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Alex Raben: [00:00:00] Hello, listeners, this is Alex here. Welcome back to Psyched for the month of July. Instead of one episode, you'll be getting five. That's because we're going to be doing a special mini-series in which we cover clinical skills in psychiatry. So in the past we've tended to cover specific disorders or illnesses. But these five episodes will focus on approaches and competencies that will help you in your training in psychiatry. We hope that you will enjoy. We are recording.
Bruce Fage: [00:00:39] Welcome to PscyhEd, the Educational Psychiatry Podcast for Medical Learners by Medical Learners. If you're return listener, welcome back and if it's your first time, thank you for joining. We're going to be focusing on something a little bit different today. We're going to talk about some of the ways in which psychiatry interacts with the legal system and some of the specifics regarding mental health legislation in Ontario. Your host today are Dr. Alex Raben, a fourth year psychiatry resident at the University of Toronto, and myself, Bruce Fage, a fifth year psychiatry resident here at U of T. We are thrilled to be joined today not by a psychiatrist but by Kendra Naidoo, legal counsel for the Centre for Addiction and Mental Health in Toronto. Kendra is a graduate of UBC Law School and went to University of Toronto for her undergraduate degree. I've had the privilege of learning from Kendra at different points throughout my residency and she is extremely helpful. She's an expert on mental health law and empowers us to provide the best possible patient care. Kendra, we're happy to have you here.
Kendra Naidoo: [00:01:35] Thanks very much for having me. I'm delighted to be here. It's always a pleasure to work with you, Bruce and Alex and all of our medical learners and navigating these complex and nuanced issues and mental health law.
Alex Raben: [00:01:46] Thanks for being here, Kendra. This is Alex. Should we go over the objectives for today? Okay. So number one, we'd like to review some of the history behind mental health legislation in Ontario by the end. We'd also like to ensure we have a discussion about involuntary hospitalisations, including criteria relevant to the legal forms involved in that. Number three, we're going to review capacity assessments and processes for substitute decision-making. And finally, number four, we will talk a bit about consent and capacity boards. So, Kendrick, keeping in mind that most of our listeners are not lawyers, maybe you can start us off by providing an overview of mental health law in Ontario. What are the relevant pieces of legislation?
Kendra Naidoo: [00:02:40] Sure. So there are two pieces of legislation that are most central to mental health law in Ontario. The first is the Mental Health Act, and the Mental Health Act governs hospitalisation in psychiatric facilities, admissions to those hospitals and what happens while people are there. They also provide for community treatment orders. The second piece of legislation is the Health Care Consent Act. This applies to all treatment, whether it's medical, physical or psychiatric. The Health Care Consent Act governs the principles behind obtaining consent to treatment, assessing capacity to consent to treatment, as well as identifying substitute decision makers and the rules that govern those decision makers.
Alex Raben: [00:03:21] So so it's the Health Care Consent Act, as well as the Mental Health Act together that are the two main pieces of legislation involved in psychiatry in the law.
Kendra Naidoo: [00:03:31] That's correct.
Bruce Fage: [00:03:33] So, Kendra, within psychiatry, we often work with people who are experiencing significant mental health concerns, and sometimes there are very serious safety issues. For example, someone may be extremely depressed and at high risk of suicide or experiencing psychotic symptoms, which severely impaired their ability to take care of their basic needs, like food and shelter. Thus, there are times where we as doctors are compelled to use the Mental Health Act to detain people involuntarily in hospitals. I think it's one of the more challenging and stigmatised aspects of mental health services for patients, their families and providers. It can be wrought with emotion and personally it's a part of my work that is both necessary but very challenging. One of the goals of this episode is to demystify and provide some basic information about involuntary hospitalisation. Can you tell us about some of the process?
Kendra Naidoo: [00:04:23] Sure. So one of the most common processes to initiate an involuntary hospitalisation is called an application for psychiatric assessment, and it's commonly known as a form one. A form one can be completed by any physician as long as they've examined the person within the last seven days from the day it's signed. The form one is authority for seven days for that person to be taken into custody, usually by the police and taken to a psychiatric facility for an assessment. Once they're there, the psychiatric facility is authorised to detain the person for up to 72 hours in order to conduct that assessment. There are criteria that have to be met before a physician can fill out one of these forms. And this is recognising that it's quite an extraordinary power for a physician to have. Those criteria are commonly known as the box and the box B criteria. The box A criteria have most a past or present test and a future test in the box. A past present test. The person must have threatened or attempted to cause bodily harm to A person or B currently threatening or attempting to cause bodily harm to another person or to themselves. They must have behaved violently or be behaving violently at the time, or causing someone else to fear bodily harm from them. Or they have demonstrated a lack of competence to care for themselves. In the future. Test the physician must be of the opinion that the person is likely suffering from a mental disorder that is likely to result in either serious bodily harm to another person to themself, or what we refer to as serious physical impairment, which is harm that might come to the patient but isn't intentionally brought upon.
Alex Raben: [00:06:14] So if I can summarise what you're saying, there is this form one and that is the legal form that allows a physician, once it's filled out, to compel someone to come into hospital for a psychiatric assessment. And there are two sort of branch. There's a box A and a box B criteria. And of the box A, there's kind of two branches, the past and present test and the future test. That's right. In the past and present test. That's like talking about the risk that we're trying to avoid by filling out this form.
Kendra Naidoo: [00:06:52] Right. So it refers to the condition of the person in the current state that is giving rise to concerns and also requires that there be a future risk of harm either to the patient or to themselves. So both components are necessary to fulfil the box a criteria.
Alex Raben: [00:07:07] And the present risks includes three things so harm to themselves, meaning like a suicidal risk, let's say harm to someone else. If, for instance, if someone was threatening someone else or acted violently towards someone else. And then number three is more about their ability to care for themselves when they are mentally ill.
Kendra Naidoo: [00:07:32] Right. So the serious physical impairment criteria might come up if, say, someone has a co-occurring medical condition like diabetes or heart condition, and because of their mental illness, they're not able to care for that and so are at risk themselves of medical harm because of that.
Alex Raben: [00:07:51] Well, we're talking about that risk. Is there an element of degree? I recall at some point being taught it has to be imminent risk. It has to be of a certain severity. But I also know that the like it doesn't seem that the form really lays that out clearly. I'm wondering what, from your perspective, that level of risk needs to be.
Kendra Naidoo: [00:08:14] There's no requirement for imminence, but the harm does have to be likely in the sense that it is going to occur in what we in law call a reasonably foreseeable time. That's hard to put a cut-off date on that likely criterion, but we would be thinking about it in orders of magnitude in terms of days or weeks or a few months. But if we're getting into many months, six months or into the the into years, then that's probably too far away to be likely in terms of the severity of the harm. It does require that it be serious bodily harm to themself or others, which is defined in law as harm that is more than trivial, or that the physical impairment, the medical consequences to the patient be significant.
Alex Raben: [00:09:08] Is it possible for you to give us an example of what might be considered trivial?
Kendra Naidoo: [00:09:11] Sure. So if an individual, say, were to lightly push an otherwise perfectly healthy adult, that would be considered a harm that is likely trivial. Now, if someone were to seriously push a very small child or a frail elderly person, then that could rise to the level of being more than trivial. But things like pushes or light contact would generally be considered trivial.
Alex Raben: [00:09:43] Okay, that's that's helpful to understand.
Bruce Fage: [00:09:46] And so, Kendra. You mentioned that there's also a box B. Can you tell us about Box B and some of the differences with Box B and Box A?
Kendra Naidoo: [00:09:53] Sure. So Box B is newer than Box A, It was put into the legislation in the year 2000 in response to concerns that you really do have to reach quite a high threshold before you can get to the box eight criteria. And sometimes it can be beneficial to intervene sooner so that people can get the help that they need without getting to the point where their safety or the safety or others are at risk. So the box B criteria contains a number of criteria. It requires that the person be found or believed to be not capable of consenting to their own treatment. And their substitute decision-maker has consented to treatment. And we're going to talk about that a little later in the podcast. It requires that they have a history of mental disorder and that they have previously been treated for that mental disorder and experience significant clinical improvement with treatment. It further requires that there is a likely risk of one of the harms. We've already talked about serious bodily harm to self or others or serious physical impairment, and contains this additional criteria where there could be a likely risk of what we call substantial mental or physical deterioration. So in essence, if someone has a history of being treated and improving with treatment, if they're not capable and there's consent to treatment and there is a likely risk that they will suffer substantial mental or physical deterioration, then the box B criteria can be invoked.
Bruce Fage: [00:11:26] So it sounds like one of the major differences between Box A and Box B is that in box B, you have that, I guess, extra potential risk where it includes substantial mental deterioration in addition to the criteria that are outlined in Box A And also you have to have been treated before and shown benefit from the treatment. Do you like is there any guidance on how you might define substantial deterioration?
Kendra Naidoo: [00:11:56] So the case law has said that when we're talking about substantial mental deterioration, that means the person is likely to become more profoundly symptomatic. And that use of the word substantial refers to consequential or considerable deterioration. This inevitably requires a level of clinical judgement on the part of the physician who's assessing this and is going to have to be looked at in light of the particular patient and how their symptomatology plays out. But for a particular patient, if they're likely to become more profoundly symptomatic, then that would be considered substantial mental deterioration.
Bruce Fage: [00:12:40] I think you've touched on something that is very challenging within the work that we do in that there is this element of clinical judgement and sometimes it's hard to know exactly what the actual risk is likely to be and we want to support people and use the least restrictive means possible when we're helping them get well. And we also want to be safe and make sure that people don't come to significant harm. When a doctor fills out a Form One, what happens next? What's the process for moving forward with that?
Kendra Naidoo: [00:13:11] So the form then gets sent to the police, and the police have seven days to find the person and to bring them to a psychiatric facility once they arrive at the psychiatric facility. The as I said, the facility is authorised to detain them for up to 72 hours for the purpose of getting a psychiatric assessment. So the whole idea behind Form One is that a physician in the community and it's often a family physician, sees that there are things going on with the person that likely requires a psychiatric assessment and the Form One is a mechanism by which they can have them brought to have that assessment. By the end of that 72 hours, the psychiatric facility has to do one of three things. They either decide that the person does not need to be admitted to a psychiatric hospital and discharges them, or they decide that the person. Needs to be admitted to a psychiatric hospital and the person is willing to stay and so they can be admitted as a voluntary patient or if the person needs to be in hospital and is not willing to stay, then they can be admitted as what's called an involuntary patient. An involuntary admission is initiated by completing a Form Three, and the Form Three requires that the person meet either the box, say, or the box B criteria. If that happens, then the person can be detained for up to two weeks on the Form Three, and by the end of the two weeks, if the person continues to require an involuntary admission that can be renewed with a Form Four and then there are subsequent renewals that can occur.
Kendra Naidoo: [00:14:53] There are a lot of procedural safeguards that come with these kinds of involuntary detentions. The patient has to receive written notice of their detention by way of what's called a Form 30. The forms have to be filed and reviewed by what's called the officer in charge. The officer in charge is the person in charge of the psychiatric hospital. Every hospital does that process differently. So it's important for physicians and learners to get to know the particular processes in their hospital. But the point of that is to make sure there's someone in the hospital administration who's making sure all of the right procedural safeguards are being carried out. The physician also has to give notice of the detention to a rights advisor, and rights advisors usually come from the office of the Psychiatric Patient Advocacy Office, which is an arm's length, arm's length branch of the Ministry of Health. The rights adviser will meet with the patient, explain to them that they're being detained and the criteria on which they're being detained and inform them of their rights, including and importantly, their right to consult with a lawyer and their right to apply to a tribunal called the Consent and Capacity Board, who will convene a hearing to review their detention and decide if the doctor's decision to have them detained was correct.
Bruce Fage: [00:16:10] So thanks, Kendra, for that explanation, it sounds like after a doctor fills out a Form One, the patient can be brought to hospital and detained for up to 72 hours. And they also are issued something called a Form 42 at that time, which notifies them that they're on a Form One that's right. At the end of the form one period, one of three things can happen. They can be discharged home. They can be admitted to the hospital voluntarily, or they can be admitted involuntarily on something called a Form Three. And it sounds like there's a similar process where you notify the patient with the Form 30. But at that point you also get a rights adviser involved to help advise a person of their right to consult with a lawyer and contest the finding.
Kendra Naidoo: [00:16:52] That's right.
Bruce Fage: [00:16:54] And when you say psychiatric facility, what do you mean by that?
Kendra Naidoo: [00:16:57] So psychiatric facilities are designated by the ministry under the Mental Health Act. They're often commonly referred to as Schedule one psychiatric facilities, because that's the part of the legislation that they're in. It's very easy to find out if a hospital is a psychiatric facility or a Schedule one facility. Googling Ontario Ministry of Health Schedule one psychiatric facilities will pull up the list. There's approximately 80 to 90 of those facilities in Ontario. Most of the major hospitals are psychiatric facilities. It's the smaller community or rural hospitals that may not be designated.
Alex Raben: [00:17:36] I'm just putting myself in the shoes of some of our listeners in Ontario who have a who are in medical training right now. And I'm trying to think about where they would come across this kind of legislation or where they would bump up against it. And I guess for them it would mostly be in the emerge where they would potentially be putting people on form ones, possibly if they're doing family medicine, they would see it in their office as well, although potentially less frequently than than in the emerge. So if they are seeing someone in the emerge, they would be filling out the Form One as well as doing the 42, because they are simultaneously asking for the assessment and starting the detainment in the hospital, assuming they're working in a Schedule one facility. Would that be true?
Kendra Naidoo: [00:18:30] That's right. So if they're in an emergency department in a schedule one psychiatric facility, they do the Form One and the Form 42 at the same time, as you say, applying for the assessment and starting the detention at the same time, if they're not in a Schedule one psychiatric facility, then they fill out the form one and that non-schedule one facility then needs to transfer the patient forthwith or as soon as they can to a schedule one facility. And when the patient arrives at the schedule one facility, the receiving physician there will fill out the Form 42 and that's when the 72 hour detention commences.
Alex Raben: [00:19:09] Gotcha.
Bruce Fage: [00:19:11] And what if there's no need for 72 hours? Like what if you finish the assessment early? Can the Form one be stopped before the 72 hour limit?
Kendra Naidoo: [00:19:19] Yeah, it can be stopped at any time when the assessment is complete, and that would either occur by discharging the patient, filling out a Form three for the involuntary admission, or just cancelling the Form one and documenting that the patient has agreed to remain as a voluntary patient.
Alex Raben: [00:19:35] And kind of riffing off that. Bruce Like, I think we often find ourselves in situations where we're not entirely sure on day one, and so we may. And so even though you've a psychiatrist or a psychiatry resident may have seen someone on day one, they can also kind of continue the assessment onto the second and third day if need be.
Kendra Naidoo: [00:19:57] That's absolutely right. As long as they get it done and make one of those three decisions before the 72 hours expires.
Alex Raben: [00:20:03] Right.
Bruce Fage: [00:20:05] What about if a family member has concerns about their loved one and the their loved one refuses to go and see a doctor?
Kendra Naidoo: [00:20:14] So. If they can get them to say, go see their family physician, any doctor can fill out a Form one if they've seen the patient in the last seven days. If they are refusing to go see a doctor, there isn't a doctor available. There is something called a Form two, which is a justice of the peace. Order for examination is the official name of the form. Justice of the peace for those that don't know is another kind of judge. You can go see a Justice of the Peace 365 days a year in any courthouse in Ontario, and they don't work 24 hours a day. But you can always call the courthouse to find out what the hours are for the justice of the peace. The process is to go to the courthouse, ask to speak to a justice of the peace, to get a Form Two, and then whoever has gone there can swear information before a justice of the peace that either the Box A or the Box B criteria or both have been met. And they need to give specific information to support that finding. If the justice of the peace is satisfied with the information, then they'll issue one of these form twos that get sent to the police, who then have seven days to go and find the person, pick them up and bring them to a hospital for examination.
Kendra Naidoo: [00:21:31] It doesn't authorise the hospital to detain the person. And that's a big difference between a form one and a form two. So when the person arrives at the hospital, they have to be assessed as soon as possible and then a decision will be made about whether to admit them voluntarily. Is more psychiatric assessment needed so that they can do it. And if that's the case, they would do a form one and start a 72 hour detention at the hospital. For anyone going to get a Form Two, it can really be anyone. There's no stipulation on who it can be. It's often friends or family members, but it can be members of a care team, neighbours, any kind of supports that a person has in the community, they have to swear the information under oath, which means it has to be true and it's really helpful to give the justice of the peace all of the information that you have, including information about how to find the person, because the police only have seven days. And so the more information you can give, the better to ensure the success of the form.
Alex Raben: [00:22:33] And then I think there's also the third option, where someone is brought in voluntarily to a hospital, which is if the police are called because they have certain powers under the I think it's the Mental Health Act, I could be wrong about what part of the legislation, but they you can correct me, Kendra, but then they have the power to bring someone to an emergency department. By that sort of third option. Is that not?
Kendra Naidoo: [00:23:01] Yeah, that's absolutely right. It is. Under the Mental Health Act, the police have their own discretion if they're called to a scene and when they arrive, they believe that somebody appears to be suffering from a mental disorder and is either at risk of causing harm to others or not able to care for themselves. They have their own discretion to decide to take someone into custody, into a psychiatric facility. An important thing to note about that is that police forces generally won't invoke that power unless they actually observe the behaviour giving rise to the risk of harm. So it can be a very powerful thing in the moment. If there's a crisis, call the police and they have the ability to take someone to a hospital. But if by the time they get there, the person is quite settled and they're quiet and they're not exhibiting any of the behaviours that give rise to a harm, the police might at that point say that they're not going to exercise their discretion. And that's where the form too can be a very useful tool for friends and family members. Right?
Alex Raben: [00:24:04] So just like in any normal life situation, if you feel at risk or something is happening, that's an emergency. You would call the police if your loved one is not doing well, but there's not an acute emergency that would warrant the police coming, then you could fill out a form, too, to get them seen.
Kendra Naidoo: [00:24:21] Absolutely.
Bruce Fage: [00:24:23] So thanks, Kendra, for outlining some of the processes that relate to involuntary hospitalisation in Ontario. I'd like to shift the conversation a bit and talk about another area of psychiatry that intersects with the law, its capacity and specifically capacity to consent to treatment of a mental disorder. Sometimes patients and their providers will disagree about a diagnosis. So for example, a psychiatrist may make a diagnosis of schizophrenia and the person might not agree that they have the diagnosis and may not want treatment. What happens in these situations?
Kendra Naidoo: [00:24:54] So the first thing to think about in those situations is whether that person is actually able to make that decision. In other words, are they capable? When we're talking about capacity, it's important to remember that capacity to consent to treatment is treatment specific. Everyone is presumed capable of making their own decisions about their health care, and if they are to be found not capable with respect to a treatment, there has to be a particular treatment that is proposed. That treatment has to be discussed with the patient and they're given all of the necessary and relevant information and then their capacity to consent to that particular treatment assessed. There are two branches to the test for capacity, and that's legislated in the Health Care Consent Act. The first branch is whether the person is able to understand the information that has been given to them. And the second branch of the test is whether they're able to appreciate the reasonably foreseeable consequences of a decision or a lack of a decision about that particular treatment.
Alex Raben: [00:25:58] Can you take us through those two branches? Like what differentiates between understanding the proposed treatment versus appreciating it?
Kendra Naidoo: [00:26:10] Absolutely. And I think one of the things to bear in mind is that the emphasis is on their ability to understand and their ability to appreciate. It's quite a significant thing to take away someone's right to make their own decisions about treatment. And so we only do that where they really lack the ability to make the decision. As for the two branches, the first branch of the test, the ability to understand, boils down to a basic cognitive capacity test. Do they have the ability to process, retain and understand the information that's been given to them generally? So it doesn't have anything to do with how they view their own situation or how they apply the information to themselves. It's about generally are they able to take in process and retain information in the context of someone suffering from schizophrenia? A classic example of that is someone who's able to recognise generally that there are people out there who may suffer from something that resembles schizophrenia and those people might benefit from, say, antipsychotic medication. It's in the second branch of the test that we focus on. How does the person take that information and apply it to their own circumstances? So that starts with an investigation of whether the person is able to recognise that they are affected by the objective manifestations of their mental condition. So the mental condition will manifest itself in terms of symptoms and behaviours arising from those symptoms. Are they able to recognise the possibility of those symptoms and those behaviours? It's important to note that the patient does not or the person does not have to agree with the diagnosis or the label that we put on their condition. They don't have to agree that it's an illness. They don't even have to cast it necessarily in negative terms.
Kendra Naidoo: [00:28:01] But when we think objectively about how that illness is manifesting in terms of symptoms and behaviours, are they able to recognise that they're affected by them? If the answer to that is no, if they're not able to recognise that they're affected by the manifestations of their condition, then they're not capable and they fail the second branch of the test. If they are able to recognise that they're affected by the manifestations of their condition, then we go on to an examination of their ability to appreciate what we call the parameters of the decision. So the nature of the treatment, what is it? Is it a pill, is it a needle, Is it surgery? Are they able to recognise the possibility that that might benefit them? Are they able to recognise the potential consequences of not taking the treatment? And if they are, then they are considered capable and if they're not, if they are not able to recognise the potential benefits or the consequences of not taking the treatment, then they're not able to appreciate the consequences of their decision. So once we've decided that they're able to recognise the manifestations of their condition, it really turns to an analysis of whether they're able to weigh the information. They don't have to weigh the information the same way as their healthcare team. They may ultimately come out the other end with a decision that we consider to be ill-advised or not in their best interests. But it's not about what it's in their best interest. It's not about whether they agree with their physician or their healthcare team. If they're able to weigh the information to recognise the possible risks and benefits, then that person is capable.
Alex Raben: [00:29:44] Of making any decision whether we agree with it or not, just like.
Kendra Naidoo: [00:29:47] Right. With respect to that particular treatment. Yeah.
Alex Raben: [00:29:50] So the. Um. When we kind of lay it out in legal terms, it I think there's a lot to take in there, but it certainly can seem clear cut. But in reality, I think, Bruce, maybe you would agree. I think it's anything but Maybe it would be helpful for us to propose an example of when this might apply and kind of think through that as a group. I suppose we could think of someone with schizophrenia who, well, we would label him as schizophrenia, but who, let's say when they become unwell, they get worried that their brother is trying to harm them. So then they, you know, try to protect themselves, maybe at times are violent towards the brother because they think that they're going to hurt them. And so when we see that, we point that out to them, we tell them the diagnosis and let's say the understand piece of that is that they understand this illness of schizophrenia exists. They understand that it can cause paranoia. But then we move. Let's say that's true. We then have to move to the appreciation. And let's say they recognise even that they're paranoid. But when we propose a treatment like an antipsychotic to help with that, they say no, that's not, there's no chance that could help me. Would that, what would, would that case be a lack of appreciation if that's true.
Kendra Naidoo: [00:31:29] Well, I think you'd have to drill that down. So, you know, when you're having the when you're doing the capacity assessment and having that conversation with the person, you'd want to, as you've said, not only tell them about the diagnosis, but explain it to them in reference to the symptoms and the behaviours and be mindful of the labels that we're putting on things. So you may tell them we believe that you're paranoid. And what we mean by that is that you sometimes believe things that are not true. For example, this belief you have that your brother is trying to harm you and that has resulted in you being violent against him. So there is a certain aspect of how you frame the information in your example. If the person accepts that, yes, sometimes I believe he's trying to hurt me and maybe that's not true. But no, I don't want to take that anti-psychotic medication. You then want to get into a discourse about why not. Right. And exactly take a look at the patient's reasons for refusing the medication. If it's because they know that in the past they've taken medication and gotten better, but have, for example, experienced significant side effects, then that may reflect an ability to weigh the risks and benefits of the information. But if they're showing signs that the illness itself is interfering with the decision-making process, so they, despite a history in the past of improving with medication, if they're adamantly denying any improvement and you talk to them, remember last time you were in hospital, we gave you this medication and you were able to go back to work and we discharged you from hospital and you were doing great.
Kendra Naidoo: [00:33:11] If they're still adamantly denying that, then that may be an indication that they're not able to weigh the information. Right. The last piece that's really critical because we as we said, we're focusing on the ability to understand and the ability to appreciate not actual appreciation and actual understanding. We have to ask ourselves, why did they lack this ability? Why don't they understand or why don't they appreciate? And we need to show that it's because of the mental condition itself. There are a lot of reasons why somebody may not actually understand or appreciate information. If there's a language barrier, for example, if they have particular communication difficulties that mean they can't take in complex ideas and need it to be presented to them in simple, concrete terms, maybe they have a poor relationship with the physician and that interpersonal difficulty is getting in the way. Those are all reasons why they may lack understanding or appreciation, but have the ability, if the information was presented to them in a way that was consistent with their learning needs. So you have the final part of the test is getting to the point where it's the illness itself or it's the condition itself that is interfering with the decision-making and not other factors that could be mitigated.
Alex Raben: [00:34:27] Right. That's helpful because that helps me understand this word ability and why that's so important. It's you have to go to the necessary lengths to make sure you're testing the ability. And it's not for other reasons.
Kendra Naidoo: [00:34:40] Exactly.
Alex Raben: [00:34:41] And it also sounds like it really does require some drilling down and some time you have to spend some time on this to really understand the capacity of the person you're you're seeing.
Kendra Naidoo: [00:34:55] I would agree with that completely.
Alex Raben: [00:34:57] Yeah. And then I guess we've talked about appreciation a bit more than understanding, and perhaps that's because it's the one that comes up a bit more often. But are there like what kind of cases would we see that might involve debt understanding peace.
Kendra Naidoo: [00:35:14] So someone might lack the ability to understand, for example, if they have extreme memory deficits. So when you tell them something within a couple of minutes, they're not able to recall that information if they have extreme thought disorganization. So they can't process the information that you're giving them. The other time it may come up is if the person's mental condition leads them to be so disregulated or agitated that they cannot sit and sustain a conversation for any meaningful period of time. And that's because of the illness that may reflect an inability to understand because they can't taken the information. So it's really referring to cognitive deficits that prevent them from receiving or retaining the information.
Alex Raben: [00:36:01] Right.
Bruce Fage: [00:36:03] So it sounds like it's a really high bar to deem somebody incapable to consent to treatment. And I think within mental health, we want to support people to make the best decisions that they can and work with them to develop a plan to meet their goals, to make sure they're living the kind of life that they want to live and helping them manage symptoms. Once you if you think somebody is incapable, what practically happens? Are there forms? Who do you have to tell?
Kendra Naidoo: [00:36:34] So it depends on the setting that you're in. If the finding of incapacity is being made in a psychiatric facility and it relates to a psychiatric medication, so medications to treat the mental condition, then they have to receive what's called a Form 33. And that's a formal notice to them that a finding of incapacity has been made and they have a right to retain a lawyer. They also have to receive rights advice similar to the rights advice that's provided for an involuntary detention. And they have the rights adviser will meet with them, explain what it means to be found, not capable of consenting to that particular treatment. And they have a right to apply to the consent and capacity board for a review of whether they meet or don't meet that two-part test for capacity.
Bruce Fage: [00:37:20] And if they are found to be incapable and the ECB upholds that finding, who decides?
Kendra Naidoo: [00:37:29] So then a substitute decision maker is identified, and neither the health care team nor the patient get to choose the substitute decision maker. There is a hierarchy, a list that is set out in the Health Care Consent Act that determines who will consent the high from starting from the highest ranked. It's a guardian of the person. So that's appointed someone appointed as the decision maker by the court, followed by a power of attorney for personal care, then someone that has been appointed by the ECB. And then after that we get into family members. So first a spouse or a common-law partner, then a parent or a child, then siblings, and after that, any other relative.
Bruce Fage: [00:38:14] And what if the person doesn't have anyone available in their life who could provide that consent?
Kendra Naidoo: [00:38:20] So if none of those people exist, then the Office of the Public Guardian and Trustee, which is an office of the government that is specifically designed for decision making, they will become the substitute decision maker.
Alex Raben: [00:38:33] What happens in that period where you've found someone is incapable of making a treatment decision and they've decided that they disagree and they are going to appeal to the ECB, the consenting capacity board. Can you can you start the treatment? Well, we're waiting for the ECB. Can you look what what happens in that period while you wait for the ECB to decide one way or the other?
Kendra Naidoo: [00:39:05] So if the patient has indicated an intention to apply for to the CCB (Consent Capacity Board), then no new treatment can be started for the next 48 hours. When I emphasise new treatment, because if they have already been on treatment, then that treatment can continue, provided you have the consent of the substitute decision maker. But you can't start any new treatment in the category that they've been found incapable for until 48 hours has passed at 48 hours. If they have not applied the consenting capacity board, then the new treatment can be commenced. If they have applied to the ECB, then the new treatment cannot be commenced until after the ECB has rendered their decision.
Alex Raben: [00:39:49] And what qualifies as indicating that they want to go to the ECB?
Kendra Naidoo: [00:39:54] It's I'd say it's a relatively low bar. Not everybody is sophisticated enough to voice the words I want to apply to the ECB, but in the process of providing them rights advice, following the finding of incapacity, it will be explained to them that there is this tribunal who reviews these decisions and they will be asked, Do you want do you disagree, and do you want to challenge the physician's finding? And it's really any statement by the person that they want to exercise that legal right. So they might say, I want to go to the ECB, but they might say I want a lawyer or I want to challenge or I want to appeal. And that would all be indications that they want to exercise that legal right. So something that sounds like that.
Alex Raben: [00:40:38] Right. And then they have 48 hours to make that decision. After that be able to start the treatment.
Kendra Naidoo: [00:40:47] Right.
Alex Raben: [00:40:47] Gotcha. And what about stopping treatment.
Kendra Naidoo: [00:40:50] If the treatment is not medically recommended or is otherwise harmful to the patient, then absolutely, you can stop it. Okay. Yeah.
Alex Raben: [00:40:58] So let's say you go to the ECB. What happens then?
Kendra Naidoo: [00:41:06] So the ECB will render a decision within one day of the end of the hearing and they will either confirm or revoke the finding of incapacity.
Bruce Fage: [00:41:19] And is there any step after that? Like what if the patient disagrees with the finding of the ECB?
Kendra Naidoo: [00:41:25] So any party to a hearing before the ECB and it could be the health care practitioner if the finding was overturned or it could be the the person who's subject to the finding. If the finding was upheld, either party has a right to appeal the decision to the Superior Court of Justice, which is the next level of court, and then the Superior Court would review the decision and decide whether it was reasonable. If the person does file an appeal of the ECB decision, then that new treatment cannot be started until the appeal has run its course and the court has rendered a decision.
Bruce Fage: [00:42:04] And I imagine that can take a while.
Kendra Naidoo: [00:42:06] It can. It varies by region, but it's not a very fast process wherever you are in the province.
