Episode 27: Serotonin Pharmacology From SSRIs to Psychedelics with Dr. Robin Carhart-Harris

• Episode 27: Serotonin Pharmacology From SSRIs to Psychedelics with Dr. Robin Carhart-Harris

  Lucy Chen: [00:00:17] Hi guys. Welcome to PsychEd, the Psychiatry podcast for medical learners by medical learners. I'm your co-host, Dr. Lucy Chen. I've recently graduated from the University of Toronto Psychiatry Residency program, but definitely most definitely still considering myself a medical learner. I'm currently working at the Centre of Addiction and Mental Health, doing a combination of women's inpatient and general adult psychiatry work. I'm joined today by Dr. Chase Thompson, a PGY3 resident.

  Chase Thompson: [00:00:48] Hi, Lucy. Happy to be here.

  Lucy Chen: [00:00:50] And Dr. Nikhita Singhal, a PGY2 resident from the University of Toronto.

  Nikhita Singhal: [00:00:56] Thanks, Lucy. Also very excited to be here and it's my first interview, so really excited.

  Lucy Chen: [00:01:03] Great. So we have a really brilliant, like, exciting episode. I'm really excited to introduce our guest and dive in. We're covering a topic that touches on the foundational psychopharmacological principles in addition to the fringes of the unknown with respect to psycho-pharm treatments for depression and exactly how they work. We are zooming in. We're on Zoom, so we are also focusing and zooming in into serotonin function and pharmacology with a focus on an excellent review article called Serotonin and Brain Function: A Tale of Two Receptors, written by our guest expert Dr. Robin Carhart-Harris. Dr. Carhart-Harris is a psychologist and neuroscientist who heads the Centre of Psychedelic Research at Imperial College London, where he conducts leading research in the field. We're really lucky to have you on the show, Dr. Carhart-Harris. Anything else you'd like to share about yourself or your work?

  Dr Carhart-Harris: [00:01:58] No, but very happy to to be here and yeah, honoured to be, that people are interested in this article, so I'll be delighted to go through it with you all.

  Chase Thompson: [00:02:10] Yeah. So as Lucy mentioned, we're discussing Dr. Robin Carhart-Harris's review. We chose to discuss this review on our podcast because we believe it provides a resonance in psychiatry and medical students a scaffold of knowledge about the serotonin system to further build upon throughout residency training. Our experience of learning about serotonin transmission involved a broad range of different receptors with different functional profiles and a variety of different medications that act on these receptors, all of which can be a bit confusing and dizzying to us as learners. With this discussion, we really hope to provide a slightly different and distilled way to think about these receptors. In addition, as psychedelics and MDMA enter contemporary psychiatry, some of the topics discussed today will become increasingly relevant.

  Nikhita Singhal: [00:02:57] The learning objectives for this episode are as follows. By the end of the episode, the listener will be able to: understand the general anatomy and function of the serotonin system with a focus on the purported activity of the more common serotonin receptors and transporters as well as serotonin's basic mechanism of action. To describe the effects of serotonin reuptake inhibitors and how they lead to symptom improvement in mood and anxiety disorders in addition to the mechanism of action of other serotonergic medications and to consider the two-pronged serotonin system conceptualised by Dr. Carhart-Harris and understand how serotonergic agents, including SSRIs and classic psychedelics and the concepts of active and passive coping, fit within this theory.

  Lucy Chen: [00:03:40] So that's a mouthful, guys. I know we're going to explore some in depth concepts and topics, but just follow along, we'll do the best that we can to condense this material for you. So I think we should just start, Dr. Carhart-Harris, before we delve into the main content of your review, it might be helpful for us and our listeners to just go over the basics of serotonin anatomy and physiology, anything that you think would be helpful for our foundational understanding.

  Dr Carhart-Harris: [00:04:10] Um, well, serotonin, um, you know, it's an old evolutionarily evolutionarily old neuromodulator. So let's start by, by, I guess, clarifying what a neuromodulator is. Um, neurotransmitters are chemicals in our brains that alter the activity of neurons, um, in different ways. But, but neuromodulators, like serotonin are more about kind of tweaking the system rather than a sort of direct excitatory or inhibitory action. And so I think of these neuromodulators like serotonin as kind of, um, you know, tuning the function of the brain rather than exciting the brain or inhibiting the brain. It's a more subtle but no less sort of profound, in effect, action of these particular particular neurotransmitters. And you have, you know, similar neuromodulators in terms of tweaking the system like dopamine and acetylcholine and noradrenaline um, but serotonin is, is particularly interesting, um, for a few reasons, implicated in lots of psychiatric disorders in different ways. Um, and interesting drugs, you know, like the psychedelics work on the serotonin system, MDMA, you know, the Prozac-like drugs, the selective serotonin reuptake inhibitors, I think probably the most prescribed drugs in, in psychiatry, maybe benzodiazepines could compete with that um and so, you know, very, very important. And what surprises people sometimes is that most of the body's serotonin is actually outside of the brain, it's in our in our gut.

  Dr Carhart-Harris: [00:06:19] Um, but, you know, the serotonin that is produced and released in our brains plays a very crucial function in how our brains and minds work modulating states of consciousness, so modulating sleep, plays a big role in modulating sleep architecture um, and mood classically. You know I guess to the layman people, they may have heard of serotonin as the happy hormone, they might think of the general rule that high serotonin levels equals better mood and the flip of that low serotonin levels equals maybe depression or low mood. Um, I mean, in the broadest sense, there's some truth to that, but the reality is much more complex. And speaking to complexity, the serotonin system, what arguably sets it apart from the other neuromodulators is its complexity. So these neuromodulators have a number of different receptors, which are the proteins that sit in the membrane of neurons and when they're bound to by by the chemical itself, the neurotransmitter neuromodulator itself, they'll initiate a different response. They're kind of locks that sit in the membrane of neurons and the key is the neuromodulator, the chemical, the serotonin, so that docks into this complex protein, the receptor, lots of these different receptors, and in the serotonin system there are truly lots of these receptors, I think something like 14 different receptors have been identified. And what struck me when I was studying the serotonin system, this is this was my introduction to neuroscience, really, I started my PhD in psychopharmacology, and I studied the serotonin system for four years and then I was lucky to segue into studying psychedelic drugs that work on the serotonin system in a more direct way. But yes, just the sheer number of different receptors, serotonin receptors, and then to to see that different receptors were associated with such different responses I thought was really remarkable and actually that sowed the seed for this paper. You know, I started studying psychopharmacology, um, in 2005, I think it was and this paper published in 2017, serotonin brain function. I guess the seeds were sown early on in my PhD for thinking, you know, trying to kind of, I guess, make some effort to solve the riddle of the serotonin system. I don't think I've done that at all. But, you know, I guess speaking to some of the things that puzzled me about the serotonin system, that certain receptors can do such different things and certain serotonin acting drugs like, say, a Prozac or LSD, both work on the serotonin system, but they couldn't be more different. And so I thought that was that was just incredible and process of trying to get to grips with this and, you know, writing things on on the whiteboard in my office for what different functions and behaviours are associated with, with certain serotonin receptors and what are associated with others, kind of led to the to the creation of this particular paper.

  Chase Thompson: [00:10:14] Great. So that's a perfect segue into what you mainly discuss in your paper, which seems to be the 1A and 2A receptors. So maybe you could tell us a bit more specifically about these receptors and why your paper focuses on it.

  Dr Carhart-Harris: [00:10:30] Yeah, sure. I suppose what was coming through the literature, I mean, I studied MDMA for my PTSD, for my PTSD, for my PhD. That's an interesting Freudian slip. I think there was any PTSD there, and what was coming through there was that certain behaviours that were associated with the post MDMA period seemed to be of a certain category. So there were things like impulsivity and aggression, um, and so, you know, I started, I started jotting these things on the board and with a view to, to, to writing this paper and, within the paper for those who have it in front of them, Table One is, is kind of the product of, of this, this process. And so you know certain, I guess, symptom clusters like impulsivity and aggression,anxiety, depression, low mood that seemed to be a fair bit of work on on you could say MDMA abuse you know um sort of a lot of use of MDMA, regular and high doses, there were reports of these behaviours afterwards. And so for me, this was, I think, you know, suggesting a clue as to what serotonin does, broad brush if you want. And then, um, you know, so, so these could be, you know, examples of behaviours and symptoms associated with low serotonin functioning. Um, but the inverse of them seemed to be things that were, um, promoted by stimulation of the serotonin system.

  Dr Carhart-Harris: [00:12:40] So a reduction in things like impulsivity and aggression, the kind of things that you see when you yeah, stimulate the serotonin system, like with, with, with MDMA, uh, probably the most potent serotonin releaser that we, we know of. Um, and people often say, oh, MDMA, well, it releases other monoamines, but you know, the next highest monoamine that's, that's released noradrenaline, I think you get five times as much release of serotonin than you do to noradrenaline. So while people say that, you know, MDMA really is a serotonin drug, it is, you know, really hitting the serotonin system hard, spitting out serotonin into the synapse um, and, and, you know, people report this profound pro pro-social quality to the experience, you know, things like impulsivity and aggression dropping away. They describe MDMA as the kind of hug hug drug or, you know, love drug. I think hug drug is probably better and empathogen. Um, and so for me, all of this was, was kind of clue to serotonin functioning generally. But then, um, looking more into the literature, it seemed as though, uh, there was one particular serotonin receptor that arguably encapsulated these effects better than any other, and that was the serotonin 1A receptor. Now the picture is complex as it always is, um, in relation to the serotonin 1A receptor, because they are expressed in, in two key areas.

  Dr Carhart-Harris: [00:14:42] So the serotonin system has its cell bodies in the midbrain, in the raphe nuclei that they're called um, and that's where the nuclei of these serotonin cells, uh, serotonin-synthesising cells are found deep down in the old brain and the fibres innervate all the way up into the cortex, really long fibres. It's remarkable how long, you know, these neurons are, individual neurons stretch all the way, their axons all the way from the old brain, the midbrain, all the way to the furthest reaches of the of the cortex. And so if we trace down to those cell bodies in the raphe nuclei where 1A receptors are expressed on on the cell bodies themselves, when they're stimulated by serotonin or a 1A-agonist, meaning stimulating, drug um then that serves to inhibit the firing of those cells and this is a feedback inhibition. It's serving a function like a kind of regulatory brake to slow things down. If there was excessive spill-over of serotonin into the synapse, this system would shut that off because it would stop the spitting out of serotonin from from the axon terminals. Um, so that's what the 1A receptors do in those cell bodies but then what we call postsynaptically, so this is presynaptically in the cell bodies, but postsynaptically on the receiving end of the synapse the effect is of 1A stimulation is, is somewhat different.

  Dr Carhart-Harris: [00:16:35] It's going to it's going to inhibit the activity of those receiving cells, so it has a kind of quelling inhibitory action elsewhere in the brain. Sure, you can inhibit the cell bodies themselves in the raphe nuclei, but that's going to stop the spitting out of serotonin and that'll have lots of, you know, repercussions. Um, but what I was seeing in the literature is that postsynaptic stimulation of 1A receptors in regions like the stress circuitry, the limbic system, was associated with this inhibition and reductions in, in, in functions that you associate to associate with those stress circuitry like anxiety and stress, of course, impulsivity, aggression, you know, so for me, it started to make sense that MDMA was, you know, to a large extent and also the antidepressant Prozac-like SSRIs are to a large extent working on stress circuitry to, um, kind of smooth things out. And while it would be too simplistic to put all of that on the serotonin 1A receptor, um, it is highly characteristic of the, at least the postsynaptic serotonin receptor. Um, and for me that, that, yeah, that, that kind of got things sorted in my head to some extent about what the serotonin system is, at least in one dimension of the serotonin system. Now there's another one, the one that the psychedelics work on. But perhaps I'll pause because I covered quite a lot in relation to the to the 1A system there.

  Chase Thompson: [00:18:35] Yeah. So maybe I'll just make an attempt at summarising what you said, just so we understand here. So we have these serotonergic neurons with the and their cell bodies are in the raphe nuclei and they have an axon which kind of loops back and acts on itself at an autoreceptor which acts as sort of a brake or a self inhibiting mechanism. But then it also extends and acts on the stress circuitry to provide an overall overall inhibitory action on the stress circuitry. Is that sort of.

  Dr Carhart-Harris: [00:19:13] Oh, broadly So. So I mean, you have the cell bodies, the the nuclei deep down in the old brain and they'll express these 1A receptors. When serotonin or a 1A-agonist drug, whenever anyone hears the term agonist, think, oh, that's a drug that's going to stimulate those receptors and they're kind of mimicking the endogenous ligand or, you know, the serotonin itself, the serotonin imposters and they'll so the 1A receptors sit on the cell bodies there. There isn't, the axon shoots off into the rest of the brain, but it's the 1A receptors on these cell bodies and when that's hit, stimulated, it inhibits now this this cell, it's going to release less serotonin. So that's the kind of inhibitory brake on on serotonin release. Is this mechanism is very relevant to how the SSRIs work, because in time this break gets sort of desensitised, it stops working so that the cell bodies continue to to spit out serotonin. Early on when you take an SSRI, activating these cell bodies and stopping serotonin release might relate to some of the irritability and worsening of symptoms that sometimes is seen early on in the in treatment with SSRIs.

