on that is that mental illnesses are absolutely valid, as valid as any other illnesses, but it does not mean they're the same as everything else. No two illnesses are exactly the same. If they were, they'd be the same illness. And that applies whether it's mental illness or medical illnesses. And we just need to look at things like the issues of suicidality or how decision making is potentially affected, even while capacity is retained, to give some hints at that. And so I think we have to move away personally from the idea that, well, everything has to be treated the same or it's discrimination. We need to treat things for what they are. Equity is not the principle of everything being the same, but being treated properly for what it is.

  Dr. Sonu Gaind: [00:56:35] The other is that it's autonomy, right? That it's an issue of autonomy. And the push for expansion has largely been about that. And there are some valid points to that, that what you do see is that in many of the situations where people seek MAID and these are probably the ones that you and I can picture. If I picture ahead about various life circumstances that might unfold, I want to have some autonomy over my life and death decisions. And so that's a valid point. However, we have to keep in mind that things need to be reasonable public policies, not just for me or for you, but for everyone that they're going to apply to. And so the autonomy, I actually think it's the autonomy myth that's largely fuelled this because people can easily see that argument that, well, I want autonomy to have a dignified death. But when we see the differences that data and evidence point out to how these issues play out differently for different populations, especially for marginalised populations and ones that suffer from mental illness that tend to be marginalised. So again, I'll take a segway here to the Aboriginal suicide rates. Nobody would say that Aboriginal suicide rates and it's not just Canada. First nations everywhere suffer this. Nobody would say that those suicide rates are because they just have a higher predisposition to mental illness. It's not that it's a social disenfranchisement that literally leads to that, and it may at times combine with mental illness. So the point I'm making there is that the drivers that lead people to wish to end their lives differ for different populations.

  Dr. Sonu Gaind: [00:58:23] And so the autonomy myth that's fuelled the wide expansion suggests that MAID is safe. And what I would say is that MAID actually may be safe for many people. It's a little ironic to use the word safe in me, but I think you know what I mean, that it could be provided in an appropriate way that society thinks is being done for the right reasons. However, the broader we expand the criteria and eligibility, the more and more people potentially fall under it. And we're now at a point of expanding it so far that it's not just the people who've lived a life of dignity, who want to lie, who want to die with dignity. It's people who've never had a chance to live a life with dignity, who seek an escape from life suffering. And so there is a group that may get more autonomy as these things expand. And again, that gets back to your gets back to your question. What's one of the fundamental reasons for this expansion? I think that's one of the fundamental ones. But the problem is that when you expand that autonomy for me, you are also expanding the risk to a marginalised population. So it's actually not true autonomy, it's a privileged autonomy. It's more autonomy for the privileged at the expense of the marginalised. And that's where my concerns come into play. And they're fuelled by the fact that in my opinion, if. We are making determinations of irremediability that science and evidence tells us that we're not able to make and we're abandoning our role as medical experts as well.

  Dr. Urvashi Prasad: [00:59:57] Doctor, again, I think your answer tugs at some of the fundamental principles of that most of us perhaps have thought about in the field of medicine. And the topic of MAID and mental health perhaps is posing a challenge, which is the conversation around autonomy versus doing no harm. And I certainly do think that this conversation, it speaks to that largely. I know I'm just keeping an eye on the amount of time that we have together. And I do want to thank you for your time here today and in assisting with my grand rounds, helping facilitate it. I do really appreciate you being here as the other individuals on today's episode as well. I will pass it back to Alex to facilitate the Q&A period.

  Dr. Alex Raben: [01:01:03] Thanks, Urvashi. And I echo your thanks to Dr. Gaind as well. Of course. So now we'll move to the Q&A period for you, Urvashi and Dr. Gaind, as mentioned before, you should feel free to add to this. But this is kind of a tradition of grand rounds, is that we do get a chance to ask some spontaneous questions towards the end. And so one thing I'm wondering, hearing this discussion and being a physician who doesn't come up against the MAID legislation very often in my practice, although that may be changing as we're hearing today. One kind of question that didn't quite get answered for me is we've talked about these criteria, but how is it implemented practically in the real world? Who is doing this assessment? Is it only would it be only psychiatrists? Would it be any physician you talked to? We heard about these clinics in Europe that are doing assessments. So how will this play out Dr. Prasad in Canada or what's the legislation currently?

  Dr. Urvashi Prasad: [01:02:10] So based on my understanding, the legislative currently is not limited to just psychiatrists and it is open to other medical professionals or doctors specifically who are participating in doing these specific MAID assessments. And I believe it's more than one doctor, so it would be at least two doctors opinions in order to perform these assessments. And for somebody to be eligible to go ahead with MAID. I will certainly open up the space here for Dr. Gaind and as well to add his input on this.

  Dr. Sonu Gaind: [01:02:58] Thanks, Urvashi. And you're correct, the current legislation requires two medical practitioners, but they don't have to be just physicians. It does allow for nurses, nurse practitioners or physicians. And one of the things that's changed so the original legislation, it's easy because they're the kind of, I guess one is half the other. So that's how you can remember the numbers. The original legislation was C-14 back in 2016, and that one is the one that required two medical practitioners but didn't have to be physicians, could be nurses, nurse practitioners, and it didn't define who you needed to be. With the change in C-7 in March 2021, as I mentioned, there are now the two pathways, one for if death is reasonably foreseeable and the other if it's not. So the non-dying disabled pathway you could say. And for that second pathway it is something where the requirement is supposed to be that at least one of the medical practitioners is expert in that particular area that the person is applying MAID for. And so presumably if that held true down the road, it would mean that a psychiatrist would need to be one of the people if the person's applying for MAID for mental illness. But again, that's all pending what happens in 2023 in terms of the specifics of the legislation.

  Dr. Alex Raben: [01:04:24] All right. Thank you both for those answers. That's quite helpful. And David, I'm wondering if you had any questions. I've got one or two more myself, if there's time. But I wanted to make sure you had an opportunity as well.

  David Eapen-John: [01:04:37] Yeah. Thanks so much, Dr. Raben. One question that I kind of wanted to talk about a bit, I think a really good point was brought up before about how these bioethical discussions can have different implications on different communities. And I really like the idea that MAID in the context of mental illness may mean more autonomy for the privileged and less autonomy for people who are more marginalised. And I think it also relates to kind of the data we have from other countries in Europe which may have a different population structure and makeup of their population compared to a more diverse place like Canada. And I was wondering if there are like ideas or ways that we can protect marginalised communities specifically by adjusting the kind of legislation that we already have in place, or will that involve like a major rewriting or redoing of the legislation altogether?

  Dr. Urvashi Prasad: [01:05:36] I think, David, you bring up an excellent question and an excellent point. And you speak to the probably the biggest challenge that we currently are experiencing in regards to the the biggest sort of shortcoming of the current MAID criteria in regards to the way it is currently laid out and the fact that individuals from more marginalised communities, particularly lower socioeconomic parts of the community, might be disproportionately affected by the way the law is currently laid out. And I think this speaks to something that Dr. Gaind has had alluded to a little bit earlier in regards to safeguards. I think the legislation would certainly need to expand and or rather narrow down its eligibility criteria and perhaps be more specific to have some safeguards in place to protect individuals that might be more vulnerable and more disproportionately affected by the law. In terms of how we could possibly do that, I think we may have to take a closer look into the definition of what irremediable might be in regards to not just looking at it from a biological lens, but also from a psychosocial lens. So are there financial stressors that are contributing? Are there housing stressors that are contributing? Is there loneliness? Is there social isolation and ways in which to address some of these important struggles and challenges that many of our patients do face? Dr. Gaind, if you have anything else to add in here, we'll be great to hear your input on such an important question as well.

  Dr. Sonu Gaind: [01:07:43] Thanks so much. I think you gave a very good answer to that. And David, that's really on point and insightful question because that's precisely part of what we need to be concerned about. And my kind of I liked your answer Urvashi, I'm just concerned that it may not be implementable. And I'll tell you why. I've been in policy discussions with and this was actually a psychiatrist who was saying that, look, when we see somebody who applies for MAID now, if they are applying for poverty and that's how they framed it, if they're applying for poverty, well, we wouldn't provide MAID. And I thought that's not a realistic actual reflection of what happens because suffering is cumulative. We don't compartmentalize our suffering and say that this amount of my suffering is from poverty, this is from my mental illness symptoms, and this is from my separation, from my family. It's all cumulative. And we've known this for many years in palliative care. There's a concept called Total Pain by Dame Cicely Saunders. And it's that idea that all of the suffering that we have kind of that's what we respond to. So in any practical implementation, if somebody is applying for MAID and they happen to also have poverty, how would we possibly rule that out? Because if we say that, oh, we're not going to let you get it because you are of lower socioeconomic status.

  Dr. Sonu Gaind: [01:09:22] Imagine the discrimination charge is there because then you're actually saying we're not going to provide something to you because you have poverty. No one's going to come and say I want it for poverty, although some people are now actually saying that. But in practical terms, I don't know how you could actually separate it out. And this is why even the UN rapporteur on the Rights of Persons with Disabilities and in fact the UN,there were two UN reports that came out quite strongly against what Canada is doing with this expansion, because they essentially are saying that much of the expansion is based on ableism and that disability should never be a ground or justification to end someone's life directly or indirectly. And they add in the idea of the socioeconomic suffering that also fuels disability and the sense of being a burden to society. And so I really liked your answer. I just don't think it's in practical terms doable because when people come with that cumulative distress and apply for MAID, how do you separate it out?

  Dr. Alex Raben: [01:10:41] Thank you both for your answers there. Yeah, it sounds like quite a complex question and the complex answer that will be very difficult to tease out in a legislative, practical way because of these disparities that exist in our society. I'm sorry, Urvashi. I'm going to ask one last question, but it's kind of double-barrelled, but one I think will be a relatively faster answer. And that's just to bring it back to the case of Anna. I'm wondering if you think with the current legislation, if we fast forward to March 2023, do you think she could be eligible for MAID given her situation? And then my sort of final question is we've talked about feelings of hopelessness in the context of depression, possibly leading to someone applying for MAID. But I think just personally speaking, some feelings of hopelessness have come up for me in this discussion tonight that I'm wondering how we see, what we see, the future of this legislation being and if there is some potential for change here, because we've talked a lot about some problematic potential issues here in the future.

  Dr. Urvashi Prasad: [01:11:57] Yeah. Alex, you ask a question that certainly been on my mind, especially with having some of my interactions with the patient that I alluded to a little bit earlier. So bringing this into Anna's case, particularly, I think if we were to fast forward to March 2023 and if I was faced with this question, the one criteria that I feel would be, possibly the most challenging and one that I would struggle with the most would be within the eligibility criteria. I'm just going to read this out loud just to bring everybody on the same page. So this the point being the patient is enduring physical or psychological suffering caused by the medical condition or the state of decline that is intolerable to the person and cannot be relieved under conditions that they consider acceptable. So given the way that that's worded, saying that it relies on the patient's level of acceptability, I do think that Anna would meet criteria for this and would likely meet criteria for being eligible for MAID. However to me if I were to be looking at that criteria and perhaps maybe even looping this back into David's question in terms of ways in which we could take a look at the current criteria and change it, I think one way of one way of perhaps revising this criteria would be to change it to both the physician and the patient, considering what might be acceptable versus what might not be acceptable treatment.

  Dr. Urvashi Prasad: [01:13:54] So in Anna's case, she's only been on one trial of an antipsychotic medication that we know of. And from a physician perspective, I would consider that to be not acceptable in regards to knowing that there are other treatment options that we could pursue. So, from my regard, I would not find that to be acceptable. However, I think from a practical perspective, if we were just going by the criteria, I think she would meet criteria for MAID. And I'll get Dr. Gaind to weigh in on that in just a second. But I'm hoping to also answer the second part of your question, which is the question of hopelessness that some of our patients might be struggling with. And I do certainly think that in the case of Anna, that was something that was also very much evident.

  Dr. Alex Raben: [01:14:54] Well, let me add to that Urvashi, because I was actually talking more about the provider feelings of hopelessness and where you see our role in this legislation or the role of Canadian Society in addressing some of the problematic issues we've talked about today. And I know it's very complicated, but do you see and it doesn't fall on any one of us. So it is a big question, certainly. And I don't expect you to know to have a single answer. Where do you see the hope in this?

  Dr. Urvashi Prasad: [01:15:28] It's a big question. And to me, I think the first step really is raising awareness on this issue in regards to perhaps as health care providers feeling less isolated in our level of distress and hopelessness around such a complicated issue. And this also speaks to the reason why I was hoping to participate in a grand rounds on this and do a podcast, because I think, surprisingly, there isn't as much awareness on this very important issue. And I think a lot of us perhaps are dealing with the hopelessness around it in sort of silos independently. And I think the biggest step would be to increase awareness on this issue so that collectively, as a group, we could perhaps discuss some of our feelings around it and maybe even take that a step further to creating perhaps some expert panel groups or working with individuals that are working on improvising the policies for MAID in mental health so that there can be some movement driven by psychiatrists and mental health professionals to bring to light some of the challenges around the way the law is currently designed and to perhaps make some changes that would revise the eligibility criteria in a manner where we would not feel so disheartened when so many of our patients possibly maybe talking about or inquiring around MAID. Now how that might happen in terms of what sort of changes we would see in regards to the law would be difficult for me to answer to for all the reasons that Dr. Gaind mentioned a little bit earlier. But I think certainly being able to have being able to raise awareness and being able to discuss some of these emotions and then lead that into perhaps even pushing for changing policies might be the first couple of steps around this.

  Dr. Alex Raben: [01:18:03] That's great Urvashi, I already feel more hopeful after hearing that from you. So thank you. Dr. Gaind, do you have any parting thoughts or thoughts on that? Last question there before we wrap up.

  Dr. Sonu Gaind: [01:18:14] I would just echo actually what Urvashi said. I think you are absolutely right in what you're saying, that the answer to despair and hopelessness in this case is actually both us getting engaged. And by us, I mean all of us in the medical field and residents are the future of our medical field. So especially resonance and raising awareness, because what I can let you know is that although, you know, it's leading to a lot of challenges right now, this is something where as more people become aware of it, they're actually very surprised at the way things have proceeded. It is not something, you know, normally we have a sense of trust and confidence that by the time things come around to being said as national policy, they've gone through all the appropriate due diligence. And I can say to you that in this case, that has not happened. And although that's not a good thing, that it hasn't happened, but it also does really highlight, as more people learn about it, is, you know what, maybe we need to take another look at this. And it's not to say ideologically that something is or isn't right, but to understand what we're doing it for and to do it in at least what we can best try as an evidence-based way. And so, I do think that as people learn about this intermingled, I'd say, Alex, with that sense of "Oh, I'm feeling a bit hopeless" is also, you know what, this is actually a significant issue that's going to affect a lot of my patients and people that my patients know when the people were here trying to help, and that can be very motivated. And so I would say don't despair about it, but I think become aware and informed and also help others become aware and informed. And that can actually lead to positive policy changes and pressure.

  Dr. Alex Raben: [01:20:11] What a wonderful note to end on that. There is there is hope here. And that as has been mentioned already, this episode itself serves as a platform for us to start or continue the discussion. And I hope that continues as well. Thank you again, Doctor Gaind for being our guest expert on this episode and to you, Urvashi and David. And of course, thank you to our listeners and we hope you enjoyed and we'll catch you on the next episode. Bye for now.

  Dr. Alex Raben: [01:20:53] Psyched is a resident driven initiative led by residents at the University of Toronto, McGill and UBC. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Dr. Urvashi Prasad and Dr. Alex Raben. The episode was hosted by Alex Raben, Urvashi Prasad and David Eapen-John. The audio editing was done by Alex Raben. Our theme song is Working Solutions by All Live Music. A special thanks to our incredible guest, Dr. Sonu Gaind for serving as our expert on this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening!

Episode 40: Suicide Epidemiology and Prevention with Dr. Juveria Zaheer

• Episode 40: Suicide Epidemiology and Prevention with Dr. Juveria Zaheer

  Chase: [00:00:06] Welcome to PsychEd the Psychiatry podcast for Medical Learners by Medical Learners. Today, we'll be taking a deeper dive into talking a bit more about suicide. It will cover additional topics relating to suicide risk assessment, suicide prevention and suicide epidemiology. Today, our guest expert is Dr. Juveria Zaheer. Dr. Zaheer is a clinician scientist with the Institute for Mental Health Policy Research, and she is also the medical head of the CAMH emergency department in Toronto, Ontario. She's also a assistant professor in the Department of Psychiatry at the University of Toronto. Her research integrates both population level investigations with qualitative research on an individual level to better understand mental health service delivery and service outcomes as it relates to suicide and psychiatric care. My name is Chase Thompson. I'm a fourth-year psychiatry resident at the University of Toronto, and I'll be hosting this episode. The learning objectives for this episode are as follows: One, develop an awareness of suicide risk and suicide prevalence as it pertains to the general population as well as psychiatric populations. Two, incorporate additional contextual information into suicide risk assessment that goes beyond SAD PERSONS or other list-based approaches. And three, develop a deeper understanding of how to approach and help individuals with suicidal thoughts and behaviours. Hope you enjoy the conversation.

  Chase: [00:01:44] Thank you so much, Dr. Zahir, for joining us today and talking a little bit more about suicide. Just for our listeners, this episode is meant to build on some of the previous topics we've had in suicide, assessing suicide risk, as well as how to manage suicidal patients. But I think that it's important for us to have a little bit more of an in-depth conversation on this topic, given how often it comes up and how important it is to psychiatric practice. So thank you so much for joining us, and I'll just let you introduce yourself. I know you've been a frequent podcast guest at this point. I think this is your third interview, as we discussed earlier.

  Dr. Juveria Zaheer: [00:02:28] Yeah. Thanks so much, Chase. My name is Juveria Zaheer, please call me Juveria. I am a psychiatrist at the Centre for Addiction and Mental Health in Toronto, Ontario. I am the emergency department medical head at CAMH. So we are the only standalone emergency department in Ontario and our goal is to provide ethical, evidence-based and dignified care to the people who walk through our doors. And I am also a clinician scientist and my program of research is focussed on suicide and suicide prevention, trying to understand the epidemiology of suicide, the lived experience of people with suicidal behaviour and to bring them together to co-create interventions that work.

  Chase: [00:03:05] So I think one of the things that I wanted to touch on, you know, in this conversation is something that you spoke about in the previous conversation you had with us about: we tend to stratify individuals as low, medium or high suicide risk. But, you know, as trainees and residents working in the emergency department, sometimes it's hard, I think, for us to kind of have a more concrete idea of what that means. And we often don't really get taught about some of the statistics around suicide and the numbers or how often this actually happens. So I'm wondering if we could go through that a bit and kind of talk about suicide risk as it pertains to different populations in psychiatry.

  Dr. Juveria Zaheer: [00:03:46] Yeah, I think that's a really important question because it's sort of like zooming out to see what the lay of the land is and then we can zoom in to make sure we understand a person's individual risk. So I think if you if you meet 100 people, probably 100 of them have been affected by suicide in some way. Suicide is the leading cause of death for young people and it is a top ten cause of death here in Canada. So when we think about what our rates of suicide, we often put them in person-years. So in Canada, we have 11 suicide deaths per 100,000 person-years, and person-years can feel a little bit tricky. But basically what it means is it's using, it's trying to account for the number of people that you're following and the length of time that you're following them. So I could follow a thousand people for one year and that would be 10,000 person-years. Or I could follow 100 people for ten years and it's the same amount of person-years. So we're looking at about 11 per 100,000 in Canada across the general population. And I know that one of the first things that medical students and residents are taught is that men die by suicide three times more often than women do, about 3.2 times more often in Canada, which is very consistent with other sort of white majority countries, European, North American countries. I think it's really important to point out, though, that women engage in non-fatal suicidal behaviour at a rate about 3 to 4 to 1, and that in itself is a really important treatment target and this gender ratio is quite culturally mediated. So in other parts of the world, that gender gap is much lower and up until about 15 years ago in China, women actually died by suicide more than men do and the rates there are about 50/50.

  Dr. Juveria Zaheer: [00:05:24] And I think it's really important when we think about how we stratify risk or how we understand risk, to understand that there are certain things that are going to be more important than others. If you're a clinician and if you have a man or a woman sitting in front of you, the most important thing isn't their gender on an individual level, the most important thing is their history of suicidal behaviour or their current suicidal ideation, or whether they've been recently discharged from hospital. So, for example, in a in a psychiatric population and we consider that to be like anyone who has been admitted, say in the last year, you're looking at 500 suicide deaths per 100 000 person-years. And if we look at like closer discharge, so if you look at people who are discharged within the past week, it's close to 3000 per 100 000 person-years. So the closer you are to a discharge, the higher your risk is. And then I think an area that we don't talk about too much that can be quite frightening and dramatic for folks, for families and for patients and for care providers is that people do die by suicide in hospital. And so one out of every 600 or so psychiatric admissions can end in a suicide death in hospital but it's really important to point out that environmental factors, programmatic factors are so important and this is a really important area where we could reduce suicide risk and there's a lot of variability within institutions based on the kind of care that's provided and the kind of environment that you're looking at.

  Chase: [00:06:46] Right. And I know you had mentioned that the gender gap in suicide rate is actually quite culturally mediated. I know you've done some work in this area, and I'm wondering if you could speak to the kind of anomaly that China represented where they didn't have that same gender gap that we see in North American culture?

  Dr. Juveria Zaheer: [00:07:05] Yeah absolutely.

  Chase: [00:07:06] Do you know what's going on there?

  Dr. Juveria Zaheer: [00:07:07] Yeah, I think it's a really big and a really important question, especially when we live in a place like Canada that's so diverse and we know that, for example, my background is Indian Muslim, and although I was born in Canada, my risk is actually more similar to an Indian woman living in India for at least 2 or 3 generations and so understanding suicide risk in different cultures can be really important in prevention. And so, you know, classically when we formulate suicide, so people like Durkheim, Emile Durkheim, who was a sociologist, talked about how only men have the sort of the strength and the decision-making ability to die by suicide. And so it's the idea that non-fatal suicidal behaviour then culturally becomes something that a woman does and death by suicide is something that a man does. And these cultural scripts are so important because for a man who's suffering, who may be socially isolated or who may be not engaging in mental health care, it becomes a script that that makes sense to them and that's really important in suicide prevention. In China, though, up until, you know, the 90s and the 2000s, like psychiatry, is a relatively new discipline and suicide often didn't show up in psychiatry or neurology textbooks. It was more of a behaviour, it was an act of a powerless person in a very difficult situation. And the other thing to to point out around Chinese women in particular is the gender gap where women are dying more often than men is often seen in rural areas because women often engage in the consumption of poison, so rat poison, agricultural poison. And when you, those can be very fatal and so there's if you have an impulsive overdose attempt, for example, the risk of death is quite high. And there's a beautiful quote from some sociological work in China that said, 'when somebody dies of suicide, we don't ask why, we ask who is to blame'. And so we sort of start to see how important culture, gender construction of suicide is in suicide prevention.

  Chase: [00:08:58] And the other thing that stood out to me about what you said, you know, when we're talking about the population of individuals who's recently discharged from hospital, the number I think was 3000 suicide deaths per 100,000 person-years, which, you know, is almost 300 times population-based rate. You know, I guess that kind of brings up other issues. Like one might look at that number and think, are we discharging patients too early or what is, is there some sort of lack of risk assessment going on at the discharge period? Or how do you understand that sort of really high risk period right after discharge?

  Dr. Juveria Zaheer: [00:09:41] For sure, and I think what you're speaking to is can we develop a sense of therapeutic nihilism that our interventions don't work or our hospitalisation, which is often like the biggest card in your deck for acute care psychiatrist, doesn't work. I think another way of framing it is is a way of trying to be optimistic about the fact that we have a population of people that we know are high risk that we can identify. Often we don't know who's at risk and, you know, in the general community. So is this a place where we can act? And, you know, epidemiological data tells us what's happening. It often doesn't tell us why. And so the other half of my work is qualitative, where we interview people about their lived experiences. And one of the things we've just done, we're doing a study right now where we've interviewed all told 70 people, people who have lived experience of suicidal behaviour, who've been admitted, their family members, care providers. And what keeps coming up in that study is that you're in so much distress, you're in so much pain, you go into a hospital, you get support, you get the right treatment, and when you're discharged, your level of care goes from 100 often to zero. There's a really important paper authored by Paul Kurdyak, who's one of my colleagues, that says in Ontario 68% of people who have a suicide attempt don't have follow up within a month. And so I think as a system, we really need to think about intensive access to care in that post discharge period. So there are things that can work like close-contact follow up, so calling or following up with a person within 24 hours of discharge, higher intensity things than just offering an appointment. So can we meet someone on the inpatient unit, even start psychotherapy with them, have them discharged to the same provider? So I don't necessarily think that it's because hospitalisation doesn't work or that we're necessarily doing something wrong in that piece. I think in all of health care, transitions are so important and cardiac care, if you have an MI, then you go to cardiac rehab and trying to figure out in mental health care, how we can sort of honour the suffering of the people that we're serving and make sure that we don't go from 100 to 0.

  Chase: [00:11:37] Right. Makes sense.

  Dr. Juveria Zaheer: [00:11:38] And I think and I think the other piece is that, you know, epidemiologically, we're selecting for a very, very sick population. And I think anyone who has you know, it's an honour often to sit with someone on the worst day of their life and they tell you their story and they're in so much pain and you bring them into the hospital to help them. There's you see ten people you may admit two, and they are people who are very, very unwell and they're deserving of sort of very good in-patient care and then transitional care thereafter. And I think that's another piece of it.

  Chase: [00:12:09] There's I guess, been some conjecture that potentially with the sort of deinstitutionalisation of psychiatry, the burden of suicide risk has actually kind of moved from, you know, the institution in the past, as we would call it, and now sort of exists more in the community. Do you think that's also plays into that part of the elevated risk in the post-discharge period or.

  Dr. Juveria Zaheer: [00:12:35] Yeah, it's a it's a great question. We know that length of stay is a little bit shorter now, much shorter than it was back in the day and we know that very intensive services are less available. I do think, though, that one of the really important pieces around framing suicide prevention is it's not just a psychiatric issue. I think it's more about it's a public health issue and it has public health components, and that's food security, housing security, financial security and freedom from trauma and oppression. And I think as we see a bit of an unravelling of the social net where we see, you know, people who can't get a job out of high school and buy a house and, you know, have supports in that sense, I think that these broader social factors are really important as well. And so I think it's difficult to sort of understand deinstitutionalisation in context versus kind of the broader picture. And I think to a lot of people who are suffering from suicidal thoughts don't necessarily have the kind of mental illness that is severe enough for long term hospitalisation. So I think we always there's always that stuff that gets thrown around that 90% of people who die by suicide have major mental illness. That psychological autopsy studies are fairly flawed. And there's been some interesting work by the CDC and a nice paper in the New England Journal of Medicine that sort of talks about how the intensity of psychiatric symptoms are only one piece in risk prediction and things like relationship breakdown and conflict, things like housing insecurity, things like financial distress or trauma all play a huge role.

  Chase: [00:14:06] So I kind of want to switch gears a little bit. So we have this sort of idea as residents and psychiatrists that, you know, one of our primary tasks is to assess suicide risk and to really kind of quantify the risk when we're presenting the case and charting that risk. But I think one of the things that I've learned from you in part, is that there's a lot of other factors about, you know the patient's wishes. What would be best for them in their certain scenario, whether that means hospitalisation or actually returning home and whether they're able to kind of participate in an outpatient plan that you put together for them. And I think you've also spoken about this on previous podcasts, but, you know, sometimes that means that patients who may have a higher, you know, quantitative risk, if we can say that would end up being discharged versus someone who might be lower risk being hospitalised. I just wanted to ask you, like, are there certain cases where, you know, even when an individual seems sort of reasonable, doesn't seem to have overt symptoms on the face of it, but the, you know, the plan you're sort of putting together seems good, but for whatever reason, you kind of have a bad feeling about the case, either from information you've gotten from family or from collateral, and in those cases, you're considering certification. I'm just wondering, like, how do you sort of approach those cases where the patient is actually presenting very well, but the family is very concerned and sort of saying, you know, well, if they go home, then I'm really worried what's going to happen to them, but there may not be like any sort of material evidence so far that the person is at risk.

  Dr. Juveria Zaheer: [00:15:58] Yeah, I think that's a really excellent question, Chase. As an emergency department psychiatrist, I think one of the hardest sort of sets of cases you deal with is when there's conflict. In a perfect world, everybody is on the same page that I say to the patient, I think you're deserving of hope and help. The patient understands that and is hoping to come into hospital for initiation of treatment, and the family is on board as well. And as you say, when there's there's lack of consistency in that triangulation, it can feel very difficult. One of the things that I tell myself and I often share with patients and families, in obviously more appropriate language, is that admission to hospital in and of itself is not an evidence-based strategy for suicide prevention. There are things that we can do in hospital that can prevent suicide. For example, if someone's experiencing depression with psychosis, we can treat that psychosis, which would reduce someone's suicide risk considerably if that's what's driving the risk. If someone is intoxicated and having suicidal ideation in the context of that intoxication, holding and being able to sort of understand the person in context and safety plan thereafter would reduce their risk. And so I think that helps me sort of move beyond admission versus discharge. The question of and the other thing I say and I think I said this in our last podcast together as well, is if I'm working with someone and they want to be admitted, I should have a really compelling reason that I don't think that they should be admitted. And if I'm working with someone and they don't want to be admitted, I should have a really compelling reason for bringing them into hospital and engaging in what is trauma and what is quite carceral.

  Dr. Juveria Zaheer: [00:17:28] And so the things that I sort of think about in terms of involuntary hospitalisation is trying to hold on to a thread of hope, if someone can hold on to a thread of hope and they want to be alive and they want to engage in care, then there's a lot that we can do to support them. So, for example, safety planning is an evidence-based intervention in suicide prevention. There's a lovely paper in JAMA Psychiatry that shows that we show a 50% reduction in suicidal behaviour post discharge if a safety plan is completed. So a red flag for me is if someone can't safety plan, if they say I have nothing to live for, I don't really I have no hope, I have no one to connect with, that makes me a little bit concerned. Things that can really affect someone's ability to plan or to not be impulsive make me really nervous. We did a study that showed that of people who die by suicide between the ages of 25 and 34 in Ontario, something like a fifth or a quarter of them have a diagnosis of schizophrenia. So for younger folks, having a psychotic disorder is a really big risk factor for suicide, and it's really treatable. Psychosis is treatable and psychosis hurts and bringing someone to hospital to manage that, if someone has psychosis, whether it's an affective psychosis, whether it's a primary psychotic disorder, postpartum psychosis is very high risk. These are people I tend to bring into the hospital because if you're not able, if you think about keeping yourself safe, the psychosis can really interfere with that. Around family work, I think one of the biggest principles in working with families is is radical genuineness and radical transparency. So to be honest and open about what we're thinking, I'll often say to a patient, I'm really worried about you. I'll say to a family, you know, I would really love to keep your loved one in hospital. I'm worried too, and not but, and, here are the limitations of the Mental Health Act. And so I think if somebody I think one of the dangers in risk assessment is say, if I see somebody and they had a very serious suicide attempt. They engaged in preparatory behaviour, so they wrote notes to their loved ones, they've been giving away their belongings, they have a very deep depression that is sort of characterised by decreased problem solving ability, a lot of pain and potentially even some psychotic symptoms and that person has an overdose attempt.  They made efforts to seclude themselves, they happen to be found and they come in and they're sitting in front of you and they say, oh, everything's fine, I'm not suicidal anymore. One of the really important things to think about is like, what has changed between now and then? And for this person, not much has changed and there's very much that could be modified. And if you can come up with a way to keep that person safe, in hospital, can someone stay with them 24 over seven? Can we start treatment? Can they come to day hospital and be seen every day? Then you can kind of modify that risk. But if the person says, no, I'm done here, and you know that three months ago they were going to work every day and they were really active in parenting their children. And, you know, they have a family history where someone died by suicide in the same circumstances. That's a situation in which I would certainly certify. If you meet someone who, you know, brings themselves in, I have a very difficult time when someone brings themselves in for care and they're really honest about what they're going through, you know, that's a really good sign that they're able to engage and they're able to share with you what they need. And that's a it's kind of like the the door is open. There's a crack, there's a light where you can kind of connect with them and support them in that sense.

  Chase: [00:20:48] For sure. Even sort of talking about, you know, the individual who's brought in by family, who's kind of concerned about suicidality. It sort of, even reminds me of when you see patients who are suffering with addictions and the family brings them in similarly and the person isn't kind of really ready to engage in that sort of care. And, you know, I think we understand that they need help at some level. And but at the same time, in terms of addiction and sometimes suicidality, the person is still kind of in that stage where they're not ready to engage with care or that can make it really hard too when you and the family are sort of on the opposite page as the patient.

  Dr. Juveria Zaheer: [00:21:33] For sure, one of my colleagues, Gina Nicoll, who has dual expertise, she has lived experience with suicidal behaviour and is also does research with me, she says something really beautiful. She said, 'it's really important, not like not to just try to understand the plan, but to understand the pain behind the plan'. And so I think sometimes when people are feeling really ambivalent about living or dying or getting care or not getting care to try to focus maybe less on the plan and less on keeping someone safe and more on what's going on in your life that is so painful and what is driving it. Yvonne Bergman often says, one of her lines that is so moving, is when people want to die by suicide and you ask them what they want to end, they don't often say my life, they often say I'm exhausted or I'm a burden or I'm terrified. And sometimes connecting with that emotion and that feeling, it's almost like a motivational interviewing approach, as if we can connect with that person as a person, then it can help us understand how we can get at that underlying piece behind the work. And so I think there's some really interesting parallels with addictions as well. And I think any kind of tools that families have are really useful. In our work with families, so we've interviewed people who who've lost loved ones to suicide and who've supported loved ones in navigating the health care system. People don't necessarily often complain about like, I brought them to the hospital and they weren't admitted. They are really distressed about lack of communication, lack of open communication. They are really distressed about the differences between like confidentiality and safety, like that kind of space there. They get really distressed that the follow up plan makes no sense. Like, oh, you want me to follow up in three months? That doesn't make a lot of sense. And so I think there's instead of getting stuck on admission versus discharge, even with families, to sort of try to understand their concerns and context and try to do whatever we can to make sure that we have a safe discharge plan for someone and that we can help them engage in the supports they need. And if the person isn't ready, then that we have a plan in place that if they're ready, like can we like harness that moment and bring them into the hospital and do what we need to do at that point?

  Chase: [00:23:37] Yeah. One thing you stressed is evidence-based care for patients with suicidality. And one of those things is completing a safety plan for that patient. I'm just wondering, is there any sort of particular, you know, diagnostic category that you might consider completing a safety plan, or are they really good for most patients who are having suicidal thoughts or behaviours?

  Dr. Juveria Zaheer: [00:23:59] Yeah, I love that question. I talk about safety planning all day. So I think the old term that people often use to use is like contracting for safety. So like if I say like, you promise you're not going to do anything right, there's no evidence for that because you're not actually giving the person any support or skills in that moment. The cool thing about safety planning, you know, you talk about reasons for living. How do I distract myself? Who do I call to distract myself? Who do I call for support, resources that I can talk, I can contact and keeping my environment safe. So a little bit of means restriction in there. Every time you use the safety plan effectively, it's positively reinforcing, which is really, really cool. Although like safety plans aren't a panacea, like there's certain times where it's not going to work and timing is really important. So you mentioned around, I'll come back to the timing piece, but around diagnosis. Suicide safety planning is a pan diagnostic intervention, but there are certain people who may struggle with safety planning. So, for example, someone who's experiencing mania or psychosis, this may not be the right moment or the right time to engage in safety planning, although you can still engage in kind of a modified form of safety planning. We just had a meeting yesterday with our colleagues at the Adult Neurodevelopmental Service, and we talked about how do we adapt a safety plan for people with intellectual disabilities or people with autism. We're doing some research right now where we interview people about their views on safety plans. And so I think that's a really great place to start, is ask someone what do you think about this process? And if someone is like all in on it, then absolutely do it. If someone is kind of ambivalent, sit with them and show them. If someone is like, No, I've done it, this doesn't help me, find an alternative.

  Dr. Juveria Zaheer: [00:25:32] The other piece that I mentioned earlier is around timing and safety planning. My colleague Gina often talks about waiting until the emotional bleeding has stopped. It can be extraordinarily invalidating, if I came to you in crisis and you were seeing me and I was saying that my relationship has broken down and I have been staring at a bottle of pills and I feel so alone and I'm not working, and you hand me a safety plan, you haven't even assessed me yet. A safety plan should be something that we come to collaboratively and we talk about the sort of striking while the iron is cold rather than trying to do the safety plan in the midst of crisis. I really like the idea of talking to folks about what works for them, and people are really good about about telling you. And I didn't realise until we started to do the research, but some people say to me, I prefer visual safety planning. Someone said to me once, I prefer a safety plan that's like a circle, so there's not an end to it. Some people say, like, I've been through this enough times that I can do it all in my head, and having a piece of paper isn't helpful. There's something at CAMH called the Hope App, which is really excellent. And for people who are like really good at the Internet, the app might feel a lot better. Often we ask who's important to you and we can photocopy the safety plan and give it to people that they love or give it to their care team too, which is really useful. One of the things I say is if you have like an iPhone, take a picture of it and then do the heart so it goes into your favourites so you can always find it easily. So I think that safety plans, again, they're not going to solve everybody's problems for sure, but they're sort of a tool in your arsenal that can be very helpful. And also it gives us kind of a shared language. So if my outpatient, for example, is struggling, they can say, you know, I've worked all the way through my safety plan and I know I need to come to hospital, and that's very useful and effective to know.

  Chase: [00:27:15] I've definitely had the experience of being sort of an earlier trainee and bringing a safety plan to, I believe it was an older gentleman who was having suicidal thoughts, and he did find it to be quite invalidating to actually receive the plan and sort of fill it out with me. So I think I have sort of learned to ask as well if people find that helpful or appropriate or if they've done one in the past before, sort of jumping into completing one at this point.

  Dr. Juveria Zaheer: [00:27:43] Yeah, absolutely. Like any time like it's we always talk about how like we always try to find the perfect question or the perfect thing to do, but it's not about the perfect thing to do, the perfect questions but the relationship. And so figuring out what the relationship, that's another Gina-ism. So figuring out what the relationship is is really, really useful and and reading the room before you start with one intervention or the other. And I think in in suicide-safe mental health care, choice is so important. Treating someone with dignity is really important. Not jumping to conclusions is important. Like if someone has been on Mirtazapine in the past and they hated it, then you probably would offer other choices. And so in the same in suicide safe care, if someone doesn't like doing a safety plan, is there something else that we could do that could be helpful?

  Chase: [00:28:29] And just on the lines of evidence-based care for patients with suicidality. Are there other sort of treatments that we should be looking towards when a patient is having a high degree of suicidality, maybe across some diagnoses? We could talk about those a bit.

  Dr. Juveria Zaheer: [00:28:46] Absolutely. I sort of think about suicide prevention strategies in four large buckets. So the first is how do we create a world where every life is worth living? And that means things like housing interventions, universal basic income, making sure that people are free from trauma and oppression, sort of like one bucket. How do we make the world a better and safer place? The second bucket is around understanding the treatment of underlying mental health issues. So we if somebody has depression, if somebody has schizophrenia, engaging in treatment for those for those illnesses. So we know that lithium, for example, is an evidence-based suicide prevention strategy for folks with mood disorders. We know that Clozapine is an evidence-based suicide prevention strategy for folks with psychotic disorders. So making sure that we know what the diagnosis is and then treating it. DBT, CBT, other types of psychotherapeutic interventions and antidepressants, not individually, they're not like lithium or clozapine, but as a class has level one evidence. Young people are really, really, really responsive to any kind of suicide prevention strategy. So any kind of sort of psychotherapy or higher term support for those young folks. And then the third bucket I think of is like public health interventions that are maybe more specific than the first bucket we talked about. So that's things like means restrictions. So gun control, lock boxes for poisons, bridge barriers that that kind of group of interventions, and then things like positive messaging around suicide and suicide safety in the media. So we think about the Werther effect where suicide can have a contagion effect. The opposite is the propaganda effect where we can talk about suicide in a safe way, show that there is care available and hope exists and help exists, that can be really important. Other types of interventions in that kind of bucket are things like gatekeeper education. So, for example, in the armed forces, if you can train like the generals and the corporals and the people who are kind of higher up to understand mental illness and to be open about it, it might make it easier for other people to get care. This works very well in schools as well, and religious institutions. And then primary physician knowledge and engagement, so like upscaling family docs and other care providers to be able to pick up on the signs of depression and suicidality. And then there's like this last bucket, which is kind of one that I'm really interested in, which is like specific interventions for suicide, often pan diagnostic. So the safety plan is one of them for sure. Another one of them that we're sort of trying to build evidence for is something called close contact follow up. So it's a little bit what we talked about earlier. So if you're getting discharged from an emerge or you're getting discharged from an inpatient unit, like someone will call you or reach out to you or you'll have like more intensive care in that period.

  Dr. Juveria Zaheer: [00:31:26] There's also psychotherapies that are specifically designed for suicide prevention. So things like CAMS is a really effective treatment, DBT, CBT for suicidality, these sorts of interventions can be very useful. Family and patient psychoeducation can be very useful as well. And then individual means restriction, so like talking to people about safe prescribing. If someone is, a risk factor for someone for engaging in suicidal behaviour is alcohol, like getting the alcohol out of the house. If somebody is like feeling really unsafe around subways, like avoidance of those things. So it's kind of like safety plan adjacent, like trying to make your environment safe. And then we also, I think in the biological treatments we mentioned things like ECT, rTMS, ketamine, lots of new things with evidence building. So I think basically the principles are how do we create a world that's safe for folks both in terms of like both broadly and more narrowly? How do we make sure we treat the underlying illnesses that are raising suicide risk and reminding ourselves that mental illness is only one part of suicide prevention. And then the third, the last bucket is how do we engage in suicide safe care in terms of suicide specific interventions?

  Chase: [00:32:39] And on the note of providing evidence-based care for patients with suicidality. I think sometimes, you know, we hear this sort of comment that like, oh, it's impossible to prevent or or we don't know that this particular intervention, including like SSRIs, even, is known to prevent suicide. And I think sometimes that can make one feel a little bit disenfranchised with some of the treatments we have. And are we even, you know, this patient's coming to me with suicidal thoughts and am I even helping them because I have this supervisor who told me this is this particular intervention has no evidence for reducing suicide. So I guess my question is like, you know, why is it so notoriously difficult to prove that our interventions are effective for reducing suicide? And and why do we have limited evidence on these?

  Dr. Juveria Zaheer: [00:33:36] Yeah, absolutely. And as for like the Zaltzman paper that came out in 2016, it's a review in Lancet psychiatry and suicide prevention, SSRIs as a class do have level one evidence in preventing suicide. But you're absolutely right. It's not like I can link this prescription for Prozac with reduction in suicide deaths, because doing an RCT around suicide is very, very difficult because suicide is an extraordinarily rare outcome. So we often use proxy measures like suicidal ideation or suicide related behaviour. The other piece is that but even those aren't necessarily common, especially suicide related behaviour. The other thing is often in studies like people with suicidality are often excluded and so people think we're there too. Even for me, someone who does qualitative work, you know, you have to struggle with IRB to get approved, to even talk to folks who are experiencing suicidal ideation. And I think, too, like suicide is so multifactorial that one of the challenges in working with folks with suicidal ideation is that it's a complex problem that requires complex solutions. But there are interventions that work and hope and help exist. And I think to your initial point, I loved kind of hearing you describe that feeling as a trainee when you're sort of trying to navigate these two messages. So one message is that we can't prevent suicide. We get that in training. We have a terrible outcome and we reassure each other with this statement and it has its benefit in that it can help us feel better when something awful happens. It can be reassuring for families too, who did everything they could for their loved one. But it has, it's problematic in the sense like how do you, it can cause therapeutic nihilism. It can make us like not think as seriously about treating people who are really, really suffering. And then the second one is like, every suicide is preventable and that's lovely because we want to make sure that nobody dies of any kind of illness. And the goal of zero suicide and suicide, perfect care for people with suicidal ideation is so, so important. The problem with that, though, is that it can lead to a lot of distress in care providers and families. It can also lead to really bad outcomes like, are we just not going to see people who we think we can't help? Are we going to put everybody on a form one? It can be, it's really a tough kind of dichotomy to navigate. So like swinging between like therapeutic nihilism to like feeling awful about ourselves and our system.

  Dr. Juveria Zaheer: [00:35:47] So for me, the way that I kind of the story that I tell myself is that like every suicide death is an extraordinary tragedy that affects families and care providers and the person whose life is cut short. And at the same time, suicidal ideation is a really important treatment target and people who are experiencing suicidal thoughts are deserving of hope and help, and we do have treatments and therapies that work. And so if it takes all of us to prevent suicide, I individually can't change the way the world is. We can advocate and we can be activists, but we can't change the whole world, but we can do our part. And that makes me feel better. And when I think when I do a suicide risk assessment, my goal is to make the person feel comfortable and safe. To say, I'm so glad you came, and like these these thoughts can often feel really shameful, but to say, like a lot of people have been through what you've been through and they've come through the other side. So stories of hope and recovery can be very useful for people, not in a toxic positivity kind of way, but in a natural and genuine way. And then once the person is feeling safe or more comfortable with you, then how can we understand their risk in context? How do we get all the answers to all the questions, understand their narrative of suicide, understand their risk factors, understand their protective factors, and work systematically to manage the risk factors and to strengthen the protective factors. And that's kind of the approach that I take. So it's less about prediction and most more about like best practices and providing good care. So if I see someone who has alcohol use disorder and when they use alcohol, it makes them at higher risk for suicide, we can do things like taking the alcohol out of the house. We can also help them enrol in addiction services, we can start them on naltrexone, we can introduce them to to other psychosocial rehabilitation models. And so if we can kind of link everything that the person is going through to their suicide risk as like making it higher or lower, and we can both address their suicide risk, but we can also decrease their suffering, which is ultimately the goal and have them live a life with meaning.

  Chase: [00:37:41] Right. And I think one of the things, too, that I also came to understand is that, you know, saying that something doesn't have any evidence in preventing suicide doesn't mean that it has been proven not to have any benefit in preventing suicide. It's just that also that we don't have possibly the power of or powerful enough studies to kind of show the effects that we're looking for as well.

  Dr. Juveria Zaheer: [00:38:07] Absolutely. And that's the challenge. So we know, if we can understand what the risk factors are across a broader population, then I think it makes sense that treating those individual risk factors can help. And I think the other really important piece is and this is like a plug for for qualitative research, is that understanding. There's no there's no like with like for us without us, right? Like there's no way of understanding someone's lived experience of suicidality and what helps and what doesn't unless we actually talk to folks and have them help us understand what's meaningful or not. So I think like engagement and co-creation is really, really valuable too in this population.

  Chase: [00:38:45] So one thing that I think comes up in the emergency department quite often, and we have touched on this topic briefly in our borderline personality disorder episodes, but, you know, there's this, I guess, constant balance that we're trying to strike with some of our patients who have borderline personality. On the one hand, we are concerned about their safety and on the other hand, we're also told that we don't want to create sort of this situation where, you know, the individual comes to hospital and we make them feel safe in hospital and we sort of become a de facto coping mechanism for that individual. And I'm just kind of wondering, how do you balance that care for someone's safety and wanting to be validating, but at the same time sort of taking on the cruel to be kind sort of mantra that others have advocated for in terms of treating borderline personality. 

  Dr. Juveria Zaheer: [00:39:41] For sure. And the first thing I'll say around BPD is it's a diagnosis that does not have a ton of like construct validity in a sense. Like it's not a it's supposed to be a diagnosis that indicates like a lifetime, pervasive pattern of dysfunction. But we do know that a lot of people who are experiencing other types of major mental illness, particularly people who have a trauma history, can look like they have BPD, but that might not be the most appropriate diagnosis or it may be a comorbid diagnosis. So I think for me, one of the things that helps me is to move beyond like how do I treat someone with BPD to like, how do I use universal precautions from trauma at all times? And so many people who come to psychiatric emergency departments have a trauma history. Many people with BPD have trauma. Almost everyone with BPD has trauma, and the system and having suicidal ideation and behaviour is traumatic in and of itself. It's like threatened loss of life and threatened loss of integrity. And so for us at CAMH, and I think for me personally, it's like, well, how can I understand someone's story? How do I make them feel comfortable? How do I make them feel safe? How do I work with them to build safety and autonomy? I think one of the things that we do is if we have someone who is coming into hospital a lot, it's really important to look at their narrative arc of suicide risk. So, for example, if you have someone who is has come in eight times in the last month but hadn't come in in the three years before that, you know, a diagnosis of BPD or a formulation of 'we don't want to reinforce this behaviour' might not be the most accurate one because it could be that there's an episode of severe mental illness that we're just not treating all the way. If we know that someone is not doesn't get better in hospital or gets worse in hospital, I think it's really worth striking while the iron is cold again, having conversations with this person in the context of safety planning outside of the moments of crisis. There's a lovely paper by Von Bergmans and two of her former patients who have BPD that talk about how different I look when I'm not in crisis. And so if we can engage with people and we do this in the CAMH Emerge often as they engage with people when they're not in crisis with their care teams to figure out what exactly is most helpful in the moment. Sometimes what we do is we want to sort of it's kind of a I'm not a DBT expert by any means, but sort of taking we we live and work in a system where, like there's sometimes suicidality can be seen as a ticket to admission and if you don't endorse suicidality, then you can't get admitted. And so then it ends up that people have to up the ante to get the care that they need.

  Dr. Juveria Zaheer: [00:42:15] And I often reflect on the word manipulative, right? Like we often use this. It's a very gendered word, first of all. And for someone like me, if I if I had like a loved one or if I myself was struggling, I could call like 100 people and they would help me, like get the care that I need. But that's an incredible privilege. And if you don't have that privilege, all you may have is the emergency department. And so I think, like we see somebody who has increased service utilisation, one of the strategies we use is to try to strike while the iron is cold. It is very difficult to safety plan or to identify one's feelings or needs when one is in distress. And so if we can work with a patient and their care team outside of crisis, then it can really help us understand what they may need when they are in crisis. For some of our patients, we try to get rid of that ticket to admission kind of construct. And so often in mental health care, it's you're admitted if you're suicidal, you're not admitted if you're not. And then the ante keeps getting upped. Well, you're only going to get admitted if you self-harm in the department, you're only going to get admitted if you have a serious suicide attempt. And so what we try to do is disentangle the reinforcement from the behaviour and to say things that we sometimes we do something called a green card strategy where someone can come into hospital for a set number of days, a set number of times in a six-month period. And we really validate and reassure and support people for coming in before their crisis. I think it's really important to remember that people with BPD do die by suicide and they often die by suicide after periods of intense service utilisation. And so coming into hospital to break that cycle can be very useful. We work when we when we bring people in, I think it's really important to identify goals of admission and so that can be really tough when someone is like really activated and struggling. But to say, you know, we'd like to bring you in, we'd like to review your medications, help you connect with family, try to arrange good follow up, which is part of the problem, right? Like if you go from everything to nothing, that's a huge problem. And I think trying to be open and transparent and honest about, here are our behavioural expectations, what are your expectations of us? What do we think this length of stay is going to be? When people have a lot of trauma, they can't predict their environment and even neutral stimuli can feel very frightening and threatening. So should try to be as as as reassuring and supportive and open as possible, I think is a nice approach. And again, like if I if I'm working with someone and I know that when they come into hospital, things don't get better and they probably know that too, I try to be really honest about it and try to problem solve. And I think the other thing I know you and I have talked about this even on call, where it's a lot easier to be empathic and kind when it's 11 a.m. on a Tuesday and you're just back from vacation than it is at 3 a.m. where there's a full waiting room with 15 people waiting and you haven't slept and you haven't eaten. And so I think for us, it's really important to reflect on our own ambivalence and our own distress and what we're bringing to the encounter, because it can it's a it's a bidirectional process, assessment. And so to be kind to ourselves as well and to check in with ourselves, before we work with folks who are also in crisis and struggling, can be very useful.

  Chase: [00:45:20] Yeah. And you know, it also brings to mind sometimes I feel a bit disingenuous telling people, well, you know, the treatment for this is DBT and that's ideally what you should get on an outpatient basis. But in reality, you know, the person may not have any funds to access it and the wait times for publicly available DBT, you know, this is an Ontario based podcast, but I'm sure it's very similar no matter where you are, accessing DBT can be quite difficult. And so admission also becomes the fastest way to speak to someone who may be like first in DBT or able to kind of work with you on your distress tolerance in a really immediate sense.

  Dr. Juveria Zaheer: [00:46:03] Yeah, absolutely. And I think that's not a bad indication for admission. I think we need to think about the failures in our system and to be really open and genuine about those failures and then thinking about ways that we can advocate for better access to trauma therapies and better access to DBT and we definitely can't do it alone for sure. And I think I really like what you said about like picking up on those moments of feeling disingenuous and to sort of say like, does the plan I'm giving this person actually make sense? Like in talking to patients in our studies, like I think they would rather hear from us like, look, here's the treatment and the waitlist is going to take a really long time. And I'm so sorry about that. And what can we do in the meantime to help you feel supported, whether that's, you know, an urgent care clinic or other types of support rather than DBT is the way to go, here's a list and then when they call everybody, they realise that nothing is open or available. So I think that that kind of that feeling that you have, that empathy for the person you're working with is so important.

  Chase: [00:47:01] Wanted to get your thoughts on another topic that I think is becoming maybe more relevant as we move towards legislation for made for people with psychiatric illness. And this sort of revolves around the topic of involuntary hospitalisation for people who have suicidality or who have had suicide attempts. I guess I'm wondering how you sort of frame that or how you think about the ethics of involuntary hospitalisation for people who have suicidal thoughts or behaviours.

  Dr. Juveria Zaheer: [00:47:37] Then starting with the involuntary hospitalisation piece, I think psychiatry is facing a reckoning of sorts where we have to come to terms with our own history of oppression. We need to come to terms with our own systemic racism and anti-black and anti-indigenous racism specifically. We also need to come to terms with the fact that we are how we are the third arm of the law in many ways. We are carceral and so part of this sort of process needs to be understanding the power that we have and needing to understand the experience that people who are being held involuntarily are having. So for me, I think it's really important. There's a few things that I do to help myself understand the ethics of this. I think, as I said earlier, if I'm going to bring someone into hospital involuntarily, I better have a very good reason for it and I better be able to describe that rationale to the person I'm working with. Here's what I'm worried about. And for someone with suicidality to be very clear that it's not a punishment, that these are the goals for you coming in, whether it's collecting more information or providing support or whatever it is. I think that's really, really important.

  Dr. Juveria Zaheer: [00:48:46] And I think one of the things that is really helpful around forms and certification is to actually speak with the person about it, asking about past experiences of certification, asking about what it means to them. Like I have people who I say, I'll say, I'm so worried about you and I'm worried that if you were to leave here, you would continue to suffer and your life would be at risk and I think that we can help you here in the hospital. But I also know that being held involuntarily is really traumatic. What are your thoughts? And then people, you have these really interesting discussions about some people will say, you know what, I'd like to come in voluntarily and being formed would be really awful. Other people have said to me, the act of being put on the form is reassuring to me because it shows me that people care about me and I don't, sometimes when the thoughts get really dark, I don't trust myself and so I understand. Other people say, I don't like this, but I know it'll make my family feel better. And so actually having that conversation can be very useful. And I think like owning what we're doing is really, really important.

  Chase: [00:49:56] So I know we've taken up a lot of your time already, but I just wanted to get your thoughts on what do you think the future holds for suicide prevention and suicide treatment?

  Dr. Juveria Zaheer: [00:50:08] I was reflecting. I was doing teaching for our first year residents yesterday, Gina and I were. And we often ask people like, when was the first time you ever heard about suicide? Like when you were a kid? Like, what was what were those conversations like in your family? And the answers are so thoughtful and meaningful and so sad in some cases. And I feel badly, I'm the kind of person who never thought they would always talk about their kids, but I always talk about my kids. And I have an eight-year-old and a three-year-old and, you know, in my family, we were a muslim family, you know, suicide was haram. We never talked about suicide. We didn't even kind of understand it. And if it happened to someone else it was 'how could they do that to their family?' There wasn't an understanding of the mental health piece. And with my daughters, you know, we talk about how we're so happy that they feel well now and there's going to be things in their life that make them feel worried or scared or happy or sad. And sometimes sadness or worries can stick around even when good things are happening and they can make us not feel like ourselves and they can make us feel so sad and scared. And sometimes for some people they can even make us not want to be alive anymore and if that ever happens to you, we're always here and we'll figure it out together and people get better from this. And so I know it's like a long-winded way of saying, you know, when we think about the future of suicide prevention, it's not my eight-and three-year-old for sure, but I think it's like these conversations that's striking while the iron is cold. It's the work that's done by people like Jack.org. It's like changing the way we talk about suicide and making it easier for people to understand that there is hope and there is help and there are treatments that work.

  Dr. Juveria Zaheer: [00:51:39] I think, when I think about the future of suicide prevention in terms of research, I really do think that the future of suicide research is in co-creation and working with people to develop interventions for communities that work and then to test those interventions. And the future of suicide prevention is around accessibility and availability of evidence-based treatment. As you say, we have really good treatments that work, and universal health care means universal access and equitable access. And I'm really interested again in these kind of like suicide specific interventions that that we might not think of because we always think about like diagnostic silos, but I think that's really exciting. And I think the last piece is, is how do we go back to creating a world where every life feels worth living and how do we invest in social cohesion and a social net and freedom from the stressors that make us feel really scared and worried. And I think a lot about gender and race and how we, like the cultural scripts of how we act. So how do we encourage white middle-aged men in rural communities to get care? How do we make sure that people from indigenous communities have clean water and freedom from trauma and have ways to tell their stories in ways that matter? And I think that's what suicide prevention looks like to me.

  Chase: [00:52:54] Thank you so much Juveria for joining us today. We really appreciate having you on the podcast. Your answers were incredibly insightful and always helpful in guiding how we think about suicide as trainees and helping us move forward beyond risk assessments. So thank you so much. Did you have any final comments or any words of advice for our listeners?

  Dr. Juveria Zaheer: [00:53:17] I think what I would say is that we're you guys are really good at this, like you're good at talking to people about suicide. The more you do it, the better that you get and don't ever think that the checklist is more important than your humanity. You need to learn the checklist; you need to make sure that you're thorough and you create a plan that works for people but the thing that people are going to remember about you is your humanity and your kindness and your openness.

  Chase: [00:53:42] Thanks for listening. We hope you found our conversation informative and enjoyable. PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and recorded by myself, Chase Thompson and our theme song is Working Solutions by Olive Musique. You can contact us at Psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thanks again for listening. Bye.

Episode 39: Electroconvulsive Therapy with Dr. Wei-Yi Song

• Episode 39: Electroconvulsive Therapy with Dr. Wei-Yi Song

  Jake Johnston: [00:00:14] Welcome to PsychED, the psychiatry podcast for medical learners by medical learners. This episode covers Electroconvulsive Therapy or ECT for short. I'm Jake Johnston, a fourth year medical student at UBC, and I'll be the host for this episode. I join my wonderful colleagues who will be co-hosting. Why don't you all introduce yourselves?

  Arielle Geist: [00:00:36] Hi, I'm Arielle Geist. I'm a second year psychiatry resident at the University of Toronto.

  Randi Wang: [00:00:42] Hi. I'm Randi Wang. I'm a first-year resident also at the University of Toronto.

  Alex Raben: [00:00:48] And I'm Alex Raben. I'm a staff psychiatrist at Camh and a lecturer at the University of Toronto.

  Jake Johnston: [00:00:55] And last but certainly not least, it's my pleasure to introduce our guest expert for this episode, Dr. Wei Song, a psychiatrist who are several different hats. Dr. Song is the Department Head of Psychiatry, Director of Mood Disorder Services and Director of ECT Services in Victoria, British Columbia. He is also a clinical professor at the University of British Columbia and a past president of the Canadian Psychiatric Association. Thank you, Dr. Song, for joining us for this episode. Do you want to introduce yourself?

  Dr. Wei Song: [00:01:26] Thank you, Jake, for a kind introduction, and I don't really need to introduce myself as you have already introduced. I'm so glad to be here and very privileged to be able to discuss the topic of ECT. As you know, it's a perennial topic. It's been going on for almost a century. So I'm happy to be here to answer your questions.

  Jake Johnston: [00:01:51] Thank you very much, Dr. Song, for joining us. Let's dive into our learning objectives. By the end of this episode, the listener should be able to one briefly describe the history of ECT from inception to the present to debunk common misconceptions about ECT. Three, describe the major proposed mechanisms of action of ECT. Four, describe the efficacy of ECT for common psychiatric illnesses. Five, list the indications, contraindications, side effects and risks of ECT. Six, understand how the procedure of ECT is performed. Now that introductions are made and learning objectives are covered, let's get into electroconvulsive therapy. Randi, do you want to start us off with some questions for Dr. Song?

  Arielle Geist: [00:02:45] Yeah, that sounds good. So I'll focus on the first part, which is for us to briefly describe the history of ECT from inception to the present. So based on our background readings, we read on uptodate some background information. So we know that ECT is a treatment during which small electric currents produce a generalised seizure under anaesthesia. We know that it's mainly used for severe depression, but can also be used for a bipolar disorder, schizophrenia, schizoaffective disorder, catatonia and even NMS. So from a historical standpoint, it started when physicians observed that patients with schizophrenia actually get better after they spontaneously have a seizure. So that led to some physicians actually inducing seizures, using medications to help treat these conditions. And then beginning in 1938, physicians actually began inducing these seizures, using the electric currents that first there were some physical injuries that were associated with treatment. But now that we have much better understanding of anaesthesia and muscle relaxants, that's really gone away. So nowadays almost all psychiatric facilities offer ECT. And based on data that we've collected, we know that patients who are they're more likely to receive ECT are those who are white and of higher socioeconomic status. So Dr. Song, I'll give you the stage to maybe talk about anything that we've missed. And yeah, why don't you describe what you see is to us?

  Alex Raben: [00:04:30] Well, I think you captured very nicely that brief history and remember the treatment way before modern psychopharmacology. So, you know, mental illness has been plaguing, I think. Our human species since written a history. So for thousands of years and and there are a lot of search for a cure and not to sort of a distant past. You know, you're talking about hydrotherapy and essentially having some sort of an induction of fever that may actually cure mental illness. And I remember my professor in McGill and Dr. Heinz Lehmann talking about injecting sort of comfort oil in the peritoneal and then causing sort of a fever and then having seizure as well to cure catatonia. When you talk about EKGs, do you remember the residency time, the picture of this? 1938. That facility, this Italian psychiatrist and holding this switch of this electric current. And there was a five orderlies jumping on the patient. It was pretty gruesome in some ways. But on the other hand some of the patients were dying of catatonia and psychosis. Right. So certainly it provided dramatic improvement. Of course, like you said, Randi, associated with some of the side effects because those days the ECT was unmodified. I think in some parts of the world, as far as I know, sometimes a modifier is still being conducted because the limited resources and so on. But in the developed world the ECT is very refined. I'm sure you have questions about how it is conducted and so on.