Alex Raben: [00:42:15] And let's so let's say that you have a patient and they've exercised their right to go to the ECB. You've you've put forth the treatment of anti-psychotic and now the ECB has found that actually they are capable of making a decision around that and but but they're involuntary. So now what do you do in that scenario? Because they're you're holding them in hospital, presumably to treat them. But now your hands are kind of tied in a way.
Kendra Naidoo: [00:42:48] That's a very challenging clinical scenario. And I'm glad you raised that point because it's it's an important aspect of the fact that, as we talked about at the beginning, hospitalisation is governed under the Mental Health Act, but treatment is governed by the Health Care Consent Act, which means you can have people who are incapable of consenting to treatment but don't meet the box or Box B criteria and so cannot be detained in hospital. Conversely, you can have someone who is meeting the Box A criteria and so involuntarily detained but is capable and so refusing treatment. At that point it becomes a case of clinical judgement. If you cannot treat the person, what is the purpose of the hospitalisation and what is the goal of the hospitalisation? Maybe because the person is capable, maybe you can work with them to bring them around to consenting to the particular treatment. Maybe you can look at what is it about the treatment that they are objecting to? Is it the side effects? Is it that they don't want a needle and would prefer to take oral? Is there some kind of compromise that you can arrive at? And if they are adamantly, capably refusing that treatment, then you would have to consider what is the goal of this admission and should it be continued. And I would certainly encourage all medical learners, obviously, to speak to their staff and consult with the administration of the hospital on those kinds of decisions.
Alex Raben: [00:44:22] Right.
Bruce Fage: [00:44:22] Yeah. Thanks, Kendra. I think I think that's a really great point in that the loss is perhaps a bit more black and white than the clinical reality in any capacity assessment needs. If you're a psychiatrist or a resident or a medical student who's working with a patient who's admitted to the hospital and voluntarily and you're trying to do a capacity assessment, you really need to do a thorough assessment and understand the person's values and their perspective and their rationale for making whatever decision that they're choosing to make and really trying to help support them to make the best possible choice for them. So it is important to look at all of those things that you mentioned and not simply take away somebody's right to to decide for themselves if you don't like the choice that they're making.
Kendra Naidoo: [00:45:11] Absolutely.
Alex Raben: [00:45:13] So, Kendra, sorry, you were mentioning that that was the way of making a finding of incapacity if you're in a hospital. But what happens if you're in an outpatient rotation or you're seeing someone outside of hospital?
Kendra Naidoo: [00:45:25] So if the finding of incapacity is made in a non-schedule one hospital or in the community or it relates to non-psychiatric treatment, then there is no form 33. The physician documents their assessment in the finding and then the physician has to deliver rights advice. So that involves informing the patient of the finding of incapacity, informing them that that means a substitute decision maker will be making the decision for them, informing them that if they disagree with the identity of their substitute decision maker, they have the right to apply to the ECB for a different substitute decision maker and informing them that if they disagree with the finding of incapacity, they have a right to apply to the ECB for that. If the person indicates that they want to make either of those applications to the ECB, the physician then has an obligation to assist the person in making that application. How far you have to go to assist is really going to depend on the individual person. If they're able to do it themselves. It may involve just pointing them to the ECB website or helping them print off the form. But if they have more functional impairments or the physician believes they wouldn't be able to do it themselves, it may be all the way down the spectrum of filling out the form with them and faxing it off to the ECB, and that delivery of rights advice should be documented. And the person doesn't see a rights advisor from the PPO.
Alex Raben: [00:46:54] Right. And on the topic of helping the patient get rights advice, I've also seen like calling up the rights advisor and like being there with the phone and that kind of thing as well.
Kendra Naidoo: [00:47:07] Absolutely. If the person is not in a psychiatric facility, the rights advisors won't come and see them. So that's where the physician may call the ECB with them or help them fill out the form and fax it. But if they're in a psychiatric facility, any time a patient wants to speak with an advisor or have access to their legal rights or wants to speak to a lawyer, if they don't have one, then helping as much as you can to facilitate their access to the rights adviser is the best thing to do.
Alex Raben: [00:47:34] Right. So the big differences are no form 33 and you as a physician or as a health care team, have to help facilitate the rights advice.
Kendra Naidoo: [00:47:45] Right? You deliver the rights advice.
Alex Raben: [00:47:47] Okay. You you actually deliver it? Yeah. I have a question around documentation, because often, I mean, it's always important to document it a medical legally safe way. And in particular when things go to the ECB. Your notes are often used as I don't know if evidence is the right term, but it's used it's reviewed in the ECB. So how should residents and medical students document capacity and also like involuntary making someone involuntary?
Kendra Naidoo: [00:48:22] Often and thoroughly. I think, you know, the best thing you can do to set yourself up for the ECB is to be really familiar with these legal tests. And when you're doing these assessments, document them in relation to the legal tests. So when we're talking about involuntary detention, being very thoughtful in your documentation about which on which criteria am I relying, is it the box or the box be criteria? Your documentation should reflect that. It should reflect are we relying on serious bodily harm to others, serious bodily harm to self serious physical impairments? Here is mental deterioration. And what are the factors or the indicators or the evidence that have led me to that decision? When documenting a capacity assessment, it's very important to document all of the information you have given to the patient because otherwise you're exposing yourself to an allegation that you cannot possibly have assessed their ability to understand and appreciate information if it hasn't been given to them. So all of the information that you've given to the patient and their responses to that information. Right. Another tip is to write your documentation using the language of the legal tests. So the test for involuntary detention requires a likelihood that the mental disorder is likely to result in one of the harms. So language likely is really important. Avoiding words like might or could or may because the legal threshold is a likelihood. Similarly, when you're doing your documentation of a capacity assessment, avoid terms like patient disagrees. They have schizophrenia because of course they don't have to agree that they have schizophrenia. So documenting in accordance with you've you've informed them of their symptoms. If you've expressed to them the manifestations of their illness, remember to document it in terms of a mental condition and not do what I just did, which is refer to it as a mental illness or a mental disorder mental condition. And remember, that key is ability to understand and ability to appreciate, not actual understanding or actual appreciation.
Alex Raben: [00:50:39] Right? That makes a lot of sense. And then springboarding from that. Still on the topic of documentation, another thing that comes up for medical learners and it's happened to me the other night, I was on college campuses messing up, filling out a Form One because it's kind of a it's a long ish form and there's lots of tick boxes and things that can be forgotten. Why are we so finicky about that and what happens if we do mess up?
Kendra Naidoo: [00:51:12] So it's a three-page form, but in the context of evenings, I know in the emergency department things are very busy. There's a lot of boxes and a lot of lines to sign and things can go wrong. I think we are really invested and certainly the consent and capacity board is really invested in seeing those forms being filled out, right, Because the powers that the legislation confers on physicians to impact people's rights is so profound, right? There is no other area in our law or in our society outside of the criminal law where an individual person can sign a piece of paper and have somebody detained. So the the information on the form is critical for the patient to understand what is happening to them. It's critical for an evaluation of whether all of the right steps were met. And so it's very important that those films be filled out correctly. That said, things happen. People, you know, counting hours is sometimes complicated. People make typographical errors and things happen. If there's an error on the Form One, the best thing to do is to fill out a new form one deliver a new form 42 to the patient and try to be mindful of not extending the length of the detention because we made an error. So if a Form One is filled out and the error is not discovered until 48 hours later, we fill out a new form one at that 48-hour mark rather than counting. From 72 hours from that 48 hours, which results in a five-day detention. Being mindful that we should be still making that decision about discharge, admit voluntary, admit involuntary within the original 72 hours to be respectful of the rights of the patient and not unnecessarily delay their detention and their access to the legal rights that they have.
Alex Raben: [00:53:15] So you would backdate it to when the form was originally filled out. Would that be the way of handling that?
Kendra Naidoo: [00:53:23] Well, when you when you sign the form, the date and time of your signature would be the date and time that you signed the form. I see. But you could write on the there's a portion on the form that says date and time detention commenced. You could write 48 hours ago. Right. And then I would also recommend just putting a little notation that says form redone because of typographical error, just so that it doesn't look like you didn't sign the form until 48 hours after the detention commence. Just so anyone looking at the face of the form can sort of identify what happened and why the dates are a little skewed.
Alex Raben: [00:54:00] That makes sense. And just for our listeners, because these forms can be a bit tricky, especially at first to get used to filling out. And it's hard for us to describe all the various boxes in an audio format. We will link to a visual walkthrough in our show notes. This was done by a psychiatrist here at IMH, Dr. Patricia CAVANAUGH, and I think it will help you guys to learn how to fill them out.
Bruce Fage: [00:54:27] So, Kendra, thank you so much for taking the time to meet with us and share your knowledge. Involuntary hospitalisation and capacity assessment can be very challenging aspects of providing psychiatric care. I think certainly for patients and their families, but also the mental health care teams that support them. I think it's extremely important that patients receive due process and that their legal rights are respected and I'm glad that you are around to help us navigate that process. Thanks so much for coming in.
Kendra Naidoo: [00:54:53] Thanks for having me.
Bruce Fage: [00:54:54] And thanks to all of our listeners. We'll see you next time on PsychEd.
Alex Raben: [00:54:57] Thanks, guys. 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 by Bruce Phage and hosted by Bruce Fazio and Alex Rabin. Audio editing was done by Alex Rabin. Our theme song is Working Solutions by Olive Music. A special thanks to Kendra Naidoo for serving as our expert on this episode. We look forward to your comments and feedback and you can contact us at Info@psychedpodcast.com or visit us at Psycedpodcast.org. Thank you so much for listening!
Episode 14: Diagnosis and Treatment of PTSD with Dr. Dana Ross
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Lucy Chen: [00:00:03] Hey there, podcast listeners, this is Lucy Chen. I'm a PGY4 for psychiatry resident at the University of Toronto. Today, I'm going to be hosting an episode on post-traumatic stress disorder. I'm here at Women's College Hospital with Dr. Dana Ross, who I had the pleasure of working with as a PGY2 psychiatry resident, and also attended some of her interesting trauma workshops. So maybe without further ado. Dr. Ross, maybe you can tell us a little bit about yourself and your work with trauma and treatment and diagnosis.
Dr. Dana Ross: [00:00:37] Absolutely. Thank you for having me. So my name is, as you said, Dr. Diana Ross, and most people call me Dana. And so you're most welcome to as well. I am working at Women's College Hospital in the trauma therapy program, which is an outpatient trauma therapy program, where we see people who have a history of childhood trauma and that can be all kinds of trauma. So sexual abuse, physical abuse, neglect, abandonment, psychological abuse, all of that kind of a thing. And we do a lot of group work and then we do some individual as well. And in terms of my background, I did my medical school at the University of Calgary and I came and did residency at Queen's University for my first year and then came to Toronto to finish my residency here.
Lucy Chen: [00:01:19] That sounds great. So maybe I'll right now cover some of the objectives that we're targeting for this episode. And Dr. Ross really kind of created some specific objectives, so it'll help us with guiding the episode. So the objectives are to cite the prevalence and incidence rates of post-traumatic stress disorder or PTSD. Recognise the clinical features of PTSD using DSM five diagnostic criteria. List five Common Risk Factors for the development of PTSD. Identify three neurophysiological mechanisms underlying PTSD. Differentiate the three stages of trauma therapy. Describe evidence-based pharmacological and psychological treatments for PTSD. So we're covering a lot. So we'll do our best. So, Dr. Ross, why don't we start with, like, I guess, like the prevalence rates or how common PTSD is, how common trauma is?
Dr. Dana Ross: [00:02:22] Absolutely. So when we talk about prevalence, there's a lot of different studies on there's sort of a wide range of figures. And we'll talk a little bit about why that is as well. So we know that although about 50 to 90% of the population may be exposed at some point in their life to traumatic events, most people don't actually go on to develop PTSD, which is an interesting thing to think about. And I think later we're going to circle back around to talk about some of the factors that actually contribute to developing PTSD. So what we do know is the lifetime prevalence of PTSD ranges from about 6.1 to 9.2% and national samples just in the general population in the United States and Canada. And within one year, the prevalence rate is around 3.5 to 4.7%. And as I was mentioning it, it can be difficult sometimes to get an accurate rate there. And one of the reasons for that is that people may have symptoms of PTSD for many years before they actually seek treatment or they may have sub-syndromal PTSD. So the prevalence rate of PTSD may actually be underreported. So we do know that the prevalence of PTSD is considerably higher among patients who seek general medical care and among persons who are exposed to anything like a sexual assault or mass casualties, including, of course, war, national natural disasters and in refugee populations. And of course, in the veteran community. Different studies show prevalence of PTSD is somewhere between 10 to 30%.
Lucy Chen: [00:03:50] Mm hmm.
Dr. Dana Ross: [00:03:51] We also know that the lifetime prevalence of PTSD is higher in women than in men, and it's higher in the presence of underlying vulnerabilities such as adverse childhood experiences. We'll talk a little bit more about what that exactly means down the road and if people have comorbid diagnoses as well. And I think one of the most important things we need to know is that it's extremely common for people in mental health settings to have a history of trauma which may or may not include a diagnosis of PTSD. And so when we're working with people in the health care field, in mental health, I think it's very helpful for us to be holding a sense of that prevalent.
Lucy Chen: [00:04:28] This also it makes me think about like what's considered a trauma or like how I suppose in DSM five, it's something very specific, but lots of people will say, Oh, that was so traumatic for me. Or, you know, we talk about PTSD in a sense that it kind of it's just general symptomatology in response to trauma. But maybe we can better define and clarify that understanding of what a trauma really is.
Dr. Dana Ross: [00:04:53] Absolutely. It's a great conversation in the field. I think what is trauma and also just in a wider society. It's a great conversation that's going on. And so certainly I don't have the the one and only definition of trauma, but let's break into it a little bit. So if we look at the definition of trauma in the DSM five, we can start with that criterion, A, which is that exposure to actual or threatened death, serious injury or sexual violence in one of the following ways. And they include directly experiencing, witnessing, learning about it happening to others or experiencing repeated extreme exposure to the details. So for example, police officers, officers and that kind of thing. And so that's sort of the formal definition. But if we talk and think a little bit about the the less formal definition of what is a trauma, it can be anything from a single experience to multiple experiences. And it's often something that just completely overwhelms the individual and their ability to cope, to integrate things like ideas and emotions that are involved around that experience. And it can take a really serious emotional toll on those who are involved, involved in that kind of a trauma. It can have an impact on things like a person's identity, their sense of self, and really result in negative effects in mind, body and soul and spirit. Really often there are four elements that are identified in trauma.
Dr. Dana Ross: [00:06:15] So one was sometimes it's often or often it was unexpected. The person was sometimes unprepared for the trauma. There was nothing that the person could do to stop it from happening. So that sense of helplessness or lack of control and again, just the traumatic events were beyond that person's control. So those are more not formal definitions, but often I find key components of traumatic experiences for people. But certainly the scope of trauma and what is or isn't trauma I think is a larger conversation for us as a again, as a society and for us within the field of trauma as well. But it encompasses a wide variety of experiences like physical abuse, sexual, emotional violence, abandonment, neglect, of course, domestic violence and trafficking, all kinds of things around significant invalidation neglect that can happen. Harassment, discrimination. We see a lot of things around class and race, sexual orientation, age, religion, disability, gender, things like, of course, war, refugee populations, economic stress, mental physical illnesses, natural disasters. And then I think it's important when we're thinking about trauma to that, we think about it broadly. So trauma can be an experience of the individual, but it can also really be propagated and experienced through organisations and institutions. It can be embedded in cultures and communities, take place with service providers and families as well.
Lucy Chen: [00:07:46] This concept of like sub-syndromal PTSD, and I also think about invalidation or, you know, someone growing up with a really sensitive temperament to sort of parents that were a poor fit or and I wonder about like how that manifests. Like it's not sort of like a serious threat to their life, but they I guess I'm curious about this idea of like complex PTSD or like some of these other sort of manifestations of PTSD that are not clear cut, but they clearly are distressful. We clearly see it.
Dr. Dana Ross: [00:08:19] Absolutely. So in the DSM five, right now, we have PTSD, but we don't have complex PTSD. And so those who work in the field of trauma are pretty familiar with the idea of complex PTSD. However, because that, especially in my identity, is actually what I see. And so the diagnosis of diagnosis of complex PTSD is actually in the ICD 11, which is that international classification of diseases 11th revision, and it really defines it as arising after exposure to an event or a series of events of an extreme, extremely threatening, horrific nature. And what they really underscore there is that it can be prolonged. It's often about repetitive events that were difficult to escape or impossible to escape. It can cover a whole bunch of stuff like childhood abuse, repeated childhood sexual, physical abuse, torture, slavery, genocide, domestic violence, and all of the core symptoms that we find in PTSD are under that umbrella of complex PTSD. But it adds a few other things in there that I think are really important. And one of the things that we really see a lot with complex PTSD is really difficult abilities to regulate affect.
Dr. Dana Ross: [00:09:28] So moods are up and down and all over the place, and that can be really disruptive for people in their sense of who they are and their sense of their ability to function and their day to day life. It also encompasses a lot around sort of beliefs about oneself. A lot of people hold this idea in complex trauma of I'm worthless or I don't have value, and so it really hits those kind of core components of self. Other things that it touches. And I think this is one of the most important things we see as well here, is that it leads to a lot of difficulties in relationships, not just the relationships with self, which we've touched on, but also relationships with others, boundary issues, issues around trust. People can get into repetitive patterns of behaviours and relationships that are really rooted in past trauma. And so that's a lot of the work that we do here. And there's a whole bunch of stuff around dissociation, forgetting cognitive impacts. And again that kind of identity disturbance piece I think is a big one.
Lucy Chen: [00:10:30] Yeah. And I suppose it's naturally kind of leads into us into a discussion about like the DSM five criteria for PTSD, which I think covers spans like five pages or like really if you we have it like next to us right now, like it's kind of daunting sometimes when we kind of look through the criteria to be able to then make sort of a confident diagnosis of PTSD. So maybe you can give us some tips on how to navigate that.
Dr. Dana Ross: [00:11:01] Yeah, absolutely. I think the four symptom clusters are really important to just have a handle on the number one thing being avoidance. So avoidance of anything that reminds you of the trauma, that brings up emotions, feelings, people, places are avoided. And it's sort of the bedrock of trauma in some ways because on one hand, we're very happy that people have that ability to avoid because it allows people to live, to survive, to get through their day to day and not be completely overwhelmed and not functioning because of the experiences of trauma in their life. At the same time, avoidance really helps PTSD stay stuck because if you're not sitting with those emotions or body sensations or experiences, there's no chance to process them and to move through and past them as well. And so the other categories are that re-experiencing of past traumatic events like flashbacks, that kind of a thing. That's an important category as well. And then the other categories are negative changes on cognition and mood, which is a lot of people will say, you know, I have a lot of trouble holding on to positive emotions. I'm really stuck in those negative emotions, or sometimes I'm hardly feel any emotions at all because they're so shoved down, because they're so painful and so overwhelming.
Dr. Dana Ross: [00:12:22] And then the hyperarousal symptoms are probably something we see a lot of as well, which is holding that kind of tension and stress, being really concerned about safety, all of those kind of things. And so one of the mnemonics we can use is traumatic to remember some of these things. So the T is for trauma, which is reminds you about that criterion. A The R is for re-experiencing, the A is for avoidance. The U is for Unable to Function, which is a criteria for all of our disorders. The M is for the one month criteria. So for PTSD we want to have those symptoms lasting for more than a month. A is for arousal, Two is for two specifiers; so there's Depersonalisation and Derealisation of specifiers. And I think we'll talk about that in various ways over this podcast. And then I is for illness, so it's not due to an illness, substance or general medical condition and C changes in cognition and mood.
Lucy Chen: [00:13:23] So just to summarise, so there seems to be so there's four symptom clusters that we can organise PTSD into in terms of symptomatology. So one of them is intrusion symptoms, the other is avoidance, the other one is negative mood and cognition. And the fourth one is arousal and reactivity. And it sounds like dissociation symptoms. They can emerge in PTSD, but we sort of indicate the existence of them through specifiers.
Dr. Dana Ross: [00:13:51] That's correct. And so that's a new one for DSM five. We didn't actually see that in DSM four. Tr And what they're talking about there is really there's a big prevalence of dissociation in people who've experienced trauma and dissociation in its most simple way of understanding it I think is about disconnection. So it's disconnection from your self, disconnection from others, disconnection from the world, and that can look like a lot of different things. But two of the really common ways that people dissociate are depersonalisation, which is that disconnection from yourself. And so when I'm talking to people about what that looks like and feels like, people will say, I actually feel sometimes like I'm floating above myself and just watching what's happening. Or they'll say, I feel like and actually I'm actually just a brain walking around. I don't even feel a sense of connection to my body or I don't feel anything below the neck or I feel just not real. That's something that's not to the point of being psychotic, but there's a sense of unreality to their being in. The world and then do you realisation is that disconnection from their surroundings, from the world? People describe that sometimes as it's like I'm watching a movie of my life but I'm not participating in it or people will say there's like a fog between me and the world or like a pane of glass. Everything is sort of happening. I can see it, but I'm not in that flow of life. There's no vitality in there for me.
Lucy Chen: [00:15:17] And so in PTSD, are all patients supposed to have like one of each symptom cluster. So what I have here is that it has to be one or more of those intrusion symptoms, one or more of those avoidant symptoms, and two or more of the negative mood and cognition symptoms and two or more of those arousal and reactivity symptoms.
Dr. Dana Ross: [00:15:43] Yeah, that sounds correct. And there's under those I think you'll go through the criteria in more detail. So there's it can look very different for different people because there are a number of symptoms that fall under the DSM five criteria. But I think those having something from those categories in the number that you said, I think that's fairly accurate to what we see.
Lucy Chen: [00:16:02] And just in terms of timing to I wonder about like the one month of of symptomatology compared to someone who would kind of maybe have some of these symptoms after a traumatic event only lasting, you know, a couple of days or a few weeks. And maybe this leads into this idea of a risk factors. But what makes someone predisposed to having these symptoms for longer and really turning in and manifesting us as this disorder?
Dr. Dana Ross: [00:16:30] Yeah. So we think about when we're less than a month, we think about acute stress disorder as a possible diagnosis, and then after a month, we're thinking more about that PTSD. So there are risk factors for developing PTSD and those are numerous, but there's different studies that show a little bit of slightly different things. But some of the things that come up are a female gender, the age of the trauma. So if people are younger age, they're more likely to go on to develop PTSD. Being separated, divorced, widowed, having previous trauma, of course, increases your risk of then developing PTSD as well. Having a lot of history of general childhood adversity, adversity, which we'll talk a little bit more again, having a personal or family psychiatric history, poor social supports. And I think there's probably a number of other things as well. But those are the things that kind of come to mind.
Lucy Chen: [00:17:25] We were sort of indicating that, you know, the five most common risk factors for the development of PTSD. So we talked about sort of childhood adverse events. I guess it's I guess like thinking about PTSD in the sense that it's so it's also it's so comorbid with multiple other DSM five sort of diagnoses. How to tease that out is sort of is MDD sort of a predisposition to PTSD? Does PTSD lead to more MDD? Are substances, I can imagine substances kind of perpetuating avoidance of certain traumatic events which can maybe lead to more PTSD. I suppose it's quite complex, but maybe if we can kind of maybe outline five particular common risk factors for the development of PTSD.
Dr. Dana Ross: [00:18:15] Sure. Do you want me to talk about comorbidity a little bit in there as well?
Lucy Chen: [00:18:18] Yeah, that'd be great.
Dr. Dana Ross: [00:18:20] Let me start there and then we'll we'll kind of see where we go. Yeah, I love talking about comorbidity, actually, because I think it's really the bedrock of psychiatry generally, and certainly it's the rule in PTSD rather than the exception. And so when we look at comorbidity comorbidity rates, we can see that in the National Comorbidity Survey. It suggests that 16% of people with PTSD have at least one existing psychiatric disorder, but actually 17% have two, and up to 50% have three or more comorbid psychiatric disorders when they have a diagnosis of PTSD. So again, when we're working with people who've experienced trauma, who have a diagnosis of PTSD, we really need to be thinking about what else might be complicating that picture, adding to either increasing the risk of developing PTSD or just being more morbid and making that more of a complex picture. So in terms of comorbidity, we know that substance abuse is really a high rate of comorbidity with PTSD up to like 60 to 80%, depending on what studies you're looking at. And that can be all kinds of different addictions, but substance abuse, alcohol, cocaine, whatever it is, we have to think about that as a way to modulate some of the symptoms of PTSD, some of the feelings, some of the body sensations and stuff like that as well. And so when we're asking about PTSD, we want to always be asking about substance abuse, depression as a huge one. Again, depending on the study, it can be up to 65% of people with PTSD who have comorbid depression and anxiety, social anxiety, panic disorder. Those are very common and I'd say clinically, a majority of people that I see who have trauma also have anxiety and depression both now and often throughout their lifetime. There's a whole bunch of other stuff too; brief psychosis, somatization disorder, eating disorders can be really aligned with that as well. Pain disorders, Dissociative disorders, of course, and personality disorders, including BPD, can be associated as well.
Lucy Chen: [00:20:30] You know, and it makes me think about these are all manifestations of how people end up coping with trauma like or maladaptive coping, rather. I can see how so many people there's such a diverse range of ways that people can end up sort of like maladaptive, trying to handle what they've experienced.
Dr. Dana Ross: [00:20:50] Absolutely. I often think about and I think there's a discussion in the field as well about even the title PTSD or post-traumatic stress disorder. Because when we see people and they've been through these horrific experiences in their life, the way that those symptoms are coming out and the behaviours that people have make complete and total sense given their history and their experiences and they make sense as a way to self protect, to cope, to be able to function. And so if we look at the disorder of PTSD through that lens, it really isn't in some ways a disorder. It's actually a very human, very understandable way of coping. But PTSD gives us a framework for understanding it. And of course, it can be very helpful to have a diagnosis, to do research and to lead treatment as well.
Lucy Chen: [00:21:36] Yeah, that sounds like it'd be so helpful for someone encountering someone with PTSD, kind of having a trauma-informed approach, but understanding where those avoidance symptoms are coming from that it's really it's for it's for survival, it's for self maintenance. It's being able to to sort of navigate what they're going through and maybe being able to understand that and kind of communicate with the patient could be a window into better being able to relate with these patients.
Dr. Dana Ross: [00:22:01] Absolutely. I think a lot about when I'm sitting with somebody and they're telling me what they're struggling with, thinking about what are the advantages and disadvantages of the behaviour, the thought process, the way that they're dealing with emotions because there's something protective in there, there's something that makes sense and I think it's our job together to try and figure that out. And when you're taking away that kind of judgement or and you're sitting in that again, trauma-informed kind of way, which means really holding the idea and the knowledge about the prevalence of trauma, knowing how common it is in patient populations and holding that in mind when you're doing interviews, when you're designing spaces, all of those kind of things. But if we can sit with people from that kind of a lens, this work just becomes even more interesting, even more collaborative. And I think this I can't even think of another way to look at it at this point in my career.
Lucy Chen: [00:22:52] I suppose that's kind of also leads us into this idea of like how people manifest trauma in their body and like what's really happening in neuro physiologically. And I guess this idea of like hypervigilance and I think about the HPA axis, but there clearly is some underlying neurophysiological sort of understanding of PTSD.
Dr. Dana Ross: [00:23:16] I think that's a great question because what we're learning more and more in the field of trauma is exactly how much of trauma is really held in the body and experienced in the body. And so that can look like a lot of different things for people. A lot of people are really dealing with tension throughout their body and with pain that gets either brought up or exacerbated by all of that tension, by all that stress that people hold, a lot of people hold a lot of the abuse that they've experienced in their body. And so a lot of people are very also disconnected, not having sensations or feeling any kind of connection with their body. Of course, it impacts people sexually as well. If you have a difficult relationship with your body, especially if you have a history of childhood abuse, I actually forgot what your question was now.
Lucy Chen: [00:24:04] The sort of the underlying neurophysiological underpinnings, underlying PTSD.
Dr. Dana Ross: [00:24:09] Yeah, absolutely. So I think there's a couple of things to think about are a few things that we can think about when we're thinking about neurobiology. So there's kind of four areas of the brain that I tend to think about. I think about the hippocampus, the amygdala, the prefrontal cortex, and I also think about the brain stem. So what we know is that when we're really feeling threatened, the body releases stress hormones, including things like cortisol, adrenaline, and those are really going through the body and having a profound impact. And so what we know from research is that something like cortisol can actually damage cells in a part of the brain called the hippocampus that's really responsible for laying down and integrating memories. And so often when people are really struggling with memories and. Trauma. There's actually a way for us to kind of understand why that might be. We also know from research that people on imaging have had a smaller hippocampus, and that can also contribute to difficulties with learning and memory, because that's a big centre for those two important functions. But what we do know is that the more we're learning about the brain, the more we're learning about neuroplasticity, that we can make changes in the brain through medications and through psychotherapy. And there's a lot of hope in the field of trauma because of that. We also think about the amygdala a lot and we talk about the amygdala in psychoeducation when we're working with patients as well.
Dr. Dana Ross: [00:25:30] So we think often about in a very simplified way about the amygdala as a fire alarm in the brain. And so when people are triggered or stressed that amygdala is firing fire and firing and really taking over the show, and what it does is it kind of shuts down our frontal lobes, which is where we're thinking, planning like kind of more rational, logical kind of stuff. And when people are triggered, they often report, you know, I can remember what my skills were. I barely remembered my name. Sometimes I don't even know where I am. And I'm just completely overwhelmed by this emotional, physical response to being triggered. And the amygdala, when it's kind of taking over in the brain, can be largely responsible for that as well. And so what we're thinking about when we're thinking about learning skills, all of those kind of things, learning strategies and techniques to work with patients, we're thinking about how can we calm and soothe that amygdala, get that frontal lobe back online or those frontal lobes back online, and help that person be able to access both their emotions and their rational thought at the same time. And the other big area that we think about is the what we call the survival responses, which is like fight or flight freeze collapse. Most people are pretty familiar with fight-flight, which is that urge to either lean in the anger or the fight, or sometimes to run away. And sometimes we'll have people just get up in the middle of a group and kind of leave because it's such a strong urge.
Dr. Dana Ross: [00:26:58] And the freeze response is sometimes not as familiar to people. So that's a really high energy state along with the fight-flight, where people are really experiencing those high stress hormones, but they're feeling actually frozen. Sometimes it's literally they can't move and they're frozen. But inside it's this high energy, frightening, overwhelming kind of environment. Or sometimes people are actually you wouldn't even know they were in a freeze response. But inside they're feeling that experience. And then the collapse is a low energy kind of state where everything kind of goes into that collapse or feigned death kind of state. And those are four ways of being four reactions for survival responses that we see a lot when we're working with trauma. And so having even just a basic understanding of that allows us to organise our skills and some of the emotion regulation techniques and body techniques we use with people with trauma. And we can really be thinking very specialised for each individual. Are we working with a fight, the flight, the freeze collapse? Is the amygdala really taking over? How much is this person holding this trauma in their body versus are they in a more of an intellectual place? And so all of these kind of things and understanding bring in the neurophysiology helps us personalise the treatment. I think for people.