  Dr Carhart-Harris: [00:20:45] Now, just to to finish this thread, so here's the cell bodies with their inhibitory 1A receptors on serving as kind of brakes on the activity of these serotonin spitting cells that shoot their axons out to the rest of the brain, into the cortex and into the limbic system. So let's follow an axon now, and it's going all the way up into the brain, maybe into the stress circuitry, into like the hippocampus or something and the serotonin is going to be released from this this axonal terminal. Now, that's going to hit a receiving neuron, also in the hippocampus, because these synapses are, you know, just tiny, tiny little gaps. So here's the the cell body from the from the from the raphe nuclei spitting out its serotonin and here's the receiver and on the receiver you have 1A receptors, the serotonin is released potential you know to bind to 1A receptor here binds, inhibits this receiving cell and the activity in this region drops because the action of 1A stimulation is to inhibit the host cell. So I know it's complex, but that's it.

  Lucy Chen: [00:22:04] Yeah. For sure. And like, I always, my understanding around the impact of serotonin reuptake inhibitors in treatment of depression is this idea that we're, we're down regulating 1A receptors presynaptically so that the cell can release more serotonin in the future, like it's it's not as inhibited. And that's basically like that was my kind of really that's how I grappled on to my understanding was that that's the that's the antidepressant effect of a of an antidepressant.

  Dr Carhart-Harris: [00:22:39] Right. I would say that half of the picture. So you're you're desensitising these breaks, these inhibitory breaks on on the serotonin spitting out neurons so that it can start spitting out more freely. There's nothing inhibiting it spitting out a serotonin so in time that should lead to the cell spitting out more serotonin. And generally speaking, that seems to be good for mood in a sense. So that's part of the picture. The other part is that general increase in serotonin in the synapse is going to lead to more of it hitting these these post-synaptic 1A receptors. So in a sense, you're you're ramping up the serotonin system a little bit with an SSRI, dialling up a little bit the serotonin system but if you were to introduce a drug that worked directly on these inhibitory 1A receptors, you would essentially do the same thing. And that's one thing that people have tried to develop in in, you know, I guess biological psychiatry drug development, is the combination of a 1A agonist, just mimic serotonin and also reuptake inhibition to get that kind of sort of double whammy effect. So yeah.

  Lucy Chen: [00:24:08] Yeah so I think this is a good transition to talk about the 2A receptors um, and more specifically, you know, I'm not sure if this is a good place to start, but there's differential expression of these receptors in different parts of the brain. They seem to be located on higher cortical areas of the brain and so we're kind of curious about that and how that sort of manifests its effect when it's stimulated or blocked.

  Dr Carhart-Harris: [00:24:34] Yeah. Yeah. Well, I'm I'm really curious about that as well, because, I mean, if the listeners have the paper open and they look at Figure One, this for me was really stark, you know, and this, this tells a story. Sometimes a picture says a thousand words, for me that says a lot because we have two maps on the left. You have the in blue or at least the, you know, highlighted frame is blue, is the 1A receptor and where it is in the brain and it's hard to see the raphe nuclei, they're labelled, but you can see the the postsynaptic receptors labelled in kind of the limbic circuitry there. Um, and then look at the 2A receptor on the right and it's very much a cortical receptor. There's not much going on subcortically there, there's not much in the hippocampus really in the amygdala, not much. And yet in the cortex and particularly in association cortex, there's loads of it, loads of this this receptor and this receptor is in my mind, really interesting because of psychedelics and because psychedelics are so interesting. You know, how is it possible to to pin the the action of these drugs that can yield, you know, the most profound experiences of a person's life that leaves them just, you know, struggling to find words to describe what they've experienced. And ad yet we can pin all of that to a large extent on at least, you know, the 2A receptors, stimulating this 2A receptor is the start of all that.

  Dr Carhart-Harris: [00:26:23] I mean, if you block this receptor, you don't trip. It's as simple as that. And so for me, that just screams there is something really important about this receptor because if you want to profoundly alter the quality of conscious experience, you can stimulate, you can stimulate this receptor. So we don't know why and what and you know why it's so critical, but we just know that it is, um, and a lot of a lot of, you know, little clues make sense. Like, you know, if you're going to profoundly alter consciousness, maybe it does make sense that you're perturbing receptors that are expressed in aspects of the brain that are the most developed in our lifetime as the brain develops from infancy into adulthood as well as in phylogeny or the evolution of of the human brain, Um, the expression is particularly high in aspects of, of the brain that are particularly evolutionarily expanded. I find that intriguing. There are some wacky theories about psychedelics being involved in the evolution of, of the human brain and human consciousness. Um, I don't quite buy that, but I'm intrigued by the possibility that the serotonin 2A receptor has played a role. Um, and you know, and then, you know, questions like what does it, what does it do? I mean it's again, there's wacky theories that it's there for psychedelics, maybe endogenous psychedelics like DMT, psychedelics that you can find occurring naturally in the body.

  Dr Carhart-Harris: [00:28:11] But the evidence there is pretty slim. The concentrations of DMT in the body and in the cerebrospinal fluid are really, really low. They spike up during actually during induced death in, in, in rodent studies, but so does so much else, you know, so there's no specificity there. Serotonin spikes right up if you essentially induce a heart attack in a in a in a mouse. Um, and you have the complication of cells dying and spilling out their content anyway, which sort of makes for a murky picture. Um, so I don't think that's necessarily compelling evidence for, you know, endogenous psychedelics being the key ligands for these 2A receptors. I think it's a simple, you know, kind of Occam's razor go with the simplest explanation, I do think they're there for serotonin. But then, you know, what did they do? Well, increasingly, we're discovering that they promote plasticity. They promote synaptogenesis, so the generation of new synaptic connections, functional components of the synapse, the key bit where the communication is, is done in the brain. Um, uh, and, uh, yeah, so it's the especially especially fascinating receptors associated with plasticity and particularly high-level cortex and I suppose high-level aspects of of cognition and consciousness. Yes. Yeah.

  Nikhita Singhal: [00:30:06] Okay. Yeah, it's very interesting just how there are these two different receptors with very different effects. Could you tell us a bit about under normal conditions, what determines where most of the serotonergic activity in our brain is going? Is it mostly involving the 1A receptors or the 2A receptors? And are there different factors?

  Dr Carhart-Harris: [00:30:30] Yeah, I'm glad you asked that question, Nikki, because that's a key component here. If you were to look at where the serotonin transporters are, in fact, this this paper that I got, these maps from Beliveau et al 2016 is worth looking up because it's a kind of nice atlas of of different aspects of the serotonin system are the receptors and also the serotonin transporters. And what you find when you look at the transporter map is that a lot of the transporters, which are kind of like hoovers, you know, hoovering up serotonin from the synapse to kind of recycle it, essentially.  Um, uh, these transporters are heavily expressed in the stress circuitry and in the sort of older brain, quite, quite high subcortically and they overlap to a fair extent with, with the distribution of the 1A receptors. Now there's a so for me this is a bit of a clue that the serotonin 1A receptor might sort of dominate the serotonin picture, so to speak, broadly. You know, this question, what does serotonin do in the brain is more dominated by what the 1A receptor does than the 2A receptor. Otherwise, if we tweaked serotonin levels with Prozac or MDMA, we would trip out, you know, and you might a little bit with MDMA, but not really to the same extent as what you do with a drug like LSD. So for for me, you know, it is it's this this sort of stress related, um, um, you know, mollifying, taking the edge off thing, action of serotonin that seems to be mediated by these 1A receptors. Another key consideration here, and I'd love to find more literature on this, we cite something in our paper, but I was really on a quest to find more because it seems like such a critical question.

  Dr Carhart-Harris: [00:32:37] And the question is this what is the what is the relative affinity of serotonin itself for its different receptors? I mean, you might just think it has a uniform affinity. First of all, what's affinity? Well, it's stickiness. It's the binding potential of serotonin for its different receptors. You might just think, well, you know, these are all proteins that recognise serotonin. It's just going to be a uniform thing. Serotonin sticks to them all equally well, but that there's some suggestions that that's not the case. And actually serotonin has a higher affinity for its 1A receptor than its 2A and its natural affinity for the 2A receptor is quite low. And for me that's kind of intriguing because that could suggest that, again, if you're going to modulate serotonin levels with a drug like, you know, Prozac or another SSRI Citalopram, um, uh, you're not really going to have a big impact on the 2A receptor in its, its functioning because if you did, you might feel something more akin to a psychedelic experience with, with those, with those SSRIs and you don't. So that seems to be a key question. And, and there seems to be some evidence that, yes, the affinity of seratonin itself is higher for the 1A receptor than the 2A.The 1A receptor is also very heavily expressed and expressed in regions that have a very dense innervation from those serotonin fibres coming up from the from the, the cell bodies. Um, so again, that that might be suggestive to this principle of the 1A receptor kind of dominating the serotonin picture in a, in a general sense.

  Chase Thompson: [00:34:35] We just want to take a moment here to pause to provide some context for the upcoming discussion. We are about to discuss some theoretical positives and negatives of taking serotonin reuptake inhibitors, as well as classic psychedelics for the treatment of depression. It is important to note that this discussion is purely academic and no clinical decision should be made based upon it. Further to this, we are also not recommending that anyone pursue or undergo psychedelic therapy outside of a rigorously controlled medical setting. One should be aware that there are medical and psychiatric risks from taking these drugs in uncontrolled environments.

  Lucy Chen: [00:35:08] And, you know, you've talked about in your paper that, you know, 1A seems to be a mechanism for passive coping and sort of this degree of like a degree of kind of like release under stress or punishment. And then the 2A receptor having a differential like mechanism by which it causes plasticity or kind of improves the depressed state. So can you kind of talk about, I guess, the bipartite model?

  Dr Carhart-Harris: [00:35:39] And yeah, so, you know, the principle here would be there's multiple roads to Rome. Is that how the saying goes? Or more than one way to swing a cat? You know, you can you can get to the same sort of, you know, end goal by different by different means and and here so you know, what's the end goal? Well, it's an antidepressant effect. You can either take your Prozac for two, three, six months, years, whatever, and it's going to just take the edge off things, help you get through less of the intense anguish that you can see in all sorts of disorders. Or you can undergo a psychedelic experience, maybe just one and first of all, think about how different that that is, the model there, you know, years, I don't know, maybe a thousand administrations ofof your SSRI daily administrations or one versus one potentially one or a small number anyway of a of psychedelic administrations. And so this must be radically different. I mean, if psychedelic therapy, and I'll unpack that in a moment, works for depression then it works in a radically different way. It's got to yet it's working on the serotonin system but the serotonin system is is a chimaera. You know, it's a it's a at least, you know, certainly has more than one face and these faces are radically different to each other.

  Dr Carhart-Harris: [00:37:26] Um, and so and so for me, you know, tackling that in a sense, the less exciting side of serotonin, the one related to taking the edge off things, was something I felt I needed to do to properly understand the system, or at least get a bit of a handle on it. Whereas the other one was more naturally exciting and interesting, the psychedelic side and the 2A side. Um, and for me, you know, I came across these terms active and passive coping and I just found that a really useful phrase, active and passive coping. Here it is, Puglisi-Allegra and Andolina. Yeah and so for me, I was like, well, this is kind of speaking to the principle here. You know, if you're on your SSRI for six months, a year, years, and it's taking the edge off things, you've gone to kind of doctor and said, I'm struggling, I need some help and the prescription comes and in a sense it's quite a classic medical model. It's quite passive: Doctor, fix me, give me, give me medicine, I just need to take medicine, medicine makes me better kind of thing. Sorry for being sort of so kind of simplistic about it, but you get what I mean. Whereas the psychedelic model is quite different.

  Dr Carhart-Harris: [00:38:54] It's, um. You know, Doctor, what have you got for me? Well, let's talk. And I guess that's how it starts. It's like, let's talk, you know, tell me about yourself. You build a relationship of rapport and trust. You get to know the kind of nooks and crannies of the individual in front of you on a much more intimate and personal level to build that rapport and trust. And then you're going to have this huge, I would say, hugely destabilising experience potentially um, that's in a sense the, it speaks to the complexity and maybe the limitation of psychedelic therapy is that the experience can be damn hard, you know, really, really tough and weird, weirdest experience that you might ever have um, at least you're conscious of, um, and can remember, because birth's got to be pretty weird. Um, and, um, yeah, and you're in a state of vulnerability and so, you know, how do we, how does your clinician, your supporter, your guide, your sitter, whatever, therapist, how do they look after you? And so that critical role of the therapist or guide in Classic Model, it's two individuals that are doing the prep work, then the facilitation or support during the session itself and then the integration, the landing afterwards, talking through the experience. Um, you know, as you land, if you follow the arc of the experience from, from prep and then the intense experience itself, then trust the arc, you know, you always come down and then the, the work that's done afterwards to kind of to allow for space to talk through insights that might have arisen during the experience, moments, periods of perhaps cathartic release, crying, sometimes floods of tears, um, sometimes serious anguish, sometimes serious confusion as well.

  Dr Carhart-Harris: [00:41:16] But to allow space for talking through all of that weirdness and wonderfulness and, you know, the richness of the experience is so critically important. And that's why earlier on I intentionally put some emphasis on therapy. So one is a classic medical model. Doctor, what have you got for me? Medication, you know, take your pills and off you go. And the other one is this engagement where, okay, there's some work to be done here. It's drug doing something in my mind and brain, opening it up and now this is ripe, ripe conditions for some deep therapeutic work. So for me, when I came across these terms of active and passive coping, which I think were outside of the context of the serotonin system I think, I have to remind myself, they resonated with this, these different properties of the serotonin system and serotonin drugs, antidepressants.