  Arielle Geist: [00:06:36] All right. Thank you. So next, moving on to some common misconceptions that we want to help debunk. We have an article here called Ten Myths about ECT from Current Psychiatry. And I guess I will just get started on some of the most common ones. So the first one, I guess you have alluded to it already. The first misconception is that ECT is very barbaric. So this is actually untrue because those of us who've actually seen ECT know that it's conducted in a very controlled medical environment. We have a psychiatrist there, anaesthesiologist, and many nurses present. Patients are given anaesthetics beforehand to not feel pain and muscle relaxant, so they're not jerking around or experience any physical injuries. And of course, we monitor their vitals the entire time and make sure they're medically stable. And another misconception is that it's very dangerous when in reality, death from ECT is extremely rare. The mortality rate is actually only 2.1 in 100,000 treatments, which is lower than that of just anyone going of an average person going through general anaesthesia. And we can even it's so safe that we can even use it on patients who are pregnant and on patients who have a history of epilepsy. Another misconception is that it could cause brain damage and this is untrue. Studies using MRI's have shown no evidence of negative changes before and after ECT. If anything, it can cause an increase in neurotrophic factors which support growth of brain cells. And then finally, a lot of people have this misconception that it creates permanent memory loss and this is also untrue. So ECT may temporarily impair anterograde memory, which are the events that happen right after the treatments for a few days, maybe a few weeks, and very rarely may cause retrograde amnesia, but overall it is not harmful to memory. So, Dr. Song, please correct me if any of these facts were incorrect. And what are some of the misconceptions you often hear from your own patients?

  Alex Raben: [00:09:02] Stigma is number one. So people, even staff who have not been exposed to ECT. You still remember the movie One Flew Cuckoo's Nest and that movie itself had killed ECT treatment for over a decade, so sometimes the media can have pretty strong influence, be it positive or negative. I'm hoping this is a positive influence doing this podcast. So the reality is ECT, safe, ECT is life saving for a lot of our seriously ill patients. And it's done, just like I say, in a very controlled environment and it's been refined over the last number of decades in terms of anaesthetics, paramedics and even the ECT machine. So the side effects, as you know, it can happen with memory. And like you mentioned, the memory loss is mostly transient. Most of studies will say it's transient and once the ECT treatment is discontinued, most of the cognitive problems will restore within the first two months post-ECT. However, there are patients that we have rely on ECT for maintenance and they can go on basically as a sort of a dialysis for kidney failure. So for years and obviously these patients will say they have some permanent memory difficulties. What I would say is because they have ongoing ECT and there is evidence showing that the more you have, then obviously the more likely you're going to have more cognitive difficulties like memory problem. So stigma is number one. I think people just feel like it's something that's barbaric. And then the misconception, obviously, the some of the practice in certain parts of the world may not have contributed to the positive image of the ECT. For example, conversion therapy or ECT for homosexuality, for example, in history. And those were obviously misuse of treatment just like any other treatment. But with the right patient's right condition, it is one of the treatments that I don't think anything else has surpassed.

  Arielle Geist: [00:11:47] Thank you.

  Jake Johnston: [00:11:49] Yeah. Thank you very much for going over all of that Dr. Song. It seems like a detrimental cycle where misconceptions about propagate stigma and stigma propagates these misconceptions. And moving on down a list of learning objectives. I'm wondering if you could discuss the mechanism of action of ECT. So research over the years has eliminated much about the neurobiology behind its therapeutic effects, although its exact mechanisms remain to be elucidated. So without going into too much detail, can you outline some of the major theories of its mechanism of action?

  Alex Raben: [00:12:26] Oh, that's I think that's a very, very large topic. And I think one can say it's still largely unknown, but there are increasing evidence in research showing that [00:12:42] OECD works. [00:12:43] And why it works involves a number of things, including neurobiology and connectivity and neurophysiology. So one of the theories actually is about the seizure itself. And this actually stemmed from what Randi had mentioned, the history of the evolution of ECT. So the seizure has a lot to do with it. And one of the mechanism perhaps relates to the seizure itself. As we know, with the ECT treatment, every treatment does seem to increase the seizure threshold and then the duration of seizure activity actually seem to shorten with every treatment. And there are some studies stating that using PET scan and EEG, looking at the post, ECT as a reduction in the original cerebral blood flow, glucose utilisation and neuronal activities in the cortex. And there are some increase in the blood flow across certain brain regions, particularly in patients with depression. There are studies also looking at the neurotransmission systems, looking at serotonergic, dopaminergic and adrenergic systems and as well as glutamatergic. So, going back to the theory about the myth about ECT damaging brain, there were some studies that have been done, particularly using a sort of animal studies where the primates, sort of shocking the brain and then surprise the primates and slicing the brain. And there's absolutely no evidence showing the brain damage. On the contrary, for some of the animal studies and we show there is perhaps increase in sort of a neuroplasticity and sort of a connectivity in terms of brain regions and synaptic genesis and neurogenesis and biogenesis. So it's actually it's still emerging. And I think in time we probably have a better understanding. As you know, there is a theory about depression and a lot of psychiatric conditions being sort of neuroinflammatory process. A lot of the treatments we do actually is anti-inflammatory in the CNS system. So I wouldn't be surprised there would be some data showing that ECT itself can be sort of an anti-inflammatory in the in the process. So, you know, really, we don't have a one single explanation why it works. I wish I had anyone who as you have a one some theory I think it will be destined for a Nobel Prize.

  Jake Johnston: [00:15:57] So thank you for taking us through that Dr. Song. I realise it's a very large area of research. Just to summarise for our listeners, the mechanism of action of ECT is multimodal involving neurophysiological processes such as changes to the seizure threshold and regional cerebral blood flow. Neurobiochemical processes such as neurotransmitter, neuroendocrine and neurotrophic changes and neoplastic processes such as alterations in synaptic wiring and changes to the volume of certain brain structures. Is that a fair summary?

  Dr. Wei Song: [00:16:36] Yes. 

  Jake Johnston: [00:16:39] All right. Fantastic. All right. Do you want to take it away and tackle our next learning objective?

  Arielle Geist: [00:16:46] Yeah. Thanks, Jake. So now that we've spoken about the mechanism of action of ECT, I'm wondering if you can tell us about what the indications for ECT are. So what might we consider? When might we consider recommending ECT?

  Dr. Wei Song: [00:17:02] The number one indication, at least from what I know and also what we do in Victoria is the treatment-resistant depression. So patients who have failed trials of medications, patients who are the index episode of depression that is very severe and obviously patients who need an urgent sort of a symptom reduction, for example, acute suicidality or inability to have nutritional intake due to catatonia or severe depression. So these are the conditions we do ECT and we do ECT on the pregnant women on a regular basis. As you know, it's very important to have a rapid resolution of depressive symptoms during pregnancy. Depression itself, it's probably more teratogenic to the fetus than some of the medications. However we also just have a very limited amount of approved medications for treatment of pregnant women. So that's what depression. The interesting thing about ECT responses, the sicker the patient, the better the response. And also the patients who are more elderly, they tend not to respond to pharmacotherapy and the ECT also shows a lot more robust response and it is lifesaving for some of the suicidal patients. A lot of times you can see the difference within the first two or three sessions, particularly those individuals who are showing catatonic features who can't eat or drink, who have psychotic symptoms in a depressive episode.

  Dr. Wei Song: [00:19:09] So that's the main indications for depression. Of course, there are other indications as well, like bipolar depression, bipolar mania. I just had a patient who was refractory manic episodes, was in hospital for a good two months. And with multiple antipsychotics and mood stabilizing medications after three or four sessions of ECT, she showed dramatic improvement. So that's another indication. And then some other indications when I was the resident is about 30 years ago now and the we have seen some response with patients who have Parkinson's Disease and we treated actually the depression. The Parkinson's symptoms actually got better. And in literature, you see that new Neuroleptic Malignant Syndrome is one of the indications a few years ago there is emerging sort of evidence looking at treatment-resistant psychosis in schizophrenia patients, particularly patients who have partial or no response to Clozapine. And so we've seen some good results in those patients as well. So these are the major indications. And obviously, number one thing also is the patient preference as well. And some of the patients who can tolerate medications and neurostimulation may be one of the options.

  Arielle Geist: [00:20:45] Thank you.

  Dr. Wei Song: [00:20:46] I hope I answer your question.

  Arielle Geist: [00:20:47] You did. That was very helpful. And it's good to get a sense of what the indications are going forward in our training, thinking when we might want to recommend ECT. I'm also wondering what are some of the contraindications to ECT?

  Alex Raben: [00:21:04] I think it's really there's no absolutes, absolute contraindication that if somebody has got a brain tumour, sort of the space occupying lesion in the brain. So one has to be very careful and probably if you have a known aneurysm, you probably won't want to apply ECT because there is a transient increase in terms of intracranial pressure. Right. But, you know, you've got to be careful. What we do is we always have anaesthesia consult and particularly people with a complex medical comorbidities like cardiac and pulmonary and endocrine. So we want to make sure that those parameters are under control. For example, if somebody has uncontrolled hypertension and that's probably one of the things we need to do is really getting that out of control. I will walk you through about what we do in the ECT suite. And this morning for example, I was doing ECT and this patient's blood pressure was 220 over 100. Anaesthesiologist obviously said, well, you know, I'm going to give some asthma. And so we actually, in a very controlled environment, making sure that blood pressure is down to the acceptable level and then we proceed with the treatment. So I would say those are the space-occupying sort of lesions in the brain and aneurysms and some serious cardiac conditions. You know, that may be even a relative contraindication. I've done ECT on post-stroke post in my patients who are very, very ill and didn't respond to medications and very in within the first couple of months. Even with ICD or pacemakers, it's not a contraindication. Some sides will say, "Okay, let's turn off the ICD or pacemaker". And in my experience, actually, we don't even turn off the pacemaker and because it's really focal right in terms of stimulation to the brain.

  Arielle Geist: [00:23:28] Thank you. That's super helpful! And one of the other things we were wondering about, we did briefly touch on before you had talked about memory impairment, but we're wondering if you could go into a little more detail about some of the possible side effects of ECT?

  Dr. Wei Song: [00:23:45] Yeah, the main side effects actually are headaches, which is fairly common. And I think it's because despite the Paralympics, patients are well modified in terms of what we use in the colon or other muscle relaxant. But we when we do the electrode placement, usually straight to the your  temple area. So you will induce whether you have paralysed sort of a major muscle groups or you induce your sort of a jaw clenching. And so that perhaps causes some headaches and maybe other reasons that cause headaches too. And a lot of times those can be mitigated as patients to take  Tylenol before ECT at times we'll just give a IV pre-ECT and so on to mitigate that. A memory is another major one, but usually the first treatment, especially index treatment we use anywhere between 6 to 12 treatment sessions. And memory is not a major issue at all. As you know, when one is depressed cognition, there are three major sort of symptom domain, right? You have your emotional symptoms, you have your physical symptoms and you have your cognitive symptoms of depression and cognitive symptoms. Depression, usually a very profound and that's probably why when they do the studies for their acute ECT, even though patients may complain about memory problems and when you look at the results, actually there's not much of difference because depressed patients already have cognitive impairment.

  Dr. Wei Song: [00:25:34] Yeah. So I think, there is some truth about short-term memory and anterograde and retrograde memory problems, but it's not a major issue. You know, the times people have we have had patients may have had dental issues. So we have to be very careful and there's a bite block and making sure that you have the partial if it's secured or not. And those are just related to due diligence, really making sure that the patient's oral cavities sort of checks. Right. You know, some patients may have some nausea, but those can be mitigated as well. Anaesthesiology is of great thing doing that also with psychiatrist, we always communicate on an ongoing basis. Right. And some patients may need to take Ondansetron before or after ECT and that can be done as well. So in short, actually, the side effects is minimal. It's not that much.

  Arielle Geist: [00:26:46] Okay. Thank you. That's  helpful to learn about. And I think kind of speaks back to some of the the myths that Randi was talking about earlier  in the podcast. One of my last questions for you before I hand it back over to Jake is about some of the risks of ECT and if you could tell us what the risks are. When you say risks, you're talking about side effects or death or more. The second one, we're just kind of wondering about maybe what the mortality rate might be or when do you consider that?

  Dr. Wei Song: [00:27:25] I think the number one risk, what I see is that not the right indication. You've got to be very careful. You know, if it's not the right selection, because we actually do turn down when we do ECT consultations, not everybody comes for consultation, we'll get it right. So, you know, if it's not the right indication, primarily, for example, if somebody has a severe personality disorder and you're using ECT and the outcome is not that great. But you know, in terms of potential mortality, I have never seen a case of death and I've spoken with a lot of people across the country. I don't think anybody's seen that, that there is a theoretical risk of death. And I think the anaesthesia risk is about one in 70,000 because this is a general anaesthesia. Right. And I think there are some reports saying that maybe two per 100,000. So, it's more or less in line with the risk of an anaesthesia. If you select the right patients and you do the right medical screening and control the medical comorbidities, I don't think the risk is negligible, really.

  Arielle Geist: [00:28:53] Thank you. I'm going to hand it back over to Jake now to talk about the efficacy of it.

  Jake Johnston: [00:28:59] Yeah. Thanks, Ari. I know that you've already touched on it a little bit earlier in this episode, Dr. Song, but now that we've heard about how ECT works and why we should use it, can you please fill us in on how well it works? Let's start with its efficacy in major depression.

  Dr. Wei Song: [00:29:17] I think it's a very efficacious treatment and it's still the gold standard if any new treatment comes out and they always want to sort of compare it to ECT, right? So if you look at the literature, it's anywhere between 70 to 90%. Some of the older literature even higher, I think in part is because in the seventies there were not a lot of medications but ECT were the pre. One Flew Over the Cuckoo's Nest sort of a time it probably was used a lot more readily. I mean in the fifties actually ECT was the office procedure in New York because it was so popular. And so if one comes in depressed and you sign up for ECT, your chance of response is really high. And I think, more recent studies may not be as high priced because there is a lot of comorbidities. And sometimes you may miss the sort of a therapeutic window, as you know, that the index episode of depression. The longer it goes, longer it goes under treated or untreated, the longer it takes to get well to get into remission. So I suspect if you see the numbers like 70, 80 or 75, that's probably one of the reasons. But still it's probably still the most efficacious treatment compared to any other interventions for major depression.

  Jake Johnston: [00:30:56] Thank you. The fifties in New York sound like a wild time. The efficacy of ECT for major depression is quite impressive. Are there factors that can help predict whether or not a patient will respond to ECT treatment? You've already mentioned one of them that longer lengths of depressive episodes are associated with poorer response to ECT.

  Dr. Wei Song: [00:31:19] Now I mentioned about old age, right? So you see the geriatric psychiatry we use is a lot more is because there is more medical comorbidities and also the geriatric patients tend to have a poor response to medication treatments and so they actually tend to have better if you compare it to other treatments with ECT, the more severe the symptoms, including psychosis catatonia, the better the response to ECT. Nowadays, we call it endogenous depression, which is reactive and so on, but we don't differentiate that anymore. And essentially, if you have endogenous severe depression, catatonic features and psychotic features and the response to ECT usually is very predictable and the remarkable and I do want to mention, I did mention about personality disorder, it's probably more of a negative sort of predictor of a response to ECT if you have a severe personality disorder. That said, if somebody who has episodic depression along with personality disorder, it is still an indication to use ECT.

  Jake Johnston: [00:32:41] Okay. Thank you. That's a pretty remarkable takeaway point that the more severe depressive episode is, the better. It seems to work. We can't say that about many other treatments in medicine. So Dr. Song. Well, ECT is primarily used in the treatment resistant depression. You've mentioned it can also be used for other illnesses such as bipolar disorder or schizophrenia. Can you please comment on its efficacy in these other disorders?

  Dr. Wei Song: [00:33:09] Yes, I think a lot of our patients actually tend to be bipolar depression, as you will learn. Actually, bipolar depression probably is one of the most difficult to treat condition because there is always a worry about switching to mania and it's a very unpredictable in terms of response to treatment. We tend to use mood stabilising medications we tend to use. I mean, we only have, what, two or three medications that have official indication for bipolar depression. And if you look at the guidelines, it's like sort of a soup recipe for all different kind of medications and so on. It's very difficult to predict. So in that sense, I think bipolar depression, using these, it's probably even better choice because it's more predictable. It does have a similar response rate as compared to a unipolar depression. You're looking at about 70 to 80% response and efficacy. And then we touched base on the schizophrenia, right? So, this is probably more in the last ten years, ten, 15 years. And I think. 50, 60, 70 years ago institutionalised patients with catatonia, with psychosis, they tended to use ECT.

  Dr. Wei Song: [00:34:38] But since the the utilization of antipsychotics and also de-institutionalisation, I think it probably was not used as frequently for schizophrenia patients only in the last, I would say, 20 years. There is some literature suggesting, for example, a combination of Clozapine was a plus, ECT has shown some additive benefit and efficacy and this is probably a treatment algorithm for a lot of refractory psychosis program. You're looking at about between 40 to 50% sort of improvement in terms of response in that population. Still a lot of room to improve for sure. And my experience with that also is it tends to have more you going to actually go extra mile, so to speak, because for depression, we don't usually go beyond 12. If somebody is not responding right, but it predictably 80, 90% of the patients will respond after 6 to 9 sessions, some of them human response much earlier on. Whereas for schizophrenia, we tend to go beyond 12 and 24. A lot of times we see patients actually start to show response after 13, 14, 15 treatments. So that's a bit of a caveat there.

  Jake Johnston: [00:36:01] Thanks for that Dr. Song. It's good to know that in cases of severe schizophrenia, it often takes more treatments to see response. But patients and providers shouldn't lose hope because symptoms do often remit or improve after upwards of 15 or 16 treatments. Dr. Song you mentioned earlier this episode that one of your patients with refractory mania underwent ECT with good effect. Can you expand on the use and effectiveness of ECT for bipolar mania?

  Dr. Wei Song: [00:36:32] It's  quite high in terms of success rate. The issue with refractory mania is obviously a consenting process, you know, and it's we don't usually do involuntary ECT but in life, if it's life-saving, we will have to get the patient's advocates and family members involved or substitute decision makers involved. But even that I think, we don't take it lightly to impose ECT as involuntary so that probably one of the barriers and also we know that with time with the treatment milieu reduced stimulation in the inpatient environment and that itself it's anti-manic. So we just don't know when that will happen. So this particular individual actually was a psychiatric nurse and she had good insight, but she was really manic but a good insight. So it's quite interesting and psychotic, but a good insight. So and it is I can't go on like this. And then we went on to get consent and after four or five treatments and she's done she actually we only did in total eight and she's out of the hospital. So she was in the hospital for two months before that. In other words, it's very efficacious, but it's not done as frequent as, say, depressed patients. Right.

  Jake Johnston: [00:38:13] Wonderful. Glad to hear that she had a good outcome in the end. So to wrap up this section on the efficacy of ECT for various psychiatric disorders, let's recap. The literature shows that ECT has a response rate of 70 to 90% in unipolar major depression, 70 to 80% in bipolar depression, 80% in bipolar mania, and approximately 50% in people with Clozapine-resistant schizophrenia. I'll pass the mic over to Alex now to go over our next learning objective.

  Alex Raben: [00:38:47] Yeah. Thanks, Jake. So I'm in charge of helping our audience understand how the actual procedure of act is performed or looks like this is a difficult thing for us to do over a podcast. Of course, it'd be nice to invite you guys to an ECT suite to see it in person, and I would encourage our listeners who have opportunities to certainly shadow people who are doing psychiatrists who are doing it. But Dr. Song, if we can put this challenge to you, because we've talked about how bits and pieces of how act is done, right? There's an anaesthesiologist, there's nurses, there's a psychiatrist, there's these electrodes that are placed on the temples. But maybe you could take us through like a chronological order of how this is actually performed, maybe with a patient who's starting to act for the first time.

  Dr. Wei Song: [00:39:42] Thank you, Alex. For those of you who didn't study in UBC, I mean, I've been involved with the undergrad curriculum for many years. ECT is a must see too. So we made sure that we actually developed a module for ECT. Jacob I've gone through that module and even it was an embedded video. And so for those of you listening to this podcast, I can walk you through. So once patients sign a consent or deem that it's life-saving, so basically through the consultation process and anaesthesia has done the consultation.

  Dr. Wei Song: [00:40:33] So we every setting is different. In Victoria the are of hospital. We do ECT in our PACU, the post-anaesthetic recovery room. We have a little ECT suite within the PACU. So the patient, the porter will take the patient in or patients of outpatients will come in and check in with our porter and then they get changed a lot of times. Some patients may not, and in summertime it doesn't really matter that much. But in wintertime, a lot of them just get changed into screw ups and downs, and then they will be comfortably lying on the stretcher and wheeled into the ECT suite. And then the nurse psychiatrist anaesthesiologist will greet the patient and really trying to make patients comfortable. Imagine the first time doing ECT. You have no idea what's going on and we tend to show some of the information, including videos. There are a number of good's sort of videos out there on YouTube, right from Australia, for example, and from the Duke and other universities. So we show the patients to give them a sort of a bit of comfort, this is what's going on. And then I'll explain. I usually make a joke and say, "well, I'm going to prep your scalp", right? Usually it's your foreheads. And so "I'm doing a facial for you this morning" and sort of put patients at ease and using basically wanting to make sure that patients will have a good sort of a conduction.

  Dr. Wei Song: [00:42:18] So the impedance minimize the impedance if you look at the physiology of sort of a physics of it. So by doing the skin prep and chatting with the patients, I will ask patients how they're feeling and so on and so forth to do a quick mental status while I'm doing that. And then we put the leads on and usually we're monitoring the EEG, EMG and EEG. We have a telemetry sort of monitoring and two sides and anaesthesiologists will establish IV while we're doing all the prep and some of the centres will use the paddles putting on the dependence by temporal or by frontal or unilateral in our sensor. Many years ago I thought to eliminate some of the variabilities, we use these thermal pads actually just stickers. And that actually I believe it's more consistency. So it's not really dependent on the practitioner's strength or how they sort of hold the paddles. So once that's done most of the time we do the by frontal as sort of starting point and then we determine the seizure threshold for the first treatment. So what happens is the anaesthesiologist will give anaesthetic. A lot of times we use Propofol. Sometimes patients if they have resistance or not having good seizure and they may use some other induction agents such as accommodate or Methotrexate, which are more difficult to come by because it's a special access drug.

  Dr. Wei Song: [00:44:12] So Propofol is probably standard across the country and then they use the suction and colon to as a muscle relaxant. And then we hyperventilate the patients and within minutes, patients are already anaesthetised and the muscle a minute or two. And then we apply the electric current. Missing is the only two types of machine that's approved by FDA and Health Canada. Right. So it was back to the other ones. So we have the time machine and we started with 10% sort of an energy and help to give it to somebody 50 and over over the younger it started 5%. So basically we're looking at the seizure threshold. Once we determine the seizure threshold and then we apply one and a half or two times of energy above the seizure threshold as a therapeutic sort of intervention. So we induce a seizure that probably takes about looking at 25 to 60 seconds, sometimes a bit longer, sometimes less. And we look at the seizure quality by looking at the tracing, looking at the EEG, the morphology, the symmetry, the cleanliness and the possible suppression. So the few things that we look at. I'm describing the whole seizure, but actually it goes very quickly. So after the patient complete the seizure and within a minute or two the patient wakes up and the anaesthesiologists will assist patients for recover.

  Dr. Wei Song: [00:46:07] The whole process probably takes about the actual treatment. Getting into the suite and getting out of the suite is about 10 minutes. Well, we can do six ECT in an hour or sometimes nine and a half to 2 hours. So sometimes in this morning we've got a little bit longer because one of the patients had a difficult to establish an IV. So that part is more of a sort of an issue in terms of time. It takes a long time, try to like 7 to 8 sort of access to establish IV. That was more of a time consuming. And then patient goes to recovery sites and usually within 20 to 30 minutes they get up and they go to have a we provide a tea and muffins. This is pretty covered, though, but now I don't think we actually can. And then they go home or the wheeled to the ward if they're inpatient. That's the walk, you know. Give you a visual if you can.

  Alex Raben: [00:47:12] That was amazing, Dr. Song. Thank you so much. You really painted a picture there of walking us through that. And yeah, I don't think people realise how fast this procedure is. I mean, even in the time we're talking, we spent talking today, multiple people could have been going through treatments.

  Jake Johnston: [00:47:29] But do the poor anaesthesiologist, they'll have time to do their Sudoku puzzles.

  Dr. Wei Song: [00:47:34] No, you don't have to check the stock markets us to do that. I think one of the things, though, it's very important to have a good relationship with anaesthesiologist because trying to have the optimal seat for the patient. We have to give the input. Because I talk to anaesthesiology on a regular basis as well. You know, we should probably reduce the Propofol or anaesthetic because I know I've seen it even by ten milligram reduction patients, seizure can be so much better. You know, you can just have this kind of discussions and and whether some patients need to have some other intervention to have a seizure and so on. And as a psychiatrist, I think it's important to be able to give the valuable input to anaesthesiology I you mentioned by temporal by frontal unilateral electrode placement.

  Alex Raben: [00:48:46] Could you take us through the differences there and why you would choose one or another? So I think there have been studies looking at these sort of electoral placement, whether looking at the efficacy versus certain side effects, particularly they're looking at cognitive side effects. So you want to minimize the cognitive side effects. There were a couple of studies sort of comparing head to head, so to speak, looking at the high temporal by frontal and and unilateral. I think if you look at unilateral, the the efficacy is more or less the same as compared to by frontal.

  Dr. Wei Song: [00:49:39] The difficulty was unilateral is you got to have a five or six times of a seizure threshold. And the most machines governed in such a way. We started with the point five, the pulse width, and that's the sort of a short pulse and 2.75 of one. So if you use unilateral what they describe as an ultra brief unilateral, so you have 0.25 pulse width. If my machine if patients set a seizure threshold, for example, is determined that this machine is 40% of my the machine that the output, that means I have to go. Hundreds. Worth 200% which is impossible because the machines 100% is 101 joules. And unless I sort of overwrite. So in other words, a lot of our patients we can't do unilateral because of the depending on the seizure threshold, giving our machine the limitation of the machine. And then if you look at the comparison, the probably the most I mean, it's very slight in terms of differences, in terms of side effects, but there are some differences. So the bitemporal tend to have probably more cognitive short-term memory problems as compared to unilateral and conversely bitemporal may have a bit higher efficacy compared to unilateral. So we chose actually by frontal as a sort of default to begin with.

  Dr. Wei Song: [00:51:30] Based on that, it's simple, it's easy. Perhaps it's in the middle in terms of the chance of having cognitive side effects and then they're looking at the established efficacy. But if patients is not improving, it's just like prescribing medication, right? We'll titrate the stimulus in terms of the how much of a current we were delivering. And then when we changed the electoral placement from by frontal to temporal, we may increase the pulse width as well, just like a titrating the dosage of antidepressant or antipsychotic in accordance of the response. So I'm hearing there that there are some maybe modest differences in terms of maybe by temporal being slightly more effective, but also possibly causing more cognitive side effects and sort of vice versa for unilateral by frontal, you mentioned this word called sweat, so maybe we should just briefly define that. What does that mean exactly? Well, I think the modern city machine versus the old the one I described the doctor selected in 1938. And I think those are a sine wave current. Right. That's as you see, it's not like a whole thing. Whereas modern ECT treatment essentially has these sort of abrupt sort of pulses of electricity, sort of more of a resembles the action potentials endogenous in our brain. So instead of a sine wave, you just have a spurt, right? And  there is a frequency.

  Dr. Wei Song: [00:53:19] Basically how many pairs of pulses per second and versus the mini seconds. We use point five as a sort of a standard. Some people even even shorter, which becomes more of a ultra brief. 0.5 is a brief one is probably considered in the past, maybe more standard. And then obviously there's a currency of the amp. So all these actually parameters determine the current how much you gave to induce a seizure. I mean, in the end, we want to induce ultimate sort of a good seizure response. And then that can be measured by the EEG monitoring. And obviously, we also have to look at the patient sort of response in terms of a symptomatology.

  Alex Raben: [00:54:22] Thank you so much for taking us through that a concept that is definitely hard also to talk about without a visual. But we will link to a lot of those videos that you were describing and others that we find as well for our audience. One thing, this wasn't really a planned question, but I think it's something we didn't yet talk about. I just wanted to maybe and I think it's a good topic to wrap up on is we've talked about how effective ECT is, but we haven't really talked about the relapse that can happen post-treatment and how we can mitigate that. I mean, you did mention Dr. Song maintenance treatment, but what does that actually look like?

  Dr. Wei Song: [00:55:08] There's not a lot of studies on maintenance. I mean, there have been a couple of good studies. As you know, depression is a chronic illness and that is sort of episodic for a lot of our patients. So patients may respond very nicely to a course of treatment. But for patients who has severe depression or chronic depression, the relapse rate is quite high when you stop Ect. So in other words, you have to have a very good maintenance strategy. When I was in residency in the nineties actually, I remember looking at the American Psychiatric Association guidelines for ECT. They actually want you to stop mitigation when you do ECT, which is not the practice anymore. So we want to initiate if they're not on medication or we want to make sure that we plan to have an adequate medication for maintenance. So when we say adequate medication, we're talking about more standard. I know you guys use a Kellner Charles as a reference of who is an ECT guru. And he had led several sort of studies, including the maintenance study they use, for example, comparing maintenance these see versus. No trips. Plus Lithium or vaccine doses plus Lithium. So these are what we would say, very robust, potent and sort of maintenance strategies.

  Dr. Wei Song: [00:57:00] So maintenance versus medication, the relapse prevention seem fairly similar. But in reality, some of our patients, even with a potent medication, they still have to have a maintenance. What we usually determine that is if patients relapse and come back and do it again, then we would discuss about options. Obviously, you need to have to be on good medication regimen. For me, I would use something plus Lithium, that kind of a regiment or high doses of vaccine and so on, and then we'll taper ECT once they reach remission like once, once a week, times four weeks, and then every other week times four weeks, times four times, and then monthly. Sometimes in this kind of a process, patients know I can actually from every two weeks to one once a month, because by the third week, you know, I started having symptoms. So then we can sort of really titrate according to patients. So there is a sort of a whole range of sort of time frame for our maintenance program patients. Some patients I have patients who had ECT, one of our patients actually had a severe schizoaffective disorder, started having this when she was 14 years old. And she's 34 now and she's still on weekly ECT. Every time I try to space it, her psychosis just became so much worse. So that's extreme right weekly for decades.

  Dr. Wei Song: [00:58:48] Another is will do every four weeks and then after a year or two, some of our patients view stable is every a monthly for two, one or two years. And I try to space it to say five or six weeks. In my experience, once you're done, you can maintain wellness or your remission after five, six weeks space, probably you can stop ECT. I mean, the idea is always trying to wean people off ECT. Right. As I mentioned earlier on the to sort of if you have a permanent sort of a memory problems is because you have repeated ECT on an ongoing basis for years.

  Alex Raben: [00:59:31] Great! Thank you so much for taking us through that. So if I understand correctly, the relapse rates can be high and that's because depression is a chronic mental illness, as we know, and or it can be relapsing and remitting. But you have options in terms of medication as it maintenance usually Nortryptophan plus Lithium or Venlafaxine or maintenance ECT which is sort of this tapering schedule, as you described it. And you try to get to the kind of lowest frequency that keeps people well. But in reality, often those are not maybe not often, but they can be combined for people who benefit from them. So thank you so much for taking us through that. I'll hand back over to Jake.

  Jake Johnston: [01:00:18] Yeah. Thank you very much, Dr. Song, for taking us through. It's a large topic to cover, but you did an excellent job at conveying the salient points. Do you have any closing thoughts before we wrap up the episode?

  Alex Raben: [01:00:33] Well, I think this is a great opportunity. I'm so glad that you provided the opportunity for me to talk about this subjects and particularly for learners. And it's always amazing to see the learners who has never watched the ECT and exposed to ECT for the first time and realize, "Wow, this is what it is". Because a lot of times you have these pre-conceived notions then from media and from what you talked about. So, I think it's very important to demystify to really educate our learners, but hopefully, actually educate the public. Right? So this is actually a very effective treatment. It's not barbaric, it's scientific and it's safe and it should be available to anybody who wants it who is suitable for it.

  Jake Johnston: [01:01:39] Thanks again, Dr. Song, for joining us. That concludes our episode on Electroconvulsive Therapy. PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. They've used endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Jake Johnston, Arielle Geist, Randi Wong and Alex Raben. The audio editing was done by Jake Johnston. Our theme song is Working Solutions by All Live Music and special thanks to the incredible guest, Dr. Wei Song for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

Episode 38: Clinical High Risk for Psychosis with Dr. Thomas Raedler

• Episode 38: Clinical High Risk for Psychosis with Dr. Thomas Raedler

  Welcome to PsychEd, psychiatry podcast for medical learners by medical learners. This episode covers clinical high risk for psychosis. I'm Alex Raben.

  I'm the host for this episode. I'm also a staff psychiatrist at CAMH. I'm joined by two co-hosts today, Rebecca Marsh.

  Hi, everyone. I'm Rebecca. I recently finished medical school at U of T, and I'm an incoming psychiatry PGY-1 resident at McMaster.

  Thanks, Rebecca. We also are joined today by our co-host, Luke Fraccaro. This is your first time on the podcast, Luke, but Luke really led this episode.

  Thank you.

  Thanks for having me, Alex. My name is Luke. I'm a PGY-1, soon to be PGY-2 psychiatry resident at the University of Toronto.

  Thanks, Luke. And we're very thrilled today to have our expert all the way from Alberta, Dr. Thomas Raedler. He's a psychiatrist and associate professor at the University of Calgary.

  He's also a member of the Matheson Center for Mental Health Research and Education of the Hotchkiss Brain Institute at that same university. Dr. Raedler is also one of the authors of the Canadian Treatment Guidelines for Individuals at Clinical High Risk of Psychosis. And that was actually how I personally gained some interest in this topic.

  So we're really thrilled to have you, Dr. Raedler. Welcome to the show.

  Thank you for having me. This should be interesting.

  For sure we hope so. So why don't we jump right into the learning objectives for today's episode. We'll talk about what we hope to cover.

  So by the end of this episode, we hope that you will be able to, number one, recognize a patient who is or may be clinically high risk for psychosis and have an approach to a differential diagnosis. Number two, understand the importance and utility and prognosis of the various risk groups within that clinical high risk population. And then finally, number three, that you have an approach to the initial management of this patient population and an understanding of the array of options of more specialized treatments that are available.

  Okay, so that's what we're hoping to cover today. And we're actually going to start off with a case that we can bring with us through these various learning objectives to help bring it alive a little bit. And so I'm going to hand it over to Rebecca to take us through that case.

  And then we'll launch into some questions.

  Okay, so for our case, we have Eric, who is a 19 year old high school student who lives at home with his father and presents to the early psychosis intervention program today after referral from his family physician. So for the last four months, Eric has been absent from school several times a week, avoiding his peers due to a sense that they're out to get him and feeling as though someone is trying to speak to him directly through his assigned readings. Eric reports seeing markings on his parents' furniture move around on their own and has tried using self-talk on several occasions to remind himself that what he's seeing is not real.

  He denies using any substances and is not currently taking any medications. His father expresses great concern that Eric has become increasingly withdrawn over the past year and Eric admits that he has not been feeling like himself at all. Both him and his father are hoping that you could provide some sort of answer.

  Okay, so that's our case for today to keep in mind as we speak a little bit about this topic. So I guess just to get started in terms of a basic introduction to clinical high risk for psychosis, Dr. Raedler, would you be able to tell us what does it mean to be clinically high risk for psychosis?

  The whole concept of clinical high risk for psychosis is a fairly new concept. Taking into consideration that we're trying to identify people with a severe mental illness or who are at risk of developing a severe mental illness at an early stage of illness because we believe that our ability to intervene is the best at the beginning of illness. So the whole concept of clinical high risk of psychosis is looking at a group of people who are considered to be seen at a higher risk than the general population of developing a psychotic illness.

  Please keep in mind that it is not entirely uncommon for quote unquote healthy people to also experience some form of psychosis like symptoms. But this is a group of people who are considered to be at higher risk of developing a psychotic illness. However, at the same time, the symptoms have not crossed a threshold to a psychotic disorder like the ones that we all know.

  And in order to get back to your vignette, obviously, one of the questions that I have just reading the vignette is, is this person still in the clinical high risk area of things? Or has this person already crossed the threshold to a true psychotic disorder? I would also like to mention that the group from Melbourne who has been implementing this concept has recently expanded on their concept of clinical high risk.

  They're not just looking at clinical high risk for psychosis, but they're also including other psychiatric disorders, including bipolar disorder, depression, severe personality disorders, and psychosis as a way of identifying people who are at risk of developing a severe psychiatric illness and then try to help them at a very early stage and prevent a worsening of their condition.

  And what kind of criteria or symptoms would you typically look for that would make someone clinically high risk?

  In order to be eligible for diagnosis of clinical high risk of psychosis or attenuated psychosis syndrome, as it is now listed in the DSM-5, interestingly enough, it's listed in with a lot of details as a research diagnosis. As a condition that is subject to further studies, but at the same time, it's also listed with a lot of descriptors in the other schizophrenia spectrum disorders. So it has made it into DSM-5 and it also has a code now 298.8.

  And the criteria that we're looking at are psychosis like symptoms, including delusions, hallucinations, disorganized speech. Again, that are not occurring at the same rate or intensity that we would expect for somebody with a psychotic disorder, but more than what you would consider to be quote, in quote, normal or explained by other factors.

  That makes sense. And is there a typical age that someone who's clinically high risk presents at?

  In most cases, people present in their late adolescence, early adulthood, which is, as you surely know, the age of onset for many other psychiatric disorders, especially schizophrenia, and with the whole concept of clinical high risk for psychosis, we're trying to identify people early on who are at risk of developing a psychotic disorder and then trying to implement treatments so that we can prevent worsening from occurring.

  That makes sense. And with this presentation, are there other psychiatric illnesses that you should have on the differential or that can mimic some of these symptoms?

  Yeah, there's always a lot of different diagnosis on the differential. And keep in mind that establishing a psychiatric disorder is frequently a process, not based on a one time assessment. Part of what we do in our clinic is we try to get to know people better.

  Sometimes it takes a little bit of time for people to be willing to acknowledge the full extent of their psychotic symptoms. But obviously, first of all, you would want to make sure that you're not dealing with people who actually have a psychotic disorder, either unspecified schizophrenia spectrum disorder, bridge psychotic disorder, schizophrenia, schizoaffective disorder, or any of the other psychiatric disorders that can also show psychotic symptoms, including bipolar disorder and depression. There's also large overlap with personality disorders, especially with schizotypal personality disorder.

  You always want to make sure that the symptoms are not caused by substance use or use of other substances or other medical problems that could be causing the symptoms that we're seeing.

  Yeah, doing some reading, I was definitely considering a lot of those in terms of the schizotypal personality, the potential for substances. And I think now I'll hand it over to Luke to talk a little bit about the importance of having this clinical high risk for psychosis and the utility of it.

  Yeah, so now that we have a bit of an understanding on what clinical high risk for psychosis is and who may be at risk for it, wondering now if we can talk about its importance and its utility. Kind of just like general question, why is it important to identify these individuals who are at risk of psychosis?

  As I said earlier, the goal is to prevent a worsening of their clinical condition. And we're always hoping that we can prevent the manifestation of a true psychotic disorder or a serious mental illness to begin with. We're hoping that with implementing the right kind of treatment and also helping people to make lifestyle changes, that they will be able to stabilize their condition and not go on to develop a serious mental illness.

  So this has seemed to be a prevention at a very early stage of illness.

  And when reading through the research for this episode and thinking back to my experience observing in your clinic in Calgary, I was wondering how do these individuals get referred to clinical high risk clinics? Are they being referred by their family doctors or other concerned physicians who may see them maybe in an emergency scenario? How do the patients get referred to these clinics?

  We try to make things as easy as possible. Essentially, we take referrals from whatever source. We take self-referrals.

  We take referrals from family members. We have an organization, Access Mental Health in Calgary, that helps people find psychiatric treatment in the community. We take referrals from emergency rooms, psychiatrists, family physicians, or other community agencies.

  We used to be part, well, we're still part of the NAEPL study, but as when the NAEPL study was at its height, NAEPL stands for North American Prodroma Longitudinal Study, which is a multi-center research study focusing on people who are considered to be at high risk of developing psychosis. They had a whole person dedicated to recruitment of possible subjects. We're very fortunate in Calgary that we have several clinics here that focus on people who are seen to be at high risk of developing psychosis.

  The reality, however, is that these services are not as widely used as you would expect them to be. There should be a tremendous clinical need for these services, but we actually see far more need for early psychosis services as compared to the clinical high risk group of people.

  So, for family physicians then who may be concerned about a patient of theirs who is showing possible signs of being at high risk for developing psychosis, are there like available screening methods that they can then use to maybe identify those who would be at higher risk to then make referrals to a psychiatrist who could assess them?

  There are several tools available that we use to establish a diagnosis. There's the SIPs and there's the CARMS. Both are structured clinical interviews that focus on people who are considered to be at high risk of developing psychosis.

  The problem is, however, that both interviews take a lot of time. They take about one and a half hours. And in order to be able to administer them properly, the RAIDAs have to be well trained to be able to use these tools.

  So they're not very practical for family physicians or other health care professionals. I guess the reason to refer to one of those clinics is if they have concerns that there may be a in quotation marks, budding psychotic illness occurring in a given patient. There's also another screening tool which I just read about.

  I don't have personal experience with it. It's called the EPSI Early Psychosis Screening Over the Internet, which is a shorter version. It's about 26 questions or so and it can be administered over the internet.

  But as I said, I haven't seen a lot of studies using this tool. So I cannot say for sure if it is as helpful as it seems on paper. And in our clinic, whenever we get people referred, we start out with doing a detailed interview and then we do what we would always do, try to get as much information either from past records, try to obtain collateral information.

  And sometimes it takes a little bit of time to get to know people, to have them build up trust, to get the full story of what has been going on. Some people hesitate to admit to all their symptoms when we see them for the first time.

  So once these patients have been referred to a clinic such as yours by concerned physicians, whether it's a family doctor or like you said, even sometimes self-referrals, I'm wondering now like what does the prognosis look like for these individuals who are at clinical high risk for psychosis? How many go on to develop psychosis?

  That's an excellent question. And there's actually fairly good news there because it seems as if over the last decade, the conversion rate to psychotic illness has decreased significantly. It used to be in the range of 30 to 40 percent over a two to three year period.

  And now it's more in the range of 15 to 25 percent. The longer you wait, the more cases there seem to be. But in most larger centers now, the conversion rate has decreased significantly.

  But it still seems to be in the range of 20 to 25 percent over three years. And it's important to keep in mind that with people whom we see in our program who are being assessed for having a clinical high risk state for psychosis, that only a maximum of a third go on to develop a psychotic illness. However, this is not the only thing that I'm concerned about when I treat people who I see a clinical high risk of developing psychosis.

  Because we also know from further studies that a lot of people who don't convert to a psychotic illness still continue to struggle with their level of comfort and also their level of functioning. So it's not all about preventing the conversion to psychosis from occurring. It's also helping people be more comfortable and reach their full potential and their full level of functioning.

  So then to follow up on that, like what are some of the other possible outcomes for individuals who are clinical high risk? Like you mentioned, only around like a third or less would go on to convert to like a psychosis in the non-conversion group. What other possible outcomes can happen for these individuals?

  Well, first of all, there's a large comorbidity with other psychiatric disorders, including anxiety disorders, mood disorders, substance use disorders, personality disorders. And in our clinic, we've also seen a significant amount of people who present with a previously undiagnosed autism spectrum disorder. So we do see a very varied group of people.

  If there's another comorbidity present, obviously, we try to help people address that comorbidity. We treat their mood disorder. We treat their anxiety disorders, if possible.

  We encourage people to use, make good choices for themselves. We encourage people to ideally stop using substances altogether. Or if that is not possible, if that is not what people want to do, to reduce their substance use as much as possible.

  We encourage people to lead a healthy life by focusing on healthy activities, good nutrition, sufficient level of physical activities, and thereby trying to help them improve their overall level of functioning and their overall level of comfort, while not losing the risk of conversion out of sight. Obviously, whenever I assess a patient with a clinical high-risk clinic that I run, it's always on my mind to make sure that I'm not seeing a worsening of their risk of developing psychosis.

  And are there any protective factors that can reduce an individual who is at clinical high risk of psychosis from progressing and converting to a psychotic disorder?

  Yeah, we know that being health-seeking is a protective factor. Those are individuals who are interested in receiving help and we're trying to give them as much support in a multidisciplinary setting as possible. We know that addressing substance use helps to limit the risk of conversion.

  We know that treating psychiatric comorbidities helps to limit the risk of worsening of their overall condition. So by implementing all of these treatments, or I would say by offering all of these treatments, we're trying to help people. And for some people, we try to come up with a treatment plan, and for some people, we just tell them that we're going to be monitoring their condition, or we're going to be available for them just in case if things do change.

  Sometimes we see young people who are not that interested in undergoing more intense treatment, but we tell them the door is always open if things do change. We tell them our program runs for three years. Within those three years, if they want to come back, if they want to receive further treatment, or if they want to have further assessments done, all they need to do is give us a phone call, and we'll try to schedule them as soon as possible.

  Great. So maybe just kind of taking this back to our clinical vignette example here. So if we look at our case with Eric being a 19-year-old high school student, who seems that he's been experiencing some of these, like, attenuated positive symptoms of psychosis, the fact that he and his father together are going to see a physician about this, that they are help-seeking, and that in his case, he does not use any substances, and I believe doesn't have any other comorbidities, would be like protective factors in this clinical example.

  Eric's situation sounds like a very scary situation. And for a lot of people, just to know that there's a program available where they can get help, where people understand them, makes them feel more comfortable in itself. So I would be happy to admit Eric to my clinic, and then we would try and come up with a treatment plan to help limit his level of distress and help him to resume his previous level of functioning.

  And on that note, Dr. Raedler, you mentioned kind of early on that you even wondered if Eric might be at that tipping point of conversion. And I wanted to explore that a little bit further. It's kind of the opposite of what Luke was saying with protective factors.

  Are there also different risk levels within the clinical high risk population? I know people throw out terms like blips and attenuated positive syndrome and genetic risk. What do those terms mean?

  And do they convey different risk? And does that apply in Eric's case?

  Well, whenever we look at people who are at clinical high risk of psychosis, we look at three different syndromes. There's attenuated psychosis syndrome. Those are people who are experiencing psychosis like symptoms.

  They happen at an intensity that does not cross this artificial threshold where we start to call it a true psychotic disorder, either because they're not severe enough or because they're not happening frequently enough. But they're still happening frequently enough that people are concerned about them. And in our clinic and in most other clinics, they're the bulk of the population that is considered to be a clinical high risk of developing psychosis.

  However, there are two other syndromes that are different from the attenuated psychosis syndrome. There's the BLIPS, the brief limited intermittent psychotic symptoms. Those are people who for a very short period of time experience an acute psychotic episode.

  It can be a couple of minutes. It can be up to a couple of hours where they experience typically very intense symptoms of psychosis. Either they become very paranoid or they start to experience perceptual abnormalities.

  But then these symptoms are of short duration, either a couple of minutes or a couple of hours and don't tend to occur very frequently. And the other syndrome that we're aware of is genetic risk and deterioration syndrome, which encompasses people who have a family history of a first degree relative with a psychotic disorder and who have experienced some kind of decline in their own level of functioning. Again, the blips and the genetic risk and deterioration syndrome tend to be much occur much less frequent than the attenuated psychosis syndrome.

  We know from different studies that interestingly enough, it seems as if the outcome of the genetic risk and deterioration syndrome actually doesn't seem to be that different from health seeking individuals who are not seen to be at high risk of developing psychosis. That came as a bit of a surprise to me, but that's the outcome of some of the studies. At the same time, we also know that over time, the risk of conversion to psychosis seems to be the highest for people who suffer from blips, the brief limited intermittent psychotic symptoms.

  And those are the ones who are at the highest risk of developing psychosis. However, please keep in mind that the attenuated psychosis syndrome group is by far the largest of all groups. We also know that there are a couple of risk factors that put people at higher risk of developing psychosis.

  Nothing should come as a big surprise. Those individuals who have a fairly high symptom burden in terms of psychosis like symptoms seem to be at higher risk of developing psychosis. Also, those individuals who present with primary negative symptoms seem to be at higher risk of developing a psychotic illness.

  Those individuals who struggle with a significant decrease in their level of functioning at the time of their initial assessment also seem to be at higher risk of developing psychosis over the next three years.

  I see. That's really helpful to break it down. So to recap, the attenuated psychosis syndrome is the largest group, but it's kind of in the middle in terms of level of risk because blips is what seems to be the highest and then the genetic deterioration risk and deterioration is the lowest there.

  And then there are even some nuances within that, so if there's a lot of functional impairment or negative symptoms, that can also be an independent risk factor. With Eric, I'm wondering what category we think he falls in here. I was just reading through the vignette to see if I could identify.

  I don't think he has a family history, from what I can see here, but he is seeing markings on his parents' furniture moving around. So that sounds like a visual hallucination. So I'm guessing he's blips, but I don't know what you guys think.

  I guess that's the most likely assumption.

  He may be blips or possibly also attenuated psychosis syndrome, because I think it said somewhere that the symptoms were going on for a couple of weeks. I don't have the vignettes right in front of me. I think there was a statement on the time course.

  For the last four months.

  Four months. Yes. So that would be too long for what you would expect in blips.

  It would be either a couple of hours or maybe a day or two at the very most. And then again, you're getting into threshold territory. At some point, you need to distinguish blips from a brief psychotic disorder.

  Keep in mind, there's no clear cutoff for those things. In many cases, it's clinical judgment and it is up to the treatment team to make the ultimate decision. If they're still considered to be in the clinical high risk area of things, or if people feel that they have crossed the threshold to primary psychotic disorder, which then would put them out of the range of clinical high risk.

  Right. So yeah, thanks for clarifying. And it sounds like the timing is quite important there.

  As you say, blips, you would expect it to be briefer than the four months, but it sounds like we would need a bit more information. We'd have a few more questions for Eric and his family to sort that one through completely. I just had a quick follow up with the attenuated psychosis.

  Can you give us a concrete example of that? Would that be like an overvalued idea versus a delusion? Like, is it just like fixed?

  Would that be one attenuated symptom?

  The criteria that is frequently used is that people still continue to have insights into these symptoms, that they're not convinced that they're happening. They still have some doubts into the reality of.

  Part of the beauty of our field is that things are not black and white, that we have a lot of gray and sometimes it's light gray and sometimes it's dark gray, but gray remains gray and ultimately in many cases there is not an easy solution. And as I always tell my students that clear situations are clear, it's easy to identify somebody who's in the midst of a clear psychotic episode because the symptoms are so clear, it's this gray zone that can be very difficult. And also you would want to watch the time course of symptoms.

  We also know that those people who are experiencing a clear worsening in the severity of symptoms are also at higher risk of eventually transitioning, converting to a psychotic illness. So that's something that we will be monitoring very closely.

  Right. So that's a very good point that we're talking at idealistic terms here to help learn a lot of these points. But in clinical reality, it can often be pretty gray, but you could take advantage of longitudinal assessments and monitoring over time and certainly thinking through these principles in those clinical decisions.

  I wonder if we, I think maybe now we can turn to treatment. We've alluded to some of that already. Dr. Raedler, you alluded to it, like treating comorbidity.

  Helping with function. But yeah, I thought we could go through the some of the points you raise in the guidelines, the Canadian guidelines and how that applies to our case or people who fall into this category. So as you mentioned, and as the guidelines mentioned, ideally, these patients would receive specialized care at a specialized clinic, although you were mentioning that's not always possible.

  How, I guess my question surrounding that point is how do these clinics run? Like how often would people be followed? Who's part of those teams?

  Well, I can only speak for our clinic here at the University of Calgary. We're part of the Early Psychosis Intervention Program. All individuals who join our program are teamed up with a psychiatrist and a case manager.

  And we tend, in the beginning, we try to see them more frequently, maybe every three, four weeks. But we always tell people clearly that we're always available for crisis situations. And I always tell people that we're just a phone call away.

  If things change, they should just give us a call and we'll try to see them the very same day. We're in a fortunate situation that we have a lot of other services available in our program. We have a social worker who can help with some of the social aspects of life.

  In Eric's situation, that doesn't seem to be that much of an issue because I think he was still living at home. So presumably, he didn't have to worry, have immediate worries about his livelihood, his safety. But it's important to have the support of a social worker if the social situation seems very difficult.

  Then we also have occupational therapists working on a program helping people to look into options for their return, either back to school or back to work or planning what the next steps should be. We also have psychologists and individual therapy specialists in our program. We offer group therapy.

  We offer individual therapy. We also have a family worker working in our program, which means that we can provide a lot of the treatments that are recommended for people who seem to be at a clinical high risk of developing psychosis. First of all, it's important to keep in mind that unfortunately we don't have a lot of clear information available.

  There was a meta-analysis done recently and the summary is always the same, that we need more studies, we need more information to come up with clear recommendations. But with regards to treatment, we do have some general recommendations. We know that individual therapy can be very helpful, mainly CBT.

  We know that there are some studies showing that CBT was superior in terms of outcome when compared to supportive therapy. We also know that there's a tremendous role for family therapy as a first intervention. So we try to offer these interventions as well.

  And then ultimately, there is also the risk of pharmacological treatment. And that is where I have two different thresholds. I have a fairly low threshold for treating subjects who seem to be a clinical high risk of developing psychosis for comorbidities like depression or anxiety.

  I start treatment in a lot of my subjects with an antidepressant to try and help with those comorbidities. And it's frequently very helpful. But I do have a higher threshold for the use of antipsychotic medication.

  But obviously, that's one of the issues that always comes up. First of all, it's important to keep in mind that we do not have good data on the use of antipsychotic medications. There were to date only two studies that I'm aware of, one using risperidone, one using olanzapine.

  The study with risperidone showed initial superiority to people who were on placebo. But then after one year, the differences were no longer present. And the study with olanzapine showed some clinical advantages, but the side effect profile was fairly pronounced.

  So the recommendation was to exert some caution about the use of these antipsychotics. But we have newer antipsychotics available. Unfortunately, there's not a lot of data supporting the use of these agents in people who are considered to be at clinical high risk.

  The reality is, however, the closer people get to this artificial threshold for a psychotic illness, the more likely the treatments team will be to consider antipsychotic treatment. And it is something that I always bring up with people. I tell them, well, we typically try therapeutic interventions first, and if they're not getting the benefits they're hoping for, I tell them there's also the possibility to look into pharmacological treatment.

  I tell them that is beyond the indications for these medications, but there is anecdotal evidence supporting their use. Ultimately, it is something that I leave up to each individual to decide for themselves. Please be, it's important to be aware that the NICE guidelines strongly recommend against the use of, using antipsychotics for preventative reasons.

  However, as soon as people are seen to be psychotic, then obviously antipsychotics are being indicated. There was a fairly interesting recent development, and I also run our clinical trials program here at the University of Calgary. We were part of a clinical trial that was sponsored by Boehringer Ingelheim, that specifically focused on people who were diagnosed with attenuated psychosis syndrome.

  It's an interesting story because the initial outcome measure for this clinical trial was a conversion to psychosis, and then apparently they did some more reading and saw that this doesn't seem to be that much of an issue anymore. With the cohort that they were hoping to recruit, they would not be able to see the effects that they were hoping for. They had some pretty convincing evidence from preclinical trials were using this compound, which was a phosphodiesterase 9 inhibitor, which works on the second messenger system and is also supposed to have some effects on synaptic pruning.

  There were some interesting results from animal studies were using this compound in combination with doses of methamphetamine prevented some of the sensitization for psychosis that were seen in untreated animals from happening. However, this study was off to a very slow start because, as I said earlier, this condition is very difficult to recruit for and then COVID happened. And then I think it was about six months ago that the company eventually decided to discontinue this clinical trial after they had changed the outcome from conversion to psychosis to time to stabilization.

  So the interesting thing is there's some interest from the pharmaceutical industry to pursuing treatments for this condition. And I do use pharmaceutical approaches frequently in my treatment. I think it would be great if we had a medication that even if the conversion rate is only 30 percent, if we could offer effective treatment to limit this risk of conversion.

  But so far we have no agents with proven efficacy available.

  But it's good to hear that there's interest in developing that because that's where you're going to have huge, I guess, public health ramifications down the line, fewer psychotic illnesses, which we don't have cures for at the moment and can be quite debilitating. And thank you for painting that picture of the clinic. It sounds very multidisciplinary.

  It sounds like you take a sort of stepped approach with psychotherapies, primarily CBT sounds like has the most evidence. And then if needed, and the family therapy and family therapy.

  That's a very important part of our program as well. And there's really good evidence for family therapy as well.

  Of course. Yes. And I think that's also true for schizophrenia and the adult population.

  So that makes sense to me intuitively. And then what I'm hearing, though, is you have a fairly high threshold for using antipsychotic medications, given the side effect profile of those medications, the sort of lack of research so far in that realm, but some degree of evidence. So it can be used, but more as a higher threshold before you go there.

  I wonder, because I work in chronic care, so my mind is thinking longitudinally these days. How long do you follow patients in these clinics and what happens afterwards? Like if someone doesn't convert, but they still have these functional deficits, like, can you give us some idea of how that plays out?

  We know from longitudinal studies that a significant proportion of people attending a clinic for high risk does convert to psychosis and will eventually end up in the psychosis stream, like for us, the early psychosis program or the adult psychosis program. We also know that there's a significant amount of people who do recover fully and then don't require further interventions, but we also know that there's also a significant amount of people in these clinics who, even though they do not convert to psychosis, continue to struggle with their level of functioning over time. Where even though the psychosis risk has been eliminated, their level of functioning is not what we would hope for.

  And those people will then end up in the general psychiatric population. Our program runs for three years. And at the end, then we need to make decisions.

  Obviously, if people have become symptomatic in terms of a psychotic illness, or also transitioned to, let's say, depression, or bipolar disorder, severe personality disorder, then we would refer them to for ongoing psychiatric care. A lot of the people, once they're done with the three years in our program, don't require ongoing psychiatric care, and then are discharged back to their family physicians. Well, knowing that if things change, they can always be referred again for psychiatric outpatient care.

  Right. So it's quite a range of potential outcomes. But you tend to follow people for three years, and then make decisions based on where they're at at that point, it sounds like.

  And also what kind of treatment people want to get.

  Right. Makes sense. Thank you for covering that, Dr. Raedler.

  I just want to see if my co-host had any last burning questions here, as we're almost out of time. But I want to make sure they have an opportunity.

  Yeah, not so much of a question, but just kind of like an observation after reviewing for and prepping for this episode and our discussion today is that it seems that this group, like Clinical High Risk for Psychosis, even as you mentioned, Dr. Raedler, the proportion that are transitioning or converting to psychosis has decreased over the years, but there's still a significant amount that continue to have functional impairment or comorbidities. It kind of seems like this population is like a high risk for psychiatric disorders rather than just like a high risk for psychosis. And it's interesting to see how this, like studying this population continues in the future.

  I'm wondering like, where do you see this field heading in the future? Or what more could be done?

  Well, as I mentioned earlier, the group from Melbourne is now switching more to a general approach where they're looking at people who are considered to be at high risk of in quotation marks something and not so much of a focus on the high risk for developing psychosis, because we know that we can identify a group of people who are at high risk of severe psychiatric disorders. And I think it's a very good use of health care resources to try and offer as much treatment as possible to these people, because if we can prevent their situation from getting worse, if we can help them to get more comfortable, they will be able to have lifelong benefits from this treatment. In terms of where I see the field going is, first of all, it would be nice to have a better understanding of what is going on, having some kind of factors that help with risk stratification to identify people who are really low risk, people who are very high risk of developing psychosis or another psychiatric illness.

  There's a lot of interest into biomarkers or other factors that help to identify the risk of an individual. It would also be great to have better treatment options available, more specific treatment options for this group of people, being able to find the right treatment for an individual patient. At this moment, we're using treatments that are well established in psychiatry, but we don't have a lot of very specific treatments for this group of people.

  Hopefully, over the next couple of years, we will gain a better understanding of what we can do to help this fairly vulnerable group of people to become more comfortable and reach their goals in life.

  Well, what a wonderfully hopeful message to end on. Thank you so much for that, Dr. Raedler. And as you say, this is an area where we can have an impact on people's lives that will potentially change their trajectory, for lack of a better word, for the better.

  And so it's quite impactful and quite hopeful. I just want to make sure we have a nice wrap up here before our Zoom call closes on us. And I want to make sure, Dr. Raedler, that we thank you again for joining us.

  And we really appreciate you taking the time out of your busy schedule to join us and to help our audience understand this really important topic. So thank you.

  Thank you. It was my pleasure.

  Well, until next time, everyone, thanks again for listening.

  PsychEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization.

  This episode was produced and hosted by Alex Raben, Luke Fraccaro, and Rebecca Marsh. The audio editing was done by Rebecca Marsh. Our theme song is Working Solutions by Olive Musique.

  A special thanks to our incredible guest Dr. Raedler for serving as our expert for this episode. You can contact us at psychedpodcast at gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

Episode 37: Treating Eating Disorders with Dr. Randy Staab

• Episode 37: Treating Eating Disorders with Dr. Randy Staab

  Welcome to PsychEd, the psychiatry podcast for medical learners by medical learners. This is the second episode of a two-part series on the topic of eating disorders. In part one, we discussed the diagnosis, initial assessment, predisposing factors, explanatory models, and medical complications of eating disorders.

  In part two, we'll explore the treatment of eating disorders. The learning objectives for this episode are as follows. One, outline the management of eating disorders using a biopsychosocial framework.

  Two, identify the indications for various levels of care. Three, understand the ethical and medical legal dilemmas that may arise in treatment of eating disorders. And four, consider the treatment of special populations.

  Hi, podcast listeners, this is Dr. Lucy Chen. We're back for part two of our eating disorders episode with Dr. Randy Staab. And we still got Nikhita and Vanessa with us for this episode as well. So I guess just to segue into the next part of the interview where Dr. Staab, we're going to get into, I guess, the treatment of eating disorders.

  Sure.

  Maybe generally, can you give us a little bit of like, I guess, maybe a general approach to what eating disorders treatment looks like?

  Sure. I mean, the treatment of eating disorders is complex and multifaceted, right? And it involves nutrition, psychotherapy, skills acquisition, education, medical monitoring, and definitely medications can play an important role as well.

  But they're definitely not the main focus necessarily of treatment. I always tell patients that the most important medication that they can take is food, right? So having a balanced diet with a regular breakfast, regular lunch, regular dinner, regular snacks.

  That's the most important thing that they can do is kind of establish a healthy meal plan with adequate calories and good nutrition, with good balance and variety is the most important step that they can do. And early diagnosis and intervention definitely enhances recovery. And treatment can often, often needs to be kind of longer term, as there's no sort of quick fixes often for eating disorder recovery, right?

  These are sort of more, we kind of take more of a rehabilitation model. Looking at eating disorder recovery, kind of like substance abuse recovery, it does take time. And these are complex illnesses.

  So, you know, longer term compassionate support throughout the treatment process is essential.

  Yeah, thanks for that, Dr. Staab. And, you know, I guess in terms of treatment approaches, right? Like, I've done like a grand rounds on reviewing the nine international sort of evidence-based clinical treatment guidelines around the world.

  So there's definitely several approaches. What's the approach that you typically tend to practice on your unit?

  So we kind of take like the best practice guidelines, you know, from Europe, from the APA, from the American Psychiatric Association. There are some Canadian guidelines from BC, some provincial guidelines, and we kind of take, you know, bits and pieces from all of them. They're similar.