Lucy Chen: [00:28:14] For sure.And for me just hearing this right now, it's helping me to kind of take me through the DSM five and really understand I give meaning to some of those symptom clusters, like the idea of the fight-flight freeze kind of maybe leading to some of those hyper arousal symptoms. The idea of sort of the amygdala sort of shutting off the frontal cortex, maybe leading to some of those cognitive symptoms or sort of the dissociation perhaps also as well.
Dr. Dana Ross: [00:28:39] I like that you brought in that cognitive piece because I actually think we don't talk enough in the field of trauma and working with PTSD about the impact of trauma on cognition. So when I'm actually seeing people for consultations, one of the most common things I'll hear is when I say and what I was. One of the main things that you're struggling with, people will say, I actually think I have Alzheimer's or I think I have dementia. It's such a profound impact on their cognition. So people will say, I can't remember words. My memory is just shot. I used to be able to read. I can't read anymore. I had a conversation with my friend on the phone yesterday and I didn't even remember what we talked about, all of those kind of things. So memory, recall, focus, attention is really negatively impacted as well. And you can imagine if you can't do all of those cognitive functioning skills, how difficult it is to go to work, have a job to do, any kind of activities, go to school, to just function at all in your day to day life. And so I think the profound impact that PTSD has, especially when it's also always, not always often associated with depression and anxiety and those co-morbid things like substance abuse and all of those other things we talked about. There are multifactorial reasons. Why people are really struggling with cognition when they've had experiences of trauma in their life.
Lucy Chen: [00:29:58] And do you see those symptoms reverse through trauma therapy?
Dr. Dana Ross: [00:30:02] Absolutely. And I think that is a really important message of hope for people. That's when that amygdala settled, when the body isn't going into that fight, flight freeze, collapse response automatically, when people are feeling more in control of their their body, their feelings, their emotions, that there's more room for that frontal lobe, again, to be present, more room to feel kind of in control, to have access to all the memory centres, to have access to thinking and planning and being focussed and all of those things. So I really see people progress through our program and absolutely see changes that are very positive in that arena of cognition.
Lucy Chen: [00:30:47] And this also it makes me sort of better understand why they're stages of trauma therapy and that the first stage really is about finding safety and then then kind of feeling safe enough to progress through through the rest. But maybe you can better sort of outline what the stages of trauma therapy really look like.
Dr. Dana Ross: [00:31:06] Absolutely. This is something we explain when we're working with patients. And it's also something that is really important for us to hold as clinicians and when we're doing education as well. So I'd say back in the day, going back in the 30 or 40 years ago when people were thinking about trauma, they often thought about we should jump into it, get into those memories, really tease all that apart in order to kind of have a cathartic experience and really discharge some of that emotion, some of that body sensation. But what they found in the field was that a lot of people, when that happened, they got worse, their symptoms got worse, they regressed. They were feeling much more triggered, actually weren't functioning as well. And so it was pretty obvious pretty quickly that that wasn't a great way to go. And so what happened in the field is this concept of three stages. And so the first stage, as you mentioned, is really about safety and stabilisation. And when people are doing that phase, which in my opinion is really the biggest piece of work that people do, is they're working on things around safety, around housing, around they're working on people if they're struggling with suicidal thoughts or self-harming behaviours, we're really working a lot around affect regulation in that stage. So we're doing a lot of skill-based work and really increasing people's toolboxes in terms of what they can do to self-manage as well. We're doing a lot of psychoeducation in that phase and we're doing a lot of alliance-building as well. A lot of people who are coming into therapy or treatments of any kind who have a history of trauma, have had negative experiences just interpersonally generally or in the health care system.
Dr. Dana Ross: [00:32:49] And so that's a period of time when we're really working on building trust, having people come in and feel safe in the environment, which is sometimes for some people, they've actually never had that experience of feeling safe in a space with another person in their entire life. So that's a really actually important and big piece of that work. And so the safety stabilisation is about building people's skill set and toolset and self-understanding, self-awareness. And what we see is people's symptoms really go down. People are starting to function a bit better and a lot of people actually don't have to go on to the other stages because they're functioning better, their life is looking better, their relationships are functioning better. And so we see a lot of people in our program who don't go on to the other stages. They're ready to go after stage one, which again, can be a varying amount of time for months to many years for people. It's a very big piece of work that that stage, stage two, we're looking at what we call remembrance and mourning, what we find with people who have histories of trauma, especially we work with people with complex trauma who have histories of child abuse is. That people have missed out on a lot of opportunities in their life because of their traumatic experiences and the symptoms that they've had. And so people do a lot of work around mourning and stage two, which is about opportunities lost, relationships lost. Who would I have been? Who could I have been if I didn't have this trauma in my life? And there's a lot of grief that has to be processed in that stage.
Dr. Dana Ross: [00:34:18] It's also can be about doing more memory work. And we're not ever digging for memories or looking for memories. We're working with whatever people come with. People can do profound pieces of work in trauma with very limited memories of the traumatic abuse itself. So we don't need to dig for those memories. But some people, when they finish stage one, really feel there's more work to do. There's some sticky pieces in there, and there's something for some people as well around having their story, their narrative witnessed by another human being, by having that validation and that empathy around that and by processing some of those details and some people need to do that work. And that can be very powerful, very important work for people as well. Stage three is about reintegration. So stage three people are starting to move out of trauma therapy. We're really focusing on your support system, getting back into life, redefining who you are. Sometimes when people start trauma therapy, they feel like they are their trauma and they've lost or never had a sense of self. So what we want to see over that course of trauma therapy is people really come in to a stronger sense of who they are, have a stronger foundation under their feet, be able to set boundaries and have healthy relationships and to go and pursue whatever it is that they want to pursue in their lives and be whoever they want to be.
Lucy Chen: [00:35:39] That's really interesting, this idea that most of the work or a foundational piece of the work is really stage one and that not everyone sort of progresses to stage two. And I find that sort of difficult sometimes when we were in this setting, when we're seeing patients in the emerge or sort of these one time encounters or these limited sort of the limited scope sometimes in which we're able to see patients. And I wonder how we can best help those patients or and figure out who who does progress to stage two and how we can better connect them to resources.
Dr. Dana Ross: [00:36:10] Absolutely. So one of the things I think we try to do here at U of T is really build more about trauma into the curriculum. And I think that's so important because I know when I did my training, I came and actually was at women's college during my residency and learned a lot of the stage one skills and the ideas and approaches and theories. And what I found was when I then went on call or was in the emergency department, I felt so much more equipped to work with people who are struggling from trauma, not just trauma, but just struggling in general, which is most people who come to the emerge. But I had models. I had tools that I could show and work with, with people who are coming in. And I felt like it was a much more effective approach for me as a resident because sometimes we're so busy, sometimes we can't give as much as we would like to give in terms of time. And so having tools and skills and handouts that you can give to people can be rewarding, I think not just for patients but for us in our work as well. Having said that, in terms of identity-identifying stage one and working with that, most people haven't had a lot of access to trauma work.
Dr. Dana Ross: [00:37:22] And I think there's a real lack of trauma treatment in the community. And we need to have more people who are trained in doing trauma work in stage two, trauma work in particular, and often people who have really complex histories of trauma and need longer term work, which is of course a problem in our system as we're working on access and and trying to hold all of those principles in mind. One of the biggest pieces that you can do, just based on what we talking about, is have that very basic understanding around the neurophysiology, which I often find when I explain to patients it can be actually transformative for people. A lot of people will say, I feel like I am just a black box of chaos inside. I'm a mess. Everything is. I'm clearly a terrible person. I can't control myself. All of these kind of self judgements that come up around that. When people start to have a real understanding, just the basics of neurophysiology, of trauma and stress, it can be a real shift in decreasing self-judgement and feeling validated and then understanding how and why we apply tools. Because some of, for example, a grounding tool might be to look around the room and name everything that's blue, and sometimes people will think, Well, that's a bit Mickey Mouse.
Dr. Dana Ross: [00:38:37] I'm kind of looking for a bit more than that. But when we have explained that background neurophysiology, we can say, Well, let's stop and think about that for a moment. If you're taking a moment stopping when you're feeling overwhelmed, looking around the room, you're actually moving your head, moving your eyeballs, you're searching out something that is blue. You have to think about what? Is that colour blue. And then you have to think of the name of the object. You have to say it out loud. There's multiple, multiple steps in that. And that is all about bringing the body back online, calming down from the bottom up, we would say, and top down using turning on that cortex and turning on those frontal lobes to be able to name things, to be able to see the colours, look around, interact. And so we really are using the full body to try and get people more regulated. And so I think when we know some of those really basic neurophysiology pieces, it's very helpful for us to then do some very basic grounding kind of skills with people, and that can be quite useful.
Lucy Chen: [00:39:34] Yeah. And I think about instances of, like, patients or even myself when I'm in a crisis sort of mode and I can't speak right. It's very hard to find language to represent how you feel or the state of mind that you feel. And it sounds like these are sort of strategies to reconnect with some of the language.
Dr. Dana Ross: [00:39:55] Yeah, a good point. So one of the big things that can happen with people with any kind of trauma is when you get overwhelmed by it or triggered by it, it takes you back into the past. It takes you out of the here and now. And so people are often in an internal state where they're not here, not present, not taking in the information. And so we are bringing people back into the present. Often people are in a nonverbal state or lost in emotions and feelings that don't have necessarily necessarily words and language that go with them. And so having some of these tools can be really helpful. So one, for example, tool I use a lot is I have people build just a little box at home by a box and put things in it like scented oils or photographs or letters or photos, pictures, that kind of a thing. So it's like a grounding box because when we're really overwhelmed, it's really hard for us to remember, to think about our skills, to remember the steps involved. But when we have kind of a grounding box, we can just grab it. We have it. We don't have to put a lot of thought into it. So it's good to have skills when you're really triggered that work and skills when you're less triggered and you might be able to do more cognitive kind of things.
Lucy Chen: [00:41:03] That's great. So we've covered a lot of ground in terms of describing stage one, which is safety and stabilization. Stage two, which is..
Dr. Dana Ross: [00:41:13] Remembrance and mourning.
Lucy Chen: [00:41:15] And processing a lot of the trauma that sort of residual work from after sort of finding for finding that sort of foundation and grounding and stage three, which is kind of reintegration back into society. So I'm curious now about sort of some of the pharmacological options in treatment of PTSD and then sort of, I suppose, like what's most evidence based.
Dr. Dana Ross: [00:41:39] Absolutely. So we don't have as much research as we would love to have in PTSD. And a lot of it, we have to really look at it like like everything. We have to look at the source of it. A lot of our research on PTSD is done in the military, in the States, and we're very happy and very grateful that that work is being done. But it doesn't always overlap and speak to the patient populations that we're working with. Having said that, there is a very strong research looking at first-line treatments that are pharmacological for PTSD. So what we want to start with and work with are first-line SSRI. So sertraline, fluoxetine and paroxetine are the recommended first-line agents and there's a first-line snris venlafaxine which is also first-line. And so those are really our go to medications when we're working with PTSD that have evidence behind them. There are other medications that we can use, but they're not as evidence-based as we would like. And so we're we might be using a second generation antipsychotic like quetiapine or risperidone. But again, the preliminary studies there are very entry-level. And I think if we're making decisions around what we're going to be doing pharmacologically, we want to really start with those first line four options.
Lucy Chen: [00:42:58] And we think about those options. Are we sort of targeting something specific? So I can see sort of for the anxiety, the depression sort of piece using the SSRIs or using the SNRI as well. But I think about is it also addressing the hyperarousal? I guess I'm trying to break it down by symptom clusters.
Dr. Dana Ross: [00:43:19] It's such an interesting idea to think about really, because as we already talked about, the coma, the rate of co-morbidity is so extensive that it's sort of hard for us to really be as precise as we would like to be. But if we're meeting with someone who has PTSD and by chance, you know, likely has some anxiety and depression, then it also is just very convenient that we have these SSRIs and that's an area to use as well. So I think what I see shift for people with PTSD who are using those first-line options is a decrease in the hyperarousal, which is a big, big component. And so sometimes. I can come with a bit of relaxation in the body as well and a little bit less focus on concern on safety and being aware of safety issues around you. So I would say it kind of takes down the stress level, the hypervigilance kind of stuff and also of course helps with the anxiety that goes with all of that and some of the low mood that goes with having experienced trauma. And that's just a high comorbid condition with that.
Lucy Chen: [00:44:23] And I suppose I'm wondering and I don't know if there's is there like in terms of antipsychotics and, you know, it's not first line, but treatment for dissociation or those two pieces.
Dr. Dana Ross: [00:44:38] We don't really have pharmacological treatment. That's good for dissociation. So that we're really targeting with with the psychotherapy component. In terms of the anxiety, we'll sometimes use benzo but very judiciously and we're really worried about again, we just talked about how high the comorbid rate of substance use disorders is. So we want to be holding that in mind. I find I will use a benzo maybe once or twice a week with somebody when they're experiencing a significant trigger, particularly at the more early stages of treatment. But that's not something that has a lot of evidence. And again, we want people, I think, not to be overly reliant on those because of the risk factors that go with them as well.
Lucy Chen: [00:45:21] Yeah, and I think that you kind of emphasize this, but yeah, the psychological treatments for really targeting specifically the dissociation with multiple aspects of PTSD. Is there sort of like categories of psychological approaches or ways to organise those psychological approaches to PTSD?
Dr. Dana Ross: [00:45:38] Absolutely. So we've got some evidence-based treatments that are in that arena. So we have things like prolonged exposure. We have EMDR, which is eye movement, desensitisation and reprocessing therapy if cognitive processing, therapy or CBT. There's also a lot of evidence around cognitive therapy or CBT and some evidence for narrative exposure therapy outside of those evidence-based interventions, which are all good and great to know. There's also some things like sensory motor psychotherapy, which really focuses on the body and how trauma is held in the body. I use a lot from DVT. A lot of the skills that you learn around there are just essential and basic, I think, for all of us to know. Psychodynamic psychotherapy really underscores and underlies, in my opinion, all of the therapeutic interventions. So that's also a good one to know. It's good to know a lot about or at least a little bit about the attachment theories because those are very prominent in a lot of the complex trauma as well, and art therapy, some of the creative therapies and there's a type of therapy called Seeking Safety in which looks at trauma and substance use specifically, and it's a group therapy and there's a manual for that. And so I've done that one before and I've found it to be really well thought out and effective.
Dr. Dana Ross: [00:46:56] When we're thinking about psychotherapy treatments, we really want to also be thinking about different cultures. We want to be knowledgeable and respectful of different cultures. We really want to be thinking about the cultural meaning of symptoms of illness, cultural values of the patient, the patient's family, and trying to hold in mind what is the cultural context in which the treatment occurs? How might that affect the treatment course, the development and expression of symptoms? And we also really want to be holding that. We know that there are higher rates of trauma in certain communities like the LGBTQ+ community with an indigenous communities, refugee populations and of course in other cultural, racial, minority communities. So we really want to be holding that lens and all of our treatment and interaction and psychiatry, but of course with PTSD and trauma as well. So I think those are the main ones we certainly in our program use. I would say we don't do a formal prolonged exposure, but that is built into much of what we do. A lot of us are trained in EMDR, CBT. We do a CBT. I do a cognitive therapy group here that I that I love. I think it's a great group and we do a lot of relational kind of work and body work as well.
Lucy Chen: [00:48:05] Maybe if you could take us through the perspective of a patient going through this program and what it would look like for them in terms of their schedule or kind of the progression through the program.
Dr. Dana Ross: [00:48:15] So in our program we're really working on, we just redeveloped it and we're really holding in mind access and equity in those kind of principles. And so what we have people go through now is kind of two pathways into the program. One is into our day treatment program, which is called Wrap or Women Recovering from Abuse Program, which is about eight weeks, Monday to Thursday, 9 to 1. And there are really working in all of those modalities during that intensive period. The other pathway is through our groups and that are more individual groups. So once a week, like an hour and 45 minutes, so people will come through the program, they'll do our foundational trauma group, which is eight weeks and we're really focusing on skills, on psychoeducation, on understanding models and theories of trauma, and we're really focussed on the here and now. So we're not talking about details of trauma at all in those groups. And that again, is that foundational. As people move through that, they can then stream into either focusing on healing through the arts, through the body, through the mind or through relationships. And so there's some choice to personalize and their pathway there. And then as they move on and through the program, eventually they can get to individual stage two therapy and or stage two groups as well. And when you're in stage two, you can talk a little bit more about the details of trauma. So people really need to be ready for that stage of work because like all therapy and like all trauma therapy, but particularly in stage two, it can be really harmful if people aren't quite ready to be in that stage. And that's why stage one is so important.
Lucy Chen: [00:49:49] It sounds like a lot of stage two is exposure.
Dr. Dana Ross: [00:49:53] I think so. I think in some ways I think everything we do in psychotherapy is a form of exposure, right? When I'm thinking about working with trauma patients and groups and individually, I'm thinking about sitting with emotions that you're not comfortable sitting with. And how can we start to do that in bite-sized exposures that aren't overwhelming and that aren't going to make things worse? Right. But a lot of times people will come say they're really in a state of anger. I'm really thinking automatically, well, where is their sadness? Where's their grief? Or if someone's coming in a really collapsed state of depression, I want to know where their anger is. And so what we're doing through that is really sitting with and teasing apart people's ability to sit with their physical body, with their emotions, with their thoughts and with their sense of self, and through any of those kind of pathways of treatment or any of those modalities, I think we're very slowly exposing people to those things that they've been avoiding. And again, avoidance being one of those core components of trauma and PTSD. But we have to be thoughtful. We have to personalizing that to the person in front of us. But I think exposure therapy really underlies everything in some ways.
Lucy Chen: [00:51:01] Yeah. Well, thank you so much, Doctor Ross. I mean, I'm wondering if you have any sort of lasting sort or sort of anything, any tips or any ways that you suggest that we could be better, I guess, like health care providers in general in managing and treating patients who present with trauma.
Dr. Dana Ross: [00:51:23] So I think there are more and more training opportunities, both online and workshops. There's a lot more that's getting built into curriculums and medical school and in residencies as well, which is fabulous. There's usually a local resources where you can get more education or they might have good handouts and that kind of thing online a lot. There are so many organisations that have so many good infographics and stuff like that. Then when I go online and I just kind of pull them and we find them really helpful here as well. So basic grounding skills I think should be in the foundation of everybody's toolkit as a clinician, as a care provider, even if you're not doing therapy directly. And that would be around knowing kind of breathing skills, deep breathing, some basics around how to bring people back into the here and now if they're in either hyper that hypo arousal state. And then DVT is a good one. If you have that opportunity, mindfulness can be really helpful. Understanding some of those basic concepts like transference, counter-transference, reenactments, all of those kinds of things. We've talked about a little bit about the neurobiology of trauma. So again, I think that's a bedrock of the approach there as well. And then there's a lot out there about this concept of trauma-informed care, which is really care that is really rooted in principles around things like safety and trust, choice, collaboration, empowerment, having a respect for diversity and for our common humanity.
Dr. Dana Ross: [00:52:54] And I think those principles are things we're trying to really think about all the way through. From the moment we have contact with somebody through the moment, they walk through the door while they're in the program, while they're in the room with us, and while they're exiting the program as well. And so those are principles that we're always working on. We never reach a pinnacle of trauma informed care. We're always learning and seeing where our blind spots are and kind of moving forward. I think the best advice that I got in terms of how to learn more or when people are feeling really intimidated by working with trauma or asking about trauma, is from one of my mentors who said, you know, when in doubt, just be a human being. And in that moment we can just sit with people and just name what's in the room. So that was overwhelming. I can see that emotions coming up for you. Wow. That's an incredible amount of things that you've been through, all of those kind of things. And so a lot of just basic principles of being a human being, basic principles of psychotherapy. It can take us a long way.
Lucy Chen: [00:53:52] Thank you so much. Any sort of access to every sort of interview, but any lasting or sort of suggestions for young learners in navigating sort of their potential sort of interest in psychiatry or trauma therapy or PTSD or anything related to the field?
Dr. Dana Ross: [00:54:10] Sure. First of all, I'm just going to put a plug in for coming into trauma, coming into the PTSD field. I think if you're interested in the mind and the body and taking a real holistic lens to people, this is just a phenomenally interesting area to specialise in. And if you look at that, again, rates of comorbidity, you're going to be seeing everything, you're working with everything. So you're both a specialist and a generalist at the same time, which is very exciting. Everything is every patient is unique and diverse as they are in any area but in trauma and PTSD. With all of this comorbidity as well, you're really getting a lot of combinations of symptoms of people struggling with different things. And so I also find that in trauma, we have a lot of really effective treatments, a lot of really effective interventions and skills. And so it's also a very rewarding area to work on, to see people move through, get better and really be functioning in a way that they maybe didn't even think that they could. And so it's a very gratifying area to work in. And the people that we work with, the patients we work with, are just incredible human beings as well. I think if you're interested, there's definitely a lot of books that you can read and I can provide some a list of that. Maybe you can go on the website.
Lucy Chen: [00:55:22] On the show notes. That'd be great.
Dr. Dana Ross: [00:55:23] Great. And I'll provide a link to an article on how trauma impacts the brain that I wrote as well. That kind of summarises some of that neurobiology. But certainly, you know, reaching out and finding out what the opportunities are coming to workshops. There's two conferences I tend to be interested in and go to. One is called the through an organisation called the ISSTD or the International Society for the Study of Trauma and Dissociation. And the other one is ISTSS and it's sort of similar, but I'm not going to try and spell it right now. So those are two great opportunities to really network and to learn and get in on the ground floor as well.
Lucy Chen: [00:56:06] Thank you. Such a rich sort of episode to really understand the foundations of trauma and diagnosis and treatment. Thank you so much.
Dr. Dana Ross: [00:56:14] Thank you for having me.
Lucy Chen: [00:56:15] Thanks. Take care.
Jordan Bawks: [00:56:18] 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 meant to be representative of either organisation. This episode was produced and hosted by Lucy Chen, audio editing by Jordan Bawks. Our theme song is Working Solutions by Olive Music. A special thanks to Dr. Dana Ross for serving as our expert this episode. You can contact us at info@psychedpodcast.com or visit us at psychedpodcast.org. Thank you so much for listening. Catch you next time!
Episode 31: Understanding Psychodynamic Therapy with Dr. Rex Kay
Episode 10: Treatment of Schizophrenia Part II with Dr. Albert Wong
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Alex Raben: [00:00:08] Welcome back to PscyhEd, the Educational Psychiatry Podcast for Medical Learners by Medical Learners. I'm Alex Raben and I'll be your host today. This episode is the second of four in our series on schizophrenia treatment. If you haven't listened to episode nine, the first episode in this series, I would recommend you go back and listen to it because this episode builds on ideas that are in that episode. For this episode, we sat down with Dr. Albert Wong, a psychiatrist and research scientist who is an expert in schizophrenia. He is also heavily involved in our education at U of T and is known for challenging our views on psychiatric illnesses in a way that I believe gives us a deeper conceptual understanding. It is my hope that we have replicated some of that experience for you in this episode. This episode also uses a slightly different format than past episodes, in that I was joined by three medical students in their first, second and third year. The intention of this format was to provide the medical student perspective, but I think in that aim we failed somewhat. Partly because the conversation became pretty high level and partly because I just wasn't used to balancing such a large group. I really wish we could have had more of the medical student voice in this episode, and I apologise to my colleagues for that. But either way, I think there's some great information that you guys can benefit from in this episode and I hope you'll enjoy it. And please let us know what you think of this format so that we can continue to build and learn with you. So there is some overlap between this episode and the last one, but I think it takes a deeper dive in a number of the concepts.
Alex Raben: [00:01:47] So by the end of this episode you should be able to, number one, conceptualise antipsychotic drug categories in an unconventional and clinically relevant way. Number two, have an approach for choosing an antipsychotic medication for a patient and be able to consent that patient to treatment. And number three, understand the limitations of our understanding of schizophrenia and our current treatments and some of the problems that remain to be solved in this area of psychiatry. There is also one concept I'd like to clarify before we jump into the interview, and that is extrapyramidal symptoms or EPS. So these are side effects that can occur with antipsychotic medications and they're essentially disruptions in motor functioning due to the global dopamine blockade caused by antipsychotics. In other words, these are involuntary muscle movements that happen because of the medications. There are three main types that happen acutely or more acutely. These are dystonia, Parkinsonism and akathisia, and then one that occurs months to years after treatment has started called tardive dyskinesia tardive because it happens late. So I'll go through each of these in turn. Dystonia is a sustained involuntary muscle contraction. So the muscle essentially gets stuck and it can be quite painful. It can happen to any muscle group, but often involves torticollis of the neck. Second is Parkinsonism, and this is similar to in Parkinson's disease. So there's rigidity, limited arm, swing tremor, masked face. However, it's usually symmetrical because the drugs affect both sides of the brain, unlike in idiopathic Parkinson's disease. And then there's akathisia, which is a subjective restlessness that will often occur with also a physical restlessness, but not always such as pacing or not being able to sit still.
Alex Raben: [00:03:50] So for this one, you need to ask about the patient's subjective experience, because if they don't have that, it's not akathisia. And finally, there's tardive dyskinesia. This is the late occurring one, and it's a hyperkinetic movement, usually jerky, rhythmic or slow and sinuous. And this can also involve any part of the body, but often will involve the face and tongue muscles. We also need to briefly review the case of Muhammad because we use it again in this episode. So recall from last time that Muhammad is a 19 year old man who lives in his parents house and was brought to the emerged by them for acting bizarrely, he was admitted to the hospital and received a provisional diagnosis of first episode psychosis, likely related to schizophrenia. He was showing signs of psychosis both at home and in the hospital and had delusions that people were spying on him. And this had something to do with the electrical wiring in his home. At one point, he even tried to tamper with the wiring in his home, and he has no training on how to do that safely. Okay. So that's all the background you guys need. So without further ado, let's jump to the interview. I'm just going to introduce everyone who's in the room today. So as you know, I'm Alex Raybon. I'm a third year resident at the University of Toronto. And our expert guest today is Dr. Albert Wong, and I'll have him introduce himself to you.
Dr. Albert Wong: [00:05:35] I'm a psychiatrist at Camh, and I also have a lab. I do some neuroscience research.
Alex Raben: [00:05:39] Great. Thank you. I'm also joined by three medical students here at U of T, and I'll have them introduce themselves as well.
Sabrina Agnihotri: [00:05:47] I'm Sabrina Agnihotri, a CC3 at U of T.
Yunlin Xue: [00:05:50] I'm Yanlin Xu, and I'm a second-year medical student.
Theresa Park: [00:05:55] I'm Theresa, and I'm a first year medical student.
Alex Raben: [00:05:59] Great. Thank you all. So as before, we're going to sit down together as a treatment team and discuss antipsychotic medications for the treatment of schizophrenia, and especially as they apply to the case of Mohammed. So why don't we start with general principles of antipsychotic treatment for schizophrenia? Whoever would whoever would like to jump in.
Sabrina Agnihotri: [00:06:32] So there are so many medications that you could choose to start for a first episode of schizophrenia. Where do you even start?
Dr. Albert Wong: [00:06:42] Okay. I mean, I think a few things here. The first thought that I would have is that it doesn't really much matter in first episode which antipsychotic you pick because all of them will be likely to be effective. Any of them will be likely to be effective. So first episode, schizophrenia, for whatever reason, probably because it's at the beginning of the illness, it responds very quickly and very easily to most antipsychotic medications at fairly low doses. And I think but, you know, one of the reasons why you're having this educational session is because it's unclear if it was very obvious which medication to pick in this instance, then we wouldn't be having this conversation. So what is the controversy, do you think? I mean, you all have said the same thing. So what's the controversy then? Why are we having this session?
Yunlin Xue: [00:07:35] Um, potentially the side effects. Okay.
Dr. Albert Wong: [00:07:38] So that doesn't really affect the choice of antipsychotics. I mean, they all have side effects. So what do we. I'm just trying to clarify what it is that is the subject of debate, really. What is the controversy that's in this field that we really need to talk more about? I mean, in the end, we have to choose one medication. But in getting there, we might think a lot in the background about the issues at hand. So from my standpoint, I think there's it's confusing because there's a significant mismatch between treatment guidelines and the literature. You know, there are a number of studies, very well conducted studies comparing various typical and atypical antipsychotics, and they typically find no difference among these two categories. So why is it that we keep on saying that we should pick atypicals? That's one question. And so, you know, I think it's hard for people because the treatment guidelines say atypical. But then if you asked what is the advantage of an atypical antipsychotic, then I think it's difficult to say. And even more upstream question is what is it that distinguishes typical from atypical antipsychotics?
Alex Raben: [00:08:46] So I think there's even controversy about around that. But it would be the different receptor profiles. So a typical is more purely D2, whereas an atypical has the five H to a blockade as well.
Dr. Albert Wong: [00:09:04] So I think that's one criteria. A common one that's been advanced to categorise antipsychotics into typical versus atypical. And I would argue that that makes no sense. So the reason I would say that is because there are so every antipsychotic has only one therapeutic target, and that is the dopamine D2 receptor. And so far there has been no medication that's been discovered that has antipsychotic effects that we use clinically that does not bind significantly to the dopamine D2 receptor. So that's the first thing. If you then look at the dose of antipsychotic that's used clinically, that reflects only one physical property, which is the affinity for the dopamine D2 receptor, which is just another way of restating what the earlier statement was. So there is, of course, a dose response curve here. And in order to achieve the same response with a different drug, you need to occupy the same number of dopamine D2 receptors. So because of that, I think really there's no it doesn't make any sense to talk about typical versus atypical because there are some drugs which are considered typical because they're old drugs like chlorpromazine or clozapine, which are given in fairly high doses, you know, in the hundreds of milligrams. And these medications are given in that dose because they don't have a very high affinity for the dopamine D2 receptor, whereas other drugs, old drugs that are considered typical, such as Haloperidol or drugs that are considered atypical, such as risperidone, are given in very low doses somewhere, you know, under ten milligrams.