  Lucy Chen: [00:42:25] So I'm wondering because it's interesting that you're kind of talking about the 2A receptor also in this psychotherapeutic process where there may be like a profound realisation or working through of some past traumatic content. So is that sort of the mechanism of action of certain types of therapeutic processes that are more sort of expressive or they're more sort of exploratory?

  Dr Carhart-Harris: [00:42:51] Yes, there is some evidence that processes like destabilisation can actually paradoxically be a good thing in in psychotherapy. So there's empirical evidence to back that up. So but but this, you know, intrinsically is a more complex model than the much simpler, and this is the merit of the of the classic medical model, you know it's simple. You don't, you know the complexity of human beings and interactions and relationships areare not so much involved. Uh, whereas here you, with psychedelic therapy, you have a model that depends on the therapeutic work that is combined with the drug action. You can't pull these things apart because if you try to you, you can get adverse events and you know, even iatrogenesis meaning things get worse rather than better. So it's the point I always emphasise, you know, not through any sentiment as such, only that sentiment in the sense that it just follows from the science and everything about what these drugs seem to do in my mind is saying they are um, sensitising the, the individual to experience to environment. Um, and therefore, you know, logically, scientifically, one needs to pay very careful attention to environment. And while you can't change the past, you can, you can, um, you can engineer the present and the future to some extent and so you have a therapeutic duty, based on the science and the logic, to do that when you're making someone exceptionally sensitive to environment. And another little qualifier that's important, environment doesn't, in my mind at least, doesn't just mean external environment. There's an internal environment that often we're not aware of, and it runs so deep, you know, because there's aspects of our minds that we are remarkably unaware of, and yet they're revealed under psychedelics. And the psychedelic therapy model is typically lying with your eyes closed. So there's not much, you know, visual input from the environment at all. Yet the experience is so experientially rich and content rich. So where is that material coming from? Well, it's coming from our minds, of course. And so that's just evidence for the the depth and the richness of our minds that we're unaware of ordinarily.

  Chase Thompson: [00:46:01] So it sounds like with action at 1A, we're kind of talking about, you know, an individual learning to tolerate their current circumstances or at least experience less stress in their in whatever they're already doing. But with action at 2A we're talking about kind of like an expansive or neuroplastic type changes or someone really learning to cope with their environment rather than just tolerate it. I guess I'm just wondering because, you know, when we're talking about the action of psychedelics at 2A, do we know that the new beliefs or the plastic changes are always in a more positive direction, or are there cases where it's really not a good idea for someone to undergo that type of experience?

  Dr Carhart-Harris: [00:46:54] Uh, yeah. So. So first of all, um, you know, we can look at the aggregate data, whether from control studies or population studies or observational survey type studies and say, well, at the aggregate level, at the average level, the psychedelic experiences, even actually outside of an obvious context of therapeutic care and support, the outcomes appear to be positive. Now, there might be some, some there may well be some biases in in in data from certain sources, but generally that is a very, very clear picture, you know, large effect sizes in the direction of positive. But that's not to say this is an absolute rule and that somebody could come to have a psychedelic experience and be negatively affected by it. And this is a really critical point that, you know, again, speaks to this principle that psychedelics are not intrinsically healing, in my view. Now, some would even challenge that, but I would sort of challenge them back and say, maybe you're being slightly naive here. Um, you know, most of the time the large majority of uses of psychedelics, people are taking them, especially these days, with some forethought and planning and so, you know, the outcomes are skewed in this positive direction.

  Dr Carhart-Harris: [00:48:30] But I do still emphasise that, um and sometimes I oscillate on it because I could see how this process of breakdown and reconfiguration could could be healthy, you know, or it could be intrinsically healthy, speaking to, you know, a mechanism of a recalibration. You know, you take someone who has, um, crystallised, set into a pathological mode of being, you may well think, well, this isn't working or this, this isn't right so we're going to destabilise and the, the hope I suppose is that you return recalibrating into a healthier state. And, you know, maybe there maybe there is something to be said for for that model but I just think it's a bit of a dangerous model to to have too much faith in that psychedelics are intrinsically healing and sort of work in this sort of resetting way because most of the time and most of the evidence is is backing up, you know, careful intention for the experience and, um, and, you know, directing it in a particular, in a particular way with therapeutic support.

  Lucy Chen: [00:50:10] I'm curious about sort of the longitudinal impacts of like the 2A stimulation treatment model. Like, is it the neurogenesis? Like what is it? What is sort of what is a longitudinal impact of that treatment model?

  Dr Carhart-Harris: [00:50:26] Yes, I'm curious about it, too and I would say we're yet to really have the answers. There hasn't been that much done in the way of brain imaging work, for example, on the longer term changes in brain anatomy and function from from psychedelic use. We have some data that we're processing currently and I suppose the principal, if there is a principal that's coming through, it's that the kind of changes that you see during the experience itself, you will see in the opposite direction afterwards into the longer term. And so for example, if you were to look at our, um, I mean this is limited data to extrapolate from to an extent, but in our depression trial, this is a paper published in scientific reports, we scan people a day after their second treatment session with psilocybin and, whereas, we know now with a high degree of confidence that during a psychedelic experience itself, brain networks break down, they kind of disintegrate. But it's a transient disintegration as the drug effects wear off, they spring back and reconfigure. And we saw this in the default mode network, a network associated with, um, well, actually it's a network that's the regions that make up the default mode network have very high expression of serotonin 2A receptors and it's a network associated with high level cognition, self-reflection, imagination, daydreaming, theory of mind, thinking about the future and the past, mental time travel. So these really high level, arguably species specific, at least to the extent that we do these things, functions, um, is associated with the default mode network.

  Dr Carhart-Harris: [00:52:22] We see it break down under psychedelics and this correlates with the intensity of the psychedelic experience but then a day afterwards, at least, the network seems to spring back and actually the magnitude of this springing back and, and there was a we're not sure how salient this is, but we noticed it, there was a slight expansion in the spatial extent of the default mode network um, one day after the treatment in our depressed patients who weren't depressed when we rescan them, a good majority of them were feeling well. Um, and that actually predicted, that was prognostically predictive meaning that those who were responders out at five weeks later were those who showed this slight expansion in the spatial extent of the default mode network. That's a bit arguably a bit too much detail I would say. But generally the rule is that disorder during the trip and a return to order afterwards and maybe there is a kind of um at least a lot of this is sort of theoretical, but maybe there is a kind of, um, uh, kind of, um, sort of spring cleaning of the system. It, it springs back simpler. Um, there's some of the redundancy has been, has been lost, uh, into the longer term maybe, which might make for a kind of cleaner, crisper style of, of, of being, dare I say.

  Chase Thompson: [00:54:07] It kind of sounds what you're talking about with the psychedelic experience of being broken down and then rebuilding back up, a little bit like the model of therapeutic action that some people talk about, where the goal is kind of integrating a bunch of diverse experiences into sort of one unified whole person. Do you think that that maps on in this case?

  Dr Carhart-Harris: [00:54:35] Well, there's suggestive evidence that that it does. I mean, you know, to many people, this might feel almost, I don't know, it might speak to to the way sometimes people push back about the reductionism of science, where if you were to say, look, you know, these these profound mystical type experiences, these this sense of, you know, mystical union or spiritual union sense of interconnectedness relates to some, uh, you know, alteration in brain function during the experience itself, where, for example, the brain is operating more as a, you know, coherent whole unit. It's more globally interconnected, and you see correlations with that effect and ratings of things like ego, dissolution. Um, it's quite easy to say, ah, you know, those are the neural correlates of ego dissolution and those are the neural correlates of the unitive experience, that sense of profound interconnectedness. Now, if I was really pressed on it, I would say I do actually think that that's, that's the way things are um, but I also acknowledge that that's just one piece of the puzzle um, and there's, there's so, so much more to the story that we've yet to really flesh out um, I would say and you know, part of it is that in a sense we're, you know, inching our way forwards with a model of, um, in a sense, what's lost under a psychedelic experience in terms of the, the usual sense of stability and familiarity of one's self and the world that's lost, um, and that relates to a breakdown in familiar systems that are usually stable in their functioning.

  Dr Carhart-Harris: [00:56:57] But the thing that we haven't yet cracked and for me is the most tantalising sort of next frontier for psychedelic research is how do we explain the more, the stuff that comes in when something is lost? You know, the emergent order, how can we explain these visions of of, you know, seemingly timeless motifs that, um, you know, enter enter our minds um, and so, you know, stark um, or memories that flood back that are felt you know, as if one is re-experiencing something and um how do we explain the order amidst the disorder or the emergent order from, from the disorder. And we're not there yet. And, you know, we've got ideas about how to try and do it. It's going to be how to be a kind of, um, oh gosh, a sort of, we're going to have to capture these things as they play out in real time, and that's a challenge. But yeah, that's the kind of next frontier, I would say. Yeah.

  Chase Thompson: [00:58:23] So maybe I'll just bring us back a little bit to the original model you discussed related to 1A and 2A. Earlier on, you had talked about MDMA being a potent serotonin releaser and with the potential to act on both of these receptors. But I guess the kind of phenomenon you're talking about under a classical to a experience is quite different than what one might experience with just MDMA. Is there a way to explain that or.

  Dr Carhart-Harris: [00:58:57] Yeah. Yeah. Sorry. In the sense that, you know, why doesn't MDMA produce these psychedelic-like experiences?

  Chase Thompson: [00:59:06] Right.

  Dr Carhart-Harris: [00:59:08] Yeah. And I think part of that is that MDMA isn't a direct agonist of the serotonin 2A receptor. It doesn't really have any appreciable affinity stickiness for the 2A receptor. So any action at the 2A receptor that's being caused by MDMA is being caused through its increase in the endogenous ligand, serotonin. So you might think, well, you know, if you're if you're whacking up the the serotonin levels in the synapse profoundly with MDMA and and as I said earlier, you know, MDMA, maybe mephedrone could compete and not much more else, all these things are dose dependent, of course. But, you know, for sheer big release of serotonin, it's hard to beat MDMA, really. Um, and so why doesn't it produce, you know, trippy psychedelic effects? And I think part of the explanation for that is that, well, there's a lot of serotonin receptors and some of them counteract each other um, and you're not just increasing activity at one receptor, you're increasing activity at 1A receptor and the 1A receptor in particular has a counteracting effect to the 2A receptor. And 1A receptors are found in, even though they're heavily expressed in the limbic circuitry, they are expressed in the cortex and they're often co-expressed with 2A receptors. And so the assumption, and there's a little bit of evidence to back this up, Rick Strassman did some related work, um, there's a bit of evidence that the 1A activation, 1A activation say with uh MDMA-induced serotonin release might counteract the the effect of any 2A agonism through the serotonin release. So it's kind of like a diluting, you know, having a diluting effect on what otherwise would be a big trippy effect through the release of serotonin.

  Chase Thompson: [01:01:27] Just in follow up to that, you know, when we are prescribing these medications that promote passive coping, namely, you know, SSRIs, do you think that that limits the individual's capabilities to actively cope in some sense?

  Dr Carhart-Harris: [01:01:44] Maybe. And, you know, it's a dangerous question because of the implications of it, given that millions of people are prescribed SSRIs. You know, you might think on a sort of policy level like, you know, what are we doing? Are we doing a good thing here? And I mean, that's a very complex question because you you know, you have people on the cusp of just complete breakdown and and just turmoil and often suicide and so, you know, if you can get through the initial rough ride of going on an SSRI, this can really smooth things out for a period and help you get through a crisis that otherwise might have led you to do something drastic, like, you know, attempt on your own life. Um, and so, uh, it's a complex one.

  Dr Carhart-Harris: [01:02:44] You know, so but, but, but let's be honest in our opinions, in my opinion um, yes, I think probably that would be the implication that instead of, you know, really getting to the nitty gritty of of, often there's not a clear, obvious solution to why one is suffering, you know, very, very complex, but, um I'm not sure it's helping to, to in terms of insight and self-development, I'm not really sure it's helping to, to actively cope, to, to, to be just smoothing things out with an SSRI. Might help you engage and be willing to go and talk to someone, a therapist and the evidence of the combo SSRI-time-psychotherapy suggests a bit of an additive effect, but not much. It's quite modest. Um, and so, you know, might just get you out of the house and, and so it might just be helping in that respect.

  Chase Thompson: [01:03:51] Yeah, absolutely. And definitely don't mean to suggest to anyone that one way or the other is better that they should seek out one style of treatment. I think it it's a selection issue or who should really pursue each type of treatment at this point.

  Dr Carhart-Harris: [01:04:07] Yeah. Who and when. You know.

  Chase Thompson: [01:04:09] Right.

  Dr Carhart-Harris: [01:04:10] In the throes of, you know, period of real serious turmoil in your life. Is it right to go and have a big, you know, dose of ayahuasca? I'm not sure. Um, so yeah, who and when I think.

  Lucy Chen: [01:04:28] I'm actually really curious about whether people have thought about like developing guidelines for approaching treatment, like in a staged model or stage approach to care, you know, is there a way to determine sort of readiness for, you know, a psychedelic treatment-based modality, and how is that determined? And I wonder about your kind of your study criteria, too, and who you decide to recruit?