  They're not identical, but there's mostly a lot of similarities between them. So, you know, the overarching themes are, you know, nutrition rehabilitation, right? Which for people with bleeding nervosa involves, you know, obviously, you know, proper breakfast, lunch, dinner, snacks involving adequate calories and good balance and variety.

  And for anorexia nervosa, again, well-balanced meals. However, their calories do need to be increased to support weight gain. And the literature does support a more sort of rapid refeeding approach.

  Not as conservative or slow that may have been advocated, let's say, you know, five or ten years ago in the nutrition rehabilitation with anorexia nervosa. So we are proceeding a bit more quickly than we would have, let's say, ten years ago in the field. People with anorexia nervosa, because they're underweight, their metabolisms often get revved up in treatment and they have a lot of repair work that their bodies need to do.

  You know, they need to repair their heart and their kidney and their organs and their bones and their muscles. So they often need to go on higher calories than the average person would need. So we start off at a lower rate and then often we bring them up to at least about 2800 calories or 3000 calories by about three weeks.

  If patients are not able to complete their meals in a program or in a residential setting or day hospital setting, then we do ask that they complete a liquid nutritional supplement to kind of make up for the calories. Because they're main, like I said before, their main treatment, their main food, their main medication, especially in the early days, is definitely food and nutrition.

  I guess we often think in psychiatry of this biological, psychological, and social approach and thinking about those different aspects. So it sounds like the nutritional rehabilitation is really key from that biological perspective.

  Very much so, yeah. So again, without the nutrition, you know, without the biology and nutrition, then the psychological and the social are probably not going to, you're not going to get very far, right? So people who have very poor nutrition who are underweight and malnourished do not respond well to antidepressants or other medications as well.

  So there's actually no FDA approved medications for the treatment of anorexia nervosa to date. However, medications can sometimes be helpful to treat the comorbid conditions that frequently go along with anorexia nervosa. So, you know, antidepressants or low doses of neuroleptics can help to treat, you know, comorbid depressions or anxiety disorders, PTSD, you know, panic disorder, generalized anxiety disorder, things like that.

  But they tend not to work very well when people are really malnourished and underweight because the components, the building blocks for SSRIs to work comes from food, right? People need to have enough tryptophan in their diet and in their brains for those medications to actually work.

  Dr. Staab, what about the use of, you know, sometimes atypical antipsychotics for weight gain or some of the obsessionality in anorexia?

  So, yeah, we are, we are, we definitely use those quite a bit. You know, people with eating disorders often have a lot of anxiety around food and meals and social situations and gatherings and, you know, eating new foods and around body image and things like that. So we often use small doses of atypical neuroleptics.

  So things like, you know, risperidone or Seroquel or Zyprexa can be used, you know, in the short term, kind of around meal times or in the evening to help with their sleep and their anxiety. And it can help with some of that very rigid kind of black and white, you know, distorted thinking that people with anorexia often have around food and eating and weight gain. And they often have a lot of like, you know, catastrophizing and black and white thoughts.

  And it can kind of take the edge off a bit. So there's no sort of large scale double blind placebo controlled trials showing their effectiveness. But there are some smaller open trials demonstrating that they can be effective.

  And we often use them quite frequently in combination with an SSRI as well. So I personally find them very helpful. I know many other, you know, internationally renowned treatment centers as well use them, you know, in Oxford and John Hopkins and Columbia and UCLA.

  So there may not be it's kind of a new and emerging frontier in the field of eating disorders, particularly the anorexia nervosa. Yeah, for sure. And I think it's important to consider options because, you know, I feel like some of the cases can be so challenging with respect to changing those cognitive distortions around eating. It could be so stuck that we'll talk more about the psychological treatments.

  But sometimes it's extremely challenging and it's nice to note there's options too.

  Yeah. Sometimes when you're when you're interviewing, you know, when you're when you're speaking with clients with anorexia nervosa, you know, if someone comes in and they're, you know, 80 pounds and they're BMI of 14 and they're too scared to eat a sandwich because they're worried that if they eat a chicken sandwich or something, they're going to become obese. It almost feels like you're talking to someone who's delusional at times, right?

  I mean, they're not they're not fixed firm beliefs and they can be modified and they can, you know, fluctuate depending on their mood and things like that. However, you know, low doses of antipsychotics can sometimes help to loosen up those those rigid thoughts and those distortions to make them a little bit more amenable to being a bit more flexible, trying some new foods, you know, hopefully tolerating a bit of the weight gain a little bit better. Many of those medications I just mentioned do have weight gain as a side effect, which can actually be helpful with someone like with anorexia nervosa who is needing to gain weight anyway.

  Sometimes patients can be a bit resistant to that because obviously they have a lot of fears around weight gain. But when you kind of explain the pros and cons, the advantages and, you know, when they get some of the group input as well, people in a group therapy program can often give patients feedback about how helpful they are. They can help with anxiety.

  They can kind of take the edge off. They can help with panic. Most patients, I would say, eventually come around to trying them.

  That's so interesting. Maybe just to finish off biological treatments for anorexia nervosa. We talked about nutritional rehabilitation.

  We talked about medications. And I guess obviously also just, you know, treating physical complications.

  Yes, 100% for sure.

  Yeah.

  So again, people with eating disorders that we talked in the last episode often come with a lot of, you know, medical complications that need to be treated comorbidly with them. Right. So, you know, heart conditions or kidney problems or, you know, GI difficulties, constipation, those kind of go hand in hand with eating disorders.

  And so we typically spend time treating those medical problems as well. Just in terms of Blemiam nervosa, so there aren't any, you know, medications per se that have been proven to treat anorexia nervosa. But Blemiam nervosa, SSRIs, higher doses of SSRIs definitely do help.

  So in about 60% of cases or so, they can significantly reduce bingeing and purging and also help with some of the underlying psychopathology that goes along with Blemiam nervosa as well. So Prozac has the most evidence for it because it's been around, you know, since the late 80s. But other antidepressants as well also work quite well.

  So, you know, you could also try Zoloft or Celexa, you know, Effexor or, you know, Cipralex, Pristiqe can also be helpful to decrease impulsivity and decrease some of the bingeing and purging. So, again, sometimes patients with bulimia also can be reluctant to try a medication. They may be a bit guarded around that.

  However, we still often use them to treat the comorbid conditions that are very common with anorexia nervosa.

  Yeah. And then would you say, Dr. Staab, that like the doses for the treatment of bulimia nervosa, they're about equivalent or do we require higher doses?

  Higher. So yeah, for sure, higher doses work better for bulimia. So for example, like Prozac around the 60 milligram range or Zoloft around 200 or, you know, Ciprolen 20, Selexa 40.

  So definitely higher dosages work better than lower dosages. Kind of like what you think about kind of used to treat like OCD or something like that. Yeah, that's been demonstrated in many double-blind placebo controlled trials that higher dosages, you know, Prozac 60 milligrams works better than Prozac 20 milligrams works better than placebo.

  So definitely if you're going to use these medications and higher dosages are the way to go.

  And are we kind of, I guess, like mechanistically, is it more of like a serotonergic agent that's kind of helpful for the bingeing and the purging?

  Yes, yes, we think so. Again, people who have failed, let's say a serotonergic agent. I have used Effexor or Cymbalta or Pristiqe, and depending on the person, I have had actually some good results with it.

  So the most evidence-based for sure is like Prozac and Zoloft and the serotonergic ones. But again, if people have tried those and have not had a great response, you can try other antidepressants as well. Again, at higher dosages.

  And now is probably also a good time to emphasize that bupropion is contraindicated in bulimia nervosa due to the risk.

  And now is probably also a good time to emphasize that bupropion is contraindicated in bulimia nervosa due to the risk. For sure. Yeah. So 100% do not prescribe bupropion for either anorexia nervosa or bulimia nervosa.

  It's contraindicated because it does increase the risk of seizures. And because bupropion sometimes causes a little bit of weight loss, sometimes these patients will do their research and actually go to their family doctor and say, Oh, I'm not willing to try any other antidepressants except for bupropion. So please prescribe bupropion.

  Sometimes I've seen family doctors make the mistake of actually prescribing it. And then, you know, having to stop it later on because it is contraindicated. So it's definitely not allowed.

  And I guess while we're on the topic of biological treatments for bulimia nervosa, what's the difference in the, you know, the refeeding process for bulimia nervosa compared to anorexia?

  Right. Well, people with bulimia nervosa, by definition, usually are normal weight, right? They're usually normal weight or sometimes above average weight.

  So we're just trying to get people on to a healthy meal plan, basically, you know, approximately 2000 calories per day, depending on your age and your height and different things like that. But, you know, in that ballpark range and just, you know, dividing it up between, you know, a proper breakfast, lunch, dinner and two snacks, including a good balance between protein and carbohydrates and vegetables and fruits and added fats and it includes some desserts in the meal plan. So with Blemiam Nervosa and Enderexnosa, the goal is to get exposure to some different treat foods or like typical sort of binge foods in quotations.

  So get some exposure to those things that they learn how to eat, let's say, you know, one donut, right? And keep it down and not have that turn into eating, binging on 12 donuts, right? Or eating one small bag of chips and keeping it down or eating, you know, a portion of french fries.

  In moderation, so we're trying to find that balance, that middle path, not the extremes of extreme under eating or over eating or binging, trying to find that middle ground somewhere in the middle.

  Thanks so much for that. That overview of the differences there. Coming back to the biopsychosocial framework, what are some of the key tenets of the psychological approach or psychotherapeutic modalities that you might use in the treatment of eating disorders?

  For both of them, for anorexia and for bulimia nervosa, the gold standard of treatment, the main evidence-based treatment would be CBT, cognitive behavior therapy. The evidence supporting cognitive behavior therapy for bulimia nervosa is actually very good. You're looking at doing thought records and challenging some of their cognitive distortions, working on exposure, working on modifying their perfectionism, working on problem-solving skills and coping skills, ingrated hierarchies and thought records, things like that.

  There's very good evidence for CBT with bulimia nervosa. There is some decent evidence for anorexia nervosa, but it's not as robust. It's more in the relapse prevention once people are at a decent weight and are hopefully maintaining.

  Other psychotherapeutic modalities that are commonly used are IPT. Interpersonal therapy also has good evidence for bulimia nervosa. DBT is emerging as a new frontier for both anorexia and bulimia nervosa as well.

  Particularly, the DBT skills. I find those to be very helpful. When people come into treatment, we're asking them to engage in a very scary process.

  The process of eating normally, stopping the cycle of bingeing and purging, stopping excessive exercise, stopping laxatives, stopping diet pills. We're asking them to give up their crutch or their old coping mechanisms. DBT skills and CBT skills are really helpful to try and fill the void that's left behind when the eating disorder symptoms are no longer there.

  A lot of focus is done on mindfulness skills or relaxation skills, distress tolerance skills, interpersonal affective skills, emotion regulation skills. I find the DBT skills are amazing and the patients often really take to them as well. Even though DBT was initially developed for borderline personality disorder, it's been adapted for eating disorders and for substance abuse and depression anxiety as well.

  Often, in reality, people often don't just stick to a very pure, let's say, CBT model or just a pure DBT model. We often use an eclectic mix of different therapies. In our program at Credit Valley Hospital, we have a strong dose of CBT.

  Every meal that's eaten and every meal supervision is getting exposure and working on coping skills. But then we have specific CBT group. We have DBT groups.

  We have distress tolerance groups and emotion regulation skill groups. So often it's kind of an eclectic mix of many different types of therapies kind of rolled into one. And people still do also some psychodynamic psychotherapy as well.

  I was just going to say family therapy. You often do family therapy as well, especially for younger adolescents or for younger adults who are still living at home, let's say, or marital or couples counseling for adults who are living with a partner. For younger adolescents, let's say, you know, a little over the age of 18, family-based treatment actually is the number one.

  Evidence-based treatment, even more so than CBT. So yeah, that's the way to go for like younger adolescents where parents basically kind of are in the driver's seat and are prescribing, you know, the doctor prescribed the dietitian and doctor prescribed the meal plan. And it's up to the parents to kind of like be meal supervisors and kind of almost be like the nursing staff that we have here in our program in terms of monitoring patients, you know, not allowing them to go to the bathroom for an hour after meals to prevent purging and, you know, having contingency management and getting on top of other symptoms like laxatives and exercise and things like that.

  I guess I wanted to ask quickly, Dr. Staab, it's so interesting, this Maudsley based approach, you know, usually used in the children, adolescent population. I also wonder, is it sometimes used almost in an adult sort of setting when, you know, the patient, you know, maybe doesn't have as much capacity to manage themselves like this family therapy approach, I feel like can also be used in so many adult contexts as well.

  Yeah, and it can, it has, there's some preliminary data showing that it can help with, let's say, you know, younger adults, let's say under the age of 25 who are still living at home, who may be, may be still a bit regressed or maybe a bit immature, that it can actually be helpful for that. It's still again, it's in its early days. So still, you know, the primary modality would still be, you know, individual or group CBT.

  But I have seen it done. We don't typically do that here in our program. But I have seen it done at other centres.

  For, let's say, adolescents who start off in FBT, you know, just because they turn 18, you don't flick a light switch and then all of a sudden they're a different person. And then you switch to CVT, you know, you can still continue on with modality therapy, especially if they're living at home and they're quite financially and emotionally dependent still on their, on their parents. So it can sometimes be done, you know, 18, 19, 20.

  I think depending on the person, yes.

  And Dr. Straub, I'm wondering what's the role of allied health in supporting these patients?

  If they're real, like if they're, you know, going into DT or having withdrawal or they're getting drunk every night or they're abusing cocaine, they may need to kind of go to a detox or like a higher level of care for substance abuse addictions first, before they come into our eating disorders treatment program. But we, yeah, we're very adept at treating, you know, run of the mill depression, anxiety, general anxiety disorder, panic disorder, OCD, PTSD, you know, concurrently with our program. The main focus is always obviously going to be the eating disorder.

  But we do a lot of work on the comorbidities as well.

  And I guess following up on that, comorbidities are probably one of the determinants of this. But would you be able to walk us through what the various levels of care are that are available for treatment?

  Sure. So, you know, going maybe from the highest level of care would be inpatient treatment program, right? Where you're in a hospital and you have 24-hour nursing care and access to, you know, other specialists and emergency treatment if needed, you know, IVs and other fancy medical paraphernalia.

  And then, you know, the step down would be a residential treatment program where, again, you're still having some 24-hour care, but it's not as highly specialized or it's not as, you know, as an acute facility. They may have more staffing with PSWs or things like that. And then going down to like a day treatment program or partial hospitalization program, which is usually at least about, you know, six to ten hours per day involving, you know, meal supervisions, group therapy and individual therapy.

  And it can be anywhere, you know, from four to seven days per week. And then going down to like more of an intensive outpatient program, which may be typically around the range of three hours per day, again, five to seven days per week. And then outpatient programming could be, you know, seeing a therapist once a week or a dietitian, social worker, attending an outpatient group, you know, maybe an outpatient CBT or DBT skills group.

  And then eventually a community support group or, you know, a drop in or things like that. So at Credit Valley Hospital, we have a, we go from a very high level of care. We have, you know, inpatient treatment.

  We have day hospital treatment. We have a transition program, which would be considered to be like an intensive outpatient program. And then we have some outpatient groups and follow up with psychiatric, with psychiatry and with our case managers as well.

  Yeah. So again, depending on people's levels of severity when they present to us, typically inpatient care is reserved for people with anorexia nervosa who are quite underweight and medically compromised. Usually, typically a ballpark would be like under a VMI of 16.5, let's say, or who people who have, you know, low potassium or QT prolongation, or they're having fainting spells, dizzy spells, seizures, things that require a higher level of care, low blood sugars or severe hypoglycemia.

  And then a day hospital, you know, residential treatment again would be for people who maybe don't require an intensive hospital based program, but still require kind of like round the clock treatment because they have such severe symptoms that they may be engaging a lot of bingeing and purging at night. And they require like more intensive guidance and supervision. And then they program would be for people who have, let's say, less severe anorex nervosa, typically, let's say above a BMI of 17, who are able to commit to come to a program daily, who are a bit more motivated and who maybe don't require as frequent blood work or medical monitoring.

  And then an intensive outpatient program. So our transition program would be for people who kind of graduate from our day program. And they're typically within a normal weight range.

  So above a BMI of 19, between 19 and 20, who their symptoms are quite minimal. So usually less than, let's say, once or twice a month. They can be followed in our intensive outpatient program.

  And then for people who are not as severe, could perhaps benefit from just, let's say, a once a week group or once a week individual support. So, yeah, so, you know, a gold standard of treatment would involve all these different levels of care and kind of meeting patients where they're at in terms of what they need. Sometimes, though, having said that, though, so you can have all these wonderful steps of care.

  But sometimes people with eating disorders, with anorexia and bulimia, because of the high levels of denial and resistance, may not always access these. Right. So even though someone may require inpatient treatment, they may not be ready to engage in such a high level of care that requires so much change.

  And they may only be ready to engage in, let's say, a once a week group or a motivation group or an education group or something very minimal, just to kind of get their foot in the door and kind of see what it's like. And because they can be, you know, a bit guarded and suspicious about making changes and not 100 percent gung-ho.

  Thank you for that. That's a really helpful overview. And yeah, ideally, I mean, the severity would match up with kind of their level of motivation and readiness to change.

  It often wouldn't be the case. Is there any kind of a harm reduction approach that you can take with patients who have very severe and during eating disorders, but perhaps the idea of full recovery is not something that's palatable to them?

  Yeah. So again, you know, that would be, let's say, for a more chronic patient. So if someone has, let's say, come into a typical, you know, a classical kind of standard program numerous times, you know, and how many times is maybe up for debate, but at least three to five times where they've been into a regular standard inpatient or behavioral sort of day treatment program and have not done well or have not completed or they've relapsed, then you might look at more taking a more of a harm reduction approach.

  At Credit Valley Hospital, our inpatient program and day hospital program, we don't take so much of a harm reduction. We our goal in our program is more of a full recovery. Our goal is to, you know, completely weight restore and stop, you know, symptom abstinence, basically.

  But we do have people, you know, we refer, let's say to Toronto General Hospital. They have a med act team, like an sort of community treatment team, or they might come in for a short stay, or let's say instead of getting fully weight restored to a BMI of 19 or 20, they may just come in and contract to have a goal of, let's say, gaining 10 pounds, just to reduce their symptoms, to improve their medical status. But their goal may not be to achieve a full recovery.

  Obviously, when people go for a full recovery, their outcomes are better and their chances of success are better. If you, if the closer people can get to like a BMI of 19 to 20, the better their prognosis and their better their overall quality of life and long term trajectory is. But sometimes people need to take things in smaller steps in a more gradual approach.

  If there is someone who is kind of an imminent medical danger and unwilling to engage in treatment, I suppose that's kind of an ethical dilemma. And there's different laws that vary from region to region. Are people certified kind of under them?

  Yeah, so rarely, rarely that happens. So, you know, in Ontario, if people, you know, to be certified is they have to be quite extreme. So, you know, for someone to be certified and then to put in voluntarily against their will, we're looking at people who are quite very, very ill, like we're talking, you know, people under BMI of like 11.5 or something in that ballpark range, people who have been losing weight very quickly, people who have really severe low potassium below 2.5 and they're refusing to get help, people who have like really severe cardiac arrhythmias or, you know, seizures, they can then be certified and treated against their will often with tube feeding.

  But often it's just kind of short term to get them out of an imminent sort of crisis, medical crisis, and then they can sign themselves out against medical advice. So it's just kind of like, like, let's say an alcoholic or a drug addict who is in a very bad state. They're having seizures, they're going through duties or something, and they refuse to stay in hospital.

  You often just treat them, you know, medically with Valium and get them stabilized. And then they have the opportunity to sign themselves out once they're more medically stabilized. So it's more just like a crisis intervention.

  You know, if some people come in and they're very debilitated and they have ongoing chronically low blood sugars that put them at risk of seizures and passing out, they may need to stay in hospital for some two feedings sometimes for about a month to get them more boosted, to get their blood sugars more stabilized. But you wouldn't keep someone in hospital, you know, until they're BMI of 19 and they're fully weight restored. It's just more of like a crisis short-term sort of intervention.

  And I'd imagine that might be traumatic for somebody.

  It can, because when you look at that, like, obviously, I've done that. You know, I do that, you know, not frequently, but I would say, I don't know, you know, on average, maybe I do that four or five times a year, right? We see like 300 new consults a year and I'm doing that maybe four or five times a year.

  So it's only it's run rarely and it's not done easily because once you do that, you can really jeopardize your treatment alliance with that person, right? Once I've certified someone and declared them incompetent and force fed them against their will for a week, they may not be so inclined to book appointments with me in the future or follow up with me again. And they may then say to help with Credit Valley, I'm never going back there ever again.

  Or, you know, it can be quite damaging to your treat your therapeutic alliance. But sometimes it needs to be done because if not, they're going to die, right? So if someone is an imminent risk of death, then you have to do it.

  Yeah. And I also think about kind of the children and adolescent population, right? And the considerations of are a little bit different with that.

  So good point, Lucy. So for people who are under 17 or 16, that is done, you know, whatever you want to call it, more coercive treatment is done much more frequently. So because again, you know, parents are the boss, so to speak, in younger children and adolescents.

  It's up to the parents to decide how long they're going to stay in hospital, when they're going to come out, things like that. But once people are kind of, you know, 16, 17, 18 years old, it's difficult to keep them in hospital against their will, especially for long periods of time.

  You know, how, what about treatment for men? And I guess like how is that, I guess, how common do you see that? And is there a way that you kind of approach treatment that might be different for men with eating disorders compared to females?

  Yeah, so we don't see that many men again. So for you, you know, if we see 300 patients a year, I'd say maybe like less than 5% of those are men. So even though 10% of eating disorders are men, we're seeing probably more like less than 5%.

  And the amount, the amount of men coming into our inpatient or day hospital program is way, you know, much, much, much less. In terms of the actual disorder, it's actually very similar. Like a lot of their, you know, disturbed thinking and behaviors are very, very similar to females.

  There can be more stigma for males to come into a treatment program, which is predominantly, you know, 95% female. They may feel a little bit awkward and like they don't fit in. But once they're there, I have to say, and they're talking to people and they realize that people have the same fears of fatness and body misdistortions and drive for thinness and underlying low self-esteem and perfectionism and depression, anxiety.

  They often fit in very well. Often male patients, not always, but sometimes male patients are not as averse to gaining weight, but they want it to be muscle. They want it to be, you know, muscle in their shoulders, on their chest and to keep a very trim, you know, waist with a six pack abdomen.

  I guess like, yeah, we talked about the kind of the child and adolescent population and the treatment approach using the Maudsley approach. You know, adult populations, more so kind of individualistic or group-based CBT. I guess other populations, I'm just wondering, maybe like elderly population, other maybe, I guess, different other considerations of certain populations with eating disorders.

  Yeah, I mean, we don't see like tons of elderly people. Usually eating disorders start more in the, you know, teenage years and early 20s. That's not to say that older people can't develop eating disorders, but it is more rare, you know, above the age of 50.

  So some of the treatment considerations would be like for some of the more really chronic older, you know, when I'm saying older, like older for eating disorders is like above the age of 40, right? Which is obviously not older in the general population.

  But if someone's had, you know, someone has been sick for over 20 or 30 years, they're often going to be quite debilitated, quite run down, you know, have multiple system damage and organ failure and they're going to be quite fragile.

  They're going to be medically quite debilitated. So those considerations would be, you know, often with chronic pain, they have osteoporosis, they have compression fractures, they have hip fractures, they have heart failure, they have, you know, a whole bunch of other medical problems, which can be quite disturbing.

  Yeah. The population, yeah, the medical. And then I guess for, and we talked about kind of, you know, the preponderance, like the ratio between females and males for eating disorders is around 10 to 1 for anorexia.

  So they're not as this is not everyone, but some male patients are not as disturbed by a number on the scale going up, but they may be more disturbed by, let's say, their belt size increasing or their jeans not fitting their waist in particular. But actually, you know, surprisingly, they actually fit in very well to a typical traditional sort of eating disorders program.

  There's there aren't any like specialized male eating disorder programs in Ontario, you know, in the States, United States, they do have some that are specifically just meant for males.

  With males, there is a higher rate of people who are homosexual or bisexual. So there may be some more sexuality issues or conflicts around that as compared to female patients with eating disorders.

  Yeah, and I guess one of the other categories or kind of subpopulation talk about it, I guess, like our LGBTQ and like trans individuals eating disorders, is that is that sort of is is that a population that's more at risk or how often do you see this within the scope of your programming?

  They are. From what I've read, they are said to be more at risk for a whole host of psychiatric disorders, depression, anxiety, and eating disorders. And I think, again, along with that, there may be more some gender dysphoria that goes along with it.

  So we have seen several patients who are transgender and who many of them have been experienced are really terrible sexual abuse histories and may feel sort of an aversion to female characteristics like, you know, breast tissue or thighs or our hips or things like that.

  And so in the weight gain process, they may have some more anxiety or distress around sort of their feeling disgendered or that they're in the wrong body. But we have definitely seen patients who have completed our program and have gone on to have surgeries and take hormones, male hormones or female hormones, and actually done quite well and have made a full recovery.

  Yeah, but that's so great just to even have that context, lots of special considerations and different things you might consider when working with these types of patients.

  And with these different populations, one of the things that can be quite helpful is in the community, there are some resources and support. So, for example, here in Toronto, places such as Sheena's Place offer kind of support groups for folks outside of the more traditional medical model of treatment.

  Great, yeah, no, Sheena's Place is wonderful, right? There's also Body Brave and Hamilton. Yeah, I love Sheena's Place and Body Brave, they're amazing.

  They have some different sort of like different types of groups sometimes, like belly dancing groups and yoga therapy groups and art therapy groups and a lot of other wonderful, you know, music therapy and some sort of non-conventional sort of modalities or approaches to treatment, which is great.

  Yeah, and speaking of kind of like non-conventional, there's also more novel interventions being explored. Did you have any thoughts on, I think, some studies underway about repetitive transcranomagnetic stimulation or brain stimulation even being used?

  Sure, yeah. I was actually part of a working group looking at deep brain stimulation at the University of UHN, and they did have some preliminary data, again, very small sample sizes, for very chronic, intractable people with eating disorders. There's still some discussion about where is the best place in the brain to stimulate, right?

  There's a lot of work being done around the insula, so it's still kind of in its infancy. We're not exactly sure, but it's a bit of a shot in the dark, but for some, again, a minority of people who've had chronic treatment resistant eating disorders, there may be some hope on the horizon with things like deep brain stimulation, RTMS. Again, I'm not an expert in that, but I've heard there's some good success with patients with bulimia nervosa and with comorbid PTSD as well, that there's been apparently some good success with that, which is a lot less invasive, obviously, than deep brain stimulation, which involves neurosurgery.

  And then there's other things, again, that are sort of in the experimental phases, looking at some psychedelic assisted psychotherapy with things like ketamine or MDMA. And again, those are not things that we're doing here in Credit Valley Hospital. But again, you hear these things at conferences and you see some presentation, again, very small sample sizes.

  It's experimental and it would be considered for people who have failed conventional treatment numerous times. It would not be sort of the first line treatment, right? So people who have had multiple attempts at like traditional inpatient day hospital residential treatment, multiple attempts at CBT, different medication trials, DBT, IPT, you know, the works and nothing has worked.

  These may be some newer avenues to explore.

  Very interesting for sure.

  Yeah.

  I guess we also that this has been a really great overview of all the different treatment considerations and approaches and to manage eating disorders. We did have a question from a listener, which may help kind of tie things together as well. They were wondering, they say they have a 23 year old daughter who was recently diagnosed with anorexia, depression, anxiety and OCD.

  And she says that her eating disorder and extreme weight loss is not about body image. They managed to refeed her at home and they're waiting for ongoing treatment. The waiting lists are quite long.

  And they're basically their mother is wondering, are the treatment protocols different from anorexia where body image and maintaining weight loss are the focus? They also noted she's struggling to complete university but insists on living in her university hometown. And they want to know really like what can parents of somebody who is in their 20s and kind of has autonomy, what can they do to support her without kind of walking on eggshells?

  Yeah, I guess, you know, one thing we always like to leave with the audience are, I guess, if you have any kind of, I guess, words of wisdom that you'd like to impart on learners or, you know, honestly, our listener population is quite vast as well. We've got, you know, a variety of social workers, psychologists, you know, mostly medical students, people in the medical field. I guess any tips you'd like to impart on learners?

  Sure. I think I think one thing might be just, you know, most people listening to this podcast are not going to become psychiatrists or necessarily eating disorder specialists. But I think just in the medical field in general, just be careful.

  You know, if you're seeing, you know, typically, you know, a younger woman who's had, you know, weight fluctuations, she's presenting with some maybe some odd symptoms or, you know, concerns around their eating habits. Be a bit careful about what you say sometimes, because I have seen patients sometimes react negatively to some comments they receive from their doctors. Right.

  So, you know, let's say if somebody has lost 20 pounds and then they see their doctor and their doctor's like, wow, good for you. Keep up the good work. Keep going.

  Right. And then meanwhile, like, you know, 20 pounds later, they have anorexia nervosa. So just be careful sometimes about, you know, I think we're so obsessed, I think, in our culture with, you know, getting more activity and eating a low fat diet and not having junk food and eating more fruits and vegetables.

  That's all great for sure. Right. For probably the vast majority of Canadians.

  But just be careful for some of the vulnerable people that who may take that message too far and too extreme, that for some people actually applauding weight loss and diets. And, you know, increasing their activity is actually not helpful. It may actually be harmful.

  Yeah.

  Thanks so much for that, Dr. Staab. I think that's such an important message to give in this climate where I think there's, you know, there's like a movement or there's a lot of like this health obsessed culture. Yes.

  It's a tricky landscape to navigate and that's an important message to deliver.

  This brings us to the end of part two of our Eating Disorders episode series. PsychEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association.

  The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Dr. Lucy Chen, Dr. Vanessa Aversa, and Dr. Nikhita Singhal. The audio editing and show notes were completed by Dr. Vanessa Aversa.

  Our theme song is Working Solutions by Olive Musique. A special thanks to the incredible guest, Dr. Randy Staab, for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org.

  Thank you so much for listening.

Episode 36: Understanding Eating Disorders with Dr. Randy Saab

• Episode 36: Understanding Eating Disorders with Dr. Randy Saab

  Welcome to PsychEd, psychiatry podcast for medical learners by medical learners. This is the first of a two-part episode on the topic of eating disorders. In part one, we'll be covering diagnosis, an approach to initial assessments, predisposing factors and explanatory models for the development of eating disorders, and medical complications.

  In part two, we'll delve into an exploration of eating disorder treatment.

  I'm Dr. Lucy Chen. I'm a staff psychiatrist at the Centre of Addiction and Mental Health. It's been a while since I've last hosted a podcast and it's lovely to be back, especially joined by a couple of very lovely and brilliant residents.

  We have Nikhita Singhal.

  Hi, I'm Nikhita. I'm a second year psychiatry resident at the University of Toronto and very excited to be co-hosting this episode.

  Yes.

  And then we have also Vanessa Aversa and I believe this is your very first podcast. Experience.

  Yes, thanks Lucy. I'm Vanessa. I'm a third year psychiatry resident at the University of Toronto and I'm excited to join in today.

  Great. And our esteemed guest for today is Dr. Randy Staab. He's a staff psychiatrist at Trillium Health Partners and the lead of the eating disorders program at Credit Valley Hospital.

  Thank you very much for having me here today.

  Yeah, that's great. So I have had the absolute pleasure to train under Dr. Staab as a senior resident and that was clearly very inspiring. I work primarily with women with a trauma history on an inpatient unit at ChemH and there's certainly a lot of comorbid eating disorders.

  And I work closely with a dietician on the team and I feel like I wouldn't have a lot of confidence working with this patient population if I hadn't done the elective with Dr. Staab and very excited to have him on the podcast.

  The learning objectives of this episode are as follows. By the end of this episode, you should be able to recognize the clinical features of various eating disorders using DSM-5 diagnostic criteria, identify predisposing factors using a biopsychosocial framework, list common comorbid psychiatric conditions associated with eating disorders and identify and describe the medical complications of eating disorders.

  So Dr. Staab, I guess, you know, a very natural kind of question to begin with would be what exactly is an eating disorder? How do we define that?

  Sure, so eating disorders are very, you know, complex biological brain disorders. They're, you know, they are complex illnesses that involve an unhealthy relationship with food, eating and body image or body size. They're definitely not a lifestyle choice, right?

  So, you know, sometimes in the media they're portrayed as being sort of frivolous, you know, lifestyle choices or something, but these are definitely really important biologically brain based disorders. And they can be quite difficult to treat because of all of the medical comorbidities and the psychiatric comorbidities that go along with them. In fact, anorexia nervosa has the highest mortality rate out of any mental illness.

  And could you tell us a bit about the different types of eating disorders?

  Sure. So there's a bunch of them in DSM-5. So the ones that we can talk about today are anorexia nervosa, or AN, bleme nervosa, or BN, binge eating disorder, or BED, and then avoidant restrictive food intake disorder, or RFID, and other specified eating disorders, and then unspecified eating disorder.

  So despite a number of common psychological and behavioral features, these disorders differ substantially in terms of clinical course, outcome and treatment needs. You know, people with eating disorders display a broad range of symptoms that frequently kind of occur along a continuum between those with anorexia nervosa, bulimia and other eating disorders. So usually weight and shape preoccupation and excessive self-evaluation based on weight and shape are the primary symptoms for all eating disorders, but not exclusively.

  And most people don't try to set out to develop eating disorder on purpose. It just kind of gradually develops over time as people get more and more obsessed with dieting and weight loss. So anorexia nervosa are AN, right?

  So, you know, the main criteria is restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health. So just as a general ballpark figure in the eating disorder world, we kind of use like a body weight less than approximately 85% of expected or usually less than about a BMI of 17.5. That's not an absolute number.

  So, you know, that's just a general ballpark sort of guideline. When you start to make the diagnosis, and this could be weight loss or failure to make expected weight gain during a period of growth in adolescents or teenagers. So it has to be quite a substantial level of emaciation.

  And then secondly, they have an intense fear of gaining weight or becoming fat or persistent behaviors that interfere with weight gain. So often ironically, the fear of becoming fat and body image disturbance often actually gets worse and intensifies the more the weight is lost with anorexia, which is very different from like an average, routine sort of dieter. Many people in the world might go on a diet here and there, but some of the anorexia kind of they keep dieting, it's never good enough when they reach a weight goal, they may feel happy or kind of be in control for a short period of time, but then they keep setting their weight goals lower and lower and it's never kind of good enough.

  “Man, ironically, let's say if somebody started at 130 pounds, let's say hypothetically, right? They started to die, they started to lose weight, they get down to 120 pounds, they might feel good and kind of happy and in control for a short period of time, but then they lose more weight, they diet more extremely, they exercise more or start to engage in purging behaviors, right, they get down to 115 pounds, 110 pounds, they keep pushing it, it's never good enough. Eventually when they get down to quite low, let's say 100 pounds hypothetically, ironically, they often feel worse about their body image at like 100 pounds than when they did, when they started off the whole dieting process at like 120 or 125, which is very different from an average dieter, right?

  So that's when the distortion starts to get worse and worse. Not everyone with anorexia has this intensive fear of gaining weight or becoming fat with this body image disturbance, the majority do, but maybe 10 or 15% of people don't. And it's more around, you know, difficulties with control or having a difficult time changing their habits or maybe related to sort of like religious aestheticism or things like that.

  There could be other sort of motivations behind it, but the bottom line is that they have other persistent behaviors that interfere with weight gain. And then, so moving on with the criteria. So there's a disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight and shape on self evaluation.

  So really most of their self worth is determined by weight and shape, and they really see weight loss as an impressive achievement and weight gain as an unacceptable failure of control. Or the persistent lack of recognition of the seriousness of the current low body weight. So there often tends to be a lot of denial and a lot of resistance with anorexia nervosa.

  And often they seek treatment more in the prompting of their friends or their family or their doctor, their therapist, and they often kind of feel like people are exaggerating, that it's not such a big deal, that they're fine, they can take care of it on their own. So there is a lot of often denial and resistance that goes along with the disorder. In the Eating Disorders program, we do these sort of like self-esteem pies.

  And a regular person, hypothetically, let's take myself for instance, if we were to do a self-esteem pie, picture a kind of a circle and then picture a pie divided up into, let's say, eight or 10 pieces. Part of people's healthy self-esteem would be divided into a lot of different areas. So, someone's self-esteem could be related to their work or their family, their wife, their spouse, their children, maybe their hobbies, some of their clubs that they're involved with or their spirituality, traveling or books or friends and family.

  So there could be lots of different things that contribute to how you feel about yourself and your self-esteem. Whereas at some of the anorexia nervosa, most of their self-esteem and how they feel about themselves is really related to weight and shape and volumage, the number on the scale and how much fat they can pinch on their abdomen, which is obviously very unhealthy. It's not a very balanced way of living your life because if one thing happens, if you gain one pound or you gain a quarter of an inch, then your whole world is ruined, right?

  Your whole day is destroyed because it's built on kind of a very shaky foundation. In the past, in DSM three and four, they used to include loss of menstrual periods as a criteria for anorexia nervosa, but that was dropped in DSM five because it's not a very sensitive or specific criteria. Some women lose their periods when they're actually at normal weight.

  And then some women maintain their periods even though they're at a very low weight. And it doesn't really count when people are just going through puberty because sometimes their periods can be kind of hit and miss. Or if they're on birth control or have an IUD that can kind of alter it, or if they're going through menopause, or obviously, you know, for boys or for men, that criteria doesn't count.

  So for that reason, you know, that criteria was dropped a number of years ago. So for anorexia nervosa, there's two different subtypes. There's the restricting subtype.

  That's the one that most people in society would think about when they think about anorexia nervosa. So people who died in the extreme and have excessive exercise to lose weight. And then there's also the binging and purging subtype.

  So people who have all the criteria of anorexia that we just mentioned. And then on top of that, they also have regular episodes of binging and purging as well. And then, you know, the severity is based on their weight.

  So the severity of the BMI. So a milder form of anorexia also would be a BMI greater than 17. Moderate would be a BMI between about 16 and 17.

  You know, severe between 15 and 16. And then extreme would be less than 15, which is obviously worse, you know, prognosis, more complications. So about 10 to 15% of people with anorexia will die from the disorder.

  On long-term follow-up studies, it may go as high as even 18 to 20% when people have had chronic anorexia for more than 20 years. So pretty disturbing, you know, that so many, you know, young, talented, often, you know, smart, sophisticated young people are dying from this disorder.

  Yeah, thank you so much for that, Dr. Staab. You really kind of painted a clear picture. And I think a lot of times, yeah, there's like these very clear like media images of what anorexia is.

  And it's good to know that it's kind of quite multifaceted. I liked how you also mentioned, you know, how for some people it's, you know, there's cultural factors here too. There's sort of a diverse range of people that can find themselves with this disorder and there's different types of contributions.

  For sure. Yeah, I mean, it's not, there are, you know, there are specific criteria, but people also have their own individual personalities and their own, you know, upbringing and life experiences that they bring that can, you know, manifest in a various of different ways, right? So just one little sidebar note too, like the term anorexia is a little bit of a misnomer because in medicine, right, if you look up the term anorexia, it means, you know, loss of appetite, which these patients often don't usually lose their appetite.

  Maybe in the very end stages or late stages of disorder, it's just that they often have a very good appetite. It's just that they're not giving into their appetites, right? And then because of the high levels of denial and resistance, they're often not complaining about the symptoms, right?

  They're not walking into a doctor's office, you know, complaining about weight loss and emaciation and the symptoms that we're talking about. These are symptoms that are seen by, you know, their clinicians or their friends or their family more often.

  I think this is a natural segue to kind of then talk about bulimia nervosa and the differences between anorexia and bulimia.

  Sure. So for bulimia nervosa, so again, in the general public, if you know, people think about bulimia, they think about vomiting, but actually for bulimia nervosa, you have to have binge eating and some type of compensated behavior, which may or may not be vomiting, right? So to qualify as binge eating, it has to be eating in a specific period of time, a very, very large amount of food, right?

  So this is way more than people would eat under usual circumstances. So, you know, sometimes when I go to a party or whatever, you know, people will say to me, Oh, Dr. Staab, you have to help me for my binge eating or something, right? And then I'll just say, oh, you know, what did you eat last night or something, right?

  And they'll say, oh, I binged because I had one extra piece of pizza, or, you know, I had an extra bowl of potato chips or something like that. So that doesn't qualify as a binge, right? But usually for research purposes, it would need to be a minimum of extra 1,000 calories in one sitting.

  And that's not like 1,000 calorie, like a large meal. That would be 1,000 calories on top of a person's regular meal plan. And it's usually eaten very quickly, usually less than two hours, usually less than about a half an hour actually.

  People are eating it very quickly, almost in a frenzy, they feel out of control. And it's often all the sort of high fat, high calorie, high carbohydrate foods that they would normally never allow themselves to eat, right? So it's kind of like a lot of cakes and cookies, ice cream, chips, fast food, sort of all the forbidden foods that they would never normally allow themselves to eat.

  And then they also have a lack of control over it. So there's a feeling that once the binge has started, that they feel that it can't stop, that it has to kind of just like run its course. And then they also have recurrent inappropriate compensator behaviors to prevent weight gain.

  So after a binge, people with bulimia feel horrible. They feel a lot of guilt and anxiety and disgust and shame. And then to try to undo the binge, they will engage in either purging through vomiting or laxatives or diet pills, diuretics, enemas, other medications or fasting, or sometimes excessive exercise as well.

  And the binge eating inappropriate compensator behaviors have to occur both on average at least once a week for three months, right? So if there's a teenage girl who, you know, goes to a party one night and maybe drinks a bit of extra beer, and then, you know, it feels disinhibited and binges and purges one time, that wouldn't count as bleeding nervosa. It has to be an ongoing regular pattern for it to qualify.

  People with bleeding nervosa, their self-velation is also unduly influenced by weight and shape as well. So they have basically the same underlying psychopathology as with anorexia nervosa as well. They have an intense drive to lose weight and extreme body dissatisfaction as well.

  And the disturbance does not occur exclusively during anorexia nervosa. So if you're underweight and you meet criteria for anorexia nervosa, then that kind of trumps the diagnosis for bulimia nervosa. So sometimes medical students, it can be a bit confusing why, you know, when does someone anorexia or bulimia?

  So if you're underweight and, you know, under BMI of let's say 17.5 approximately, and you're binging and purging regularly, then you would meet criteria for anorexia nervosa binge purge subtype. And if you're normal weight or above average in weight, and you're binging and purging regularly, then you might create criteria for a bulimia nervosa.

  Yeah, that's really important to highlight. And yeah, like I guess some of the ways that I conceptualize this, yeah, bulimia is more of a disorder of chaotic eating, right? And then anorexia is more so restricted eating to the point of, you know, severe significant emaciation or low body weight.

  Yes, although about half of them do have chaotic eating with bingeing and purging as well. I mean, the binge is not to get too technical, but some of the binges that are seen with anorexia nervosa tend to be smaller than with bulimia nervosa often because, and they're doing, you know, they're purging out more of the calories obviously just to maintain a low body weight.

  And then I guess some things that I also kind of picture or kind of use to kind of differentiate between these disorders, also like their comorbidities. Anorexia with more comorbidity with cluster C, sort of OCPD obsessiveness, like, you know, harm avoidance traits.

  Yes.

  And the bulimia more cluster B borderline personality, substance abuse can kind of risk taking traits.

  Definitely. Yeah, so with anorexia and also we see, you know, very high levels of perfectionism, you know, obsessive compulsive personality traits. They often are very rigid and harm avoidant and have a need for exactness and perfectionism and conform to authority.

  They tend to be often, I mean, this is a stereotype, but they often can be quite hardworking and diligent and responsible. They often are quite modest and earnest and very sensitive to criticism and have high levels of anxiety and often a lot of social anxiety too. They often tend to be and have more sort of sexual disinterest as well and be very obsessional as well.

  With bulimia nervosa, like you said, Lucy, with bulimia nervosa, people tend to be more, you know, have more dysphoric moods, have more, you know, difficulties with interpersonal stressors and can be more labile, they can be more thrill seekers and have more sort of, you know, novelty seeking behaviors with bulimia nervosa.

  Yeah, so then why don't we move on to binge eating disorder?

  Sure, so binge eating disorder, we don't actually treat binge eating disorder here at the Trillium Health Partners Credit Valley Program because the treatment approach is actually quite different than what you would use with anorexia and bulimia nervosa. So for binge eating disorder, people also have recurrent episodes of binge eating. So the same type of binges that you would have in bulimia nervosa that we just talked about.

  So eating a very large amount of food in a short period of time, feeling out of control. And then the binge eating episodes are associated with three or more of the following. So eating much more rapidly than normal, eating until they're feeling uncomfortably full, often they feel really sick by the end of it.

  Eating large amounts of food when not feeling physically hungry. Eating alone because they feel embarrassed by how much they've eaten. So again, a lot of shame and guilt and anxiety goes along with it.

  And then feeling disgusted with oneself, depressed or very guilty afterwards. They also have a lot of market distress regarding binge eating. And the binge eating also occurs at least once a week on average for three months.

  So again, not just one isolated episode on Christmas Eve or something like that. And they don't, I think the important distinction with bulimia, they don't have recurrent inappropriate compensator behaviors, right? So they binge eat and then they do not purge, they do not vomit.

  They do not try and get rid of the calories afterwards. And often, you know, afterwards they feel really sick and disgusted and horrible, guilty, awful. Yeah, and that often, because they're binging a large quantity of the food, often that can lead to weight gain over time, often leading to, you know, metabolic problems, obesity, problems with type two diabetes, cholesterol, et cetera.

  So with anorexia nervosa and bleeding nervosa, we didn't mention, but it's more like 10 to one women to men. Whereas for binge eating disorder, it's a little bit more evenly split between men and women. It's about more like 60% women and 40% men, something like that.

  And they tend to be slightly older, more in the late 20s or 30s. And they also tend to have a lot of comorbid conditions as well. So depression, anxiety, social anxiety and things like that as well.

  And the severity for binge eating disorder is based on the number, frequency of binge eating episodes.

  And Dr. Staab, is there sort of a bit more motivation in this population with respect to engagement and treatment or?

  There is, yup. So actually both. So yeah, binge eating disorder, there tends to be more, there's less denial than with anorexia nervosa.

  The same with bleeding nervosa as well, right? So with anorexia nervosa, sometimes there's a lot of denial. People have no idea there's something wrong.

  They feel like, you know, other people are just unfairly criticizing them. And maybe other people have the problem or other people are jealous of them or something. Whereas bleeding nervosa and binge eating disorder, there's a lot more insight, right?

  They still may have a lot of shame and not be open to talk about it because they feel so, you know, guilty and ashamed. But in their heart, they know there's something wrong. Like if you're binging on, you know, 10 donuts, or you feel disgusting afterwards, you know that there's a problem, right?

  Or people are binging and then vomiting. They know that there's something wrong. They may not be still so keen to get help in the beginning stages, but there is more motivation to change because they really feel disgusted and actually hate the symptoms.

  They really can't stand the symptoms. They're disgusted by them.

  Okay, so maybe now we should move on to ARFID or avoidant restrictive food intake disorder. And I find this disorder very interesting because I see so many different manifestations of it.

  Okay, sure. Yes, it's quite a heterogeneous disorder, right? So this disorder just sort of arrived on the scene in DSM-5.

  It was known as a whole host of different sort of other disorders before. So it is quite a mouthful to say. So avoidant restrictive food intake disorder.

  So it is also an eating or feeding disturbance, which leads to significantly low body weight or significantly nutritional deficiencies, dependence on enteral feeding or oral supplements. And it also markedly interferes with their psychosocial functioning. So it can present in a lot of different ways, right?

  So some people with ARFID present with like, choking phobias or like a swallowing phobia or a vomiting phobia, or they're concerned about, if they had a really bad gastroenteritis, maybe they're worried about if they eat, they're gonna get like food poisoning or bloating or cramping or stomach pain. So they often have like unusual eating habits, but they don't have that dry for thinness or body image distortion that you see with anorexia nervosa typically, right? So, you know, they may be, you know, have lost 30 pounds over the year, but they're desperate to gain it back.

  They don't like being skinny. They don't like being underway. They don't admire their bones.

  That they don't look at themselves in the mirror and, you know, are fearful about eating a cheeseburger or something. It's more about, you know, their fear of swallowing or nausea or the sensory effects of food. They're very sensitive to tastes, things like that, but they actually don't like being skinny and underweight.

  They actually would prefer to gain weight. So just to continue with our for the criteria. So it's not better explained by lack of available food or other sort of associated cultural sanctioned practice.

  It does not occur exclusively during the course of anorexia nervosa or bulimia nervosa. And it's not attributable to some other sort of concurrent medical condition. So it's not better explained by another mental disorder as well, right?

  So it's not related to, you know, Crohn's disease or, you know, celiac disease or some other sort of medical condition like, you know, malabsorption syndrome or hyperthyroidism or something else that causes weight loss.

  I do wonder though, about sort of comorbidity, right? So, you know, in autism spectrum disorder, there's a lot of, you know, preoccupation with different textures of food, you know, or maybe they're only eating one food group or even less. And so, you know, or even in, you know, specific phobia of choking.

  So I suppose that RFID is a comorbid disorder to some of those presentations.

  Often, yes. So it can be like, it's quite heterogeneous, right? So RFID, like, you know, people with anorexia, often when you speak to them, you feel like you're almost speaking to like, you know, a bunch of people who are related or something, right?

  They all seem like sisters of the same person in some ways. Whereas some of the RFID, they seem very different, right? You can have people who have like, you know, a fear about eating, you know, crunchy foods, or they're gonna choke on it or something, or fear some people are, you know, they'll only eat white foods or something like that.

  And they have like autistic spectrum. They only eat like chicken nuggets and French fries and rice or something like that. You know, whereas like someone with anorexia wouldn't be caught, you know, wouldn't probably touch French fries or chicken nuggets with a 10 foot pole.

  These people would just eat one thing and maybe higher in fat, but ultimately it does lead to some nutritional deficiencies because they're just kind of just eating like one thing all the time.

  This is also very interesting disorder in the landscape of, you know, current people engaging in very extreme health practices. And I say, health practices in quotes, right? Like the carnivore diet or, you know, people only eating, you know, like fruits, literally only fruits.

  Yeah, because again, they're not getting the proper variety, right? It can lead to nutritional deficiencies and you know, problems obviously. A lot of these people that we see here at the clinic with ARFID, they have also had a lot of anxiety.

  So these tend to be really, I mean, people that interact with somebody and also have a lot of anxiety, but these people tend to be like, you know, very worried, anxious kids. And then something happens where maybe they had one bad experience where they ate, I don't know, they ate pizza one time and, you know, got food poisoning or got diarrhea or something. And then they're like scared about getting that again.

  And then they start restricting their food more and more and more and more to the point when they're only eating like three things or something like that, right? So they tend to be really highly anxious, highly worried and ruminating all the time and are kind of looking for danger all the time in their environment or within themselves.

  So that's a great summary of RFID. And then our final category is other specified feeding or eating disorders. And I guess this just sounds like a mishmash of things, but maybe you can break it down and make sense of diagnosis.

  Sure. So other specified eating disorder. So it's kind of broken down into sort of five different subcategories.

  And again, it's very heterogeneous. So you have to say when you're diagnosing someone, like you would say, you know, other specified eating disorder dash atypical anorexia nervosa, or whatever is the subcategory. Because just by itself, it wouldn't really mean that much.

  So this is sort of a grab bag of people who have significant eating problems that cause a significant distress or impairment in the person's functioning, but it doesn't meet criteria for anorexia or bulimia or BED or RFID like we talked about already. So some examples might be sort of like atypical anorexia nervosa. So people who have significant weight loss for whatever reason, but their weight may be within a normal range, right?

  So we see people sometimes who start off with obesity and let's say they go from 200 pounds down to 125 pounds. And for all intents and purposes, their eating habits and their fear of foods and their exercise and their, the caloric intake is basically like that as someone with anorexia, but they're actually at a normal BMI. Their BMI may be, you know, 20 or 21, but they've lost a huge amount of weight.

  So they would still qualify as having, you know, quite an eating disturbance. So, but then you qualify as, you know, atypical anorexia nervosa. Someone with bleeding nervosa who may be just sort of sub-threshold as well, where they have binge eating and inappropriate compensated behaviors, but it's less than the average than once a week for three months.

  Someone with binge eating disorder of low frequency or limited duration. So again, they're having binge eating episodes, but maybe it's just once or twice a month instead of once a week on average for three months. And then purging disorder.

  So people who are just purging regular meals, right? So they're not binging and they're just purging like a regular lunch or a regular dinner routinely. And then night eating syndrome is people have recurrent episodes of eating in the nighttime.

  You know, often most of their food intake happens and then we eat hours in the morning at two or three in the morning and they're awake. It's not that they're like, you know, they're not sleepwalking or something like that.

  I suppose, yeah, it's sort of sub threshold criteria for some of the disorders we already talked about.

  Exactly, yeah, pretty much.

  And then just in addition to maybe and purging disorder and night eating syndrome.

  Yes, exactly, yeah.

  Yeah, and then there's, I guess, I guess there's another final category in the DSM-5, this unspecified eating or feeding.

  Yeah, and that's again, just kind of a grab bag for anyone who has significant eating pathology and causes distress and impairment, but it doesn't meet any other criteria of things we've talked about already. So some people who kind of go on these fads or kicks and have eating disorder symptoms for a while and then they eat normally, or they do this for a couple of weeks in the summer, then they get over it, or people who have chewing and spitting symptoms, or basically for anyone who has significant pathology, but doesn't meet criteria for the other disorders we've already talked about.

  Yeah. So, this makes me just think about, when I guess a resident is to approach a patient and having some of these diagnostic criteria in mind, right? How would they begin to take a history to get sufficient data to like substantiate a diagnosis?

  Like what, maybe you can give us a little bit of like a, kind of a general approach to taking an eating disorders history.

  Sure, so I think, you know, some of the main points to clarify would be, you know, definitely to get their weight and their height and their BMI to kind of see where they're at, to maybe look if they've had some large weight fluctuations over the last year or two, you know, maybe what's their highest weight they've ever been, what's the lowest weight they've ever been, has their weight been stable, are there a lot of fluctuations? Maybe to do a typical sort of daily food intake about what they eat on a typical day gives you a sense of kind of what their eating is like. Do they engage in symptoms of binging, vomiting, laxatives, dipels, diuretics, chewing and spitting?

  How much exercise do they do? Is their exercise kind of compulsive? You know, do they have a lot of guilt or shame or anxiety with eating?

  Do they spend a lot of their day thinking about issues related to food, weight, shape, body image, binging, purging, et cetera? You know, what are their menses like and, you know, how do they feel about their body image? Do they do a lot of body checking or mirror checking in the day?

  Do they place a lot of their self-esteem onto their body image, right? How would they feel if they were to gain five pounds? I guess, you know, a lot of people maybe wouldn't be too happy to gain five or 10 pounds, I'm not sure if we can catch them all, but someone with an eating disorder would be solely devastated and floored if they were to step on the scale and gain five pounds, whereas most of us may not be too keen on it, but it wouldn't destroy our entire day or our entire week or something like that.

  So those would be some of the main points, and then obviously clarifying some of their comorbid conditions, commonly depression or anxiety or substance or OCD, and then also some of their medical history as well, can be important, especially if you're concerned about someone who's been underweight or having, you know, a lot of binge purge symptoms as well.

  Thanks, Dr. Staab, for going through this with us. One of the questions that I had was related to some of your discussion around how a lot of the patients with anorexia and nervosa experience high levels of denial and resistance related to their illness. And I can see how maybe in treating or assessing some of these patients, you know, the goals of the patient and the goals of the health care provider are kind of at odds.

  And so I was wondering if you sort of have any thoughts about certain strategies that residents might be able to use either in the initial assessment or later on in treatment in terms of engaging these patients in care.

  Sure. I mean, that's the that's probably the toughest or one of the toughest jobs of that I have to do and our team does here at Credit Valley is trying to motivate, you know, trying to motivate someone who maybe doesn't see they have a problem or doesn't really want change or doesn't really want to get better. You know, sometimes I see people in the clinic at the first consultation.

  And the first thing that they'll say, I'll say, you know, hi, I'm Dr. Staab. I'm just going to take your history and, you know, run run through some of these questions. And the first thing that they'll say is, I don't want to be here.

  Right. And I'll say, okay, well, can you tell me why you end up coming? And I'll say, oh, I came here because my mom made me.

  Right. So sometimes just try to roll with some of the resistance and just say, okay, well, you know what, let's just try and get a history today. It's up to you if you want to get any help or not.

  Or if you want to, you know, work on anything or change anything in the future. But why don't we just get a history so that we have a baseline and we have it documented. And then it's totally our choice.

  I think giving them the control, you know, it's totally our choice if you want to do anything about this or or pursue any treatment in the future. So just letting them know, I guess just that you're going to get a history to start off with and that there's no, you know, except in rare instances where you might have to certify someone, you wouldn't say that. But, you know, the vast majority of people eating disorders, you're not going to certify in forced treatment.

  So just letting them know that this is just an assessment, we're just going to get some history to start off with. And maybe at the end, if you can try to try to develop some discrepancy between maybe what are some of their future goals, and where they are right now, and are their current behaviours, and their current health status and mental health status, are they consistent with, you know, going to university and getting a job and perhaps getting married or having kids or being able to travel or just being able to be free and go to a party and eat food and, you know, partake with friends and family and just to try to develop some discrepancies between where they would like to be in five years from now and where they are currently. “You know, sometimes you get people to do certain exercises like writing a letter to their eating disorder or looking at the pros and cons of their eating disorder or, you know, if their eating disorder is working so well for them, would they recommend it to their friend or to their family member or their daughter or if they had an imaginary person with it, if it's working so well for them, is this something they would recommend to everyone?

  Usually the answer would be no, because they often tend to be unhappy and quite miserable and often quite hate themselves deep down. And so they would see, you know, they often tell patients and family members often what we see as being the problem, you know, we see the extreme dieting behaviors and binge purging behaviors and other extreme behaviors being the problem. The patient who suffers from anorexia may actually see those as being the solution to the problem, right?

  So it can be a difficult task to try to bring someone into the light and hopefully change some of these behaviors to become healthier and more moderate and less extreme. But it is a difficult task, just again, similar in some ways to someone with alcoholism or substance abuse, who may not see that they have a problem and, you know, get off my case. I don't need the help.

  It can be a difficult job sometimes to help them get treatment and work towards change. Sometimes it takes people kind of falling on their face and unfortunately having complications or hitting kind of rock bottom sometimes for them to access the help or the care that they need.

  Thanks Dr. Staab. So it really sounds like in cases where, you know, you might not need to certify a patient necessarily reinforcing autonomy and also trying to align some of the patient's goals with the health care provider's goals can sometimes be helpful in terms of engaging them.

  Yeah, even just to get a history, just to say we're just going to do a history today. You know, if you don't want to have your mom come in at the end of the session, it's up to you if they're an adult, right? We don't have to have your mom come in to the session afterwards.

  It's totally confidential. Whether you want to do anything to pursue after this is up to you. You know, we have a lot of different treatment options.

  So you know, we have an intensive treatment option. We'll talk about that later. But you know, there's inpatient care, day hospital care, but there's just some minor, sometimes just some really small little, little interventions like going to an education group or, you know, seeing a dietician a couple of times.

  There are just some very small little interventions that maybe don't involve a lot of change. It just involves education or developing some insight.

  That's really helpful, Dr. Staab. Yeah, thank you. Thank you for walking us through it.

  Can we maybe delve into a bit how eating disorders actually develop?

  Sure. So there's no like one single pathway to developing an eating disorder, right? There's a lot of different, we consider it to be multifactorial, right?

  So there's, you know, there's biological factors, there's psychological factors, there's, you know, family factors and cultural factors. We see, you know, predisposing factors, precipitating factors, perpetuating factors. So we see people who often present with a lot of similar constellation of symptoms, but they all come from different, you know, cultural backgrounds, socioeconomic backgrounds.

  They have had different life histories and different friends and, you know, lots of different experiences often, which again, shape how the disorders come to fruition, so to speak. So I guess we'll start off maybe sort of biologically. The more time I spend in eating disorders, the more sort of like biological genetic factors, how important they become.

  So, you know, if I would have been giving this podcast, let's say, you know, 25, 30 years ago, we probably would have thought more that psychological and socio-cultural factors would have been the most important determinant. But now in 2021, there's a consensus more that really, you know, genetics and biology and neurotransmitters play the most important role, we would say. So people with eating disorders, there's people with anorexia nervosa, I guess we'll start with.

  There's definitely an increased incidence of anorexia nervosa in families where you see higher rates of depression, eating disorders, anxiety disorders, obsessive compulsive disorder and obsessive compulsive personality disorders or styles within the family. You know, there's a very high concordance rate of anorexia nervosa in monozygotic twins. It's about 50% concordance, which is way higher than you would expect in the general population, right?

  In the general population anorexia, thank goodness is still quite rare, right? It's talking maybe 0.5 or 1% of young girls have anorexia nervosa. Whereas if you have an identical twin with anorexia nervosa, your chance of getting it would be about 50%.

  So about 100 times higher for someone with exactly the same genetics. But the thing is, it's not 100% concordance. So there are certain, you know, protective factors that could help a person not develop anorexia nervosa, even if they may have the genetic setup that they would be genetically loaded for, is what I'm trying to say.

  In terms of bleeding of also again, again, more and more studies are proving that genetic factors are really important for bleeding of also as well. There's definitely a higher rates of bleeding of also in families that have also eating disorders, depression, mood disorders, substance abuse and obesity tends to be tends to run more in the families with bleeding of also. And you know, there's more and more genetic studies coming out.

  There's a really big one being done by the Price Foundation. It's a multi-centre site trial. I think they have over like 14,000 samples or something now.

  And they've located a numerous different sort of genetic loci that are of importance, right? So it's not a simplistic thing where, you know, you know, your grandmother has anorexia nervosa, and then your mother has anorexia nervosa. And then the daughter has anorexia nervosa, right?

  It's not a sort of simplistic thing like that. There may be, let's say, hypothetically, you know, 10 or 15 different genetic markers that increase the risk for anorexia nervosa. And then, you know, the roll of the dice, you know, the person develops like, you know, 10 of them, they may be at higher risk of let's say depression, they may be at higher risk of anxiety and perfectionism and low self-esteem and obsessive compulsive features and, and then poor body image and that sort of sets them up, including other life experiences that kind of, you know, shape them into to go down that road.

  That's really interesting. It's sort of it sounds like it's sort of the traits that that lead a patient to go down that path a little bit more easily.

  Exactly. Yeah, for sure. You know, there are some brain differences between people with anorexia nervosa and blemium nervosa and sort of, you know, regular controls.

  There's some interesting work being done looking at the insula and the limbic system. So things that are, you know, I'm not an expert in these things, but there's more and more studies being shown that they're definitely this is a brain disorder, right? This isn't just sort of, you know, a fad that has gone too far or something like that, right?

  There are definitely sort of strong biologically genetically determined underpinnings to both anorexia nervosa, bleeding nervosa and other eating disorders.

  Yeah, we'll talk more about kind of like medical sequelae, but also, you know, there are definitely brain changes that are reflective of malnutrition.

  For sure. Yep. So about 50% of people with anorexia nervosa actually have a brain shrinkage, right?