Dr. Albert Wong: [00:10:37] So at least an order of magnitude lower, in some cases two orders of magnitude lower than drugs that are given at high doses like quetiapine and chlorpromazine and clozapine. So in my mind, the the low potency drugs such as Quetiapine, chlorpromazine and Clozapine share much more in common with each other versus the drugs that are high affinity such as haloperidol and risperidone that are given in fairly low doses because they have very high dopamine D2 affinities. And the reason I'm making this point is because while some of these drugs may bind to other well, all of these drugs bind to other g-protein coupled receptors that are evolutionarily related to the dopamine. Dopamine receptor system. They do so in proportion to their affinity. So if a drug has got a low affinity for dopamine D2 receptors, in order to achieve therapeutic occupancy, you have to give a whole bunch extra, which will then end up binding to histamine receptors, adrenergic receptors, serotonin receptors and so on. And so the side effects from low potency drugs mostly come from these off pharmacological target effects. So for example, the sedation comes from histamine. Sexual side effects can come from the serotonin, cardiac effects come from alpha adrenergic. In contrast, the high potency drugs like Haloperidol and risperidone, because they bind so tightly to the dopamine D2 receptor, there may main side effects come from a pharmacologically on target, but anatomically off target effect.
Dr. Albert Wong: [00:12:08] In other words, they bind to dopamine receptors, the D2 receptors wherever they are, including parts of the brain and body where we have unintended effects for the purpose of antipsychotic use for the treatment of psychosis. So the obvious one is extrapyramidal symptoms that come from binding to the dopamine D2 receptors in the nigrostriatal tract. So you really can't get out of this. The drugs that are high D2 potency are going to have side effects that relate to D2 occupancy in areas other than what we intend for therapeutic effects. Whereas the drugs that bind to receptors other than the dopamine receptors are going to have their side effects from that and they will include sedation, weight gain, sexual dysfunction, etcetera. So in my mind, this distinction between typical and atypical, at least based on off target binding to the serotonin receptor, whichever subtype including the 2A1 really has nothing is not useful as a category because again, there are drugs that have almost no binding to this serotonin receptors that are considered typical or there are drugs like that that are considered atypical and vice versa, drugs that don't bind very strongly to D2 and bind to a whole bunch of other receptors, some of which are classified as typical and some of which are classified as atypical. So I don't see that there is any pharmacological basis for that notion.
Alex Raben: [00:13:26] Right. So you're saying that rather than distinguish antipsychotics based on first and second generation or atypical versus typical, you would rather categorise them as low potency and high potency because that is more useful in figuring out what their side effect profiles are going to be.
Dr. Albert Wong: [00:13:45] Exactly. So I think the first and second generation category is based on the time at which the drugs were first brought to market. So that's perfectly reasonable way of looking at drugs. There are old drugs and there are new drugs. And that is, you know, I'm not sure how clinically useful that is, but that's certainly something that people think about. It's certainly important to drug companies in terms of which drugs are making money or not. So there is that first generation, second generation idea, and that's not a problem. But I don't think that it matches with typical versus atypical. I think that's part of the problem that atypical drugs really are marketed as such, but they don't necessarily have anything pharmacologically different than drugs, which are so-called typical. So to me, it's a conflation of a number of ideas, which is quite confusing. And this is what is partly why we're trying to clarify this today.
Alex Raben: [00:14:34] Right? So I agree. It's it is a confusing subject. I wonder if we might turn to the medical students because I know that's a lot to kind of all take in at once. Are there any questions you guys have about what was just discussed?
Sabrina Agnihotri: [00:14:51] I think the way that they package antipsychotics to us as CC threes is exactly like that. The atypical versus typical and the side effect profiles and. One of the things that they stress to us is that Atypicals are superior because they don't cause movement disorders. And I've actually heard that that phrasing used. And so as a CC3 going through psychiatry, the rotation, like I was surprised to learn that it's not that they don't cause movement disorders, that the risk is lower. So I wonder like why it gets packaged to us like that.
Dr. Albert Wong: [00:15:29] Yeah. So I think there's a number of issues here. I think there is. So to to borrow from Donald Rumsfeld, there are known unknowns and there are unknown unknowns. What we. What we don't know for sure is what the long term risk of all of these drugs is in terms of causing tardive dyskinesia, the long term movement disorders. And part of that is because we don't prescribe antipsychotics the same way now as the as they used to be. So there used to be prescribed in much higher doses generally, not always, but generally. So we see a lot more patients today, older patients who have been on antipsychotic medications for decades who have tardive dyskinesia. We think, again, we don't know for sure because we can't do you know, we can't do a randomised clinical trial and prospectively assign someone to a very high dose versus low dose antipsychotic and see how they do in 30 or 40 years. That wouldn't be ethical and we wouldn't we're not interested in doing that. But it means that there's a gap in our knowledge. So it's hard to compare what the risk of long term treatment with antipsychotics is between the older and the newer drugs. So if we want to consider first injection second generation simply as a time category. Time on the market kind of thing, it's hard to compare. So the older drugs will look worse for sure because they were given in a higher equivalent D2 occupancy doses. So that's a fundamental problem with our data. However, what we can do is, look, there are many good clinical trials looking at active treatment of different antipsychotics in a patient population that are part of a clinical trial.
Dr. Albert Wong: [00:17:11] So that is a prospective, randomised controlled type of study. And in those cases we don't see differences in tolerability or efficacy. So that's, that's sort of the bottom line. You know, the reality is that unlike other areas of medicine, there have been really no new targets. Well, for for antipsychotic treatment. There has been no new targets since the original antipsychotic, which was chlorpromazine, that was developed in the 1950s. It binds to D2 receptors, and every antipsychotic that's come out since then also has dopamine D2 receptors as the target. Now, there's nothing necessarily wrong with that, except if you compare that to other areas of medicine. So if you imagine, say, in cardiology, so I'm not sure exactly which were the first category of Antihypertensives was it beta blockers or diuretics? But certainly now we have, you know, many, many different categories of cardiac drugs that work on different biological targets in the treatment of schizophrenia. We have still only one target. So I think it's really important to keep that in mind. We're not talking about the choice between an ACE inhibitor, calcium channel blocker, a diuretic, a beta blocker. Et cetera. In the treatment of hypertension, we're talking about the selection of an antihypertensive just within the category of, say, beta blockers. Which beta blocker should we try? So in other words, the, the the choice we have is very limited and we're looking at very, very fine distinctions between drugs that have the same pharmacological target.
Alex Raben: [00:18:43] Right. So what I'm hearing a lot of is that these are all equally effective with the exception of clozapine for treatment resistant schizophrenia, which we'll get to in another segment.
Dr. Albert Wong: [00:18:57] But I agree. I mean, just, you know, just as a quick point, you know, I only I think the only atypical antipsychotic is clozapine. Right? So if we want to talk about differences in efficacy, that's the only one, right?
Alex Raben: [00:19:10] So then we are forced to make decisions based on side effect profiles, which, as we were talking about, is more a low potency, high potency question. I know that the CPA guidelines at least used to recommend starting with a second generation for the reason of avoiding the EPS, the Extrapyramidal side effects, because people who are first episode are at a higher risk or people who are naive to antipsychotics are at a higher risk of developing EPS symptoms. So would you like is it better to pick a low potency antipsychotic first based on that principle?
Dr. Albert Wong: [00:19:51] I would say that it's best to choose a drug based on an individual patient's symptoms and their complaints. Right. As we said earlier, if you give risperidone at higher doses, people will get EPS versus an atypical such as with a typically classified as an atypical like QUETIAPINE, for example, it's a fairly new drug compared to Haloperidol. And Quetiapine never causes EPS because it causes sedation before it causes EPS, which is the same for the drugs, other drugs that are high given in high doses. So I would say you should choose a drug based on the patient's symptom profile. So if the patient, for example, is complaining of insomnia, then you would choose a low potency antipsychotic. It will because it will most of them bind quite a bit to histamine H1 receptors and like Gravol, like Benadryl, they make people really drowsy. And that's. A bad thing if you don't want to be drowsy, but if you're having trouble sleeping, that's great. Also, if that person happens to in addition to their psychotic symptoms, has a lot of anxiety, primary anxiety or secondary to psychotic symptoms doesn't really matter.
Dr. Albert Wong: [00:20:54] All of these treatments are symptomatic. So I think it's important to keep that in mind. We don't know what causes schizophrenia or any other kind of psychosis except in some very rare examples when people have some structural disorders, structural brain disorders. But because we don't know that, we're just treating the symptoms. And so if there's a side effect which happens to also mesh with a patient's complaint that actually improves one of their complaints, then you would choose that. And conversely, of course, if somebody, for example, already has a problem with being overweight, you would try to avoid a drug that increases their weight further, for example. So, you know, you can't. But because each drug just comes the way it does and it has its pattern of side effects, we may not be able to find the best drug for everybody. And we still pick the best drug for everybody. But it may not be optimal for some people. They might just have a combination of symptoms which fits perfectly with a particular one particular antipsychotic, and that's great. But that may not be the case for everyone.
Alex Raben: [00:21:54] Great. Sabrina, you look like you have a question.
Sabrina Agnihotri: [00:21:57] Does the fact that some of them have injectable forms come into play at all with your decision?
Dr. Albert Wong: [00:22:02] Absolutely.I think, you know, the discussion here, you know, we started with some sort of more basic pharmacological ideas. But really clinically, I think the the considerations are just pragmatic, very practical. And so that's a good that's one, you know, area that has a practical aspect to it. So if somebody has a problem with compliance or some people like having depots instead of taking pills every day, you know, it's just like with birth control, you know, some women don't like to take a pill every day. They want to have an injection. You know, it depends on the patient. So it could come from the patient. You know, they prefer a pill versus an injection. They prefer, you know, once a month or once every two weeks. That's it. Or it could come from, you know, the family who are concerned about compliance and convince the patient or perhaps from the treatment team as well.
Alex Raben: [00:22:51] One question that comes to my mind, especially for our audience members who are trying to remember all the side effects of these drugs for later consenting patients. To them, how do we keep how do we remember those in a way that makes sense?
Dr. Albert Wong: [00:23:11] Yeah, I wish I could draw something because when we have this discussion in a clinical situation, I usually draw a picture. So if you imagine a spectrum from left to right and on the left side, we can just doesn't matter. Arbitrarily. We can say the left side are high potency drugs that are given at low doses and on the right side are drugs that are low potency, that are given at high doses. So the ones on the right side are the ones are going to have sedation, sexual side effects, weight gain, cardiac effects from all of the non dopamine g-protein coupled receptors that the drug will bind to. Conversely, the drugs on the left side, like Haloperidol and risperidone, are mostly going to cause the dopamine related side effects. So prolactin elevation from the tuberoinfundibular system and extrapyramidal symptoms acutely from nigrostriatal tract and tardive dyskinesia in the long run from also from the nigrostriatal tract. So I would just sort of put drugs into three categories low, medium and high dose or in other words, high, medium and low potency. So basically the drugs that are given in the hundreds of milligrams, those are the ones that are low potency and those are the ones that are going to cause sedation and cardiac effects and so on. And those are the ones in the middle that are given somewhere between 10 and 100mg. So things like olanzapine, for example, loxapine, they fall in that category. And then there's the drugs that are high potency that are given at less than ten milligrams. So just sort of really three orders of magnitude and the ones the tens and the hundreds of milligrams. And so I would just I think that's enough of a of a guide for a clinical scenario because there's enough interindividual variability and people have idiosyncratic responses. You can't predict those things. They have changes, differences in metabolism, differences in illness and so on. So I think that level of general categorisation is enough, basically low, medium and high, and from that you can get a good idea of what the side effects are that the patient is likely to experience.
Alex Raben: [00:25:07] Great. Thank you. I'm wondering, maybe we could touch a little like drill down a bit more into the high potency side effects so the D two related side effects, because they are, as you put it, are anatomically more anatomically related. Could we go into that a little bit how how those relate to the anatomy? Because I find that helpful.
Dr. Albert Wong: [00:25:34] So, you know, we don't know how antipsychotics work, so we don't know for sure where the therapeutic effect is, but we think. That it's got to do with. But we know we can infer that it's from the dopamine D2 receptors. So there are four main dopamine tracks in the mammalian brain. There's there are two tracks that originate in the ventral tegmental area, which is just ventral to the substantia nigra and that's in the midbrain. So that's why it's called. So these two tracks are called the Mesocortical and the Mesolimbic dopamine tracks. So they project from the ventral tegmental area in the midbrain. They project forward into parts of the cortex and the limbic system. The second tract is the tuberoinfundibular, which is the one that goes from the hypothalamus pituitary and regulates prolactin secretion in an inverse way. So more dopamine, less prolactin. And then there's the Nigrostriatal tract, which is the track that degenerates in Parkinson's disease. It originates meaning that the neurones in this track live in the substantia nigra and they send their axons into the striatum. So that would mean that the caudate, the Globus, the Globus, Pallidus and the Putamen.
Dr. Albert Wong: [00:26:46] So, you know, so that's the list. So if you go back, you know, the mesocortical dopamine tract is one that we think is involved in higher thinking, obviously because it involves the cortex, the mesolimbic tract, it's mainly a projection to the nucleus accumbens, which is the track that we think is involved in reward. And this is the tract in which, for example, cocaine and amphetamine act on to prevent the uptake re-uptake and sometimes promote the release of dopamine. And so that's why drugs like cocaine and methamphetamine are so addictive because they derail the brain's mechanism for determining what is rewarding and what is not. And that helps to guide behaviour with normal physiological inputs. But if you take a drug that just specifically activates the reward pathway, then of course this drug will be highly addictive and of course it'll distort behaviour. And then the tuberoinfundibular tract, of course prolactin is involved in lactation and if you block dopamine D2 receptors with antipsychotic, then you will increase prolactin.
Alex Raben: [00:27:47] Because you're cutting that dopamine break.
Dr. Albert Wong: [00:27:48] You're blocking the right and you're blocking the receiver for that break. And then the nigrostriatal tract, you know, the, the Corticospinal voluntary movements tract, you know, the pyramidal tract, so-called, it originates in the cortex, of course, and the motor cortex, and it goes through the internal capsule which flows through the globus pallidus the bottom and the caudate through the striatum before descending into the spinal cord to control voluntary movement through skeletal muscle. The fluency of normal voluntary movement comes from essentially motor subroutines that are stored in the striatum. So when you learn a new activity like playing a sport, at first it's very stilted and awkward because one is thinking consciously using the cortex about every small movement. But when somebody gets good at a sport, then of course they don't think about these things. They think about more advanced things like the strategy, you know, what kind of move they're going to use to fool their opponent. They're not thinking about the individual movements that you do when you start off. And that's because those automatic motor programs are now stored in the striatum. So that's why when people get Parkinson's disease, when their nigrostriatal tract degenerates, they become so awkward. They have difficulty initiating movement because that those those motor subroutines are lost. And that's why they seem so that's why their movements are so impaired. So. So you wanted to drill down into each system, Is thatwhat you're thinking?
Alex Raben: [00:29:08] Yeah. No, that's great.
Dr. Albert Wong: [00:29:09] Um, maybe just one point. As I was just thinking about it, you know, part of the reason why antipsychotics are so unpopular among patients, why it's so difficult to get people to take them and why compliance is so bad is because they're blocking the mesolimbic cortical, the mesolimbic dopamine tract. So many of the drugs that we prescribe in psychiatry have some street value, especially the benzodiazepines. Even sometimes the anticholinergic drugs. People abuse these drugs. They find them, they like to take them on their own and you can buy them on the street. There's a price for them. You can't sell antipsychotics on the street. That tells you something about them. These drugs are profoundly unpleasant to take because they block the very system that's rewarding. So not only do they themselves are not rewarding, but they make everything else in life not so rewarding as well. So it's kind of like an anti-cocaine. It's like not fun to take.
Alex Raben: [00:30:03] Right. So that's part of the side effect profile as well.
Dr. Albert Wong: [00:30:04] Right. And it's unavoidable that, you know, we have found a system in the brain which is very effective for modulating psychosis, but it's also the same neurotransmitter that's used for signalling reward expectancy. And so when you block the system, it has this very unpleasant side effect, which is there's no way to get around it.
Alex Raben: [00:30:26] Because that's where we think the target is.
Dr. Albert Wong: [00:30:29] For because the dopamine D2 receptor is found in these different anatomical tracts and it has different roles in each tract. The brain doesn't have this problem because when you release dopamine in the reward pathway, it doesn't it can't get to the other parts of the brain. I too, can't find its way to the pituitary. It doesn't get to the cortex. It doesn't go to the striatum. So the body is fine because it can segregate these neurotransmitter signals in different pathways. And this is a common problem in pharmacological and pharmacology in the treatment of illness. You know, we can, even if we have a very good target for treating that illness, if that target is found in other parts of the body or brain, then you're going to have side effects because you can't Right now, we don't have the technology to get that drug only to one brain area and not the others.
Alex Raben: [00:31:16] To summarise again, low potency, you're going to have those off target side effects.
Dr. Albert Wong: [00:31:23] Yeah so I think the main off target side effects would be from the other g-protein coupled receptors. So there's the muscarinic acetylcholine receptor. So that's where people get dry mouth, blurry vision, they can get constipation, that kind of thing. Histamine H1 receptors are the main origin of sedation. The serotonin receptors, the, you know, that are the off target targets of the antipsychotics cause, you know, a bunch of changes in neurovegetative functioning, including sexual dysfunction, perhaps also dysregulate appetite. And then the adrenergic receptors are where the cardiac side effects mostly come from. So, I mean, this is a broad generalisation, but I think for the purpose of this and you know, at this level of training and trying to understand where the clinical, you know, to organise things clinically and to think of where side effects come from, that's where they're coming from.
Alex Raben: [00:32:11] And how do we mitigate some of those side effects?
Dr. Albert Wong: [00:32:16] Well, there's really no way to directly mitigate them.
Alex Raben: [00:32:22] Like, um, I guess what I was thinking is, um, like we do a lot of investigations for, for the low potency. Like we will monitor weight gain and metabolic parameters. And then for EPS we'll do scales and that kind of thing.
Dr. Albert Wong: [00:32:41] Yeah, I mean, I think but in the end we have no real way of treating these. I mean, the only side effect that we have a good treatment for, I would say maybe there's two with akathisia. We can give benzodiazepines, but that's not a great long term solution. And with extrapyramidal symptoms, we can give an anticholinergic drug. Benztropine benztropine procyclidine sufentanil. So, you know, just as a connect this back to what we're talking about earlier with the high potency drugs because they're purely D2 drugs, you get the EPS, you get the Parkinsonism. The reason that low potency drugs don't give you Parkinsonism even at the same level of D2 occupancy is because they also bind to the muscarinic acetylcholine receptor. So they have like a built in side effect pill that you're taking with it. It's like a, you know, like a combo. It's not. But you know, and you can think of it that way. So but, but your point about, you know, how can we mitigate these side effects? I don't think you can. You can choose a drug that has less of the side effect. That's a problem. But in the end, we really have no treatments for any of these side effects. I mean, you know, you can think of symptomatic things. I guess you could, you know, for erectile dysfunction. There's Viagra, which, you know, I'm sure you get all kinds of spam every day. So if you want to buy some cheap Viagra, you know where to get it. But, you know, in terms of things like EPS, you know, you can give anticholinergics. So that's that's probably the only one we can really treat. But things like sedation, I mean, we have no treatment for that. Definitely wouldn't use some kind of stimulating or activating medication in the context of psychosis.
Dr. Albert Wong: [00:34:07] So that's out. And then the weight gain, I mean, the majority of the population doesn't exercise already and has, you know, problems. You know, in North America obviously has a very high proportion of people who are overweight and obese. So it's already a problem in general in society for which there is no good solution. So in somebody who's got schizophrenia, who may be having metabolic side effects from the antipsychotics, you have obviously added a whole other layer of problems. Somebody who has negative symptoms and has problems with motivation and may have difficulty organising their behaviour in the first place. Plus they may have psychotic symptoms. And then now you also want to try and get them to exercise and watch their diet. Plus they're usually in a lower socioeconomic strata. You know, that's a really big challenge. So that's why it is a serious problem. But, you know, we have really not a lot we can do about it. I think, you know, the, you know, one, you know, to step back for a minute, what we really need are is a is a better understanding of the illness and better drugs, like a different category of drugs. Like we're still stuck with beta blockers for treating hypertension kind of thing. We need to go beyond the beta blocker. We need to go beyond the D2 receptor. We need new treatments for schizophrenia. And then we would have options because if you hit a completely different receptor system, then you're going to get completely different side effects. Maybe, maybe not be completely different, but they will be definitely from a different cause. And then you have something that you can you can do, you have something to play with. But right now, we've basically we don't have much.
Alex Raben: [00:35:32] Sabrina, do you have a question?
Sabrina Agnihotri: [00:35:34] Well, it sounds like a lot of these drugs are targeting the positive symptoms in schizophrenia. What about the negative symptoms? What is like are there pharmacological treatments for the negative symptoms of schizophrenia?
Dr. Albert Wong: [00:35:46] Not really. I mean, I think sometimes I mean, there are studies that show that there are some effect on negative symptoms. But I would say that overall, it's either very weak or nonexistent. The bottom line is that we don't do very well at changing the course of illness and schizophrenia. We're very actually not too bad at treating psychotic symptoms. Of course, here, you know, there are many patients who are refractory and who, you know, are noncompliant. But for the majority of patients, most of the time, antipsychotics do have an effect on reducing their symptoms. But what we aren't able to do is change the overall outcome of the illness, and that mostly has to do with their cognitive and cognitive symptoms and negative symptoms for which we really don't have any good treatments. And just to point out that we don't have a good way of treating cognitive symptoms in any disorder, in any context, really, whether it's schizophrenia or not. So, you know, think broadly back to the original conception of schizophrenia by Kraepelin as dementia praecox. You know, that highlights the fact that even 100 years ago it was noted that the primary feature of this disorder that gave its name was actually the dementia. It's just that it was a kind of dementia that came on earlier in life than senile dementia, which was obviously the other main kind of dementia. So it's been well known in some ways it's been kind of I wouldn't say it's forgotten, but it's been overlooked. It's been de-emphasised in this quest to come up with a really effective treatment for the psychotic symptoms. I'm not saying that psychotic symptoms are a great thing to have. It's just that. It's only a it's only part of the picture. And in fact, the psychotic symptoms are not the main determinant of outcome.
Yunlin Xue: [00:37:29] So can you go through the pathophysiology of negative symptoms and why it's hard to treat them compared to the positive ones.
Dr. Albert Wong: [00:37:38] You know, I don't think we know. Well, first of all, we don't know what causes anything in in any major psychiatric disorder. Right. So we don't know what causes psychotic symptoms, nor do we know what causes negative symptoms. I think this is a great this is a major challenge for our field. It's very difficult to develop rational treatments without knowing the cause. All of the you know, there are many cases in medicine where treatments are discovered by accident. And then from that, something more is learned about the illness for which that treatment is usually given. So, I mean, we do we have learned a lot about psychosis in the sense that we now know how important dopamine is. Dopamine is clearly a modulator of psychotic symptoms. And we know that people can get psychotic sometimes when you overstimulate the dopamine system, when there's too much signalling to the dopamine system, say with crystal meth, methamphetamine, that's sort of a common clinical presentation. And conversely, of course, if you block the dopamine D2 receptors, you can reduce or get rid of psychotic symptoms in regardless of the original cause. But that's not really that's just a proximal cause. We don't know what the upstream distal cause is. And schizophrenia is likely not to be an illness per se, but it's a collection of different things that end up with the same presenting symptom.
Dr. Albert Wong: [00:38:54] It's a very crude way of categorising things in medicine, you know, in terms of just looking at symptoms. So in psychiatry, we do not yet know what the cause of different types of psychosis is. Mostly, you know, occasionally again, if somebody has a stroke with a sudden onset of psychosis or they have a space occupying lesion or, you know, something like that, then we can presume that the psychosis originated from that etiology. But it still doesn't really tell us what the pathophysiology is because brain lesions in many different brain areas can cause psychosis. So there is no sort of psychosis area. It's not it's a non-localising, non-localisable abnormality. And that's partly what puts it in the realm of psychiatry. Some people would argue that that's what distinguishes neurology from psychiatry and neurology. They have focal localising symptoms and therefore there is a lesion somewhere. Even if there's more than one lesion, say, in multiple sclerosis or, you know, some kind of autoimmune other autoimmune disorders. But still there are lesions that can be identified in psychiatry. We don't have that. Two people can have what seems like a similar presentation and they may have, you know, lesions in different parts of the brain or no lesions that are discernible at all. So the answer is we don't know. I don't know and we don't know.
Alex Raben: [00:40:05] I'm thinking about Muhammad, our patient. If he were here in the room or his family, you know, given the conversation so far, he may not be too thrilled about being on a medication like this. What are the ways we can how do we frame this to patients to help them with that?
Dr. Albert Wong: [00:40:24] I don't know if I would try to frame it for them. I would be straightforward with the patients. It's not a good option. We don't have good options. We need better treatments for schizophrenia. I would be frank about that. I am frank about that with my patients.
Alex Raben: [00:40:35] And yet it's necessary. Is that fair to say?
Dr. Albert Wong: [00:40:42] Well, I don't know, you know. There are patients who I mean, I think, you know, we see psychosis as being something which is abnormal. And I think that it is a reflection of some brain dysfunction. But, you know, we have trouble framing the situation and selling this treatment to patients because we know we're not selling them a great deal. If this drug was going to make their life better and and have, you know, not that many side effects, then we wouldn't have this discussion. It would be simple. But the fact is that it's not a great option. We don't have a great treatment. Again, if you have if you have transient psychosis for some reason, then it's different because the drug these drugs are good for treating psychotic symptoms. So if you show up in the emerge and you've been smoking a whole bunch of crystal methamphetamine and you're super psychotic, and for the day or two that it takes that to clear, you get some antipsychotic and then you're much calmer and, you know, then that's, I think, a great outcome. But if you have schizophrenia, if you have this chronic psychotic disorder, you know, it's not again, the antipsychotics do not improve the outcome overall. At least not very much. So I think it's a difficult sell. Now, there are cases where there are patients who are otherwise fairly high-functioning. If their psychosis is controlled, they can do well. And I have some of those patients who I first saw in first episode, and I've been following them for many years now, and they're doing quite well. They're the exception. So there are cases like that. So it's not hopeless. But these patients also have very good insight about their symptoms and they're able to comply. And all these other factors are there as well. But in terms of like when you have somebody who is in a first episode like this, this case we're talking about, I think you have to be honest. And for them to be prepared for the likelihood the outcome is going to not be so good. You should be truthful about it.
Alex Raben: [00:42:41] Sure. Yeah. What would you say if Mohammad said he only wanted psychosocial interventions and he was not interested in trying medication? I'm just thinking about the guidelines. Like I think NICE says that you should recommend you should strongly recommend medication or something along those lines because therapy alone is not as effective.
Dr. Albert Wong: [00:43:14] I don't think therapy is going to do anything for the psychotic symptoms as bad as they are. I think that's a treatment we've got. But I very I understand why patients don't want to take them at the outset and also why they don't comply with them after they've even started on them. You know, it makes sense to me why they're doing this. You know, there are some drugs which people really want to take which we never have to convince people to take. And actually, we have to try and convince people not to take like opiates, like benzodiazepines. There's a number of drugs in medicine like this. And then there are drugs which people really don't want to take that we have to convince them that they should take. And then there are drugs that people don't want to take, but they take because they know that they have to in drugs that have unpleasant side effects like chemotherapy and cancer. This kind of thing. So, you know, we have the unenviable position of trying to push treatments which are fraught with bad side effects and which have a really limited spectrum of efficacy. They treat part of the illness, but not actually probably the most disabling part of it. So it's difficult. So again, I don't try to sell them. I'm honest about it and make people let people make their own choices.
Dr. Albert Wong: [00:44:22] You know, there's also this idea of which, you know, I think the evidence is still kind of indeterminate about whether chronic antipsychotic treatment is really the way to go. You know, people could say that, for example, if there are other examples in medicine where there are illnesses that have relapsing-remitting course, in which case we treat just the relapses and when the symptoms remit, we also stop the treatment. So for example, autoimmune disorders are a good example where we might use intermittent steroid treatments. So knowing that our treatments are symptomatic, you know, this is a bit of a heresy. But, you know, because all the treatment guidelines say you must use antipsychotics and you must keep keep patients on these antipsychotics. And it's true that sometimes when patients get psychotic, then they lose the insight about their symptoms and then don't comply with antipsychotics. So certainly you would lose you know, you would you wouldn't be able to treat those patients. You would lose those patients. But there are you know, the question in my mind is for an episodic illness, you know, so some people have chronic psychosis. It doesn't really seem to go away. But other people seem to have episodes of psychosis that come and go. Why? We're using a treatment that's there all the time for symptoms that are not there all the time. I'm not sure that there's a good rationale for that, but that's not the orthodoxy.
Dr. Albert Wong: [00:45:43] And we say, you know, we should always keep patients on their on their medications, but I'm not sure that that's the way we should be doing it. So in some ways, you know, we could reduce a lot of the concerns about antipsychotics if we weren't giving them all the time. You know, the issues about metabolic side effects, for example, are not such an issue if the patient is not on it for their entire life, if they're only on it sometimes, obviously that makes it a lot better. Same thing with the tardive dyskinesia, you know, so there is the clinical problem of getting somebody who has become psychotic to restart their antipsychotics. But, you know, we don't really try and address that problem. We don't try and come up with ways to have people on and off antipsychotics just when they're symptomatic. We just try and get them treated with it all the time. So that's why, you know you know, I know you're just phrasing the question in the vernacular way, but that's why we have this feeling that we're trying to sell these drugs to people because they're you know, they do have all these problems. And especially the way that we give it, I think is it just it's not a it's not a good for the side effects.
Alex Raben: [00:46:41] That kind of leads into my next question a little bit. Time of treatment. I know there's an orthodoxy and then there's, you know, potentially some wiggle room there for the field to try some other approaches. Is there for a first episode, Is there a recommended amount of time someone should be on this to avoid a relapse? Is there what is the orthodoxy and what is maybe the wiggle room?
Dr. Albert Wong: [00:47:08] Yeah, I mean, the people say, you know, something like a year, but you know, why is it a year? Why is it not 11 months and why is it not ten months? Why is it not 13 months? You know, there's no real rationale for it being a year. Yeah, I would say it depends on the patient. You know, many patients will want to stop their medications after their first episode. Even if they're successfully treated, they will think, and I think reasonably so, that maybe it's just happened once and it will go away. And it does sometimes happen that it's just a single episode. So I think it's reasonable. But at the same time, you know, sort of the flip side of this is that I don't think that being psychotic is good for the brain. And I think that the longer that somebody is psychotic, the harder the more entrenched those symptoms become and the harder they become to treat. And I don't know if that's partly an illness factor. Again, I don't think schizophrenia is an illness. It's a heterogeneous collection of all kinds of different pathologies.