  Dr Carhart-Harris: [01:04:54] Yeah. Um. Well, that's something that we're trying to crack. We've been doing these surveys for a long time, collecting data prospectively from people taking psychedelics in the wild, so to speak, you know, whether they're microdosing or LSD in the bedroom or, you know, uh, mushrooms at Burning Man or whatever, or ayahuasca at a retreat. Um, and so for us, there's an advantage in doing that naturalistic work because people are taking the psychedelics in all sorts of novel contexts. So we can look at, you know, set and setting, we can look at, um, how ready people feel simply by asking them, um, and if you do this with a tracker, you know, that's going to capture data before the event as well as afterwards, then you can do that and, and grab more useful data you know. If you try and do it in retrospect, it's always just in retrospect so you're, you're not really predicting things. You need to make your prediction ahead of time or collect the data ahead of time to really predict. But we've made a stab at that. We've got a couple of publications that have tried to predict or do predict response and a lot of our assumptions about set and setting were consolidated by that work. Um, but we're still getting to grips with it and getting to grips with the relative weighting of different factors like for example, emotional support and trust appears to be particularly heavily weighted as a predictor of the kind of experience that you have, which is the mediator of the longer-term outcomes.

  Dr Carhart-Harris: [01:06:48] And so, for example, let's, let's do a quick sort of back of the envelope algorithm here. If you feel, uh, you report feeling ready, there aren't distractions in your life you're ready to do this, you're willing to let go to this experience, surrender to the experience, you're in the company of people who you trust and you feel emotionally supported then these are all, you know, green lights, meaning the these are good signs. These are good signs. Um, uh, now ahead of time, there's not much else, I said a back of the envelope algorithm here, so what what's this going to predict? Well, it's going to predict a stronger chance, not a done deal, but a stronger chance of a of a mystical-type experience, a peak experience if you want to put a more sort of obviously humanistic spin on it, you know, sense of bliss, a sense of interconnectedness, sense of timelessness um, and if you have this, this is another kind of green light or good sign that the longer-term outcomes are going to be favourable. And, and then things can come in, and I would say it's a bit too early to put any empirical data on this, but again, there are strong assumptions about integration, you know, to help sustain the positive effects that you got from the experience. And you know, this great phrase from Jack Kornfield, "After the Ecstasy, the laundry", you know, after the big experience comes the work, you know, the work never stops. Uh, doesn't have to be painful, but it's the work needs to continue.

  Dr Carhart-Harris: [01:08:39] And so I think, you know, very, very simply that's a kind of back of the envelope algorithm that at least, you know, helps us put a lot of emphasis early on, which is critical and that helps me address, I could try and do it briefly, the other part of your question, which is the screening, you know, how do we screen? And I suppose in a sense, you know, in our clinical studies there is a bit of selection bias because we are looking for people where we feel that we've developed some rapport. There is a sense of trust. We're picking that up from, from from the people that we're talking to um, and those are kind of ideal for psychedelic therapy it seems. Uh, but so, you know, people see the results of these small studies and they get very, very excited and think psychedelics are the big breakthrough treatment in mental health and while they may well be, um, also it's healthy to have some critical acumen and think, well, there may be a selection bias in the patients that come into those trials. Um, maybe a bit of confirmation bias. The patients really want to get the psilocybin and believe it's going to work, you know, so well that doesn't mean that, you know, that will never be part of the treatment effect and always is, you know, that positive expectation at least just be conscious that that's part of the vehicle that can that can be producing these really impressive outcomes.

  Nikhita Singhal: [01:10:15] Thank you for that. I think it's really exciting to hear about some of these benefits of possible future therapies coming out and I guess just one more question, coming back to this idea of the receptors. So the 2A agonism seems to be able to induce these very positive changes. I just wonder about some of the medications that we prescribe people for depression that are actually 2A antagonists such as Mirtazapine. How like how can we reconcile the the fact that they may both, 2A agonism and antagonism, have positive effects on depression.

  Dr Carhart-Harris: [01:10:52] Yeah. Again really key question. And that brings us back to the you know many roads to Rome analogy that what 2A antagonism might do. So now we're blocking these these receptors rather than stimulating them um, what that might do is to work more in the direction of passive coping. You know, again, it's sort of maybe anxiolytic, flattening people out, less, less scope for any extremes in emotion. Um, and you know, Mirtazapine is kind of a bit of a sedating medication often I think taken just before sleep and it's it's probably that that that mechanism it also promotes sleep as well so you have deeper sleep so less awakenings and that can be a problem in depression, poor sleep, you know, waking up hyper aroused. Um, and so it's a it's a, yeah a different road to ideally a similar effect, but more just passive coping, taking the edge off things rather than, you know, getting to the, to the root, um, maybe the root cause of the suffering and promoting insight and therapeutic development.

  Lucy Chen: [01:12:18] Um, well, thank you so much, Dr. Carhart-Harris. You know, a goal of our podcast is to not only cover like fundamental key concepts in psychiatry, but also to stimulate curiosity and to create opportunities for depth of understanding and to allow for expansive thinking when it comes to learning about treatments and treatment options in psychiatry. Your article and your ideas most definitely facilitate these values and goals for us, um we truly appreciate your time and your your valuable expertise. Um, I just wanted to know if you have any parting thoughts or ideas to leave our audience who are comprised from a variety of learners, um they're mostly sort of senior medical students and junior residents in psychiatry.

  Dr Carhart-Harris: [01:13:03] Oh uh no, just to say that I appreciate your appreciation. I guess that's why, you know, people like me, write these things and do this work is that hopefully it should inspire others. And so I suppose one passing thought might be improve on this. You know, this isn't by any means the end of the story. It's just everything's iterative in science. So I'd love to see some bright young people come along and take this on to the next the next stage and develop our understanding.

  Lucy Chen: [01:13:35] All right. Thank you so much.

  Chase Thompson: [01:13:40] PsychEd is a resident driven initiative 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 Drs Nikhita Singhal, Lucy Chen and Chase Thompson. This episode was audio edited by Chase Thompson. Our theme song is Working Solutions by Olive Musique, and a huge thank you to our incredible guest expert, Dr. Robin Carhart-Harris. You can contact us at psychedpodcast@gmail.com or psychedpodcast.org. Thank you very much for listening. Bye.

Episode 26: Nutritional Psychiatry with Dr. Laura LaChance

• Episode 26: Nutritional Psychiatry with Dr. Laura LaChance

  Alex Raben: [00:00:00] Hey, listeners, it's Alex here. I just wanted to say how excited we are to have our very first episode coming out of Montreal. This episode on nutritional psychiatry was led by Sarah Hanafi. Sarah works tirelessly behind the scenes as our head of research, and we really appreciate all she does for PsychEd. I hope you'll learn as much about this important and often neglected topic in psychiatry as I did. Enjoy.

  Sarah Hanafi: [00:00:36] Welcome to PsychEd, the Educational Psychiatry Podcast for Medical Learners by Medical Learners. In today's episode, we're going to be covering the topic of nutritional psychiatry. My name is Sarah Hanafi and I'm a PGY2 in psychiatry at McGill University. We're very happy to be joined today by Dr. Laura LaChance, who is a psychiatrist at Saint Mary's Hospital here in Montreal.

  Nima Nahiddi: [00:00:59] My name is Nima Nahiddi, and I'm also a Pgy2 psychiatry resident at McGill University.

  Gray Meckling: [00:01:06] And my name is Gray Meckling, and I'm a third-year medical student at University of Toronto.

  Sarah Hanafi: [00:01:11] By the end of this episode, we're hoping that you'll be able to have a better understanding of how we define nutritional psychiatry, that you also develop an understanding of the mechanisms, common misconceptions, challenges and current evidence supporting the role for nutrition in mental health and finally, that you'll be able to apply this understanding to clinical cases in psychiatry.

  Nima Nahiddi: [00:01:44] So to start off, Dr. LaChance, we're so happy you can be here with us, although here is virtually. Can you let us know a bit about your professional background before we start?

  Dr Laura LaChance: [00:02:00] Sure. So thanks so much, guys, for having me on the podcast today. And you know, I know we were having some scheduling difficulties and Covid obviously didn't help and at a certain point you just need to get on with learning activities, so I'm glad we're able to make this happen. So I'm a psychiatrist. I work at Saint Mary's Hospital, which is a McGill affiliated hospital in Montreal, and my clinical practice right now is in general psychiatry, so I work with patients in the emergency room and the outpatient clinic. I'm also newly the director of outpatient psychiatry here at Saint Mary's and the my focus right now is actually on working in the Mental Health Crisis Clinic so I work with a lot of transitional aged youth in particular through that clinic. So that's kind of what I'm doing now clinically. Um, you know, where does that place me in relation to nutritional psychiatry? So this is my research interest. I graduated from the University of Toronto in 2017 residency program in psychiatry and, as part of my residency I did a fellowship, a research fellowship in the social determinants of mental health and there I focused on nutrition and food insecurity as determinants of mental health. And so that kind of, you know, early on informed my research interest in the field. And I've been doing research in this field since about 2012, I would say. Um, so yeah, I guess we'll get more into specifics. Um, but I'll just add, I'm also doing my Masters in psychiatry right now, so I kind of have a few different hats that I'm wearing.

  Gray Meckling: [00:03:33] Okay. Thank you so much, Dr. LaChance, for sharing some of your background. So I think to jump things off in the episode, we're going to just ask if you could define nutritional psychiatry for our listeners.

  Dr Laura LaChance: [00:03:47] Yeah, it's a good question and there are a bunch of different definitions floating around if you Google it. So what I choose, the definition that I choose to stick with is nutritional psychiatry is basically integrating nutritional approaches into both the prevention and the treatment of mental disorders and their comorbidities.

  Gray Meckling: [00:04:08] Okay. And so that's one question that I had starting this episode, was whether or not the nutritional interventions are really just looking at the mental health disorders or if they're also addressing things like metabolic syndrome that can happen to people who have mental health diagnoses.

  Dr Laura LaChance: [00:04:29] I mean, I think it's both because, you know, you're obviously going to have some side effects, quote unquote, of your nutritional interventions, which are going to be impacts on physical health as well. And we know that our patient population has high rates of metabolic illness, cardiovascular illness, so you can't really separate the two.

  Gray Meckling: [00:04:47] Yeah. And so being a medical student, this was definitely a new field of psychiatry that I've just been exposed to. Could you maybe walk us through sort of the origin or the history of nutritional psychiatry as a field?

  Dr Laura LaChance: [00:05:02] Um, well, I mean, it's interesting because we think that nutritional psychiatry is this new field and, you know, the whole kind of concept of food as medicine is getting a lot of attention and, you know, all the health blogs in the general population and obviously in scientific research as well. And um, when you look at the scientific literature, there are actually a ton, there's been a ton of research in nutritional psychiatry kind of even predating our medications. So I did a meta-analysis of, um, biomarkers of gluten sensitivity in individuals with schizophrenia in 2014 and the reason I mentioned that is because there were research papers where psychiatrists were looking at biomarkers of gluten sensitivity in that patient population schizophrenia back in the 1960s. And so like, you know, they had randomised controlled trials in the, in the standards that were, you know, typical of research at the time where they randomised one psychiatry inpatient unit to a gluten free and a casein free, which is the milk protein, one of the milk proteins that's most likely to cause an allergic reaction. So they had milk free, wheat free, um, wards versus wards that got just like the regular control diet and then they measured psychiatric symptoms and time to discharge, yeah and this is the 60s. And you know, another example would be like Orthomolecular psychiatry, which I couldn't actually put a date on that but the person who most closely comes to mind is Linus Pauling and high doses of vitamin C to treat a number of conditions, including psychiatric conditions. And this is all, you know, really, these are all really old ideas. And so I think nutritional psychiatry was actually popular, um, you know, more than 50 years ago, but is now seeing a resurgence really in the last ten years or so I would say.

  Sarah Hanafi: [00:06:55] It's really helpful to hear that background and get a better sense of what, where or where this field has kind of come from in the past few decades. Um, you know, I know for myself, I've heard of terms like inflammation and the immune system is, is possibly explaining some of the link between mental health and nutrition as well as concepts like oxidative stress and the microbiome gut brain axis. I'm wondering if maybe you could touch briefly on some of the mechanisms we're starting to think are involved in the relationship between nutrition and mental health.

  Dr Laura LaChance: [00:07:37] For sure, and I'll try my best to be brief on these because each one could be, you know, a podcast in and of itself. So when we think about the different mechanisms that underlie the links between nutrition and mental health, before we get into it, I just want to emphasise that it's a bidirectional relationship. So, you know, we're talking today about how nutrition can impact mental health, but obviously the reverse is also a very important relationship to consider, so how having a mental disorder or your mental health can impact your nutrition. And so kind of taking a step back, like thinking about things like food insecurity, how mental health disorders can impact, you know, appetite, how our psychiatric medications can impact appetite and how that impacts eating behaviour. You know, obviously eating disorders is kind of a separate entity that's beyond the scope of today but so just kind of before we get into the science, looking at, you know, nutrition impacting mental health, just recognising that this is obviously complex and bidirectional.

  Dr Laura LaChance: [00:08:37] Um, but so with that, so thinking about mechanisms, so inflammation is certainly one of the, one of the important mechanisms, explaining how nutrition can impact mental health and inflammation is an area of research in psychiatry that's gaining a lot of traction recently. So, you know, a number of meta-analyses have found that there are heightened number, heightened levels of peripheral biomarkers of inflammation, so things like inflammatory cytokines, um, interleukins, TNFs, CRP, you know, those types of molecules in bipolar disorder, in depression unipolar in schizophrenia and we also know that, you know, when we think about the comorbidities that our patients often are diagnosed with like metabolic disorders, cardiovascular disorders, we know that inflammation plays a role there, too. So this is a really important topic and I think for today we're interested in understanding what does diet have to do with this. So try to kind of break it down. So we know there are certain foods or dietary factors that tend to promote inflammation, so those are things like refined carbohydrates, ultra processed foods and also sugar. There are also dietary factors that tend to reduce inflammation so things like vegetables, fruits, fibre, so legumes are examples of sorts of sources of fibre, whole grains, healthy fats like omega-3s or monounsaturated fats and also fermented foods. And so when I'm describing kind of the factors that tend to either promote inflammation or reduce inflammation, I'm describing a dietary pattern that maps pretty closely onto the Mediterranean diet. And, you know, it hasn't been shown yet in psychiatric populations. But if looking at other clinical populations, there's a recent meta-analysis of 50 experimental studies that found that Mediterranean diet can reduce biomarkers of inflammation. So, you know, that's kind of one way of thinking about it as from like a dietary pattern perspective.