  And their brains, you know, they have enlarged ventricles and enlarged sulci from emaciation and malnutrition. About half of them will then, you know, half of those then will, when they, with recovery, will normalize again. But about a quarter of them end up staying kind of shrunken down, which is a bit disturbing.

  And we're not sure of the long term sequelae of that. But yeah, I know at SickKids, they were doing CT scans and MRIs of everyone that was going through for a while. We don't routinely do that here at Credit Valley or an adult program.

  Because if we tell people, oh, your brain is shrunken down, they're like, okay, well, what do I do about that? Well, the treatment is to eat the food and to get healthy and get back to a normal weight. So it's not something that we would do routinely.

  But I know that there are research studies that have shown that there are definitely malnourished brain changes that happen with anorexia nervosa, which is kind of scary.

  But I guess, yeah, that's also part of psychoeducation with the patient, which is a way to get them to engage with education.

  Yes, exactly. Because often they tend to be very determined and perfectionistic and have high standards. So realizing when something starts to impair your school, and my brain is shrinking down and my myelin is getting damaged, sometimes that can be a motivator to actually get help and get better.

  Yeah, for sure. So maybe this is a good point to sort of switch gears and then talk about kind of like, I guess, the psychological more of the, I was going to say nature, but I mean, nurture sort of factors that the development of an eating disorder.

  Sure. So I mean, there's a lot of psychological factors that can increase a person's risk of developing eating disorders. So having low self-esteem is definitely a risk factor.

  Often people with eating disorders have low self-esteem and low feelings of control and a perceived lack of autonomy. Often they have issues with sexuality, a lot of depressive and anxiety symptoms often that come up in their teenage years. Sometimes in the family, we see certain sort of characteristics sometimes in patients with eating disorders.

  So often in the families, there may be sort of like a lack of feeling of safety or a lack of acceptance or validation. They may feel that there's sort of a lack of conflict resolution in families or sort of low expression of emotion in families with anorexia nervosa. Sometimes there can be kind of enmeshment that you might see, particularly, I guess, in adolescent kids with eating disorders.

  Sometimes you see sort of poor boundaries between parents and child and often sometimes families that can be kind of rigid and very black and white, that can reinforce that sort of black and white all or nothing thinking that you might see with both anorexia and bulimia. Sometimes in families you see sort of an over concern with weight and shape within the family that the mother is always dieting or there's pressure to lose weight all the time. Again, perfectionism within the family is quite common and there is a higher rate of early childhood sexual abuse in anorexia nervosa and bulimia nervosa as compared to the general population, right?

  So a woman or a child who's been, you know, damaged or who's been sexually violated may turn to an eating disorder as a way of protecting herself or may have a way of appearing less feminine or less sexually attractive. You know, dieting or bingeing and purging may be a way of numbing painful emotions or PTSD symptoms or flashbacks or it may be a way to kind of control the body, purify the body or kind of punish her her body.

  Yeah, for sure. I see a lot of this comorbidity on the women's inpatient unit. I work with women with trauma and there's lots of comorbidity with eating disorders and that's exactly it.

  Like, you know, starvation almost allows them to kind of dissociate, right? And so they're not able to recall their trauma or cognitively participate in therapy, which is really disturbing for them because it evokes a lot of these memories.

  Yes. I mean, unfortunately, fortunately or unfortunately, eating disorders do serve a lot of functions for people, right? And so, you know, with people with PTSD or trauma histories, it does, it can help to regulate emotions.

  It's almost a way of like self-harming. It can calm people down. It can decrease nightmares and flashbacks and dissociations.

  And then when people are in the refeeding process, unfortunately, some of the, you know, some of the nightmares, flashbacks and memories that have been numbed out or suppressed can start to come back. And that can be quite an unpleasant experience for a lot of people going through recovery. So again, that's like, that's one of the hard jobs of recovery is working on other coping skills to deal with the trauma, the abuse, the emotions without using your eating disorder as a crutch to get through.

  Yeah, exactly. I feel like, you know, giving them a set of new skills and helping them practice them allows them to replace these maladaptive coping strategies with healthier ones.

  Yeah, for sure. That's so important on the road to recovery.

  And I guess, yeah, so we talked kind of about cultural factors and then also, you know, definitely some occupations, right? And, and activities like cheerleading or gymnastics, you know, elite athletics that can also sort of perpetuate a risk of developing an eating disorder.

  Yep, yep. So definitely there is something in, you know, sort of, you know, our first world sort of westernized culture that increases the rate of eating disorder. So there are higher rates of eating disorders, you know, in Canada, United States, in Europe, than maybe in some less developed countries in Africa or some other places in the world.

  And so I guess it often relates to the rate of dieting. So, you know, not necessarily, you know, I guess the more people that diet, the more people that will eventually take it to an extreme and will develop eating disorder, right? If we lived in a culture where nobody dieted, right, and it was kind of frowned upon, there would be much less rates of eating disorders, right?

  Because there wouldn't be this cohort of people that again, then take it to an unhealthy level and become obsessed with it. So people that move, let's say from a lower developed developing country from Africa or from certain parts of Asia or South America to a developing a developed country, their rates of eating disorders increase then to the country that they migrate to. And then definitely, there are certain professions, you know, acting or gymnastics, ballet, you know, jockeys and men, anything where there's a strong emphasis on weight and shape and being thin to maintain your job or your career, where there's a lot of pressure, then obviously it's going to increase the rates of eating disorders.

  And it also makes me think about like onset of an eating disorder. It's typically in young like an adolescence.

  It does you typically so anorexia. Typically the onset is between about 12 and 20 years old during the adolescent teenage years. But like I said before, it's 10 times more common in women than in men.

  We're bleeding of all sets, usually more in the later teenage years and early 20s. And again, much more common in women than as men as well.

  And what are your thoughts Dr. Staab on kind of this correlation with adolescence? Is it because of puberty? Is it about self-identity during like, why is this sort of a vulnerable time to develop an eating disorder?

  I mean, we don't know for sure, but it is it is a time of a lot of transitions, right? So, it's a time where autonomy, where, you know, autonomy and control goes more from the parents to the teenagers, the teenagers are making more decisions around their clothes or their hairstyle or their friends or their hobbies or whatever. And that can be a difficult negotiating, you know, time to negotiate for kids.

  You know, there's hormonal changes happening at that time. There are increased rates of depression and anxiety and substance abuse around the same time as well. So any type of big change, again, for someone who's maybe very kind of rigid, controlling, you know, maybe can come across as being a bit willful.

  Sometimes it can be hard to go through a big massive change, right? So one big massive change is going through puberty and adolescence. And then another time with another big spike with eating disorders is when people finish high school and then decide to move away from home or go to college, university.

  That's also another time when we see a spike in eating disorders, probably related to all the changes that happen, people then being more independent with their eating and having less supervision. So I don't think we know for sure 100% why, but I think those are some theories about why it tends to occur predominantly during the teenage years. It's not always then, I have to say, though.

  We do see people that develop eating disorders in their 20s and 30s. So it's not absolutely in the teenage years, but that tends to be the highest risk time. I think one thing I'll just say as well is, so we talked about a lot of predisposing factors.

  So in terms of precipitating factors, any type of change or stress or loss, can often see that triggers the on-seminary disorder. That could be sometimes a really big stressor, could be sexual abuse or rape or something like that or molestation, or it can be a lot of stresses that just pile up, like maybe not doing as well in school on an exam, or being shunned by some friends, or some teasing or bullying, or a move or a divorce in the family, or other stressors that pile up that lead the person to feel out of control, or that they may try to latch on to something to try to desperately feel more in control, and try to feel like they're to boost their self-esteem. Unfortunately, it's not a good long-term solution, of course.

  I think the thing that's important to remember as well is eating disorders do occur in all cultures, in all countries, in all socioeconomic status levels, and all professions, right? Because sometimes there's a bit of a stereotype that, you know, anorexia only occurs in white, wealthy, you know, perfectionistic upper class people or something, which is not true, right? So we see anorexia and bulimia in all different ethnicities and cultures and sexualities and socioeconomic status in all different countries, right?

  “So even in countries in Africa or the Middle East or Asia where thinness is not viewed as an ideal, where it's actually considered to be kind of maybe unattractive or kind of ugly, that eating disorder still exists, right? Even in, you know, places where, you know, Bedouin tribes in the Middle East, where people have never seen one television show or one Hollywood movie, they've never seen one Vogue magazine or any, they've had no exposure to Western culture one bit, they're living, you know, in a tribe somewhere, their eating disorders still happen, anorexia and bulimia. So it's not, there definitely are, you know, biological factors that happen outside, completely outside of other socio-cultural factors.

  That's really interesting, Dr. Staab. And, you know, I think that's great for us to kind of keep in mind. So, you know, that when we're approaching a patient, you know, irregardless of how they're presenting, like, you know, we should ask about eating disorders and we shouldn't discount someone just based on, you know, how they appear.

  For sure, definitely. Yeah. And the majority of people with eating disorders are normal weight, right?

  So I think that's important to also remember that, you know, people with anorexia nervosa are obviously underweight, but the majority of people with eating disorders in the world, right, which would be, you know, bleeding nervosa, binge eating disorder, and other specifying disorders, most of them are either, you know, normal weight or above average weight. So the majority of people are not underweight. So that's also important to remember.

  Yeah, and I'll say like, I also do just general, you know, outpatient consultations and assessments. And, you know, prior to maybe my elective with you, I probably wouldn't have regularly asked about eating disorders. It's a lot more common than the people might think.

  You know, I would say. So always have your antenna up for sure, you know, with like, you know, younger teenage girls are in their 20s. But keep your antenna up all the time for everyone.

  But I think even more so in when you see young females who are struggling with, you know, body image or self-esteem, depression, anxiety, et cetera.

  OK, so why don't we move on to some of the medical medical and physical complications of eating disorders?

  Sure. So, yeah. So eating disorders can affect, you know, every organ system, every part of the body from the top of your head down to the tips of your toes, from the effects of starvation and or bingeing and purging.

  So it's important to remember that even when people have normal electrolytes or a normal ECG or normal vital signs, that they still could be suffering quite a lot and be at quite a high medical risk. Because sometimes things can happen suddenly out of the blue and people can still die even with normal, you know, supposedly normal testing. So just, I guess, starting off with the cardiac system.

  So, you know, when the body, when the human body is starved or malnourished, it tends to focus calories and energy on the things to keep you alive, right? So other things in the body tend to get a bit neglected. So things like your skin or your hair or your fingernails or teeth or things like that tend to get neglected, where it tries to focus energy on like your heart and your liver and your brain, things like that.

  When people are malnourished, the body tries to conserve energy, your metabolism slows down, right? So your heart rate slows down, your blood pressure slows down, which is great to conserve energy. But if it becomes too low, you can start to get symptoms, right?

  So you can get low blood pressure, can lead to dizzy spells, fainting spells. People can get like chest pains. If your heart rate becomes too low, it can lead to really deadly arrhythmias, again, fainting spells or dizzy spells or even cardiac arrest.

  The effects of purging in combination with being underweight and having a low heart rate can be really deadly. That's actually the number one cause of death in eating disorders, is from cardiac abnormalities. The highest risk of death is actually people who are underweight who are also bingeing and purging as well.

  Often people get edema, which can either be due to heart failure or typically, if they're dehydrated for a long period of time from purging, and then they stop purging, let's say if they come into a program, they can have rebound fluid edema because their bodies are hanging on to fluids because they have aldosterone or antidiuretic hormone circulating in their body for a few weeks, or from just generalized protein malnutrition. They can have low hemoglobin, low red blood cells, low white blood cells, low albumin, just low protein in general, can lead to edema because of fluid and electrolyte disturbances. Then moving on to the endocrine system.

  Again, most hormones go down when people are malnourished or starving themselves. Eastergene, progesterone, testosterone, right sex hormones go down, which can lead to either irregular menstrual periods or complete cessation of their menstrual periods, which puts them at risk of things like osteoporosis or osteopenia can lead to bone loss. It's kind of like the body's protective mechanism in the body.

  So it's kind of the body's way of saying like, you know, this woman is not healthy enough to get pregnant or to carry a pregnancy to full term. So we're going to kind of like shut down the whole thing to preserve energy to not lose blood, which is in short supply, lose protein. So it's kind of the body's protective mechanism to prevent a pregnancy.

  Having said that though, we always tell people even if they haven't had their period in a long time and they are sexually active, that they still should use some type of birth control because sometimes accidentally, you know, an egg can just kind of pop out and can get fertilized. So I have seen that a couple of times in my over 20 year career where people have not been menstruating for long periods of time and they're being sexually active and they accidentally get pregnant. And if you do get pregnant in the middle of an eating disorder, it's not a great idea.

  So there's definitely, you know, higher rates of pregnancy complications, premature babies, low birth weight babies, lower APGAR scores. There's more C-sections and more stillbirths. So definitely not a great idea to get pregnant in the middle of anorexia nervosa or bulimia nervosa.

  We always tell people when they finish our program, when they finish our day program, that if they can, to try to wait at least a year after they finished our day program to repair the damage they've done to their body, hopefully. And also just psychologically to get more settled and feel more comfortable with their body image changes. So people with anorexia nervosa sometimes have to gain 20 or 25 pounds in our program to get to a healthy weight.

  And then the average woman when she's pregnant may gain another 25 or 30 pounds, which can be very difficult and unsettling for someone with anorexia. So we usually try and get them to weight a year so their body image kind of feels a bit better. They feel a bit more settled.

  They've had some redistribution before they try to get pregnant. When people have recovered from their eating disorder, so they get to a decent weight, they stop symptoms of binging and purging or laxatives and excessive exercise, their fertility does go back to normal. I think that's important for patients to know and doctors, that they haven't permanently damaged their ovaries or their fallopian tubes or something.

  That is reversible and their fertility will go back to normal for a woman of their age, right? That's important for people to know.

  In terms of the thyroid gland, so often people's thyroids will kind of shut down when people are malnourished or very emaciated and underweighted. It's kind of the body's protective mechanism to lower their metabolism, to lower your thyroid, so that you decrease sort of energy expenditure to kind of conserve energy. And then again, with refeeding and weight gain, often their thyroid levels will just return to normal.

  So it's not something that you need to treat with Synthroid or thyroxine or something like that. Again, that would actually increase their metabolism and lead to more weight loss. And it can be a medication that can often be abused by people with eating disorders for weight loss purposes.

  So it's definitely not something we want to give to people when they're in the middle of their eating disorder.

  And this also just makes me think of patients with type 1 diabetes and like, I guess, omitting their use of insulin, right? As a way of losing weight.

  Yeah, that's a big problem. So it's such an easy way to lose weight, right? You can eat whatever you want and then just not take your insulin and spike your sugars really high and not absorb the food or the glucose.

  It's very deadly, right? It's a very deadly practice, but we do see this on our clinic quite a bit. Right now in our intensive program, we actually have two patients with type 1 diabetes.

  Patients with type 1 diabetes have much higher rates of eating disorders than the general population because it is such a quick and easy way in some ways to lose weight. Again, very deadly, very dangerous, but very difficult for some of these patients to give up.

  Interesting. And then I guess something that's been always counterintuitive to me that sometimes in extreme starvation states, like the cholesterol levels could be high.

  Yeah, which is quite unusual sometimes, right? So sometimes again, from starvation can put a bit of a strain on your liver and it can actually churn out more cholesterol. So sometimes people are very emaciated, very underweight.

  They're not, they wouldn't touch a steak or a fatty food to, if their life depended on it. And they're eating like a lot of fruits and veggies and whatever, but they can have high cholesterol from their liver kind of churning out excessive lipids and cholesterol and fats. So just moving on in terms of different systems.

  So muscular skeletal system, again, so muscle wasting again from protein, malnutrition, excessive exercising, and again, bone difficulties. Most of the medical complications that I'm gonna talk about today are reversible, which is the good news. Unfortunately, bone problems like osteopenia and osteoporosis are often not reversible.

  So usually for people who are, let's say, above the age of 30, it can be quite difficult to actually improve your bone mineral density. Even if people make a full recovery, they get to a good healthy weight and their periods come back. Sometimes it can be quite difficult to increase your bone mass after the age of 30.

  I've seen younger patients, you know, when they're teens and twenties, who've gone from osteopenia, osteoporosis back to normal, right, they get to a healthy weight, their periods come back and then five or six years later, we test their bone density and it's actually normalized, which is amazing, it's a miracle, which you would never see in an older woman postmenopausal. But it can be quite difficult for patients to do that in the 30s and 40s to really improve their bone mass. You can prevent further deterioration, which is a good motivator, but sometimes it can be hard to increase their bone mass.

  So yeah, often these patients, the risk factors for osteoporosis are being at a low body weight or being at a low BMI, not having your period for more than six months, having a low dairy intake, having low calcium and vitamin D intake, being Asian is a risk factor. Obviously nothing you can do about that, right? Having a family history puts you at higher risk, having low protein intake.

  And then some of the things that you can influence would be like your caffeine intake, right? Caffeine is not good for bone mass or alcohol intake. Alcohol or smoking or steroids as well can be damaging to bone.

  So trying to minimize other exposure and other risk factors where possible.

  Okay, maybe move on to the gastrointestinal system.

  Right, so there can be a lot of GI complications with eating disorders. So in general, people with anorexia have also had very slow gastric emptying. So slow stomach emptying, which can lead to like nausea, bloating, cramping, fullness, burping, gas, you know, so it can feel quite uncomfortable when they're trying to refeed and trying to eat a bit better because they get all these GI symptoms all the time.

  So just normalizing eating will eventually normalize that. So just eating proper breakfast, lunch, dinner, snacks, eating properly for a couple of weeks or months will eventually hopefully normalize their delayed stomach emptying. There are some medications that we sometimes prescribe that may help a bit with that, like Domperidone or Metoclopramide can sometimes speed up gastric motility.

  Constipation is very common with both anorexia nervosa and bulimia nervosa from not enough food intake, or it can be from laxative abuse, can make the bowels kind of lazy. So that often again normalizes just by proper eating again. Sometimes we give them things like a fiber supplement or coles or a stool softener or laxadate to kind of get them going.

  We don't recommend any purgative laxatives in people with eating disorders. So we don't recommend, you know, X lax or Senacot or Correctol or, you know, those typical kind of like life brand generic ones, anything with Sena because they can make the bowels a bit lazy when they're abused. And often these patients take too much of them for the feeling of weight loss, right?

  They do not, laxative do not cause real weight loss. They just cause a lot of water and feces and salts, but you're not actually losing real weight, right? So that's important, I think, a distortion often to correct with these clients.

  And then again, from chronic purging that you would see either with anorexia or bulimia can lead to damage to your esophagus, it can lead to ulcers, it can lead to erosion of your gums and your teeth, damage to your enamel. If people have chronic vomiting for many, many years, they can actually get a condition at the base of their esophagus called Barrett's esophagus, which is like neoplastic changes to the cells in the base of your esophagus, which can actually lead to cancer, which can obviously lead to death, right? Which is very disturbing.

  I've seen a couple of patients who've had that. They were chronic vomiters for 15 years or something like that, and then they developed this other disorder, which was sad. Yeah, and then just chronic malnutrition and bingeing and purging can place a strain on your pancreas, right?

  It can lead to pancreatitis, it can lead to hepatitis. And I've seen gallbladder problems again from weight fluctuations and from chronic malnutrition and bingeing and purging, gallstones. That's great.

  So I think we already talked a little bit about the neurological system and the impacts in terms of the enlarged ventricles and the myelin sort of wasting, anything else within the neurological system?

  So just commonly, people often get headaches quite commonly, low blood sugars again can lead to sort of brain fog or even seizures, numbness and tingling quite commonly, or muscle spasms from electrolyte disturbances, low potassium or low magnesium or low phosphate can lead to that. Yeah, and just again, just poor memory and poor concentration, just feeling like your brain is kind of in a fog because of lack of nutrition, lack of glucose or poor, you know, low blood pressure, low heart rate. And then moving on to the kidneys.

  So again, either the extremes can cause kidney damage. So dehydration can lead to kidney problems or over-hydration. Sometimes patients will drink, you know, liters and liters of like, you know, six liters of water a day and two liters of coffee.

  And that can lead to damage or diuretics can lead to kidney damage. It can lead damage the kidney's ability to concentrate urine, can lead to kidney stones, and then other sort of dermatological problems. So again, skin can become very dry and flaky, can lose its kind of like elasticity.

  People can get kind of color discolorations to their skin, more bruising and bleeding to their skin. They can, you know, their nails become kind of brittle and cracked or their hair becomes dry and get more split ends. Again, just from lack of nutrition, you know, the things like your hair and nails and skin kind of get neglected and don't grow as fast and more of your hair cells go into like a dormant stage.

  So they get more damaged. And then those things, again, all of those things kind of reverse with hopefully proper eating, getting to a proper weight and stopping bingeing and purging. Yeah.

  And Dr. Staab, thank you so much for going through all that. I think this is all important because I think this is sometimes information we can present to a patient. They are sometimes fully aware of the impacts of longitudinal impacts of their eating disorder and how it's actually affecting their health and their body.

  Yes. And sometimes this can be the motivating factor to get them in the door for treatment, right? So you know, they may be sort of, you know, in denial for years.

  And then all of a sudden they, you know, slip on some ice and they break their pelvis, right? And they're 30 years old and the doctor tells them they have severe osteoporosis and they can't believe it because they had no idea, right? Or they, you know, are walking down the street and have a seizure because their blood sugar is one, right?

  You know, we've seen these things happen and then people hopefully get more motivated and have some more insight to get some help of, you know, before some major catastrophe happens that's not reversible, right? So hopefully.

  And I guess just very quickly going back to my law, my previous question that I kind of banked for this would be just, you know, what would be typical blood work that you would do when you have a patient that you're suspicious of having, you know, an eating disorder?

  Sure. So we do a pretty broad, a broad array of blood work here at Credit Valley. So we do a CBC quite typically, right?

  Extracting sugar or random sugar, you know, electrolytes, CK, we often measure to kind of look at their muscle breakdown of people are exercising like maniacs. Sometimes that's really elevated liver enzymes we commonly do. We often check their iron, their calcium, magnesium, phosphate.

  They can be low or they can also be influenced by refeeding syndrome. We often check their amylase. Those would be, I think, the main things that kind of stand out that we check here, B12.

  Extracting sugar or random sugar, you know, electrolytes, CK, we often measure to kind of look at their muscle breakdown of people are exercising like maniacs. Sometimes that's really elevated liver enzymes we commonly do. We often check their iron, their calcium, magnesium, phosphate.

  They can be low or they can also be influenced by refeeding syndrome. We often check their amylase. Those would be, I think, the main things that kind of stand out that we check here, B12.

  And I guess thymine.

  Thymine, yeah. And again, we often test thyroid levels as well. If their thyroid comes back low, we don't jump the gun and recommend treatment.

  Again, if we have to like you treat people, you treat the individual, you don't treat their blood tests, right? So you don't just treat low, you know, an elevated TSH or something. You have to you have to treat the individual.

  And just quickly for audience members that aren't aware about of of refeeding syndrome, you know, quickly from my understanding, it's you know, when a patient's been starved for a long period of time, and they suddenly have a surge of sort of caloric intake, the body produces a lot of ATP, and it could use up a lot of phosphate, and that could cause a plummet in phosphate, which could lead to, you know, rhabdomyolysis, coma, seizure.

  Yes, yes, it's a very, it's a rare but very, it's a life threatening constellation of symptoms, syndrome. So just like you, just like you said, Lucy, so when people have been starved for a very, very long period of time, their bodies stop using sort of glucose as the primary energy source, and they start to use more protein and fat, which is not supposed to be the case, right through ketogenesis. And then if they come into a program or they go somewhere and they start eating better, their bodies have more glucose, they get this surge of insulin, and their body is trying to repair itself.

  So they have a dramatic increase in the need for things like phosphate, magnesium, potassium and calcium, and they get kind of like sucked into intercellularly. And you can get a big drop in phosphate is the primary indicator, but also you can get a big drop in magnesium and potassium as well. So you need to check their electrolytes pretty frequently when they first come in for reheating, especially if they're really emaciated or on the feeding tube, or they could be at high risk of repeating syndrome for the first couple of weeks.

  So you want to monitor that pretty closely. It's usually treated quite easily by giving them supplements. In severe cases, you might want to reduce their caloric intake a bit, and maybe even shift some of their calories more to protein and less a little bit with carbohydrates.

  But it's usually, as long as it's recognized early, and it can be treated quite well.

  This brings us to the end of part one of our Eating Disorders episode. Listeners stay tuned for part two, which will cover eating disorder treatment. PsychEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Dr. Lucy Chen, Dr. Vanessa Aversa and Dr. Nikhita Singhal. The audio editing was done by Drs. Vanessa Aversa and Nikhita Singhal, and the show notes were completed by Dr. Vanessa Aversa. Our theme song is Working Solutions by Olive Musique.

  A special thanks to our incredible guest, Dr. Randy Staab, for serving as our expert for this episode. You can contact us at psychedpodcast.gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

Episode 35: Pain Psychiatry with Dr. Leon Tourian

• Episode 35: Pain Psychiatry with Dr. Leon Tourian

  Nima Nahiddi: [00:00:09] Welcome to PsychEd, the psychiatry podcast for medical learners by medical learners. In this episode, we'll be exploring the psychiatric aspects of chronic pain medicine. I'm Doctor Nima Nahiddi, a pgy3 at McGill University, and I'm joined by Doctor Sarah Hanafi, a fellow pgy3 at McGill.

  Sarah Hanafi: [00:00:28] Hi everyone.

  Nima Nahiddi: [00:00:29] And Audrey Lee, a fourth year medical student at McGill.

  Audrey Lee: [00:00:33] Hello everyone.

  Nima Nahiddi: [00:00:34] We're grateful to have our guest, Doctor Leon Turian this week to share his expertise. Doctor Turian, if you could introduce yourself.

  Dr. Leon Tourian: [00:00:41] So I'm Leon Tran, I'm a psychiatrist at the Munk, and my branch of speciality, where I spend the vast majority of my clinical time, is as a pain psychiatrist at the Allen Edwards Pain Management Unit at the Munk.

  Nima Nahiddi: [00:00:57] Thank you so much for joining us, Doctor Tour. And we're so happy, uh, that you took the time to be here with us today.

  Dr. Leon Tourian: [00:01:04] Thanks for inviting me.

  Nima Nahiddi: [00:01:05] During today's episode, we'll touch on several learning objectives. First, we'll explore the world of psychiatry in the management of pain. Then we'll discuss the epidemiology of psychiatric comorbidities and pain disorders. We'll outline the pathophysiology of pain and its relationship to psychiatric disorders. We'll outline the role of non-pharmacological management and treatment of pain. We'll discuss a general psychopharmacology approach and management of pain relief and psychiatric comorbidities with chronic pain. And finally, we'll discuss the intersection of pain medicine with somatic symptom and related disorders. So to begin, Doctor Turian, can you explore the role of psychiatrists in the management of pain?

  Dr. Leon Tourian: [00:01:55] So that's a that's a fantastic question. So in essence, I think, um. Psychiatry has a very central role to play in pain management only by virtue of the comorbidity between psychiatric illness and chronic pain. So the main goal of psychiatry in the care of patients with chronic pain is actually decreasing the burden of mental health disorders in chronic pain to actually increase the prognosis of pain patients and their outcomes in pain. So the way I explain it to patients is you say, you know, you have pain. Pain causes depression. Depression increases pain. And so, you know, in mental health, we're very good at trying and supporting our patients in the treatment of depression and anxiety. And essentially that improves their outcomes, decreases, you know, decreases their morbidity and mortality related to pain and basically leads to a better quality of life.

  Nima Nahiddi: [00:02:59] Is there a difference between, uh, you know, the role of someone who's working in general practice and perhaps someone who's working in a multidisciplinary pain management team?

  Dr. Leon Tourian: [00:03:09] So that's an excellent question, because I think from a training standpoint and from, uh, I think, you know, uh, family, med residents and family medicine training and even in psychiatry training, I think that the exposure to pain is very limited. Um, I think there is very little exposure to pain training for trainees. Um, and so if you don't if you're not trained in it as a resident and if you don't practice in it in any shape or form, I think you develop what everybody develops in terms of their concerns about managing chronic pain patients, which is a phobia and a kind of a stigmatisation because they're complex. Uh, the medication lists are long, the complaints are long. And I think, um, the main, the main barrier for, for patients, for pain patients is the fact that if you're not kind of exposed to it on a regular basis and have a support team around you, it becomes very difficult to treat these patients because the needs are great. Um, and so I think the I think if I was a general psychiatrist treating pain patients, I think I would feel very overwhelmed, um, if I didn't have my colleagues in the pain unit at the pain unit, you know, it's a multidisciplinary, interdisciplinary approach.

  Dr. Leon Tourian: [00:04:22] Um, and I think we support each other because this population has a lot of needs. Um, and the, the. Yeah, I can't even there's no way I could express it more than that. It's just, uh, doing it alone. It would be impossible. Um, so I find that I have a lot of respect for folks that are not in, in tertiary care areas, uh, managing pain patients and even in tertiary care areas. There's not a lot of psychiatrists managing these patients. Um, so I think one, you know, there's a bidirectional vulnerability in our health care system. Uh, so I think, you know, it's not it's kind of peculiar that, you know, there's only one psychiatrist right now in Quebec that, uh, uh, devotes most of their time for pain. And that's me. And now I'm very happy to say I have a psychiatrist who graduated last year who's, uh, visiting us from Quebec City, um, and who's, uh, seeing a bit of what I do. Um, but it's, you know, it's a tough crowd. So you need help. I guess that's where I put. I'll put it.

  Audrey Lee: [00:05:20] Um, I wanted to go back to something that you had touched on Doctor Turian about this mental health burden that we have in these chronic pain patients. So when I was looking at the existing research, a lot of it talks about how psychiatric disorders and pain disorders both overlap and interact with one another. And, you know, given this dynamic, you had mentioned depression. But are there other psychiatric comorbidities that we frequently encounter in patients with chronic pain?

  Dr. Leon Tourian: [00:05:46] Absolutely. So one that we one that we don't often talk about is anxiety, you know, generalised anxiety disorder, um, which is as deleterious in terms of outcomes in chronic pain as depression is. Ptsd is another one that comes up. And obviously, I'm very I'm very careful to approach the substance use issue because a lot of it is, you know, there's a there's a part of that that's very oestrogenic, um, it's a part that we've created, unfortunately, uh, by not not by any virtue of any fault or anything, it's just by virtue of not having enough tools and suddenly, you know, you have a patient who's on long terme opioids dealing with the effects of that, but also needing those opioids to function. So I would say that, yes, substance use issue is um, uh, is an issue, uh, in terms of our population and uh, it is something that is a bit of a, it's a delicate kind of topic because, you know, I think it's a very small proportion of patients that we treat that have long terme, you know, chronic pain that actually have a bonafide, uh, opioid use disorder, if you will. Uh, but, you know, part of the part of the physiological dependence that they've developed is just by virtue of the nature of the medications that we give them, um, and by virtue of poor pain control, not because we haven't explored other medications, but they just don't work. So you load up on opioids, opioids, you know, they work. If you load up more, your pain signals go down. And but you create a problem, right? You create a problem for these patients, unfortunately.

  Audrey Lee: [00:07:19] Thank you for taking the time to kind of explain that aspect of pain psychiatry. Yeah. Are there certain pain characteristics, for example severity or duration of the pain that affect prognosis of of psychiatric comorbidities for the patient?

  Dr. Leon Tourian: [00:07:34] Um, that's an excellent question. So I think there's a few ways to answer that question. So again we mentioned, you know, I think it's the most the most significant emphasis I could put in, in answering all of the objectives that you have for this podcast is as long as you remember that there's a bidirectional relationship between pain and psychiatric comorbidity, namely depression and anxiety. Uh, but any of them, in fact, um. I think that the more comorbidity you have on one end or the other, so the more medical comorbidities that you have, uh, the higher the risk and the more complex the depression. So, um, I think I would answer the question by this way, is that I think that it's just a question of balancing out. So it's just a question of accounting for how many medical comorbidities do you have? And the more you have, the more the heightened risk you have of developing depression, because individually, most medical illnesses that we know have a bidirectional relationship with depression. So you add those on and essentially you add on to the difficulty of treating depression. Uh, the difficulty of actually getting a like a response and getting closer to remission. So the more medical comorbidity you have, the more difficult it becomes to treat depression and vice versa. So I guess, yeah, I would respond that way to kind of oversimplify very complex interactions.

  Audrey Lee: [00:08:56] So you're kind of talking about, um, the load of, of more having more conditions and how that affects, um, psychiatric comorbidities. But are there also any specific pain conditions that are associated with a higher suicide risk?

  Dr. Leon Tourian: [00:09:11] So I think I'd answer it by not by identifying a condition, but identifying, um, how well they respond to pain management. Um, so I think, you know, there's many different pain diagnoses, I think for myself anyways, from a clinical standpoint, uh, you know, chronic regional pain syndrome remains the toughest one, uh, to be very frank. And then essentially, we have certain, you know, degenerative, uh, disorders, uh, you know, whether it's degenerative disc disease or rheumatoid arthritis or the whole, the whole dossier of fibromyalgia, um, become, you know, become potentially, uh, challenge to treat. But I think it's the response, if you have a positive response to treatment, then, you know, even if you have a very serious diagnosis, then your, your, you know, your prognosis will be good. I have patients who, you know, they the the pain is so intense. But, you know, they've kind of adhered to non-pharmacological and pharmacological methods of treatment. And they're doing well. But they have a lot of pain. They just, you know, they have function. Uh, whereas others, you know, uh, even despite their best intentions, uh, the pain is so unsurmountable that it, you know, it does impact quality of life. Um, and it doesn't allow them to function. So I guess it's not one diagnosis that will make it bad. It's actually how the patient copes with it. As you know, with everything else that we know in mental health. Right. Uh, but in pain, I think I've seen the worst pain diagnoses and the severity. And some patients do good and others not.

  Sarah Hanafi: [00:10:43] Thank you for that, doctor. Torian. Um, I was hoping we could take a bit of a step back. I know we've been, you know, talking about this overlap between chronic pain and psychiatric disorders, thinking a little more along the lines of aetiology, though. How do we explain this, this link at a biological and psychological level?

  Dr. Leon Tourian: [00:11:05] Uh, okay. So that's a that's a fantastic question. And the overlap and the from an ideological standpoint is very interesting. Uh, this is a massive oversimplification of a very complex relationship between these. But if we really want to bring it down to the basics, it's essentially is in our brain, you know, our regions that control pain, the regions that control, uh, mood and anxiety. So depression, anxiety, uh, mood in general and cognition actually are. The same regions. And there is a theory that kind of puts this all together. It's a limited resource theory. And it says that essentially if you override, you know, your electrical circuits. So if these three functions pain, mood and cognition are on one breaker, if you overload one of them, the other ones will decrease and become more vulnerable. So think about it. If you look at and this is this is really helpful for patients when you explain it this way. And it's very helpful for whether students or residents to understand because they see patients with pain and they don't understand why it is that they're complex. And it is by virtue of just wiring. Um, if and again, massive oversimplification. So look at it from the perspective of pain. So you have a lot of pain and essentially your two other circuits mood and cognition. Uh, basically they're more vulnerable. What are the most common complaints from pain patients. You know, they the depression is at the forefront and cognition is as well. And essentially, if you look at the group, the age group that has chronic pain, uh, in its preponderance is really, you know, you're looking at the age group of 40 to 60 year old, uh, patients and they'll start thinking, oh, my, am I getting demented or, you know, am I why am I forgetting things? Um, so you've loaded up on pain.

  Dr. Leon Tourian: [00:12:54] That's how you explain the two other symptoms. But the explanation works for, uh, from a psychiatric perspective, to look at folks that have depression, you load up that circuit, you that kind of that electrical circuit is loaded up. We know that in depression, people present with physical pain and they present with cognitive complaints as well. So I did this whole this whole kind of, uh, circle to explain that. But in fact, that's what it is. That's why these, the, these are intertwined so intimately. And if you look at it from an evolutionary standpoint, it makes sense. These three functions of are, you know, of our being is need to be interlinked because, you know, way back we always use that example, you know, when, uh, you needed basically to be very aware, if you were injured, to mobilise your mood, mobilise your, you know, your organisation to take care of your wound. The problem now is, is that before that was, you know, very primitive kind of, you know, functioning people barely lived until 30 years old. Now we're leaving until 90 years old. And so dealing with these chronic issues is not exactly how the brain had intended this to be. Uh, initially that connection was meant to be very appropriate evolutionarily, now somewhat problematic because the signal is chronic, whereas before it was not.

  Sarah Hanafi: [00:14:17] Now that makes a lot of sense. And I guess thinking a little more along the lines of psychological frameworks, I you know, I understand there's the fear avoidance model of pain. Could you speak a little bit to that and how that links psychiatric comorbidities and pain?

  Dr. Leon Tourian: [00:14:34] Sure. So, um, obviously the way I kind of present it when we have learners at the pain clinic is really basing ourselves on the biopsychosocial model. Right? So in terms of from a psychological perspective, there's many theories. There's, you know, looking for solution, the harm like movement avoidance like so kinesiophobia develops. Um, and then there's, you know, the, the exterior like, so the locus of control where it's located. Uh, whereas if it's very external, that becomes a problem as well. Uh, so from, in terms of some of the basic tenants, you know, in terms of, uh, pain and pain management, uh, base ourselves on these tenants. So one of them being essentially looking for, um, avoidance of movement in terms of harming self, that's a huge, uh, that's a huge cognitive distortion that pain patients have, because in essence, they've lost control over their body and they are convinced that, uh, minor movement or any movement might harm them. Because you have to remember, some of these folks did, you know, got injured with a very basic movement, uh, at the source of it. Whereas we know that movement is actually key to, uh, you know, um, improving from a pain standpoint. Um, and then we have, you know, folks that look for, like, solutions in pills. Um, they think that the solution is only medication or treat a given treatment. Um, and then we have folks that, you know, really focus on somebody else managing them because they, they invest themselves in a sick role that is very much not involving them in the in the care process and not taking over, not taking over their own care.

  Dr. Leon Tourian: [00:16:10] And I guess taking a step back to that, I think the main, the core element of pain management from the psychological perspective is actually taking over, you know, taking over that loss of control that people with chronic pain have. So, in essence, you know, if you remember the last time, you know, you're injured yourself and the experience that you had, you felt like you needed to mobilise yourself, but you knew that it was for a short period of time. Whereas chronic pain patients. They know that they're in this for the long haul. And essentially, depending on their psychological framework, when they, you know, when they're injured and they start trying to manage that is that there's a loss of control. Um, and they've lost control over their body, and there's a signal in their body that keeps basically interrupting their functioning. And so that leads to essentially pathways that could be either very healthy or not. And when you start going out too much of yourself and looking for, you know, solutions with different, you know, wanting to find a diagnosis, wanting to find the right pill. Right. You know, wanting to find the right intervention, um, and or avoiding, you know, movement or avoiding, you know, activity. You get yourself into, uh, more precarious situations. And that's when you benefit from a multidisciplinary team like the one we have to kind of break those fears down, explore what their reasons is and, and kind of get outcomes better.

  Sarah Hanafi: [00:17:38] I'm glad you spoke about the biopsychosocial approach. Um, and a multimodal approach. I was going to be my next question. You know, when we're thinking about psychotherapy. Um, which specific frameworks do you find are beneficial in patients suffering from chronic pain?

  Dr. Leon Tourian: [00:17:55] So the what we use at the pain clinic is that we're very lucky. We have a fantastic psychologist. And, you know, when I did my fellowship training at UBC, there was a lot of psychologists there. So the framework the what has the most evidence is CBT, right? Uh, so you kind of do the exploration of where there's, you know, where there is barriers to essentially increase, you know, increase resilience, increase level of activity, decrease fear of movement. Um, however, in that component, the behavioural aspect of CBT. Um, you know, from a basic, you know, behavioural activation to, you know, mindfulness meditation, hypnosis, um, all of the I think the branch of meditation is very important. And you have to again, tying it in very much to the, I guess, aetiology of pain and that loss of control. These techniques as you know. Right, bring back a sense of control because by virtue of mindfulness and meditation, you're basically taking ownership of how your body is in the moment and you're controlling a whole bunch of parameters just by virtue of, you know, the activity of meditating. Hypnosis is a, you know, an intense version of, um, meditation. Um, so that gives control back to patients. And that's fantastic. And so we do that a lot at the pain clinic. And we encourage patients, pain patients to do that. Another thing is biofeedback.

  Dr. Leon Tourian: [00:19:22] So again in that behavioural aspect. Uh but again biofeedback you can do it through cardiac coherence or EEG or whatever technique you use. Uh, you essentially again give ownership back to patients of their body and their bodily function, which that's, that's what they feel that they've lost. Um, there is a lot of increasing evidence for acceptance and commitment therapy, uh, for pain patients. And I have to say that is, um, it's very ironic how things change over time. When I was in your stage and and even a little later, uh, you know, act was not very much, you know, taken seriously. It was kind of seen as a kind of a, uh. Anyways, it wasn't taken seriously. I don't want to say anything more, uh, because I regret that when I was a Pgy five finishing Psychiatry Act was, you know, nobody took it seriously. Everybody thought it was kind of a spin off of different therapies and kind of given a the same kind of thing, but given a given, another type of a costume, so to speak. However, now act is very much, you know, the centrepiece of some of the behavioural and cognitive interventions that we do. So I think it becomes a little eclectic. But acceptance and commitment therapy turned out for pain to be quite useful and increasing in its, uh, in its importance.

  Sarah Hanafi: [00:20:42] Wonderful. And, you know, moving beyond psychotherapy, um, I was reading a little bit about central non-invasive neuromodulation strategies, and I was wondering whether that's something that, um, you've come across within your practice and is there a role for this population?

  Dr. Leon Tourian: [00:21:01] So that's an excellent question. Um, how do I answer that? So in terms of our experience with it, um, I've only had, uh, just a few patients that have had interventions with Rtms, for example. Um, and I have to say, you know, there is an increasing evidence for the role of rtms, for example, in the management of chronic pain. Now, as you know. Right. Rtms is a massive commitment from a time perspective. You also have to have the right machines with the right kind of, um, settings to deal with pain versus depression versus, uh, other modalities. So, um, so we have some experience. It is limited. And I think, um, yeah, I think that essentially, you know, we always kind of think about it because we don't have access to it for our more severe cases. And so the outcomes are not very, you know, they're not amazingly encouraging, but sometimes they do work. So we have to think about it. Uh, but I think that it's an accessibility issue, even, you know, in Montreal we have four, five centres doing rtms now, but they're more geared towards, uh, primary mood disorders. Um, and so not for pain specifically, but they do help, uh, with the mood aspect. So they become a useful tool for chronic pain patients.

  Nima Nahiddi: [00:22:16] I wanted to take some time and focus on, uh, the first part of the biopsychosocial, uh, approach, which is the biological, the pharmacological management. This is something which can particular interest our listeners, given your psychopharmacological expertise. Can you outline, uh, if you have a general pharmacological approach for the management of chronic pain?

  Dr. Leon Tourian: [00:22:41] Sure. Um, so I think I think the first thing to remember is that there's guidelines, right. Um, and I think. It is very important to be mindful of guidelines. But we're not technicians, we're physicians and we're, you know, caring for human beings that are one like versus the other, uniquely different. And so that has to be taken into consideration. But the guidelines are your framework. So you start with the Canadian neuropathic pain guidelines, uh, which kind of give you an order of medications to go through for neuropathic pain. If you have visceral or somatic pain, you know, opioids remain the centrepiece. However, if it lasts long enough, there is a centralised component that becomes interesting and your pain guidelines kind of, uh, become relevant then. Uh, but essentially, as for the Canadian neuropathic pain guidelines, and essentially if you look at all the guidelines, they're all the same, pretty much in terms of what they recommend. Some of them vary in terms of what they've chosen as, uh, staying in a level one evidence, but as a first versus a first line, that will depend on, you know, different motivations and, uh, depending on what group is writing it. So in essence, your first line for neuropathic pain, for example, are the snris. So, you know, thinking about snris, it's very it's very helpful to be mindful of not the only two. We don't only have two snris or two antidepressants that modulate, uh, serotonin and noradrenaline, nor, uh, noradrenaline.

  Dr. Leon Tourian: [00:24:12] So, you know, we have some, you know, duloxetine, Cymbalta. So and we have Effexor. Those are the common ones that we think about. But the ones that are not necessarily indicated in pain, but that work equally as well, obviously is Desvenlafaxine. Uh pristiq. We have to remember Wellbutrin bupropion. So bupropion actually does the job. You know, it does increase noradrenaline. So, um, it does reinforce our downward inhibitory pathways, um, and um, and are an effective management tool. Uh strattera. Um, you know, uh, the, the kind of ignored molecule in psychiatry because it kind of doesn't help with ADHD, or at least the evidence is not that strong. And it kind of doesn't do much for mood. But I always mention it because I do have, you know, one experience as a physician and helping one individual. And it worked. But so I keep mentioning it just because, you know, people listening to this might have a patient that nothing is working and maybe that will work. Um, so in essence, bear that bearing that in mind. Uh, so and then we have our tricyclic antidepressants. Right. So they are uh, they are really, you know, in terms of efficacy for neuropathic pain, very helpful, but associated with side effects. Right. The anticholinergic aspect of TCAs is problematic. The narrow therapeutic window is problematic. And so if you have somebody who's suicidal or who has had past suicide attempts with overdoses, you want to be careful with tricyclic antidepressants.

  Dr. Leon Tourian: [00:25:39] But, you know, I've seen amazing stories of folks coming in, very lucky folks that their general practitioner did not give them any opioids for, and they diagnosed them with neuropathic pain, but did not want to go down the opioid pathway. And you know, thank you know, they're very lucky. And then you give them 10mg or 20mg of amitriptyline. And you know, they don't even come back to the pain clinic. Uh, they you know, they tell you, can you just renew this? And I'm good. Um, and then the GP takes over and you never hear from them. So TCAs remain there and the gabapentinoids so Lyrica, uh, pregabalin and gabapentin. So those are your first line. And then the second line, depending on what recommendations you're reading you fall into the opioids. Um, and then third line cannabis, ketamine uh, you know doesn't figure in in it. But for centralised pain it is really important. Um, and then your fourth line agents are the anticonvulsants SSRIs. There's not a lot of evidence for them. You know, when you look at the anticonvulsants, um, uh, you know, aside from carbamazepine, there's not a lot of good evidence for, uh, our anticonvulsants, like topiramate. Uh, um, valproic acid, lamotrigine, for example. Um, the studies are not very conclusive, so it's not very helpful. But that being said, it's really important for folks to remember that even if you have a negative study for a medication for a given diagnosis, you have patients in those studies that have responded to these molecules, but you just don't have a, you know, statistically, there's not a significant amount that but you have people that responded in these studies, and you might have a patient sitting in front of you that might potentially respond.

  Dr. Leon Tourian: [00:27:18] And if you've tried everything non-pharmacological, and if you've tried things that are pharmacological and they haven't, but you have to offer it because they might want to try and guess what? You might be able to help them. But as long as they know. Right. Um, so we have a whole bunch of medications. You follow the evidence, um, and then you try to help them out. Uh, I think the other branch of pain management from a pharmacological standpoint is sleep. Sleep is a massive issue for pain patients, as you could easily imagine. So, you know, trying to. Tell the pain patients, hey, you know, how about you follow this sleep hygiene? Um, and you know, it's impossible. And, you know, I, I try. Uh, but I have the, you know, I have the greatest respect for my patients. Um, and, you know, even if you don't have chronic pain, following a sleep hygiene protocol is immensely difficult. Imagine trying to go to bed and all you feel is different. Aches and pains that might increase as a as a result of pain. Uh, so essentially in terms of pain, you know, you obviously always go for non-pharmacological methods, sleep hygiene, meditation, melatonin, for example.

  Dr. Leon Tourian: [00:28:26] And then you fall into obviously the not a trap. I don't want to call it that, but unfortunately you do fall into giving the medications for sleep, uh, that have side effects. But that work, right? Uh, old medications that are reliable. But, uh, you know, so I use a lot of, um, I use a lot of method. Method. Trimipramine. So Nozickian, uh, for sleep, it does have some pain properties that is, uh, interesting, but again, riddled with side effects. Antihistaminergic. Uh, they folks, uh, gain weight. And, you know, you keep maintaining focus on these class of medications over time. You need to be mindful of the cognitive burden that that has as well. But they need to sleep as well. So it's a it's a very fine balancing act. I have to say. My training was in Psycho Pharm, uh, in going into chronic pain. Um, and one thing you realise very rapidly when you're very comfortable with meds is you realise what their limitations are. But the reality of our patients is that they do need medication because, you know, their body has failed them and you know, they need the non-pharmacological methods. They need to do mindfulness, hypnosis, the whole bit. But sometimes they need that boost. And medication is is unfortunately necessary. But if it's as long as it's used rationally, the minimum dose is, uh, necessary. Check for interactions. Uh, then you're pretty. You're good to go.

  Nima Nahiddi: [00:29:47] Thank you, Doctor Turian. That was a really good overview. I think it would be very helpful if we went into some detail for some of the different categories. So the first question I had is kind of going right back to the beginning, because I realised maybe some of our listeners maybe want a clarification on what's the difference between neuropathic pain and central pain, something that you, that you've mentioned when talking about this pharmacological approach?

  Speaker5: [00:30:17] Yeah.

  Dr. Leon Tourian: [00:30:18] So we could go through the pathogenesis of neuropathic pain to kind of help. And then we could branch in the pharmacology in there one by one as well. So in essence, you know the types of pain the you have somatic pain somatic visceral pain. And you have neuropathic pain. So neuropathic pain is in the context where there's damage of the nervous system. Um, and essentially an aberrant repair of the nervous system leading to an ongoing, uh, an ongoing, um, electrical signal. So kind of like you could think about it along the lines of epilepsy. But if your sensory pathways. Um, and so if you look at it that way, actually, it makes, you know, it kind of starts decreasing the mystery of pain and kind of simplifies it. So somatic and visceral as you, as, you know. Right. So the motor system, the nervous system is not involved and it's tissue damage that um, that is you know, that has gone awry a bit. But essentially the experience of it is through our neural pathways anyways. Right. But the initial damage is really focussed on, on non-neural tissue. But if we focus on neural tissue. Right. So essentially what happens is, is that in the periphery you have a repair of your nervous tissue that in 90% of the cases your nervous tissue when damaged will repair itself adequately.

  Dr. Leon Tourian: [00:31:36] And you know you'll move on 10% of the population, again using the biopsychosocial framework will develop neuropathic pain. Um, and so the biologic tenants of that is very much in the periphery. The central one is, uh, basically an aberration in the voltage gated sodium channels. So as you all know, right, you need the voltage gated sodium channels to have an action potential. And once you have an action potential, you have a pain signal. So it starts in the periphery. And so, you know, there's this has been researched a lot. There are various mutations of the voltage gated sodium channel, um, and essentially, uh, leading to essentially with low stimulation or none, uh, to a pain signal. Right. So if you look at the voltage gated sodium channels, what blocks them is our TCAs, the tricyclic antidepressants. That's why in an overdose situations they're toxic for cardiac because it's the same voltage gated sodium channels that you have in your heart. So the TCAs all block that and all the anticonvulsants. Right. Um, so when you go from, you know, keppra to, uh, valproic acid, lamotrigine, topamax, all of them block. So, uh, the voltage gated sodium channel efficacy not so great. Tca is fantastically efficacious, but some side effects. So in the periphery you have the voltage gated sodium channels that are really the prime target.

  Dr. Leon Tourian: [00:32:58] Right. So when you go from the periphery to the central nervous system, so you kind of do a first stop right in the dorsal root of your, of your spinal column there. It's the calcium channels that are dysregulated. So voltage gated calcium channels again if you remember from your medical school courses from the signalling, you need calcium to release neurotransmitters in the synaptic cleft. Um and essentially calcium regulates that. And you need the voltage gated calcium channels to maintain calcium homeostasis. So uh, pregabalin and gabapentin block those. And essentially what you have is, is if you have an aberrant signal coming from the periphery, you inhibit those by using the gabapentinoids. So you've used your voltage gated sodium channel blockers, TCAs or anticonvulsants in the periphery in your dorsal root. And as you enter the central nervous system, you block them with a, um, calcium channels, blockers. And then you go to the central nervous system there. You also have a dysregulation of the voltage gated calcium, uh, voltage gated sodium channel. Sorry. So your TCAs will act centrally as well to modulate it. So in essence, without getting too complex in some of the pain phenomena, um, that is the periphery, that is the pathway going up. So but there is a pathway going down. What I mean by that is the brain has developed really awesome pathways to regulate pain and to diminish the pain signal coming from, um, coming from the periphery.

  Dr. Leon Tourian: [00:34:28] And those are our downward inhibitory pathways. And, uh, to make this simple, for the purposes of this conversation, we'll limit it to about 4 or 5 classes, um, uh, 4 or 5 pathways and translates into, you know, the the same number of classes of medication. The first one is opioids, right. Our body has an. Natural opioid pathways, and its role and their role are very much in pain modulation excite from a whole bunch of other things that they do. Um, but that's why we have opioid medications, right? They enhance the pathways, we have the right receptors for them. And you go along from that pathway. The other one, obviously getting a lot of attention right now is cannabis. So the cannabinoid pathway. So that is another downward inhibitory pathway blocks pain signals coming from the periphery. And we can have a whole conversation about those. But let's I won't go there. Uh, related to you know, the some of the, the pros and cons of cannabinoids. Um, but again, a meaningful but not that well studied enough, uh, medication or class of medication, if you will. Um, and then we have the three medical pathways that kind of marry chronic pain management to psychiatry in by virtue of just the molecules are the same noradrenaline the most evidence one um, that we that we have the most efficacious one uh, serotonin.

  Dr. Leon Tourian: [00:35:46] Not so great. I haven't had one person come and tell me. Oh, you know, Doctor Turian, it's been great. The celexa has really helped my neuropathic pain, and I've never heard that before. Uh, but I hear it with, you know, venlafaxine, uh, you know, uh, duloxetine and prestige. Um, desvenlafaxine. Um, so, but not with the serotonergic agents. And then you have dopamine, which is kind of unfortunately, the the, um, you know, nobody paid attention to dopamine. They kind of got wasted, like, it kind of got. Yeah. Not wasted. But there's an opportunity wasted there. But I think it's, uh, probably a very complex one in by virtue of how dopamine plays in with the pleasure centre and addiction, um, and by virtue also of, uh, you know, uh, the complexities of modulating that with ease without causing a whole bunch of other problems. Uh, but nonetheless, dopamine modulating agents, whether they're blocking or not, have been found to be somewhat efficacious, but absolutely no evidence for their use in a first, second or third line situation is that I think that kind of breaks it down with all the meds.

  Nima Nahiddi: [00:36:49] That was incredibly helpful. Thank you. Talking about dopamine. So is is there any role of antipsychotics in the management of chronic pain.

  Dr. Leon Tourian: [00:36:58] So that's a that's a fantastic question in in any official manner. No. Um, like from an evidence standpoint, there's nothing however, uh, being that this is going to go to folks that are either in psychiatry or have an interest in psychiatry, there's I'm going to throw a few nuggets of information for you to consider. One is if you have done if you've worked with chronic patients with schizophrenia, um, and you look at, uh, and observe, uh, when they injure themselves, what their pain thresholds are like, they are remarkably different than, you know, somebody who doesn't have a persistent psychotic disorder. Um, and it's less so, you know, folks with folks that have been Long Terme on Long Terme dopamine modulators, the antagonists have a very different way of appreciating pain because chronically, we've, uh, depressed, uh, the dopaminergic pathways. In terms of. So there's that. So that's the first thing to bear in mind. Another thing is, is that we do have a very you know, we don't talk about it very often because the evidence is not there, but the sigma pathway in the brain. Um, and so, uh, one of the antipsychotics that we have that modulate, that is haloperidol again, uh, you know, when I started out as faculty, we had a patient that had tried everything imaginable and possible, and me and one of my anaesthesia colleagues at the pain clinic were thinking, should we try Haldol? And we did, and it didn't help. But nonetheless, you know, there is biological evidence for the sigma pathway in our brain that modulates, uh, pain signal.

  Dr. Leon Tourian: [00:38:39] Third and last observation, which I still have to get around to writing up, um, is the role of dopamine agonists, uh, or partial agonists? Uh, so, um, you know, as we know in, uh, as augmentation agents, we know that antipsychotics have a role. Novel antipsychotics, such as aripiprazole brexpiprazole have a partial agonistic profile. And I have, you know, I have a cluster of patients that have unfortunately not responded for a mood perspective but have actually significant decrease in neuropathic pain symptoms, but unfortunately, no improvement in mood, uh, which was really terribly you know, it was not what I wanted, but it turned out to actually be beneficial either way. Uh, so and, you know, there is one case report out there showing the efficacy of aripiprazole in the management of neuropathic pain. So dopamine is a really you know, I use I kind of use the word the rejected pathway because nobody pays attention to it. Uh, nobody wants to touch it. Um, uh, research has not gone there. We really focus on noradrenaline. And it really a shame because I think there's a lot to be done with the dopamine pathway. Uh, because I think that, uh, you know, we forget that dopamine, uh, you know, the, the regulation between dopamine and cognition, dopamine and pain. I think there's something really interesting to be done there. Um, but, yeah, no, not not as exploited as it should be. Uh, that pathway.

  Nima Nahiddi: [00:40:11] Very interesting. Finally, for the to wrap up this biopsychosocial approach, uh, you had also mentioned the role of cannabinoids and cannabis, and I think this is something that many of our listeners might be interested in, given the recent legalisation of cannabis and how it's taken up importance in Canadian culture recently. Can you elaborate more on the current role of cannabis in the management of chronic pain, and perhaps how it is involved in a biopsychosocial approach for patients?

  Dr. Leon Tourian: [00:40:46] Uh, okay. So yes, um, the first I'm going to say is in terms of its role in, again, in from an evidence based standpoint, it's still there's a long way to go in terms of having solid evidence for the role of cannabinoids in the management of chronic neuropathic pain. So that's my first statement. So again a lot of unknowns. Um, and so there we need to we need to do more research. However there is evidence showing that it does help. So I think that there is no we're not at a stage right now that we could kind of just brush off cannabinoids and say, oh, you know what? This is just, you know, this is just a, you know, a in Vogue right now. It's in style. We won't be talking about cannabis in ten years. That's impossible. We've been we've been, you know, we've been engaged in in cannabis in, in our culture for, uh, so many years. You know, uh, this is nothing new and it's not going away. So, um, and nor should it in the context that it has its place, but it needs to be studied more. So cannabis and its main two components, CBD, THC is both of them have analgesic properties so great they should not be and they are now. And that's a problem, uh, be heightened to the level as a safe alternative to opioids.

  Dr. Leon Tourian: [00:42:06] There's no evidence for that statement, even though, uh, you know, cannabis companies are popping up all over the place and they're posing it as, oh, you know, your opioids not working for your chronic pain. Try cannabis. Absolutely not. That should not be what we're doing right now. I guess you know, that's what I'll say. If you look at the evidence in terms of cannabis, in chronic pain, um, uh, chronic pain diagnoses, in terms of FDA approvals or Health Canada approvals, it's only approved for spasticity related to multiple sclerosis right now. So that's another thing to consider. Um, so the evidence again for neuropathic pain does not have level one evidence. So there's that. So. I guess, you know, the main thing is, is twofold. One is, you know, we've legalised it. So essentially everybody's extremely curious about it. And because it's legal, everybody thinks it's safe. Just like alcohol and cigarettes. We all know that. That's not the fact, right? There's risks associated with cannabis. So I think that as psychiatrists, you know, I think we have you know, we have really one set of eyes on cannabis and it being, you know, bad for young people and heightening the risk for vulnerable populations to psychosis. So that's problematic in terms of THC. Now CBD is a whole different, uh, topic. Cbd is being posed right now, as you know, the miracle molecule and the pathway to be the curing, you know, from depression to psychosis to, uh, chronic pain to everything.

  Dr. Leon Tourian: [00:43:37] Um, and that part, I think needs a lot of research, but and I think that part also is a bit of a, you know, a fad, uh, like it's in vogue now to talk about CBD. And in ten years, when the evidence hasn't, uh, you know, we don't have enough evidence, so we'll pass on to something else. But I think CBD has a lot of promise. Um, and, and I think that there's a lot to be done with, uh, with CBD research and seeing where it could go. Uh, but I think that one thing we tend to forget, um, and given the legalisation, actually physicians have fallen into this trap if they don't inform themselves enough is the deleterious effects of THC in certain age groups. And so we know that it's problematic in, in, in youth, but it's also very problematic in our cardiovascular patients. And that's something we don't often talk about. It is there is an heightened risk of cardiovascular events. So heart attack, stroke, um, in the use of THC and that we don't talk often enough about and not a lot of specialities are aware of it. Um, so I think that it's really important to consider that profile of THC in our more, you know, in our elderly patients, more elderly patients.

  Dr. Leon Tourian: [00:44:44] I'm talking about, you know, the ones that are risk for these events. So we're talking about 50 plus, let's say, um, so it increases blood pressure. It increases heart rate. It increases risk of heart attack and stroke. So I think that we need to be mindful of how we use it. We need to inform folks that their side effects, um, and I think that there is a lot of promise, so I don't I started off my practice as a pain psychiatrist, being the anti-cannabis guy because of, you know, the training we get in psychiatry because we know the risks. Now, I'm very comfortable with using cannabis with the right patient at the right time, with the right profile, when other level one, level two, uh, medications have failed. So I guess, yeah, I've come a long way with cannabis. I have to say. Um, and, uh, I, I'm very comfortable with its limitations, but I'm not, um, I haven't, you know, I'm not as strict against its use because some patients, it changes their life. Um, and we do sometimes avoid using cannabis in certain patients. But again, you know, cannabis opioids, what's good what's bad there. You know, it's you're basically exchanging a side effect profiles for another side effect profile.

  Audrey Lee: [00:45:57] Thank you for all the valuable insight you've been able to provide into the pharmacology of chronic pain management. Doctor Turan so to finish off, I wanted to go down a different avenue and explore the diagnosis of somatic symptom disorder and how that relates to pain disorders. So, you know, according to the the DSM five, the the following criteria are necessary to diagnose somatic symptom disorder. So criteria A is that the patient has to endorse one or more somatic symptoms that are distressing or result in significant disruption of their daily life. B is that they have to have excessive thoughts, feelings or behaviours related to somatic symptoms or associated health concerns, as manifested by at least one of the following. So one disproportionate or persistent thoughts about the seriousness of one's symptoms to persistently high levels of anxiety about health or symptoms. Three excessive time and energy devoted to those symptoms or health concerns. And then criteria C is. Although any one somatic symptom may not be continuously present, the state of being symptomatic must be persistent and typically more than six months then. Additionally, the criteria for somatic symptom disorder also includes a specifier for predominant pain or previously known as pain disorder, and this specifier is included for individuals whose somatic symptoms predominantly involve pain. So my first question about this is what distinguishes somatic symptom disorder with predominant pain from something. For example, like chronic pain with comorbid anxiety.