Dr. Albert Wong: [00:48:04] But in some cases, there may be some kind of disease progression that occurs. Or maybe it's not that. Maybe it's simply a question of memory, that, you know, the longer somebody does something, whether it's playing basketball or the violin, the more entrenched that that activity, that experience is going to be. So the longer somebody spends being psychotic, I think the harder it is for those, especially the delusions, the harder it is for those delusional beliefs to be kind of squared properly with reality. So I don't think it's good for someone to spend a lot of time psychotic for that reason. So, you know, this goes against what I'm saying earlier, but, you know, the point is that there's obviously two sides to this and it's very difficult to decide for each given patient without having any kinds of real predictors of outcome. We don't have any biomarkers, any ways of really predicting how things are going to go, how long someone's episode is going to last, how long they should be on treatment, all these types of things we just don't know.
Alex Raben: [00:49:03] So yeah, another thing that's on the top of my mind, having just come off of inpatient psychiatry is that, as you were pointing out, this illness or collection of illnesses can often come with a lack of insight and can present safety issues to the patient as well as those around them. So I think that's that's almost like a third factor for why treatment may be important. I'm wondering your thoughts on that.
Dr. Albert Wong: [00:49:36] So patients who are you know, so for example, you know, you mentioned sort of safety risks. I mean, the majority of people with schizophrenia are not violent. And I think that the main determinants of violence in schizophrenia are the same as they are in people who don't have schizophrenia. And those are for the demographic factors are the obvious ones age, sex, substance abuse. So it's the young drunk man who you worry about punching you. You don't worry about the elderly, sober woman, whether either of them have schizophrenia or not. So, you know, yes, schizophrenia in some cases, especially when delusions involve a specific person and so on, there is an increased risk for violence. But I think it has more to do with the person and how they react to things as opposed to the delusions. Somebody can have the same delusion. They just don't think that violence is a good way of dealing with it. Some people, you know, one patient could think of it that way.
Alex Raben: [00:50:29] Right. And bringing it back to our case here, Mohammed has delusions around the electrical wiring in his house. Some patients may not even react to that necessarily, whereas he's going around and digging in the walls and grabbing these wires.
Dr. Albert Wong: [00:50:44] And that's exactly that's that's a perfect way of tying it to this case. And a perfect example that it's an interaction between the patient's symptoms and their personality and their environment. Yeah. So, you know, if Mohammed did not have schizophrenia and he was, you know, it was, you know, kind of handy, it might be good, you know, that he would actually fix some of the wiring problems in his house. But if his psychosis happens to involve something to do with the wiring and he's not trained and in the midst of psychosis in a disorganised state, he decides to rewire the house. And obviously that's super dangerous.
Alex Raben: [00:51:20] Right. So many, many factors to think about here in terms of outcome, um, not just of positive symptoms, but overall quality of life safety, patient preference, lots of different factors.
Dr. Albert Wong: [00:51:35] So, you know, you're asking earlier about the, you know, the sort of mandate for treatment. And so, you know, I think you've sort of summarised it well that it depends on the situation. You know, if a patient's delusions involve something that leads to a dangerous behaviour, whether it's electrocuting himself while rewiring the house or something to do with, you know, something violent about targeting somebody else, then these patients, obviously it's a much higher priority to get them treated, whereas somebody who's maybe psychotic and may have no insight, but if they are a gentle, pleasant, calm person, they could be very, very psychotic. You know, I have obviously, we all have patients like this, too, who are kind of quietly psychotic. And although we may try to convince them to take antipsychotics because it relieves their distress, because it takes away the, you know, the bothering symptoms, it's less of a priority, obviously, than somebody who's going to do something that's physically dangerous. And unfortunately, sometimes, you know, patients end up in the forensic mental health system because of the fact that they're doing something that's dangerous to somebody else. Right.
Alex Raben: [00:52:39] Great. Yeah. I think that nicely highlights the nuances to when to start this treatment in the first place. I want to turn back over to the medical students and see if you guys have questions or things you want clarified because we've spoken about a lot here.
Sabrina Agnihotri: [00:52:56] Well, I'm actually curious from this discussion, it sounds like our current treatment options, there's a lot of room to grow. And you mentioned that, you know, we're targeting dopamine and why aren't we sort of targeting other areas of the brain, other receptors? Do you have any ideas of like the future of antipsychotic research and use and where we could be going?
Dr. Albert Wong: [00:53:19] Yeah. So I mean, I'll start off by some shameless self-promotion. You know, I've done some work with Fang Lu, who's my lab neighbour and colleague, and she's a protein biochemist and recently published a paper showing that in a protein-protein interaction between the dopamine D2 receptor and another protein called disc one, that this complex between these two proteins, it's elevated in schizophrenia and that in animal models, if we disrupt this protein complex, it has antipsychotic like effects. Other people have explored, for example, the cannabidiol as one of the cannabinoids. That is not the one that people want to use when they want to get high, but it actually has some anti-anxiety antipsychotic properties. There have been some clinical trials with the Mglur2 three receptor, which didn't work out, but that seemed like a promising avenue, and it may be that there's something there as well. We know that drugs that block the NMDA receptor, which is a kind of glutamate receptor, can cause psychosis. Drugs like PCP and experimental drugs like MK 81 are used as models of psychosis in animals, actually. So there may be something. So we know in other words, there are other receptor systems that also modulate psychotic symptoms and also the GABA system. It seems that, you know, this is partly work that's done by that's been done by Karl Deisseroth, the one of the inventors of optogenetics, showing that it is the GABA receptors in Interneurons that set up the gamma synchrony across the cortex that you see in the EEG that's disrupted in schizophrenia.
Dr. Albert Wong: [00:54:47] And this may have something to do with the binding of different aspects of experience. And when this doesn't happen properly, then people can start to have psychotic symptoms. And we know that, you know, there's good evidence that benzodiazepines also have some antipsychotic effects, especially when they're combined with dopamine D2 and, you know, the conventional antipsychotics. So I think there are other transmitter systems. So I think that's one promising avenue that could have you know, that could produce some drugs within the next decade or so. I think that that's likely. I hope so anyway. But I think even that's not that would be only a sort of modest goal, I think a bigger ambition. And the ultimate goal would be to figure out what the causes of some of these types of psychosis are and intervene to prevent them. I think especially with brain disorders, ones that are developmental, but even degenerative brain disorders, once you know, the brain does not repair itself very well, it's not like a bone or the liver. So once we start to have problems with the brain trying to ameliorate those symptoms after the fact, I think is always going to be limited in its success. I think the best way of doing this would be to figure out what the cause is and then stop it in its tracks before the symptoms actually start. That would be the ultimate goal.
Alex Raben: [00:55:59] Great. We're almost at time where we are. At time. I'm wondering if maybe Teresa could ask a question before we wrap up, if you had one.
Theresa Park: [00:56:09] So you mentioned quetiapine has sedative effects and I've seen Quetiapine used in like young adolescents for sleep issues. So could you talk about the off label uses of antipsychotics?
Dr. Albert Wong: [00:56:22] Yeah, I think that's a that's a terrible idea. That's a simple answer. Don't do it. Yeah. You know, there are many causes of insomnia, none of which are worth the risk of tardive dyskinesia. It's the I think it's a it's a class-action lawsuit waiting to happen. So just don't do it.
Theresa Park: [00:56:43] Use antipsychotics only for psychotic symptoms. Nothing else.
Dr. Albert Wong: [00:56:47] Very simple. Psychiatry is like, you know that joke? Psychiatry is like dermatology. There's a thousand rashes, but only three creams. So that's the way it works. If you're psychotic, you get an antipsychotic. If you're depressed, you get an antidepressant.
Theresa Park: [00:56:59] So what about like antipsychotic use in general in the adolescent child population?
Dr. Albert Wong: [00:57:08] Yeah, again, I think if somebody, you know, if there's an adolescent who very clearly has psychotic symptoms, then antipsychotics are a reasonable choice. They're the only choice. So yeah, again, antipsychotics should be used when somebody is psychotic and never when they're not. Okay. And that includes in other areas of medicine. You know, when somebody is delirious in the ICU. Yes, you should give them I.V. Haloperidol. There's no question. Don't don't hesitate in doing it. The chance of them getting tardive dyskinesia is not, you know, not a consideration at that point because the acute delirium is so much more problematic for the brain and for the rest of them, the rest of the body. But, you know, the converse is that if somebody is not psychotic, do not use an antipsychotic. There are many medications you can use for sleep, many of which are quite benign. Quetiapine is the worst choice, especially because the sleep promoting effect of the quetiapine is not coming from the D2 receptor blockade. So that's even worse because you're giving them the risk of TD without even requiring that the target that's going to produce the TD, you know, potentially in the future is not even necessary for the therapeutic effect you're going for here. If you're going for the treatment of insomnia and you're going to use Qeutiapine, you're basically targeting the histamine receptor. So you might as well just give somebody Gravol, which is perfectly which people use for sleep. It's perfectly fine and they won't wake up nauseous either.
Alex Raben: [00:58:34] Right. But I think we I think we've all I think that's a great question because I think we've all seen off label uses of antipsychotics. And just to that point, choosing wisely for psychiatry came out with a list of guidelines. And that was one of them was a recommendation not to use antipsychotics for sleep until everything else has been tried. Um, so I think we will wrap up, but I think that was a terrific conversation around the use of antipsychotic when to use it, when definitely not to use it, what the side effects are, what the benefits are, and how that maps onto different people in different situations. So thank you very much, Dr. Wong, for joining us and thanks everyone who's come today.
Theresa Park: [00:59:19] Thank you.
Alex Raben: [00:59:21] Thank you. And we'll sign off until next time. Thank you.
Alex Raben: [00:59:34] PscyhEd 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. This episode was produced and hosted by Alex Rabin, Yunlin Xue, Sabrina Agnihotri and Theresa Park. Henry Barron and Lucy Chen were also involved in producing this episode. Audio editing was by Alex Raben. Our theme song is Working Solutions by Olive Music. And we'd like to give a special thanks to the incredible Dr. Albert Wong, who served as our expert for this episode. Of course, we'd also love to hear from you and you can contact us at any time at info@pscyhedpodcast.com or on Twitter and Facebook at PsychEd Podcast. As always, thank you for listening!
Episode 18: Assessing Suicide Risk with Dr. Juveria Zaheer
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Alex Raben: [00:00:00] Hello, listeners, this is Alex here. Welcome back to PsychEd for the month of July. Instead of one episode, you'll be getting five. That's because we're going to be doing a special mini series in which we cover clinical skills in psychiatry. So in the past, we've tended to cover specific disorders or illnesses, but these five episodes will focus on approaches and competencies that will help you in your training in psychiatry. We hope that you will enjoy!
Lucy Chen: [00:00:39] Hey there podcast listeners this is PsychEd the podcast for medical learners by medical learners. I'm Lucy Chen and I'm joined by Alex Raben. And today we are officially PGY-5's. Yeah, yeah, we made it through, guys. So today we're going to focus on the clinical skill of suicide risk assessment and we're lucky enough to be joined by DR. Juveria Zaheer again for this topic as she has a great deal of research expertise and clinical expertise in this area. So in terms of the objectives for this episode, we're going to familiarise ourselves with the risk factors and predictors of suicide, as well as protective factors. We're going to learn about the components of a suicide risk assessment, and we're going to learn how to comprehensively document and communicate the risk assessment as well. So without further ado, we'll let Dr. Juveria Zaheer introduce herself and talk a little bit more about her research experience, and then we'll delve right into the episode. We've brought back Dr. Juveria Zaheer. So we already got a little bit of an introduction on her. But Dr. Zaheer, maybe you can refer maybe you can explain a little bit more about your research on this topic.
Dr. Juveria Zaheer: [00:02:12] Absolutely. So suicide risk assessment prevention is a real passion for me. When I was a resident at the University Toronto, I'd completed my master's in the Arthur Sommer Rotenberg Suicide Studies Unit at St Michael's Hospital, and there did a lot of research on suicide, qualitative suicide research. So understanding the experiences of people who have had suicidal behaviour, people who've died by suicide through suicide notes, clinicians, family members who work with suicidal people. In my fellowship here at the Centre for Addiction and Mental Health, I focused on understanding how we can use big data or linked health administrative data to understand how patterns of service utilisation or presentations or risks differ for different populations, for suicide risk. And also another part of my research portfolio is Best Practices in Suicide Risk Management. So recently worked with the Canadian Armed Forces to write their clinical handbook for suicide risk assessment and prevention. So and I'm an emergency psychiatrist, so risk assessment is the bread and butter of what I do on a daily basis. Initially, my suicide risk assessment approach was very similar to what we were taught in residency to use sad persons to understand the risk factors for suicide, which I think is a really, really important place to start. One of the things that I found really challenging is people often told us, and I think they meant to tell us this in a supportive or a way to reduce anxiety, but that it's you can't predict suicide on an individual level.
Dr. Juveria Zaheer: [00:03:40] And so it was very tough to reconcile these pieces that were trained in suicide risk assessment, and we can't predict suicide. And so it was something that I really thought of. I thought about a lot. And I think something that guided my research career in my clinical practice. I think understanding the data, reviewing the literature, doing our own work has shown me that although yes, it's very difficult to predict suicide on an individual level, we have very good epidemiological evidence. We have very good clinical evidence about what is risk, what increases someone's suicide risk. We can also use a suicide risk assessment to better understand a person sitting in front of us. And rather than looking at the suicide risk assessment for me as something that stratifying people's risk arbitrarily, their low, their medium, their high, and often we only link it to whether they're admitted or not. And hospitalisation isn't actually an evidence based intervention for suicidal ideation or suicidal risk. And so what we thought about is how do we understand suicide risk in the way that doing a really good assessment can help guide treatment, can help us manage the risk factors that can be modified, can help people keep people safe, and how can we do it in such a systematic way that we can think about suicide risk prevention as more of a public health concern rather than something that we do clinically?
Lucy Chen: [00:04:55] That's great. So for our learners, where are they going to be expected to perform a risk assessment?
Dr. Juveria Zaheer: [00:05:01] That's a great question. I think that, you know, there's a lot of data on this topic. So, for example, Kelly Posner, who wrote the Columbia Suicide Prevention Suicide Assessment Scale, she said that in every appointment, everybody should be screened for suicidal behaviour, like in suicidal ideation, even in medical settings. And then on the other hand, you have the Canadian-American guidelines that say that suicide screening shouldn't be done regularly in family practice unless there are resources available or unless it's a high risk group. We're psychiatrists, so, or we're training to be psychiatrists. So we should be doing suicide risk assessments because we are sort of by definition, working with a higher risk group, people who have mental health concerns. It's really important to point out that everybody that, you know, in North America, over 90% of people who die by suicide would have had a diagnosable access one or access to mental health concern. But the vast majority of people with mental health concerns don't die by suicide. It's really, really important that there is hope and that there is a way forward for us. We always want to do a suicide risk assessment. If it is a new assessment with somebody, even if they're saying, I don't have any suicidal ideation right now, the act of getting the historical information and the current risk and the acute risk factors is so useful because then you have a baseline for when you see them later. You always want to do it in an emergency department setting. You want to do it if they're expressing to you that they have new or worsening CI or suicidal ideation, thoughts of suicide, you want to do it. If you're repeating an assessment for someone who's at elevated risk for suicide, or if there's concerns from a health care provider or a family member in your clinical practice, if you do a thorough suicide risk assessment on visit one and you're doing CBT with the client you want to screen every time you see them, and if there's no elevated risk, then you wouldn't repeat this whole process.
Alex Raben: [00:06:39] You you were mentioning right at the beginning that we there are ways of knowing what puts people at higher risk for suicide or that we know some of the factors involved in that. We also know that hospital admission is not an evidence based intervention for prevention of suicide. So could you help us understand from your perspective, what are the goals of a suicide risk assessment?
Dr. Juveria Zaheer: [00:07:06] So it's so for me, the goals of a suicide risk assessment are to understand the risk of suicide for that person in the short term and the long term to understand if their risk, their personal risk is changed over time. So is there something that's happening that's changing their risk that needs to be addressed? By doing a thorough risk assessment, we can identify modifiable risk factors. So for example, by understanding if somebody is having suicidal ideation, we can ensure that we're going to do a safety plan with them, which is an evidence based intervention. If somebody is having worsening depressive symptoms or worsening psychotic symptoms that are contributing to their suicidality, then we can make sure that we treat those pieces. So in that case, an inpatient hospitalisation to treat these modifiable risk factors is completely useful and important. If someone tells us that in our suicide risk assessment that they have a specific thought of a specific plan and they have insomnia and they're not sleeping and they're thinking about it all the time and they have access to means we can make sure that the firearm is removed from the home. We can think about Daily Dose prescribing. We can know that compared to their baseline, their risk is higher. So maybe hospitalisation for stabilisation is important.
Lucy Chen: [00:08:14] And I'm wondering if there's a better way to understand are there components of risk or can we break that down?
Dr. Juveria Zaheer: [00:08:19] Absolutely. I think and we always we also often think about risk as a negative thing and they're doing a good risk assessment should also highlight the positive factors, too, and the protective factors and strengthen them. I think we can understand risk in a few ways. So one is somebody is historical risk. So what are things that they have on a population level that would put them on average compared to another person at higher risk for suicide? So those could be sort of demographic risk factors, gender, age, history of family history, of suicidal behaviour, of history, of trauma. We also want to understand suicide specific risk factors. And so those include past attempts, a past history of suicidal ideation, a past history of deliberate self harm, which all, even if there's no intent to die, is an independent risk factor for death by suicide. We also want to understand acutely what's happening that is potentially modifiable. So what are the acute risk factors, whether it's mental illness, substance, medical illness, as well as acute psychosocial risk factors, occupation, marital status, financial stress, immigration, stress. And we also want to understand how the person perceives suicide. What are the psychological risk factors? Are they do they feel a sense of perceived burdensomeness? Do they have a sense of exhaustion? Do they feel alienated? Do they have a lot of cognitive rigidity around this issue? And finally, and most importantly, we want to understand warning signs for suicide. So what is happening in the short term that puts someone at high risk for suicide? Are they engaging in suicidal communication, talking to people about dying by suicide? Are they engaging in preparatory behaviour which might mean making plans for suicide, researching ways to die or the other half is getting one's affairs in order reaching out to people. Have they had any recent attempts? And I think we're probably moving as a field to looking at these suicide specific warning signs to predict suicide death rather than relying solely on sad persons, because a lot of those features are quite static.
Lucy Chen: [00:10:13] Yeah. So can we talk about SAD PERSONS? Because I remember learning this in medical school, this acronym and just memorising it for the sake of memorising it. It's a suicide risk, I suppose other components of a potential suicide risk, that approach that we can take, like maybe we can go through it and then like, what is it? Is it good.
Dr. Juveria Zaheer: [00:10:32] Enough? Yeah. So I think SAD PERSONS is a really important place to start because I think suicide is it's such a tragedy. It affects people and families and communities and health care providers and it can feel very mysterious because it's an outcome that has social and biological and cultural factors. I think that SAD PERSONS is a great tool for learners because it shows us, it sort of illustrates the depth and breadth of risk factors associated with suicide. We also know that suicide is so, so rare that it's very difficult to predict. It's very it's a small signal. So getting epidemiological risk factors are pretty tough. So you need really, really big samples. So that person is sort of a distillation of the evidence as it exists. And so would you like to go through the risk factors?
Lucy Chen: [00:11:15] Yeah, sure. Yeah.
Dr. Juveria Zaheer: [00:11:16] So the essence that person's is for sex. And so in North American constructs as well as in sort of other high ses European countries, Australia, New Zealand women have engaged in suicidal behaviour at a rate of maybe three or 4 to 1, but men die by suicide at a similar rate. So about in Canada it's about I think 3.2 male suicide deaths to every female death by suicide irrespective of this history of behaviour. And then this varies by culture. So until the last decade in China, women actually died by suicide more often than men did. And in several European and several Asian countries, the risk is actually much closer. There's a there's a much lower ratio. As a multi sort of ethnic society, that's really important for us to know. People tend to carry, according to the World Health Organisation, carry their own sort of cultural risk for suicide to their new country for at least two or three generations before it kind of normalises. The second thing that we talk about is age. So I think in general we teach our students that especially for men, the older you are, the higher your risk for suicide. Although, you know, if you look at the Canadian and American census data, I think what we're kind of landing on is that 45 to 64 age is the highest risk, that middle age for both men and women, for men that that risk remains elevated through the course of their lifespan. And, you know, older men are at higher risk than older women, although this isn't a largely Caucasian population.
Dr. Juveria Zaheer: [00:12:42] So older men, middle aged men and women. And then there's the youth and emerging adults factor. And there was a really disturbing and important paper that just came out in JAMA Psych that showed that the rates of suicide are going up in young people. And so males tend to be at higher risk young males than young females. But certainly that's another high risk period. We'll call that emerging adult. The next risk factor is D is for depression. So again, it's really, really important to point out that the vast majority of people who suffer through major depressive disorder and even who have suicidal ideation do not die by suicide. And there are people with other diagnoses other than depression that are at high risk for suicide. But certainly having suicidality, suicidal thoughts is one of the criteria for major depressive disorder. And so if you're having an episodic depression, a major depressive episode is a risk. People who are treatment refractory in particular carry the highest risk. The next one is P for previous attempts. This is the big one. This is the most important risk factor for suicidal behaviour is a past history of suicidal behaviour. People often ask, you know, what are the percent of people who die on their first attempt? And there's a nice there's a nice paper that says it's probably about 40% of people die on our first attempt, 60% have had recurrent attempts.
Dr. Juveria Zaheer: [00:14:00] But again, the vast majority of people, even who've had a suicide attempt or we like to say suicidal behaviour if we can don't die by suicide. The next one is E is ethanol. It's a bit of a stretch, but is ethanol abuse? Alcohol can mitigate the risk for suicide in myriad ways. It's really, really important. So having an alcohol use disorder in and of itself raises your risk for suicide considerably, depending on the study you read here in Toronto. According to coroner's data, I think 30 to 50% of people who die by suicide across coroner studies have alcohol on board. So alcohol, like you think about it in sort of different stratified by different classes, right? So having an alcohol use disorder, it's it can have mood related symptoms which can result in suicidal behaviour. The second piece is that when people are intoxicated they may be more susceptible to co ingestion, they may miss, they may misinterpret risk of self harm behaviour, they may become more impulsive, they may become more emotionally disregulated. They may use alcohol as a way to reduce inhibition. Alcohol withdrawal can potentially make people feel agitated or, in the case of delirium, tremens, sort of do things that they wouldn't normally do. And then the last piece I think is a really important one, right, is an alcohol use disorder can have really serious psychosocial consequences. It can affect your job, can affect your marriage, it can affect your relationships. And I think often that's something that we need to really think about.
Dr. Juveria Zaheer: [00:15:25] The next one is our rational thinking loss. And you know, you want to call it rational thinking loss. We can call it cognitive rigidity. I really like Thomas Joyner's theory; interpersonal theory of suicide, which says that people feel a profound sense of alienation as well as a sense of perceived burdensomeness. The Beck hopelessness scale is a good one. Talking about losing hope, being quite black and white, having a negative view of yourself in the future and the world not being able to problem solve right. Being really in a dark place like thinking of, you know, often when people have unsolvable problems, suicide becomes sort of an awful solution to an unsolvable problem. Even though we know that with appropriate treatment, people's risk can come down considerably and people can live really happy and resilient and well and meaningful lives. I would say the last one is social. The next one is social support lacking, particularly for men being divorced or being socially isolated as a risk factor for suicide. There's some really innovative and interesting work in that area, but when people are alienated, they don't have a lot of social support. Makes it really tough to safety plan. Like if you don't have anyone to call it feels really stressful. And that's something that we can certainly build when we care and work with people who organise suicide plan. So one of my challenges with that persons is this feature here organized suicide plan or p previous attempts on the face of it looks like it has the same weight as something like sex and age, which it certainly doesn't, but.
Dr. Juveria Zaheer: [00:16:58] It is a great way to remember all of these pieces. So that's the caveat and we'll talk about that organized suicide plan at length I think during the session. No spouse, especially for males, as we discussed and asked, is for sickness so chronic or severe? I think there's there's lots of things that are missing from SAD PERSONS, you know, especially in our, you know, 2019. We always want to think about addiction, right? Opioid use. And there's a really growing body of evidence that opioid use disorder would be associated with suicide risk, things like personality disorders. And here, schizophrenia isn't here. All of these illnesses carry risk for suicide. Trauma, I don't think is on this list. And trauma is associated with, at the very least, an increase in suicidal behaviour, you know, things like LGBTQ2s+ or indeed like being Indigenous. Being an indigenous person isn't on this list. That's exactly right. And so, you know, I think it's a useful feature, but we need to maybe move beyond it. And we really need to distinguish between things that put an individual at risk for suicide over the course of their lifetime versus things that put people at risk for suicide in the immediate in the days or weeks or months coming up.
Lucy Chen: [00:18:12] So thanks so much for bringing SAD PERSONS to life. I think it adds a little bit more dimensionality and kind of a context for why this acronym is used. I can actually see many categories of SAD PERSONS within the scope of the components of suicide risk in terms of suicide specific risk factors, mental illness or psychosocial risk factors and psychological risk factors. So I see more as a memory aid, but then kind of to stratify that further in terms of what what components of risk assessment were actually assessing for?
Dr. Juveria Zaheer: [00:18:45] Absolutely. I think it's really difficult to move from not knowing anything about suicide risk assessment to using a formalised template or having a formalised approach without the intermediate step of that person's.
Lucy Chen: [00:18:54] Mm hmm.
Alex Raben: [00:18:55] Sure. So how do we move, then, from SAD PERSONS, which is a great memory aid, and it gives us a foundation of some of the risk factors. How do we move from that to a more fulsome risk assessment?
Dr. Juveria Zaheer: [00:19:08] So I think we want to exactly, as you guys said, use SAD PERSONS as a jumping off point to help us feel comfortable and help us make sure that we don't miss anything. And we want to focus in our suicide risk assessment on a few different areas historical information, current risk, including acute risk factors and warning signs as well as collateral information. So we want to be able to pull everything together. And in our formulation, you know, the you'll hear me talk about this a lot. If you work with me clinically and maybe even today on the podcast. But often medical students and residents are asked by your staff, what is this person's suicide risk? And we say low, medium or high, but we never talk about low, medium or high. Compared to what? Compared to whom? You know, there's no evidence around what makes low, medium or high risk. It doesn't really guide treatment. So doing a suicide risk assessment, that's an evidence based approach with based on understanding someone's risk in the moment and using it not only to come up with low, medium high, which is actually not super useful, but using that information to create a safety and treatment plan. Then we're talking. Then we're actually talking about something that can help people.
Lucy Chen: [00:20:20] Mm hmm. So I guess, you know, the approach to kind of maybe a successful suicide risk assessment, I guess essentially like we have to talk about kind of maybe the space and kind of the environment of a risk assessment and then maybe also the content of a risk assessment. And then we'll move on to kind of maybe formulation of risk assessment.
Dr. Juveria Zaheer: [00:20:39] So this is hard stuff to talk about. And I think for a lot of us who work in this field, I'm sure you've had a loved one or a friend or someone who's on psychiatry say to you, well, or even a family member of a client say, "Well, if you ask about suicide all the time, doesn't it make people feel more suicidal?" And we know from the data that a clinician asking about suicide doesn't actually increase someone's risk for suicide. We've done some work in this area. There's a nice qualitative study about or a survey study, I believe, of people's experiences of being asked about suicide. So I think part of the comfort we want to create a safe and comfortable environment. Part of that safety and comfort is our own safety and comfort. This is hard stuff to talk about and it feels really good. And I know a lot of the people listening to call it feels great when you meet someone and they say, I have no suicidal ideation. And then there's like this feeling of relief because first of all, you care about the person and you obviously don't want anything bad to happen to them. But then the second is like, Oh, now I don't have to go through any of this stuff. It saves me a bit of time. I can think about other things. But you know, if you can do a really good suicide risk assessment early, you create the scaffold for which we can understand this person's risk over time, and we can understand this person better and we can show them that we care. And there's lots of different pieces that we're thinking about.
Lucy Chen: [00:21:51] And maybe diving into the actual assessment. What is historical information? What's a sort of historical what's that that scope? What does that look like? So, you know, I think if.
Dr. Juveria Zaheer: [00:22:02] We don't go through this process, if we just sort of ask about current suicidal ideation intent and plan, then we miss all of this historical information, which is you look at that person's a lot of that is historical information. So this is a way that we can get all that information up front. You get it up front. And even if the person doesn't have active suicidal ideation, you have it. It's always there for the next clinician or for yourself when you're looking at it. So historical information informs the current state risk assessment and provides context for the current presentation. We will always want to ask about the history of suicide attempts. Again, sometimes you'll hear me say suicide attempts. Sometimes you'll only hear me say suicidal behaviour. I tend to prefer suicidal behaviour because we try to move away from the language of attempts or completion because it's maybe potentially unnecessarily stigmatising. So and I think often people aren't really sure either. There's a lot of grey area between deliberate self-harm and suicidal behaviour with intent to die. So if we want to call it suicidal behaviour with intent to die, it's a bit of a mouthful. But in their history and historical information, I usually cut it by the HPI. So if someone comes to you and we talked about this in our last session before the demarcation, so not in the last two months we'll see a number of attempts, most recent attempt method lethality efforts to seclude an emotional reaction to surviving the attempt. And I often ask for contextual factors as well. The second piece is a history of suicidal ideation, intent or plan or preparatory behaviour.
Dr. Juveria Zaheer: [00:23:34] This is something that I think before I started using a really formal approach that I would miss, because if someone's presenting with suicidal ideation now we want to know, have they. We often you see when you see a chart chronic SI (Suicidal Ideation) have you ever seen that all the time. And so chronic aside, does that mean that they've had it one day a week for their entire lives? Does that mean they've had it every day for six months? It's pretty vague, right? So I kind of draw out like you think about the person's life history. We say, I know you've been having suicidal ideation. You told me right now because you get that in your HPI write tell me about your life. When was the first time you ever had thoughts of suicide? When when were they there? Are they always there? Do they come and go? And and someone might say to you, I only ever had suicidal ideation in 2011 in the context of a major depressive episode. And now I'm having it again. It's super valuable information. Another person might say, I had my I had suicidal thoughts for the first time when I was seven. And they kind of come and go depending on if I have stressful things happening in my personal life. That's also really important information, right? We also want to do the same kind of process with intent and plan as well as preparatory behaviour. And we can talk about each of those things in a bit more detail if you would like now or we can do that later.
Lucy Chen: [00:24:47] Yeah, maybe we can elaborate on this topic now. I think preparatory behaviour is something that we're always mindful of, but I guess how to do that robustly or kind of scope.