  Dr Laura LaChance: [00:10:45] We can also break it down so we can look at, for instance, the balance of omega-6 and omega-3 in the diet. So those are two types of fatty acids that are they make up a minority of the amount of total fat that we eat. But in recent years with, you know, how agriculture and the food processing industry has changed, we've seen really major shifts in the amount of relative omega-6 and omega-3 that we consume today relative to 100 years ago. And omega-6 fatty acids tend to be pro-inflammatory, whereas omega-3s are anti-inflammatory. So that kind of imbalance that we see in the diet is another way that diet ties to inflammation. And then the microbiome is implicated there too but I think I'll save that for a bit later.

  Sarah Hanafi: [00:11:32] Fair enough.

  Dr Laura LaChance: [00:11:33] So yeah, because we'll get to that. There's a lot of overlap.

  Nima Nahiddi: [00:11:38] It's really fascinating, this idea of the bidirectionality between, you know, nutrition and then some of, you know, implications of mental health. Do you think that there's common misconceptions about things that are happening in, you know, mental health and the role that nutrition can have? Maybe things that are in the media or things that physicians might think of that could be common misconceptions?

  Dr Laura LaChance: [00:12:19] Yeah. So the first misconception that comes to mind is the idea that mental health and nutrition are not related, or that somehow nutrition is not important for mental health. And I'm obviously an early career psychiatrist, but I would say earlier in my career, that's the one that I was really pushing up against. And so every time I would give talks or presentations or whatever, it was always kind of like, you know, newsflash, nutrition is important for mental health, whereas now I find that's already become, um, you know, sort of accepted, at least relative to where things were about five years ago. Um, so I'm happy that there's a growing recognition now that food is medicine and that psychiatry is part of medicine, so that one is a little bit less relevant. What I'm seeing a lot now in terms of misconceptions is this idea around helping psychiatric patients to change their diet is not feasible, in some way, or that it's futile. You know, there's always something else that's higher priority than talking about diet and so I have some thoughts about about that if you guys are interested.

  Nima Nahiddi: [00:13:30] Yeah. What is it that that you think is the greatest barrier?

  Dr Laura LaChance: [00:13:34] Well, I mean, we know that nutrition is not a huge part of medical training.  So there's definitely a piece around lack of knowledge, um, for like perceived lack of knowledge for health care providers. But I don't think you need to have a graduate degree in nutrition to be able to counsel your patients on diet because, you know, we all prepare food for ourselves and eat every day. Um, so, you know, I think it, I think it's more like some kind of barrier that, that we've put up based on, um, you know, what our comfort level is or what like we learned from observing other clinicians. So, you know, other clinicians aren't talking about food, so, so we shouldn't like, I don't, I don't think that there's, um, I don't think it's anything really more complicated than that. And, you know, I see that we talk to our patients about all kinds of stuff. We talk about substance use, we talk about, you know, finances, their innermost private thoughts, past trauma, their sexuality, you know, everything. And so why why would it not be appropriate to also talk about food?

  Dr Laura LaChance: [00:14:42] And then, you know, when you think about who is best suited to help psychiatric patients to make these often basic changes in their diet, I think we actually, as mental health professionals, have a lot of tools at our disposal to help our patients make behaviour change because, you know, that's what we do, whether it's sleep hygiene, taking medication, you know, engaging in psychotherapy. Um, so I mean, I think we're actually well suited and, you know, often patients are coming to us with like, okay, well what can I do to take care of myself at this early stage while I'm waiting for the medication to take effect? Or families are asking us, what can I do to support my loved one who's struggling with depression? Well, I think actually preparing healthy food for yourself or your family member is something tangible that we can do that gives some direction to families and patients. And I think we have to remember that these interventions are also very safe. So, you know, I talked earlier about side effects of dietary interventions being possibly improved physical health. And so, yeah, I think we need to kind of take that into consideration as well as we're like, you know, waiting for the perfect research to to guide us in terms of making recommendations for our patients.

  Nima Nahiddi: [00:15:52] And being mental health professionals, do you have or can you discuss a bit about some of the research and some of the evidence supporting the role of nutrition in the management of psychiatric illnesses?

  Dr Laura LaChance: [00:16:08] Yeah. So, um so I think it makes sense to probably focus a little bit here just because it's hard to give like a broad overview of everything. But if I take depression for an example, which is a condition that like anyone's going to treat, and it's also the condition that has the most advanced literature in terms of nutritional psychiatry. So depression, so there's at least three randomised controlled trials now of dietary interventions in depression, like clinically significant major depressive disorder, and they're all a little bit different. So one was an individual intervention of a mediterranean diet. One was a group intervention of a mediterranean diet with supplemental omega-3, and the other was basically a video with two five-minute follow up phone calls and some information on FAQs and like tips and recipes. And all three of those studies found that the Mediterranean diet, as compared to a control intervention, significantly reduced depressive symptoms. And so these are these are add-on treatments, I think that's an important point that you know nobody's recommending that you don't offer you know the gold standard treatments that we have but it's just like something benefit something additionally that's beneficial because we don't like you know we don't have 100% remission rate for depression with our current treatments.

  Nima Nahiddi: [00:17:40] And as you said, the side effects, the side effects are or can be safe when it comes to nutritional interventions.

  Dr Laura LaChance: [00:17:51] Yeah, exactly and another sort of piece of literature, so there's, there's been a shift in the field where initially there was a lot more emphasis on studying individual nutrients or individual foods. And then in recent years, to say the last ten years or so, people have been talking a lot more in the literature about dietary patterns and understanding which dietary patterns can either increase risk or decrease risk of depression or be used as treatment. And so a couple of years ago, probably for I don't know, honestly, I think was in PGY2 when I first came up with this idea, um I was wondering okay, so there are these dietary patterns which seem to be helpful for depression, but what are the actual active ingredients here? Like, if somebody wanted to actually design a diet that was going to promote recovery from depression, what foods would be included in that? So I partnered with Dr. Drew Ramsey, who's a nutritional psychiatrist in New York and runs the brain food clinic there, and we conducted a literature review to identify what are the, what are the, we call them "antidepressant nutrients", so which nutrients have the highest level of evidence to support their role in either prevention or treatment of depression? And then we took this list of antidepressant nutrients, and we applied a nutrient density formula and then tried to identify what are the foods that actually have the highest nutrient density of these antidepressant nutrients. And we looked at individual foods, we looked at food categories and the findings were super interesting to me because the foods that came up on top were, you know, leafy greens, seafood, organ meats, other vegetables, fruits and it was really foods that are highly prevalent in traditional diets from a number of different cultures, but certainly foods that are not common in the Western diet. So it was like another, you know, kind of coming at it from coming at the question from a completely different angle and then finding the same answer.

  Nima Nahiddi: [00:20:00] And so do you think with the dietary patterns, you know, we should be looking into making new diets with these types of foods in them?

  Dr Laura LaChance: [00:20:11] Well, not necessarily. I mean, I think what's interesting about the findings is that I think that they could be like the foods that came up on top could be integrated into any dietary pattern that that's fitting with your culture and preferences. So, you know, like seafood came up on top, for instance and like, depending on what your culture is and what your preference is, you could choose different kinds of seafood. I mean, you know within reason, I think it's I think it's reasonable to sort of shift towards, you know, maybe a certain food that may have a higher nutrient density than another, but I don't think anybody, you know, I think compliance would be a problem if you if you try to be too prescriptive with any diet.

  Nima Nahiddi: [00:20:55] Yeah, I can imagine that that would be it would be difficult. Compliance would be difficult with any diet and I think we see that in with a lot of different people. Um, do you have any, any evidence about you talked about omega-3 versus omega-6. Have there been any, any evidence or any studies about those and their roles in the management of mental health disorders?

  Dr Laura LaChance: [00:21:26] Mhm. So, um Omega-3s so again, there's probably the most literature in, in depression, although there's a decent smattering of literature in schizophrenia as well, although probably a bit more controversial. So in depression, if you look to the most recent CANMAT guidelines,so C-A-N-M-A-T, which are the guidelines that we typically refer to in Canada to um, you know, guide us in terms of treating depression, omega-3s are listed there as second line evidence, as either monotherapy or as adjunctive therapy. Um, and the International Society for Nutrition and Psychiatry Researchers published in September 2019 a series of specific guidelines for using omega-3s in depression. So basically what's been shown is that for both bipolar depression and unipolar depression, there's there's multiple, you know, 15 plus RCTs to support use of omega-3s as adjunctive treatment. If you have mild depression, you can start with just omega-3s as monotherapy, so by themselves and it's more important that the omega-3s contain a higher dose of EPA relative to DHA, and those are the two long chain fatty acids that are the most bioavailable and usable by the brain. So you want to look for a dose of EPA somewhere between 1 and 2g, so 1000 to 2000mg and depending on which supplement you're taking, that might actually involve taking more than one of those little gels, so you have to read carefully on the label, but that's the dose for acute treatment. And then if you're more in like a maintenance kind of brain health, then you can then it's okay to use to use lower doses, similar as with medication. We have doses for acute treatment and then doses that we would use for maintenance.

  Nima Nahiddi: [00:23:18] Similar to any other type of medication.

  Dr Laura LaChance: [00:23:21] Yeah. So I treat it as such. And it's the same kind of thing, right? I'll start the omega-3s, you know, assess tolerability at two weeks, think about maximising the dose based on tolerability, wait 4 to 6 weeks to see an effect. You know, same same kind of principles.

  Gray Meckling: [00:23:35] So we've been discussing some of the research around nutritional psychiatry. I think the next section we wanted to touch on was really tie things back to clinical practice. And so I'm wondering if you can take us through maybe a common clinical case that might demonstrate some of these principles. For example, one that I saw in the literature and I'm sure there are many others, would be something like iron deficiency and how that may relate to depression.

  Dr Laura LaChance: [00:24:02] Sure. So so I mean, I can think of a number of cases. So what I'll share with you is probably just like a bit of a fusion of several individuals. But I tend to think of iron deficiency when I see somebody who's presenting with depression, who has decreased food intake for whatever reason, it may be due to their depression itself as a symptom or there may be other reasons like, you know, food insecurity, dietary preferences, they're restricting a bunch of different kinds of foods and as part of our usual workup for depression, we should be doing a CBC. But I think that in certain, if you have certain risk factors, like somebody who's vegetarian, a woman who's of in their reproductive years, you know, decreased intake for another any other reason I always add on a ferritin with that first CBC that I order because you can see early signs of iron deficiency even before the person becomes frankly anaemic. And often when you think about symptoms, often the person's presenting with cognitive difficulties and low energy, right? A lot of fatigue in in context of their depression. And then I'll basically include adjunctive treatment with an iron supplement as part of the treatment. And I'll also counsel my patients around iron rich foods to increase into their diet.

  Gray Meckling: [00:25:34] Right, and so have you seen this play out in any of your patients where prescribing the iron or the ferrous sulphate as an adjunctive treatment has really shown an improvement in their symptoms beyond maybe the standard of care?

  Dr Laura LaChance: [00:25:49] Yeah, I mean, I've seen I've seen it a few times. I've presented a few cases at our clinical rounds, which feels like an eternity ago, which was in April. But one person stands out in particular. She's the young woman with bipolar depression and she she looked kind of iron deficient to me. She just looked so tired all of a sudden and she was complaining a lot of low energy, and it was really a change from her mental status before. And she had been following a diet that was, um, like it wasn't vegetarian per se, but she was really focused on weight loss and so her main protein source was chicken breast and a lot of just like basic salads and stuff like that. So her actual intake of iron is down and she's a menstruating woman and she was iron deficient. And so I added that to her treatment for depression. Um, you know, I would never, like if somebody has symptoms of depression, I would never deprive them from the normal, you know, standard of care treatment. So it's challenging in nutritional psychiatry because you never have the situation where you're just treating somebody with a dietary intervention. Um, but, you know, she responded really well and I could see the improvements in her mental status track with, with her ferritin levels normalising. So I mean it's, it's challenging because you don't really have you know, you can't say what did what with 100% certainty. Um but I have been seeing definitely a pattern in my clinical practice.

  Gray Meckling: [00:27:26] Yeah, that's great. And it sounds like it can be really important to watch out for these nutritional deficiencies or other dietary factors that may be contributing to people's mental health challenges. One question related to this is I'm wondering if you think most psychiatrists are comfortable prescribing these types of dietary or supplemental interventions.