  Dr. Leon Tourian: [00:47:29] Yeah, that's that's a fantastic question. So I'm gonna answer by stepping back a bit because, uh, I guess, you know, again, I'm ageing myself a little bit, but, um, I did my I did my whole college with DSM for T.r. Um, and you may not be familiar with that. And it pains me to say it like that because it wasn't that far off. Um, but, you know, you have to remember that the somatic symptom disorder and related, uh, somatic symptom and related disorders chapter, um, is a revamp of the Somatisation chapter, which was riddled with so many problems. Uh, like, you guys don't know the soma, you know, somatisation disorder. But that was a very complex diagnosis to be rendered. Um, and they simplified it, and they simplified it in a way that is very pro patient. And what I mean by that is that there's a reduction in stigmatisation of patients that present with unexplained, medically unexplained symptoms. And that's the core of the revision of DSM five is removal of that. So that has been very helpful. But now what is even more helpful I find is there is there's almost an, you know, there's almost an educational aspect to the diagnosis itself. And what I mean by that is very simple. When you look at the basic tenets of the requirements, it is cognitive, behavioural and emotional.

  Dr. Leon Tourian: [00:48:47] Right. And those are tools we could use. If you look at if you spend a little time looking at the Somatisation disorder chapter, there's nothing in there that you could use to anchor and help your patients. The somatic symptom and related disorder. Fantastic revision. However, um, you know, there's limitations to it because if you look at those symptoms, you know, in essence, almost 100% of my patients would probably qualify for the three disruptions in cognition, behaviour and emotions. Um, so I think, you know, there's one needs to be mindful of that. Um, and so how it relates to chronic pain is the following. Is that in proportion to the seriousness of their their presentation and their medical illness, uh, the disproportionality needs to be proven. And that's where your symptoms lie. For somatic symptom disorder. However, one needs to be mindful before putting that diagnosis down because once you put that down, you've essentially, uh, labelled your patient as being, you know, somatic, which they're not. You know, our chronic patients, our chronic pain patients are not patients that have somatic symptom and related disorders. For the vast majority, I have to say, in my practice in the last, like I said, uh, most of the time I spend is in chronic pain. And in terms of maybe, I don't know, I think I've seen 7 or 800 patients in terms of diagnosing somebody with a clear somatic symptom disorder.

  Dr. Leon Tourian: [00:50:18] I only have five. Five patients, where it was overtly clear in terms of the information that we got from our colleagues, the investigations that were done that there was no that the that the symptoms were much, you know, out of proportion. However, if you, you know, while the symptoms while the diagnostic criteria have been simplified, uh, they render itself too easily to be diagnosed and that's a problem. However, what I take from that is the tool. And the tool is, is that you have to intervene in chronic pain with, you know, looking at emotions, looking at behaviour, um, and looking at, uh, the cognitive distortions associated with that. And I think that that's where it's beneficial. So I know I did a huge loop there to try to explain this, but I think it's really important because as a pain psychiatrist, I feel like one of the biggest roles that I play in our patients, in my patients life, is to decrease the stigmatisation. So adding on another psychiatric illness, even though it fits diagnostically, may not be essentially the most helpful thing that you're doing with them using those diagnostic tools to help them. That's, you know, where you are able to essentially, you know, make it make a meaningful impact in their life.

  Dr. Leon Tourian: [00:51:37] Uh, so pure somatic symptom disorder with predominant pain. Sure. You know, if you look at those criteria strictly, you know, a lot of our patients can meet that diagnostic criteria, um, where, you know, where it's helpful for them, the strict minority, because those five patients that I was relating to you, if we did anything from an interventional standpoint, if we, you know, referred them for surgery or anything, that would be terrible, right? That would be terrible because they don't have there is no substrate to treat. Whereas the vast majority of my patients need a multimodal intervention, need blocks need, you know, uh, you know, some kind of, uh, non or, you know, non-invasive or invasive procedures to help with their pain. And it's relevant because they warrant it. Uh, and I think that these, um, that category is really exclusively meant to alert us to folks that don't have an underlying, you know, uh, disorder and need, uh, you know, need to be identified as being really, truly, you know, uh, somatic in their presentation, whereas all the rest could just benefit from the tenets of that diagnostic framework and address, you know, uh, address the three main poles cognition, behaviour and emotions.

  Audrey Lee: [00:52:57] Um, I really appreciate you addressing kind of how we have to be cautious about assigning patients this disorder and the downfalls that it can have for them. Um, going back to something that you had mentioned about, you know, the previous DSM where these this chapter on Somatisation was quite controversial. Um, when I was reading the literature, I saw that there was there's still a bit of controversy regarding somatic symptom disorder, as a lot of clinicians think, that it's stigmatising and overinclusive, like you said. So they've suggested perhaps to, um, change this to an adjustment disorder as a more appropriate and accurate diagnosis. So what do you think about that? And what differentiates somatic symptom disorder from adjustment disorder. And in terms of how they relate to chronic pain?

  Dr. Leon Tourian: [00:53:41] Yeah, that is a very interesting question. And so how would I answer that? Okay. So I think that, you know, no matter how you simplify something, the more you simplify it and the more you put it somewhere else, the stigma is just going to follow the problem, right. The stigma is not related to a given diagnostic framework. It's related to how we feel about something that we know are not familiar with. I think that that's the main like the basic tenant of stigma is if you are unfamiliar with something, you get afraid of it and you can't. When you can't explain it for yourself, then you have two reactions. Either you avoid it or you, you know, you you kind of berate it and ignore it and kind of, you know, that's that's the misery, unfortunately, of chronic pain patients because, you know, they end up showing themselves in er, um, and essentially the doc goes, oh, you know, this is all in your head. And then, and then they sent a psychiatrist. And what does the psychiatrist say? Oh, you know, this is because of your blah, blah, blah, you know, whatever it is that you have. And that's where, you know, I really feel strongly that our patients, you know, you know, we need to educate folks about what is chronic pain. And just because you can't see it, it doesn't mean that they're not suffering from it. So I think though the main, um, the important aspect is, is that this chapter. Can be stigmatising if used inappropriately. And I think that if you appropriately use the diagnostic framework, it can be very protective of certain patients, but not as many as we think.

  Dr. Leon Tourian: [00:55:07] Um, at least not in our population. And the one that we treat and the one that I kind of encounter at the mosque, or at least, you know, the consults that I've had across our network. So I think, you know, somatic symptom disorder versus adjustment disorder, I think they're very different things. An adjustment disorder is you look at us, you know, you look at a given stressor and you look at, you know, the the spectrum of reactions, uh, that you could have to it. And you're looking at a specific like a specific strata that are responding more intensely towards a given stressor. Somatic symptom disorder is really the manifestation, uh, potentially, of the stress through physical symptoms. So you could potentially oversimplify it and call, you know, create a new category of adjustment disorder with predominantly physical symptoms, you know, but the stigma is going to follow because the stigma is actually, you know, the unknown, the unknown being is that, you know, you don't know exactly why they're manifesting with physical symptoms and why aren't they just sad, you know? So that's the that's the kind of a massive oversimplification of an experience of patients that is, you know, that needs to be appreciated. And then we need to heed to and listen to. But no matter where you stick something you don't understand, the stigma will follow. I think that's really important. And I think I really, you know, I really am invested in trying to do these things like this podcast and like other things that I do at the pain clinic to make folks understand what the experience of chronic pain is so that it brings down the stigmatisation.

  Dr. Leon Tourian: [00:56:35] The more medical students, the more residents kind of understand what chronic pain is, then the less you know you. Those individuals in context of ER or family practice or referral will be more understanding of these patients that have great need. And you know, it's not a benign number. We're looking at 10% of the population um with chronic pain. So and the older you get the higher those incidents becomes. And 5 to 7 you start off with 5 to 7. In paediatric populations that's not insignificant. And these are young folks. And as you go along it increases I think I hope that answered your question, but it's just very, um, it's very delicate putting a label on something that is very complex. Uh, and I think, I think if I was to summarise and to answer your question, I don't think it will it I don't think it needs I don't think it, it should be housed in the adjustment disorder because again, the stigma will follow. But I think though we should be very careful in how we use somatisation somatic symptom disorder diagnoses, because you have to appreciate that once you put that in a patient's chart, you will essentially, uh, you know, decrease the quality of care that's going to be delivered every time another doctor reviews that chart because they'll go, oh, you know what? It's in their head. And then you know what the trap there is. The patient gets poor care. And then at one point, you know, there is going to be something significant and it's going to be missed, and that's what you want to avoid.

  Audrey Lee: [00:58:00] You had said how you had maybe only five patients in your practice that you actually found had somatic symptom disorder in those instances. How did you approach the treatment of that?

  Dr. Leon Tourian: [00:58:12] So you approach it with one creating an alliance with patients, right? You can't just say, oh, you know what this is. You know, this is it. This is your diagnosis. Good luck. No, it's you have one is that I've never I've never actually done that with a one shot, like a one shot, uh, assessment. Um, and so it's been done. If I have done it, it's because I've had all the information from our psychologists who've met the patients multiple times, and we needed to stop the medicalisation of these patients. Um, so I think how we've done it is really, you know, either we've developed an alliance with them, I have or our team has, and you kind of sit down and you approach it in a multidisciplinary, interdisciplinary approach. So you sit down with a patient, with everybody around the table, and you go, you know what? You're suffering very real. And we are hearing it. However, you know, we at this point cannot find, uh, you know, a medical explanation for this. And these are the tools that you would get whether you had a medical explanation or not, because you're a chronic pain patient, you present it that way, and essentially you stop intervening from, you know, you stop intervening from interventions blocks. You wean off medications slowly, but you always focus on the suffering, not the cause. Because the cause, you know, the patient will always remain, you know, convinced of needing to identify. And that's the virtue. That's our nature. Right? We want to know why this XYZ is happening.

  Dr. Leon Tourian: [00:59:39] But you focus on the suffering and then you give them tools. And the tools are, you know, minimal pharmacology. Uh, one person kind of managing these, these patients and essentially, you know, investigating appropriately but limited. And the GPS is usually at the core of that. And, uh, I think that there's ways of doing it, but you have to do it very respectfully. But you have to do it. You can't just say, oh, you know, we'll just kind of, you know, we'll glaze over the fact that this is we can't find. No, you have to tell them, listen, we haven't found any evidence matching, you know, we haven't found any evidence of a medical reason. But focus on the suffering, minimise interventions, minimise pharmacology and optimise, you know, uh, focus function and their independence. Um, and, you know, from a psychology standpoint, uh, our team is fantastic with that, uh, because we have honed our skills to identify these complex patients, um, and, and address them and refer them and do it with a lot of care and respect because, as you know. Right. The the number one stigma at the pain clinic, especially when they're referred to psychology or psychiatry, is, oh, you're going to tell me it's in my head, whereas, you know, it is in your head. It's all in our heads. Um, and, you know, our sensory pathways are located in our heads. And when you educate patients and make it makes a lot of sense to them, they're very reassured.

  Audrey Lee: [01:01:02] So, so to to end off, I actually had one last question for you, Doctor Turian. Um, so, you know, throughout our discussion about somatic symptom disorder, we spoke a lot about about stigma. And you kind of touched on how, um, psychiatrists should do a better job at educating learners and, and medical students and residents about, about chronic pain and how you jump on these opportunities to educate people because you think that it can reduce the stigma. Um, how do you see the role of, of psychiatry in, in reducing the stigma around chronic pain patients?

  Dr. Leon Tourian: [01:01:36] Um, so I just want to be clear, I don't like the psychiatrist in general. Don't do this. I do this because it's the virtue of my practice. Uh, but I think, you know, um, I think that the number one and I was actually, you know, uh, I was actually going to I think my closing remark in this is that, you know, education is at the core of understanding the chronic pain patient. If you understand how chronic pain comes about, then it's not a it's not a invisible diagnosis. Right? That's the problem with chronic pain. You don't have, you know, you don't see it on imaging unless, you know, of course, you have an injury that you could identify leading to it. Um, you it's just not tangible. And that's what makes it more vulnerable to stigmatisation. But if you understand it and if you can appreciate the complexity and how to manage it, then it doesn't become as problematic anymore. Um, and I think so in terms of Psychiatry's role in chronic pain, I think that as any speciality, we have to advocate for patients. And I think that, you know, we need to have more pain psychiatrists, for example, um, you know, there needs to be more people invested, uh, and more invested time in it. And you can't do it in a silo. You can't just be the consultant. You need to be really integrated in an interdisciplinary, interdisciplinary team. Because if you're not, then you essentially, you know, create a separation in the patient's mind that the brain is here, physical is here at the pain clinic. You know, I'm the I consider myself very lucky physician to have. A situation like the one I have is that we have a playing clinic. Everybody is part of the pain clinic. Our approach is very interdisciplinary and we tell the patients that it's all one.

  Dr. Leon Tourian: [01:03:22] We are one. You're one. You're suffering, you know, is your brain is not separated from your your body. Um, and the experience is, you know, uh, is a bidirectional one. And we approach both and we really put a lot of emphasis on the. Patient taking ownership. Um, and I think so, I guess I guess one of the things is educating oneself. I think that, you know, it's not only psychiatry that's going to advocate for chronic pain patients, but also a whole bunch of other specialities. I think pain clinics are the advocates for patients. Um, and I think pain patients attracts folks that want to deal with more complex patients. And I think pain, chronic pain is by virtue of complex patient. Um, and I think that once you have folks doing that and advocating, then that's, that's that's one thing. The other thing is, if you look at the organisation of pain clinics across Canada, for example, you know, there's different ways in which they're organised. Not all of them have the luxury of having psychiatry, um, just by virtue of resource or by fear. Um, and I think that when you have folks coming to our unit and getting that experience, well, you know, they go elsewhere and they talk about it and they see how it's done. And we're lucky because there's not a lot of clinics that are set up the way we are. And there's not a lot of departments that have the luxury to have a psychiatrist being lodged and only doing or mostly doing, uh, pain. Uh, but it's education. Education is at the core of bringing down stigmatisation. Um, and we need advocates, and the advocates are folks that really have, uh.

  Speaker5: [01:04:57] The well.

  Dr. Leon Tourian: [01:04:57] The well being and and the. At the heart of what they want to do is really advocate for complex patients.

  Nima Nahiddi: [01:05:06] Thank you once again, Doctor Turian. I can hear the passion that you have for this subject. Uh, you know, you've educated me today, so hopefully our listeners can also benefit from this wonderful conversation.

  Audrey Lee: [01:05:20] Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Doctor Nemonychidae. Doctor Sara Hanafy and Audrey Lee. Audio editing by Audrey Lee. Show notes by Doctor Nemonychidae. The accompanying infographic for this episode was created by Doctor Luba Brozkova. Our theme song is Working Solutions by Olive music. A special thanks to our incredible guest, Doctor Leon Turian for serving as our expert on this episode. You can contact us at Psyched Podcast at gmail.com or visit us at Psyched Podcast. Org. Thank you so much for listening and we hope you'll tune in again next time.

Episode 34: Ketamine for Treatment-Resistant Depression with Dr. Sandhya Prashad

• Episode 34: Ketamine for Treatment-Resistant Depression with Dr. Sandhya Prashad

  Hi, everyone. It's Chase from PsychEd. Just want to let you all know that we're going to be including a written transcript of today's episode in our show notes.

  If you find this transcript useful, looking at either during or after the episode, please let us know. We'd love to hear your feedback. You can send us a message at psychedpodcast.org.

  Thanks and enjoy the episode.

  Hi guys, welcome to PsychEd, the psychiatry podcast for medical learners by medical learners. In this episode, we hope to give a whirlwind introduction to the use of ketamine within psychiatry. Today, we will be discussing the topic with Dr. Sandhya Prashad.

  Dr. Prashad is a psychiatrist and is the founder and medical director of Houston Ketamine Therapeutics. She has extensive expertise using ketamine and is one of the most experienced ketamine psychiatrists in the US. Her clinical practice focuses on treatment-resistant depression and also incorporates RTMS, sometimes in conjunction with ketamine. Dr. Prashad completed both medical school and residency training at Baylor College of Medicine in Houston, Texas. She is a founding member and current president of the American Society of Ketamine Physicians, which is a nonprofit organization created to advocate for the safe use of ketamine for mental illness and pain disorders and to expand access to ketamine therapy. I am Chase Thompson, PGY 3 at the University of Toronto and I'll be hosting this episode.

  I'm joined by my colleagues who will be co-hosting. Today I'm joined by Dr. Nikhita Singhal.

  Hi, I'm Nikhita. I'm a PGY 2 psychiatry resident, also at the University of Toronto and very excited to be co-hosting today's episode.

  And we're also joined by our co-host Jimmy Qian.

  Hi, everyone. My name is Jimmy Qian. I'm a MS2 at Stanford University and really happy to be here today.

  Great. And we also have our expert amongst us. So Dr. Prashad, do you want to briefly introduce yourself?

  Of course. I think thanks for having me on. I'm really excited to be here and to do this.

  I think you kind of touched on a lot of my background. About for the past four and a half years or so, I've been using IV ketamine in my practice. I first started using ketamine because I had a patient who was very treatment-resistant and actually quite suicidal.

  At that time, there was a lot of literature and talk coming out about the anti-suicidal effects of ketamine. That's kind of how we decided to treat him. It worked amazingly well and probably saved his life.

  About a year and a half ago, Sporvio, the nasal S-ketamine was FDA approved. That's something we use in the practice as well. That's a little overview about me.

  Our practice is focused only on treatment-resistant disorders, pretty much at this point, using ketamine as ketamine and TMS.

  Thanks so much. Maybe we'll jump over to discussing the learning objectives for this episode.

  Great.

  By the end of this episode, the listener will be able to, one, describe ketamine and how it came to be used in the field of psychiatry. Two, develop an appreciation for benefits and potential harms associated with ketamine and how this compares to other treatments for depression. And three, understand how ketamine fits into the treatment of depression and suicidality, patient characteristics to consider before initiation, potential mechanisms of action, different models of administration and incorporation of psychotherapy.

  Wonderful. So without further ado, we'll jump into things. So to start with, Dr. Prashad, could you tell us just a little bit about what ketamine is?

  Yeah, so ketamine is actually a synthetic molecule, but it was originally created for anesthesia and still used for anesthesia. It's been out for decades. We use it now a lot, mainly in children, to kind of reset bones and things like that in the ER.

  And it's what's considered a dissociative anesthetic. And we can get into that a little bit more later, but that's basically the fact that it causes kind of out of body and dissociative experiences.

  Perfect, thank you. And can you tell us a little bit about how ketamine made its way into the field of psychiatry from anesthesia?

  Yeah, so interestingly, I mean, over 20 years ago, they were actually doing research using ketamine, knowing that it had this sort of psychedelic out of body type experience to, they were trying to study schizophrenia actually and the positive symptoms of schizophrenia. So they were doing these studies and somewhere along there, they started to notice that there was some mood improvement. And so they actually did a real small study.

  The first one was published back in 2000. And I think back then, no one really thought much about this. It was very small.

  I think it was only like eight patients. And then again, in 2006, it was replicated. I imagine that one, as it was given IV and it's an anesthetic, right?

  And so I think obviously many in psychiatry thought this is kind of out there, right? I mean, it's not something that really took off at that time. My understanding too is because of the dissociation and it has a history of being used as a club drug as well, that created some barriers with regards to the FDA.

  So for a number of years, people were trying to develop a drug that worked kind of like ketamine but without the dissociative effects because of I think concerns with like the FDA and things like that, which of course never came to fruition.

  What about the terms R and S ketamine and maybe you could touch on the differences between those.

  Any racemic molecule, right, has R and S. IV ketamine that's typically used for infusions is what we call racemic ketamine. A year and a half ago, Janssen developed S ketamine in a nasal form, which they have a patent on, and that's just the S enantiomer.

  There was some thought that the S enantiomer is actually has a higher affinity for the NMD receptor than racemic, and it seems to be a slightly less dissociative molecule. So there are some differences there.

  You've mentioned dissociative properties a few times, and you also mentioned that this can be used recreationally. So could you discuss how medical use fits with this recreational use and also describe maybe the term K-hole?

  So with regards to recreational use, it tends to be a lot more than we use for mood. So mood doses are actually quite small. A typical starting dose, and what most of the literature is on, is actually on half a milligram per kilogram, which is about 20 times smaller than probably an anesthetic dose.

  And with recreational use, and that dose is over 40 minutes. In recreational use, it's, I think it's typically sordid. It's a much higher dose, it's usually done daily.

  Whereas with mood doses, we dose less frequently, usually two to three times a week, over two to three weeks for that initial ramp-up period. So it's a very different type of use. And then with regards to dissociative effects, there's kind of a range of dissociation that people can experience, starting with lower doses and just kind of a little bit of a floaty kind of feeling all the way to kind of out of body, seeing your body from the outside.

  And then even further to, like you mentioned, cave hole where the person doesn't really know they exist or they feel like a speck in the universe. And it's a lot more, it's this deeper, more psychedelic experience that's much, much deeper. And that's not really the goal that we have for mood doses.

  It can happen, but it's not very difficult. And certainly not the goal of treatment. So patients find that actually incredibly scary, right?

  So really the experience that we're aiming for is something much more comfortable than that.

  Okay, so just to summarize for our listeners, ketamine is a molecule that's been used in medicine for some time within the field of anesthesia. And it's also used recreationally, but in much higher doses than what we'd be using for treating mood disorders. And there were some very promising studies that were conducted, kind of examining its use within psychiatry in the early 2000s.

  Although it was quite kind of radical and different at the time, not something that people were really used to. And now it's really becoming more mainstream within psychiatry. And I was wondering if you could tell us more about where exactly it comes into play in the treatment of resistant depression, like the patients you see in your clinic, and like what kinds of patients would be suitable to receive this therapy?

  So one thing I think that's important to talk about when we say where does ketamine fit within the treatment resistant realm, I think is to talk about how important remission is with depression and how infrequently we usually are able to accomplish that. So for example, after about two antidepressants that a patient has failed, the chances of going into full remission with the third antidepressant is only 14% and it drops further and further with each medication trial. Many of the patients that come in have actually tried something like six antidepressants.

  And even if they respond a little bit, they haven't gotten it into remission. So I think that's an important thing to think about, that it's not just patients who are still extremely depressed and maybe meaning hospitalization or they have suicidality, that wouldn't have to get Ketamine. A lot of times it's a lot of patients who have tried a lot of treatments, but they haven't been able to achieve remission, even though they're not necessarily bedridden.

  So that, I mean, I mention it because it's a common thing that people ask. A lot of people think that, you know, my whole practice must be people who are like completely non-functioning. And that's not true.

  I think there are a lot of people who just partially respond to antidepressants. So that's, that's a big part of that. What was the other part of your question?

  I think you were just asking like where it fits.

  So yeah, thank you for that clarification around. Yeah, it doesn't necessarily need to be the most severe cases, but people who have it.

  And I think where this fits is different for different people based on their knowledge, right? But one thing that's important to know is sometimes people are looking at TMS, Ketamine and ECT sort of like as these treatment resistant modalities. And ECT has a potential for a longer term side effects.

  Ketamine with just a couple infusions really doesn't have any long term side effects or side effects in between infusions. So it can be a much safer option to try up front instead of jumping to ECT.

  And there's a lot of discussion about its use in kind of acute suicidality. Could you speak to that at all?

  Absolutely. So two things there. One, just from my clinical experience, I really think I've seen it save many people's lives.

  I've had patients that I was about to send to the hospital, we decided to try an infusion instead, and they all say the same thing after the infusion. They say, I can't make my brain go bare. And it just goes away.

  That doesn't mean it doesn't come back. But at least in that moment, they're in a safer place. Laurie Calabrese is a psychiatrist who also does a lot of IP ketamine.

  And she took some of her patients from her actual clinic and looked at them with regards to suicidality. And she found that patients that had suicidality with their depression were actually more likely to respond to ketamine and their suicidal thoughts resolved as well. Janssen, which we mentioned with S-ketamine, they have a second FDA indication that just came out that is not for suicidality per se, but basically for depression that has an imminent risk of suicidal thoughts.

  So this is coming more to the forefront. I think it's probably one of the most important things for people to take away, even if you never actually give ketamine, just knowing that it could potentially be very life-saving for a patient, I think is really important, even if they are not treatment resistant. The second indication doesn't talk about treatment resistance.

  It's if you are that severely depressed and suicidal, you should go to this right away, is basically what that indication is saying. And I have to agree that you don't need to fail everything before using it, especially if suicidality is something you look for.

  Are there any contraindications for ketamine?

  Sorry, are there other indications for ketamine?

  Are there any contraindications for ketamine?

  Contraindications for ketamine, yes. The most notable is probably going to be somebody who is actively psychotic or they have a psychotic disorder. And then we do use it, something bipolar disorder, but when patients are in a bipolar depressed state, so you want to make sure they're not in a manic state.

  That's a little bit trickier to do, but those would be the most common like contraindications really.

  Is there any risk of a manic switch with ketamine?

  There is in theory a manic switch, and I have seen it, actually with S-ketamine. It was a patient that was not diagnosed as bipolar, and so she was not on a mood stabilizer, and she got a little hypomanic, and we were able to kind of reverse things. So there is always that potential, which is why many people who do treat patients who have bipolar depression will have something like an anti-psychotic on board to kind of prevent any emerging medium.

  And I'm wondering if you could tell us about the efficacy or overall usefulness of ketamine as a therapy, maybe in comparison to some of the other therapies that we have for depression.

  So one thing that's important to talk about also is that ketamine is not easily translated across different sets, meaning that different people dose things differently, right? That there's no set way of doing treatment, which is why it's so important that we get more data on what actually works and what's the optimal way of using it. So depending on what you're looking at, some people will use half a milligram per kilo and they usually report a response rate as someone in the high 60s to low 70s.

  And a lot of people who do more dose titration to the patient and adjust their doses accordingly, and also maybe take off medications that might interfere like Lamictal, they will often say their response rate is closer to 80%. So somewhere between 70 and 80% is probably fair to say.

  And in terms of timeframes, how quickly does ketamine tend to work in alleviating those depressive symptoms and how long do the effects last?

  So it definitely depends on the patient. Some patients will have this sort of immediate antisocial effect or even an immediate mood lifting effect. And if you look at some of those like really early studies, that's what they were looking at.

  It's a single infusion and people did report some improvement in their symptoms. I would say that's not necessarily always the case. A lot of people take a couple treatments usually to start feeling better.

  We usually tell people somewhere around the third or fourth treatment, we start to see some functional improvement and that can look like just finding it a little easier. We do things, a lot of times it's the family that's starting to notice that or they shall come in and say, I cleaned my house this weekend or something that they've been trying to do for a long time that they haven't been able to. So that's kind of where we start to see efficacy.

  A typical series upfront is six infusions over like I said, two to three weeks. After that period of time, most people will need a booster infusion sometime around a month or so after that series. Now, at that month mark, it's usually just starting to fall off.

  We usually tell people somewhere around the third or fourth treatment, we start to see some functional improvement and that can look like just finding it a little easier. We do things, a lot of times it's the family that's starting to notice that or they shall come in and say, I cleaned my house this weekend or something that they've been trying to do for a long time that they haven't been able to. So that's kind of where we start to see efficacy.

  A typical series upfront is six infusions over like I said, two to three weeks. After that period of time, most people will need a booster infusion sometime around a month or so after that series. Now, at that month mark, it's usually just starting to fall off.

  It's not that they've completely relapsed. A lot of people would probably take many months to completely relapse, but obviously if you've responded, well, we don't want that. So in order to just kind of keep things going smoothly, somewhere around that month mark is pretty typical.

  It does require ongoing treatment. For the most part, it's a treatment and not a cure. It doesn't completely get rid of depression.

  Know that once people have had about three episodes of depression or they've been depressed for a long period of time, which it does tend to be this patient population, a lot of them will tell you they've had depression for 10, 20 years. Sometimes they find that they do best continuing treatment. What that regimen is is different for different patients.

  Again, some people only need one once every three months. Some people still need one once every six weeks. It's just different depending on the patient.

  And some young patients that have had a single episode of depression, I have been able to treat them and then we don't need ketamine anymore. So, but again, I think that's a different profile patient because they don't have that long-term history of kind of staying depressed.

  How many sessions would you do before you kind of come to the decision that maybe the patient isn't going to respond to ketamine?

  Yeah, with IV, I mean, I have seen patients get to that fifth infusion and I'm like, man, I don't think you're going to respond. They come in for that sixth one and they're like, I'm better. And so I've seen it.

  And sometimes people just start to respond at that fifth or sixth infusion. And then you might even keep going a little bit more with that kind of twice a week or once a week, keeping them kind of close together. So I think as long as you see some improvement by like five or six, it probably still makes sense to continue.

  Earlier, you mentioned that TMS and ketamine were two of the major TRD treatments, but you're pretty innovative in that you sometimes do both at the same time for your patients. So could you talk a little bit about that?

  This is something I kind of tripped on. I had a patient who responded really, really well to ketamine and then some stressors came up and you're not very anxious. And all of a sudden this ketamine wasn't responding to ketamine.

  He wasn't sleeping very well because of the anxiety and he wasn't responding to ketamine. We even tried repeating a little series of ketamine, increasing doses, increasing light, doing all of these sorts of things. It wasn't improving.

  So we decided to try TMS because of how he was doing. And a couple weeks in the TMS, we decided to re-challenge him with ketamine and he responded beautifully. I started looking into the literature and there actually is a doctor, Steve Best, who's done about 250 and he's published them.

  He does ketamine simultaneously with the TMS and sees some very nice results. I've also been able to treat some patients who maybe they've gone elsewhere and they have had some ketamine treatments and they didn't really respond very well. And we do TMS and we challenge them and they respond very well.

  So I did a presentation on this a couple of weeks ago. There's definitely a very clear synergy between the two mechanisms. And it seems like ketamine sort of potentiates the effect of the TMS.

  And that has been a great go-to for some of the patients. And it's also helpful if a patient doesn't seem to be, like they get better but they're not able to go maybe a full month between treatments because it can be very expensive, right? Ketamine is not covered by insurance.

  And so anything we can do to sort of lengthen that time between treatments can be very helpful. TMS is covered by insurance. So sometimes if we have a patient that's only staying well for maybe two weeks at a time, but they are better, something that makes sense in some of those patients is to do TMS and then re-challenge if they can and it seems to work better.

  So I think we've talked about the need for ongoing treatment. Are there other kind of limitations of ketamine treatment that are important to know about?

  Yeah, so I just touched on one, which is cost, not covered by insurance. Two, I would say limited availability, right? There's probably lots of areas of the country where there's just not really access to treatment.

  It's not an FDA approved treatment, so we don't have those trials that you usually would have that lead to an FDA approval, meaning we don't have long-term safety data. I've already alluded to the fact that we don't really have a clear sort of regimen in which to give the treatment with regards to doses and how you might escalate it. So there's not really consistency amongst treatment and then there's no clear right protocol either.

  So I think some of those things are certain limitations.

  Yeah, you just mentioned kind of the lack of information around different protocols across clinics. And part of the reason is there are no clinical trials, but in some other areas of medicine like oncology, that issue has been alleviated using real-world data or real-world evidence. So how do you see the field being able to utilize that for research purposes and maybe it'd be appropriate to talk about what ASKP is trying to do in the area?

  Yeah, so absolutely. So you're right, we'll probably never get this data with regards to like an FDA kind of, those trials are very expensive to conduct, but we have so many people doing these treatments. And I think if we were able to pull their data, it would be very useful.

  So there are some software platforms out there that allow us to have kind of real-time patient monitoring between treatments and then have the time treatment so that we can really kind of see and extrapolate and look at that data. Like you mentioned, I'm the president of ASKP and we're a national organization for providers, not just physicians, but also psychotherapists and other providers who are using ketamine. And so it's a large group that it would be great to have that data and to look at that data as well, to try to come to some of these conclusions and establish long-term safety data.

  So we have the information out there to get these things that we need. It's just not being done. And so this is something, you know, ASKP and several others have had some interest in doing.

  Yeah, I think it's definitely interesting. And so here in Canada, although things are slightly different, we also, we have our kind of our can-met guidelines that we follow. And ketamine in there is still considered an experimental treatment.

  So it will be, yeah, interesting to see how things progress in terms of-

  Yeah, even here, when a person comes in for a treatment, part of their consent form is that it says on there that it's not FDA approved. And, you know, that it's a treatment, not a cure, and those sorts of things as well.

  So thank you for talking about kind of Ketamine as a treatment and it allows us to put it in perspective with some of our other treatments like antidepressants and the neurostimulation. Taking a step back, are there any proposed mechanisms of action for how Ketamine can lead to resolution of symptoms?

  Yeah, so what we know is that in NMDA receptor antidepressants that it's most basic. Downstream from that, it seems to then turn on a number of pathways. It activates AmpOID, it increases BDNF, turns on mTOR, and these cause downstream signaling that seems to increase the way neurons will actually function and communicate with each other.

  So we seem to know that there's some sort of almost like neurodegeneration of the signaling, especially in the frontal lobe with depression, and that ketamine seems to be able to repair some of that. We have some interesting electron microscopy from rat neurons, where they show within 15 minutes that new dendrites are starting to bud right after ketamine. So there seems to be this very quick uptake of things like EDNF that help to repair some of that neuronal signal.

  I'm sure it's much more complicated enough, but you just don't know everything that it's doing downstream.

  You've been talking about IV administration of ketamine, but it seems that there are also new different types of administration, including intranasal as well as oral. Would you be able to speak to some of those and whether there's any differences in the effects and safety profile?

  Yeah. So there's a lot of difference between these. The most common ones that are used would be oral, and then we have intranasal, intramuscular, and intravenous.

  The first thing to look at is just how much is bioavailable. So with IV, about 100 percent is bioavailable. With IM, 90 to 95 percent.

  With IM, IM is 90 to 95 percent. Intranasal is, and it can vary a lot because it depends on how someone administers it, how much goes down the back of their throat. So somewhere between 30 and 50 percent is probably feasible.

  And then with oral, probably even less than that. So sub 20, so something like 10, 20, very small amounts. Because of all these different amounts of absorption, what you can kind of get out of them, how frequently you might have to administer changes.

  So for example, oral, because of the small dose that someone's getting, they would need much more frequent doses in order to probably see any kind of response. If at all. The other thing that's worth noting, and we haven't talked a whole lot about is just the experience of the treatment itself.

  And that varies a lot with the different modalities, not just because the dose is different, but also because of how it's given. So for example, with IV, you'll usually do anywhere from about 40 to 60 minutes. It's a pretty typical infusion.

  And like I use a syringe pump. So you're literally telling the pump like how many micrograms to give like right every bit. And so you can really control keeping that person in that sort of dissociated state for that period of time.

  IM tends to get a lot harder, a lot faster, and then kind of wear off. And then intranasal tends to also be wear. It's not as like long, it'll kind of go up and then sort of come down rather than sort of stay even.

  And oral can have kind of a variable sort of experience, but usually a very short period of time. So there's some thought that maybe, and again, we're not sure how to exactly predict efficacy, how to predict dose, but there's some thought that maybe the time spent dissociated, or the nature of dissociation, might have some sort of correlation to response. There's some data out there for that, it's not a whole lot of data out there for that, but that's where you start to see a big difference with those also.

  Yeah, thank you for that. I think it's also very helpful to get a sense of what it's like from the patient perspective when we are talking about different treatments like this. In addition to the different administrative routes, there's sometimes discussion around a purely medical model of getting the ketamine, and then ketamine-assisted psychotherapy.

  I mean psychedelic-assisted psychotherapy is a growing area of interest, and although ketamine is not a classical psychedelic, it can be used in this way, is my understanding. Do you have any thoughts about that?

  This is a great question because there's the possibility of getting both in a treatment, where you're getting that medical model because at the end of the day, it's still a medication, it's a molecule that's hitting that receptor and causing these downstream things that we talked about, and that's that medical piece of the treatment. The other side of it is especially in not necessarily the higher doses with deeper dissociations, but more that in between area, patients can often engage in therapy when they're in those states. That's incredibly useful.

  This is very useful in patients who have PTSD. What it allows them to do a lot of times is to experience emotions or to see things from a perspective that maybe they hadn't seen before. Doing therapy in that space can be incredibly useful to be able to explore emotions that they might not have otherwise.

  I think there will be more and more of this as time goes on. MDMA is on its way to being FDA approved for PTSD, but in conjunction with therapy. This therapy piece I think is going to become more and more important as well.

  Is there any data thus far comparing IV ketamine without therapy with ketamine-assisted psychotherapy?

  I don't think there's really a direct comparison. I think it would be a little tricky because it would be, I guess, one population. You probably have to take out the trauma from that population and then look at it.

  Then the question is, does the dose matter more than the therapy?

  Has anyone tried to do maybe a hybrid model where you are doing the medical model of IV, but as you mentioned earlier, maybe there is a month in between. Would sending that person to psychotherapy improve things in your mind?

  Oh, sending them in addition to the IV. Not at the same time. I would say 98% of my patients are in therapy.

  I highly, highly, highly recommend therapy. Even if it's not during, it can be after, there's some data that showed that 24 hours after infusions, particularly, we don't hold to have therapy during that time. There's a lot of reasons why therapy can be useful.

  Besides just working through things from the past, one of the main things is it's a rapid and acting antidepressant. Sometimes you will have patients that were depressed their entire life, go from not functioning, go from that to really remission in a number of weeks. That in itself is jarring.

  While it's exciting, it's something the patient may not have ever thought they would be able to achieve. Now, it's how do I piece my life back together? While I was depressed, I lost friends, I didn't have a job, I wasn't doing all of these things.

  But now that I feel good, I want to do things. Sometimes patients can get really overwhelmed by that. So this is where therapy can become really useful also.

  You alluded to this a little while ago, but just talking about maintenance and keeping people well in between sessions, do you tend to use concurrent antidepressant treatments or other forms of therapy?

  Again, that's totally anecdotal. But in my experience, I have noticed that patients who stay on antidepressant tend to stay, they don't need infusions as frequently. For esketamine, the FDA will actually says that it must be taken in conjunction with the oral limiters.

  So that's part of the label. So I do, I do a lot of that. So in addition to just doing ketamine or TMS or something for my patients, I often adjust medications to optimize things with these modalities.

  Thank you so much. I think we've definitely learned a lot about kind of how ketamine came to be used in psychiatry and the current state of things and different applications for it. Do you have any thoughts or ideas about the future of ketamine research and where expansion might happen next, different patient populations?

  I think ketamine became the medication that we used for this treatment with TRD because it was already had an update group, although it was in anesthesia, so it's accessible. Things like MDMA and psilocybin, they're not accessible, they're not legal. And so I think the reach on those have been more difficult to use, right?

  And that's why these trials going on now will ultimately lead to probably FDA approvals and we'll be able to use those treatments. Interestingly, I mentioned earlier, for a number of years, there's a lot of research going on on this NMDA receptor and how do we... I think ideally they do not want to use ketamine for this treatment.

  They were actually trying to just find something that would work with the receptor. And cause the antidepressant effect, maybe without dissociations, just to be a little cleaner. And they weren't able to achieve it.

  There were even other NMDA receptor antagonists medications that got to face three trials and they didn't have dissociation as part of it. And they didn't get a group. They could work.

  So that's certainly been, I think, probably a long journey. And I think things have shifted a little bit now to more some of the psychedelics that we do know, like I mentioned, and those are actively undergoing clinical trials. And I think there will be a lot of that in the future.

  Like I mentioned, it will probably involve a lot of therapy as well, which I think is great. But this is very much we're going to see a lot of this in the future.

  Given that psychiatrists are going to be the ones administering ketamine, and maybe a lot of psychiatrists are not exactly used to administering ketamine, is there certain safety risks that we have to watch out for during administration or shortly after?

  So a lot of psychiatrists actually don't get ketamine, right? I think that's another reason why there is this sort of access issue. And in ASKP, for example, we have a variety of different specialties.

  So there's actually a lot of ER doctors and anesthesiologists who are giving this treatment. And then some other physicians, both different specialties as well. Going back to your question, though, the doses that we do use for mood with ketamine in psychiatry are actually very, very safe.

  It's very low there. I think education is definitely important. And it's one of the reasons we also created ASKP is the collaboration piece is really important.

  I was actually trained by two anesthesiologists, went up to their practices and did treatments with them. They kind of really mentor me. And I think that was that was very important.

  I don't think as a psychiatrist on my own, I could have just gone out and just started doing this. I think you have to work within your comfort level and constant learning and collaboration is really important. As it becomes more and more popular, I think there are more and more opportunities to do so.

  And I think it's just very important. I know for myself, I could never have done this on my own. So when I'm giving an IV treatment, I have an EKG, I have a pulse ox, and I've got blood pressure.

  I'm watching pulses. Those are the things that I watch during an infusion. It's very common to see transient increase in blood pressure and then it tends to come right back down.

  A lot of some of the difficult things to manage during a ketamine infusion is actually some of the behavioral type of things. So it's actually some people will struggle with that losing control out of body type of reaction. And so that sometimes it's a matter of walking them through that and helping with the anxiety.

  And then nausea, I guess, would be the other one that you probably see, but very easy to manage.

  I'm curious to hear your thoughts on, I guess, this part of psychiatry as a whole. This is a podcast for medical trainees, and it seems like there is a push to get more interventional or more intensive, I guess, modalities within psychiatry. And we've talked about psychedelic medicines, things like that.

  So I guess in terms of medical training, how do you see this playing out over the next 10, 20 years?

  Yeah, I feel like psychiatry will have more and more of these sort of interventional-type treatments as these new modalities come out. It will be interesting to see how they actually incorporate those into training programs. They have a few interventional psychiatry fellowships.

  So this time Yale has one, for example. And they focus on TMS, PCT, and Ketamine. So IV, Ketamine, and ASKP.

  So there will be these opportunities for people who want to seek this out and learn more about it.

  Yeah, thank you. And for our listeners, we'll also include some resources in the show notes about places that you can learn more about this topic.

  I'm curious if you could speak a little bit to the data on PTSD or OCD or other indications. Today, we've mostly talked about depression and TB.

  So the data, the actual published data on PTSD as well as OCD with ketamine is much more limited. OCD as a whole is pretty difficult to treat. I have had some success with doing, I've had to do what seems like longer and higher dose infusions in OCD patients, but there seems to have been some improvement.

  I actually typically combine that. I have a Brainsway H7 helmet, which is for OCD specific with TMS. So we'll combine those two treatments a lot of times.

  And then for PTSD, again, not a lot of published literature for PTSD, but there is some. And it's certainly seems really useful. And again, this is sort of that out of body type of thing.

  “I think it's the same reason. I think MTMA will probably end up kind of replacing Ketamine from the PTSD realm. I mean, I'm not 100% sure, but I would imagine maybe that, you know, they're trying to make that very much protocol driven, very set training ahead of time, you know, that people have to go through.

  So it will probably have a bit more rigorous and a little bit more clear like how to do it.

  “But definitely, I mean, people definitely tend to use it in regular depression, bipolar depression, PTSD, OCD, you know, even some anxiety. And a lot of times patients who have anxiety, maybe there's some history of trauma there. And sometimes that anxiety especially will respond well to Ketamine.

  Thank you so much, Dr. Prashad, for your time and answering our questions today. I think we all learned a lot about Ketamine and its use within psychiatry. Sounds very promising and a lot of new ground to break in the future.

  Is there anything you wanted to leave our listeners with before we part ways today?”

  The only thing is I touched on this already during the talk, but I think it's really important as a takeaway that this can be a life-saving treatment for some and somebody struggling with suicidality is something to think of sooner rather than later. I think it's just important that, like I said, even if you never actually administer Ketamine, I think all psychiatrists need to know that piece about Ketamine. I think that part is really important because I don't think we have anything else in psychiatry that works like that for suicidality.

  That's really important.

  Great. Thank you so much.

  Thank you so much for joining us today and learning about ketamine. PsychEd is a resident-led initiative at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association.

  The views within this episode do not necessarily represent those of the U of T or the CPA. This episode was produced by myself, Dr. Nikhita Singhal, Jimmy Qian, and Gray Meckling. This episode was audio edited by myself, Chase Thompson.

  Our theme song is Working Solutions by Olive Music. And finally, a special thank you to our guest, Dr. Sandhya Prashad. If you want to contact us, our email is psychedpodcast at gmail.com and our website is psychedpodcast.org.

  Thanks so much for joining. See you next time.

Episode 33: Treating Borderline Personality Disorder with Dr. Robert Biskin and Dr. Ronald Fraser

• Episode 33: Treating Borderline Personality Disorder with Dr. Robert Biskin and Dr. Ronald Fraser

  Dr. Sarah Hanafi (PGY3): [00:00:09] Welcome back to Psyched, the psychiatry podcast for medical Learners By medical learners.In this episode will actually continue exploring a topic that I'm certain remains of interest to many of our listeners. Borderline Personality Disorder. In the first part of this episode, we reviewed the diagnostic considerations of the gist of this disorder, and the second part of this episode will touch on management of borderline personality disorder.

  Audrey Le (CC4): [00:00:34] During today's episode, we'll touch on several learning objectives. One understand the frame and principles of care for the treatment of individuals with borderline personality disorder or BPD. Two, to explore the approach to the treatment of individuals with BPD, including the presentation in crisis to the emergency department, the inpatient psychiatric admission, and finally the context of psychiatric outpatient care. Three understand the use of psychotherapy in the treatment of individuals with BPD, and four understand the use of pharmacotherapy in the treatment of individuals with BPD. Now let's get started.

  Dr. Nima Nahiddi: [00:01:17] I think it would be a good idea to start off with describing the general principles of care for treatment of individuals with borderline personality disorder.

   Dr. Ronald Fraser: [00:01:26] As Dr. Biskin mentioned sort of in the first podcast, there's a lot of different frames, a lot of different theoretical perspectives on the treatment of borderline personality disorder. I think the one thing that most have in common is that they're psychotherapies. So the most robust evidence for treatment of borderline personality disorders is psychotherapeutic rather than pharmacological and. You know, obviously they have other commonalities. But personally, Dr. Baskin may disagree about this. Personally, I think the thing that's most important is just having a frame, like just having a conceptual framework that that you have confidence in as a therapist. And from my perspective, it's always been important to me to be part of a team and that the team share the same basic conceptual framework. I think that provides a grounding which is particularly useful when situations get challenging or if there are clinical situations that are difficult for the team or for the individual or for the patient. I think having that framework to structure the work is very grounding for everybody involved. And for me, I think that's the the essential ingredient. I have no doubt that the various disciplines of various schools of thought would disagree with that, and they would say that, no, no, no, it's super important that you do X, Y, and Z. I'm not so convinced that that's true. Now, I'm biased because when I put together, along with a team, a framework for our program, we consciously decided to go with a trans theoretical approach where we basically stole components of all kinds of different schools of thought that we thought would best serve our patients. And and I think that has served us and served our patient population well.

  Dr. Robert Biskin : [00:03:54] I would I would actually completely agree with what what Dr. Fraser said, that the framework and the structure is probably the most important part of treatment for people with BPD. It highlights one of the challenges in terms of treating people with BPD in an outpatient setting versus other settings. There's a lot more variability in teams and structures in both the emergency room and the inpatient units. So having a consistent team with the same theoretical framework, the same approach to treatment is is extremely important. There was an interesting paper actually a number of years ago that looked at many of the different specialised types of psychotherapy for people with BPD, and it highlighted that the use of a team, the use of a consistent theoretical model, consistent frame force for treatment, the use of psychotherapy and particularly obviously looked at psychotherapies and particularly the use of multiple different types of psychotherapies, often with different treaters providing different parts of the therapy are some of the elements that are really essential or consistent across many different many of these different theoretical models, many of these different specialised treatment programs, which again kind of highlights what Dr. Fraser was saying about how no matter what type of psychotherapy that you choose to employ, there's many different tools from different approaches that can kind of be brought in and are probably very useful for treatment of people with BPD so that those structural elements are probably extremely important. So that would be what I would focus on as primary principles.

  Dr. Nima Nahiddi: [00:05:40] Can you discuss what you both mean by the idea of the therapeutic frame?

  Dr. Robert Biskin : [00:05:45] So the the idea of the therapeutic frame incorporates a few different components, but it's often a very structured approach to the therapy with very clear therapeutic goals, therapeutic steps and therapeutic outcomes or consequences for different sorts of actions. So a lot of the types of treatment will have very specific types of therapy every week. So you'll have a number of different individual sessions or group therapy sessions every week. And oftentimes attendance at these sessions, at these appointments is very, very important. There's often a lot of specific rules that people might have about attendance, about showing up on time, about communicating with the treating team or indoor therapists in between sessions. But in addition to that, there's a more global framework as well in terms of identifying early on specific targets for the treatment. So this is, in my opinion, an area where focusing on functional outcomes actually becomes very important. Having that as an overarching goal, not necessarily the only goal, but one of the goals for for treatment, for example, being able to find a job or look into or be able to develop new friends or relationships as kind of overarching functional goals for therapy is another part of the framework. And finally, another essential component of framework is that therapy must end. And I do believe that having an endpoint that the patient is aware of from the beginning of therapy is one of the important steps for having this consistent approach, not only because it gives patients the chance to recognise when therapy is going to end and they must take those steps to work on their own and learn to trust themselves in the skills that they've developed on their own. But it's also necessary because otherwise we won't be able to continue providing treatment for new people if we're continuing with the same groups of people indefinitely.

   Dr. Ronald Fraser: [00:07:49] Yeah, I think all of that is really, really key. I think the only other thing I would add is that there's also a secondary frame for the team itself. And, you know, both the teams that both Dr. Biskin and I belong to meet on a weekly basis that provides our own internal structure. And one of the things that we do is obviously we provide support, peer supervision, guidance. But also, you know, we have a place where we all feel safe enough to ask difficult questions and ask ourselves, what are we doing and why? But also, what are we not doing? And why. And those are really important questions for us to step back and reflect on, because we have to be accountable to the patient. We have to be accountable to the system. We have to be accountable to each other, and we have to be accountable to ourselves. And so there are two frameworks one, the clinical framework for the patient. And then secondarily, but equally important is a clinical team framework that we work with in.

  Dr. Sarah Hanafi (PGY3): [00:09:11] So you've both touched on the emergency department as one of these areas where maintaining that frame is perhaps a little more challenging. And I know in the previous episode we talked about how patients can sometimes present in crisis in the emergency department. I'm wondering, can you walk us through an approach to the management of someone who's presenting with BPD in the emergency department and is in crisis.

   Dr. Ronald Fraser: [00:09:38] So that can be. Theoretically easy and. Extremely difficult in reality. So one of the advantages that our teams have is team consistency. Emergency rooms sometimes have that where they have consistency of staffing, but most often they don't. So most often there are different psychiatrists on different shifts, different days with different ideas, which is all fine, but different nursing staff and different patient attendants and just different everything. And you can imagine that that doesn't necessarily lend itself to consistent messaging. And that can be problematic because the one thing that these patients do, all patients do well with is consistent messaging and not mixed messaging. So wherever possible. It's important to try to really communicate amongst ourselves within the emergency room of what the plan is. Why that's the plan, What's the rationale? What are the goals with complex patients that may present more often to the emergency room? Often we'll have case conferences with various stakeholders in terms of their outpatient care, their inpatient care, their emergency care, and try to put together treatment plans. So when a patient presents under such circumstances, this is going to be the consistent response. And obviously the patient is involved in that treatment plan so that there's no there's no surprises. And so they understand what the plan is and they understand what the rationale is. The rationale is to do no harm and to hopefully improve the situation. You know, ideally emergency room team sort of come up with consistent approaches of how they're going to manage these patients and how they're not going to manage these patients. So, you know, not using things that are punitive, not we don't have control over what other people do. So we don't have control over what patients do when they're in crisis. But we do have control over how we choose to respond. And that's what we need to focus on is our choices. And our reactions. I think that's really the key starting starting point for any patient that we see in the emergency room in crisis.

  Dr. Robert Biskin : [00:12:35] I'll add a few other points as well. It's interesting because for my experience, the way that I work with patients who are in my clinic at the Jewish General Hospital, it's I have the I have the ability to provide care for them in whatever setting they come in. So if they're in active treatment with us, I will be the one who will go down and see them in the emergency room. I will see them when they're admitted on the inpatient unit and I'll follow them as well when they're discharged into the outpatient clinic. So it provides a lot of consistency in that context, but that's not feasible for people who don't have my job. So in general, the approach that I take for for patients the first time that they're coming or one of the first times that they're coming and presenting to the emergency room is I tend to take approach that gives people more time. So the assessments of the work often does end up taking a little bit longer. And I actually have a rather particular approach that I will use with these patients, oftentimes beginning with the interview similar to what Dr. Fraser described before, more emphasis on people's or in the previous podcast, more emphasis on people's personal history, understanding their context or situation. I'll give people a lot more time to talk and share a lot about their story. And during those times, I'll be looking for clues as to what's the stressor, what are the triggers for why they're presenting to the emergency room that particular day? Because sometimes it's very obvious there was a particular stressor problems at work, relationships, school, etc.. But sometimes people will come in and say that they've just been feeling unwell for a very long time and being able to identify what it is that was making today that much more difficult than the day before is is very useful and it's a source that are the ones that I identify that particular topic. I spend a fair bit of time validating and validating that the person is having a lot of difficulty, that they're doing their best to cope with the situation. They might not necessarily have the best coping skills at work over the long term, but again, to come back to that idea that they're trying their best. So a fair bit of time validating and oftentimes patients who are coming in to the emergency room have not had the opportunity to have these sorts of specialised types of therapies that Dr. Fraser and I are both able to provide. So I'll also talk to them about the the hope for change and see how motivated they are for something like a specialised type of psychotherapy that might be different than other treatments they've received before. I don't try to do psychotherapy in the emergency room. I'm not going to be trying to teach them skills because it's not the best time to do that. But emphasising that there is hope and there are things that can be done. I take a model that's similar to a school that you never had the chance to learn this before in the past, so you kind of need to sit down with the books and have a chance to learn it in a structured way to kind of catch up for the things that you've missed. It often, again, destigmatize a bit about the illness and. Helps people feel more comfortable with the idea of going for a therapy if they're not so comfortable with it before. So, yes, that's kind of the approach that I take. Again, it does take a little bit longer, but most of the time patients again, it often ends with disclosing and discussing the diagnosis. Most of the time patients are quite satisfied with that. They feel like they've been heard, they've been understood, and they're interested in treatment when they're eventually able to get it.

  Dr. Sarah Hanafi (PGY3): [00:16:16] Thank you for that. So it sounds like in the emergency department, the stance is very supportive. I'm wondering, outside of the emergency department, can you touch more on these different specialised psychotherapies? It sounds like psychotherapy really is the mainstay of of treatment.

  Dr. Robert Biskin : [00:16:43] it's worth mentioning at the very beginning that there's not really any evidence of superiority from one to another. So they're all probably equivalent in many ways. And it's possible that certain elements from one or slightly better than another, but it's minimal. As we talked about before, the frame is kind of a central component of these these specialised psychotherapies. But one of the ones that probably are the one that does have the most research behind it is specialised treatment called dialectical behaviour therapy, which is a variant or it developed out of cognitive behavioural therapy, specifically designed for people who have intense or chronic recurrent suicidality and a lot of self harm. So like many of the cognitive behavioural therapies, it emphasises a toolbox approach. So in DBT it's again a combination of individual and group therapy. In DBT, there's many, many different skills that are taught to patients depending on how you might read the book. There's about 30 or so core skills with a few hundred variants of all of those different skills. So it can often be overwhelming for people at the beginning, but emphasising that there's just a few core skills that people need to work on and develop is part of the treatment and the four main areas that the skills come in is mindfulness, which overlaps a lot with mentalization or sorry, mindfulness based CBT. I mean the ability to just be aware of what's going on inside you and ideally do so non-judgmentally. The second main area is emotion regulation, which kind of steals a lot of the ideas from cognitive behavioural therapy, such as thought records. In DBT, we would call it checking the facts. Opposite action often incorporates a lot of elements of exposure therapy from cognitive behavioural therapy, and there's a lot of activity or a lot of emphasis on kind of having pleasurable activities and developing skills and mastery and things in different parts of life. The third component in DBT is interpersonal effectiveness, which is a lot of skills about managing relationships. So both being assertive but also trying to learn how to validate other people when it's appropriate to or to set boundaries and establish or self respect, as well as managing conflicts and building new relationships as well. And the final component of DBT is what we call distress tolerance, which is a lot of crisis management skills. So distraction techniques, breathing exercises. And a huge component of this section is also radical acceptance, which is accepting things that cannot be changed, accepting things the way they are. And that's often a very challenging part for people in therapy. But the very core idea of DBT. So DBT is typically a therapy that's given over about a year and has been shown to be very effective, particularly for suicidality, self harm. And depending on how you read the literature, certain other elements of BPD as well. So that's the most common type of psychotherapy. But there's a number of others. So mentalization based treatment focuses on the capacity that somebody has to recognise the internal states of other people as well as themselves. So be it. Emotions, thoughts, impulses and the work in that sort of therapy is focused on practicing and developing that is built. It's kind of emphasise as a muscle that you continue to develop, to develop with treatment and it also includes individual and group therapy, other types of therapies such as transference, focus therapy, take a more psychoanalytic approach and focus on the relationship between the therapist and the patient and the expectations that the patient might have of the therapist. But this is just a few of the psychotherapies, and there's a good dozen more that I probably can't talk about in much detail because I don't know them enough.

   Dr. Ronald Fraser: [00:21:07] I actually wanted to share a clinical point that has absolutely nothing to do with your question, but popped into my head as I was listening to Dr. Biskin, and it's related to actually to diagnosis. So oftentimes one of the reasons I see people who have never been diagnosed with BPD that have BPD is because they lack one of the nine criteria. And if they happen to be an individual that has never had a past suicide attempt, does not engage in self harm. For some people, for some reason, clinicians feel that this is an essential component of BPD, and if you don't have that, then it's like exclusion criteria. But there's up to 20% of patients with BPD actually don't don't have that criteria. So often these patients will not get picked up and not get identified as having borderline personality or even if maybe they have eight, all eight of the other criteria. So I think that's actually an important point for learners and for trainees to realise that just just because of the absence of suicidality and self harm, that doesn't necessarily mean that this individual may not have borderline personality disorder.

  Dr. Sarah Hanafi (PGY3): [00:22:35] Thanks for that clinical pearl, Dr. Fraser. So I wanted to go back to the topic of therapy after that. So bouncing off of the discussion that we've just had about psychotherapy. Could you maybe discuss the role of pharmacotherapy in treatment for these patients, for example, in in terms of how different medications can be used to target the different symptoms that we may commonly see them present with?

   Dr. Ronald Fraser: [00:23:00] So this is actually. Probably one of the areas of greater controversy. If you look at the treatment guidelines that come out of, say, the U.K. and compare and contrast treatment guidelines that come out of North America with the APA, there's tremendous differences of opinion on the role of medications. There certainly can be a role. I think everybody agrees that there could be a role for medications. There's no medication that has an indication or treatment of any personality disorder. So they're all used off label. Often the approach is symptom focused. So for example, there are certain medications that one might use for impulsivity. Other medications that people or the exact same medications that people might use for mood stabilization or for anxiety or for insomnia. There's another whole set of medications, obviously, that might be indicated for comorbid conditions, and those have much more robust evidence. One of the things that's always sort of of concern and, you know, I've seen hundreds of patients and so I've seen patients on zero medications and I've seen patients on 12 different medications. And there isn't necessarily much in the way of clinical differences in terms of their outcome. And there's other patients know, you give them one medication and they really find that it makes an a profound impact on one domain. So perhaps there's a diminishing of their anxiety, and that really makes a significant difference in their quality of life. But the main concern that we often have as clinicians is that we see polypharmacy where there's one medication added and maybe there's a little bit of benefit, but it's not certain. And so then another one is added maybe targeting a different symptom or trying to augment the first medication. Very seldom medications are taken away and then gradually over time, you get you find a situation where you're on a 10 to 12 different medications, including medications to treat the side effects of the original medications. You're not entirely sure how the heck we got here, and you're certainly not sure how are we going to get out of here? So you don't like today? I had a follow up appointment with patients, which of course was done virtually because we're in the middle of a pandemic. She joined our program in January, and since she arrived in January, we've been gradually trying to clean up her pharmacotherapy. She's been since let's we're September, so that's nine months. So in nine months we've taken away one at a time. And so she's been taken off lithium. Let's see. So when she started, she was on three mood stabilisers. One of which was lithium, two antipsychotics, two antidepressants, two sleep aids. And so we've removed lithium. Epival, Emmavain, regular Seroquel, Seroquel, XR and Zoloft and Wellbutrin. And her clinical condition is no different, except she has a lot less side effects. So it's complicated and every patient is different. Some patients have a significant response. Very rarely is there like symptom remission. So if you're treating anxiety, it's very rare that they're going to describe, you know what, I'm no longer anxious. I don't have any anxiety. But their anxiety might go from 10 to 8 or 8 to 6, and that may be clinically significant. Even though you don't have remission of the particular symptom, you may have taken enough of the edge off that it makes a difference in their quality of life and perhaps allows greater functioning.

  Dr. Robert Biskin : [00:27:21] My opinions about pharmacotherapy are probably a little stronger than Dr. Fraser's. I'm not particularly fond of pharmacotherapy for patients with BPD, and there's evidence that the medications themselves are of generally limited value. And when you look at the literature, the research, the better quality of the study is, the less likely it is to show any benefit over placebo. And this has been shown now with a number of different agents, Zyprexa, Lamotrigine or two that come to mind with recent examples. So I'm skeptical of most of the medications because again, these are most of the medications we use in psychiatry do have a substantial side effect burden. And as well, one of the things that I'm always concerned about is toxicity. So I'm highly concerned about people who are, for example, on mood stabilizers and things like that where the risk, if they overdose on it is quite profound. So I'm very reluctant to prescribe these medications and will often do prescribe medications as well. I tend to if in situations where, for example, anxiety or things like that Are Significant, depressive symptoms are really getting in the way. I occasionally do prescribe medications more than occasionally. Sometimes we'll prescribe medications, but often it is ones that are lower risk, less side effect burden as well. And interestingly, there's been one study that showed that when you prescribe medications for depressive symptoms with people who are actually in the program, the people who receive medications actually did worse. Which is fascinating. And it interestingly fits with my clinical opinion perspective as well in that sometimes people wish or hope for the medications to be the solution because it seems easier to take a pill than it does to do therapy because therapy involves a lot of hard work, whereas the pill, the side effects are not immediate. You're not going to feel anything immediately after taking it. So they might prioritise taking medications as solutions as opposed to therapy. So sometimes emphasising medications too much or people focusing on medications too much lessens their focus on actually making the necessary therapeutic changes and committing themselves to the to the process of psychotherapy. So again, I do use medications on occasion, again, lower typically lower risk medications and again, always monotherapy stopping the medications if they're not effective, sometimes medications for sleep as well, but more or less, less frequently.

   Dr. Ronald Fraser: [00:30:05] Yeah, I wanted to actually emphasise this point because I think it's really key in Western society. We have a real love affair with medications and we have this sort of belief that we should never feel any physical or psychological discomfort and if we do, there should be a pill for that. And. As Dr. Biskin points out, it can actually prevent people from engaging fully in the therapy because of their never ending quest for just the right medication or just the right combination of medications. People's belief that there's got to be some medication or combination of medications, and we just haven't hit it yet. And that's going to resolve. All my distress can can really be quite remarkable and it can be very difficult, despite providing tremendous psychoeducation, that that's unlikely to happen. We know from the literature that medication is not likely to be that beneficial. And we know from the literature what is likely to be beneficial is psychotherapy, which sadly is a heck of a lot of hard work. And I think that it can't be emphasised enough but dynamic.