Dr. Juveria Zaheer: [00:24:57] Yeah, absolutely. So you know, in our little I think there's a handout that you guys will get to that describes preparatory behaviour. I think this is a really, really important concept and we don't talk about it I think nearly often enough. So preparatory behaviour refers to one of two things. One is are there things that we're doing to prepare for death? So are we getting our affairs in order? Are we saying goodbye to people or are we, you know, maybe selling items off that kind of thing? And then the other half preparatory behaviour is are we like researching methods online, are we stockpiling medications or are we doing rehearsing? So I think preparatory behaviour goes as sort of both of those categories as well as suicidal communication. Are we talking more about suicide? More people talk about suicide before death by suicide than not. And I think people think, oh well, you know, they won't necessarily say anything about it, but everybody who has suicidal ideation, you have to remember, is deeply ambivalent. Right, because there's a part of them that is still alive and there's a part of them that's really, really suffering. And it's important to kind of highlight that piece.
Lucy Chen: [00:26:04] And I kind of would like to sometimes see suicidal ideation to intent and to plan and to preparatory behaviour a sort of like a spectrum. So I guess it's a little bit more nuanced sometimes the difference between ideation and intent.
Dr. Juveria Zaheer: [00:26:17] Absolutely. And I think we often think about the really classic presentation. We think somebody gets very depressed, they're functional, they have functional impairment, they start to feel really sad, then they have suicidal thoughts, and then slowly they develop intent and then slowly they engage in preparatory behaviour. And then there's a tragedy that needs to be averted. I think in practice you can think of suicidal ideation as pretty binary in the sense that either you have thoughts of suicide or you don't. And that to me is the biggest jump. You have thoughts or you don't, right? And you think about having suicidal ideation is like going through life with a sunburn. It's like, you know, if you normally take off your shirt, put on your shirt, have someone grab your arm and you don't have a sunburn. It doesn't feel it's fine. That's okay. But when you have suicidal ideation, everything hurts, right? Like you're more sensitive to things and you go, but you cycle between these scales, right? Sometimes you have intent, sometimes you don't. Sometimes you have a plan, sometimes you don't, sometimes like small. And that's why means restriction is so important. Sometimes you can feel so distressed in the context of see that you get closer whether you're intoxicated or you've had, you're feeling isolated. And so thinking about it as less as a continuum and more about like, do they have ideation or not? If they have ideation, getting all of this information and figuring out what makes it better, what makes it worse. Thinking about suicidal ideation is like taking a pain history, frequency, intensity, alleviating factors, associated factors. I think that's probably your best bet.
Lucy Chen: [00:27:42] Okay. And then now delineate delineating kind of between suicidal ideation, intent and plan and then self-harm.
Dr. Juveria Zaheer: [00:27:49] Yeah. So again, I think, you know, when I was training, I always thought that this was so binary. But I think for you guys, when you work with people in our emergency department or you do consultation or people with lived experience will tell you it's not that black and white. There's certainly, you know, we call it deliberate self-harm without intent to die. So and that can be cutting, head banging, hitting. Often we focus a lot in the cutting, but there can be other, other types of behaviours that we might be missing. And so, you know, I ask about both separately and there's this kind of non-specific kind of grey area. I think in the middle when I ask about history of deliberate self-harm, you want to be systematic about it. When did the behaviour start? What is the behaviour looking like? What is the frequency? What is the intensity, what are the triggers and is it changing over time? And you also want to understand the person's explanatory model because they want to. They want you to for two reasons. One is you want to be empathic and understand someone's pain and suffering. And it's a behaviour that can be really stigmatised and can feel really shameful. So an open explanation, exploration is really important. And also most importantly, if you understand the explanatory model, then you can actually figure out how to support them and figure out how to replace the behaviour or reduce their suffering or distress.
Alex Raben: [00:29:06] And then I guess also in the historical information we would get at some of these non-modifiable risk factors that we were kind of going talking about with the SAD PERSONS such as sex and age and those kind of things as well.
Dr. Juveria Zaheer: [00:29:22] Absolutely. And I usually write them all out early and then when I do my risk formulation, I'll always have it in the same place because that's the stuff you can't change. So it's important to know that we think about high, medium and low risk compared to what and compared to whom and compared to when. This is the compared to whom. Right. It's this is this is who is at a stratified risk of suicide that's higher compared to the general population. And it's really important because we would do that in medicine, too. Who are people who have risk factors for cardiac events or for developing diabetes?
Alex Raben: [00:29:55] Right. Subsets of the population that have higher risk?
Dr. Juveria Zaheer: [00:29:58] Exactly.
Alex Raben: [00:29:59] And then I guess we would move more towards the proximal factors that are putting someone at risk.
Dr. Juveria Zaheer: [00:30:05] Absolutely. So we call this current risk, and I usually focus on the HPI. So differentiating your HPI from past history is so important for lots of reasons, especially for suicide risk assessment. So we go through the same process. So on the template, I think I call it suicidal ideation intent plan and preparatory behaviour within the last month, but I think within the last month is useful if you're seeing them or or it can be since the last appointment or it can be like during this episode. But you know, it doesn't matter how you differentiate as long as you differentiate, I think. And then I think about it again, like pain intensity, frequency triggers, alleviating and aggravating factors, associated features. The next step is understanding suicidal behaviour, both attempts and deliberate self-harm since the last visit, within the last month in this time period. And then acute risk factors, worsening depression, presence of psychosis, substance use, relationship breakdown, financial stress. I think we sometimes think of suicide as so related to depression that we don't think about the other things that are happening in someone's life. And suicide is a tragic outcome that's so multifactorial. So you want to make sure that you explore these psychosocial pieces and some of those psychosocial pieces are can be quite modifiable or the target of the target for support or the target for intervention. One of the things that I should have mentioned is you always want to ask about access to firearms in the United States.
Dr. Juveria Zaheer: [00:31:26] Rates of firearm death by suicide are higher than they are in Canada. But you I always ask everybody about firearms because it's a small thing and you don't want to miss it. And I also ask about stockpiling medications or access to medications at home, and then the next one is warning signs. So this is a way you know, this is something that sad person doesn't really get at. Right. This is what is happening now in the in the days or minutes or weeks or, you know, hours before someone is presenting to you, are they more agitated? Do they have worsening insomnia? Really, really important, especially in qualitative explorations of suicide and suicidal behaviour? This insomnia agitation is so important irritability, anxiety, hopelessness, suicidal communication, psychosis including command, hallucinations, planning for carrying out a suicide, a suicide plan, engaging in suicidal behaviour, making arrangements for death, worsening substance use or intoxication. So these are things that you want to take really, really seriously. If you if someone is describing these these behaviours. And then the last thing that I try to focus on and it's something that, you know, it's something that I've had to learn and it's not something that comes very naturally to me, but I think it's really important is suicide narrative is what does suicide mean to them? Is it a function of hopelessness or helplessness? Is it a function of burdensomeness, alienation? What is their explanatory model that's really useful, right? Like if someone is describing all of these things to you and they say, I'm going to do this because I don't think my depression will ever, ever, ever, ever get better then targeting the depression, instilling hope becomes so important if it's because, you know, my wife has left me and I'm going to punish her and I'm going to punish myself, that it might mean that, you know, you might need to bring this person into hospital to stabilise them to do a little bit of family work, because there's something going on here that's really difficult to engage with.
Dr. Juveria Zaheer: [00:33:21] If it's a sense of perceived burdensomeness, then you can do some interesting family work to bring the family there and have the family say that, you know, we really you're really meaning you really mean a lot to us. We had no idea you were suffering, you know, so there's there's kind of ways that you can work with that narrative. And that's how and then I also I think it's really important to stress protective factors. I don't think we think about that nearly often enough. But what are these person's personal characteristics, their social supports, their treat and capability to engage in treatment, their ability to safety plan? What is it about this person that's keeping them with us that we can harness and work with them to create a robust safety plan?
Lucy Chen: [00:33:56] It's sometimes so hard to kind of assign weight to the protective factors and versus sort of the weight of. All of the historical context of suicide attempts or suicidal ideation, self-harm history, and then the current risk and then how we balance all of those features. Yeah.
Dr. Juveria Zaheer: [00:34:15] One of the things that's really helped me is to try to move in my mind, which is a bit challenging as an emergency psychiatrist. Right. But between like, is this person at risk or not? Or do I have to admit them or not? But more moving towards how do I understand the protective factors in the context of safety planning? So rather than assigning them a weight, if I can say that they have tons of suicidal ideation, but they have a loved one who's willing to stay with them. 24 seven They have access to date treatment so they can come into hospital every day. They're willing to start medication treatment. So there are pieces that would and they don't want to come into hospital. It's not really in keeping with their values at the moment. There are pieces that we can definitely work with them to engage in a robust safety planning process and a treatment plan that doesn't necessarily facilitate hospitalisation. But, you know, it's it's a bit of a mind shift. But I'm trying to personally and I think in the teaching that we do try to move beyond like having it be like typing it all into a computer and coming up with like a decision tool. Because I think that's really, really challenging, especially when the decision tool is often around hospitalisation, which again is isn't necessarily the the best proxy for for safety plan. I will also say that like recent hospital discharge or increasing service utilisation is another risk factor for suicide. And we have to whenever excuse me, you see somebody who's being having more admissions or going to the emergency department more, you want to take it seriously and think about breaking that cycle by an admission or another type of treatment modality.
Alex Raben: [00:35:45] So it sounds like the if we shift a little bit in our mind frame, the risk assessment can be thought of more as a layered understanding of someone's relationship with their suicidal ideation and behaviours and the various factors in their lives that affect that. And you know, just hearing you talk about that, you mentioned multiple times that there were interventions you can actually tailor to each of those kind of things. And so having this layered understanding, I imagine, is really helpful in that way.
Dr. Juveria Zaheer: [00:36:20] Absolutely. And there's a lovely paper that I'll send to you guys that gets at exactly this. It's we train so long to understand, to do an assessment, to come up with a metric for risk. And, you know, if we can switch that focus to doing a really robust and thorough assessment that serves three purposes, one that engages the client, the second is that it gives us a benchmark so we can compare risk over time to know when things are going sideways or to adjust our plan. And three, it shows us all of our targets for intervention. I think it's it's it's a much more hopeful process.
Alex Raben: [00:36:57] I think how do we as as learners balance this approach versus what our staff will often ask of us on a call which is kind of like, give us the bottom line in terms of what you think the risk is or what your disposition might be. How do we synthesise all of that to to that point?
Dr. Juveria Zaheer: [00:37:14] And I hope I really do hope that they're sort of mutually they're not mutually exclusive. Right. And so what I would say is, if I'm reviewing with you guys and it's on call and it's four in the morning and you want to you know, I would say two things. So go through the process and tell me what their suicide risk is. But not just high, medium, low, but compared to X and Y. Right. So you can say I've seen Mr. Jones compare to his A, he has this, you know, demographic risk factors, this sort of warning, these clinical risk factors, these warning signs compared to the general population. I think his risk for suicide is elevated compared to psychiatric outpatients. I think his risk for suicide is elevated compared to other psychiatric outpatients of his same demographic group, you know, a 70 year old white male who's divorced. Even compared to that high risk group, his risk is elevated and I think his risk is as elevated as psychiatric inpatients. So I think he merits a psychiatric admission. The second half is I think Mr. Mr. Jones is risk state. His risk compared to himself is the highest it's ever been. He had a major depressive episode 20 years ago, but never had this intensity of suicidal ideation at his baseline.
Dr. Juveria Zaheer: [00:38:20] He doesn't have any suicidal ideation. And so I think his baseline risk is, is that the highest it's ever been because he's engaging in preparatory behaviour, he's had recent average visits or recent hospital discharge and I think that understanding. Mr. what do we call him, Mr. Jones, is risk. Here are my treatment targets. So one is I think he has depression with psychosis. So I think that we should admit and consider ECT, which is an evidence based treatment that's shown potentially to reduce suicide risk. And we can also treat his psychosis with X or Y medication to is I think that he has a firearm in the home. So we need to talk to his family about removing that three. We can talk to his doctor about he's had an overdose recently about daily or weekly dispense versus like giving three month. At a time and for I think he has an alcohol use disorder so we can consider safety talks and naltrexone. So you can sort of look at the risk factors you have. And then the fifth piece is he's having a lot of stressors around sense of burdensomeness. His daughters live elsewhere, but seem to me to be very supportive of him. Maybe as part of the process we can engage in family meetings.
Alex Raben: [00:39:25] So just the same way in which your assessment is very layered, your delivery can also be very layered in terms of what you're putting forward.
Dr. Juveria Zaheer: [00:39:34] Yeah, absolutely. And if you look at the time, it doesn't take that much more time. I think we you know, the last thing we would ever want to do for our learners who are learning how to be psychiatrists is to make them do things that it's going to take a lot of time with no payoff or no benefit, most importantly to the client. But I think this approach doesn't actually take too, too much longer, and it can come up with a treatment plan that I think is more robust. And I think it's something that probably would be we're going to do a study on it to see how people experience various suicide prevention initiatives like qualitatively. So, stay tuned. But I do think that a client is not going to mind going through this process. And we do know that a safety plan which is also included in your materials, there's a lovely paper in JAMA Psychiatry from 2018 in the summer that showed that a safety plan intervention, which doesn't take very long done in an emergency department, reduces suicidal behaviour in the intervening three months by half. So there are, there are reasons to do this kind of stuff.
Alex Raben: [00:40:35] Speaking of the safety plan, like I find that particularly useful for me in especially in an emerge setting to do with someone not only because, as you say, it's an effective intervention, but also I find you get at a lot of this nuanced information because I will often just even give a quick explanation of the safety plan and hand it to someone, have them fill it out while I do some other paperwork and whatnot. And when I come back, I then have all this rich information onon the page and it starts a conversation.
Dr. Juveria Zaheer: [00:41:06] I agree completely. And it shows you who's important to them. It shows what the triggers are. It shows what kind of thoughts they have. It shows you what their reasons for living are. And I think even in addition to what you said, which is so important, it can also serve as a bit of a diagnostic tool. Right. If someone tells you, you know, how many times have you seen somebody who very sadly engaged in suicidal behaviour and was transferred to psychiatry? And they're saying to you, I have, I don't want to do it, I want to go home. But then you give them a safety plan and they can't really tell you anything and they can't really and they're maybe dismissive of it or they're feeling they have they're in so much pain and suffering that they can't really engage with safety or safe living. And I think that to me is maybe an indication that supporting them through hospitalisation might be something that would get them to a place where they feel safer for sure.
Lucy Chen: [00:41:57] I also want to emphasise a really essential component of the safety assessment is collateral information. And so we touched on it and I was hoping you can elaborate further about this component.
Dr. Juveria Zaheer: [00:42:08] Absolutely. I think collateral is super important because people remember that suicide is a social suicidal ideation. Suicidal behaviour or death by suicide is inherently a social act. Right. And so if somebody is expressing worry about someone, you know, it doesn't necessarily mean that you have to do what they say, but you really want to be able to understand where they're coming from. I think especially if you had a loved one who was having suicidal thoughts and you brought them into hospital, you would definitely want to be contacted. You would definitely want to be able to say your piece because when people are in a cognitively rigid or inflexible place, they might not be able to tell you what you need to know and engaging in collateral also improve safety planning because then people are on board, you know, because of that ambivalence around suicidal ideation or behaviour. And I think a pretty profound fear of hospitalisation, which I don't blame people for. People might not or might not be in the place where they can tell you how they feel or, you know, they haven't. If you don't go through this whole process, you might not know that they're okay now. But when they binge drink, which they're planning on doing later, the suicidal ideation ramps right up.
Dr. Juveria Zaheer: [00:43:19] And so I think, you know, you always want to get collateral if the person is risk as such that the collateral is going to make the difference between staying or going, then absolutely. But also, I always ask everybody if I can talk to a loved one and that safety plan is useful. Right. Because then I can say, can you mention that Joe's a support? Can I give you a call? Our child nonetheless. And colleagues do this so well, right? Thinking about people and systems and engaging systems and providing some psychoeducation even for family members about what do you do if I there's a lovely handout. We have one in the military manual that we wrote of. How do you support someone that you love if they're having suicidal ideation? Like how do you give people the tools? So I think for that reason, collateral is really, really key. And also in terms of people's health care team, like with consent or if the risk is so high that you can sort of circumvent consent, you know, if you're someone's. Treating psychiatrists, you'd probably want to know that they came to an emergency department with suicidal ideation.
Lucy Chen: [00:44:09] Yeah, I just want to emphasize this because oftentimes I've encountered an emerged sort of a patient who minimises all of their symptoms or they say there's nothing going on, you know, you know, my I was told to come in, but I really don't see what the big deal is. And then you sort of get some collateral information from their parent or from a loved one. And there's there's a lot of concern like they've they've witnessed some preparatory behaviour.
Dr. Juveria Zaheer: [00:44:31] And this is so important because without that collateral in your assessment you would right patient like no elevated risks, no intent, no plan low risk for suicide and you know, for the person's life is sort of in the balance here. And we want to respect people's autonomy and dignity, but we also want to give them the very best chance to alleviate their suffering and to get treatment for treatable conditions. And I think it's really, really important. And like medical legally, you know, you hate to say it, but medical legally as this is not why we practice and we should never practice because we want to avoid litigation. But, you know, the optics aren't great, right? If you know somebody is at risk and you don't get collateral, the optics aren't great if they've had a suicidal behaviour and then you discharge them and right. Low risk, no intent, no plan.
Lucy Chen: [00:45:16] For sure. Yeah. Like the labelling of those scenarios would be completely different. One case would be sort of not acutely elevated risk at all. And the other case, there's some cognitive rigidity or there are some like lack of ability to engage and we have some more information about preparatory behaviour which would put them at high acute risk.
Dr. Juveria Zaheer: [00:45:34] Absolutely. And you still may not admit that person to hospital, but you could do a robust risk assessment with recommendations and safety planning and follow up that would give them the very best chance to recover rather than sending them out without anything.
Alex Raben: [00:45:47] You very imagine a scenario where in gathering collateral, if the risk is high enough, you may not get consent for that. Could you talk about that a little bit more, just so it's clear for our listeners?
Dr. Juveria Zaheer: [00:45:59] Absolutely. And we should all work within health care systems where confidentiality is treated with utmost respect and our patient's autonomy and dignity is treated with respect. And also people may come from marginalised communities or have trauma and they may not want us to contact specific people who may be perpetrating violence. And you know, it's also interesting because we talk so clinically about suicide risk, but, you know, to reduce risk for suicide as a society, we need means restriction. As a society, we need safe housing, we need freedom from oppression. All of that to say around confidentiality. We want to support people's dignity and their autonomy. At some point, safety trumps confidentiality. And if I'm for my line as an emergency psychiatrist is if I have somebody on a form or who I think about being able to certify or hold and voluntarily, safety has to trump confidentiality. And so in those cases, I'll say, you know, I need to talk to your loved one. And I always remember you can always get information, right? So you don't necessarily have to give information, but you can collect information if someone tries if someone's trying to contact you. And I think people are pretty, you know, of course, imagine being in that situation, being an emergency department, not wanting your partner or your parents to know. And sometimes I'll frame it with people. It's like, I'm not going to call them right now, but I think they're really important for your safety planning. So maybe we'll sleep on it. We'll talk about it tomorrow.
Alex Raben: [00:47:22] And then you mentioned, um, how we communicate the, our risk assessment is very important and you kind of gave the example of someone communicating it very briefly as in something like no change in risk, say to be discharged. How should we be? I imagine I'm guessing the answer is fulsome, but how do we communicate all of this?
Dr. Juveria Zaheer: [00:47:49] Absolutely. So the first thing I would suggest for learners is to get into a habit of like communicating the suicide risk fulsomely for everybody. And I have we were going to distribute some case summaries that show like a way of documenting suicide risk for someone who has no elevated acute risk. And so if you get into that habit, you can see it's like three lines in your chart, but it's so valuable and so important because it creates a baseline. I would say that you don't have to you don't have to write a novel to do this effectively. I usually have one line that is the historical risk. I have two or three lines that are the current risk and the warning signs, and then I have a collateral piece, and then I will say risk status, risk state. So their risk status, their risk compared to general population, peer matched demographic group, psychiatric outpatients, psychiatric and patients. The inpatient thing is really key because if someone is at super elevated risk in hospital, like if they have a history of suicidal behaviour in hospital, their risk of suicide in hospital is elevated over psychiatric inpatients, which means you're going to need a higher level of observation, right? So and then then align that is their risk state. So their risk compared to themselves. And then I have my safety and treatment plan. So here are the things that I'm going to do to alleviate their risk. And that's actually your treatment plan anyway. Like a lot of there's a lot of overlap. Yeah, yeah. Your, your, your plan is going to be to treat depression and so you're going to write that out anyway. So it's a way of kind of considering it all in one place.
Lucy Chen: [00:49:18] And maybe to help our junior learners maybe conceptualise some of these levels of acute risk. Like I guess what would a low acute risk sort of look like? What would moderate acute risk look like? What would high acute risk look like? Just for our learners to have an approach and to how they can best communicate those scenarios.
Dr. Juveria Zaheer: [00:49:37] It's great. We have in our military manual, we have a table that I adapted from the American Armed Forces Manual that I really like, and I sort of use it myself just so my nomenclature is consistent. The challenge in psychiatry, you know, we want words that mean something. We want them to be reliable, meaning that everybody does the same thing and we want them to be valid, meaning that it measures what we say we're going to measure. My concern around this stuff is I don't think that this is particularly reliable or valid unless we all start doing things the same way. But I think you're going to have to use the wording that we use like as a discipline. So I can give you some examples right now. The other thing I would say is just there's one particular pitfall that I think we all fall into residents, staff, medical students is sometimes we reverse engineer our risk assessment. So if we're admitting someone, we say it's moderate or high, and if we're discharging someone, we say it's low. But I would really strongly encourage you to you know, you can discharge people who are at moderate or high risk for suicide with a safety plan and like targeted treatment. And you can admit people who are at low risk for suicide to manage other symptoms, you don't necessarily have to link the two.
Dr. Juveria Zaheer: [00:50:49] But the way that we define it in the manual and in the materials that you have is not acutely elevated, is no suicide, no recent suicidal ideation and no history of suicide-related behaviour. So that's like many of the patients that we see low acute risk is recent suicidal ideation, but no intent or to act can control impulses have not engaged in preparatory behaviour, no previous attempts, limited risk factors and some protective factors. So you ask how I write out my assessments. Sometimes I'll just use one of these terms and I'll write down the things that pertain to that patient from this list. It's pretty useful and it's fast to moderate. Acute risk is current suicidal ideation with no intent to act and no recent attempt and no preparatory behaviour. They have warning signs or risk factors and limited protective factors. The next one is high. Acute risk is persistent suicidal ideation, strong intent to act, or a well developed plan or feel unable to control the impulse to harm themselves. It also refers to those who've had a recent suicide attempt or who have participated in preparatory behaviour. They may also be in acute state of mental disorder or psychiatric symptoms, psychosis, agitation, intoxication or have precipitating events and inadequate protective factors.
Dr. Juveria Zaheer: [00:51:59] And then we always want to talk about the chronically high, acute risk. So these are people who have a history of multiple suicide attempts, acute stressors, including major depressive episodes, substance use or relationship conflict that can increase their risk or recent hospital discharge. And for those people, you want to use an acute on chronic risk assessment model, which is a little bit beyond the scope of what we're doing today, but not really. Right. They have a high risk compared to the general population, but where is the risk compared to themselves? And again, there are going to be times where you are going to discharge someone with high, acute risk because they've had a suicide, they've engaged in suicidal behaviour, they're feeling really depressed. They were intoxicated at the time. They're committed to staying away from alcohol. They really don't want to be hospitalised. They can engage in safety planning. They have follow up within the next three days and the bridging service. They have family who are willing to stay with them. They don't have any psychosis. You could discharge that person safely and in keeping with their values. No prescription drugs in the house, but you just want to document accordingly.
Lucy Chen: [00:53:04] So thanks for that clarification. I think a lot of the times we're often afraid to make these calls, right? Yeah. And hopefully there's a little bit more context now into getting a sense of what's all the information available to us and how we can communicate that and make sense of that and formulate that effectively.
Dr. Juveria Zaheer: [00:53:21] Yeah, that's exactly right. Like we I think sometimes I worry that when people see these materials, they say, oh my goodness, now we have to do so much more work and it's not going to help anybody and it's not predictive of death. And what's the point of any of it? I hope by listening or by engaging with the material, we can say this is actually not going to make the assessment that much longer. It's really going to help me and my colleagues and my client because we'll be able to track the risk better over time, and it's going to facilitate better safety planning and a shared common language. And I think that would be the goal of this kind of work.
Alex Raben: [00:53:57] Make sense.
Lucy Chen: [00:53:58] And maybe with or for early learners or sort of early trainees, any words of wisdom or advice you can give to them on their first psychiatric rotation or their first day emerge with you?
Dr. Juveria Zaheer: [00:54:07] Yeah, so I really like this question or lucky enough in the camera merge to have all of our U of T psychiatry residents now come through. So I think 36 PGY-1s every year we have a big call pool too. We have a lot of our wonderful senior residents like you guys who do call and who come back. What I would say for your first day of psychiatry is to be kind to yourself. This is a big field and you're in it because you care about people and you're going to learn so much from your clients and you're going to learn so much from your staff, and people are going to learn from you. And to remember that your decisions are supported by your staff. And all you can do is gather the information that you can and do the best job that you can. Try to always triangulate your data, try to get information from more than one source and enjoy the process because it's it's a learning process. And we're really happy to have you in the field and it gets easier.
Lucy Chen: [00:55:04] And we've got some tools for you guys, so you'll feel a little bit more sort of relieved or relaxed about having some type of approach.
Alex Raben: [00:55:11] Yeah, exactly.
Lucy Chen: [00:55:13] Okay. So that's it. We'll see you guys in the emerge. Take care!
Speaker4: [00:55:18] 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 meant to be representative of either organisation. This episode is part of our mini series on psychiatric skills, which are intended to provide you residents with content directly related to the trustable professional activities or EPAs in our curriculum. Since EPAs are designed to capture core professional psychiatric competencies, we trust our listeners outside. You will still find them entertaining and educational. This episode was produced and hosted by Alex Raben and Lucy Chen. Our theme song is Working Solutions by All Live Music. A special thanks to Dr. Juveria Zaheer for serving as our expert this episode. You can contact us at Info at Select Podcast or visit us at Podcast Talk. Thank you so much for listening. Catch you next time!
Episode 56: Understanding Trauma and Addictions with Dr. Gabor Mate
Episode 12: Treatment Of Schizophrenia Part IV Advanced Principles of Schizophrenia Treatment with Dr. Gary Remington
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Lucy: [00:00:01] Okay. All right. Okay. Welcome back to PsychEd, the Educational Psychiatry Podcast for Learners by Learners. I'm Lucy Chen, now a PGY4 psychiatry resident at the University of Toronto. I'm excited to introduce to you the fourth episode in our four-part miniseries on schizophrenia, which will be an advanced look at the clinical management of schizophrenia, a discussion on treatment resistant schizophrenia and clozapine. So just a warning, the content in this episode is going to be a little bit more advanced than usual, but it's also ultra interesting. Alex, Henry and I had the pleasure of interviewing Dr. Gary Remington for this episode. He's a researcher and chief of the Schizophrenia Division at CAMH and an author of the 2017 Schizophrenia Treatment Guidelines. His knowledge base on the topic of schizophrenia is impressive and later into this episode, he reveals some fascinating context on the history of clozapine and the idea of ultra resistant schizophrenia and the future of treatment in schizophrenia. But to bring it back to basics, the primary learning objectives for this episode are as follows. One: to know how to treat a first episode of psychosis of schizophrenia. Two: to understand the important components of maintenance treatment in schizophrenia. Three: to know what treatment resistant schizophrenia is. Four: to know about the application of clozapine in treatment resistant schizophrenia and five: know some of the psychosocial interventions involved in treatment. This episode is based on the 2017 Guidelines for the Pharmacotherapy of Schizophrenia in Adults, which we'll include a link for in the show notes. And I thought I would just highlight a quick summary of some of the recommendations in the guidelines that we discuss.
Lucy: [00:01:46] Firstly, that antipsychotics should be recommended in first episode of psychosis, and we should use the lowest effective dose. We should consider changing an antipsychotic after four weeks with no response to treatment and after eight weeks with partial response to treatment. Maintenance on an antipsychotic should be at least two years or longer. Treatment resistant schizophrenia is failure of two adequate trials of two different antipsychotics and clozapine should be offered to patients who have treatment resistant schizophrenia. Family intervention should be offered in all cases where patients are in close contact with family. CBT should be offered. Social skills training, life skills training and employment programming are also really important to consider in management. So I'll also preface that we used a case from our earlier episodes, episodes ranging from 9 to 11. I'm not going to repeat the case to you, but briefly, it was about a young man named Muhammed who presented with psychotic symptoms that likely reflected a first episode of schizophrenia. He was brought in by his father after he presented with paranoid ideations and was a risk of harm to his father in the context of his psychotic delusions. He was admitted to hospital for stability, safety and treatment. So we can jump right into the episode. And I basically started to ask Dr. Remington about the treatment guidelines and how it's relevant to the case. So let's get rolling.
Lucy: [00:03:13] I guess firstly, because we're talking about the schizophrenia treatment guidelines, Dr. Remington maybe you can tell us a little bit about the guidelines first.
Dr. Remington: [00:03:21] Sure. The guidelines have been available, and certainly they're available through a number of sources now, different guidelines. But here in Canada, they've been available now for at least several decades and they were just updated in the last 12 months. The purpose of the guidelines is really to offer clinicians in the community the most up-to-date evidence-based approach to treating people with psychosis, whether it be schizophrenia or one of the other related diagnostic categories. And they walk us through the various aspects of treatment from the very onset of the illness to individuals who move into more chronic stages. They reflect in part, and when we establish the most recent guidelines, they weren't done absolutely independently. I think as most guidelines are now put together, there's an attempt to look at what's happening across other parts of the world and to ensure that the guidelines are similar in terms of not only intent but practice as much as possible one guideline to the next. So, for example, we looked at the the NICE guidelines as, as a comparator, one of the comparators when we put these together.
Lucy: [00:04:49] And I guess based on in the context of like understanding what the guidelines are in this specific case, we have, you know, a presentation of a first episode psychosis and is there, so I guess in this context, what would be the approach of treating, of treating this sort of presentation?
Dr. Remington: [00:05:10] Sure. Well, initially and you touched upon it when you detailed the case, obviously what you want is as much collaborative history as possible. So you have the family involved at this point, and it's critical in terms of trying to establish the background in terms of issues that that may have been identified while the individual was growing up. More recent incidents that may have precipitated this particular set of circumstances, shifts in behaviour that have been identified more recently prior to this particular encounter, other issues that that may be playing a role: trauma, difficulties at school, substance abuse, those sorts of things.