  Dr Laura LaChance: [00:27:53] I think the supplements are a little bit trickier. They're also higher risk. For instance, you wouldn't want to indefinitely prescribe somebody an iron supplement because, you know, you can have toxicity from having too much iron. You know, similarly, if you took four grams of EPA, you know, every day for the rest of your life, maybe you'd be at increased risk of bleeding, for instance. So the supplements are a little bit trickier. So I think we do need to, you know, lean on guidelines, for instance, like the guidelines I mentioned for the omega-3 supplements in depression or looking to clinical, you know, point of care resources like UpToDate to understand how to prescribe iron supplementation for iron deficiency. But I think that the food interventions, I think the beauty of the actual nutritional interventions is that they have such a better safety profile. So really, I think that any doctor, you know, can feel comfortable and I can get into kind of more specifics of how do I assess diet and what do I recommend if that's of interest?

  Gray Meckling: [00:28:54] I think maybe for now we can just put a flag in that point, because I wanted to quickly ask you also about psychotic disorders and if there's any evidence or any clinical cases that you can think of that might relate to diet and any of the psychotic disorders.

  Dr Laura LaChance: [00:29:12] Yeah. So I published a scoping review on that topic about a year ago and so there is there is a very, you know, plentiful body of research on this topic and I think it speaks to the fact that we still don't really understand schizophrenia very well. The treatments we currently have are limited so it's one of those disorders where, you know, pick a theory and somebody studied it 50 years ago because it's just like, you know, we just really don't, we have more questions than answered than answers. But so for for psychotic disorders, I mean, where to start? So certainly we know from observational literature that individuals who have schizophrenia spectrum disorders follow a lower quality diet than the general population and kind of just summarise it at that. There's a large body of research on omega-3s as adjunctive treatment for psychotic symptoms themselves, but also for metabolic comorbidities in schizophrenia. And there are a couple of RCTs that have found that you can prevent weight gain or triglyceride abnormalities in in individuals with schizophrenia treated with antipsychotics by using omega-3 supplements, so that's kind of interesting. In terms of the effect on psychotic symptoms, it's more heterogeneous. So there seems to be more of a signal in early disease that omega-3s can potentially have an effect as opposed to chronic illness that's less clear.

  Dr Laura LaChance: [00:30:46] Um, there are no so there's, there's some, you know, people have looked at probiotics, people have looked at different micronutrients like a bunch of the B vitamins, for instance. In terms of whole diet interventions, so I'm involved in a randomised controlled trial of a virtual care intervention to target diet, exercise and smoking in youth with first episode psychosis. So again, the intervention is, is like it's a compound intervention, it's complex, it has, you know, those three elements. It's not just diet, but, you know, it's an intervention where we follow participants over 12 weeks and we help them make changes in their health behaviours and so I have experience with participants from that research study of just like, you know, experiencing huge changes in not necessarily psychotic symptoms, but mood, energy within a diagnosis of schizophrenia after making dietary changes.  Concentration is another big one that comes up, motivation, and so you know we can think about also the comorbidity of depression or of even negative symptoms in schizophrenia as targets for dietary interventions aside from the psychotic symptoms themselves.

  Gray Meckling: [00:31:59] Yeah, that's all fascinating and I think I'll just point out to our listeners that we'll link to the scoping review that you mentioned, and I did flip through some of it, it was very fascinating. So that's, the paper is titled Diet and Psychosis: a Scoping Review, and you can find that in the show notes beneath the episode if you want to learn more about that. There's a lot of great information there. So I didn't have any other questions. I wanted to see if Sarah and Nima wanted to jump in with anything.

  Sarah Hanafi: [00:32:27] Yeah. Um, so I was, you know, I was hoping to maybe tease out a little bit more of your experience in trying to capitalise on this mode of intervention and what might have been maybe some of the challenges you've encountered. I know you've alluded to, to how perhaps the tide is shifting in terms of the interest in the field, but certainly I can imagine that there's still kind of some progress to be made. And the first one that certainly comes to mind is even just obtaining like the necessary workup, is that something that sometimes you face some resistance when you're ordering certain bloodwork or other investigations for your patients or even, you know, consulting, nutrition?

  Dr Laura LaChance: [00:33:13] Yeah. I mean consulting nutrition as a psychiatrist is certainly a challenge. Um, but the, I mean, yeah, I really haven't had very much luck with that at all actually in the hospital setting that I work in. So I do feel like I'm kind of on my own a little bit, which is unfortunate. Um, in terms of the workup, I mean, the workup is the dietary history at this point because there's not so much that you can actually order in terms of blood tests. So like I mentioned, ferritin and along with CBC is something that I order for anyone with depression or anyone who has risk factors for decreased intake of iron. Um, and then, you know, if they're anaemic, we can order B12 but, and or folate, but that's like pretty much it, or you can order B12 if there are other risk factors for B12 deficiency. But we're very limited in terms of what actual lab tests that we can do. So the workup at this point is, is the dietary history. Um, and you know, I'd love to see, um, you know, in Ontario for instance, it was really easy to get what's called an Omega-3 index, which is basically a blood test that measures the amount of, so it gives you the percentage of EPA and DHA that's been incorporated into red blood cell membranes and you can use that as an indicator for people, you know, to identify people who would be preferential responders to supplementation with omega-3. You can use that to target the dose because we have, you know, ranges for what the omega-3 index should be between 8 to 12%. But we can't order that here, I haven't been able to find a private lab that can do it and so that would be really that would be really wonderful.

  Nima Nahiddi: [00:34:54] For you, what would be some of the questions you would ask your patients in order to get key elements of the dietary history?

  Dr Laura LaChance: [00:35:00] Yeah. So it's like really bare bones. So the first thing I do is give people some psychoeducation about the role of nutrition and mental health. So I'll say something like, you know, your brain is an organ just like every other organ and it needs the proper fuels to function and if your brain isn't supplied with the right nutrients, it can't function in the way that it that it needs to. So, for instance, doing things like making neurotransmitters, having your neurones communicate with each other, all of those processes require nutrients to function properly. So then I'll ask people, is it okay if we talk about your diet a little bit in relation to your mental health? Because sometimes people are, you know, they're a bit confused, right? Or they're not used to having mental health professionals ask them about diet.

  Nima Nahiddi: [00:35:38] Yeah.

  Dr Laura LaChance: [00:35:38] So ask permission, give some psychoeducation and then I'll ask people to start about the number and timing of meals and snacks. So how many meals do you eat a day? How many snacks do eat a day? Do you generally eat food at home or are you picking up food or going to eat at restaurants? So just have like a little bit of a landscape, right? So the person who, you know, doesn't eat anything at all until 5 p.m. and then snacks all night is very different from the person who eats three meals and two snacks a day. So that's the first question. Then I go through, I go for like, biggest bang for your buck. So how many servings of vegetables do you eat in a day? How many servings of fish and seafood do you eat in a week? And how many servings of sugar sweetened beverages do you eat in a day? And like that is, you know, I mean, you can often get find targets for intervention right there. You know, lots of people have many vegetables do you eat? One. How much seafood do you eat? No, none. How many sugar sweetened beverages do you have? Oh, just two, you know, so that's kind of a really easy place to start. And then the next question kind of if I have time and people are actually cooking at home, I'll ask them about what kinds of cooking fats do they use in the house and to try to shift them towards olive, avocado or coconut oil if that's something that's of interest to them. And so that's kind of where my assessment. And then as we've been kind of talking about this, you know, people have like even, you know, the somebody with the most basic food literacy, they usually have some idea of something that they could do better with their diet. So even just from talking about it, I'll ask them, you know, is there is changing your diet something that you feel that you could do? You know, what's your motivation? What's your confidence that you could make a change? And then do you have an idea of something that you could change about your diet? And like that, you know, you don't need a nutrition degree to do any of that.

  Sarah Hanafi: [00:37:38] So it sounds like you take almost a bit of a motivational interviewing approach to coax behavioural change.

  Dr Laura LaChance: [00:37:47] Certainly, yeah. Yeah. If it's their idea, they're much, much more likely to do it.

  Sarah Hanafi: [00:37:53] And you know, you mentioned a little bit how your interest in the social determinants of health is part of what led towards nutritional psychiatry. A lot of the patients that we work with in psychiatry are vulnerable and might have limited access to financial resources or other kind of economic resources. I'm wondering if that's a challenge that you've encountered sometimes for patients who may be interested in adopting diet-based interventions or other kind of physical activity changes, but are limited.

  Dr Laura LaChance: [00:38:34] Certainly. So, I mean, one thing is, you know, work with, so collaborate, so, you know, working with our social work colleagues to ask them about resources in the community for nutritious food. There are a lot of different options out there, and we can't possibly know about everything that exists in our environment. So that's one thing is collaborate. Another thought that I have about that is that restaurant food is often much more expensive than food that you prepare at home. So, you know, shifting toward preparing more food at home can often identify a way where you can make an intervention that's cost neutral. Um, I'm currently in the process of evaluating a handout that I created based on the scoping review with one of my colleagues, Dr. Monique Aucoin, about and it's actually Aucoin, not Oakley, I'm not mispronouncing it. And it's a handout that's specifically made for individuals with severe mental illness and there's a section on there about, um, about eating well on a budget. And so certain items like, you know, frozen vegetables or very inexpensive, buying like dried beans and legumes, very inexpensive, um, eggs, another source of complete protein, healthy fats that can be added to many different kinds of meals, many different types of cuisines. So like, obviously there, you know, it's more challenging for sure, but everything else is more challenging also with an individual who is, you know, facing barriers like insecure housing and, you know, substance use and, you know, everything that we see of patients poverty really in general. So, um, I think you just you meet the patient where they're at and you try to make an improvement, you know, in one step. And just because you can't have them, you know, eating a $20 salad from pick a restaurant, um, it doesn't mean that it's not worth trying to make some gradual changes with them.

  Sarah Hanafi: [00:40:35] No and I think I think you make a really good point, too, about those opportunities to collaborate and lean on other members within the team or other resources to support our patients and in making these changes within their life.

  Nima Nahiddi: [00:40:50] All of, all of this has been really fascinating with the discussion on some of these really basic questions we can ask the patients in order to get really important information about their everyday habits and move forward with these dietary patterns and, you know, really get them interacting with us and becoming better clinicians ourselves. Do you see future directions for nutritional psychiatry? Do you have anything in mind as to what's going to be next steps in the field or what's going to be things to come?

  Dr Laura LaChance: [00:41:35] Um, yeah. I mean, so I think this podcast is a really nice next step and examples like it so thank you for giving the topic some attention. Um, you know, I look forward to opportunities for more nutrition education and as part of medical education in general so that we can have nutrition be on our radar as doctors. Um, I think, you know, there's obviously a ton of research to do. We didn't even touch on gut microbiome today, which is a huge, you know, diet is one of the major and most modifiable determinants of the gut microbiome. And I think we're just we're in like we're just in the dark. We don't even understand what a healthy microbiome looks like versus an unhealthy microbiome or what a healthy microbiome is even supposed to produce or how to influence that. So I think that's really going to be a major future direction for the field.

  Nima Nahiddi: [00:42:35] So my my knowledge about gut microbiome is quite limited. Do you mind giving us a quick update on like what's when you say that or like what is the current knowledge on the gut microbiome? Because it is something, you know, you read about in newspapers, magazines and I would think it's something that, you know, we would be interested in developing more knowledge about. But do we have current evidence or what's the current knowledge about the gut microbiome?

  Dr Laura LaChance: [00:43:06] So, so you know, microbiome as it relates to mental health has a number of important functions. Um, mostly so the microbiome is, is crucial in maintaining that barrier between outside of the body and inside of the body at the level of the gut, right? So we have this gut epithelium or intestinal lining which protects the inside of our body from what's in the lumen of our intestines. And if that barrier is not functioning normally, then, you know, toxins from food, bacteria can translocate, bacterial antigens can translocate across the gut lining and get into our circulation, and there they can cause an immune response. And that, you know, when we talked about inflammation earlier and inflammation being an important mechanism in mental illness, the question of where does this inflammation coming from? Well, a lot of people think that it's coming from the gut for exactly this reason, because the gut lining is not intact. So the microbiome plays a massive role in terms of maintaining that gut barrier integrity. It also produces a number of important molecules like short chain fatty acids, but also neurotransmitters directly, so, you know, of obvious relevance. Um, and it modulates the HPA axis, which is our stress system, which is of also crucial relevance to mental health.

  Dr Laura LaChance: [00:44:30] And the gut and the brain are talking to each other. So Sarah mentioned earlier the microbiota-gut-brain axis, and that's a bidirectional means of communication between the gut and the brain, where the vagus nerve is one of the channels of communication  but also there are endocrine and cytokine signaling molecules that communicate between gut and brain. So, um, I think like, you know, there's, there's a lot of overlap when you start to dig into these mechanisms but I think what's super important and I think exciting about the gut microbiome is how modifiable it is. And so, you know, you can modify the gut microbiome with, with probiotics, with synbiotics, with postbiotics, with, um, faecal microbial transplant, but also diet is actually coming out as the most potent way of changing your microbiome. So if you change your diet for a couple of days, you can see dramatic shifts in the composition of the gut microbiome. And so I think that's going to, you know, I hope as that field develops, we start to see, um, a lot more attention to, to diet there.

  Nima Nahiddi: [00:45:35] It's really fascinating.

  Dr Laura LaChance: [00:45:37] I mean, it is and it's just like it's a whole other, you know, like layer of complexity to apply to the physiology that we already understand about our bodies. So it's hard to even wrap your head around it. But we have now we've got at least five randomised controlled trials in depression of probiotic interventions. We've got one in anxiety, we've got two in schizophrenia and like I said, it's early days because I don't think we know what a healthy gut microbiome even looks like, so I don't think we know which kind of probiotic to prescribe. So my response to that clinically right now is we know that you can support a healthy gut microbiome by avoiding things that damage the microbiome, like ultra processed foods and sugar. We can support a healthy microbiome by providing our gut microbiome gut microbiota with lots of healthy food, which is fibre, right, another another word for it.