  Dr. Robert Biskin : [00:31:35] In  my opinion, it often comes back to this idea about trying to the self and validation that people have learned that they're not supposed to feel things, so they will seek out whatever it might be, including prescribed medications, if they're feeling sadness, if they're feeling anxiety, to do whatever they can to make those feelings go away. Many of the patients that I've worked with have said that they wish that they could turn off their feelings if possible, but that's not actually possible in psychotherapy. It's a very clear point that you have to live with your feelings. You have to learn how to cope with them and how to be with them instead of trying to make them go away.

   Dr. Ronald Fraser: [00:32:14] Which, of course, is what leads so many patients with borderline personality disorder to develop substance use disorders because there's no more effective short term solution to negative affective straights than intoxication. Unfortunately, it's a spectacularly poor long term solution, but it's the same principles.

  Dr. Sarah Hanafi (PGY3): [00:32:37] I actually wanted to address something that you had briefly mentioned earlier, Dr. Fraser, in regards to comorbid disorders. How do you approach treating comorbid disorders in this patient population?

   Dr. Ronald Fraser: [00:32:50] So my perspective on this has actually changed over the. Decade and a half. And so this is more personal opinion than anything else. So I think we should have that caveat early on in my career. Saw tons and tons and tons of co-morbidities. Now more and more I conceptualise things as really it's part and parcel of the personality disorder and that really is what needs the focus of attention. There are some exceptions to that. So occasionally I have that conceptualization and then I see them, a year into treatment and they're fluidly manic. And I say, okay, we missed that. That's what's pretty clear that they have bipolar disorder, and that happens about once every 75 patients or something like that. I think the most prevalent comorbidity that I see is substance use disorders. And despite being an addiction psychiatrist, we don't do a great job of treating that. We're not even though we recognise it, we see it. I really wish we did a better job of that. I think the next most prevalent thing that I see is probably things in the eating disorder spectrum. A lot, a lot of very clear comorbidities there. Oftentimes patients we struggle with, we'll refer to the eating disorders program, patients that they struggle with, they'll send to us. And sometimes we have success with theirs and they have success with ours. Different interventions and perspectives resonate with different patients. Anxiety and mood disorders are described as very prevalent comorbidities, but I'm less and less convinced of that as as my career goes on, to be perfectly honest, that I don't think I see it. And I may be seeing a bias sample. And then, of course, trauma related disorders are quite common because unfortunately, many of these patients have had very difficult backgrounds, some of which are just literally horrific. And and often it would be shocking if they didn't have a trauma related disorder, given their experiences. So I think those are the sorts of things you see. The good news is, is that many of the treatments for borderline personality disorders, many of the psychotherapies, also have a certain amount of effectiveness for other things. So if you are suffering from a substance use disorder or trauma related disorder, distress tolerance is a super useful skill, right? If you're suffering from different disorders, usually they're impacting on your interpersonal functioning. So improving that is tremendously helpful. So you don't necessarily have to change the interventions regardless of the comorbidities. But I do think you need to be aware of them. You need to be cognisant of them, and that may sometimes inform your pharmacotherapy in particular.

  Dr. Robert Biskin : [00:36:15] I would. I definitely agree with what everything that Dr. Fraser has said and I'm also of the mindset and perhaps slightly controversially so that a lot of the mood disorder symptoms, the depressive symptoms, the anxiety symptoms are often manifestations or components of the person of BPD as part of those difficult or dysphoric states. The comorbidities that are the ones that are most concerning and will lead to changes of treatment really are the substance use disorders, particularly if more severe. And it's that point that I'll refer people to Dr. Fraser, but as well the people with the severe eating disorders and I've seen quite a number of cases of people who once, for example, when they have an anorexia and once the anorexia becomes quite impairing and consuming of somebody's life, it's very hard to pull back from that without the structure and specialised support that eating disorder programs are able to provide. Other disorders. I've had patients in my clinics who often younger patients who at a certain point will have psychotic episodes that will persist for time. And at that point, clearly we have to revise the diagnosis to a psychotic disorder or something like schizophrenia, which dramatically changes the treatment approach. But for many of the more garden variety mood or anxiety disorders, I completely agree that treatment for BPD, whatever that treatment might be, is shown to be efficacious. People's symptoms of depression, anxiety with specialised psychotherapies will reduce will improve as well.

   Dr. Ronald Fraser: [00:37:58] I just want to add one last point, because I think this is actually Dr. Biskin touched on an important point, that it's important to contextualize for learners about the controversial aspect of these things and that I think you figured out by now that what we say is not necessarily gospel. So you can have the same patients who Dr. Biskin and I might clearly conceptualise as having borderline personality disorder. And you could have one of our very respected and revered colleagues in a mood disorder clinic who would say, Look, Fraser doesn't know what he's talking about. This is clearly bipolar spectrum disorder. And you know, it's not clear that I'm right and they're wrong or vice versa. And I think that's where it's really important for learners to decide for themselves what makes sense for them, what they think is going on, and recognising that everything you hear from me and Dr. Baskin consciously or unconsciously, has a certain bias based on our training, our background, our experience, all of those factors. And if you had two other people here with different background training and experience, you might get very different answers that might be equally or even more valid than what we're sharing.

  Dr. Sarah Hanafi (PGY3): [00:39:31] I'm really enjoying this this discussion. I think it's bringing up some really interesting points. I actually wanted to circle back to something you had mentioned, Dr. Biskin, about safety risk. Briefly, I was wondering, can you just talk about how you approach managing safety in this patient population?

  Dr. Robert Biskin : [00:39:51] Boy, that's not an easy question. Much like Dr. Fraser is mentioning about different diagnostic approaches and different diagnostic thresholds. I would say the same applies for thresholds, for accepting risk, because you'll get many different answers for many different people. I would most clearly say that I accept a higher threshold of risk, fortunately or unfortunately, than many of my colleagues who don't work with this population. And it's something that is a particularly tricky question to answer. And I guess, as I pointed out before, for learners, it's something that you would be very careful to discuss with whoever it is that you're working with as time goes on, because you'll get very different perspectives. My particular approach or understanding is that people with BPD, they suffer a lot. And the idea of suicide, because I'm assuming that's mostly what we're talking about. The idea of suicide is something that's pretty much constantly present because it's the escape hatch. If there's a lot of pain in their life and they're doing everything they can to control it and it's just not working, it's sometimes reassuring. Your comforting to know that suicide is there as a backup option, which is very both comforting for patients sometimes when they're thinking about that and also terrifying for them as well, because many times that's not the path that they want to take unless it's absolutely necessary. So accepting the risk that there might be, which is a chronic risk, but people working with this population or in general mental health problems, that accepting that suicide might be a risk is part of the treatment. And it's one of the challenges with when you're deciding what to do with somebody who's presenting in the emergency room. It makes it very challenging because what we know that reduces that suicidality is specialised therapies that exist as on the outside. We don't really have evidence that hospitalization and the treatments provided in a general psychiatric inpatient unit are able to reduce suicide in the same way or suicidality in the same way that the outpatient psychotherapies are. So it's a very difficult question to answer.

   Dr. Ronald Fraser: [00:42:18] So one of the things I would add is that, you know, if you don't want to have a patient die, you probably shouldn't go into health care because it's unfortunately an occupational hazard. Our job is, wherever possible to minimize the prevalence of that. But certain populations have higher risks than others. At certain populations are more unpredictable than others not. You have to have a certain tolerance of uncertainty and a certain tolerance of risk to work with this particular population. And not everybody has the temperament or disposition for that, which is fine. I don't have the temperament or disposition to work with other patient populations. I think it's super important to try to differentiate between chronic risk and acute risk. So, you know, I have patients that are, you know, are thinking about suicide every single day. And and as Dr. Biscuit points out. That can be perversely comforting because it actually gives them a sense of one thing in their life that they have control over. I can choose to kill myself or I can choose to not kill myself. I have control over that. I may not have to feel like I have control over anything else. And one of the rewarding things is that as people respond to therapy, you know, often with tears in their eyes, they'll say, you know, I haven't thought about end of my life in months. It used to be my daily companion. So that actually does respond to therapy, as he pointed out. But then there can be acute risk on top of the chronic. And that's where you sort of have to be cognisant of picking that up. And so particularly in acute crises, often if there's a loss of a significant relationship because relationships are so important to people in general and this population in particular. So the the loss of a therapist, whether it's through the end of therapy or if they've had the misfortune them, I've had patients with their therapists have died. So that's difficult or they've been kicked out of the therapy for whatever reason, or there's been a loss of a loved one or a relationship or a pet if there's been some other acute stressor. If you see in your patient that there's a profound clinical change, it helps if you know the patient really well. It's like, okay, this is like they're really disorganised or they're really struggling or they're really like severely dissociating or severely regressed. There's something acute going on here that's that is alarming. Then you're concerned that their chronic risk of suicide may have escalated acutely and you may need to make significant differences in your treatment plan in terms of brief containment and a brief intervention unit or a very short admission until that acute situation stabilises itself. And you may still discharge them with suicidality, but it will be back to their chronic state, not the acute state.

  Dr. Nima Nahiddi: [00:46:09] And so to finish off and building on our discussion, which we started in the diagnostic episode. Can you both speak on stigma and Treatment of patients with borderline personality disorder?

   Dr. Ronald Fraser: [00:46:19] So that's a big thing and it's less of a thing than when I started. So we're making headway. We've got a long way to go. But when I started the idea that there would be groups for loved ones and concerned others, for people suffering from a borderline personality disorder, like there's a whole network in Ontario of these things. We have Quebec here in Montreal, like the fact that there would that these would even exist was like unheard of. So we're still making headway. There's been a lot of education in the media that didn't use to exist. There's still a lot of bad information out there, as Dr. Biskin touched on in the last session. So the Internet transformed the world. But it's not all positive. And there's a lot of really. Misinformation. Know, I think that's sort of a buzz word for 2020 is misinformation. And so it's really important to try to direct our patients to reliable sources of information. For me, the National Education Alliance for Borderline Personality Disorder is a web resource that I often direct patients and families to. There's a lot of Biblio therapy that I direct people to. So you try to explain that there's just like everything else, the world is good and bad information. But the biggest challenge is, I think, still. Is stigmatization within the health care network. So the reception these patients get when they go to the emergency room. Is often far less than ideal. And many of my patients are smart people and they started to figure out I get a much better perception or reception story if I tell them I have schizophrenia or bipolar disorder, or I tell them I'm having auditory hallucinations. They sort of learn because it's aversive. To present with borderline personality disorder. And I've had patients that have engaged in self-injurious behaviour and they need sutures like that's the medically indicated treatment. And and the emergency room physician will say, you know, if you like pain so much, maybe I shouldn't give you any lidocaine or any anaesthetic or The emergency room physician who have a very difficult job, don't get me wrong, but it's very frustrated and says, you know, I should teach you to try sutures so that you can just suture yourself. How you can do one handed sutures, I'm not sure. But anyway, so they get abysmal Treatment Often when when they interact with the health care system, that really wouldn't be acceptable for any other human being, let alone any other diagnosis. So where we need to make the most progress is around reducing stigmatization within our own health care networks. And one of the ways we do that, which has also been quite fruitful, is through conferences and education and podcasts like this. You know, there's probably, I don't know, 86 people other than my father that are going to watch this podcast, but they will learn something from it. And these things make a difference over time. Maybe underestimated the numbers.

  Dr. Sarah Hanafi (PGY3): [00:50:09] We we have more listeners than that, but.

  Dr. Robert Biskin : [00:50:14] So to add to to what Dr. Fraser was saying. I do agree that the health care system is one of the sources of a lot of stigma. And I do think that one of the things that has changed and has helped improve the amount of stigma, particularly within mental health care, is greater accessibility to these specialised treatments. So the programs that Dr. Fraser have established and that Dr. Paris have established here in Montreal has helped people change their perspective and seeing that the beliefs that they have about these these disorders are not necessarily accurate. And unfortunately, not every region, not every city has access to programs like we do. Obviously, I think they should. And I think that both education information and advocating for increasing services and increasing recognition of the disorder is something that will help. And this is where I get concerned about people who might label BPD as another psychiatric disorder, such as the comment that Dr. Fraser made last time about the overlap between criteria with complex PTSD and borderline personality disorder, that one of the potential outcomes of that is that it might further stigmatise borderline personality disorder that might think of it as the unwanted illness, even though the symptoms are almost exactly the same. So further awareness and access to the disorder and to the treatments for it, I think is something that over time will help improve the perception within the health care system as well.

  Dr. Nima Nahiddi: [00:51:58] A huge thank you to both of you, Dr. Biskin and Dr. Fraser. I certainly learned a lot myself. Do you have any closing remarks for our listeners?

   Dr. Ronald Fraser: [00:52:07] Well, I think we both are really appreciative that you invited us. Obviously, hopefully it came through that this is a topic that we're both pretty passionate about. We've chosen to devote our careers to this and any opportunity we get to sort of share the gospel, we're really tremendously appreciative to have the opportunity. So thank you for expressing an interest in it and having it as a topic in your podcast series. And thank you for inviting us. We really appreciate it.

  Dr. Robert Biskin : [00:52:40] Thank you very much for inviting us. Definitely something that is not just passionate for us, but something that we genuinely enjoy as well. So any chance that we get to talk about it and to kind of share some of that, that enjoyment that we have with working with these sorts of problems and people with these sorts of problems, we're thrilled to do it.

  Dr. Nima Nahiddi: [00:53:01] Thank you both once again.

  Dr. Sarah Hanafi (PGY3): [00:53:03] Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sarah Hanafi, Dr. Nima Nahiddi and Audrey Le. Audio Editing by Audrey Le. Our theme song is Working Solutions by all live music. A special thanks to the incredible guest, Dr. Robert Biskin and Dr. Ronald Fraser for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org Thank you so much for listening.

Episode 32: Diagnosing Borderline Personality Disorder with Dr. Robert Biskin and Dr. Roland Fraser

• Episode 32: Diagnosing Borderline Personality Disorder with Dr. Robert Biskin and Dr. Roland Fraser

  Dr. Hanafi: [00:00:09] Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. In this episode, we'll explore a topic that I'm certain will be of interest to many of you. Borderline Personality disorder or BPD. In the first part of this episode will touch on diagnosing borderline personality disorder and in part two will review treatment. I'm Sarah Hanafi, a PGY 3 at McGill University, and I'm joined by Nima Nahiddi (PGY3), a fellow PGY 3  McGill.

  Nima: [00:00:40] Hi, I'm Nima.

  Dr. Hanafi: [00:00:41] We're also joined by Audrey Le, a fourth year medical student at McGill. Everyone, we're very grateful today to have our guests, Dr. Robert Biskin and Dr. Ronald Fraser, to share their expertise. Dr. Biskin, why don't you introduce yourself?

  Dr. Biskin: [00:00:59] Hello. My name is Rob Biskin. I'm a psychiatrist. I work mostly at the Jewish General Hospital, as well as at the McGill University Health Centre. I'm an associate professor at McGill, and I work mostly in personality disorders, as well as the general inpatient setting.

  Dr. Hanafi: [00:01:18] And Dr. Fraser, why don't you introduce yourself to our listeners?

  Dr. Fraser: [00:01:22] Thank you for the kind of invitation. I'm Ronald Fraser. I'm also a psychiatrist like my colleague, Dr. Biskin. I split my time, half time work as an addiction psychiatrist, running the withdrawal management unit at the Montreal General Hospital. And the other half of my time is leading a team that treats severe and persistent treatment resistant borderline personality disorder. And I'm an associate professor here at McGill and adjunct professor at Dalhousie University in Halifax.

  Dr. Hanafi: [00:02:04] During today's episode will touch on several learning objectives. One list the DSM five diagnostic criteria of Borderline personality disorder or BPD, two recall the epidemiology of BPD, Three Consider the risk factors and posited causal mechanisms for BPD, including developmental and neurobiological mechanisms. Four discuss the clinical presentation of BPD in different clinical settings, including the emergency and outpatient settings. Five Recognize the differential diagnoses for patients presenting with BPD. Six, List the common comorbid psychiatric and general medical conditions with BPD. Seven, Discuss the common diagnostic challenges and pitfalls. And finally. Eight, Explore the stigma surrounding the diagnosis of BPD and discuss a therapeutic approach to providing psychoeducation to patients with this diagnosis. Now let's get started. 

  Dr. Le: [00:03:02] Before we dive into things. I thought it may be helpful for our listeners if we first defined what a personality disorder is per DSM five or the Diagnostic Statisticians Manual. A personality disorder is an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture and is inflexible and pervasive across a range of social situations. Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute personality disorders. Now, in the DSM five, Borderline Personality disorder specifically is described with nine diagnostic criteria, of which at least five must be met to make the diagnosis. These criteria include frantic efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships, identity disturbance, including a persistently unstable self image, impulsivity, and two or more areas such as spending, substance use and sex, recurrent suicidal behaviour, gestures, threats or self mutilating behaviours, affective instability, chronic feelings of emptiness, inappropriate and intense anger, and finally transient stress related paranoid ideation or severe dissociative symptoms. So with that, I think it would be helpful for our listeners to understand whether in practice there are other associated features that are typically found. Maybe, Dr. Biskin, if you could speak to this.

  Dr. Biskin: [00:04:49] Sure. The DSM obviously gives a good presentation of the main symptoms. And we have a lot of research that's developed over the years to kind of that really gives a clear picture that it is a unitary construct, BPD and all the symptoms really kind of go together. But one of the things that it really doesn't capture adequately is to some extent the the just negative affective states how unwell people with BPD often feel. So if you look in the appendix of the DSM five, you'll see that they include an alternate model for personality disorders. And one of the nice features about that alternate model that's not captured in the current model that we use now is to some extent the amount of just angst, anxious mood, depressed mood and those sorts of components that are just really prevalent for people with BPD, they just feel unpleasantly bad a great deal of the time. There are moments when they feel better, but I think that those dysphoric states are really one of the associated features that's not fully captured.

  Dr. Hanafi: [00:05:56] So I think that one thing that many learners, including myself, struggle with, is trying to distinguish BPD from other conditions, such as primary mood disorders, post-traumatic stress disorder, or other personality disorders. Could you perhaps share with our listeners how you approach making this diagnosis and how you differentiate between BPD and other conditions with overlapping features?

  Dr. Fraser: [00:06:20] So maybe I'll tackle that one. It's an excellent question, Audrey, And it's not just about differentiating it from other conditions, but also trying to determine what, if any, co-morbidities they may have. And it's not unusual for people to have comorbid conditions. So. So, for instance, you might see somebody in the emergency room and either withdrawing from substances or intoxicated on substances, and their presentation may resemble a great deal of personality disorder. But you have to try and tease out and determine, is that a state feature of of either the withdrawal or the intoxication or is it a trait? And it's a more persistent thing. So it can be difficult to tease out all these things. And that's where it's really important to try to resist looking at things. Cross sectional, see what's happening in the moment and try to have, if at all possible, a more longitudinal perspective. And that can be certainly easier said than done in many instances. If it's the first time you've ever met an individual or assessed an individual. But if you've had the opportunity to follow people over time, often that will certainly clarify itself. Oftentimes what I see people for the first time, I may have a lot of uncertainty as to what the exact diagnosis is. Human beings are fairly complex systems and creatures. Sometimes collateral history can be tremendously informative if that's available. But often what you want to try to do is get from the patient themselves sort of what's happening in the here and now, but also try and contextualize that by having a sense as to the more longitudinal history, which often sort of goes back to adolescence and getting a sense as to are these isolated issues or have these been really quite longstanding. And I think that can be tremendously helpful because many of the symptomatology can be somewhat non-specific. So, for example, if you look, the DSM five doesn't actually have complex PTSD as a formal diagnosis. But if you look at the proposed criteria for complex PTSD, it's pretty much the same criteria as borderline personality disorder. It's problematic when you have two conditions with the exact same criteria. So it can be really difficult to determine how you're going to conceptualize something. But I think if you take a careful history, if you have some humility about the fact that you may not have all the answers in the here and now and work collaboratively with the patient to try and tease out what is going on. And often my experience has been if you review the diagnostic criteria of borderline personality with an individual, a lot of it will often profoundly resonate with them and be in fact extremely validating. And they'll say, Wow, you know, is my picture in there or something to that effect? And sometimes they're right, and sometimes it may resonate with them, and it still may in fact not be the correct diagnosis. So you have to be prudent about that. But I think those is sort of the general approach as to how we try to tease these things out.

  Dr. Biskin: [00:10:17] If I can, I would just add to what Dr. Fraser says, that I completely agree with his points and working on an inpatient unit. One of the things that that I'll often see is that when you take that cross sectional approach, you'll often see patients that look like they have a lot of symptoms of personality disorders, be it narcissism, borderline personality disorder, antisocial. And just based on that cross sectional presentation, you might be misconstruing a manic episode or a psychotic episode. Sometimes people have worked with people who have very severe depressive episodes and they look quite dependent. But again, that longitudinal history and kind of exploring how people change over time really with those symptoms that go back to adolescence is is really very crucial. I would also add that there's a few little tidbits that are sometimes a bit helpful in distinguishing some of the disorders. So, for example, sometimes I would find that people with bipolar disorder, they often report a lot of. Manic episodes. There's a great deal of elation for people with BPD. It's tends to be less likely. Elation does occur, but it's not as present. It's not present for as long. And when the mood shifts happen, that is characteristic for both disorders. The mood shifts in BPD tend to alternate between a lot of sadness, anxiety, anger. Again, much more of those dysphoric states in terms of, I guess, even some of the elements of PTSD, the chronicity and the timeline of the symptoms is something that's quite important as well. And it becomes much more this is true for all personality disorders, that it's global across multiple domains. So having symptoms with just one particular type of situation or one particular environment is less likely to be associated with a personality disorder, whereas people with personality disorders do have problems in many areas of their life that cause them difficulty. So that chronicity and the kind of global nature disorders, this is one thing that I find distinguishes it from some other disorders.

  Dr. Fraser: [00:12:28] Sort of to to add on that. One of the things you noticed, particularly in my line of work in addiction psychiatry, is you'll see somebody that meets all the diagnostic criteria for personality disorder. But if you treat the underlying condition effectively, the the other psychiatric conditions, suddenly those features will all disappear. So you may have somebody who has a severe opioid use disorder who engaged in all sorts of anti-social behaviours because they have a four or $500 a day habit. You put them on methadone or Suboxone or some appropriate treatment for their opioid use disorder, and they no longer have to support that habit and all those antisocial behaviours go away. And then there's other individuals, you treat them with methadone and they continue to engage in all those antisocial behaviours. And so that can really be essential in trying to determine what you're observing and whether it's an underlying personality disorder that requires treatment or this other condition. If it's effectively treated, then those other features effectively resolve.

  Dr. Hanafi: [00:13:49] Thank you for both of your very thorough answers regarding my question. My next question was, you know, who typically suffers from this disorder? Or in other words, what is the typical epidemiology of BPD?

  Dr. Biskin: [00:14:05] So typically the epidemiology for BPD, it's common. It's about 1 to 2% of the population. And there is some variation between different parts of the world. So certain areas, for example, East Asia might have a slightly lower rates than certain parts of Europe and North America. But in general, North America, it is about 1 to 2% of the population, North America and most of Europe. It despite what we see in clinical practice, where in general women present for treatment more frequently than men in the population, the prevalence is approximately equal. And in terms of other aspects of life, socioeconomic status and things like that. People with BPD, it's across the spectrum. So anybody can have BPD.

  Dr. Fraser: [00:15:01] I think it's to touch on the point that Dr. Biskin had. The vast majority of patients that we see are women. And to some extent, that's because depending on gender, these patients tend to have different trajectories. So female patients with BPD often are in the health care system, male patients with BPD who may have the exact same behaviours or struggles often end up in the legal system. And often the women are in hospital and the men are in prison. A given behaviour society reacts very differently based on what your gender happens to be. It's also important to realise the vast majority of people with BPD we never see. So if it's 1%, let's say it's 1% of the population. That means in Montreal there are 30,000 people with borderline personality disorder. We see a tiny fraction of that. So basically it has the same prevalence as as individuals with schizophrenia. And certainly we we don't see anywhere near those sorts of numbers. So the vast majority of people don't seek treatment. And I don't know about Dr. Baskin's experience, but my experience is unfortunately, the clinical population that we treat. Does not represent the diversity of the city. So we're not seeing the sort of diversity of different cultures and ethnicities that we would anticipate when we look at the demographics of a city like Montreal. And I think that is worrisome. And that's something that where we need to make greater inroads.

  Dr. Biskin: [00:17:00] I don't have I don't have the numbers to say exactly about the diversity in terms of the clinical population that we see. But I can say that there is a fair degree of diversity, probably not fully representing the the the full diversity accurately of the city. But I would say that there is a fair degree of diversity. One other thing that I would probably add as well is that BPD, although it is occurs across all ethnicities and socioeconomic backgrounds, it is more likely because of family history and genetic risk to be more commonly associated with people in lower socioeconomic statuses as well. And it is quite likely that people with BPD or it is known that people with BPD do tend to have kind of that same downward drift that we see with other psychiatric disorders that they tend to have more difficulty with occupational functioning, be more likely to require financial assistance and things like that. But yes, I'll completely agree with Dr. Fraser that more inroads with communities is always a good thing.

  Dr. Hanafi: [00:18:08] Going further with that. How would you say the epidemiology evolves over a patient's life span? Or in other words, how does it change as they age?

  Dr. Fraser: [00:18:18] So maybe I'll tackle that one first. So. In general. This is a disorder that has a relatively good prognosis in that it tends to improve with age, which is not necessarily the case for the vast majority of DSM five diagnoses. So it tends to have onset in adolescence or early adulthood. Many people seem to begin to develop the disorder around puberty, and as you age, many of the symptoms actually diminish and improve. And often by the time you're sort of in your thirties, you often no longer meet the diagnostic criteria. Now, the problem can be, however, you may not meet the diagnostic criteria, but you may still have residual symptoms that are subthreshold but still contribute to quite significant disability. Also, something that's problematic for many of my patients that no longer meet the criteria during the more acute phase of their illness, when they are much more symptomatic, often as a result of a variety of things. They've burnt many social bridges and are often unfortunately estranged from either their children or their extended family, have really have significant academic sequelae and have not been able to complete their educations. They've had significant occupational consequences. And so there can be significant disability even with remission. The other good news is, though, once you remit, you tend not to relapse. So it tends to be quite consistent. Once your symptomology has improved, it tends to stay improved.

  Dr. Biskin: [00:20:27] I have very little to add. I completely agree with Dr. Fraser, of course, again. And just to provide some numbers to that. If you look at like 20 year data sets of longitudinal follow ups, over 95% of people will have periods of remission from the diagnosis where they don't meet criteria anymore. But again, as pointed out, the functional problems remain notable and only about 60 or well, frame it positively, 60% of people do have good functioning. When you look at follow up 20 years later, so that's more than half. But there's still a large amount of people who do have functional problems. And trying to find ways to continue helping those people and improving their functioning is, in my opinion, a very important area for treatment.

  Dr. Hanafi: [00:21:20] I guess looking more at early in life, what are some explanatory models for why someone develops borderline personality disorder?

  Dr. Biskin: [00:21:29] So there's a lot of different models, and it's a difficult question to answer because to some extent the models for the development of BPD depend on your theoretical framework for treatment of BPD. Given that I am more comfortable with dialectical behaviour therapy, I'll give the answer for how BPD develops. So the idea behind how BPD develops is that people are born with a genetic risk for emotional instability or liability. What Linehan would call affective dysregulation so that as a child you might be a bit more difficult to sue, you might be more likely to cry as a baby and. Be more unpredictable in your response. Now, normally parents would be able to adjust or caregivers would be able to adjust and provide a bit more support and reassurance and security in the situation where there is a combination of a child who's difficult to soothe and the parent figures who aren't, who don't have the capacity to provide that support and soothing to help the child learn to manage their emotions. The parents might respond by. Saying that the emotion is not okay, the emotion is not appropriate. In other words, they'll say you're not really sad to the baby or it's not to the child. It's not a big deal what you experience. Don't worry about it. Just keep going. Push through or that often will take much more serious forms where the child would be neglected and completely ignored. They're having emotional difficulties. They could be responded to with physical abuse. If the child is crying too much, they might be hit and this would lead to the child learning that their emotional states are not worth listening to. They're not valid, they're not appropriate. And as the child continues to grow up within the same environment, the emotions continue to be present because there is that genetic risk or genetic component of the unstable emotions. But they they learn that they have to use whatever tools are available to them to help them control how they're feeling. And because the feelings are very intense, you often have to use very intense tools to cope with it. And this is what often leads to some of the impulsive behaviours, like using a lot of substances or alcohol or using very intense emotional tools like self harm, which are meant to kind of often use to help people feel or focus on their feelings or numb their feelings. So a lot of these behaviours arise as a way to control the emotions and this subsequently furthers that sense of invalidation that the patient has that my feelings are not worth listening to. My feelings are not valid. I have to do everything I can to make them go away. So that is often the pattern from a DBT perspective that leads to the development of BPD. To add a little bit more to it, there are neurobiological models or neurobiological findings that are associated with BPD that lends some support to the emotional dysregulation component. So the usual genetic findings of the long arm or the serotonin transporter gene, which is associated with almost every psychiatric disorder, it's also associated with BPD. Certain studies have found dopamine receptor associated or specific subtypes of dopamine receptors associated with impulsivity and BPD. And there's also findings on your imaging that suggest a heightened amygdala activity which might be interpreted as a stronger emotional response or threat response. So certain biological findings, although there's obviously no very consistent single pathway and as mentioned before, a lot of the different psychotherapies have different etiological models for the development of BPD. So for example, mentalization based therapy has a similar style, but uses a language that comes from attachment theory, which basically says that the way that the parents react to the child is often unpredictable. So the child doesn't learn how to predict the responses of the caregiver. And this has a whole series of sequelae for the child as well. So again, there's like a dozen or 20 or so different models for treatment of BPD, and each has their own variation on the similar theme that emphasizes intense emotions and impulsivity, often as core, but not always.

  Nima: [00:26:00] Thank you so much for that answer, Dr. Biskin. Going back to something Dr. Fraser had said about how different people may be presenting to the health care system, I was wondering whether there are different presentations for BPD, for example. Have you noticed differences in presentation when people come to the emergency department or whether they may be on the inpatient setting?

  Dr. Fraser: [00:26:21] Maybe I'll tell a story. I like to tell stories what I'm famous for. So when I came on staff, I had a number of jobs. One was working with the short term, borderline percentage sort of program led by Dr. Paris was international expert that both Dr. Biskin and I have had the fortune of learning from. And my other job was working in the mood disorder clinic. And each Monday we would have mood disorder assessments with the medical students and the residents. And the first ten weeks, you know, ten assessments and nine of them. Came with the same picture treatment resistant depression. They had failed like 12 different trials of different antidepressants. And you can imagine how discouraging that is as a patient where you've tried X number of medications, none of which have had any real, sustained, significant benefit. As Dr. Biskin mentioned earlier, you're still suffering tremendously. You know, you're not comfortable in your own skin, You're dysphoric, you're anxious, you're distressed. Nothing seems to help even though you're reaching out for help. And nine of the ten all had borderline personality disorder that had that had not been recognized, had it not been diagnosed and it not been treated, and they were all being treated for disorders that they did not in fact have and understandably weren't having great results. It's a little bit like, you know, you go in with appendicitis to the emergency room and all the emergency room physician offers you ventolin puffer, you know, you're not going to have a great outcome. So I think that things are better. But oftentimes you're seeing people by the time they get to us still, when you look at their trajectory through the health care system, they've often been diagnosed with a wide variety of different things, failed a wide variety of treatments from very well intended health care professionals. But it's very discouraging for patients and for their families. It's a bit of a marathon, and that's why it's often so validating for them when you go through the criteria with them and they say, Oh my gosh, and they feel understood, you know, for often the first time in their health care trajectory. So that's certainly one of the ways that you see people is in a variety of outpatient clinics. The emergency room is is another place where you see people I think when you're seeing people in the emergency room, you know, if you're seeing me as a patient in the emergency room, I guarantee you you're not seeing me at my best. So I think it's important to remember that when you're seeing anyone in the emergency room, they're they're struggling, they're in crisis. They're not presenting their best foot forward and it's not representative of who they are. 24/7. And you need to contextualize that. So pass it over to Dr. Biskin as well.

  Dr. Biskin: [00:29:53] I completely agree with that point. And I think that's one of the the advantages that Dr. Fraser and I have working in a clinic for people with BPD is that we get to see these patients on a regular basis over a longer period of time because many people will present for treatment when they're in by presenting to the emergency room for suicidality or self-harm, and they might not get immediately directed to treatment, which can be quite frustrating. As Dr. Fraser pointed out, it takes an average of about six or so years until people receive a diagnosis of BPD despite symptoms starting earlier. But when we're in providing therapy and treatment for these people, we're able to see them in a different context, which is often a much more, much more stable and easier or much more enjoyable experience to work with these people in a treatment context where we're able to provide a treatment that's designed for them, designed for their disorder and able to help. Because the bias that we might have just relying on people, the presentations in the emergency room is quite striking. So when we see people in treatment, it's a much more positive thing.

  Nima: [00:31:05] Both of you have spoken about the necessity. For that longitudinal. Approach. When we speak of borderline. Personality disorder and when we're interviewing patients. As a learner. I see a variety of different practices where some psychiatrists feel that BPD diagnoses cannot be made in the emergency Department when patients. Are in crisis. What do you think about that type of approach? Do you believe that the emergency department is an adequate place to make the diagnosis?

  Dr. Fraser: [00:31:45] Well, to take it even one step further, some of my colleagues don't even believe borderline personality disorder is a valid diagnosis, period. So there's. There's some controversy about these things, which is a bit remarkable because it's fairly validated diagnosis. But anyways, I think I think you have to be cautious. Particularly if you're seeing someone in the emergency room for the first time. If you're seeing someone in the emergency room for the 10th time, then you would have ten assessments. And so you have a little bit more context. I think often when we see people in crisis in the emergency room, we many, many people simply defer the diagnosis of what used to be called access to. I think there's also problems with that. I think ideally, if this is in your differential and if you are thinking that this is one possibility, I think it's important to put it as a rule out, right, that it's on your differential that you may not have enough evidence, you may not have as much clinical confidence in the diagnosis as you might ideally want to have, but it's somewhere on your range of clinical suspicions. And I think it's important to reflect that in your consultation. So you may not be able and it may not be prudent to make a definitive diagnosis, but I think it should be mentioned somewhere that, you know, at this point in time, these are the criteria that they meet in this cross-sectional, and we may not be able to comment on whether that is an acute situation or if it's an exacerbation of a more chronic situation, which would be more suggestive that they, in fact, do have the condition.

  Dr. Hanafi: [00:33:50] Maybe it's a good time to to touch on the topic of stigma and a misunderstanding surrounding this disorder. You talked about making the diagnosis. Why is it important to disclose this diagnosis to patients? And any practical tips on how to do it effectively and compassionately?

  Dr. Biskin: [00:34:11] I would like to just go back for a second because I want to expand on Dr. Fraser's comment. I have a slightly different perspective on it, and I'm much more comfortable making the diagnosis of BPD in the emergency room, assuming that the patient is able to provide adequate history or there's sufficient collateral that I'm able to trust. The real shift, in my opinion, comes in making sure that you're changing and adapting the questions to really get accurate information about the longitudinal history and not just the cross sectional. If you are able to get that accurate history, I think that your diagnosis from an emergency room setting, again, assuming good information is just as accurate as it would be for most other diagnoses. And I guess to touch on your point about stigma. The thought that comes to my mind is that we often assume that when we're making a diagnosis of BPD, it has to be a very firm, stable diagnosis, whereas we often are in the emergency room and will make diagnoses of psychosis and or psychosis unspecified, often for first episode psychosis patients to where we're not making a firm diagnosis about whether they have schizophrenia, bipolar induced or bipolar with a psychotic mania with psychosis. And assuming that we have to have a very, very firm convincing, absolutely correct diagnosis for BPD, whereas we don't require that same level of certainty for other diagnoses. I think that's part of the stigma that is inherent about BPD, that people are much more reluctant to make. The diagnosis of BPD, which is associated with poorer outcomes for our patients, is one of the reasons why it takes so long for patients to receive care for diagnosis of BPD. So I think that in general we should be cautious about any diagnosis that's made in an emergency room, whatever the diagnosis might be. But we should make those diagnoses if the symptoms are consistent with that. I forget the other part of your question.

  Dr. Hanafi: [00:36:09] So the other part was just how do you approach it effectively and compassionately when you're speaking with a patient about the diagnosis?

  Dr. Biskin: [00:36:19] As Dr. Fraser mentioned, emphasising that the diagnosis of BPD, although it is stigmatised within society. One of the things that most people don't realise, and this includes many health care providers, is that the prognosis is quite good actually. So I will often encourage people not to look on Google, not to look on YouTube because a lot of the images associated with BPD are again based on that cross sectional image of what people imagine, kind of like the worst case scenario would be like. Whereas the reality is much more complicated and there's a lot more fluctuations that you're able to see. And and people are not just identified by one specific difficult moment. So I think providing a lot of information, providing a lot of information that people don't choose this disorder, they don't choose to have the problems that they have. But it developed out of a reason or developed for a reason. And it's often meant internally to kind of cope with the intense, unpleasant experiences they have. And this is the best that they can do, because again, a lot of the difficulties are ways to avoid the one remaining alternative, which is often suicide. So people I often frame it that people are trying everything they can to keep themselves alive and to make their lives as bearable as possible.

  Dr. Fraser: [00:37:41] I think the other issue that comes from your point is clinicians, typically, because of the systemic stigmatisation of these patients, have a hesitancy to disclose the diagnosis because there's this either conscious or unconscious fear that there's going to be a bad reaction because the system views the these patients as problematic, troublesome, undesirable. So there's this systemic. The stigmatisation that gets internalised by the clinician that the patient is oblivious of. Like they they have no idea. At this point in their career. Unfortunately, they may become very aware of it moving forward as they have more contact with the health care system. But so we have this fear that they're going to react badly because we're telling them something that's really bad news and it's that internalised systemic stigmatisation. You know, I've had the opportunity to disclose the diagnosis to hundreds of patients, and most people are really relieved to finally have an answer. That makes sense. And their families are relieved to finally have an answer that makes sense. I can only actually think of one person to react badly. And she said Borderline. So you're telling me I barely have a personality? No, no, that's not what I'm communicating here. I didn't do a good job. Let me try again. So. For the most part, it's very well received because these patients have been suffering. For often years looking for answers that make sense, often for years. And finally, you've given them something. So that actually gives them hope. And one of the earlier parts of your question is why is it important to disclose the diagnosis? Because what often happens with teams is teams make the diagnosis, but they never tell the patient. And that's sort of the epitome of internalised stigmatisation. It's important to disclose the diagnosis because that diagnosis informs treatment. So we're not going to continue. To give you a pharmacotherapy for conditions that you don't have. And we're going to try our damnedest to connect you with an evidence based treatment that's demonstrated effectiveness for treating your condition. And, you know, when I started my career, that was not the situation. Right. And when I started my career, these patients were viewed largely as untreatable. And the change. In the clinical circumstances, you know, even in the last 20 years. It's remarkable. We have something to offer people. And when I was a resident, we didn't have that.

  Nima: [00:40:58] Thank you for speaking on the piece of internalised stigma. I think it's very important and refreshing to hear, and it's also nice to hear as a learner that there's hope for our patients and there's something that we can do. Do you have any tips or clinical pearls for clinicians who would like to screen for borderline personality disorder?

  Dr. Biskin: [00:41:19] I think in terms of the the comments, the tips that I would say really is that emphasis on longitudinal symptoms and don't get stuck with the cross sectional and don't get stuck with just necessarily what's going on right in this moment, but taking that chance to kind of understand the person's life. Where where are they not functioning? Where are they having problems with their emotions, their impulsivity, etc.? One of the other interesting things I've always been particularly interested in the symptom of emptiness in BPD, and I always find it fascinating how people with BPD with that particular symptom, you'll ask people, Are you empty? And that term will resonate with them very clearly. You ask somebody what it means or what it's like for them to experience emptiness and you'll get a whole variety of different answers. But the term that specific word is just so consistent. And if somebody doesn't understand that word when they say, Oh, what do you mean by emptiness? Is there anything else like it? You just move right on to the next question. They definitely do not have that criteria. And anecdotally, I'd say that the chances of them having BPD go down quite a bit at that point. A couple other tips that I would say is looking at how long the symptoms and the problems have been present. And when you ask people, when do they start having difficulties in their life. The earlier the problem started, the more likely it is to be BPD so or any personality disorder. Two weeks ago, very unlikely if it was since they were like early adolescent or childhood, then the chances are much, much higher. Those would be a little bit of the suggestions I would make.

  Dr. Fraser: [00:43:00] Yeah, I would agree with all of that, and particularly emptiness is is one of the most unique diagnostic criteria for BPD that is not very commonly seen in other conditions. Maybe a couple other personality disorders, but it's really unlike, like, impulsivity. Are you impulsive? That's like spectacularly non-specific. Almost everything in DSM five can have impulsivity as a feature. I don't do this in the emergency room because you sort of have to focus on the crisis and what brought them here. And if you don't, people get upset about that. But when I'm just doing a general assessment, seeing somebody for the first time and they're not in crisis. I often start with the personal history before anything else. And this. This is helpful for a couple of things. So I'm finding out the longitudinal history without them necessarily being aware. I'm looking at the longitudinal history and I'm going to be able to learn a lot about their childhood, their adolescence, their relationships within their family, within peers. I'm going to get that developmental history. So it's super useful for me clinically, but it's also, in my experience, very helpful therapeutically because you give you give the patient the correct impression that you're interested in them as something more than a collection of symptomatology, because eventually I am going to get to sort of a checklist of symptomatology. But by doing that personal, developmental, social history at the outset, you get that context right at the get go and it helps you have a better sense as to when you do get to the FBI and what's been happening more recently. It gives you some some contextualisation of where that fits into the larger picture. And I really do think it helps with the therapeutic alliance. It's not so effective in the emergency room. However, people tend to get frustrated with you because they want to get right to the chase and that's okay.

  Dr. Biskin: [00:45:14] Sorry, just to go back, I do need to add, even though I made that comment about emptiness from a very technical perspective, it's not the most reliable or useful diagnostic criteria. It is that the positive predictive value is a little low. If you want to be specific in terms of which criteria is the most useful to screen for, it varies by study that you look at, but the one that's probably the most useful is to look at the chaotic interpersonal relationships in multiple domains. And this kind of touches on the point that Dr. Fraser made about kind of getting that longitudinal history of their relationships. And to kind of add to that one other thing that I particularly find interesting to understand for patients is how they spend their time. Like, what does a typical day look like for them? This is more useful when initiating therapy, but it's it's quite fascinating to some extent how how people spend their time and how much of their time can be consumed by the challenges that they're experiencing or how how much empty time there might be for them to fill.

  Nima: [00:46:20] Thank you for those clinical pearls. I'm sure they'll be very useful. Lastly, I'm wondering if there are any evidence based screening tools or skills that you know of or use that could help learners who would like to diagnose BPD.

  Dr. Biskin: [00:46:37] I guess I'll answer this one. There's a number of self-report questionnaires that can be used, and depending on which expert you will ask, you'll get different opinions about which ones are the most useful. So one of the ones that I am fond of is called the Borderline Personality Questionnaire. It's a bunch of yes, no questions about 70 or 80. So it's not the fastest questionnaire, but it gives you a with good psychometric properties, it gives you a good chance to make an accurate diagnosis. Obviously, you'll still need an interview. One of the shorter ones is the McClean's, the MSI-BPD. The McClean screening instrument for Borderline Personality disorder, which is nine items that basically takes the DSM questionnaire or the DSM and puts it into questionnaire form, which has okay psychometric properties, but it's much shorter than 70 something questions. One of the tools that we use a lot and sadly seems to have fallen out of favour in the research literature is the diagnostic interview for borderlines where the DIB-Ab are revised version, which is now about 30 years old or so, 25 years old, I think. And it is a semi-structured interview that can take typically about an hour or so to do it. That really covers a wide range of symptomatology. And when you're using the the this diagnostic interview for borderlines, it will kind of select for a more homogenous group of people who have problems, not the standard five out of nine, which creates a rather diverse group of presentations, but you're going to end up with a more homogenous group of people who have a greater degree of symptomatology. But it's good if you want to get very accurate diagnoses. Having said that, most of those are used for research, clinical research and in clinical practice I rely primarily on the interview. The other ones are sometimes used for symptom tracking with so-so data about whether or not they're useful for that.

  Dr. Fraser: [00:48:48] I just talked to people.

  Dr. Hanafi: [00:48:50] Well, thank you so much, Dr. Biskin and Dr. Fraser, for joining us today. I think we can speak on behalf of all of our listeners that we're very grateful to have had this opportunity. And I think we learned a lot about an important topic in psychiatry. We're looking forward to speaking with you again for part two. So listeners, please stay tuned for the next episode on the management of BPD. Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sarah Hanafi, Dr. Nima Nahiddi, and Audry Le. Audio Editing by Audrey Le. Our theme song is Working Solutions by all live Music. A special thanks to the incredible guest, Dr. Robert Biskin and Dr. Roland Fraser for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org, Thank you so much for listening.

Episode 31: Understanding Psychodynamic Therapy with Dr. Rex Kay

• Episode 31: Understanding Psychodynamic Therapy with Dr. Rex Kay

  Jordan Bawks: [00:00:12] Welcome to PsychEd, the Educational Psychiatry podcast by Medical Learners for Medical Learners. If you're a return listener, welcome back. If it's your first time, thanks for checking us out. Today's episode is an introduction to psychodynamic psychotherapy. Your host today are yours truly Jordan Bawks, a fifth year psychiatry resident at the University of Toronto. And I'm also joined by Anita Corsini, a social worker who works in Knowledge, Translation and Exchange at the Centre for Addiction and Mental Health in Toronto. She's a new member of our team and I'm excited to have her co-hosting with me today. She's been working behind the scenes for a number of months now. Our guest expert today is Dr. Rex Kay, a staff psychiatrist at Mount Sinai Hospital and an assistant professor at the University of Toronto. He is the U of T Psychiatry Department modality lead for dynamic psychotherapy and a graduate member and faculty member of the Toronto Institute for Contemporary Psychoanalysis. He's an award-winning teacher of both undergraduate medical students and psychiatric residents. And on top of all that, he's a pretty nice guy who has a stunning book collection, which is a way to win affection in my heart. So I'll let our two colleagues introduce themselves. We'll start off with you, Anita.

  Anita Corsini: [00:01:38] Yeah, I'm really excited to be here. I think you might have mentioned this, but I am a social worker and I work in Knowledge, Translation and Exchange at the Centre for Addiction and Mental Health in Toronto. My official job title is education specialist, and what that means is I develop online training curriculum for therapists and other mental health professionals. Previous to that, the majority of my frontline experience has been working as a counsellor with adolescents and young adults in the field of mental health.

  Jordan Bawks: [00:02:11] That's awesome. We're super happy to have you. Knowledge translation is the name of the game in podcasts, so welcome to your first episode. And Dr. Rex Kay. Why don't you tell us a little bit about yourself, your clinical interests, a bit of your kind of training history and your, I guess, your relationship and interest in psychodynamic.

  Dr. Rex Kay: [00:02:38] So first of all, Jordan, Anita, thank you so much for inviting me to be a part of this Knowledge Translation indeed, the project is so important that it feels like it should have been around for a lot longer than it has been, and I'm really delighted to be a part of this. So thank you for inviting me and I'm looking forward to talking to you. I am a  psychiatrist, I trained at the University of Toronto and psychoanalyst, I trained at the Toronto Institute for Contemporary Psychoanalysis. And as Jordan noted, I'm modality lead for dynamic psychotherapy. What's a little misleading about that is that what I fundamentally am is a general psychiatrist. I trained as a child psychiatrist while I trained as a child psychiatrist. I was told that the definition of a child psychiatrist is somebody who used to treat children. And I'm guilty of that. I used to treat children. Now I work with transitional age, older adolescents, young adults as much as I can. But I've got a general practice ranging from mid teens to mid 80s, and I treat a wide, wide, wide range of psychiatric illnesses. Um, quite happily using whatever comes to hand that's going to help somebody.

  Dr. Rex Kay: [00:03:57] Prominently among that for me is dynamic psychotherapy. But I see myself and I would hope that I am seen as fundamentally a general psychiatrist who uses dynamic psychotherapy a lot, along with whatever else I can. My interests are, I'd have to say, first and foremost, education. I spend a lot of my time teaching. In any given month, it can be up to a quarter of my time is spent teaching in one capacity or another, and I love it. I have a long standing interest in creativity, both in terms of the standard creative arts output, but creativity in living and in work and a strong interest in the arts. I am co-founder of a literary journal devoted to issues of medicine and health Ars Medica. I encourage all of you, here comes the shameless plug. Ars Medica do a search for it. We're very proud of it. It's been going for about 15 years now, and I am proud to also be a co-developer. Along with two colleagues at Mount Sinai of Narrative Competence Group Psychotherapy, a program that uses the writing of narratives in treatment. That's my background.

  Jordan Bawks: [00:05:17] Fantastic. We'll expect some royalties if you get any extra subscribers to Ars Medica, but we'll work out those details later.

  Dr. Rex Kay: [00:05:26] I'll take it up with my co-editors.

  Jordan Bawks: [00:05:28] All right. So I'll quickly go over our objectives for the episode today. Psychodynamic psychotherapy is an enormous topic that you can only do so much with in 60 minutes. And so I would encourage listeners to take this as a kind of teaser. We want you to be familiar, you know, when after listening to this episode, when psychodynamic psychotherapy comes to mind, we want you to be able to sort of have a recognition of what that is, what that means, the kinds of patients that you're going to be that are going to be treated in psychodynamic therapy. So here's our explicit kind of objectives. So first off, listeners should have a sense of what psychodynamic therapy is and a bit of an idea of how it works. Number two, we want you to have an idea of who it's for, what kind of problems it's for, and a bit of a sense of the evidence that supports its use. And third, I hope that by the end of the episode you can compare and contrast psychodynamic therapy to other psychotherapies because there's a large degree of overlap. And that's something that we'll talk about towards the end of our time together today. So let's start at a pretty high level. Rex, why don't you walk us through what is psychodynamic psychotherapy?

  Dr. Rex Kay: [00:07:03] You're starting not only at a high level, you're starting at probably the hardest level you possibly could have. And I just want to note that, you know, you're starting at the hardest level you can and I will remember that because apparently I'm only a pretty nice guy. Let me answer that, Jordan, by actually moving up one level, because whenever I start talking about psychodynamic psychotherapy, I always find I'm starting a little bit too late in some ways. I want to talk about psychotherapy because it's very easy to lose how audacious the idea of psychotherapy actually is in and of itself. Uh, if we, if we go back historically, people probably since language developed. Have gone to other people with problems that we would broadly put in the emotional range. Typically what we expect are people giving advice, what we would call counselling, maybe doing teaching something educational. Often religious leaders would provide a moral slant on it. All of those factors are to some extent or another part of all psychotherapy. We haven't abandoned that, but the notion of all psychotherapies is that in some way we can help people with mental illness and mental anguish and suffering. Just by helping them talk through their problems, feel more deeply. Understand more deeply. And change. And that's audacious. And and it's remarkable.

  Dr. Rex Kay: [00:08:47] And it's only a century and a third old in formal sense. Uh. And it is still, to me, a remarkable human endeavour. And that applies to all psychotherapies, short term, long term, very brief, performed by psychiatrists, psychoanalysts, social workers, psychologists and anybody else that I think we have to start by appreciating that what the attempt here is to use language, relationship, experience together to effect change in the horrible, horrible toll of mental illness and mental suffering. So bringing down from there what is psychodynamic psychotherapy, a lot of what psychodynamic psychotherapy is overlaps with other forms of psychotherapy. But here's my best way of trying to summarise it for you at a basic level. It's about pattern recognition. That people will suffer. And suffer not just anguish, but suffer diagnosable mental illnesses as a result of their patterns of behaviour. Their patterns of being able to process inner experience, emotions, outer experience, process their thoughts and the characteristic patterns at times leads to tremendous suffering, which at times leads to maladaptive behaviour and attempts to cope. So what psychodynamic psychotherapy is about at its most fundamental level is helping somebody gradually elaborate these patterns, collaborate with them in exploring where the patterns come from, to give somebody the chance to alter those patterns and reduce the suffering and illness.

  Jordan Bawks: [00:10:47] Well said. And somehow you didn't even mention Freud.

  Dr. Rex Kay: [00:10:56] That was an error, but the sentry was the reference.

  Jordan Bawks: [00:11:02] That's wonderful. So what I'm hearing in that is that, you know, before we begin even to talk about psychodynamic psychotherapy, it's important to to really root ourselves in the psychotherapeutic endeavour, which is to help people with suffering and including when that suffering reaches the point and fits the sort of pattern of a diagnosable mental illness is to through relationship with another, through talking with another try and. Transform that suffering or alleviate the symptoms associated with the disorder. I mean, I'm not doing justice to your explanation, but talking to the key points that I heard there. If you could speak even more to like what's unique to, as you see it, psychodynamic psychotherapy, like what are the aspects of a therapy that are the hallmarks of, of psychodynamic? How would I know that I was watching somebody doing psychodynamic therapy as opposed to watching somebody do CBT?

  Anita Corsini: [00:12:08] Can I just kump in there?

  Jordan Bawks: [00:12:09] Absolutely.

  Dr. Rex Kay: [00:12:10] Please do, because I really don't want to answer that question. 

  Anita Corsini: [00:12:14] You're not off the hook, Rex, But I had a quote that I wrote down and it's kind of speaking to Jordan's two questions, right? And it is I read in chapter one of this book, it was maybe the first line. "The dynamic treatment is hard to describe but easy to understand when you watch it unfold". So not only Rex, did you do a superb job of explaining what it is you were actually did an incredible job at describing it. But now I think that Jordan is asking you to help us imagine how it unfolds in the therapy room and wonder if you can.

  Dr. Rex Kay: [00:12:54] So I have a feeling that we're going to elaborate on the answer to that question throughout the duration of our conversation. Um, so let me give you just 2 or 3 initial ideas. One. Psychodynamic psychotherapy takes place in four different time frames or spaces. We attend to. The early experience that somebody had. It's a developmental model. It says that early experience shapes those patterns we were talking about. Shapes the characteristic ways that people process experience, internal and external. So we talk about the early experience. We talk about the lived life experience from those early days until the person walks into the office. Again, looking for the patterns, the characteristic development and how that life altered those patterns or reinforced those patterns. We talk about the current lived life, What has happened to the person in between the last session and this session? And explore those And then and this is probably the chief hallmark of dynamic therapy. We spend a lot of time also looking at the relationship in the room. We look at what's unfolding between the for generic purposes. I'll refer to patient and psychiatrist. We can talk about patient and therapist, client and therapist, but we look at what's happening between the two people in the room as a source of understanding pattern. We do that. We refer to this as the transference and countertransference the therapeutic matrix. We do that not because Freud said it was important. Freud said a lot of things were important, some were, some were not. We do it because all of experience and as increasing studies have emerged from a wide range of fields, we know that he was right in supposing that early experience shaped the relationship in the room. But that in and of itself isn't enough to justify it. We do it for two other reasons.

  Dr. Rex Kay: [00:15:18] We talk about what's happening in the room because it's happening live in our patients. They're having the experience now. There's no filter. There's no time to reflect. There's no time to revise. It also live for us. We are participants in the process. We are experiencing something. We are observing something. Because it's live between the two of us. Something else is going on that's really important. And for that, I turn to the neuroscience. That's when something is experienced emotionally and intellectually simultaneously. Then the brain is most open. The the  the limbic lobe on the right side wherein rides the affect the sense of self, a sense of empathy is engaged. The frontal cortices of the brain. The rational, logical thinking in the upper left is engaged. And what we know from the neuroscientists is that when multiple parts of the brain are engaged, is the time when rewiring has the best chance of happening. But it's also the time when we can explore the patterns most clearly. So we're looking at those four times early childhood lived life current life relationship in the room as a way of seeing how they play into one another and form one another and can help us and the patient together elaborate on those patterns. So if you see a conversation that is focused on affect and experience and looking at those four different timeframes in emotionally charged, meaningful relationship. You were looking at what I would call a dynamic process. I will quickly add that that can unfold in cognitive behavioural therapy, in interpersonal therapy, in acceptance and commitment therapy, in group therapy, in couples therapy. There's no exclusiveness. But in psychodynamic psychotherapy, we are deliberately setting out to court that kind of process.

  Jordan Bawks: [00:17:29] Yeah, I think that's. Uh, that's lovely. I mean, looking at those different kind of spaces that we work in. And I'd say it's a pet peeve of mine when I hear people have described psychodynamic therapy to a patient of mine or a patient who is referred to me for psychodynamic therapy as a then in their therapy as a therapy where you're exclusively going to talk about the past. Now, there's no doubt that that's important, right? Like people are shaped fundamentally by their life experiences. So we need to get a sense of that, to get a sense of who they are now and the way in which they respond to things. But. My sense of the literature and my experience is that the therapeutic change happens most in the relationship, in the live relationship and the examination of that experience in that relationship.

  Dr. Rex Kay: [00:18:30] Jordan let me add to what you just said, because another of the misunderstandings of psychoanalysis, psychodynamic psychotherapy, is that it is mother bashing, it's parent bashing and or blaming. If we tone the word down a little bit and think I'd like to clarify that while we absolutely see those early years and early experiences as profoundly shaping and all of the evidence supports that, the purpose of understanding that. Is not to wash our hands of the affair because we have discovered that it was Dad's fault. Mom's fault. The only purpose of looking back like that is to help somebody transcend. We are looking at the ways in which an individual made sense of their early experience. We believe with some evidence that there is a rough approximation between what people remember and what happened. There's enough corroboration, but it's only a rough approximation. What matters most is the way you made sense of your childhood, the way you made sense of those experiences, the way they shaped you, given your temperament, your other experiences. And we're doing that to help you transcend the patterns, not so that you can simply lay blame.

  Anita Corsini: [00:19:58] Yeah, I kind of feel like it's emerging. For me, that part of what I'm hoping for this episode and I feel like it's already happening, is that we are going to debunk, I think, some of the misconceptions. And for me, I don't think I mentioned this at the top, but I'm really new to psychodynamic therapy. I was aware that it was existing, that it was in the aether, that it was foundational. But in terms of really understanding it, this working on this episode has really sort of like, um, illuminated a lot of things for me. And I feel like even debunking my own misconceptions like through this conversation. And I think that's, that's one of the big ones that then and their idea that sometimes people bring the assumption that we're only going to talk about the past and it's everything that you've said has kind of challenged that notion.

  Jordan Bawks: [00:20:54] I'm going to put you on the spot. Anita, What are some of the other misconceptions that you either came to this episode with or things that you really wanted to understand? What's the dirty rumours about psychodynamic psychotherapy on the street?

  Anita Corsini: [00:21:12] Mm Um, no disrespect, Rex.

  Dr. Rex Kay: [00:21:17] None. None taken!

  Anita Corsini: [00:21:18] Some of the things that came to come to mind for me are, like, outdated, out of fashion. These are these are all words I'm using that have negative connotations. Like inefficient. 

  Dr. Rex Kay: [00:21:44] Those are good. I'm glad Jordan put you on the spot. Feel free to come up with more. But but I want to I want to address a couple of those ideas quickly and in a way that might surprise you. Uh. There was a time not all that long ago. When think the early claim that you just made from the street was becoming true. Psychoanalysis had succeeded a little bit too well. And by the late 70s, early 80s had become a bit of an out of step dinosaur. And if it had not evolved, I would not be an analyst today. There was a. An attack on psychoanalysis for multiple directions from the Psychopharmacologists a term I don't love, but the people using medication and the rise of medication from cognitive behavioural therapists, from the neuroscientists, from the philosophers, from the psychologists, from the feminists, from queer theorists, and from the memory researchers, from the from all of these sources, there was an attack. I would love to say that the field dealt with that in a very open non-defensive way, but the initial response wasn't. There was actually a double initial response, though the outward facing response was, you know, it's the standard Vietnam line.

  Dr. Rex Kay: [00:23:38] You know, you weren't there, man. You don't get psychoanalysis. And if you did, you'd know that you're wrong, which is a horrible argument and fundamentally not true. The second line of response, though, was to stimulate a period of creativity within the field. Between the late 70s and early 90s, that was astonishing. And psychoanalysis revamped itself without abandoning its core principles. It recreated itself. Taking in the input from all of those fields. Neuropsychoanalysis over the last 20 years has been a really hot topic of research influencing treatment, attachment theory, serious research coming out of the psychologists. It is incorporated Feminist theory, queer theory, Post-structural theory. There is a wide range of responses to these very legitimate attacks that has produced. A different version of psychoanalysis and psychodynamic theory. That still holds onto for me a lot of the gold that goes all the way back to Freud. But made it a much more vibrant and meaningful field. So fair criticism. But I like to think that it's the criticism itself is now largely out of date.

  Jordan Bawks: [00:25:25] And I'll jump in to talk a little bit about the evidence base, because I think this is also a misconception about psychodynamic psychotherapy, including psychoanalysis, is that it's not evidence-based or that it doesn't have a robust evidence base. And I think this will also bleed into answering your question about efficiency, which I think is a very valid question to be asking in, you know, from a systems perspective. Um, uh, so I'll briefly, um, there are a couple of pretty comprehensive and high level reviews that I'm going to link in the show notes. Um, Leichsenring I'm going to butcher their name, unfortunately, but it's a giant in the field of psychodynamic psychotherapy, and there have been a number of high quality studies published in The Lancet. There was a Cochrane Review. There was a pretty rigorous meta analysis in the American Journal of Psychiatry, all within the last 5 to 7 years that have shown that psychodynamic therapy is equal, in effect, size to most other standard interventions and may be superior in some situations. One situation where it actually looks like it's superior to other kinds of treatments is in the treatment of what they call complex mental health disorders. So these are personality disorders, people with chronic mood anxiety conditions or people with multiple disorders and in comparison to treatment as usual, to medications, to shorter-term psychotherapies, a variety of modalities, long term psychodynamic psychotherapy as defined by more than a year of weekly treatment, shows superiority in outcomes for those kinds of situations.

  Jordan Bawks: [00:27:34] Um, and then the other kind of piece of this is that I, I think one of the things that happened as well is that a lot of psychodynamic psychotherapies were semi-manualized and so made themselves a bit more amenable to treatment. So there's also a pretty robust evidence base for those short-term psychodynamic therapies as well. And you know, a debate around the manualization of therapy is beyond the scope of our talk. And I think there is something that's lost in that setting, but it's also something that was necessary for psychodynamic psychotherapy to sort of prove itself on the same playground as something like CBT, which I think at this point in time it's done extremely convincingly. And I think for me as a, you know, a psychiatry resident who's about to graduate, who is a real, I'd like to think a student of psychotherapy, like I train in CBT, mindfulness, acceptance, commitment, etcetera.

  Jordan Bawks: [00:28:30] I think the place where Psychodynamics kind of separates is in some of these situations where people have failed multiple other therapies, you know, they end up in this complex category. They failed sometimes like 10 to 15 medications. I'm talking about chronic conditions and people who've had neurostimulation treatments who haven't gotten better. And, you know, this is an evidence-based intervention for these people where there are almost no evidence-based interventions. And so when we talk about efficiency in the health care system, there's a lot of talk right now about a stepped-care model that we sort of start at the lowest level of intervention. And to me, just based on the evidence, psychodynamic therapy has a place either in the sort of early steps when you're looking at it like you can short-term psychodynamic therapy as being a non-inferior treatment to CBT, and we can look at patient preference and go from that. And once we get to the higher steps, the higher complexity and chronicity, then I think psychodynamic therapy has a robust evidence base to deserve to stand on those treatment steps when there really is not a lot of other stuff that has that kind of evidence base.