Lucy: [00:06:08] And I guess like, how would you approach treatment in this context and how would you kind of explain that to a patient and his family?
Dr. Remington: [00:06:15] Well, always, and I think that's the case in psychiatry in general, what you're trying to do is rule out any sort of medical conditions that might account for this particular behaviour. And so certainly at the outset, I think as we do with many psychiatric conditions, the intent is to try to rule out possible medical diagnoses. Although in fairness, in individuals like this, young people who come into the system, it's been established that very rarely will you find an organic cause for the underlying psychosis. But having said that, you usually go through the various routine investigations to ensure that there aren't other medical conditions that may be accounting for it. Particularly more recently, there is, of course, the need to look at other issues like substance abuse, which has now become much more prevalent in terms of pre-empting the diagnosis of psychosis as well. And it's particularly difficult during this period, which is captured in some of our strategies around diagnosis, because oftentimes in somebody who has a comorbid substance abuse disorder, that it may not be clear for a period of time whether or not it was related to the substances or whether it is a primary psychosis. And in fact, it may never be entirely clear on some occasions.
Alex: [00:07:53] So it sounds like a urine tox would definitely be part of that initial workup. Can we get into more specifics there? What else would be part of that?
Dr. Remington: [00:08:01] Well, you do the standard procedures like blood work, liver function, haematology and so on in order to rule out such things as thyroid conditions and so on. But once again, and we actually published work in that area here at the university a number of years ago, for all the tests we do do, very rarely do you find anything that would truly account for the for the condition that we're seeing in front of us. We don't do imaging routinely here, and probably what we don't pay enough attention to and it's becoming more and more evident, is doing a broad-based assessment for other areas of the illness that actually, as a rule, declare themselves before the onset of the psychosis. So we now appreciate that the first episode of psychosis that we see in individuals who perhaps ultimately get the diagnosis of schizophrenia, it's a bit of a misnomer to use the term first. It is the first episode of psychosis, but in fact, it's the end of the illness. The illness is in its final stages at that point, in as much as as there is a lot happened by that time, that is only picked up often through a thorough history.
Dr. Remington: [00:09:32] So for example, we often see changes in behaviour in the preceding months and years that involve increasing withdrawal, evidence of academic deterioration, social issues, those sorts of things. And when you look at the domains of the illness now, we talk about multiple symptom clusters and the ones that seem to be embedded when the individual comes to us with the first episode of psychosis are cognitive symptoms and negative symptoms. And going back to my point that I made at the outset, there is, I think, a need to better capture the extent of these as quickly as possible because they become the major factors over the longer term in functional recovery. And to that point, I would add that it's critical when you think of an illness like schizophrenia to distinguish between clinical recovery and functional recovery. Routinely, we assume that clinical recovery, and generally speaking clinical recovery is taken in the context of improvement in psychotic symptoms, translates to functional recovery, and that's simply not the case.
Lucy: [00:10:55] I guess this makes me think of like now DSM-5. They've included this idea of a range in the presentation of like between like schizotypal personality and schizophrenia. And so I wonder where along that spectrum we begin treatment, where in the guidelines is it appropriate to start an antipsychotic?
Dr. Remington: [00:11:17] And it's an excellent point. It's a point that we struggle with and the major part of the struggle is the hesitancy to intervene with a drug like an antipsychotic in individuals where you can't even be sure that that's what the illness is going to be. And as you're probably aware that we now talk about this so-called prodrome or clinical high-risk period before the onset of the illness, when we can begin to identify features that would suggest that this person may convert to a full-blown psychosis, but even in the best programs, we still only see a conversion rate of 20 at the best, perhaps in the range of 30%. So with that kind of conversion rate, you have to be very cautious about embracing something like an antipsychotic to treat a condition, in particular because with these individuals, it's not as though they're presenting with a first episode psychosis. It's often much more vague than that. It's a loaded history, perhaps with some unusual changes in behaviour or what we call soft positive symptoms, symptoms like magical thinking, those sorts of things.
Henry: [00:12:44] How do you know? So you have someone who presents with acute psychosis, you treat them with an antipsychotic. How do you know when to stop?
Dr. Remington: [00:12:53] Well, you raised a very good question. And indeed, that's the first and probably the most important questions that the individuals and families are interested in. Oftentimes, they're even reluctant to take the medication from the outset, but with resolution of the symptoms, as is so often the case in medicine, there's this notion that the illness has been cured and medication is no longer required. As recently as last week, we were talking about that, and indeed, in the guidelines, you will see that a position was stated whereby individuals who have a clear first episode psychosis are it's recommended that they take the antipsychotic medication for at least a year and a half before there's consideration of possibly discontinuing the medication. Having said that, we in the field actually have concerns about that kind of guideline inasmuch as it's a guideline that's very much influenced by what your primary diagnosis is going to be. So your chance of doing well in the absence of medication, i.e. antipsychotic medications, the general figure that you'll hear reported in the literature now is probably in the range of about 20%. And that's the kind of figure where you would say, well, we need to reassess these individuals and ensure that they do need to be on the medication. Having said that, we believe that that if truly the diagnosis of is one of schizophrenia, that it's considerably lower than 20%. Unfortunately, many people diagnosed with a first episode psychosis, though, have a multitude of diagnoses, some of which have a much higher chance of resolution and I think they load that 20% figure that is now talked about in the literature. So there are conditions whereby you should be considering discontinuing the medication because they are powerful medications and they come with a multitude of side effects. If it truly is a diagnosis of schizophrenia, we would suggest that you're probably going to need to take that medication indefinitely.
Henry: [00:15:17] How do you know if it's schizophrenia or just psychosis?
Dr. Remington: [00:15:21] Well, unfortunately, and it's in many ways the the most important question. And unlike so many other fields, we have done poorly in the field of psychiatry in terms of identifying biomarkers or endophenotypes that would firmly establish the diagnosis. So to your question, how do we know? We know based on clinical experience. But as I mentioned at the outset, one of the sort of protective factors that we build into this is trying to ensure that we have a period of time to watch individuals before we say with more conviction that this truly is a diagnosis of schizophrenia. But particularly in the first episode, you can see shifts in diagnosis over the first several years in particular. So the person who came in and looked like a schizophrenic individual may end up looking like a bipolar two years later, or vice versa. So time becomes one of the most critical factors in helping to make that distinction.
Alex: [00:16:26] So this is a lot for even us to think about, but I so I'm trying to put myself in Muhammed's shoes here. How do we explain, assuming this is true schizophrenia or at least at this stage, we have to believe that it is and we want to initiate an antipsychotic, how do we then explain to him the potential need for this to be a lifelong treatment?
Dr. Remington: [00:16:50] And oftentimes you try not to put that on the table initially. There's so much to take in at that particular stage that I think we're very cautious about making those sorts of ultimatums early in the course of the illness. And of course, it's not just Muhammad that we have to engage, we have to engage the entire family in particular, if we're going to see a buy in to long term care. So I think it's probably not in best interest to say, well, you have schizophrenia, you're on these medications for the rest of your life. I think we start off much more hesitantly saying this looks like a psychotic condition. One of the differential diagnoses could be schizophrenia. We may not know that for a period of time, but we do know that that the cornerstone of treating psychosis is an antipsychotic medication. So at least for the time being, we would advocate for you taking this medication and then with the resolution of the symptoms, we can begin to look at other options as we move forward.
Lucy: [00:17:59] And I guess that transitions to a question about how do you treat acute presentation of psychosis and how do you transition that into maintenance or kind of treatment as well.
Dr. Remington: [00:18:10] And there has been a fair degree of change in that area more recently. When I trained as a resident, for example, we were in a period where we were using incredibly high doses of medication with the assumption that more essentially was better. So at that time, the strategy was one of loading people with an antipsychotic medication with doses that were now, as we look back historically, much, much too high. Now we've taken an almost opposite approach and it's very much a start low and go slow strategy for treating acute psychosis. So, notwithstanding those individuals where they may be really acutely psychotic and aggressive, the strategy now may not even be confined to bringing people into hospital. Oftentimes now it's started on an outpatient basis, but the general agreement is that you can use low doses of antipsychotic and increase them. And why I'm saying that is, and we wrote about this a few years ago, what it's meant from the standpoint of maintenance is that at odds with what we used to do historically, which was to load people with high doses and then several months later begin to titrate downwards. In contrast, what we do is titrate up now more slowly. And it's very likely that the kind of dose that you used in people say, who weren't acutely psychotic and requiring high doses to control their behaviour, is that the kind of dose that you attain to establish antipsychotic control in that strategy probably reflects more of the maintenance kind of dose that you're going to need over the longer term. And as a practical example, let's use a drug like risperidone. When we used risperidone, we might have, and indeed when we did the original risperidone trial here in Canada, the highest dose was 16mg. But now what you would see if a drug like that was initiated, you see somebody started at two milligrams, three milligrams, four milligrams wait as long as possible between the different stages of titration and then once the symptoms were resolved, hold that dose. So it would be more common now to see somebody start at two and end up on four milligrams of risperidone than the old strategy of, well, let's give them 16mg of risperidone and work our way down as the psychosis resolves.
Lucy: [00:20:52] And did this transition happen as a result of adverse sort of events or...
Dr. Remington: [00:20:56] Well, we certainly had our share of adverse events. There's no question about that. We had a lot of trouble with with acute dystonic reactions and motor movements and so on. But it actually was driven in large part by work, again, done in part here at the centre, which was in the late 1980s and late early 1990s. We finally had the opportunity to begin to evaluate dosing centrally through imaging. Historically, it always had been done based on peripheral kinetics, but with the opportunity to look centrally at the relationship between these drugs, their dose and D2 occupancy, both here at CMH and at the Karolinska in particular, we were begin to we were able to begin to establish what amounted to very concrete thresholds for D2 occupancy and then link those to specific antipsychotic doses. And it was that kind of information that afforded us the opportunity to appreciate that the kinds of doses we've been using historically were just absolutely out of line. So, so when I trained as a resident I'll give you an example, we our starting dose of Haloperidol was ten milligrams. When we did our occupancy work in the early 1990s, we established that two milligrams of haloperidol crosses the threshold for optimal chance for clinical response, which is around 65% D2 occupancy.
Dr. Remington: [00:22:35] So we had for the very first time again these data that would allow you to take most drugs, not all drugs, but most drugs, and be able to say if you want to reach that kind of occupancy level, here's exactly the kind of dose that you need. And that in turn translated to a dramatic reduction in the doses that were being used on a daily basis for the treatment of individuals. We can't do that with certain drugs. And so, for example, people will say to me, well, what's the correct, we talked about clozapine at the outset, what's the correct dose of clozapine? I can't tell you the correct dose of clozapine. I can't tell you the correct dose of aripiprazole and I can't tell you the correct dose of quetiapine for different reasons. Clozapine and quetiapine because of their kinetics in terms of K off and aripiprazole because of its partial D2 agonism. But notwithstanding those three drugs, we could literally scan somebody and we have done that with most of the drugs and tell you what the proper dose of an antipsychotic is to optimise clinical improvement.
Henry: [00:23:51] So let's say we started Muhammad on a smaller dose of some sort of antipsychotic. When do we decide that that antipsychotic is not working for him?
Dr. Remington: [00:24:00] Good question. And we have to acknowledge that that decision making is being influenced now by the pressures of moving people through. So in 1994, I had a discussion with Pat McGorry, who started the first first-episode program in the world in in Melbourne, and his comment to me when we were talking about our PET data was I'm going to start somebody on two milligrams of risperidone and keep them on it for 30 days. And of course in the best of all worlds, that's probably not a bad strategy if there's no reason to increase the dose. But but in fact, that's not possible in acute care settings as a rule any longer and you don't need 30 days in order to establish whether or not a drug is working or not as a rule. In fact, some of the work, again done out of this particular centre has identified that in the case of antipsychotics, about 50% of the improvement that you see in antipsychotics occurs within the first 7 to 14 days of treatment. So the current recommendation and I think it was based embraced in the guidelines was that you look to whether or not you're getting a response in the first four weeks at a reasonable dose. And if that isn't evident and there's a partial response, you may choose to continue it for another four weeks at least, in order to establish whether that drug is going to work or not. Whereas if you're not seeing any response at four weeks, you're probably very likely not going to see a response with that medication and you might as well move on. Indeed, arguably, you should be moving on and we've not done that very well in past years. And the reason why it's so important to move as efficiently and systematically as possible is the data that suggests that duration of untreated psychosis is associated with poor outcomes. So clearly, you want to get from point A to B in a timely fashion.
Henry: [00:26:20] So say the medication didn't work at all four weeks in, do we, so we switch to another antipsychotic in the same class? Different class?
Dr. Remington: [00:26:31] Well, you raise a good point. The classes are not near as clear as when I was working as a as a resident. But you certainly switch to another medication, and most of them are of different classes, depending upon which way you want to define class. But when we published our data, looking at the first two trials before clozapine, we arbitrarily looked at two medications in particular, risperidone and olanzapine. And what you choose should be done in discussion with the individual who you're treating and discussion of the side effects that may occur with a particular drug and what they would hope to avoid and what they're willing to tolerate and so on. So, for example, an olanzapine-like drug, of course, carries a very high load in terms of metabolic side effects, whereas risperidone may be better in that regard, but carries a greater propensity for movement disorders.
Alex: [00:27:40] So taking this to, I think maybe its natural conclusion, if now we try Muhammed on a second antipsychotic and that doesn't work for him, what do we do now? I mean, I think we learned after two adequate trials, we try clozapine now because that's treatment resistant schizophrenia. But can we be very specific about what exactly is treatment resistant schizophrenia, because we don't, what does that mean in terms of the dose of antipsychotic and how long and...
Dr. Remington: [00:28:07] Sure. And treatment resistant schizophrenia really evolved through the 1980s, and it arose out of the recognition that these drugs, which were supposed to be a panacea, in fact, weren't. And so by the 1980s, it became clearly evident that there was a significant proportion of individuals with schizophrenia, in the range of about 30%, who weren't responding to the antipsychotics that we had in hand. Now, by the late 1980s, the seminal work with clozapine was done, and it identified that for those individuals, individuals who had failed two adequate trials of antipsychotics, of the other antipsychotics that is, in and adequate in terms of both duration and dose, then they would be deemed treatment resistant and candidates for clozapine. And we actually had data that came out of some of the work done here that allowed us to sit down and talk figures with individuals. So we knew that when somebody had their first break and they were treated with an antipsychotic, that roughly 60 to 75% of those individuals would respond to drug A. Now, if they didn't respond to drug A, regardless of what drug you chose for trial two, your chances of getting a response dropped from that 60 to 75% down to 15 to 20%.
Dr. Remington: [00:29:44] So we saw this precipitous decline in treatment response. But still, the guidelines are that you don't use clozapine until there's been two adequate trials if they can be tolerated. So we do advocate and I would argue that families, if they were told, well, here's clozapine as your second line treatment or here's another drug, and we can tell you in another 4 to 8 weeks whether or not that drug is going to work, they would probably choose to have the second drug trial before they moved to clozapine. But that said, if in fact you don't respond to that second antipsychotic and of course the odds are relatively low, because you only have about a 15 or 20% chance of responding to drug two, then certainly your odds for response to clozapine, now having met the criteria for treatment resistance escalate considerably. So your chance of responding to clozapine for that third trial would be in the range of about 40 to 50%. In contrast, where if you reached for a third non clozapine drug, the data would suggest that your chance of response with that third agent non-clozapine drug is probably less than 10%.
Lucy: [00:31:09] Can you tell us a little bit about what like how why clozapine is so special or maybe a little bit about the story of clozapine?
Dr. Remington: [00:31:18] Clozapine is a very interesting drug. I like history. So I'm going to bore you with just a bit of history.
Lucy: [00:31:23] Oh, we love it, too.
Dr. Remington: [00:31:24] Oh, good. Because. Because, in fact, having done a PhD in pharmacology and been in this field for a long period of time, I was trained that it was the hypothetical deductive strategy that would move us along in the field. But in fact, that hasn't worked in the field of psychiatry and clozapine is a perfect example of that. So indeed, the whole history of antipsychotics is a perfect example of that. So chlorpromazine, which was the first antipsychotic available to us, was never synthesised to be an antipsychotic, it was to be a pre-surgical anaesthetic synthesised in 1948 and 1949 serendipitously found to have antipsychotic properties and in 1952/1953 part of the work being done here in in Montreal was what took it to be established as an antipsychotic. Now clozapine has a similar story. Clozapine was synthesised in 1959, was supposed to be a tricyclic antidepressant and through various sorts of circumstances ended up being identified as an antipsychotic by the 1960s and was unique not because they had identified that it was a drug that worked with TRS, it was unique because it didn't invoke EPS at therapeutic doses. It was fast tracked and released in a small group of Scandinavian countries in the early 1980s and a cluster of people died within the first year following its release, later to be established secondary to Agranulocytosis. And it was for that reason that that almost all countries in the world chose to withdraw clozapine at that point.
Dr. Remington: [00:33:20] But seminal work done in the 1980s, looking at clozapine in those who failed other antipsychotics, allowed it to be resurrected in a lot of countries like Canada and the United States again, with strict guidelines in place that this would be the only population that it would be used in: people who had failed, as the criteria were established, two antipsychotic trials of adequate duration and dose or intolerable side effects that pre-empted adequate trials. So it was reintroduced here in North America in the early 1990s and revolutionised the field because for the very first time we had a drug that was different from all other drugs. But having said that, and I get this question asked of me all the time is, is to your point is clozapine a unique drug in schizophrenia? No, it's not a unique drug in terms of, I don't believe and I don't think the evidence supports that that clozapine will work better in first episode schizophrenia, where it works better is in treatment resistant schizophrenia. Now why would it work better in treatment in first episode schizophrenia is we now have data indicate that roughly 85% of treatment resistant schizophrenia walks through the door with a first episode psychosis. So so people don't evolve into treatment resistance the way we often conjure up that that term, a small percentage of them do but in fact, most people have treatment resistant schizophrenia when they walk through the door with a first episode psychosis. We don't have any biomarkers or endophenotypes to identify them. So as a result, we give them our two trials and then finally say you must have treatment resistant schizophrenia and we should put you on clozapine. And so for those individuals, I would like to see them at first episode get schizophrenia, but we struggle on two levels. One is, as of yet, we can't find biomarkers or endophenotypes that would clearly say you should be on clozapine from the outset because you have a treatment resistant form of the illness. And secondly, we clozapine is of the old sort of phenothiazine type of medication. It's a very heterogeneous receptor binding compound and to try to dissect what accounts for it's unique profile in the treatment resistant population has proven incredibly difficult. And to this day, we still have no idea why clozapine is effective in people with treatment resistance. Now, I should tell you, do I get to still talk for a minute? Okay. So we now recognise that only about 50% of those people who we identified as treatment resistant are going to respond to clozapine. So in the early 2000s somebody, in Montreal interestingly, coined the term ultra resistant schizophrenia and set up some criteria which we have since modified in a paper subsequently but we now recognise that in those who meet criteria for TRS, only about 50% of them will respond to clozapine, a figure that's made worse by the fact that many people will choose not to take clozapine. And if you have TRS and you choose not to take clozapine, again you're running with less than a 1 in 10 chance of responding to whatever antipsychotic they give you. But in terms of the clozapine resistant population or, what Mouaffak chose to call ultra resistant schizophrenia, it's those who now I focus on with most of my time in research because they are the group for which we have no treatment whatsoever. So for all the work that we've done, looking at what should be implemented after clozapine, and you see it in our Canadian guidelines, we actually drew a line in the sand. I think we were the first guideline to do that and we indicated that we would not make any recommendations for what to do after somebody failed clozapine and it was based on the recognition that for all the drugs that have been tried, none, including ECT, which probably ranks up there as one of the better options, has got enough data to say with conviction that there's enough evidence-based research to support moving the treatment algorithm beyond clozapine at this point.
Alex: [00:38:27] So there's not enough evidence from a guideline perspective to make clear recommendations there. But as a clinician who probably encounters that, what do you do to the ultra treatment resistant patient? What do you do for them? Typically.
Dr. Remington: [00:38:44] There's endless numbers of strategies, what almost all people do, because it just seems so intuitively correct, is that they try to augment with another antipsychotic. This idea that, well, clozapine doesn't have a lot of high affinity D2, so let's give them a D2, a potent D2 blocker like haloperidol or risperidone in combination or so on and so forth. But indeed, if you look at that, which is by far and away the most common strategy to try to treat clozapine partial responsiveness, there's no evidence whatsoever that adding another and it just it just keeps going on and on because we've tried so many different strategies: mood stabilisers, antidepressants, even glutamatergic compounds. Indeed, if you take a glutamatergic compound and you give it in addition to clozapine, there's often evidence of clinical worsening, interestingly. So we still struggle and unfortunately we haven't, I think we've obfuscated the issue by suggesting that you can do this, this and this after clozapine, when we should have been a bit more frank and honest and said there really isn't any evidence and we need to be devoting a lot more resources to what do I do when Clozapine fails from a research standpoint. So at the very least, we don't expose people to all these trials of compounds that clearly have no evidence for working. Interesting, I mentioned the ECT story. Very nice paper came out of New York in 2014 indicating that ECT might be a useful strategy in people with clozapine partial response but having said that there is only the one RCT to this point and that's probably enough, not enough and that was our position when we put the guidelines together to advocate, well, this is compelling evidence that ECT should be your treatment of choice.
Lucy: [00:40:54] Do you think in ten years that that's like in terms of ultra resistance, like ECT is going to be a part of the guidelines?
Dr. Remington: [00:41:01] I certainly could imagine if somebody could replicate that particular trial. As you can imagine how difficult it is to do a blinded, controlled trial with ECT in a clozapine partially responsive individual. But having said that, that's the kind of evidence we need. Or conversely, we need serendipity once again to step in and I think that's probably how the next major breakthrough will occur in terms of moving us beyond clozapine. It won't be through a hypothetical deductive strategy. It'll be somebody, by chance, tries something that doesn't really make sense, but translates to opening up a door that we just didn't know existed.
Lucy: [00:41:48] And I guess pragmatically, from your clinical practice, how likely is it that a patient stays on clozapine once they've started?
Dr. Remington: [00:41:56] Oh I just found out some data on that in the last month. So about half of people will stop clozapine in the first 12 months after they're started. So many people refuse clozapine and unfortunately, in many ways that's a kiss of death inasmuch as we just don't have another drug that's clozapine-like. We have olanzapine, interestingly, which was shown in the Catie trial and which was shown in a couple of other projects to maybe be the next best choice. And there was a nice blinded study done with olanzapine 30mg suggesting it might be an option for people who say no, I don't want to take the clozapine. But beyond that, we really don't have any other options for the clozapine story. So for those who say, no, I don't think then what we do as clinicians is, because we are in the business of selling hope and trying to give people every opportunity to improve, is we generally do move through all these hoping that at least you'll have that maybe 1 in 10 chance of responding to a drug that that they haven't yet been tried on. So generally what we advocate is that if you want to continue with strategies in a person who's proven to be clozapine partially responsive or chooses not to take clozapine, that at the very least you be cautious. So what you do is you you choose a drug based on what existing evidence there might be and then circumscribe the trial. That is, make the trial 12 weeks. But rather than just leave that drug hanging, as we so often do in this population so that they end up on 4 or 5 different medications, instead what you do is you quantify outcome. So we strongly advocate using scales rather than just your personal judgement as to whether that added drug helped and then at three months, if there's no compelling evidence to indicate that it's improved, then discontinue it and move to the next trial. I would also point out that when I'm talking about this, I'm talking about psychosis and I underscore that because I'd said earlier on that clinical recovery and functional recovery are independent of each other. And I say that because we only have a drug for one domain in this illness and it's the positive symptoms. So our drugs are antipsychotics, they're not anti-schizophrenia drugs. So we get the people better in terms of their psychosis but what we don't see is that translate to functional recovery. So they follow independent courses and the thinking is that even with resolution of the positive symptoms, the rate limiting steps that account for why functional recovery doesn't fall on the heels of the improvement in psychosis is that you have these other domains, the negative symptoms and the cognitive symptoms that aren't treated by the current medications that we have available. And consequently the individual, because of the resolution of positive symptoms, isn't in the same position to return to their level of functioning that they saw before the onset of the illness.
Alex: [00:45:38] I don't know if this exactly segues because I don't know the answer to this but do we have, outside of medications, treatment for those functional outcomes, like do our psychosocial treatments, do they touch on that? Can we touch on those topics, how they work?
Dr. Remington: [00:45:53] Sure. And I will say I'm not the resident expert in non pharmacology, so I start by that caveat. But obviously we've always needed to look for strategies that would take us beyond just medications and you see it in the most recent guidelines, now embedded in the guidelines now are CBT, for example, they're in the NICE guidelines they're in our guidelines. And we recognise that a lot can be done with non-pharmacological strategies and certainly in terms of strategies to help deal with the trauma of having this illness, trying to work with the symptoms that might persist and understanding the illness, an intervention like CBT can be extremely useful. The psychoeducation for the family, ensuring that the families involved, because one of the problems we struggle with is that many individuals, it's just so hard for them and their families to embrace the illness that as soon as we see resolution of the symptoms, there's talk of discontinuing the medication and not requiring further treatment. Supported employment from the standpoint of functioning, for example, is proving to be probably more effective than many of the old rehab strategies that we embraced for a number of years. So there's increasing evidence that and efforts, I think, to look at more innovative strategies that would allow us to improve in these other areas that take us well beyond the medication. Because, again, the medications have not been useful at all. It's not that they don't effect some changes, but the magnitude of the effect size is so modest that it doesn't translate to clinical improvement or functional improvement, as the case may be. So you can imagine, as is the case, that there's lots of interest in coming up with now new classes of medications that would address the cognitive symptoms and the negative symptoms. But at the same time, those are the kinds of domains that can very likely be enhanced with non-pharmacological strategies as well.
Alex: [00:48:22] Right. So there's no medication that will increase your likelihood of finding a job but if you help someone out with supportive employment, you can potentially increase their level of functioning.
Dr. Remington: [00:48:33] And indeed, you know, we now, even with cognition, for example, we used to just talk about cognition and in fact, when I trained as a resident, we didn't even bother talking about cognition. We only talked about positive symptoms. But then along came this concept called cognition and by 1990s, it really had gained legs in terms of its potential impact on the illness. Well, even subsequent to that, we now have that further subdivided into neurocognition and social cognition and that opens the door for not only developing unique strategies that are specific to improving people's neurocognitive abilities, executive function, verbal recall, those sorts of things, but we're also now much more sensitive to some of the social cognitive deficits that people struggle with, that are seen from a clinical standpoint in the form of symptoms like social withdrawal, anxiety, social anxiety, those sorts of things. So we have a number of doors now open to opportunities for non-pharmacological strategies that can hone in on these other domains.
Alex: [00:49:53] Right, it's not just about medications, it's about building our other resources, psychotherapy, CBT and family interventions and all of that is part of the treatment as well. Up until now, we've spoken about this as if Muhammad is nodding his head to all of these treatments and agreeing. But I think we all know around the table that with schizophrenia often comes a lack of insight into the illness itself. These patients can often not realise what's going on or not be agreeable to starting a treatment. How do we help someone who is not having much insight into their illness?
Dr. Remington: [00:50:35] Again, we certainly want to keep the families involved as much as possible. I don't think there's a single instrument that's as powerful as having the family on board in terms of of trying to to engage individuals. And then, of course, education around what this illness is, and it's such a foreign concept to most individuals, the whole idea of hearing voices or believing that people in the next room are talking about you, those sorts of concepts, it really requires a lot of education around two things. One is the symptoms that constitute this illness and the symptoms that take us certainly beyond the psychosis per se, but also the stigma of the illness. So for all the gains that we've made in mental health, and you can see just how far we've come in the last ten years with major industry embracing support for mental health and so on, we still have not made robust gains in the area of serious mental health issues like schizophrenia. It's still an illness that's stigmatised. It's stigmatised in the literature, it's stigmatised in social media and the movies. And so we have a considerable ways to go in terms of destigmatizing it for individuals who have the illness and for their families and supports as well. So there's a lot of work that needs to be done in that area. But to your point, and it's an excellent one, many people who, and it takes us back to something we talked about at the outset, as soon as their symptoms resolve, the next point to be made is, well, I don't need these medications anymore. And unfortunately, the reality clinically is that you will have to see people through perhaps several episodes or relapses where they've chosen to stop their treatment before they recognise that, from a cost benefit standpoint, they're probably much better off taking the medication. And again, we've tried to to certainly be more comprehensive in offering treatment beyond medication and in addition to that, be much less confrontive around the medication in terms of, you know, the history of using excessively high doses and multiple medications and so on.
Alex: [00:53:22] I know we're a little over time here. I don't know if we have time for one more question or...
Lucy: [00:53:30] So concluding question?
Lucy: [00:53:32] Yeah I guess there's been a lot of public discourse now in the domain of like the effectiveness of antidepressants in treating depression and like it's been on the agenda recently. And I'm wondering what your stance is on antipsychotics and schizophrenia, kind of like one concluding statement about that and then maybe transitioning that to your thoughts about the future of treatment of schizophrenia and what that would potentially look like.
Dr. Remington: [00:54:00] I would argue that the evidence remains compelling that antipsychotics work for psychosis. But having said that, I would also, touching upon several points we made in this talk, would argue that the current antipsychotics we have falls short of treating the full forms of the illness that we now recognise. I would conclude by saying that schizophrenia is not a single illness. It's a heterogeneous group of disorders that require different treatments and that I think going forward the next big breakthrough that we have will be very much a personalised medicine sort of strategy whereby we acknowledge that there are these different forms of illness, and this is actually where we spend a lot of our time now, and that if we had the capacity, as we do in other areas of medicine, to say, well, this is the form of cancer you have or this is the form of illness you have, that we will do much better in terms of overall outcome by being able to say, well, schizophrenia is not a single entity. You have this type of psychosis and this seems to be the best strategy for this type of psychosis as compared to that or so on. So to your point around the drugs we have, dopamine blocking drugs, which is the prototype of an antipsychotic work for one form of the illness. But we clearly have other forms of the illness that require other strategies, clozapine-responsive patients being one such example. And then those who fall in the non-clozapine response population have to have a different underlying pathophysiology, just by definition.
Lucy: [00:55:49] Any kind of advice that you have for future sort of potential medical students interested in the field of psychiatry and maybe convincing Henry to go into psychiatry. And what's so special about the practice for you?
Dr. Remington: [00:56:01] Well, psychiatry in and of itself kind of interested me but schizophrenia interested me a lot. And so I would argue that this isn't, psychiatry is incredibly fascinating, but schizophrenia is even a notch above. I would advocate strongly that if you have an interest in psychiatry, test the waters with schizophrenia and see it, it's so interesting on so many different levels and it's such a disenfranchised population.