  Nima Nahiddi: [00:46:29] Yeah.

  Dr Laura LaChance: [00:46:30] Um, and then we also know that we can consume fermented foods directly so we can eat things like yoghurt, kimchi, sauerkraut, whatever, kombucha, if you will. Um, and, you know, those are all sort of safer things that, you know, are actually probably more cost effective than probiotic supplements anyways.

  Nima Nahiddi: [00:46:52] And it's nice that even though, you know, it seems that we're at the tip of the iceberg for, you know, what we know about the microbiome, there's still a lot of things clinically that we can recommend to the patients.

  Dr Laura LaChance: [00:47:05] Yeah. And I mean, there's a lot of convergence, right? We've been talking about anti-inflammatory diets. We've been talking about supporting a healthy microbiome and, you know, having lots of fruits and vegetables like, the Mediterranean diet is essentially a template that everything kind of converges in that direction. And I realise that not everybody on the planet is going to consume a mediterranean diet for various reasons. But you know, it's rich in fruits, rich in vegetables like beans, legumes, whole grains, you know, fermented foods, healthy fats, not refined carbohydrates, not sugar. And those are really just like, I think, take home points at this point.

  Gray Meckling: [00:47:43] Well, that was great to touch on all those future directions. And I for one, I'm grateful that we've had such an expert on the topic to to chat with, and we can count on you to sort out all of these research questions. The last topic we wanted to touch on was just if you had any tips or advice for for someone who's maybe in medical school or early on in their residency who is interested in nutritional psychiatry, where they can learn more or how they can get involved.

  Dr Laura LaChance: [00:48:12] So there is a society that I alluded to that's called the International Society for Nutrition and Psychiatry Researchers, and it's actually probably 50% researchers, 50% clinicians. But they have an absolutely fascinating conference every two years and it just happened in 2019, so it'll be 2021 in Vancouver, actually. Um, and if anyone's interested in learning more about the field, that is where the experts are. It's a group of about, the last conference was about 200 people and it was like, you know, I felt like I was, you know, in Hollywood, like seeing all the stars. And, you know, it was so that's something that I would strongly recommend to anyone who's interested in the field because you'll get the the most kind of cutting edge knowledge. Um, I mean, if anyone, like anyone at McGill who's interested, please reach out to me, I'd love to chat with you and like, you know, we can definitely talk about it. So you're welcome to share my contact info in the show notes also. There's a Food and Mood Centre at Deakin University that was created by Dr. Felice Jacka, who's probably the, um, she's probably the most, I guess, famous researcher in the field. She's the person who actually started the society and she's like kind of the mother of modern nutritional psychiatry, I guess. Um, and so it's called the Food and Mood Centre at Deakin University in Australia and they have a course on food and mood that's free on, through FutureLearn and so if you're wanting to learn more as a clinician or just as a person who is interested in making healthy changes to your life, that's a good place to get really high-quality information. Um, and you know what I would say if anyone's interested, I mean, read broadly and start talking to your patients about their diets. I don't, you know, I don't think we need to wait for that.

  Gray Meckling: [00:50:06] Yeah, that sounds like great advice and we'll definitely link to some of those resources in the show notes so thank you for sharing all of that with us. I think I'll hand things off to Sarah now.

  Sarah Hanafi: [00:50:17] Yeah. Thank you so much, Dr. LaChance, for joining us for this episode. You know, I think I can speak for our listeners in saying that maybe the takeaway, the takeaway from all of this is that nutritional psychiatry is something that's actually quite accessible. It's something that, you know, in speaking with our patients, we can quickly ascertain opportunities for intervention by not only trying to to work with our patients and meet them where they're at, but also work with our colleagues and finding and facilitating access to to resources. So I think that that gives me a lot of hope as a trainee that I feel like a little better equipped to address some of this when I'm caring for my patients. So we really thank you for your time and for our listeners, keep an eye out for the show notes. We'll make a point of linking many of the the useful resources that Dr. LaChance mentioned today. Thank you.

  Dr Laura LaChance: [00:51:16] Thank you.

  Alex Raben: [00:51:26] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sara Hanafi, Dr. Nima Nahiddi and Gray Meckling. The audio editing was done by Dr. Alex Raben. Our theme song is Working Solutions by Olive Musique. A very special thanks to our incredible guest, Dr. Laura LaChance, for serving as our expert for this episode. You can contact us at Psychedpodcast@gmail.com or visit us at Psychedpodcast.org. As always, thank you for listening.

Episode 25: Understanding Attachment with Dr. Diane Phillip

• Episode 25: Understanding Attachment with Dr. Diane Phillip

  Lucy: [00:00:10] Hey there, podcast listeners. It's Lucy here. I hope everyone's well today. I'm excited to be remote co-hosting this episode on Attachment theory. Hopefully this audio quality is sufficient despite this remote recording. We have two new guests with us today. Firstly, I will introduce Chase Thompson, a PGY2 psychiatry resident who will be co-hosting with me. Fun fact I actually met Chase on an emergency psych call shift at CAMH. And basically we plan to collaborate on the episode and and here we are. So, Chase, can you just tell us a little bit about yourself and any of your interests?

  Chase: [00:00:54] Hi, my name is Chase. I'm a PGY2 in psychiatry here at the University of Toronto. I'm originally from Calgary and moved to Toronto for psychiatry residency. Recently, I became interested in attachment theory after doing some work with our guest, Dr. Diane Phillip, and I'm excited to explore that a little bit further today.

  Lucy: [00:01:16] Thanks for that Chase. And our expert today is Dr. Diane Phillip, who is a child and adolescent psychiatrist at the SickKids Centre for Community Mental Health in Toronto. And she's also assistant professor at the University of Toronto. So she's developed a family therapy method called Reflective Family Play, which is a model of therapy which aims to improve parent child dynamics and more specifically, attachment. She currently practices reflective family play and also teaches this method locally and internationally.

  Dr. Diane: [00:01:49] I'm really excited to be here today talking with you guys about attachment theory.

  Lucy: [00:01:53] All right. Awesome. So today we will be exploring a key foundational concept in psychiatry, which really informs a great deal of what we do in the scope of formulation and psychotherapy. This is such a backbone framework in theory, and I think having this understanding will also set us up well for future episodes on different psychotherapeutic modalities and other areas of psychiatry. So I hope I mean, our hope is to sort of cover the following learning objectives. It's kind of loaded, but we will do our best. So firstly, we will define attachment and attachment theory. I think that this would be a great place to start. Then we will review some of the history of attachment theory and how the field developed. We'll touch on the evolutionary basis and the functional role of attachment in infants. We will also review some of the neurobiological perspectives of attachment. Well, of course, look at the different types of attachment and attachment disorders and how infant attachment is assessed. And hopefully we'll will also have a little bit of time to also explore how adult attachment is assessed and how attachment disorders impact adult relationships and child rearing. So that's a lot. So I think we should get started. So why don't we explore this first question. So what is attachment? Is it a noun? Is it a verb? What is attachment? What does attachment theory?

  Dr. Diane: [00:03:32] Sure. And it is confusing because there's the English language that uses the word attachment to mean a whole bunch of things. And there's pop culture that has come to adopt attachment theory and kind of morph it in ways that it never was intended for. So in its purest sense, when we talk about attachment, we're talking about a specific bond that an infant or child has towards their primary care giver or primary care givers. And so I should also specify that this particular bond has to do with when the child is feeling insecure, threatened, unwell in distress, and they seek security or they seek comfort or protection. So it's a drive to seek comfort or protection with a primary care giver.

  Chase: [00:04:24] Thank you, Diane. And attachment, it's it seems to be kind of this specific phenomenon that has been observed. And I'm just wondering where the first observations of this behaviour in infants came about and how it became a recognizable phenomenon with within psychiatry and psychology.

  Dr. Diane: [00:04:45] So there. In the history that we tend to talk about. And the first is john bowlby, who was trained in psychology. He was and went on into medicine and became a psychiatrist and a psychoanalyst. And he observed children and observed. Okay children who were in more challenging and marginalized situations and started to develop this theory also influenced by mythologist Konrad Lorenz, who was observing other species actually. And so he came up with this idea of attachment and that this idea of infants and children seeking security from a primary caregiver. And he saw this really as a primary human drive, just like the drive for food and sustenance or the drive for sex and procreation. And his theory was also that which we often forget, is that infants and children seek security from their attachment figures in times of distress. They're then free to explore their environment. And so there actually he talked about two poles for attachment, the pull of security and comfort seeking when the attachment system is what we call activated. And so they're activated to try to find a secure base. And then they are able to explore when they're on the other pole, the other end of the continuum, they're able to then explore their environment. And so that's that's Bowlby stuff in a nutshell. And then we flip over to somebody else, a colleague of his, Mary Ainsworth, who is actually studying mothers and babies in Uganda and getting some of her own ideas around attachment behaviour and attachment security seeking in infants in that setting. And she came back and created this laboratory setting called The Strange Situation, where she actually created a model or a paradigm where we have been able to measure or define or categories infants and toddlers into categories of attachment. And we can talk, I'm sure we will more about those categories as we go forward in this discussion.

  Lucy: [00:07:09] Yeah, thank you for that. I mean, it's so interesting. I mean, that's why I kind of asked about is attachment sort of like a verb. I mean, it kind of seems like an impulse, like a basic instinct for survival. And that's where I kind of see this strong sort of evolutionary basis for attachment.

  Dr. Diane: [00:07:27] Absolutely. And it makes sense from an evolutionary perspective. And certainly Bowlby spoke about this and others have, too, that it makes evolutionary sense that we're not the largest or the strongest, but perhaps we're the smartest species on the planet. And these kind of prosocial behaviours that we have our ability to communicate and our ability to signal our distress and get comfort from our parents is a key thing that perhaps put us at a survival advantage from an evolutionary perspective. And so, yeah, it's this biological drive within us that may have been selected for as something that increase the probability of the infant surviving infancy because infants, infant mortality rates historically have been extremely high. So if you are an infant that is able to let your caregiver know, hey, there's a problem, I'm not well and there's something threatening happening to me, this is scary. And then your caregiver picks you up and you are soothed and comforted by that. Well, that's also rewarding for the caregiver. It's a really clear communication pattern that has a nice cycle to it for the for the parent and the child.

  Lucy: [00:08:46] Yeah, for sure. Like, I feel like a lot of this overlaps with what I've been learning through the trauma therapy program and women's college, where I'm doing an elective. You know, I think everyone knows about, you know, fight or flight as, you know, survival responses. But I've also learned about attach, cry and also freezing. But like attach cry. I forgot that that's sort of like it's definitely a protective measure as a means for survival. So that kind of maps on to what you've been saying. I guess next, what I'm kind of wondering about is exactly like when does attachment develop? Like does it begin in the womb? I guess more so curious about how attachment develops?

  Dr. Diane: [00:09:29] We believe it develops sort of over the course of the first six months of life. It's starting to develop. And then by when it became measurable in this this laboratory setting that Mary Ainsworth developed was around 12 to 18 months when she created this thing called the Strange Situation. But we believe it's developing all along through the first year of life. And there have been others who have actually done modified strange situations with much younger infants and seen kind of the precursors of some of the attachment behaviours. But it isn't until a child is 12 to 18 months old that they're able to either crawl or even walk and so give a really clear indication of their attachment behaviours. So I don't know if it's okay for me to digress a little bit and talk about the strange situation.

  Lucy: [00:10:20] Yeah, please digress.

  Dr. Diane: [00:10:23] So this is the thing that Mary Ainsworth developed, which was in the lab with infants and their mothers at that time who and the infants were 12 to 18 months old, and it's this increasingly stressful situation. So these were just community volunteers, mother baby dyads, and they brought them into the lab and they came in and they played with some toys. It was a new playroom situation for the infant. And then at a certain point, this friendly but unknown other woman comes into the room and at first she's not interacting with the baby. She then starts to interact with the baby and then they get the mother to leave and the baby is left alone with the stranger. Then a stranger leaves and the mother comes back. And with these increasing levels of stress, the baby obviously reacts to, or most babies react to the stressful situation. And then what ends up happening in the classic strange situation is everybody's left him or her. And then the mother returns and the behaviour of the baby on the return of the mother is then coded by independent coders in a way that can then categorise the baby. So a majority of the babies, somewhere around 65%, let's say, will do this thing where they they make a beeline to the mother. And that's why, as I mentioned before, you kind of want a baby that can crawl or walk so that they can make this beeline towards the mother and sort of letting the mother know I'm in distress, pick me up. Mom scoops the baby up, and within a relatively short period of time, the baby settles to the point that they are able to return to play, although there's usually this sort of guarded play for the next couple of minutes and then full rapprochement of the relationship to more back to baseline and those that what I just described that sort of distress beeline soothing bit guarded and then back to baseline is what we describe as. As a secure pattern in an infant or preschooler. And then there are these two different insecure patterns that we see, which is still considered attachment behaviour, but it's considered insecure, avoidant or insecure, ambivalent, resistant. And about 15 to 25% of babies will be insecure avoidant. And what their behaviour looks like is Mom comes back in the room after we've had lots of comings and goings of the stranger and the mom and the baby's now been left alone and mom comes back in the room and baby kind of sees them. First of all, baby doesn't show as much distress.