  Dr. Rex Kay: [00:29:49] Jordan that was really well summarised and nothing in there that I don't agree with. I'd like to provide a slightly different perspective and this addresses the efficiency question too, and it does address the stepped treatment model. But I want you to start by imagining what people come out of childhood with. That's a temperament, a fit between a child and parent or parents. An early experience. Produces. A character, a personality, a way of being, characteristic ways of being in the world. And what we know is, you know, the biography of Jim Morrison, No one gets out of here alive. No one gets out of childhood unscathed. But what we can say is that some people are more damaged by that combination of temperament, fit and early experience than others. The patterns that we talk about can be luxuries for people who suffered sufficient trauma and sufficient adverse childhood experience that the damage done to their capacity to process inner and outer experience, to manage the complexities of just living can be extreme. Now those people go through life and life happens to them. Life can be physical illness. Life can be life events. And life can actually be the onset of a psychiatric illness that isn't directly related to the features we just talked about that are more genetically or biologically driven.

  Dr. Rex Kay: [00:31:37] For those people who came out of childhood relatively unscathed. When life happens, they can often get back on track with nothing but themselves or a close friend or partner. Maybe a little bit of advice from a family doctor. Maybe a single visit to an emergency room or a single visit or a few visits to a psychiatrist. They may require a short-term treatment. They may require medication, but they're likely to do well. For those people. For whom early life was damaging. When life happens, it can be astonishingly difficult. And what we what I think of and what evidence suggests psychodynamic psychotherapy is at its best dealing with is helping those people. The complex problems that the desperately suffering damaged individual who may have a psychiatric diagnosis, who may have a physical illness or who lost a job or a partner. And for those people. We can move through the steps, but very often there is nothing else other than long-term intensive psychotherapy, which I think of typically as being based in dynamic principles, but drawing on everything that the practitioner is capable of drawing on to help from all schools of thought to try to help these people get through.

  Jordan Bawks: [00:33:19] So you've hinted I mean, both of us have hinted at this already. Who are the kinds of patients that when you see you think this person needs or deserves psychodynamic therapy?

  Dr. Rex Kay: [00:33:38] So part of the answer to that question is contained in what I just said, which is usually somebody who's tried other things. Very few of the patients who come to me come to me without having tried other treatments, medication, shorter term therapies, other approaches. There has to be a level  of suffering. Uh, not just of. But of suffering in order to justify a longer term treatment. Psychodynamic psychotherapy itself typically lasts 2 to 3 years. Psychoanalysis itself, a fuller, longer version still only typically lasts four and a half years. We talk a lot about the commitment of time of the psychiatrist. Efficiency comes in there, Anita. We talk about the expenditure of the health care dollar of Doug Ford's taxpayers of Ontario, which is a perfectly legitimate standard. What often isn't talked about, but is very much in my mind is the commitment we're asking of our patients. If somebody is going to come and see me once or twice a week for three years, two years, four years, that is an enormous commitment of time and it's a commitment of emotion. Though the therapy is often useful and often enjoyable, it's also often very hard. We're asking a lot of our patients in order to justify that there has to be a level of suffering. And by and large, there should be an attempt at other solutions that hasn't worked. That's not quite the spirit of what you're asking, Jordan, But that's the background to what I think is really important is a consideration.

  Dr. Rex Kay: [00:35:29] A patient who shows little or no curiosity about their own past life and the possible connection to current issues does not scream psychodynamic psychotherapy. A patient doesn't want to do that, but yet wants help is still fully entitled to help. Should probably try other things. Before, if at all, trying a commitment to psychodynamic psychotherapy. Uh, somebody equally. Who? Uh. Has little or no proven capacity to form a relationship. Little image in their mind. That a relationship can benefit them. Should probably try a shorter term psychotherapy or medication or other treatment. Before trying psychodynamic psychotherapy, because the one thing I can promise you is that that therapy is going to be very difficult for them and probably for the practitioner. But if nothing else is working, I deeply believe that for those most unfortunate of people, psychodynamic psychotherapy is rapidly going to become the only game in town, the only treatment that can provide an experience in which a first beneficial relationship can occur. Providing a vantage point for those patients to start exploring their life and their responses and their patterns and begin to change. So ironically, the most difficult patients are also often the ones who scream psychodynamic psychotherapy most, whether they've experienced physical trauma, sexual trauma, relational trauma. They often end up screaming once other treatments still have been tried and failed. Anybody have a thought?

  Anita Corsini: [00:37:34] Think Yeah, I was totally reacting to the word trauma because that was like the question that was on the tip of my tongue as you were talking. Just about like complex almost seems sometimes like a euphemism for having like a trauma history. And I just know that, you know, often, you know, adults who have had like adverse adverse childhood experiences, trauma histories and, you know, can have the most difficulty just, you know, dealing with day to day life, as you were saying. And then so then my question was, you know, I haven't come across that in any of the reading I've done so far. But in terms of thinking about patients who might be most appropriate and, you know, having had that early trauma history or, you know, significant series of traumatic events that processing, I wonder if that's possible in dynamic therapy. It seems to be beneficial.

  Dr. Rex Kay: [00:38:36] The evidence would tell us there are some really valuable and really helpful, trauma centric therapeutic approaches that are creative and thoughtful and very moving, even to read about when they don't work or when they only get somebody so far is really when dynamic therapy should kick in because they tend to be shorter term and very nicely focussed and often are very helpful. When that hasn't worked is when you ask for the commitment to a longer term therapy if you can get.

  Anita Corsini: [00:39:16] So transference and countertransference are sort of key concepts in psychodynamic therapy. And I'm wondering, Rex, if you could talk a little bit about what they are and if you could offer some examples of how they play out within the therapeutic relationship.

  Dr. Rex Kay: [00:39:34] Yeah, absolutely. They are central ideas and they've evolved. Transference began as Freud's concept that people make false connections between people in their past and people in their present, which is a perfectly fair way of thinking about it. But to Freud, it seemed to imply that the transference, feelings, the feelings that a patient has for their therapist are in some way not real to the relationship with the therapist. They are simply transferred from their past. Uh, this is a case where I'm going to give him his due. He fought hard trying to argue that a transference feeling was false because it was just a recreation of the past and it didn't apply in the present. And as hard as he tried, he ended up shooting down his own argument. And I just want to make this point because I think that it's it's it's so underappreciated even today. Uh, for Freud in the end. The important point about transference is ethical. Freud noted that we as practitioners, as psychiatrists, can anticipate that for many of our patients, as they work with us, the patients will experience strong emotions about us. Not all, but many. Some of them might be unpleasant for us to experience. What Freud argues. Is that as somebody experiences these feelings, we have an ethical obligation. To use that experience of our patient for their benefit, no matter truly how unpleasant it may be up to limits of personal safety, but that the idea is that an individual based on their past is, we hope, going to experience us as an emotionally significant person in their life.

  Dr. Rex Kay: [00:41:42] And as such, their old patterns will be reactivated and as the emotional significance of this other person who is in the room with you. Listening struggling as that intensifies, often the feelings will intensify. And that it is our job to not make that go away. But to use that to help our patient. Similarly countertransference which Freud did not develop at all well. Countertransference initially referred to the feelings that the therapist has about the patient. And usually to the early gang, indicated that the therapist hadn't been properly analysed or therapist that went away a long time ago. And now what we see is countertransference. Is the experience of being the other person in relationship with our patient. And it's a source of information. So transference are the patterns that the patient brings into the room intensified by the gradually increasing meaning and importance of the relationship with the therapist. Countertransference can be. My bringing my issues into the room. If that's the case, I need to address that myself and do something about it. But very often counter-transference is me experiencing something that I can use to help me understand my patient. And again, the ethical obligation. Is to use that to benefit the patient.

  Jordan Bawks: [00:43:33] I'm glad we're talking about Transference Countertransference because to me this is one of the most useful contributions of psychodynamic thinking that applies in almost all clinical settings, even outside of psychiatry, because it's natural that we're going to have feelings that are arising when we see patients and patients are going to have feelings that are arising as they see us and about us in particular, and having an understanding of the dynamics of transference and countertransference allows us to use those, as you said, to the patient's benefit. I'm wondering, Rex, do you have a clinical example to bring this to life for us?

  Dr. Rex Kay: [00:44:15] Okay. Let me preface my comment by saying that I'm going to tell you a rather sketched out clinical story. Mm. But I have the permission of the individual involved to tell this story, even though it's very sketchy and there's no identifying features. I want to reassure your listeners that I have explicit permission from the original to tell this story in teaching. Um, here's a common experience for a lot of people in the healthcare world, whether they're in any area of healthcare world. I'm working with somebody who. Rejects every single idea I propose. Uh, practical idea. Uh, perspective. Interpretation, whatever it is I have to offer. Is rejected. So we can see a characteristic pattern, perhaps. But what matters here, I'm going to talk about the Countertransference at this point. What matters is that I become aware that I'm not simply frustrated. That either I'm not good enough, I'm not putting forth useful ideas or frustrated that this person is shooting down all of my ideas. I begin to feel. Like. My university made a mistake in admitting me to a medical program, let alone a psychiatric or psychoanalytic that I should never have engaged in this work because I'm utterly incompetent, that anybody would be able to do a better job than I am doing. And I'm feeling quite worthless. Fortunately, that's not an experience I have all that often.

  Dr. Rex Kay: [00:46:15] And I begin to feel like that's an interesting response on my part. It takes a little while to gain control of my own emotional state, but as I do, I start saying it's interesting that I'm experiencing this so intensely. So I start attending to the way the patient is rejecting my ideas, suffering, individual. And yet they're rejecting my ideas. Not with a sense of sadness. I wish my doctor could come up with good ideas. Not with a sense of despair. Oh, no, he can't help me. He's not coming up with anything useful. Not even quite with the sense of frustration. He's rejecting my ideas with what I can only describe as a sense of glee. And malice, and I start reflecting on what I know about him. And the way he had described and I've known this person for a little bit of time and the way he described. His parents as being really quite supportive and very encouraging and. Having high standards for their children and for him always wanting him to do his best and always encouraging him to be the best person he could possibly be. Which sounded to me like pretty good parents and that he experienced them as pretty good parents. But I'm starting to wonder about somebody who is rejecting my ideas with this intensity and begin to generate an hypothesis based on my countertransference of feeling so belittled.

  Dr. Rex Kay: [00:48:11] And so incredibly incompetent. And I start thinking about two things. One is, I think is there evidence that this is how this person feels as he goes through life? I generate an hypothesis that my countertransference may capture his lived experience. It's not the way he narrated his life. But over the time that I've known him, as I reflected on it, I start to think. He's got a narrative of his life, but it could easily be connected to this kind of feeling that he's avoiding and warding off. And then go back and think about the parents and look at other authority figures in his life. And I look for parallels there as well. How has he described bosses? How has he described teachers? And I begin to generate some hypotheses. Don't say anything because they're just hypotheses. But over time, I'm listening in a slightly different way. I'm exploring his rejecting feelings towards me in a different way. And I'm asking different questions. Over time these things don't happen quickly. Over time, together, working together, it's such a fundamentally collaborative process. We gradually come to recognise that the way he  experiences me is a way that he's experienced bosses and teachers in the past.

  Dr. Rex Kay: [00:49:48] That he did experience his parents exacting standards as standards that he could never live up to. He did not see his parents particularly as attacking, he said, but they were impossible to live up to and it made him feel horrible. But then we so we've done really good work. We're laying out a pattern that he is now talking about benefiting him. In his lived experience that he is slower to anger. Slower to ascribe malice to others. But then we take one more step. And this is more transferential. That we start looking at the moment when he becomes attacking. And we start looking at the moment that came just before. And how he heard me and how he experienced my suggestions. And what emerges is that. He didn't experience my suggestions as possibly helpful ideas that would benefit him in life. He experienced my suggestions as evidence of his failure to have thought of those ideas himself and enact them. He experienced me not as saying, Hey, why don't you try X? But he experienced me as saying, Well, aren't you stupid for not trying x? Why the hell haven't you tried X? And as he experienced that repetition of the childhood experience of not living up to even though my tone was mild, as his parents were, he knew what I meant. He turned the tables on me. And he stopped being himself in the presence of what he experienced as a judgemental other. And he became the judgemental figure and I became the attacked other. Now that unfolded over months. But that can give you hope. And again, I recognise it's an inadequate summary, but I hope that gives you a little bit of a feel for how transference and countertransference can play out in effect change.

  Jordan Bawks: [00:52:05] I mean, if you could summarise months and months and months of dynamic work in only five minutes, I know that you were short changing us and leaving out the richness of the work, but I think there's first off, that was a helpful illustration of transference and countertransference, you know, looking at the way in which the patient was transference, being the way in which the patient was experiencing you, the countertransference, and how you were able to use that experience of you as a way into his world, into his life, in a way that was helpful for the both of you working together and also how you were able to use your own experience with him also as a way into his life that wasn't immediately apparent. And along the way, I think you've kind of hinted at, um, you know, a question that's implicitly throughout this whole podcast is how does psychodynamic therapy work? And when I when I listen to that story, I hear it come through. Like there's that sort of almost relentless attention to the patient's experience. Their thoughts, their emotions, their inner world. Um, that is so important for the work that you do together. 

  Dr. Rex Kay: [00:53:35] Let me step back in, because for time's sake, I left out the last piece, but. But I think that for your listeners, it's important to hear this as well. Uh, he experienced me as being attacking. My professional identity, of course, is someone who would never be sharply critical or attacking of a patient who is suffering and coming to me for help. But doing my job and taking my job seriously involved really looking hard at myself and wondering if when I said, Why don't you try X? At least some of the time. My frustration with his typical rejecting behaviour wasn't creeping into my voice and I decided that it was, and I talked to him about that. Uh, because I think it did. And I think that his response was based on his transference. But it was also responding to a level of frustration. That he heard in me accurately. Now, that's hard. That's hard as a therapist to own. But jerking with a patient's reality and denying that piece is counter-therapeutic. So at some point it was necessary for me. I felt. To explore his response, to explore mine, and to own up to the possibility that at times he was hearing frustration, which was very meaningful to him. So that's the last chapter. And think think it's necessary to round it out in that way.

  Anita Corsini: [00:55:16] Like Jordan, you were just pointing out that sort of very close and sensitive attention to the patient's inner world or what the patient is bringing into the room. And it sounds like, Rex, you're also drawing attention to paying close attention to what's happening in that relationship, What's happening between the both of you? In terms of affect, in terms of emotionally, but also sort of cognitively as well. 

  Jordan Bawks: [00:55:50] All right. So I want to just take a step back and kind of summarise where we've been and check in on our learning objectives. So number one, we wanted people to have a sense of what psychodynamic therapy is and how it works. And I think Rex, through that example, through our kind of discussion throughout, I hope that we've given our listeners a taste of that. I'll make an aside here to say that psychodynamic therapy and writing is extremely diverse. There's a sort of an enormous richness to psychodynamic thinking. And so this is really a taste. This is like a flight and it's like a flight in comparison to a beer hall. And so my hope is that you like what you've had so far and you want more. Secondly, we talked about who it's for. We talked about the evidence base. Our third objective was around contrast and comparing psychodynamic psychotherapy to other therapies. And I think we've done a decent job of that. I mean, just to make it explicit, I mean, I think the things that are common to all therapies is that we're attending to the therapeutic relationship, the working alliance. I think what psychotherapy psychodynamic therapy adds to that. It is a sort of explicitly looking at investigating, talking about the therapeutic relationship rather than just sort of relying on a warm, supportive stance that's going to facilitate a good therapeutic bond. Um, I think we've talked about the ways in which psychodynamic therapy pays attention to patterns. Patterns from the past to the present, from outside relationships to the therapy relationships looking at these kinds of patterns, um, looking at patterns of emotions, thoughts, and in relationship to other people and relationship to the therapist. Um, and you know, it's funny actually, the more I get into all psychotherapies, the more I see tons of commonalities that I think many psychotherapists do these things in very similar ways. Like in cognitive therapy, there's maybe just people are a bit more explicit, like they're actively talking about it with the patient, someone's core schemas, their core beliefs, the assumptions that they have. But I think psychodynamic therapists do that anyway. You're looking at the way in which people interpret the world think about themselves. It's just a sort of slightly different language and a slightly different frame. Um, so now I want to kind of take a step back. This wasn't explicitly in our objectives at the very beginning, but I think this is something that we want our listeners to leave with. I want our listeners to leave with. This is why I fell in love with psychodynamic therapy. Um, that psychodynamic therapy, something about psychodynamic theory, psychodynamic thinking feels really relevant to general clinical work. Like there's always some aspect of a clinical encounter where I kind of lean on what I think of as my own psychodynamic training and principles. And Rex, you're a few years further down the road than me in this path, and I'm wondering if you can talk about the ways in which psychodynamic thinking influences your general psychiatric care.

  Dr. Rex Kay: [00:59:22] Yeah, a few years down the road. Jordan, way back in my childhood when I was about your level, I decided that I wanted to train as a psychoanalyst, not because at that time I envisioned doing psychoanalysis at all. Uh, but because I felt that I needed to understand these principles in order to be the kind of psychiatrist that I wanted to be. That's what pulled me into the Analytic Institute initially. Along the way, I discovered that very long term intensive treatment is useful for some patients, and I still believe that and my experience goes with that. But I wanted to be a really good psychiatrist who used psychotherapeutic principles. You could be a tremendous psychiatrist without studying in an analytic institute, but the way I envisioned the work and what I felt drawn to do this seemed to be the route for me. What I feel all good psychiatrists have learned are the basic principles that we've been talking about today. They may not explicitly think of them as psychodynamic, but a lot of them do. Most every psychiatrist that anybody works with today has been trained at least somewhat in these principles and uses them. But if they weren't trained in their residencies, they were trained by their patients. That in order to do the work well, you simply have to learn to attend to the meaning that a patient is drawing from what their life is affording them. The meaning that a patient draws from handing over a prescription for an antidepressant. The way in which a patient is experiencing affective states. And when they learn to and enhances the work. If you can attend to what's happening in the room. As even a consultation progresses. And it is my strong belief that every good psychiatrist.

  Dr. Rex Kay: [01:01:41] It does use dynamic principles, but we also all use including the analyst cognitive behavioural principles, dialectic behavioural principles. Systems thinking developmental thinking that mental illness is a vicious, multi-headed beast. And those of us who work with mental suffering and mental illness need to be able to use everything that we possibly can to help and that these principles, I find, achieve their greatest value not in the hands of people treating patients directly with psychodynamic psychotherapy. But in the hands of people using the principles in their general psychiatric work and their general therapeutic work, whatever mental health profession they come from.

  Jordan Bawks: [01:02:38] Yeah, I'm. You're preaching to the converted here and I guess you literally you are because you converted me over my residency training that and now I take this work on for myself as one of the reasons I was eager to take this on is that for me, you know, again, not that this is entirely unique to Psychodynamics, but that the things that psychodynamic thinking emphasise, which is seeing the individual, seeing the person as an individual, paying attention to their past experiences, the value of attending to their relationship with you, the value of attending to their emotion. And the you know, this is, I think, one of the late developments of psychoanalysis relatively, that you hinted at that sort of transformation in the 80s and self psychology is how valuable it is to just to empathise to enter the patient, to make a really concerted effort to understand the patient's world and their experience and how healing that is, how stabilising that is, that those are things that I have gained from my psychodynamic training and things that have really greatly enriched my psychiatric work.

  Dr. Rex Kay: [01:03:57] Let me pick up on one thing you just said, Jordan, And this will illuminate the cross-fertilisation between psychotherapies. There was a time, and I can still slip into the language of saying that there's a tension in psychiatry. There was a sociologist who wrote a book about psychiatry called of Two Minds that American psychiatry is of two minds, and the minds are along a kind of biological orientation, a psychological orientation. We can talk about a tension between the desire and the need to see people in categories to make psychiatric diagnoses. And that's an extraordinary, valuable pursuit. Starting in 1980, Bob Spitzer and the DSM proposal was incredibly important and remains incredibly important because it's trying to establish categories that we can compare. So we need to make diagnoses and put people in categories, and that's crucial. The other pool that can be called attention is in seeing every individual as an individual. And focusing on their individuality as a person with a unique history and a unique way of experiencing the world. And we can call that attention. But my colleagues in the dialectic behavioural therapy world have helped me recognise that that's not attention. It's a dialectic that the two live together and they actually benefit one another at their best. And that it's actually our job to not choose between the two, but to constantly be integrating and seeing from the two perspectives and integrating what we see to the betterment of the patient.

  Jordan Bawks: [01:05:51] Yeah, I totally agree with that. Rex, I'm going to ask you an annoying question, which I've been doing all episode, putting you on the spot with these hard, monolithic questions. But we like to ask at the end of our episodes, our experts if they have any recommendations for interested listeners who want to learn more. If you were to recommend a resource, a website, a book, or even just kind of a general idea to our listeners if they wanted to learn more about second and psychodynamic thinking or therapy, where would you direct them?

  Speaker4: [01:06:26] Oh, that's such a hard question.

  Jordan Bawks: [01:06:27] I know.

  Dr. Rex Kay: [01:06:28] The literature is, as you noted, a complex literature, but it's also an enormous literature. So it's rather difficult to recommend general texts. Probably the best single volume. And Jordan, you could put this up on the website is Jeremy Safran's introductory book. Uh, as a single volume describing the therapy in about 150 pages. The best introduction to theory is probably Stephen Mitchell and Margaret Black's Freud and Beyond are a fascinating introduction to attachment theory, which also helps understand from an evidentiary base. The role of early experience is Robert Karen's Becoming Attached, which looks at the history of attachment theory, but in the process of doing so and it's a fascinating story and he tells it very well, but in the process of doing so, he helps review the literature of just how early experience shapes later. So there are three places that people could start, but I would also encourage people, especially in the field, who are interested. In any given Non-covid year there are six or 8 or 10 people coming in to speak on broadly psychodynamic themes to various groups. Through the Toronto Institute of Psychoanalysis, the Toronto Institute for Contemporary Psychoanalysis, the Child Psychotherapy Institute, the Ontario Psychiatric Association. There are multiple websites that people can keep an eye on. What I would encourage people to do, if they're interested, is grab and follow in exactly the same way that we try to do as therapists. Follow your curiosity. Don't try to start with Freud and work your way up or study the classics. My strong encouragement is to read what is interesting to you and read it until it's no longer interesting and see if that leads you somewhere else and follow your curiosity.

  Jordan Bawks: [01:08:52] Wonderful. I'll make my own plug to add to those resources, which I would generally agree with is to try and find your own Rex Kay wherever you live. Look up your local Rex Kay. Can you tell Rex that I'm trying to get you back for another episode?

  Dr. Rex Kay: [01:09:18] Where you're going about it the entirely wrong way.

  Jordan Bawks: [01:09:21] But truthfully and I'll chop this up with audio. Um, I would also encourage people to look up their whatever your local institution is and try and find a mentor. A mentor if you can so like if you do clinical work asking around in your local clinical department for people who have psychodynamic training or they do psychodynamic therapy is the best way to learn. As much as I love books and podcasts is to is through real relationships. And so I strongly encourage you to ask around for your local psychodynamic expert or trainee or whoever's keen and go through that exploration together. So I want to thank you guys both. Anita, well done your first episode. Rex, thanks so much for joining us and tolerating all my questions and admiration.

  Dr. Rex Kay: [01:10:26] No disrespect, Jordan, but Anita, coming at this from the outside, uh, stimulated  my questioning mind and I think really facilitated this discussion. So thank you. And Jordan, as always, thank you just for being Jordan.

  Jordan Bawks: [01:10:47] Can't be anybody else. Thank you for listening to PsychEd the Psychiatry Education Podcast, by medical Learners for Medical Learners. Our theme song is by Olive Musique. I want a special thank you to our guest expert today, Dr. Rex Kay. Post-production was done for this episode by Jordan Bawks and Anita Corsini, and we hope to have you back on our podcast sometime soon. Take care!

Episode 30: Anti-black Racism and Mental Health with Dr. Kwame McKenzie

• Episode 30: Anti-black Racism and Mental Health with Dr. Kwame McKenzie

  Dr. Alex Raben: [00:00:19] Okay. Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners. We have a very interesting episode for you today, listeners. We are here to discuss racism and mental health, the interrelations between those two things, and specifically with a focus on anti-Black racism and mental health. I'm Alex Raben. I'll be your host today. I'm a new staff at CAMH, working on an assertive community team here, and I'm joined by my co-hosts, Anita.

  Anita Corsini: [00:00:56] Thanks, Alex. So my name is Anita Corsini. I'm a social worker and I currently work in knowledge translation and exchange at the Centre for Addiction and Mental Health in Toronto. And previous to that, the majority of my frontline experience was working as a counsellor with youth and young adults.

  Dr. Alex Raben: [00:01:15] Great. Thanks, Anita, and we're very pleased to be joined by Rebecca Marsh, who is a fourth year medical student.

  Rebecca Marsh: [00:01:22] Hi everyone. Yeah, my name is Rebecca and I'm a fourth year medical student here at the University of Toronto.

  Dr. Alex Raben: [00:01:28] Thanks, Rebecca. And we should also say that Randi was part of this episode as well, but she wasn't able to join us this morning. But we are joined by the esteemed Dr. Kwame McKenzie, who is the CEO of the Wellesley Institute and is an international expert on the social causes of mental illness, suicide, and the development of effective, equitable health systems. Dr. McKenzie is also the Director of Health Equity at the Centre for Addiction and Mental Health and a full professor in the Department of Psychiatry here at the University of Toronto. And I'll let Dr. McKenzie introduce himself as well to add to that. Welcome to the show.

  Dr. Kwame McKenzie: [00:02:12] Well, thanks very much and congratulations, Alex, on your new position at the Centre for Addiction and Mental Health. You know, not that I'm biased, but I am biased. A wonderful, wonderful place to work. And, you know, I'm really glad to be here. As you know, I'm a psychiatrist, although my books have tended to be about the social determinants of health or about anxiety and depression. And most of my work at CAMH was in schizophrenia, running the schizophrenia department before doing other things, as in old age and children and dual diagnosis. But most of the work I did in the UK was also in serious mental health problems. So I've done loads of different things and I'm really glad to be here and love this idea of this podcast. Making myself sound old, right?

  Dr. Alex Raben: [00:03:19] Well, we're so glad to have you. We really appreciate you coming on and bringing your wealth of expertise, both clinically and in the research world. Alright. Well, let's start with the learning objectives. So, by the end of today's episode, you should be able to understand the history and legacy of racism and mental health in the Black community in Canada. Number two, understand the current state of racism towards Black people and the impacts on their mental health. And number three, explore how health care workers can be anti-racist in providing mental health care and how the system can change to improve the mental health of Black people. To start out. We wanted to go from the basics because we don't want to take things for granted. So this may seem like a question that has an obvious answer, but I'll ask it anyways. What is racism? How do we define that? And outside of the abstract, what does that look like practically speaking for people who deal with it?

  Dr. Kwame McKenzie: [00:04:41] I think that is a really great question because one of the things that always happens with this is everybody has their own ideas about what we're talking about. And racism, one way of thinking about it, is discrimination plus power. So it's not that you discriminate, just discriminate against people because of their race, but there's a power structure that is set up so that that discrimination actually means something and it changes the lives of those other people. And it's built on the idea that one race is superior to the other. And therefore there's a hierarchy of races, where there's a privileged race and there's a less privileged race, and it permeates all areas of society. It permeates how we think about other people, how we interact with other people, people's chances in life. So it's an idea, it's an abstract idea. It's not based on anything that could be considered in any way scientific, but it has very, very real consequences to the lives of people. And so I think it's a great question because there's loads of confusion about what we're talking about.

  Dr. Kwame McKenzie: [00:06:05] And when we're talking about anti-Black racism, it's actually a Canadian phrase that was coined at Ryerson University. And the idea of anti-Black racism is it tries to explain how racism is actually different for Black populations, how the systemic nature of racism — not just what we see with regards to stereotypes in the media, not what we see with regards to the way the Children's Aid Society or the prison justice system works with people — but how it permeates every part of society to produce a toxic environment for Black people in Canada that's different than the racism that other groups in Canada feel. You know, obviously there's anti-Indigenous racism, which has a similarly toxic air. But, you know, when you're thinking about Black and Indigenous, the levels of racism and the impacts of racism are very different to other groups.

  Dr. Alex Raben: [00:07:14] That makes a lot of sense to me. I guess, in terms of examples of racism, I think that it can be kind of easy to think about examples of an extreme case or a historical case where racism took on violent and overt forms. And not that I'm presuming that doesn't happen now, but I'm wondering what is the range of things that qualify as racist in terms of examples that we could talk about or we could bring alive for the listener?

  Dr. Kwame McKenzie: [00:07:53] So, it's one of these things that when you have a complex society and you have social divisions and you have ideas that create social divisions, they get everywhere. So, no, the question isn't where IS racism — the question is where ISN'T racism. So, you know, when people talk about perceived racism, so I can see that I'm getting differential treatment or, you know, our interaction is different, or I've got racist abuse or attack, or microaggressions happen, right. And I'll talk about microaggressions second. So those are perceived racism. I can actually see it. Right. But then lots of racism is NOT perceived. You may not know why you didn't get an interview. You don't know what happened. It's just, you didn't get an interview, so you never see it. But actually, it changes your life. Then there are loads of other forms of structural racism. The way the police react to people, what happens in education, educational outcomes, children's services, the prison justice system, not just the police, whether you can get a loan or not. Then there are other forms of racism, again, which we're seeing during COVID. Where we can see that there are these huge disparities in risk of COVID for some groups compared to the others. And we do nothing about it.

  Dr. Kwame McKenzie: [00:09:39] And that form of racism by neglect is some of the most pernicious types of racism in Canada, where people just don't do stuff. They see that there are incredibly high differences in colon cancer screening or cervical cancer screening for Black women, but they just don't do anything about it. And so at the Wellesley Institute, when we were thinking, how do you think of this sort of systemic racism? Is systemic racism an intent? So, I tend to treat people differently? Is it that I have no knowledge about, you know, what is it? You're a system, like the mental health system, and you can see big disparities in access, outcomes, deaths, and you do nothing about it... then, that is systemic racism. It's not that you cause the problem, it's that you're not part of the solution and you just allow it to happen. And there are all sorts of reasons why we convince ourselves that we shouldn't be part of the solution. But in a connected world, where you're a human being, when you see other people suffering, you are supposed to be part of the solution. And so it's complex. But the thing is, you look at the effects and you can see the differential effects.

  Dr. Alex Raben: [00:11:15] Wow. Yeah. So it's, I mean, quite a range. As you say, it's almost the better question is, where ISN'T it? It's actually at so many different levels. It can be at so many different levels. It can be visible or relatively invisible. And even inaction can be a form of racism, as you point out. Now, I know, Anita, you had done some looking into in terms of the history of racism in Canada, or maybe I'm misclassifying that, but I know you had dug in a little bit into the history because I was hoping we could present the listeners, because we have an international audience, with a bit of the Canadian context. Now, I know, Kwame, you're from the UK originally, I believe.

  Dr. Kwame McKenzie: [00:12:09] Yeah, that's right. I mean, you couldn't tell from my voice? From somewhere, not Canada!

  Dr. Alex Raben: [00:12:22] Yes, our listeners were ahead of me on that, I think! But I guess what I'm saying is we often in Canada talk about racism in the US context. We don't as often talk about it in the Canadian context. And so I'm wondering, what are the differences there? Are they meaningful and what do they mean to people living in Canada? Maybe, Anita, I can hand it to you, because I know you had done some digging into that question.

  Anita Corsini: [00:12:50] For me what stands out is, and it's something I've kind of been mindful of for a while, is just like the tendency, the Canadian tendency, to understand ourselves as good and benign. And I think that erases a lot of our history. And if we're talking about the experience of Black Canadians or Black people in Canada, we often think of, like you mentioned, Alex, like the histories of slavery in America, but we don't recall or talk about the history of slavery in Canada and all the ramifications of that in terms of systemic racism and oppression and the legacies of that and how that, sort of, is part of our institutions today. I think that it's kind of that if we're thinking about neglect, like the historical neglect of acknowledging those histories and the fact that there is intergenerational, I think, implications for that in terms of people who are living today, who, you know, their histories, their personal histories, sort of extend back to those experiences. But also just that the fact that those histories sort of shape our institutions today.

  Dr. Kwame McKenzie: [00:14:21] Well, fabulous question. I mean, I think that one of the things we take for granted is our understanding of our history and our heritage. So every time we have an interaction with somebody who has a very similar heritage to us, we have a whole bunch of cultural assumptions that allow us to interact with people at a certain level. And that's the foundation of the way we interrelate as humans, and that's the foundation of the way we understand what's happening in our consultations and our interactions. So what if somebody has got a completely different heritage? What if that heritage is a heritage that could produce a certain different discourse in the interrelationship? What if, you know, and it's relatively easy for people to think about it when they're thinking about the proximity to residential schools and the way that, you know, that colonial aspect of residential schools and the trauma that has been wrought on the Indigenous population through that violence. And you can understand how there is a different relationship between some Indigenous populations in the interaction with White European settlers and colonists and Black European settlers and colonists like we are. I mean, and you know, there's a dialogue and a dialectic that you have to think about.

  Dr. Kwame McKenzie: [00:16:11] But we discount the impact of racism, the impact of the transatlantic slave trade, and the impact of the legacy of the transatlantic slave trade, and also the impacts of the lies. And so Canada, like everybody else at at that time, was in North America, was part of the slave trade. There were fewer slaves in Canada. Canada didn't have big plantations, but it was part of that whole trade. And it was part of that whole trade, but made laws in the 1780s and 1790s, which were sort of earlier than other people with regards to. And first of all, I think it was Upper Canada, so it would have been Ontario, was one of the first places to outlaw the slave trade, though they didn't free slaves, but they outlawed the slave trade. And that was how the sort of the underground railway started. And I think Canada plays on that, sort of, 30 to 50 years when there was a difference between what was happening south of the border and what was happening north of the border. And we produce this narrative that slavery wasn't here and slavery was different in Canada. And it probably was, for about one eighth of the whole time, you know, between the 16th and 19th century, there's 350 years of slavery. There may be 30 to 50 years where it was a bit different. But apart from that, it was the same thing. And that sort of continual retelling of history is a bit problematic.

  Dr. Kwame McKenzie: [00:18:20] And then, of course, we don't think about the fact that there were whole structures that were set up to keep slaves in their places. So, one parent families and things like that were organised in that way and people were moved around so that there wasn't tight family units that would be strong. And then there's been a reaction to all of those. There's been a reaction to all of that, which plays itself out in Black communities, but also in the reaction of White communities to Black communities. And so that interaction between Black patients and White staff is a sensitive interaction. And understanding, you know, understanding a bit of what might be going on at various levels, at deep psychological levels, as well as present day issues that are coming up with regards to disparities, is quite important. And it's difficult, because the easiest thing and what everybody wants is a cookbook. Tell me what I need to know in order to, you know, work with Black patients, you know, and that's not how things work, because in every other part of medicine, you have to take in information, you have to understand it, and then you have to be a humble human being that's trying to work out what's going on in that particular interaction, which can be anything from somebody for whom Blackness isn't a particular issue to somebody who it's a real issue.

  Dr. Kwame McKenzie: [00:20:22] And you have to have that in the back of your mind. But it can't then become a dominant stereotype that produces inauthentic interaction with your patients, because that's like, you know, that would be a mess. It would be like me deciding that I'm going to be "down with the youth" and wear a baseball cap. And everybody would laugh at me. But back to your question. There is no excuse for me not knowing anything about Indigenous populations. I'm here, in Canada. There is no excuse for a doctor who works in Canada not to know about the history of different Canadian people. That is the basic, whether you're a doctor, whether a human being, you relate to other people, people are part of your community, so know about them. It's just respect, right?

  Dr. Alex Raben: [00:21:25] Yeah. I like your last point there about just having it being an issue of basic respect, not even talking about medicine, but as a citizen of the country. But then, you know, as professionals, as clinicians, we're in the business of people. And just like we're expected as physicians to, you know, know how to take a blood pressure and know what the ranges are on that... what you're saying is that we should have a similar expectation to know something about the people we're treating and the histories there.

  Dr. Kwame McKenzie: [00:22:04] And, like, oh, sorry, Alex. I'm doing exactly what I said I wouldn't do, I'm talking over you!

  Dr. Alex Raben: [00:22:11] That's okay. Go ahead!

  Dr. Kwame McKenzie: [00:22:12] So, you know, there are always tools and structures that help you with these sorts of things. And one of the things, you know, when you're looking in DSM-5, they've got the cultural formulation interview. And the cultural formulation interview basically says, let's start an interview by trying to work out what your location is with regards to how you think of an illness, how you know, what the culture is around the illness, who you think should be treating the illness, whether you think you'll get better, and whether you think I'm the right person who should be here. And the reason why people go into that sort of conversation isn't because you get these concrete answers that tell you everything you need to know, but it gives you a structure to start an interview from a different place, that starts saying, you know, I actually want to know who you are and how you think and what's important to you. And, you know, the cultural formulation, plus a good social history, gives you an idea of what's going on and how an interview can run and what the sensitivities are in the interview. You're not going to get, in the first interview, anywhere near somebody taking down their guide about racism. But it starts an interview in a way that allows for a better balance to a discussion, and more humility in the interview, which then allows you to get to different places. And you've got to open the door to be able to ever hear about people's trauma. Because everybody is going to protect themselves, right?

  Dr. Alex Raben: [00:24:04] Yeah. I mean, I was going to save this point for a little bit later in the interview, but since you've brought it up, I'll bring it up now, because we're talking now a bit more about how, as individual practitioners, we can be with people in a way that's culturally sensitive, competent, safe — to use some of the the buzzwords that we use in terms of the language around that. And to your point about people letting their guard down. So, I've become more intentional, I think, as I've gotten more experienced about asking about racism directly, that's been my strategy recently. But I've noticed that actually, frequently I get fairly neutral answers to that question, or patients I'm speaking to want to move on from that topic. And I'm wondering, and I'm guessing now it's maybe because of this guard. Maybe, Kwame, you could speak more to that. What advice would you give me, in terms of, and for our listeners, in terms of broaching this topic? Because I guess in my mind, I see it as something we could be more proactive about, and that's why I was using that strategy.

  Dr. Kwame McKenzie: [00:25:28] The question I would ask is, to what end? To what end are you asking that question? So, is it that you are trying to look at people's socioeconomic situation and you're trying to find ways of decreasing barriers? Is it that you're trying to work out where the traumas are? Is it that you're trying to develop a rapport? And it depends what you're trying to do, as to how you broach the subject. And that then gives you an indication about whether they're ever going to answer that question to you. Because most people do not let their guard down unless it's going to help them in some ways. You know, and if you're not the person who's actually going to help them, then what is the point of going through the trauma of having to explain X, Y, and Z to this person? You know, to what end am I doing this? Is this just, are they just curious? And they're just asking? Are they just going to put it down in a chart? To what end am I doing this? So I think it's like anything, it's like any other problem or trauma or whatever. If you're just collecting the information to be able to say, I've got the information, then I think you'd expect a relatively low yield of that question, right?

  [00:27:10] If, say, for instance, you've got somebody who you, you know, you're going to send for CBT, and you're saying to them, listen, I'm going to send you to CBT, and we've got different sorts of therapists who specialise in different things, and we have some people who — if you have, and there are those people in Toronto, at least, and I know there are the same people in Nova Scotia and there are people in Quebec — who specialise in CBT, taking an anti-racism approach. You know, you might say, well listen, I'm trying to work out who I'm referring you to. You know, I know this is difficult, but is this an issue for you with regards to where you're being referred? And then you might get a whole bunch of stuff that comes out because there's actually some utility to that for somebody. Similarly, if you're going to have that question and you're asking about police interactions, the question is, what's the utility? And it may be that you're talking about trying to set up a safer community response that tries to keep the police out of the way. And, you know, if you know that somebody has got experience of bad interactions with the police, you'd have to think really twice about a community treatment order because, you know, you're setting them up to have interactions with the police because that's the whole point of it.

  Dr. Kwame McKenzie: [00:28:49] So I think, if it's gratuitous and you're just asking the question because you want to know, then expect low yield. If there's actually a reason for knowing about this and you're saying, say, for instance, you're saying, well, you know, I really don't understand what's going on. I'm trying to make a diagnosis. I don't know whether this is depression, anxiety, or whether this is an adjustment reaction because there are specific traumas and there are traumas, like blah, blah, blah that are happening. You know, I'm trying to work out what's going on, because that's going to change how we treat you. Then I think you'll find that people will start talking. But if it's gratuitous...

  Dr. Kwame McKenzie: [00:29:35] One of the things I used to, when I was in the emergency department and you're looking over the notes that people write, you know, they'd start off with a description of the, of the patient and the patient would say, you know, a middle aged Black man who looks younger than his age or whatever. And I'd say to them, why did you write that? And they say, well, we describe the patient. And I say, okay. So you think the fact that the person's middle aged is important? Yes, because that changes what we might decide with regards to diagnoses and risk and blah, blah, blah. Do you think the fact that he looks younger than his age is important? Well, that's sort of descriptive, and blah, blah, blah, and it's helpful. And, so you think the fact that the person is Black is important? And they say, what do you mean? I said, well, you put it there, so it must be a very important thing. And, surprisingly, most people don't could not answer why they wrote it, apart from the fact that it is written, and then it's part of the notes, and then it's always part of the notes. But what it also does is it gives a signal. And the question is, what signal is it trying to portray in psychiatry? Not saying that it shouldn't be there... but the question I ask people is, what is that communication? Now, is the fact that this person is Black really important in this situation, yes or no? I mean, and it was interesting, just having that discussion, actually starts people thinking, yeah, it was important that he was Black. And you say, why? And often, we couldn't answer it, apart from race is so important that when somebody is walking down the road towards you, the first thing you notice is, you know, psychologically, is whether they're a man or a woman. The second thing is their race. And the third thing is whether they're a child or not.

  Dr. Kwame McKenzie: [00:31:59] And that's how important it is. But why? And actually, when you start asking yourself why, is when you get into some self discovery. And that self discovery, I think, is important for producing equitable care. And people always think that it's the dialectic that's important, or it's the race of the other person that's important. But, actually, it's our own biases that are incredibly important. Did you see the paper in, I think it was in the New England Journal this year? They did a simple paper on the survival of children in ICU, of high risk children. So ICU type children in born to Black women in the States. And they simply said, we're just looking at survival rates. And the survival rates varied. If the doctor looking after the child was Black, the survival rates were much higher than if they were white. Much higher. And when you look to the actual, it's not clear that the white doctors were not following the protocol. Look, it looks like they were following protocols, but somehow the care that they were getting from the Black doctors was better and the outcomes were better. And it was a it was life or death. And that is not that is about that extra thing that we all do when we identify with people and we think it's important and we go that extra mile to take a better history and to better tests and we're on top of things and blah, blah, blah.

  Dr. Kwame McKenzie: [00:34:06] It's that extra bit on top of the protocol. Yes, there are places where you see that people are getting worse care because there's neglect, but often they're getting worse care because one of the worst things that can happen in an hospital. Is if everybody works only to their contract. If the whole of the hospital and I mean, you'll know this Anita is a social worker if you just did the hours you were given to do. The whole thing grinds to a halt as a resident. You know that. Alex And unfortunately, Rebecca, you'll see this more and more as you get out of med school, that if you just did the job you were supposed to be doing, the whole system stops working and the quality of care is hugely different if you you are dependent on that extra you give. So if you study after study in the states in emergency departments, mental health and emergency departments have looked at Black patients and white patients and emergency doctors spend more time with white patients and Black patients, the interviews are longer. There's more information. Outcomes are better. Protocols followed the same with both people. And that's about. Sort of what we care about and the internalised disparities, the internalised racism and that we have.

  Dr. Alex Raben: [00:35:45] Right. And jumping off of that last point you make, it sounds like there are the discrepancies within the system. The health system can be rather subtle, right? The protocols can seem like they're being followed in an equal way, but there can still be quite a lot of room there for disparities that happen. Maybe more. Interpersonally and what have you. I'm wondering if maybe now's a good time to turn more towards the mental health question specifically and explore that landscape a bit more. What does the mental health of the Black population in Canada look like? What are the outcomes? What are the disparities there? And Rebecca, I know you had looked into this question, so maybe I'll hand it over to you.

  Anita Corsini: [00:36:36] Yeah, I did. I did see in my reading some disparities, particularly in the prevalence of some mental illnesses such as schizophrenia, as well as the burden of disease for those who are Black compared to those who are white in terms of the chronicity, the severity response to treatment. And interestingly, these weren't necessarily reported in the countries of origin of these groups, but rather where where white people are the majority. So I think reading about this, I guess my question to you, Kwame, would be what's what's the relationship between racism and mental health?

  Dr. Kwame McKenzie: [00:37:30] Last time I looked. And there were about. 500 peer reviewed good studies that were looking at the relationship between perceived racism. And health and mental health outcomes. And a lot of them were mental health outcomes. And they were split into mental health. So you're looking at stress and depression scores and the others, and then you're looking at mental illness and you're looking at diagnosed schizophrenia, diagnosed depression, diagnosed anxiety. And the groups have done various meta analyses. And the meta analyses are complex, but they essentially show that if that perceived racism increases your risk of mental health problems and also mental disorders and. Even the mental disorders that people have sort of talked about as being more biological. And increasingly, everybody realises that your biology is in an interaction with your environment and and therefore you can increase your risk of sort of a more biological illness from what happens in the social space. And racism increases the rates of physical, biological, as well as psychological problems. Think of if you were thinking just of the normal sort of thing of anxiety and allostatic load, you'd be thinking, well, okay, you don't get a job that makes you upset and increases your stress and therefore increases your risk of a number of different types of mental health problems. Because we know there are a lot of things that are linked to stress. Then if you think, okay, well, you've got that first stress, which is I didn't get the job.

  Dr. Kwame McKenzie: [00:39:43] And then on top of that, you start thinking, hey, well, just a second, that was unfair. But we've got a model in our mind that fairness is really important and that unfairness increases the level of stress now. So you don't go and get the I didn't get the job. You then get more stress because I didn't get the job and this was unfair. And then if you can't do anything about it, you get higher stress still. So this is unfair. You know, I didn't get the job. It's unfair and I can't do anything about it. And that multiplier effect on stress is what makes sort of racism stress sort of so pernicious. But on top of that, in Canada and in a lot of high income countries, it happens on a backdrop of. An increased likelihood of socio economic issues such as financial insecurity, the Black population or the one of the most food insecure populations in Canada, 28%. Increased rates of children being in care, increased rates of of of precarious housing and then sort of poorer housing in sometimes more dangerous areas. And when people talk about dangerous areas, they always think about gun violence. They forget police violence and they forgot they forget racist violence. Right. So. All of these stresses are happening on top of existing sociodemographic issues and social stresses, which means that that racism stress.

  Dr. Kwame McKenzie: [00:41:43] That multiplies even more. And the truth about the Black population and its mental health. These. If you just went with the numbers, there should be many more mental health problems than there are. But that history of having to deal with adversity has made the population much more resilient than other populations. But still, we've still got in Ontario 60% increase with regards to. With regards to psychosis, we have increased rates of depression. We have increased rates of anxiety both here and also in the in erm in the US for the Black population and a lot of trauma and chronic trauma, so complex PTSD. So we see this whole gamut of mental health problems that are happening in the Black populate Black populations. Not every Black person. Mental health problems are a minority issue, not a majority issue, but significant. But here's one thing that most people don't know. We have increased risk of illness, but in Ontario we spend 30% less per head of per head of population on mental health services for the Black population compared to the white population. And you know, what I was saying before is this idea of. When you see disparities and you do nothing about them. So this is so high risk, high risk, low service. And then we get surprised that we see a whole bunch of people end up in the prison justice system.

  Dr. Alex Raben: [00:43:42] I was just going to say what I really liked about that answer is because we often talk about in psychiatry, education, formulating patients and the importance of the bio psycho social cultural model. And I think we touched on actually aspects of that of all of those things. You touched on it, Kwame, in your answer, because there is the biology, you know, the illnesses we think of as biological that aren't completely biological, of course, like schizophrenia being one of them that has a biological component. But then you also have the psychological impacts of racism in whatever form it's taking. And then the social piece, right. The social determinants of health, which we know on a population level that the Black population has more struggles with respect to that, more potential social determinants of health that impact on them. And then of course, that cultural is wrapped around all of that. But where am I going with this is the better question. I guess what I'm what?

  Dr. Kwame McKenzie: [00:44:46] Alex One of the things that I just wanted to say from that, if find out where you're going with it, the we always forget. That the social and the biological are linked. So when we're talking about stress, stress has a psychological, social and biological substrate. So, yes, you can get high blood pressure. Yes. Your kidneys may not work as well. But, yes, on top of that, your immune system isn't going to work so well. Okay. So your immune system changes and there are t cell changes and various other changes that happen because of chronic stress. And they also are more likely because of chronic stress, because of socio socioeconomic issues. Right. So these things that happen in society can change our biology. And when we're looking at things like inflammation, neurogenesis, things that we think are important increasingly in the aetiology of disease, we can see how the social can end up being biological, how the biological can then inform the social, and that we can, unless we break the cycle and see what we can do socially, we can set populations up for disparities, that we can then turn back on them and say, well, it was just genetic. But most of the things we think of genetic are actually epigenetic and they are influenced by society and the response to them isn't genetic. The response is to go upstream and to be social.

  Dr. Alex Raben: [00:46:42] Right. Right. And you actually, you've brought me back to where I was hoping to go with that piece there, which is I mean, first of all, I think that makes a lot of sense that we think about the biopsychosocial model often separately. I think for learners, it's helpful to make those arbitrary distinctions in terms of categories, but we need to be careful that actually they're all interrelated and something that's actually social can be mimic or seem biological, and we need to be aware and mindful of that. Speaking of the social, this is where I was hoping to go is where how do we tackle things upstream? What what work is left for us to do in Canada and in the mental health care system to start to close these gaps? These disparities have a more equitable system.

  Dr. Kwame McKenzie: [00:47:36] So I think there are a few things that are say, let's just think about the mental health system and how you'd produce equity of care. So equity of care is partly and when I'm talking about equity, I'm talking about differences and disparities that can be changed. And if we're thinking and that's where we're going to inequity, some things, maybe you're not going to be able to change, but a lot a lot of things you can and some of them are down to the social determinants of health. And so, you know, it's housing, it's income disparities, it's education, it's a prison justice system. It's laws around racism and cultural safety. It's all of those things that you've got to think about. And those are things that if we want our treatments to work, we need to have a some thought about. So often mental health systems start thinking about supportive housing. They used to think about supportive jobs and income, and we all think about getting people on DSP, but we don't think about advocating so that our benefit systems are Rdsp is the the Ontario benefit, but it's the same. All you know, there are benefits for every province, but we don't advocate for that to actually be at a level where people can thrive. We actually just allow it to be for our most seriously ill people to live in poverty. And that's okay. Actually, there's a responsibility to be doing that, to be actually saying, well, actually we need to do something about the social determinants of health because you don't get recovery without dealing with that.

  Dr. Kwame McKenzie: [00:49:28] And disproportionately. Black patients have negative social determinants of health. So the generally looking at social determinants of health and focusing on the social determinants of health for Black patients will increase our will improve our outcomes. But we have to do that. And that doesn't mean every doctor necessarily has to do that. But as a system, we need to use our lever as doctors to make sure that we give people the best opportunity for access to care and outcome. On the mental health system side. Usually when we're thinking about health equity for racialized populations and definitely for the Black population, we're talking about having culturally capable or culturally competent practitioners with culturally capable and equity in outcomes because of having interventions that work equitably for different populations and then nested within a system of care that allows equal access to care and supports people so that they have equal opportunities for recovery. And we tend not to do any of that. We might do something like this to try and upskill people, to be able to offer culturally appropriate, culturally capable care at an individual level. We tend not to culturally adapt our interventions to make sure they work equally for different populations. And we know things like CBT. If you culturally adapt them, you get better care.

  Dr. Kwame McKenzie: [00:51:29] If you don't, then there are populations that don't do so well. But it's the same for child services. It's the same for it's the same for old age services. And we tend not to go to the next stage, even if we do those things is to say, how can we ensure that people have equity of access to services and how can we make sure that we do the work to make sure that the system supports them in recovery? It's all of that stuff. This idea of vertical equity and horizontal equity. Horizontal equity is people with the same problems and the same needs get the same treatment. We don't do that. And vertical equity is that people with different levels of need get different levels of treatment. We don't do that for the Black population. And so we've got to structure social determinants, improve and also improve psychiatry. We've got an equity issue with regards to identifying need and giving services to people most need, and we don't do it. And then we're surprised that we get differential outcomes. All of the information on how to do this is all available. There are Canadian studies. The Mental Health Commission have lots on its website, but the true problem we have is that as a profession, we choose not to do it. And that's why communities will turn around and say that as a profession we have a racist profession because they'll say the information there.

  Dr. Kwame McKenzie: [00:53:14] But we choose not to do it. And that's that is increasingly with Black Lives Matter and with all of the other things that are happening in society, that's increasingly the problem. I'll tell you a joke. There is a joke that goes around policy circles, which is why did the Canadian policy adviser cross the road? And the answer is to get to the middle. Right. And the truth is, in the past, that was a really completely fine and decent, pretty Canadian outcome. Yeah. But we've now reached a position in society. Where if you sit in the middle. It's not good enough for a lot of people. So if you sit on the fence around me, too, you're part of the problem. If you sit on the fence about reconciliation, you are part of the problem. And if you sit on the fence around anti-Black racism, you are considered part of the problem. Your people are increasingly saying if you are not with us, you are definitely against us. And I think it's a pivotal moment for psychiatry to start thinking about these things because we will be viewed through that lens. And if we are not clearly thinking about anti-Black racism and what that means for changes and significant changes in psychiatry, we will be considered to be part of the problem and that we we can't cross the road to be in the middle anymore. It's not possible.

  Dr. Alex Raben: [00:55:15] Right. And it goes back to, I think what we were talking about earlier, where racism can take the form of inaction or neglect. Especially when faced with the stark data that we've been discussing around the disparities. I wonder, can we come? Can you help us in our listeners understand that? In a concrete example, you've talked about adapting CBT for different cultures and that being an important step that practitioners can take. You also pointed out that it's not readily readily available, and I've actually had no experience with that in my training. So I'm wondering, can you help us understand what that looks like and can we take lessons from that and apply it to our other areas of clinical work?

  Dr. Kwame McKenzie: [00:56:05] There are very few things in psychiatry that have such a evidence base and are just neglected. And so last time I looked and this was a few years ago, there are about 400,000 people who've been in studies of culturally adapted CBT places like the London School of Hygiene and Tropical Medicine in the UK have even produced manuals of how you culturally adapt CBT. About ten years ago, something like that may be a little less and it can produced manuals of culturally adapted CBT for the Caribbean origin population, for the African origin population, and for the Spanish speaking populations of Toronto and the Caribbean and Africa. African one was picked up by women's health in women's hands, and they have seen hundreds of people and women's health in women's hands as a community health centre, and they've seen hundreds of people. Not only have they seen hundreds of people if you were a resident. Working in the emergency department at the Centre for Addiction and Mental Health. You used to see lots of Black women coming in with trauma, history histories, anxiety and depression from the Women's Health and Women's Community Health Centre. Once they started training, everybody in culturally adapted CBT, they managed to get those numbers down to a trickle, literally a trickle and all culturally adapted.

  Dr. Kwame McKenzie: [00:57:52] Cbt does, it says that spine of CBT of how we do treatment and how treatment works, that stays the same. You don't have to adapt that. You don't have to take away the fact that you are doing cognitive work and behavioural work and you don't have to take away the fact that you're going to do it over a certain number of sessions. That's straightforward. The question is, are there things about that that will make it more accessible? And the things that you tend to look at is the illness models that use the words that you use around the illness models. The examples are there Black people in the examples? Are you talking about somebody who who works in a bank or an office when most of the people you're going to come across are not going to do that? Are you going to start calling things home? Work in the Black communities that we work with in Toronto really hated the idea of it being called home work, journaling, Fine homework. No way. Right. And then are you when you're doing your CBT, going to ask people who you know Black and are hard pressed to do homework? Are you going to have to think about your model? The other thing was we for that culture that CBT for the Black population, there was an extra introductory meeting.

  Dr. Kwame McKenzie: [00:59:30] And that meeting was about CBT. It was about worries about CBT. It was about trying to introduce yourself as a therapist and getting people on the right page and all of those other things rather than just expecting everybody to to, to know you and like sort of give everything to you. And it was going back to some of the things we said before, Alex, about what you're trying to do in the first interview and what that first interview was actually about making the space. And it was about making the space for people to be able to ask all of the questions and allaying the fears. And it was also about demonstrating that, you know, there was a level of humility. You understood where they were coming from and that you were open to doing things differently if need be. And so it's all of the stuff around therapy doing it during the day. They're doing it right. Is it individual? Is it group? What do people like? You know, and all of these things when you put them together? You can change your outcomes by ten 15%.

  Dr. Alex Raben: [01:00:47] So many common themes throughout this this talk we're having, it's very helpful to hear how the CBT has adapted, that it's not necessarily changing the core therapeutic principles, but it's about making things more accessible, understanding the person in front of you, which are kind of hallmarks of psychiatry in general. And yet, as you point out, we're still not doing this stuff. There's still that gap. Things being hardwired in that aren't helpful, that aren't equitable. Those are just some of the things that popped up.

  Dr. Kwame McKenzie: [01:01:25] Yeah, no, I agree. And I think part of the part of the issue you have with the commodification of therapy and CBT is an evidence based commodification of therapy. We get a structure, we keep people structure, and because we keep we have that structure, we can replicate it. And that is the model of the Industrial Revolution. That's how it works, right? You get it, you work out how it works. You produce something that is your package and that's your widget and you produce something that everybody else can use and that is the model. Okay, fine. The problem is that if you bake in rigidity to that model, you bake in differential outcomes for people. And so cultural adaptation is just about saying we can understand why we have this model and we can understand that that increases the opportunity for different people to do therapy and for it to reach more people and for it to be demystified and for people who are not psychiatrists to do it. But we do actually have to try and say that that industrial model needs to be changed if we actually want it to work for the population.

  Dr. Alex Raben: [01:02:47] Well well, we did go into some theories there, but I you know, what I really took away from that was a call to action that there's so much we have left to do, both in terms of personal reflection and as reflect and reflecting as a profession as well and as a society. And and that inaction, as we've talked about, is not not acceptable, frankly. I'm just being mindful of the time. We want to respect your time. And so maybe we will end on that note. But we would really like to thank you again for being on the show and providing us with such a rich discussion and stretching our brains today. Site is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Anita Corsini, Randy Wang, Rebecca marsh and myself, Alex Rabin. This episode was hosted by Anita Corsini, Rebecca marsh and myself. The audio editing was done by Rebecca Marsh. Our theme song is Working Solution by All of Music. A special thanks to the incredible Dr. Kwame McKenzie for serving as our guest expert on this episode. As always, you can contact us at Psych podcast at gmail.com or visit us at Psych podcast. Org. Thanks so much for listening.

Episode 29: Cultural Psychiatry with Dr. Eric Jarvis

• Episode 29: Cultural Psychiatry with Dr. Eric Jarvis

  Sarah Hanafi: [00:00:08] Welcome to PsychEd, the psychiatry podcast for Medical Learners by Medical Learners. In this episode, we want to build off of some concepts that were touched on in a previous episode about newcomer mental health and explore more broadly the field of cultural psychiatry and the value this work can bring to communities that are increasingly diverse. I'm Sarah Hanafi, a PGY3 at McGill University, and I'm joined by Audrey Lee, a fourth year medical student at McGill.

  Audrey Lee: [00:00:36] Hi, everyone. Thanks for having me here today.

  Sarah Hanafi: [00:00:40] And we're really grateful to have our guest, Dr. Eric Jarvis, this week to share his expertise. Dr. Jarvis is an associate professor of psychiatry at McGill University, and he's the director of the Cultural Consultation Service at the first episode psychosis program at the Jewish General Hospital here in Montreal. Welcome, Dr. Jarvis, and thanks for joining us. I was hoping you can tell us a bit about your current clinical work and your research interests.

  Dr. Eric Jarvis: [00:01:08] Yeah. I'd be happy to. Thank you for having me on this program. Right now, I am the director of the Cultural Consultation Service at the Jewish General Hospital. So that's a speciality team that evaluates newcomers, immigrants, and refugees, as well as other people where there may be questions of cultural understanding or religious issues or problems in their lives. And so we will do consultations to the community, to clinicians in the hospital or in the greater Montreal area, even sometimes other places, just to try to help people understand the diagnosis or the treatment planning better. And I also run a first episode psychosis program, which is really becoming more and more a culture and early psychosis program, as we have more projects that are kind of linking the cultural consultation service to what we do in first episode psychosis as well. So that's kind of what I do clinically. Research wise, I've been very interested in how culture and psychosis interact and how culture and psychosis influenced each other. And the most recent grant we have received from Health Canada is looking exactly at some of these problems. How do we adapt culturally some of the interventions that we do in the first episode psychosis program? So most specifically, how do we adapt culturally, family psychoeducation, for example, to the many diverse members of our community? So those are some of the things I'm doing.

  Sarah Hanafi: [00:02:45] Excellent. Now I'm excited to hear more and I'm certain kind of later on in the episode you'll be able to draw from this clinical and academic work to illustrate some of the points in this episode. So in terms of today's episode, we're going to touch on several learning objectives. One, define culture. Two, describe how culture affects psychiatric care. Three, outline the goal in the structure of a cultural formulation interview. Four, evaluate clinical scenarios to determine whether to employ the cultural formulation interview or to seek a cultural consultation. Five, define the three types of cultural concepts of distress and compare these with DSM five and psychology. Six, discuss the concept of cultural competency. Seven, explore the role of advocacy in psychiatric practice. So for many of our listeners, this may be the first time they've heard of the concept of cultural psychiatry. Dr. Jarvis, I'm wondering, can you explain what this field entails and how does it differ from the field of social psychiatry?

  Dr. Eric Jarvis: [00:04:00] Sure that's a good question. I think a lot of people lump together social and cultural or social and transcultural psychiatry, and in many ways they are the same and they do overlap, at least in many ways. But there are distinctions and I think if you're in the field of cultural psychiatry, it's important to maybe think about some of those differences. So social psychiatry has more to do with examining how the power structures are aligned in society and how they may give or deny resources or access to care, for example, to certain groups of people. And so social psychiatry is interested in determining the determinants of mental health and is closely aligned maybe with psychiatric epidemiology, say, whereas cultural psychiatry is a little bit different. It's not ignorant of those kinds of issues. I mean, certainly cultural psychiatrists know that that's very important. But cultural psychiatry borrows heavily from medical anthropology, and so it's interested really in how people construct their identity or their identities. It's interested maybe in other topics like how people believe that they become ill or how people understand the illness process or the illness experience. And then how do people react? Or how do communities organise to alleviate suffering and maybe even define suffering itself? So these are kinds of the questions, more of cultural psychiatry, and I think it's important to kind of take stock that there are some subtle variations or maybe not so subtle differences between the two fields.

  Sarah Hanafi: [00:05:45] And how did you yourself come to be involved in work in cultural psychiatry?