Alex: [00:56:33] Well, thank you so much, Dr. Remington, for sharing your interest and passion about schizophrenia with us and our audience. It was quite the tour, all the way from chlorpromazine, clozapine up until the future, what the future holds in terms of maybe individualising these treatments and not thinking just about the antipsychotics, but also thinking about the other ways we can help people with schizophrenia. I think it was terrific. So thank you so much for being with us today.
Lucy: [00:57:00] Thank you so much. Thanks.
Lucy: [00:57:02] 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. This episode was produced and hosted by Lucy Chen, Alex Rabin and Henry Barron. Our theme song is Working Solutions by Olive Musique. A special thanks to the incredible Dr. Gary Remington for serving as our expert for this episode. You can contact us at info@psychedpodcast.com or visit us at psychedpodcast.org. Thank you very much for listening!
Episode 26: Nutritional Psychiatry with Dr. Laura Lachance
Episode 13: Psychiatric Rehabilitation with Dr. Abraham Rudnick
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Alex Raben: [00:00:10] So welcome to PsychEd, the Psychiatry podcast for medical learners by medical learners, and today we have an episode on psychiatric rehabilitation with Dr. Abraham Rudnick. And this is an interesting episode because usually we, behind the scenes, do a lot of preparation for our episodes and we know a lot already about our topic, and this time we don't really know what to expect. So that's a first for us. Before we get started, though, let's do our introductions. So I'm Alex Raben, I'll be hosting today, and I'm joined by my colleague Aarti Rana.
Aarti Rana: [00:00:49] I'm Aarti Rana. I'm a second-year psychiatry resident here at the University of Toronto.
Alex Raben: [00:00:54] Yes, and we're joined today, as I said already, by Dr. Rudnick. Dr. Rudnick, can you give us a bit of an introduction to you, please?
Dr. Rudnick: [00:01:01] Sure. No problem. And thanks for asking me to do this. So I'm a psychiatrist. I'm also a PhD trained philosopher, and I'm a certified psychiatric rehab practitioner. I'm just now moving into a new position. So moving from Ontario to Nova Scotia to be the Clinical Director of the Operational Stress Injury Clinic of Nova Scotia and a Professor of Psychiatry at Dalhousie University with a cross-appointment to occupational therapy at Dalhousie, which is very relevant to psychiatric/psychosocial rehabilitation, because obviously occupational therapy has a lot to contribute as well as other mental health services.
Alex Raben: [00:01:44] Great. Thank you for that. And where are you coming from?
Dr. Rudnick: [00:01:47] So maybe just a tiny bit of preliminary background even before my most recent position. So I was trained in psychiatry and medicine first, then military medicine, then psychiatry in Israel, which goes back to my roots a bit in military medicine. Then I did a fellowship at University of Toronto with a double focus, one in philosophy of psychiatry and one in psychiatric rehabilitation at what was then called Whitby Mental Health Centre, which is now Ontario Shores, and during that I also certified through an American national organisation in psychiatric rehabilitation. And most recently I've been the executive Vice President of Research and Development and Chief of Psychiatry at the Thunder Bay Regional Health Sciences Centre in Ontario, as well as a Professor of Psychiatry at the Northern Ontario School of Medicine.
Alex Raben: [00:02:45] Great. Thank you for that. So maybe we can start off by unpacking this term, psychiatric rehabilitation, because it's not something that, at least in our curriculum here at U of T we use very often or I've honestly never really heard those two words really put together. And when I think about rehabilitation, I think more physical rehabilitation, like physiotherapy after an injury or something like this. Can you help our audience who may also be like me and not very familiar with this terminology, understand what it's all about?
Dr. Rudnick: [00:03:18] Absolutely. And I think it's symptomatic in a sense that you haven't heard about psychiatric or psychosocial rehabilitation, those are synonyms, because we don't expose our learners both in psychiatry as well as in social work or even occupational therapy, psychology and nursing enough to this. Psychosocial or psychiatric rehabilitation is one of the four main types of mental health intervention, one being pharmacology, another being psychotherapies in plural, a third being all the types of neurostimulation like ECT, TMS, DBS and so on and the fourth, last but not least, is psychiatric rehabilitation. So it's a whole world of evidence-based practices that focus on facilitating recovery of people with serious or other complex mental illness. Primarily historically, it was focused on people with schizophrenia, but that goes much beyond people with schizophrenia these days. The idea of recovery is a key point. And as you may know, the Mental Health Commission of Canada has highlighted recovery as the ultimate goal of all mental health services for all populations served by mental health services. And so maybe, just very briefly, I'll unpack what does recovery mean because if we understand the goal, we can understand the means to achieve the goal. So there are at least two types of meanings for recovery. One is the more traditional meaning, which is a set of outcomes that's called clinical recovery by people like Mike Slade, and that's about symptom reduction or alleviation, that's about more independent functioning, those types of outcomes. But the second sense of recovery or what's called personal recovery are the processes of recovery, which is about seeking, finding and keeping a meaningful personal life. And immediately you can imagine that that goes much beyond pharmacology or even psychotherapy. It's about the whole person's life. And that's where psychiatric rehab comes into play, because it focuses very much on helping people live the best life they can in their environments of choice. And if we have time, I'll explain a bit more, what does that technical term "environments of choice" mean.
Aarti Rana: [00:05:55] When you speak about recovery, usually recovery is referring to some kind of injury or event. And so in a physical rehab model, for example, someone might have a knee injury, they might be a military survivor of military combat. I imagine looking at psychiatric illnesses in terms of the concept of recovery would change how we think of the illness itself in some way. So how might someone thinking about recovery think about schizophrenia differently, for example?
Dr. Rudnick: [00:06:30] So they it's a great question. The idea of recovery is that, as Bill Anthony from Boston University said, we all recover from something in life, be it a divorce, be it unemployment, be it a loss in the family, be it an unaccomplished dream, and people with mental illness, in addition to many of those challenges, also have a mental illness to to address and cope with. So in a sense, recovery is not specific to mental health issues, but in the mental health sector, in the last 2 to 3 decades, particularly from the States and then after that in Canada, Australia, New Zealand, UK and other countries, the idea is developed into a whole social movement saying that recovery's goal is really not just about the adversity we face, it's about society accepting anyone with any kind of adversity and challenge fully. And so in the States it's been fairly political movement that has aligned well with psychiatric rehabilitation but is separate from psychiatric rehabilitation. Although there are a lot of people who straddle both camps. The main leaders of the recovery movement obviously are people who are recovering. So people who have had or still have mental health challenges. Some of the most famous ones internationally would be people like Patricia Deegan, who is a PhD psychologist who has published research on coping with voices for example, as well as on shared decision making in regards to mental health care. Still, according to her public acknowledgement, still receives treatment, still experiences symptoms, but still has a full life in spite of that, and sometimes even partly because of that, because it has brought new meaning and new purpose into her life. So when we say recovery, we don't mean cure. We don't even necessarily mean symptom remission, what we mean is people living a full life according to their hopes and to their abilities.
Alex Raben: [00:08:46] I have some questions about how we achieve the recovery, but before we get there, I'm having a little bit of trouble with some of the terminology because, right now I'm working in an ACT team, so we are very much recovery-focused and yet I've never really heard this rehabilitation terminology. And you're suggesting there might be actually two camps or a recovery and a rehabilitation camp. Are they different? Is there a lot of overlap? Are they the same? Is it just different preference and terminology?
Dr. Rudnick: [00:09:12] There's a lot of overlap. The terminology is fairly similar. I would say each country and even each province in Canada would have a slightly different take on that because it's quite contextualised. But by and large, the recovery movement is composed of people with mental health challenges and people who support them. And the psychiatric rehabilitation sector is not an ideological movement anymore, it was decades ago, it's now really an evidence-based set of practices that continues to change based on research generated and helps facilitate recovery based on the visioning of the recovery movement.
Alex Raben: [00:09:57] So it's like a yin and yang, almost? Okay.
Aarti Rana: [00:10:00] Could you describe where psychiatrists who are practising psychiatric rehab, where are they working? Are they working in the same hospitals that we would be doing our residency rotations in? Are there specific centres that they work in? Are they working privately and how does their work look different than the work of other psychiatrists who are working with similar patient populations?
Dr. Rudnick: [00:10:22] So it's a whole mix in different areas of the mental health system. But I would say that there are not many of us who actually do full-fledged psychiatric rehab, partly because there are very few psychiatrists who are certified in psychiatric rehab in Canada, even in the States, not many, but some are, partly because there are more traditional understandings of what recovery and recovery and psychiatric rehab mean by many of our colleagues. And so one of the things I've published about in my research is the notion of coercion in psychiatric rehabilitation. And we all know that legally coercion is sometimes allowed and even required in treatment, in enforcing medications when people are incapable and a risk to themselves or others. But some psychiatrists still think that that is also possible for psychiatric rehab and if you understand the basic definitions of what psychiatric rehab is, which is helping people achieve their life goals, then coercion is by definition not possible because no one can impose life goals on someone else. If they do, that's not a life goal anymore. So there's a logic to this that is a very strong logic and of course has ethical implications. And therefore, other than in very special circumstances like forensic systems where psych rehab is constrained, it is constrained, but parts of it could be allowed in all other aspects of mental health care. It's all about personal choice of the service users. And I think we need a lot more dialogue with psychiatrists and others about how does that look like when there's no coercion, not even an attempt to influence in a subtle, coercive way people's goals in life.
Aarti Rana: [00:12:20] So I'd like to try to summarise what you're saying. Someone who's practising psychiatric rehab in this way would be working with patients to try to identify their own goals in life and then adjusting what they do as a psychiatrist to help the patient further those particular goals. So the system that we work in would be secondary to what the patient's trying to do with their own life.
Dr. Rudnick: [00:12:48] Absolutely. And we would be, the whole mental health sector including psychiatric rehab, would be only one fairly small piece in the whole puzzle of a person's life, including the supported parts. And so in that sense, psychiatry can be flipped on its head and looked at as a support, not the lead of the person's life, but just the support that sometimes is needed and sometimes is not whether the person is or is not symptomatic. And therefore the person with the mental health challenge is the driver of their recovery-oriented care.
Alex Raben: [00:13:27] I was going to ask who defines recovery? And it sounds like from what we're saying, it's the person who's being treated or who has a mental illness. What about like, I'm thinking about my own clinical work, what about scenarios where the person has schizophrenia, and they have negative symptoms and they don't have much motivation to really come up with goals? Is, what would someone who's practicing from this frame of mind do in that scenario? Would they start to work with them to help them think of goals, or would they say no, actually their goal is just to be by themselves and be asocial, and that's how it's going to be.
Dr. Rudnick: [00:14:04] That's a great question and a segue into the process of psychiatric rehab because there's a structured process to go through. This is not just an art. And so Boston University is an example, their psychiatric rehab centre has published for decades now that approach of, how do you help people who are not clear on their life goals get to the point where there's clarity and then psychiatric rehab can start. Because if the goals aren't clear, then we can't really proceed. PSR, psychiatric rehab, is focused on people's life goals. So there is a process, a preliminary process called readiness assessment and development. So psychiatric rehabilitation readiness assessment and development, it's not exclusive of people. It doesn't say people are not ready to, just helps better understand the clients as well as the providers at what level of readiness the person is. It's structured into a few components. The first and most important probably is does the person have a felt need for change in their life, in any aspect of their life, in what we call environments of choice, be they residential, vocational, educational, social, sexual, health care, environment, spiritual and so on. If they don't, then there's a dialogue. Why not? If it looks from outside like maybe their life is not that great, but it's their choice to change or not.
Dr. Rudnick: [00:15:32] If they do have a felt need for change then there's another component of readiness, which is are they committed to invest effort, time, sometimes even money into change? We know from behavioural change in general, in the general public, that a lot of people feel a need for change. But when it comes down to committing to that, for example, weight reduction, it's not that easy. And so if a person isn't committed enough, maybe it won't work. And there are a few other components of readiness, such as awareness of personal values and preferences, awareness of environmental possibilities and what's not possible, and eventually also the ability to connect with someone to work on this together. If the person isn't ready enough to put in place a goal for rehab, then there's a structure, that a process that looks very similar to motivational interviewing and often actually uses motivational interviewing to help them explore whether they do want to change their readiness. And so that's one of the interfaces between psych rehab and psychotherapy, for example. There are many other interfaces, so using skills from motivational interviewing can very much facilitate that readiness assessment and development process.
Alex Raben: [00:16:48] And then along the same example, does at that very early step, does it ever is there ever a point where you say it's the person's mental illness that is preventing them from forming goals and we need to treat the mental illness, perhaps even coercively, before we can get to those goals.
Dr. Rudnick: [00:17:08] It can happen. From my experience, it's not often that that happens because even if a person is actively psychotic and let's say their goal seems to be delusional, there are ways to break down a goal. And this is coming from human services, not from the health sector. How do you break down, help people break down their ultimate goals into steps to achieve that? And so often during that process, the person realises that, as an example, they may have initially wanted to be an astronaut, but because it's very unrealistic plus they've discovered that their interest is actually in astronomy and not really in being out there in space, that they may actually shift or focus on those interim steps, interim goals and be more than happy with that. So typically, that would be the readiness process where you're exploring why and what in fine detail. As you can imagine, this can take many months to just get to a clear goal for rehab. So it's very time consuming, but that's okay. We know from physical rehab, which is a model for psychiatric rehab, that things sometimes can go slow, but so long as it's clear where they're going towards, it's fine.
Aarti Rana: [00:18:30] And let's say someone is ready. So they you identify that they are ready, they're committed, and they have a clear goal. What happens next?
Dr. Rudnick: [00:18:39] So now you start with the actual bread and butter of PSR, psychosocial and psychiatric rehab, which is about identifying what are the skills needed for that particular environment of choice. I'll define what that means in a moment and what are the supports. So the two practical pillars of work practice in PSR are skills and support. And as you can imagine, there are many types of skills: cognitive, emotional, practical, social and many other skills. And similarly, there are many types of supports: social, physical supports, time supports and other supports. And so the planning with the client is to identify, for their environment of choice, what skills they have, what skills they don't have but are needed as well as what supports they have and what they don't and what supports are needed. An environment of choice literally means what setting and what role in that setting the person wants. That's a rehab goal, the environment of choice. An example would be a person wants to be a tenant in an apartment. That's a role in a setting, that's an environment of choice, putting the role and setting together. And that's the goal. That's a very specific practical goal. Now, if they wanted to be a resident in a group home, it's also a residential environment, but it's very different. The role is not a tenant and the setting is not an independent apartment. So expectations for skills and supports are very different. They would have to have many less skills in a group home and many more supports. And most people, when you ask them, prefer it the other way around to have more skills and less support in order to be as independent as they can. And we do have in Canada still a system of many group homes which is called sheltered residential rehabilitation. It's not evidence-based and some people are there for life because they've been there for decades. But most people, particularly the younger population, would prefer to go to the supported housing sector, which is more skills and less support, but there still are supports as needed. And so that's the process you identify together. What are the skills and what are the supports needed for both success but also for satisfaction. And that's part of the complexity of rehab, because we all know from our life and that's the whole exercise of rehab is learning from ourselves, is that sometimes success conflicts with satisfaction. We hope to achieve both in an environment of choice, but that doesn't always happen. So when we're planning psychiatric rehab, we need to flesh out those issues. Could there be a conflict between success and satisfaction for the person. They may not have enough life experience to actually know that in advance, and that's part of our role, to help them think it through and make some tough choices sometimes.
Alex Raben: [00:21:47] So it sounds like from what you're saying, it's, psychiatric rehab is more of a framework almost where you then can plug in like psychotherapies, for instance, or cognitive psychotherapies, emotional psychotherapies to help build skills and then social supports to help fill supportive needs, rather than it being a single intervention in itself. Is that so?
Dr. Rudnick: [00:22:12] It's both, you're right, but it's both. It's both that framework where you can input interventions from other practices like psychotherapies, for example, but it also has its own set of skills-building interventions and support-building interventions. I should also add it's not just about building those skills and support, it's also maintaining the effective adaptive skills and supports because skills and supports, even if they're very effective, can easily erode. So if someone is in hospital for a few months, their basic daily activity skills may erode. And we need to be very mindful that long stays in sheltered facilities like hospitals may actually cause some harm. And therefore, if they're absolutely needed for safety, for example, then we need to do active work in those facilities, in hospitals and other facilities to maintain the skills the person is brought into the facility. And the same would go for supports, if someone is admitted to hospital and then they lose their apartment or are evicted and a new apartment is found, we need to make sure that the right supports are in place based on their recovery goals. And so a typical example would be someone is in hospital, they're now finding a new apartment, but there's no laundry facility in the building. So they need to do laundry, if their apartment is located in an area where there is no laundromat anywhere nearby, they may not be able to do laundry. That's a recipe for disaster. And it's very simple, very practical but we have to think of those aspects of life that are critical for people to live a good life.
Aarti Rana: [00:23:59] In a sense, what you're describing is a deep study of an individual, one at a time in a kind of n-of-one. So you have a whole system that one by one looks at the n-of-one and says, okay, what are the factors that are limiting the goals that this individual has identified for themselves?
Dr. Rudnick: [00:24:16] Absolutely.
Alex Raben: [00:24:17] So very personalised medicine already at our fingertips.
Dr. Rudnick: [00:24:21] Very. And very it could be very low tech because this is really about the interpersonal connectivity between the service provider and the service user. It could be expanded to more people, but the core of the intervention is you and the client. It could be the rehab practitioner and the client if it's not the psychiatrist leading the rehab part, but it could be a psychiatrist, which I found personally to be fascinating work because you actually are invited by the service user to every aspect of their life that they want to consider changing.
Aarti Rana: [00:24:56] You know, I happen to be currently in a psychotherapy seminar group and we're reading some of early Freud's early papers and he talks about listening to patients and actually listening and seeing what's there with a completely open eye because there was no psychiatry, right? There was no sense of what you're supposed to do. And what you're describing is a little bit of that as well. I wonder if you can speak from your background in philosophy to what you're doing in this model that wouldn't be present in other models.
Dr. Rudnick: [00:25:29] Yeah, absolutely. I think the first pioneers of psychiatry like Freud and even before him, Kraepelin and so on, were looking at the whole person. They didn't have the intervention means, even Freud initially, to actually make much of a difference in the person's life but they could actually look at the person's life and they did. So from a philosophical perspective, we're talking here about a holistic approach, not H-O, W-H-O- holistic, a whole person, but also a whole system approach. And there's a similarity to physical rehab, again, which was one of the sources of inspiration for psych rehab, which were we're looking not just at the person, we're looking at the fit between the person and their environment of choice. So if you look at the person with physical disability and how rehab work proceeds with them, it's about finding out what their goals are and then finding the fit, based on those goals, between the person and their environment. And if the environment needs to change, such as ramps for people in wheelchairs, elevators for them and so on, so be it, the environment has to change and it's legislated. It goes the same for people with psychiatric disabilities. That's the focus of psychiatric rehab. It's just sometimes a bit more difficult, challenging to figure out what are those technically termed "accommodations" in the environment that would optimally support the person.
Dr. Rudnick: [00:27:00] But the research is pretty clear. In general, there are many types of accommodations, but two that stand out are social supports in environments of choice and time flexibility. So in the work environment, for example, if someone has difficulty getting up on time because they're heavily medicated or because they have some negative symptoms, an employer who is flexible and accommodating would allow them to come late to work but then finish work late. So they're still working the full workday, but they're just shifting it. And so part of the work of rehab is to not just work with the service users, is to work with their environments. Very well known evidence-based model is called supported employment, specifically individual placement and support, IPS, highly replicated in randomised controlled trials and systematic reviews. And one of the jobs of the rehab practitioner there is to work with employers in general in their region, not even specifically in regards to a particular client, but to help them destigmatize, better understand and learn what supportive accommodations are so that the next client coming their way would be better accommodated.
Alex Raben: [00:28:15] You touched a little bit on the the literature there and the research, and earlier you said that it's not just about plugging things in,there is an actual sort of codified treatment here. So in my mind, I'm wondering like, is this sort of like CBT in the sense that people have written all this down? There's manuals, people practice in a certain way and then there's research on that. And if so, what does that research look like? What are the outcomes like?
Dr. Rudnick: [00:28:44] Yeah, absolutely, much of PSR now is manualized. An example would be IPS, supported employment, including fidelity measures similar to psychotherapies, where you can evaluate if a service is working enough to the model, close enough to the model, and they can be rated on that. And the research shows the lower the fidelity, the less effective the service is compared to what's been published in randomised controlled studies. So IPS would be a great example for that. There are practices that are not yet fully evidence-based in psychosocial rehab. For example, in the vocational rehab environment, social enterprise would be an example of a promising practice that has some research to support it, but it's not yet as evidence-based as IPS, as supported employment. But it's promising enough that people are actually doing more research, including randomised control trials on that. One of the challenges in that in the methodology of the research is that doing RCTs on each and every psychosocial intervention is sometimes challenging. And even psychotherapists would argue that for some psychotherapies, because randomisation of course removes choice to some extent and there are some challenges, you can't blind these interventions, the psychosocial interventions. So, you know, compared to biological interventions, they're considered a bit weaker. But there are statistical and other ways to strengthen the studies, including using quasi experimental research, which is not RCTs but if it's done with large enough samples, it can be very, very effective, very helpful, very informative. And so I think a lot of people are recognising that for some interventions, just sticking with RCTs may not be enough, we may need RCTs, but we also may need more creative, rigorous methodological designs in order to demonstrate whether an intervention is effective or not. And I and many other rehab practitioners don't use the term treatment because that's actually very specific to the biomedical approach. We use the very generic term intervention, treatment is one type of intervention, rehab is another type of intervention.
Aarti Rana: [00:31:07] So if you're a medical student or a resident in Canada and you wanted to have an opportunity to work and do an elective in this model, where would you go?
Dr. Rudnick: [00:31:16] So you would probably want to look up psychiatrist who are CPRPs or CPRRPs That's CPRPs is an American designation, psychiatric rehab practitioner. CPRRP is a Canadian designation, the Certified Psychosocial Rehabilitation Recovery Practitioner. They're on the websites. Very few of us psychiatrists with that, but we're available. I know some in London where I worked in the past, now in Nova Scotia, I'm there. There are a few others but if it doesn't have to be with a psychiatrist, there are a few occupational therapists, social workers who can supervise that. I would also encourage looking at getting that designation with enough training eventually and also there are courses in psychosocial and psychiatric rehab. So in Canada, the two at least two colleges who provide that online training. One is Mohawk College in Hamilton, another is Douglas College in in British Columbia. There may be others and it's those two are all online. So it's an opportunity to at least get the basics of the training of PSR with many other practitioners, including service users. So patients take those courses too. No one is excluded so long as they can play, it's a fairly nominal, pay, it's a fairly nominal fee and based on that you gradually get a very diverse workforce.
Alex Raben: [00:32:41] That's great. That's very helpful for our listeners who are who are finding this interesting and want to pursue it further. I'm wondering what does recovery look like? We've talked about that there's some literature, it does show that certain outcomes are improved in certain areas. But as Arthur, you were saying, this is very much an n-of-one process, kind of at the end of the day. Can you share with us what it actually looks like when you see recovery or when you're involved in that?
Dr. Rudnick: [00:33:10] Absolutely. So first of all, it's ongoing because life changes and so goals may change once in a while. But if a person has put in place goals of, let's say, working a full-time work with this certain amount of wages, that would be vocational recovery for them and it would have to also be a meaningful job. So if they're suffering from the job but earning well, then we have that clash between success and satisfaction. That's not ideal. Sometimes it's necessary, not just for people with mental health challenges, but it's better to try to plan or at least tweak it after that towards both success and satisfaction. And people just tell you, we can use all sorts of sophisticated psychometric tools, psychometrically validated tools and measures for that, but in rehab, actually, the bottom line is pretty simple. Has your goal been achieved? We can just say fully, partly or not at all, that's good enough to know do we need to continue to do rehab work in this particular area of the person's goal.
Alex Raben: [00:34:14] One area of discomfort for me around this topic is something you mentioned early on where you said that to be coercive, to use coercive means is to really not be in this model whatsoever. But thinking about my own clinical experiences, there's many times where safety is at play and where medicolegally we're responsible to be coercive. How does that fit into what we're talking about here?
Dr. Rudnick: [00:34:46] It fits well because psychosocial rehab is not a panacea. It can't do everything. There are times and situations where it's where our hands are bound, right. Public safety trumps and that has to be the case. Think about physical rehab. It's not like a physiotherapist can always do their work. If the patient is deteriorating, develops a fever, physio has to step back for a short while at least, and let other practitioners do what they can to help the person. So as everyone in rehab recognises, although the framework is a recovery-oriented framework, there are many other ways of achieving both safety as well as success and satisfaction. There are many service users out there who have never used psychosocial rehab and never will use and don't have a need for that because they have found their own way. Or maybe meds are enough for them and their own coping and own natural supports and that's fine. So really it's just part of the puzzle doing psychosocial rehab. But if we do it, there's no coercion, there should not be coercion involved because then we're not doing psychosocial rehab.
Alex Raben: [00:36:02] That helps me conceptually wrap my head around that, so thank you. I'm wondering if we can end off with just kind of any, I'm wondering if we can end off with what you would hope that a medical student or an early resident would take away from this, someone who's maybe not considering pursuing this as a career, but is going to be maybe a general practitioner or a general psychiatrist, what would you hope they take away from this podcast?
Dr. Rudnick: [00:36:33] So I'll use an adult education framework where we look at attitudes, knowledge, skills and awareness. So the very first is awareness, that people are aware that there is such a set of practices that are evidence-based and informed that can help people with serious and other complex mental health challenges. So I'd like people to be more aware, and I think medical students and junior residents should be aware that there is this set of practices that can help some of their clients. And then gaining more information, more knowledge, I think is also important so that at the very least, practitioners, even if we're talking about primary care providers who may not really be in the realm of providing psychosocial rehab services, at least know who to refer to, they're not just aware that there's such a set of practices, they know what's it about and who to refer to if they think there's a need, because these referrals don't have to go only through a psychiatrist. They could go through a primary care provider, through a social services worker, whoever is the right person, because there has to be a very seamless way for clients to access these services and at the somewhat more advanced level, people who want to be general psychiatrists, I think should have some basic skills in not necessarily providing psychosocial rehab, but at the very least facilitating and not obstructing it. The coercion challenge is one of those issues that people need to know what to do and that this is very different from treatment in the cases of people who are incapable, right, to decide on their own treatment. And last but not least, come the attitudes. And so positive attitudes, particularly always keeping in mind that there's hope and messaging that to clients is crucial. Without hope, there is no recovery. And so if there's no recovery, no goal set for that, there's no place for psychosocial rehab. And so I think those positive attitudes, not pollyannish, but real reality-based, positive attitudes that anyone everyone can grow and learn and change based on their hopes and dreams, I think is crucial. It's not just crucial for psychosocial rehab. It's crucial for life, for people in general, but for people with serious mental illness or other complex mental illnesses who often have been traumatised in addition to having their mental health challenges. And we know the rate of trauma for people with serious mental illness such as schizophrenia is so high, both pre morbid and after they develop their illness, without that hope messaged consistently it'd be very difficult to do any work, including medication, including psychotherapy work. And so I think psychosocial rehab and more generally the recovery approach can bring that hope and it's realistic because pretty much everyone can learn, grow and develop towards their own goals if they are their own goals.
Alex Raben: [00:39:42] So hopefully today we've built that awareness. People can then go from here and learn more about this on their own to gain that knowledge and then going forward, work on those attitudes with hope being one of the most important ones.
Dr. Rudnick: [00:39:55] Absolutely.
Alex Raben: [00:39:57] Just as a last note, do you have any resources or one particular resource you would recommend people go to as a way of finding out more about this topic?
Dr. Rudnick: [00:40:06] Yes. So there are lots of textbooks, including some of mine, and many journals. So the one journal I'll highlight, because I think it has a nice diversity of types of articles, both research and opinions and educational literature about PSR is the Psychiatric Rehabilitation journal published by the American Psychological Association. It's it comes out, if I remember, quarterly, it's quite helpful. And for textbooks I would probably still highlight the William Anthony et al. textbook. It's unfortunately now from 2002, that's the second edition. But it's, from my experience, one of the best for theory of psychosocial rehab and clinical practices. Now, if people want to look at the evidence, not just through journals, but through a textbook, then Patrick Corrigan's 2006 Psychiatric Rehabilitation textbook is a wonderful resource to see what's evidence-based in psychosocial rehab.
Alex Raben: [00:41:12] Great. So guys, we'll look into those resources and we'll post them in the show notes so that you have access to them. But I want to say thanks Dr. Rudnick so, so much for coming out today. You were originally up in Thunder Bay before and you had wanted to be involved and now you're down in Toronto for the CPA and so we thought we would snag you while you're here and it worked out really nicely. But thank you so much for that talk. I feel like I've learned a lot. Aarti, I don't know about you.
Aarti Rana: [00:41:40] Definitely. I feel like there's a whole new part of our ecosystem that I wasn't aware of before. And for me, I know a lot of the principles that drew me to psychiatry do rest in the psychosocial part of psychiatry. And so to know that there are further resources I can explore, people I can talk to, to build my training in that area is hopeful, as you said.
Alex Raben: [00:42:04] So and we hope that you guys, the listeners, have also learned a lot and we will see you next time. Thanks for listening.
Dr. Rudnick: [00:42:12] Thanks so much.
Jordan Bawks: [00:42:14] PsychEd is a resident led initiative based out of the University of Toronto. We are affiliated with the Department of Psychiatry at U of T as well as the Canadian Psychiatric Association. The content in our episodes is a representation of our own views and those of our guests. Our special thanks to our guest in this episode, Dr. Abraham Rudnick. The episode was produced and hosted by Aarti Rana and Alex Rubin. Post-production editing by Jordan Bawks. Our theme song is Working Solutions by Olive Musique. You can contact us at info@psychedpodcast.com or visit our website at Psycedpodcast.org. Thank you for listening. Stay tuned for more great content around the corner as we try and meet our goal of a monthly episode for all of 2019. Catch you next time!
Episode 45: Reproductive Psychiatry with Dr. Tuong Vi Nguyen
Episode 40: Suicide Epidemiology and Prevention with Dr. Juveria Zaheer
Episode 47: Understanding the DSM-V-TR with Dr. Michael First
Episode 46: Antisocial Personality Disorder and Psychopathy with Dr. Donald Lynam
Episode 45: Reproductive Psychiatry with Dr. Tuong Vi Nguyen
Episode 43: Psychedelic-Assisted Psychotherapy with Dr. Emma Hapke and Dr. Daniel Rosenbaum
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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-methylenedioxymethamphetamine. 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 41: MAiD and Mental Illness with Dr. Sonu Gaind
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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 39: Electroconvulsive Therapy with Dr. Wei Yi Song
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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!