  Dr. Eric Jarvis: [00:05:52] Well, for me,  it was a real choice. I mean, I did a non-science undergrad degree in history and I enjoyed the humanities immensely as well. And when I went to medical school, I was looking through all the different, different programs around the country. And I saw there was a transcultural psychiatry program at McGill, and I just was immediately taken with the idea of applying to McGill and going and doing a residency there and learning more about what that might be. And when I came to McGill, I immediately started to work in that field. I got to know Lawrence Kirmayer and others of his colleagues, and from there it was such a great natural fit. I've always been fascinated with the field ever since, and I've structured my clinical and research and writing interests around those kinds of topics. So it's been a really wonderful journey.

  Audrey Lee: [00:06:54] Thank you for sharing with the listeners the journey that you took into getting involved within this field. Dr. Jarvis. So we've talked a little bit already about what cultural psychiatry is, and evidently culture is an important and central concept in this field. In the DSM-5, culture is defined as systems of knowledge, concepts and rules and practices that are learned and transmitted across generations. Could you elaborate more on what we really mean when we're talking about culture? And furthermore, how does culture differ from race and ethnicity?

  Dr. Eric Jarvis: [00:07:30] Yeah, I mean, the definitions of culture abound. There are so many different definitions. Every book that you read on the topic will have a slightly different take on what it means. A few ideas that I always think about culture is it's kind of a legacy that we receive from those who came before us. So many of the things that we take for granted in our lives, the patterns that we follow throughout our lifetimes, maybe the beliefs that we think are spontaneously coming up from our own psyches are actually bequeathed to us by the people that we've known in our lives, people that are parents or our families and people in our communities all around us. And so for me, this culture is not something that necessarily just comes into being through our own wills and our own ways of living that we choose. It's something that comes to us from long ago, and I think we can remember that and recognise that we'll see why it's so critical to take account of the cultures of the peoples around us, professional cultures as well as ethnic and religious cultures that we might participate in. So important to remember that culture is a legacy, but it's also something that is often taken for granted. It may be things we're dimly aware of, practices and beliefs that we're dimly aware of until we encounter somebody that's different from ourselves.

  Dr. Eric Jarvis: [00:09:01] And that's an important opportunity and important moment when we encounter somebody who believes or behaves very differently from how we think is what we would consider to be normal or acceptable. We have to step back, descend ourselves, and begin to ask some very important soul searching questions and try to reach out to people and form commonalities or bridges that can help us to not just communicate, but to maybe be helpful if they're in distress. So final point on culture I wanted to mention has to do with the fact that we often put culture into other people. We might say that patients or families or other people from other places have culture. But to remember that we as observers in medicine and psychiatry, we also have a culture of our profession. We have cultures that we've grown up learning and understanding and believing. And part of cultural psychiatry is to seriously consider what those core beliefs are that we have that may or may not be shared by other people. What are the things? What are the ideas and the values that we might put out there that other people may not understand or may not accept, but that we think are maybe right or valuable just in and of themselves. So this is something that I think cultural psychiatry can really bring to medicine in general, in psychiatry more particularly.

  Sarah Hanafi: [00:10:39] I really appreciate that. Dr. Jarvis, that reminder that we, you know, take a step back and consider the culture that we bring, whether as an individual clinician or as a professional body. I wonder, you know, with these differences culturally or these different legacies, how do you find that this impacts care in psychiatry?

  Dr. Eric Jarvis: [00:11:05] Well, for me, as I've kind of come along over the years, I've come to realise that culture is at the root of what makes meaning and value to people. So if I'm going to try to understand other people and try to offer some help to them, then I think for me, I need to take account of this aspect of their lives. To pretend that people are all the same, or to pretend that culture isn't really present or maybe isn't that important if it is, I think, is really missing a lot of what we need to take account of as clinicians. I think ignoring culture means we may be misled in our diagnostic practices or what disorders we think are present in people. We may completely miss the boat on proper and acceptable treatments for our patients. And if we don't take account of people's cultural backgrounds and what's at stake for them in the clinical encounter, we may not ever see them again after the first visit. I mean, they may not want to come see us again. They may not adhere to the kinds of medications or other interventions we think may be important to alleviate their distress. So to me, a cultural evaluation is just part of a routine and comprehensive psychiatric or mental health evaluation.

  Sarah Hanafi: [00:12:39] I mean, it sounds like culture or taking culture into account can affect all facets of psychiatric care. I wonder going further with that: Do you find that certain cultural communities experience disparities in our mental health system in terms of their outcomes?

  Dr. Eric Jarvis: [00:13:00] Yeah, definitely. I think that that's part of the interest, but also the challenge of cultural psychiatry, is to try to find ways to reach out to people who may, because of various problems, it may not be anything to do with them, it may be the way that society is structured, because of social structures and structural issues, maybe systemic racism or other problems. But certain people from different communities, different backgrounds, may find they can't or aren't willing to access care or may feel very mistrustful of what we think are such basic notions like psychotherapy or maybe taking medications. So yeah, I think that some communities are more adversely affected than others by this. I hesitate to make stereotypes sort of by drawing attention to particular issues. I know in the news right now, a lot of people are very upset, rightly so, about mistreatment of African Americans, African Canadians, black Britons, people of African origin in different countries and societies who have very difficult and historical legacies of oppression through the police, for example. But some of those kinds of problems exist in psychiatry as well, and Summer Knight, she's a student with us on our team, has recently done her master's thesis on this very topic and finds that people of African origin here in Montreal suffer a greater degree, greater amounts of coercive treatment measures, for example, than members of other communities. So what does that mean in psychiatry? It might mean outcomes like forced treatment orders, it might be being forced or compulsorily admitted. It might be having police contact prior to presentation at the emergency department. These kinds of outcomes she found in her master's thesis to be present. So I think these kinds of things are very real and they negatively impact the way that we can help other people. So cultural psychiatry is trying to take stock of these issues and trying to modify the way we approach members of indigenous or African communities who may feel very deeply wounded and have been deeply wounded for decades or even centuries.

  Audrey Lee: [00:15:44] I really appreciate your perspective on the impact that culture can have on the psychiatric care of certain marginalised populations within society. And I think that this is an extremely important topic to address within the current social climate that we're living in. Now that you've provided some insight into why culture is important and into its relevance in psychiatry, I think that listeners would benefit from learning about some tools that they can use to tackle cultural issues within their clinical work. So I understand that the cultural formulation interview or the CFI is one such tool that exists and that it's a framework. Can you perhaps elaborate a little bit more about the CFI and its goal?

  Dr. Eric Jarvis: [00:16:28] Yeah, for sure.  So in the DSM-IV, there was something called the outline for cultural formulation and it was really a broad general framework trying to help people who are interested in in considering culture in the clinical encounter. It gave five kind of general categories of topics to cover that a clinician could use. The cultural formulation interview arose because people found the outline for cultural formulation a little bit too vague and maybe not very specific in its direction as to how to inquire about these basic ideas. So the outline for the culture formulation interview is comprised of 16 questions, and the questions come out of the basic categories of the outline for cultural formulation, like cultural identity, for example, or examining explanatory models. These are sort of general categories from the outline of culture formulation. The culture formulation interview takes these basic building blocks and then makes concrete questions that fit into each of these larger categories. And so a clinician can use these really in any clinical setting, usually at the beginning of the interview, to make sure that at least some facets of culture are covered in the evaluation or clinical interview.

  Dr. Eric Jarvis: [00:18:04] It takes about 20 minutes to do a cultural formulation interview. And, I mean, these 16 questions really are quite basic. They're certainly not a comprehensive cultural evaluation or psychiatric or mental health evaluation. If people discover that there's more to discover or more to uncover, I guess, in the evaluation, there are 12 supplementary modules as well that a person can turn to, a clinician can turn to, and find much more guidance on how to pursue, say, issues of religion and spirituality, or if they want to go deeper into immigration or migration. They could find a supplementary module to complement what they've already tried to do in the interview. There's also a version of the CFI for families or for third parties. It's called the informant version of the interview. So it could be for family members, it could be for community members or other people who are participating in the interview. And the informant version of the CFI has one more question than the usual 16, and it just asks the person at the beginning what their relationship is to the patient that you're interviewing. So that's kind of a general overview of the CFI.

  Audrey Lee: [00:19:32] So now that the listeners have a bit of a better idea of what the cultural formulation interview consists of. When exactly do you decide to introduce the CFI when you're evaluating a patient, and what are the indications that you look for that warrant, this kind of assessment?

  Dr. Eric Jarvis: [00:19:48] Yeah, that's a good question. People wonder maybe when should I introduce it or when should I do it really? The CFI was made for everyone, every clinician to use and the idea is for people to use it all the time. When you wouldn't use it? Maybe if you're already kind of doing a more in-depth cultural assessment of a person, you may kind of surpass what the cultural formulation interview is able to give you. If you already know a person well or if you're doing a more in-depth cultural evaluation at the beginning, you may not do the CFI for various reasons, which I'll talk about. But for most clinicians, the CFI is really made for you to use. And so I would encourage the listeners to check out the CFI and the DSMV and look it over. It's not too intimidating. I hope the 16 questions are fairly simple and easy to use, I think, and you can look it over and begin to consider how they could use it in their practice. So that's what I would recommend and hope. I mean, the CFI is studied fairly widely around the world in different settings, mostly academic settings, but it's been shown to be feasible, it's been shown to be useful, and it's been shown to be pretty well tolerated by clinicians and patients alike from a wide variety of backgrounds. So I think it's something really to consider using more routinely in our clinical work.

  Sarah Hanafi: [00:21:27] So you kind of touched on something. I was hoping, you know, we would get to the the evidence around the CFI. So it sounds like it's something that's been demonstrated as as valid and feasible. I guess, just for clarification, has this been solely in Canada or the States or has this also been looked at in other practice populations?

  Dr. Eric Jarvis: [00:21:54] Yeah, the CFI, it was initially pilot tested in various centres around the world, not just in mostly the US and Canada I guess, but it was pilot tested in other settings as well. Since that time there have been a number of studies from different places that have used the CFI in the work that they're doing. One of the problems is most of these settings are academic settings, so it hasn't really been culturally validated, so to speak. It's been shown more to be feasible and useful in clinical settings. So cultural validation would be a much longer, more complicated issue. So that's something that hasn't yet been achieved. The CFI hasn't been shown to be culturally valid necessarily. It also is kind of lacking in effectiveness studies. So does use of the CFI really improve clinical outcomes? This is a question that remains still. It's  something that can be, as I say, that's useful and that can be implemented well in clinical settings. And we feel like it's helpful and it brings a lot of good things into the clinical evaluation. But effectiveness studies need to still be done. It's really kind of a work in progress. The CFI, it's still the subject of a lot of ongoing investigations and it appears in the DSMV, but it'll keep growing as the research database grows. And I think you'll get more and more attention as it does so.

  Audrey Lee: [00:23:39] I think that it could also be helpful for our listeners to get a sense of how to use the cultural formulation interview through examples. So would you be able to share with us perhaps a typical case that you might see in either the Cultural Consultation Service or the first episode psychosis program and how you go about implementing the CFI.

  Dr. Eric Jarvis: [00:24:04] Well, the CFI is something, as I mentioned, that really depends on the individual clinician. Do they want to make its implementation a priority or not in their clinical practice? So it's really an open tool that we can use. It doesn't have to be used in just speciality or subspecialty services, like in a general psychiatric practice. I would really encourage its use there. For example, I think that it's best to use the CFI at the beginning of the evaluation because it, as I mentioned, after practice, takes maybe about 20 minutes to use the CFI, but it really opens up some general information about the client or the patient, their identity, what they feel is important about themselves and their presenting problem. So it's kind of a new way to introduce the patient to the mental health evaluation. You know, there are some limitations of the CFI, though it's not been very well studied in patients that need a linguistic interpreter or culture broker. Also, if you're doing evaluations with family members present, it might be a little complicated to use the CFI if there's referring clinicians as well present or members of the cultural community.

  Dr. Eric Jarvis: [00:25:30] For this reason, in the Cultural Consultation Service at McGill, we don't use the CFI very often because most of our evaluations are with other people present. So it's not sort of a one-on-one kind of an interaction. Also, if people are acutely ill with psychosis, maybe, or acutely suicidal, if they're aggressive or if they have cognitive problems, cognitive neurocognitive disorder, for example, and they may not be able to actually finish a questionnaire like the CFI, you may have to radically adapt your interview to suit their needs. So those are some of the thoughts I have on the CFI. Personally, I think the CFI there's one question in the CFI that has to do with the clinician patient relationship, which I don't think is enough. I think the clinician patient relationship is so important. As I as I was mentioning before, psychiatry itself is a culture and all psychiatrists, all mental health professionals come to clinical encounters with their own cultural backgrounds. So I think the CFI needs to pay more attention to that, to the culture of the observer.

  Sarah Hanafi: [00:26:47] I think those are really thoughtful points and ones that maybe we don't often consider. Kind of coming from that, you've talked a little bit about the Cultural Consultation Service. Can you share with us, you know, maybe a typical case you might see on the on the CCS? And how do you approach that, especially if the team maybe isn't necessarily using the CFI?

  Dr. Eric Jarvis: [00:27:14] Yeah, well, most of the people referred to the culture consultation service are either immigrants or refugees. I guess refugees are a kind of immigrant. So it's more than 90% of the people referred come from those two kinds of groups. We've had a few indigenous patients referred over the years, about 30 total maybe, and they might make up the bulk of the non-immigrant, non-refugee referrals to the service. So what we do is we work with the referring team and we invite the referring team to come to the consultation. And we also spend quite a bit of time before the consultation learning about the client and his or her family. So we'll ask if they need an interpreter and we ask if a culture broker would be beneficial, we try to determine if that would be the case. How do we know if an interpreter is necessary, if somebody has a mother language other than French or English? In Montreal, we would at least offer an interpreter. Some people might take that to be a little bit offensive, maybe like if they've been to school in France, in French, in another country or English, another country, and they feel they're very proficient in that language, they might feel a little bit miffed.

  Dr. Eric Jarvis: [00:28:39] But we take the risk because so many people are never offered an interpreter during the time of their psychiatry evaluation or the time of their psychiatric treatment. So we take that risk. And many, many people are extremely grateful to have an interpreter present. When do we need a culture broker? We would try to have a culture broker present for every client, but sometimes we don't have a person we've identified as a culture broker. We have a network of culture brokers that we work with fairly regularly. But sometimes we don't have a person that we could pair up with a client from a particular background. So in those cases, it's up to me and the resident or the interpreter and other people who are present in the evaluation to do the best that we can. And we have to use our cultural competency skills to the best of our abilities. You know, they're strained sometimes, but it's it's always a very challenging  a kind of a career, a challenging kind of an interaction. You're trying to really reach out to people. You're trying to help people feel comfortable, people who have been horribly traumatised or may have a terrible mistrust of anything official, especially anything official in Canada.

  Dr. Eric Jarvis: [00:30:04] I mean, especially if they've been brutalised by police in the past or they're seeking refugee status, they may worry that anything they say could and will be used against them. So much of the cultural consultation at the beginning stages anyway is trying to help people feel culturally safe and comfortable in the evaluation at least enough that they can have a meaningful interaction. So the culture of consultation is usually maybe one or two evaluative sessions. And then from there we try to gain a decent sort of overview of the person's life, and we then meet with the clinicians in a separate meeting. We call it a clinical case conference, and there we present the case to the referring clinician and we have the culture broker present, if there has been one, and we present the report and we try to definitively - well, I won't say definitively - but we'll try to settle on a most appropriate diagnosis, and then we'll try also to work out some helpful recommendations. Some of them are biologic, meaning using medication or other interventions, but a lot of what we try to do is modify the social world or recruit resources from the social world, maybe from religious communities or other other community organisations to try to help individuals.

  Sarah Hanafi: [00:31:34]  I think one thing I wanted to almost circle back to that you mentioned was this idea of the families involvement in the process of evaluation. I know often when we think of child and adolescent psychiatry, when we're talking about family systems and including that in the clinical evaluation, particularly in the work of cultural psychiatry. Can you elaborate a bit more on the role of the family system and how it might differ from what we typically see in psychiatric clinical interviewing?

  Dr. Eric Jarvis: [00:32:13] Absolutely. I mean, in cultural consultation and cultural psychiatry, I should broaden out a little bit. I mean, family and family interviewing and family interventions are key, very, very critical because you're trying to establish the context of a person's behaviours. So  we do see people who are individualised, I mean people that come without their families, they're maybe in Canada alone or something, or in rare cases they might refuse to have family involvement. But the majority of cases we see with family members, I'd say, and that's because I guess like in child and adolescent psychiatry, we realise so, so much the role of the family not only in supporting, helping or sometimes harming individuals even, but also in structuring what the distress is really all about and the form the distress takes. So we want to see that interaction. So we do see people without their family members. We might if we come into an interview, we begin to suspect a problem of abuse or other issues. We will ask the family members to leave for a time and interview the individual alone, especially if it's a woman or a younger person. But oftentimes, we almost always start off the evaluation with the family together in the consultation. And that may be a little bit different than most psychiatric evaluations, because, like I say, we really are searching and seeking for the context. And we look at the interactions, we see who speaks the most often, what languages are used. Sometimes people might speak English to the interpreter and then maybe French to some people in the family, and then maybe another third language to the grandparents. And so this is all of great importance to us as we're doing our evaluation, trying to see how the system, the family system was set up and how it may or may not be a microcosm of something larger, a larger cultural construct.

  Audrey Lee: [00:34:23] Thank you for that detailed explanation of the CFI and its usage. Dr. Jarvis. In the DSMV, there's also this mention of cultural concepts of distress. Could you describe what these are in further detail?

  Dr. Eric Jarvis: [00:34:38] Yeah. So cultural concepts of distress are ways that people from different backgrounds might describe their suffering. So we have our own cultural concepts of distress in North America. So some of them are lay, some of them are professional. So we have a whole DSM full of diagnoses that you could argue to some degree are cultural concepts of distress that have kind of emerged over the last century or so of psychiatric practice and wisdom, you know. So it's kind of a new way of understanding. DSMV, the diagnoses, the nosology that we all take for granted. But I think it's good to step back and look and see how these kinds of concepts affect psychiatry and medicine as well as other people and other peoples. I don't know. There's three different kinds of cultural concepts of distress that people talk about. So I don't know if that's of interest to you guys, but I could talk about a little bit here maybe. So there are cultural syndromes that have been identified, in DSM IV, there was a glossary of these culture bound syndromes which has been abandoned. And the reason that it was  abandoned is that cultural behaviours and forms of cultural distress aren't usually limited to one group. People from all different backgrounds can experience anxiety, depression, anger, irritability and psychosis, for example. So these syndromes aren't really culture bound. They're more emphasised maybe in one place, more than another. So  one place may emphasise sad feelings or sorrow as part of depression.

  Dr. Eric Jarvis: [00:36:34] Another place may emphasise maybe backache or headache when they're feeling discouraged. So they may nonetheless experience the full gamut of depression symptoms at different times, and maybe they just won't focus on the same degree. So the new term is cultural syndromes, and these are really like clusters of symptoms that may be specific to certain cultural groups and that form a pattern of recognisable symptoms of distress. So there are some examples listed in DSMV and there's many we could talk about. One of them is an entity called taijin kyofusho, which may be related to a form of social anxiety disorder, say, in Japanese people, where people from that particular background might feel that their body odour is offensive to other people, or maybe they have offensive breath to sort of an extreme degree. But this problem of being sensitive to how your body odour is affecting other people might be relatively present in Japanese society. It might be more of an issue for Japanese people in general. It's always hard to stereotype. Individual people, of course, have great variation in every context, every society. But so this this kind of cultural syndrome taijin kyofusho might be a representation of an extreme form of this concern about offending other people. So that's sort of an example of  a cultural syndrome, and how it might overlap in some ways with an entity or a diagnostic category from the DSM. But these overlaps aren't perfect. And so  it's rare that you can have a 1 to 1 equation between what would be called a culture bound syndrome and something from the DSM. There's also some other ideas about cultural concepts of distress.

  Dr. Eric Jarvis: [00:38:40] One of them is a cultural idiom of distress. And this is not quite a cultural syndrome, it's a manner of expressing distress that is recognisable in a group of people but it's not on the way to becoming syndromic. It's something that's more kind of colloquial or in the common language of things. So a person might say, for example, focus on, as I mentioned earlier, pain or discomfort in their body as opposed to feeling sad or melancholic about a life situation. And we have it in North America as well. People might get backaches or frequent headaches or stomach upset in distressing situations. So if more people, more and more people take these kinds of use these ways to express their distress, that it might become an idiom of distress. A cultural explanation is a third kind of concept, a cultural concept of distress. And it's kind of a cultural explanation or perceived cause that has more to do with how somebody explains what's happening to them as part of their explanatory model. So somebody might say, you might ask them what their problem is and they might say, my problem is jinn possession. Say they might say spirit possession. It's not in any part of a syndrome. It's not necessarily an idiom of distress. It might be something, an explanation of what they're going through. So these are some of the ways that people might might categorise cultural concepts of distress. They differ by degree of organisation into discrete illness or syndromic categories.

  Audrey Lee: [00:40:45] You know, I think that the topics that we've touched on throughout this episode, such as the CFI and these cultural concepts of distress, just speak to this growing need for cultural competency, humility and safety and and that these calls are growing within medicine and certainly within psychiatry. However, I can understand and see that there are many variations and nuances to these different concepts. So I was hoping that you could explain the role of cultural competency within mental health care and how it differs from cultural safety.

  Dr. Eric Jarvis: [00:41:20] Okay. No problem. Cultural competency refers to the idea of skills that clinicians can acquire, that can help them to work with diverse clientele or diverse populations of patients and their clinics. So one of the problems of the cultural competency idea is it may foster a false sense of security. I mean, if you sort of pass a certain level of competency, if you're checked off as being competent culturally in a certain situation or with a certain group of people, you might kind of think, oh, now I know it all kind of. But really part of cultural competency is a concept called cultural humility, where clinicians recognise the tremendous diversity of beliefs and of health beliefs, I guess, and of values among their clients. And so we recognise and we strive to recognise that we don't have all the answers, even if we have mastered some aspects of cultural competency and we sort of recognise as kind of a lifelong process of learning more and more about the people that we're trying to help and allowing them to speak up and and teach us about what is helpful to them. And for me in my practice, and I learn a tremendous amount from my patients, about what can be helpful and what may not be. So this is just a caveat when it comes to ideas of cultural competency.

  Dr. Eric Jarvis: [00:43:02] There's also the issue of cultural safety, which I think I touched on before. Cultural safety is another component of cultural competency. And what that means is that as clinicians we recognise that people from various backgrounds, various cultural communities may have important histories of oppression where they don't feel safe coming to meet professionals like us and to them we represent the oppressor of the past. We might represent power or authority or various problems, and that to them, coming to see a psychiatrist or any kind of mental health practitioner might be a very daunting task. So for us, it's incumbent upon us as the people with the power to recognise that. And then we try, as I mentioned before, in cultural consultations, we spend time to help all of our clients feel comfortable to the degree that we can. I mean, nobody's perfect to the degree that we can. We may help people to feel comfortable and give them some space and time and then acknowledge these differences and these historical legacies that can many, many times be very harmful. So if we can do that, I think we are able to reach a lot more people and people will be more likely to come to us and take note of what we're trying to tell them, because we do have important treatments and important ideas to share with people about their health and their mental health.

  Dr. Eric Jarvis: [00:44:38] So we don't want to kind of squelch it off at the beginning by being a little too, I guess I'll say, arrogant about what we've come to understand or I mean,  this is part of the problem. So cultural competency includes these kinds of ideas. Culture competency also includes a number of other skills. Some of them are more generic, some of them are more specific that clinicians can try to - I shouldn't say try to learn - every clinician can improve, I think, some of the general skills have to do with active listening skills in a non-judgmental manner and a patient manner. Even when people are not behaving the way you anticipated, they might behave in a clinical context. There's an idea called scientific mindedness. Stanley Sue and his group in California came up with some of these ideas about some elements of cultural competency. Scientific mindedness has to do with keeping an open mind and not forming a hard and fast conclusion about the people that you're meeting too quickly, letting people have some room to move around in the evaluation or maybe in a few evaluations or in a few meetings and not locking in, say, a diagnosis or a treatment plan too quickly. There's another kind of a concept called dynamic sizing, which means that we can kind of modulate the interventions and the perspective that we're taking ourselves.

  Dr. Eric Jarvis: [00:46:15] Sometimes we might pull back and adopt a psychiatric perspective with the people that were interacting with. Other times you might want to take a little more of a on the ground level view of what's going on. We might try to enter the worldview of our clients and see if we can. Maybe they need that to establish a relationship of trust with us, for example, and so we can work on these kinds of skills preventing premature closure, trying to adapt the perspective that we come into the evaluation with. There are specific skills for cultural competency as well. We might become very knowledgeable about one or two communities over the time of our professional lives, and maybe because of our birth or where we come from, we might know third or fourth languages, and this can be very helpful. It just takes a long time to acquire the in-depth knowledge of some of these specific cultural skills. And we have to be, again, humble. And if we recognise we're a little bit outside of our comfort zone, we can reach out to linguistic interpreters and culture brokers who can come to help us to give extra input so that we can understand the patient and his or her context better. So those are some ideas of cultural competency.

  Sarah Hanafi: [00:47:53] Thank you. I think that's very helpful. I really like the way that that you explain those different concepts and compare them to one another. Building a little bit off of that, we've talked a lot about how this practice of cultural psychiatry is also related to social context and how it can be very much rooted in social systems. And therefore, social inequities can impact on what patients are experiencing in terms of health disparities. I'm wondering in your practice, how do you view the role of advocacy as a psychiatrist?

  Dr. Eric Jarvis: [00:48:36] The advocacy is, I think in cultural psychiatry, especially cultural consultation, also in culture and early psychosis. I mean, I think we are advocates most of the time for our clients because many of the people that we see are truly on the margins of society. Some of them come to us from very difficult backgrounds. They may be new to Canada as well because they have a mental disorder often, or at least they're suffering mental distress. There's a heavy stigma from families, from cultures of origins. So we as mental health professionals are poised and should be ready to advocate for people in these circumstances. I think that's a core aspect of our role as mental health professionals. When you're working with refugees in particular, I mean, as refugees are in a terribly precarious state. So they're waiting on other people to make decisions about their future lives. They're leaving very difficult circumstances. They're having a very hard time often understanding Canadian society and how to negotiate it. So as a mental health practitioner, we can help that quite a bit. We can guide them in the proper path to take. We can write letters for them. We can volunteer to speak to their lawyers, to their referring clinicians, and we can try to smooth over misunderstandings and the letters that we can write. Placing the person's individual's behaviour in a cultural context can be very, very eye opening to the judges on the immigration board and the lawyers as well who are helping to represent the clients. And so these are just some of the things we can do. I mean, we can also, in some cases, we might recognise that a refugee applicant may not be able to effectively represent him or herself for whatever reason. And so we can advocate for a designated representative that can accompany them to court and can serve some of the functions that a person regularly would do for him or herself. So, I can't stress enough the importance of the advocacy role for psychiatrists and mental health professionals, especially working with these populations.

  Sarah Hanafi: [00:51:08] You know, it seems like I mean, there's so many ways in which a psychiatrist can impact on a patient's well-being and advocate for them beyond the clinical encounter. We're starting to near the end of our episode, so I'm hoping we could end more on the topic of training in cultural psychiatry. And one thing certainly that strikes me in this clinical work is that it seems more process oriented. I'm wondering, how do you approach educating trainees about this field?

  Dr. Eric Jarvis: [00:51:40] Yeah, the training in cultural psychiatry is very experiential and there's a tremendous amount of literature as well on the topic. And in fact, it can be a little bit daunting to beginners in the field of cultural psychiatry. It's so multidisciplinary that people sometimes don't know where to begin. I mean, do you start with the social science literature, with the psychiatric literature, the anthropology, literature, history of peoples current events? They all are really important in cultural psychiatry and they help the culture, cultural psychiatrists and make or build a cultural formulation. So when you're building a cultural formulation, you're drawing in from these different, different perspectives that come to bear on the individuals and the families that you're seeing. So I tell beginners I meet with not to give up. Don't be discouraged, follow your interests. So if you have an interest in helping people in these kinds of situations as a clinician, or if you have research questions that you want to answer, follow through on those, and gradually you'll enter into this world, this larger world of cultural psychiatry and with all of its many bridges to different fields. There are some things you can do to help with this. You can watch for certain kinds of events that are going on during your training. Some people in residency training programs, for example, may not have a lot of access to cultural psychiatry training.

  Dr. Eric Jarvis: [00:53:11] Some places have more in Canada or in the United States. But if if you're a resident, for example, you can watch for something called Cultural Psychiatry Day, which is put on annually, usually in April of every year, and it's open to all residency training programs across Canada. There's also cultural psychiatry events at the CPA. Usually there are some there you can attend. You can watch for some international conferences. There's one called the Society for the Study of Psychiatry and Culture, which takes place usually in the spring as well. In April or May this year, it's because of COVID. It was moved to October. Well, I think it's September 25th and October 9th and 10th of this year. It's entirely virtual this year. There's still time for people to join that conference that they want to. There's other opportunities that come up for training for people. There is a McGill Summer program in Social and Transcultural Psychiatry, which takes place every year around May. And there's an event study institute usually in June that people can attend. This is where you network. If you come to some of these events, you'll meet a lot of the cultural psychiatry people from around the world. And before you know it, you'll be part of the group and you'll have really a great experience and some of that confusion will disappear a little bit as you realise everybody is doing different things and it's okay.

  Dr. Eric Jarvis: [00:54:43] Part of the great thing about cultural psychiatry is diversity and so people in the profession also appreciate diversity and the people that come to participate and they like to see diverse interests as well. You can do a rotation at McGill and the Cultural Consultation Service, if you like, to get kind of practical  on the ground feeling about what cultural assessments might mean during all this process. It's important to choose a mentor. You might hear of somebody or hear someone speak, or you might read an article or paper, or you might see a podcast or hear a podcast or see some other thing where somebody really speaks to you, you know? And then you can choose to write or contact that person, write them and see what they have to offer. And they'll usually be very happy to talk to you and start to guide you in ways you can foster your own interests in the field. So this is kind of the informal way I think the training takes place. I think it's very important because I think it's really the way that I learned cultural psychiatry and the readings that I do and did are part of it, but it's a vast kind of pool.

  Dr. Eric Jarvis: [00:55:59] And you need to have some personal, I think, one-on-one help in doing that, more formal ways to to engage in training and cultural psychiatry. I mentioned some things like cultural consultation, service or formal teaching structures that you can attend. A summer school, for example, can give a very good kind of overview of the field. And then gradually you begin to learn how to use interpreters and culture brokers in clinical work. And I think that when you learn those kinds of things, when you start to have an appreciation for that, I think that it really takes off. You can learn how to use the CFI, the cultural formulation interview. And to structure your thinking along the outline for cultural formulation to really make it maybe not too lengthy, hopefully, but helpful cultural formulations that can benefit the people that you're seeing. So these are some of the training problems and some of the benefits. To me, it's very wide open and cultural psychiatry, very exciting, a little daunting for the diversity and sometimes lack of structure. But if you enter in and start to look around, you'll impose your own structure and you'll start to make a unique contribution, which is, I think, what all of us want in cultural psychiatry.

  Audrey Lee: [00:57:16] I had one last question for you, Dr. Jarvis, which is a bit of a follow up to what you just talked about. So along the same lines of tips and advice that you might have for trainees, what additional insight might you offer to trainees who are interested in cultural psychiatry but can feel overwhelmed by all the cultures that they might encounter or need to navigate?

  Dr. Eric Jarvis: [00:57:39] Well, nobody is an expert in all the cultures. So I mean, I certainly am not. And when I was a new staff at the Jewish General Hospital in Montreal, I was the director of the Cultural Consultation Service. And people would come up to me and ask me what to do for this person from this country or that person from here or there. And I didn't know, I had to say, I'm so sorry. I know I'm the director of the service, but I'm going to have to get back to you on that one. So that's okay. It's okay to feel that way. And over time, what I found is if I kind of stuck to it and persisted and I found that there are some general kind of trends you can follow with people in general kind of approaches you can follow that I mentioned already some of those kind of general cultural competency skills that you can learn and you can. Those are helpful not just with our clients, with our colleagues as well, because our colleagues are also people coming with their own agendas, their own interests and their own needs. And when they ask you questions,  when they submit a consultation. So this is the way that I've kind of negotiated that problem. And I think some patience is with yourself as it is a major step. You can't be expected to learn it all right away, and you can't be expected to know everything about every culture, every group. You're kind of forced into a culturally humble position. I think when you're working with a big group, with greatly diverse groups, you have to sort of be humble that way. And then gradually over time you'll learn about how you can reach out to people to help you.

  Audrey Lee: [00:59:25] Thank you so much, Dr. Jarvis, for joining us today. I think we can speak on behalf of all of our listeners that we're very grateful to have had the opportunity to learn about this fascinating and important approach to mental health care. Do you have any closing remarks for the listeners today?

  Dr. Eric Jarvis: [00:59:42] Yeah, I mean, to me, a lot of people look at cultural psychiatry and they just give up a little bit. They think, Well, I'm not going to get into all that stuff. It's just a little bit too much, you know? And I'm going to just stick to what I know and I'm going to try to do the work I do the best I can. And I think that's understandable. I think, though, that as psychiatrists, psychologists, mental health professionals, we have a responsibility to to watch out for ways we can improve ourselves. And I think that we need to watch out for the well being, too, of everybody that we see. So I would try to be a little daring. I would crack open the DSMV and go to the cultural formulation interview as a starting point, look through the questions and ask yourself, you know, how can I implement this in the evaluations that I'm doing? Is there a way I could put this in at the beginning of what I do, try it for two or three clients and see if it isn't something that opens up some new angles you hadn't seen before and if it doesn't create a better treatment alliance with your patients. So I guess I'm asking people to be a little bit daring and try something a little bit new and see if this can really make a difference or not for themselves.

  Sarah Hanafi: [01:01:11] Well, thank you once again, Dr. Jarvis, for sharing your expertise and your time with us today. PsychEd is a resident driven initiative led by the residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Drs. Sarah Hanafi and Audrey Lee. Audio Editing and Show Notes by Dr. Sarah Hanafi. Our theme song is "Working Solutions" by All of Music, a special thanks to the incredible guest, Dr. Eric Jarvis, for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening and take care.

Episode 28: Newcomer Mental Health with Dr. Lisa Andermann, Dr. Clare Pain, and Norma Hannant

• Episode 28: Newcomer Mental Health with Dr. Lisa Andermann, Dr. Clare Pain, and Norma Hannant

  Sarah Hanafi: [00:00:05] Welcome to PsychEd, the Psychiatry podcast for medical learners by medical learners. In this episode, we're going to be exploring the mental health of immigrants and refugees. I'm Sarah Hanafi. I'm a third-year resident in psychiatry at McGill University and today I'm joined by a lovely group of experts, Doctors Andermann, Pain, as well as Norma Hannant, to teach us about this topic. And I'll maybe give everyone a chance to introduce themselves.

  Dr Lisa Andermann: [00:00:37] Hi, I'm Lisa Andermann. I'm a psychiatrist at University of Toronto and working with immigrants and refugees in two settings: the New Beginnings Clinic at CAMH and also at the Canadian Centre for Victims of Torture. And I also work at Mount Sinai Hospital, where I'm with the Psychological Trauma Clinic, as well as the Ethnocultural Assertive Community Treatment team.

  Dr Claire Pain: [00:01:04] My name is Dr. Clare Pain. I'm a psychiatrist. I work at Mount Sinai with Lisa Andermann, and I work in two settings or perhaps even three settings. Most of the week are Canadian patients who suffer from traumatic disorders. But on Thursdays I work at CCVT and our New Beginnings clinic at CAMH, exclusively with refugees, and I'm also part of the Ethiopian project where we, it's different now with Covid, but we used to send about 100 volunteers a year to partner with Ethiopians to teach into their graduate programs. The first program was psychiatry.

  Norma Hannant: [00:01:49] And I am Norma Hannant. I'm a social worker in the New Beginnings Refugee Clinic at the Centre for Addiction and Mental Health.

  Wiem Sieffien: [00:01:59] Hi. And I'm Wiem Sieffien. I'm a third-year medical student at the University of Toronto.

  Randy Wang: [00:02:05] Hi, I'm Randy and I am also a third year medical student at Uoft.

  Sarah Hanafi: [00:02:10] So we're very excited to be joined by the team today and over the course of this episode we'll be covering a number of learning objectives. So first, to explore the social, political and legal context of refugees and immigrants presenting with mental health concerns. Second, to appreciate the specific mental health needs of refugee and immigrant populations in Canada. And third, to describe the clinical approach to providing mental health care for this population. Maybe I'll hand it off to to Randy to get us started.

  Randy Wang: [00:02:44] Sure, Sarah. So just a bit of a very quick and dirty primer on immigration patterns in Canada. So immigration first started in the 1600s by British and French settlers, and immigration was really predominantly from Europe until the latter half of the 20th century. And nowadays, approximately 20% of the Canadian population are comprised of immigrants and also more recently, we have more visible minorities who come from China and South Asia. So I am curious to know from our expert panel, how have the changing trends in immigration been reflected in psychiatry practice, and how have healthcare professionals adapted to treating more diverse populations?

  Dr Claire Pain: [00:03:43] I don't know that I personally see a huge difference in the number of people from different countries. For as long as I've been working in the field, which is about 20 years, CCVT Canadian Centre for Victims of Torture have always seen about refugees from about 150 countries.

  Dr Lisa Andermann: [00:04:03] Maybe I'll jump in. I guess it also depends what immigration categories those immigrants or refugees are coming from, because we tend to see in our clinics people who require psychiatric assessments to assist with their refugee process, things that their immigration or refugee lawyer needs to help them prepare for their hearing. So in that case, as Dr. Pain said, we are seeing people from many, many different parts of the world. And as world news and frontline headlines change over time, we tend to see different populations kind of even over the last 10 or 15 years where, you know, now these days we're seeing a lot of people from East Africa, from Nigeria, and in previous years we might have been seeing more people from Colombia or other parts of South America or Mexico. So those are kind of smaller changes that we can see, that doesn't reflect on on a lot of the immigrant population who are coming by choice to Canada and setting up their lives here to go to school, to work and to do all of those other things who may not come under psychiatric observation in any way. So we're seeing a kind of very limited slice of the population. Norma, do you want to add anything?

  Norma Hannant: [00:05:28] Well, I think in terms of, you know, just adapting to like any adaptations to diverse populations, I think also just having, you know, the added benefit within, you know, the New Beginnings clinic as well, to have interpretation services, which I know that that's something that is not readily available in a lot of rural settings. And I know as well, you know, with having IFH coverage and so forth, that can also be a big challenge with a lot of the populations that we see.

  Randy Wang: [00:06:07] Okay, great thank you. And Dr. Andermann, I'm really glad that you brought up the different classes of immigrants, because that's actually the next thing we wanted to ask about. So a bit of background for those who are not familiar with the system. In Canada, we have a few different classes of newcomers, so we have economic immigrants, so those who come to work and then we have immigrants who are sponsored by family and then finally refugees. And these people are defined as those who have suffered from persecution for reasons of race, religion, nationality, membership in particular social groups or political opinion in their home country and the process is actually quite complicated. So in order to qualify for refugee status, they have to make a claim at either port of entry or in IRCC office and then later attend a hearing before the government in the end makes a decision as to whether or not they actually get refugee status. And I know this has been touched on already in some of the answers, but I just really want to hone in on any specific challenges that our experts here have identified in providing care to different classes of newcomers.

  Dr Lisa Andermann: [00:07:37] Well, maybe I'll just start by saying that refugee claimants, the people who arrive here and then make their claim for refugee protection are under an enormous amount of stress. So in in one sense, they may feel a little bit safer than they did when they were back home because they're now in a safe country, but they don't know if they're going to be allowed to remain in that safe country and that waiting period while they get their paperwork in order and find a shelter or rent an apartment and get a lawyer and start to figure out the process of how they're going to be staying here can sometimes take many, many months or even years to wait for that hearing date that we've mentioned, which sometimes gets postponed or there's not enough information the first time or the wrong interpreter came on that day. I mean, they're, you know, very rare people get their answer that they can stay on the actual day of the hearing itself. And so when people are in limbo, that can definitely add to their mental distress and sometimes even worsening of symptoms the longer that people are here waiting for, for the answer about whether they're allowed to stay. In contrast, government assisted refugees, like many of the Syrian refugees that were brought to Canada in 2016/17 and are some are still continuing to come now are brought from refugee camps either in the country where the problems are happening or somewhere next door where they've sought refuge, to Canada. So when they arrive, they have OHIP, they have funding for their first year and so they have a lot easier time seeking health care, finding a family doctor who's going to accept them. Any family doctor technically should be able to accept the IFH or Interim Federal Health funding, but you'd be surprised how many people are reluctant to do that because they're not familiar with it or because they just don't want to do the extra steps it takes to get that paperwork.

  Dr Lisa Andermann: [00:09:39] But these people are entitled to, I mean the refugee claimants with IFH, are entitled to the same health care as as most people who come as government assisted refugees. So for things like obstetrical care, prenatal care, all of those things are are covered. And some mental health care is also very easily covered if you just familiarise yourself with with that system. And then once people become permanent residents, you know, in some ways they know they're here to stay so some of that stress may have dissipated, but then there may be other stresses of adjustment, of acculturation, of worrying about family members who are left behind and maybe are not able to join their families here in a timely way if and sometimes not at all for various reasons. So there are many other kinds of post-migration stressors that come into play for all three categories of these populations and for immigrants, as well as a fourth category, the people even who choose to come here or even who choose to move from one part of Canada to another and settle in a new province, as some of our learners might do when they graduate from medical school, you know, there are still adjustments. You miss friends, you miss home, you miss the food, you miss, you know, a lot of different things. And there can be a lot of nostalgia and sort of feeling torn between two places, um, that can affect people's mood and mental health as well.

  Randy Wang: [00:11:09] Okay. Thank you, Dr. Andermann. And you just keep reading my mind here, because when you mentioned that, you know, the stress doesn't really end after a specific period of time and even after years, you know, people still experience stressors and different kinds of stressors. That brings me to the next thing I wanted to discuss, which is the healthy migrant effect. So the healthy migrant effect is an observed phenomenon where the health of immigrants starts off as better than that of the average Canadian born person, but it slowly declines with years spent in Canada and after 20 years it actually becomes equivalent to the health of Canadians. And this has typically been explained by the social determinants of health and how they really negatively affect immigrants and refugees. A study by Robert and colleagues in 2012 on 7700 immigrants found that upon four years of arrival, 29% of respondents reported what they called emotional problems such as loneliness, sadness and depression. Such issues were found more commonly in females. They also found that refugees were more likely than other classes of newcomers to suffer from emotional problems. And finally, they found that 16% of respondents reported high levels of stress, mainly due to employment and financial concerns. So my question to our experts would be how have you seen the social determinants of health affect newcomers in your psychiatry practice? And what are some ways we as health care workers can mitigate the negative effects?

  Norma Hannant: [00:13:04] So, you know, I think advocacy is something that can really help many refugees who are experiencing a lot of distress. I know within our work, like even saying something simply as talking about their rights, particularly around legal aid, for example, we have had a lot of clients that have been really terribly misinformed around their rights to have legal aid if they do have limited income. So oftentimes they might be going with someone that they believe they have to pay, which is, you know, spending thousands of dollars and creating so much more financial stress for them. Also, in terms of their right for housing oftentimes we have stepped in to provide some advocacy for clients that are living in refugee shelters and are being pushed into maybe some rural settings where they won't have access to the mental health supports that they truly need that may not be available there or the limited interpretation services that might be that may not be available in more rural settings. And also in terms of being able to find different forms of employment services that can assist them with those barriers of accessing jobs, which is extraordinarily challenging if you don't have any Canadian experience.

  Dr Claire Pain: [00:14:34] You started talking about the healthy migrant effect. It's hard to know, but certainly with the refugee population, it seems that really in order to get to Canada, to work your way through the bureaucracy, the complexity, the danger, the language barrier, you have to be a remarkable person or family, and that may be a kind of bias. So we see refugees anyway who are healthier than the normal population. They may have had hard lives, but they are future directed, hardworking people. I think I'm going to bring my bias in here, what I've learned. So all my population from when I graduated in 1992 were always trauma patients who were Canadians, who weren't immigrants or refugees. And then I started working with refugees and what I realised is, and the literature bears this out, that if you have a childhood where your family respected you and cherished you, whatever happens later as an adult is far less difficult than if you've had a very compromised childhood. I'm not saying that things that happen to adults from good families or well loved children don't struggle and suffer. But there's quite a difference. And I think that the people who come here often are people who have that confidence and that daring to jump into an unknown future. We're always talking about refugee pathology and really the most important thing is to see these people as the true, remarkable new Canadians, if we can help them stay that they are and they enormously contribute to our country. I'm not sure it's pills, therapy and programs. It's more like the individual encounter matters more than one can possibly imagine.

  Sarah Hanafi: [00:16:33] I thought that was a really refreshing perspective Dr Pain. I know you know myself, the few patients that I've had the privilege of working with and who are coming from these sorts of experiences, I've certainly been struck by the resilience that they show and I think it maybe challenges us. You know, as you say, we're so stuck on finding pathology, but maybe it challenges us to to work on being promoters of resilience and really looking to to highlight and support individuals and allowing them to kind of reconstitute in the face of what's really remarkable adversity that they face when they are coming to Canada and having to go through this arduous process of, in the case of at least refugee claimants can be a very long period of uncertainty. I think also the point you make regarding the hearing and the challenges around that and the the value sometimes that even having a report from a psychiatrist, I think that'll be an interesting point to touch on maybe later around what's the role that professionals can play in being more of an advocate, whether it's other kind of multidisciplinary team members like a social worker or a psychiatrist in terms of recommendations surrounding their hearing. But it certainly challenges us to work, I think, in different ways.

  Dr Lisa Andermann: [00:17:58] Yeah. I have another example I can add to that and I agree with everything that Clare and Norma have shared already. You know, it's very hard to separate the topic of social determinants of health from this healthy immigrant effect because, you know, when people come and their expectations are high that the future is going to be bright here and then they may find themselves unemployed, their credentials unrecognised, unable to achieve the kind of things that they did back home or having to retrain or work overnight factory shifts and PSW jobs exposed to Covid and all these other things. The unhealthy diet that comes with that, the poverty, the the housing stresses, you know, make it very difficult to achieve a sense of wellness, even if the goal of being now established in Canada is met. And there are also a lot of pressures to maybe support family members back home and send money back even from, you know, the pittance of OW or even ODSP to scrape together children's tuition fees when single parents are here on their own and supporting family members can be very, very difficult. So the one example I wanted to share was of a woman who had been in detention in her country. She had had some experiences in jail that were very traumatising and then here in Toronto, the only place she could afford to live in was a basement apartment with no windows, which was hugely re-traumatising for her. And she's referred to me as a psychiatrist, of course she has PTSD symptoms, of course she has nightmares and re-experiencing when really we have to work with social workers to get her into a second-floor apartment with a window. You know, it's very important to have this kind of teamwork because she doesn't need Prazosin for nightmares, she needs, you know, a balcony and and fresh air from a window. It's not a medical solution to these kinds of problems.

  Sarah Hanafi: [00:20:04] Maybe on that note, I think it'd be helpful to hear a little bit more about how these patients are typically presenting and the clinical realm. I think Wiem had some questions on that regard.

  Wiem Sieffien: [00:20:15] Yeah. Thank you, Sarah. So I think I wanted to kind of I was a question I asked was kind of what kind of presentations do people from immigrants and refugees and newcomers present with? And I did a little search on that, and I found that the most common mental illnesses in this population are depression, anxiety and PTSD. And what I found actually, that they experience very similar distress to Canadian born individuals but what struck me is that despite having similar levels of distress, they're a lot less likely to seek or be referred to mental health services and that was was very surprising for me. And then I wanted to kind of look more into that. And it seemed to be there's a lot of barriers that this population face that are unique to this population, including some cultural and linguistic barriers as well, and stigma, obviously. So I wanted to ask our panellists here, what type of barriers do you see in your line of practice that prevents people from seeking care?

  Dr Claire Pain: [00:21:15] So this is where we get all muddled up, I think, because people have distress and suffering and then suddenly they're diagnosed with depression, which means pills, admission, therapy in our in our culture. But I think that feelings of depression and as Lisa said, the awful feeling of, for everyone refugee or immigrant, the huge deal is you've lost everything you've ever known and valued, maybe because you have to. But there are enormous amounts of emotions around that and uncertainty about the future. But I think sometimes we over-diagnose, those are legitimate feelings but the treatment may absolutely not be psychiatric as Lisa just said, good settlement services, proper housing, ESL. So again, the great, great privilege of working at the two clinics that we work in is that we have wonderful social workers and settlement counsellors and a huge amount of treatment is not psychiatric. We get the referrals because we're psychiatrists, but the treatment is within the social determinants of health. A non-psychiatric treatment to manage a psychological presentation.

  Dr Lisa Andermann: [00:22:46] Maybe to follow up on on Wiem's barriers to seeking mental health care. You know, I think many of the patients that we see from many parts of the world have no experience of the formal mental health care system, of a psychiatrist, of knowing what a psychiatrist does. And in many parts of the world, you know, where there is psychiatry, it's kind of reserved for the most severely psychotic and maybe behaviourally disturbed kinds of of patients that do exist all around the world in the same percentages as they do, because these are universal diagnoses like schizophrenia, bipolar disorder. We can find them all around the world. Um, but those aren't the kinds of patients that were mostly seeing here. We're seeing regular people who had normal lives and families and got caught up in some kind of, you know, war or terrorist problem or family problem or they're LGBT in a country that doesn't allow LGBT. They're just normal folks who were in the wrong place at the wrong time and had to leave and find safety here. So not people that were ever really going for counselling or knowing what that is. So psychoeducation and explanations about who all of our different roles and what we do is very important and when lawyers send referrals for psychiatric assessments, most of the time the person we're seeing has no idea really why they're coming to see a psychiatrist at all. And so explaining to people a biopsychosocial model of assessment and treatment and including cultural elements to try to understand how people are connected here, what are the stressors and supports that people are connected with or not, you know, making sure everybody has a settlement agency, community support, inquiring about family supports both here and far away, those religious supports are also hugely important to people. And if they're not connected to those things, it's our it's our job to try to help them connect to to some of those things, because that will go a long way to improving their mental health.

  Sarah Hanafi: [00:25:08] It's been very helpful to learn from all of our experts about the unique approach to caring for newcomers with mental health concerns and trying to take more of a resilience-based approach and to think much more broadly in terms of the social context and to work within teams to try and support patients in having access to to necessary services and try to address many of the adversities that they're facing as they're adjusting to their new life in Canada. Now, one thing that we were actually hoping to touch on within the clinical approach is maybe some more practical concerns. So, you know, as as I think, Norma, you mentioned interpretation services is definitely something that can be very hard to come by for some of these patients. For many of them, it can make a huge difference if they're able to express themselves in their mother tongue. And I was wondering if you could all give some a few practical tips for working with interpreters, because I know, at least in my experience, I've seen some huge variation in how people approach this.

  Norma Hannant: [00:26:14] Well, I think one that we try to do within the clinic is always having a professional interpreter and again, we do have the luxury and the funds to be able to provide that. Whether it is I mean, obviously right now regarding Covid, we're not doing any in-person appointments unless it's an emergency situation. But to be able to provide as much, you know, in-person, also asking someone in terms of who they would feel more comfortable with oftentimes as well is to, you know, there have been times where family members will also want to interpret, so really discouraging that letting them know that, you know, they can be part of maybe the the end of an appointment if the client consents to that to be able to add some feedback. But that can add a lot of discomfort for someone who's coming in to tell really personal information about their lives. And also maybe, you know, letting clients know about what it entails to have an interpreter confidentiality, because oftentimes there is a fear that someone is within their community and will be spreading this information to other people. And again, that is a luxury that we have. I know that that is not often the case in smaller settings. And one thing that we've also been able to provide for a lot of clients as well is with Ontario Works, for example. So they will be given an interpreter for the first the initial assessment and then after that, they have to actually find someone. So there has been some pretty difficult circumstances where someone might be isolated and they'll be using their neighbour as their interpreter to find out about very personal financial information about them or someone in their family who they really don't get along with, and they really don't want them to know this specific information but have no one else. So often times we've been able to organise that through our clinic to have an interpreter available for them and coordinate that in our services.

  Sarah Hanafi: [00:28:08] Okay. And I'm wondering actually, you know, because as you mentioned, ideally you want a trained interpreter, but one might not always have access to that and certainly an interpreter that's used to facilitating mental health assessments. I'm wondering what kinds of instructions you might give to interpreters who are participating in an assessment.

  Dr Lisa Andermann: [00:28:31] Well, I think a mental health assessment requires a very careful translation of what the patient's words are, because we pay attention to cadence, rate and rhythm of speech. We want to know about thought process, disorganised thoughts and so we do want to make sure that the interpreter is not inadvertently or trying to help us by cleaning up the way that the patient is speaking, by editing or making things sound more organised than they are. This is especially important when we're trying to rule out a diagnosis of psychosis and then being able to get at the exact words that we're trying to use to find out about perceptions, paranoia, delusions, hallucinations, you know, asking someone, are you hearing voices? You know, can be a very confusing kind of question if it's not translated properly and then translated back to you in English. There's a lot of room for confusion. And on top of that, there are also the whole cultural overlay of what these things mean to that person. If it's part of a religious understanding or if it's part of a kind of cultural understanding of how things work, maybe after a person's died that you may hear their voice, something that could be very normal, but that we could misconstrue as a symptom of mental illness. And so there's another kind of of interpreter, not just the language interpreter, but also getting the advice sometimes of a cultural interpreter who can give us a sense of whether some of these beliefs or behaviours are actually making sense in the person's culture. And so the typical language interpreter may not be comfortable to share their opinion on that. They're there to kind of simply translate what's going on in the session. But it can be very helpful maybe to contact a community agency or a worker from a settlement agency who may know something about where the person's background is from, and to be able to give some idea. I mean, the family can also provide some of that background of whether this person's behaviour or presentation would make sense in their culture and how they would understand it.

  Sarah Hanafi: [00:30:42] So it sounds like, you know, beyond actual interpreters, there's also utility around having cultural brokers to help understand more of that cultural context and the information that's being provided. Um, I think it's really helpful to hear that piece and I'm sure there's also a lot of advocacy that's done by health care workers surrounding access to interpretation services. Um, I've also kind of wondered and had some experiences myself when it comes to advocacy around legal status and immigration status. I know this past year with some of the patients I was working with who were refugee claimants, um, there were requests by, by lawyers to write letters and support for their hearing, as well as recommendations surrounding accommodations to the refugee hearing in light of their symptoms. I was actually hoping to maybe explore some of your experiences around this. Are there any practical tips for how our listeners can effectively advocate for their patients in these circumstances?

  Dr Claire Pain: [00:31:51] All the time one wants to write in a report, "this is the most remarkable person who's been through terrible times, but who's clearly on top of things or who's struggling a bit, but who has every we have no reason to expect they won't find their feet and do well". But you can never write that in a refugee report. If you advocate in any way for a refugee, any good lawyer knows that that's death to the any kind of psychiatric report that will be taken seriously by the system. So it's important to know when not to write down the kinds of things that we might want to. I mean, I think it was mentioned earlier about advocating for housing, advocating for for a bunch of other things. But certainly in a report, it's very important people know that. Sorry there were just two little things I wanted to add to the interpreter thing. One is if you don't have the luxury, as we do of professional volunteers, when you have to work with volunteer interpreters who aren't family, you're often dealing with the same group of people who've suffered torture or imprisonment or. And I think it's worthwhile to always be quite respectful that you may be dealing with somebody whose own family members may have gone through the same thing or they may have. So I think that kind of appropriate checking that they're okay and if they're not, that we can guide them to services or debrief with us. The other thing I mean, Lisa's completely right, cultural brokers are so useful. But sometimes I hope this sounds all right. I found I had a complex woman from the islands and one of my colleagues, dear friend and colleague at work, you know, within the bounds of confidentiality. I said, what does this mean? And he immediately knew. So people who come from a similar culture or community, we all come from somewhere, right? Most of us have roots elsewhere.

  Sarah Hanafi: [00:34:07] No, I think it's helpful to hear how how we also bring in our own lens and our own understanding from our from our personal backgrounds as well as like how do we ensure the safety of all who are involved in the assessment. I wonder, though, like specifically, say, around a hearing and those who might have a trauma history, how like the way in which the hearing is conducted affect like the reliability of the report, if they have certain symptoms related to PTSD, how do you maybe prepare patients for that?

  Dr Lisa Andermann: [00:34:43] I think that kind of gently with reviewing the basis of claim narrative and going through it with people will give you a sense of how they will be able to speak about those events at the hearing. And so it gives you a chance to notice if there are any gaps in the story, if there are times when people need to pause and maybe need extra time to collect themselves, to have a break, to have a glass of water, to to kind of have a support person coming with them to the hearing. Those kinds of things are the sorts of accommodations that you can advocate for and you can also do some psychoeducation to the the hearing to explain that people who've been through trauma and many people have been through more than one event and they may be recounting events, let's say, in the case of somebody who's escaped a situation of domestic violence. There have just been so many incidents like dozens or hundreds of incidents over, you know, the 5 or 10 or 15 years that they've been married and kept in a home, you know, where so many things happened. You can't possibly remember each event, what day it happened, which time you went to the police station to report it and which time you just, you know cleaned yourself up at home like there are just so many. And to translate that into like a sequential narrative with dates and times is very difficult. So being able to explain that, you know, the way our memory works when there's been a trauma may be, you know, to go into a flashback, when you're talking about a piece of the story that you're not there to remember, Oh, it was two men in a green car, it might have been five men in a black car. Like your life was in danger, it wasn't about taking in those details and being able to tell them back in the same way, you know, 5 or 10 years later, every time you tell the story, you may tell it a little bit differently depending on the setting, how stressed you are, who's listening, what the information is going to be used for, and and so on. So Doctor Pain had already mentioned something about reliability, and that piece is is very important that people can still have been through lots of difficulties, even if they may not remember exactly specific details. And avoidance is also a big part of coping with trauma. And many people may want to push away or not go to certain places from their past because it's just too too difficult and brings up too much emotion for them. And so they may robotically talk their way through their narrative without showing any emotion, which is also not what you want at the hearing when you're talking about these kinds of things. And on the opposite side, you don't want somebody to be so flooded with with feelings that they can't tell their story at all. So I think the more times people practice and have a bit of exposure, not in the way of exposure therapy, but in the way of just being able to tell their story from beginning to end and kind of get through it and kind of be able to go on from there is is kind of helpful in preparing people for their hearing.

  Dr Claire Pain: [00:37:58] I think that the actual experience of interviewing a patient and and doing the report or working with them is an opportunity to coach the patient. Insofar as I find myself saying, "you're doing a very nice job with me, you're so respectful, you have great eye contact. If you can just focus on the question I ask you because it's like practice for the judge. I know you want to tell your story, which is great. You can tell me anything, but right now, practice". So you kind of work with a patient and let them know, the judge may ask you about your assault, they may ask you, "do you feel able to say it?" Because if you don't just say, I'm so sorry, I can't. It's like coaching people to be not advocates for themselves but feel empowered to not let the hearing get away on them. That they can pause, have a sip of water and focus on the questions. But knowing what's in store is enormously helpful.

  Sarah Hanafi: [00:39:05] Sounds like a lot of that anticipatory guidance can really be a huge support to patients as they prepare for undergoing this process.

  Dr Lisa Andermann: [00:39:14] There are opportunities to visit the hearing venue when when we're not in Covid and hearings are taking place in real time and a lot of claimants don't know about that. So there are community agencies that will take you for a tour and you get to see the room while it's empty and figure out where you're going to sit and where the judge sits. And that can be very helpful in reducing some people's anxiety.

  Wiem Sieffien: [00:39:37] Thank you so much. These were very great tips. And I think for me as a medical student, I learned a lot during this time. I think, although I thought I prepared for the episode, but I learned so much from all the experts. And I want to thank you all. I think just to kind of just summarise or to wrap up, what are some take home messages or final words that you want to make sure our audience leave this episode with.

  Norma Hannant: [00:40:02] For me as a social worker, when I started working at New Beginnings, I assumed that a big portion of my job was going to be involving processing people's traumas, and I was nicely surprised to learn that that was actually something that people really didn't feel that they needed at the beginning of their process of settling into a new country. Right. That might be something that they're interested in doing years from now, but there's also different forms of doing it and the having connection to their communities, finding spiritual and religious communities that they're connected with, being able to find housing, getting a good lawyer, going to ESL classes. Those are the things that, for me, I really learned in terms of being able to help them to reduce the distress of all of these huge shifts coming to a new country.

  Dr Lisa Andermann: [00:41:04] I would add that this work is very, very rewarding. It might sound challenging, it might sound intimidating writing reports for lawyers, but refugees are an amazing population to to work with. We learn new things every day about every corner of the world and people's resilience and what's important to them and what keeps them going. It's just very rewarding. And when people come back with good news that they've passed their hearing or you're able to do an assessment and write a letter that prevents somebody from being deported and they're allowed to stay after ten years of limbo, you know, nothing beats that.

  Dr Claire Pain: [00:41:44] Yeah, I agree. I think I actually think this is advice for all of us with patients, but in particular with refugees. It's like they're, as Lisa said, they're ordinary people, they're ordinary folk caught up in bad situations who've managed to flee for their lives successfully to find safety in Canada and then cross the next hurdle, which is to be accepted here. So I think that one of the reasons I love working with refugees is I'm a learner. Like, how did you do that? Well, what was the worst thing about? How did you overcome it? Where did you find support or guidance? You know, it's like I will never, thank God, have to do what they've done. So I'm in this wonderful situation where I can actually respectfully understand more from someone who has first-hand experience about resilience, about and it helps me understand what about human beings we need to focus on and support.

  Sarah Hanafi: [00:42:48] Thank you all so much. We're very privileged to have had your time for you to be able to share this this expertise with our audience. So once again, we wanted to thank Norma Hannant, Dr. Lisa Andermann and Dr. Claire Pain. You've been wonderful and we're really excited to share this episode with our audience. We also want to thank you all for listening to PsychEd. Feel free to contact us on Twitter @Psychedpodcast or check us out on psychedpodcast.org. We love hearing from you and your feedback and your questions are vital to the podcast. Take care.

  Sarah Hanafi: [00:43:23] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Wiem Sieffien, Randy Wang and Dr. Sarah Hanafi. The episode was hosted by Wiem Sieffien, Randy Wang and Dr. Sarah Hanafi. Audio Editing by Randy Wang. Our theme song is Working Solutions by Olive Musique. A special thanks to the incredible guests Dr. Lisa Andermann, Dr. Claire Pain and Norma Hammant for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at Psychedpodcast.org. Thank you so much for listening.

  Wiem Sieffien: [00:44:19] I was always interested in immigrant and refugee mental health, and I had the opportunity to take the Immigrant and Refugee Mental Health Project's online course, which is a free self-directed training course that is offered by the Centre for Addiction and Mental Health. It was a great learning experience. It provided me with a comprehensive overview of immigrant and refugee mental health, some of the key principles, and I learned a lot about the influence of cultural on mental health and mental illness. I also learned some great tools and resources to help me in my clinical training, which I really found helpful during my clerkship. I would highly recommend this course and the link will be posted in the show notes, so I recommend checking it out.