  Dr. Diane: [00:13:07] Outwardly Baby sees mom and seems pretty calm when Mom returns and we don't have that same distress kind of pattern with these insecure, avoidant babies that are still attached. But in this kind of avoidant of big dramatic displays of distress and then the insecure, ambivalent resistant babies, which is about 10 to 15% of babies in these studies, have more of a pick me up, put me down, stay distressed much longer kind of pattern compared to the secure babies. And then there was this fourth category called Insecure, Disorganised, and these babies were categorised as disorganised because their behaviours looked disorganised. We now recognise their behaviours as quite organised, but not they're more atypical and they are more not in the service. They don't seem to be as coherent with the idea of getting proximity. They the child may freeze the some of them may crawl backwards. They do bizarre things that don't seem to have that same goal of trying to get closer. So I should come back to the kids that are insecure but attached. Sorry, they're all attached but insecure attachment styles of avoidant and ambivalent resistant. Those babies have learned a strategy. All of the babies have learned strategies for maintaining proximity to the caregiver.

  Dr. Diane: [00:14:39] In particular, these these first three categories that I described, the secure ones and the two insecure ones, these are strategies that they have learned through the course of that first year of life to maintain proximity to their caregiver. Because, remember, the goal here is to stay safe and this biological drive, to stay safe, to stay close to the caregiver so that the caregiver can protect me and comfort me and deal with any distress that I might have. So if I've learned that my caregiver kind of the best way to keep my caregiver near me is to be is is to signal I'm in distress, I'm unhappy. I've developed what we call this internal working model that my caregiver is going to be there for me to comfort me when I'm in distress. But I may have a different internal working model that my caregiver kind of doesn't want me to make such a big fuss. So I'm not going to make such a big fuss because that's the best way to keep my caregiver around. That's the avoidant strategy, and the ambivalent resistant one is more sort of a push pull kind of relationship with the caregiver. But I'm going to pause there because I think I've talked a lot and maybe have some questions.

  Chase: [00:15:53] Yeah. So that's an interesting point about the infant wanting to keep their caregiver around as much as possible. I guess that sort of implies that parents respond differently to their infant's distress cues. And I'm wondering. Parental style that would lead to an infant developing an avoidant attachment style, and then also maybe an ambivalent or preoccupied style. And maybe you could describe what types of behaviours would lead to that.

  Dr. Diane: [00:16:22] Absolutely. So we know from research that actually the parents attachment style and that's a whole different discussion that you may or may not have already had with somebody else on this podcast. But parents attachment style or adult attachment style can be categorised into very similar categories. And so parents who have a secure attachment style tend to have what we call good reflective capacity. So they have a good sense of how they're feeling, but they also have a good sense of how their infant is feeling as distinct from them. And they can flexibly consider a number of hypotheses about what might be going on for this infant. Oh, maybe he's not feeling well. Maybe she's cutting a new tooth. Maybe they are feeling scared because we're in a new situation. Maybe they've got gas. So they come up with a they have what we call cognitive flexibility around what might be going on for their infant. And that cognitive flexibility allows them to really pay attention to the infant's cues and respond in a sensitive and attuned manner. The parents who are who have insecure infants typically are parents who have an insecure attachment style themselves, and they have less of that good reflective capacity and less of that cognitive flexibility. So for them, the infant cries and they might think, why is he doing this again to to bother me or and that's the only only understanding they have of their child's behaviour is that they're just doing this to bug me or, you know, she's just she doesn't actually have a problem. She's just a drama queen. And that's the only explanation that parent has of what's going on for the child. They're not able to come up with a bunch of different hypotheses and so they respond insensitively or in a less attuned manner. And that comes from their own inheritance of of an attachment pattern that they have perhaps with their own primary caregivers.

  Chase: [00:18:35] Yeah. So it sounds like what you're talking about, in a sense, it's the attachment style of the parent is kind of passed down from parent to child in the way that they're able to discern what's going on in their own infant and Attune provide some sense of attunement to their own infant's needs. I guess I'm wondering in that in the disorganised infant, it sounds like the infant doesn't really have an organiser consistent approach to the caregiver and what kind of behaviours from the caregiver would lead to that sort of style?

  Dr. Diane: [00:19:11] Yeah, they're a very interesting group and probably a group that is way overrepresented in my clinical population and what we know from work of folks like Dr. Karlen Lyons Ruth, who actually took the same strange situation and looked at parental behaviours on that reunion moment and in particular looked at these, these disorganised infants, is that those parents were frightened or frightening. So you can imagine that you're in distress, you're an infant and you're in distress and you look to your parent to help you with your distress and your parent either appears frightened by your behaviour or frightening. Neither of those responses from your caregiver are going to help you feel contained in your distress. And so those infants are the ones that have a more disorganised pattern. There. Typically in these dyads, there's a history of some sort of unresolved trauma or loss in the in the parent or the caregiver who who gets distressed by their child's distress.

  Lucy: [00:20:34] So thank you for taking us through each of these different types of attachment styles. And I guess I wonder about like, you know, do these attachment styles, are they sort of like fixed? Or is it possible to learn a new attachment style? And I guess I'm thinking about orphans or or children who are who go from one foster home to another. I guess is it possible to learn a new attachment style? And I guess when is it best to kind of learn a new attachment style during childhood? Or is there a specific age range in which it's it's sort of optimal to teach a child a new attachment style?

  Dr. Diane: [00:21:19] So obviously we're very interested in this because we have this population often of infants who have gone through pretty, pretty high risk situations when they were quite young and supposed to be forming these attachment relationships and. I guess there are two. The good news is all hope is not lost. And the bad news is, yeah, these it can profoundly impact you and set you up for a higher likelihood of psychopathology and just poor outcomes in general, both in terms of health, academic and mental health outcomes if you've had this rough start to life. So the earlier a child is the adoption studies where the kids were in, particularly in deprived orphanages back in the nineties, there was a lot of research on those those kids. The earlier the child is adopted, the better, the better the orphanage situation was, i.e. that there were primary care givers instead of a rotating random array of caregivers, the better the outcome. But there's actually been more recent research on adoption and that you looking at particularly actually doing these adult attachment interviews with adoptive parents around the time of adoption and looking at outcomes in the kids and securely attached adoptive parents have a much higher likelihood of having even later adoption kids end up with a secure attachment and better outcomes than parents, where in particular the mother has an insecure attachment. And the worst case scenario is when both parents have an insecure attachment. So yeah, all hope is not lost in a good foster home or a good adoption. There is some very promising, not a ton of data, but some promising data that you can shift the attachment relationship or the attachment outcome for the child. So that's that's one area of data. And the other area of data is treatment. So you can also do work with kids who are in problematic attachment dyads but have not been removed from their home or adopted out. And treatment can also shift an infant or a child towards greater security.

  Chase: [00:23:51] So it sounds like, you know, even infants who are in a more marginalised home at the beginning can shift their attachment style to from maybe insecure to secure what do parents, adoptive parents or even just parents in general, what do they actually do with their infants to create a secure attachment? And how is that actually what does specifically that look like in terms of the parent child interaction?

  Dr. Diane: [00:24:23] Right. So in the adoption population, if you've got a parent who's already got a secure attachment, they have these models of internal working models in their mind of what relationships should look like. They have good reflective capacity, meaning they have a good sense of this is what I'm feeling, this is how I'm reacting and this is how I imagine my child is feeling and how my child is reacting to me in this moment. And maybe I'm going to. And they're able to adjust and sensitively attune their behaviour not 100% of the time, because that'd be just weird to be 100% of the time attuned to what somebody else needs because we're not psychic. It's more that they have a sense and they're able to keep doing that. That dance of attunement, where they're, they're shifting their behaviour to meet the needs of their child. And through that relationship, this child who's come from a more high risk background, who's been adopted into this family with securely attached parents, is going to to shift their internal working model of what relationships should look like so that rather than adults being frightening or frightened all the time and unpredictable and erratic or withdrawn and unavailable, they they now have multiple instances where these securely attached parents are responding in this much more predictable, much more sensitive and much more attuned way.

  Dr. Diane: [00:25:53] So that that would be the the good enough foster home or the the good enough adoptive parents. And the data is looking like part of it is a securely attached parent can can help shift that child in treatment. It looks a little bit different because you're taking the parent who perhaps has their own insecure attachment and you're working with them in in in the relationship with their child and trying to help them to shift from what I was describing earlier, this cognitive rigidity. So the work with those kind of parents is to help them broaden their understanding of why else might your child be having a tantrum when you. Make him stop playing his video game and come to the table, or when you move too quickly and decide to transition him to a new activity that has nothing to do with devices and you start helping them. Then consider what else might be going on for their child as opposed to this one hypothesis that they have.

  Lucy: [00:27:00] You've been speaking a lot about, you know, I guess, how you would respond to a patient or to a parent maybe in the scope of the work that you do. So I'm kind of wondering about the type of therapy that you specialise in and how attachment informs the way that you do that form of therapy. And how might you respond to parents with with approaches that might be informed from their own attachment styles?

  Dr. Diane: [00:27:29] So at our centre we do a therapy called Watch, Wave and Wonder, which there was an RCT that looked at attachment security actually pre and post treatment, and it was found to shift the infant and preschoolers attachment towards greater security. But there are lots of attachment based therapies that do similar work. So Areal Slate has this program called Minding the Baby and the folks in some folks in the UK, Anthony Bateman and Peter Fonagy have mentalization based therapy and all of these therapies are sort of geared towards helping people who struggle with being able to view to people who struggle with being being able to keep the mind of somebody else in mind with being attuned and sensitive with that people who struggle with that cognitive flexibility and have very rigid ideas about why others behave the way they behave, or or no interest or curiosity about why others behave the way behave. So people with more avoidant attachment styles who tend to have infants, who have avoidant attachment styles, they're less curious about the minds of others and don't really take them into consideration. And that can be problematic too. So when you're working with the parents, it's actually all of these different types of therapies. We we think about the parents attachment style quite a bit because that tells us how they're going to approach their child. And so if they have cognitive rigidity or no curiosity about what's going on in the mind of others or no ability to even imagine, imagine what might be going on or motivating their infant going on in the mind of their infant or motivating their infant to behave the way they behave.

  Dr. Diane: [00:29:24] The work is in trying to help them consider other possibilities. And in the infant and pre-school population, we really use play quite a bit, whether we're more directive and behavioural in our approach or whether we're more exploratory. An insight oriented play actually usually forms a significant portion of each session in the infant pre-school population and the idea is through play, you're able to help the parent become more sensitive and attuned and thinking about what might be going on for their infant as somebody separate and different than themselves. Who who's impacted by your behaviour and plays a very non-threatening way to work with parents. But they're often able to generalise from these play moments to other moments in their life that are not so non-threatening. And the other thing that happens typically we do watch wait and wonder interaction guidance, some mentalization based work and reflective family play, all of which have this play component and then discussion about the play. And while it's supposed to be play most of the time, some of the time kids have tantrums, kids have challenging moments with their parents. Kids refuse to play with their parents. Well, what do you think might be going on for your child right now and start getting them to exercise that reflective capacity muscle that there isn't just one thing or nothing that motivates us. There are lots of things that could be going on that that can explain a child's behaviour.

  Lucy: [00:31:04] You know, I guess you've already talked about, you know, parents with different attachment styles themselves, and this makes me kind of wonder about the trajectory from each of these attachment styles. What does it look like when there is no intervention? And, you know, they these types of attachment styles persist into adulthood. How does it affect their interpersonal relationships or how do they how does it affect their work? And I'm wondering, without intervention, how these attachment styles manifest in adulthood.

  Dr. Diane: [00:31:35] So there's a lot of evidence that children who have a secure attachment when they're infants or preschoolers are going to go on to have much more positive social and emotional competence. I think I mentioned they're just it's kind of a win win situation when you have a a good working model of what relationships could look like, that people can be trusted that when you're in distress, somebody is going to comfort you. You it has a good outcome for lots of different measures that have been looked at from cognitive functioning, physical health and mental health. And the inverse is the case for children with insecure attachments. They're more at risk for negative outcomes. It doesn't mean you're actually going to have a negative outcome, but they are more at risk for those negative outcomes. And then those who have the disorganised attachment style are at much greater risk for psychopathology.

  Chase: [00:32:35] I guess going back to what you've talked about briefly in terms of adults who have a secure attachment style, are able to foster that sort of secure attachment with their infant who may go on to become securely attached in general. Is there any sort of other psychopathology which would get in the way of a parent developing that attachment with their child outside of their own attachment style?

  Dr. Diane: [00:33:08] Sure, absolutely. If the parent is psychotic or abusing drugs, then their ability to be sensitive and attuned is going to be problematic, even if they're super stressed. And I do actually worry about parental use of devices and its impact on attachment, because parents who are on their devices when they're with their children are can't be attuned and sensitively responding. And there's actually a lot of very concerning data coming out of a number of sites, looking at parental use of devices and increase likelihood of children acting out, increased likelihood of the child actually getting a device to use to but increased likelihood of problematic interactions as parental device use just in naturalistic studies. Actually one coming out of Ann Arbour, where they were just observing parents and kids and the children were more likely to get into trouble if they were if the parents were using devices more. So I do worry about that too. But coming back to your question, Chase, about psychopathology for sure, substance abuse, psychosis, severe depression, where the parent can't really pull it together to be attuned and might actually appear frightening to the child is going to have an impact. There's also a goodness of fit. So there has been a lot of research on temperament, which is kind of the wiring of the child and how easily they can be soothed and how calm they are and how easily they adjust to a schedule and new situations which seems to be biologically driven.

  Dr. Diane: [00:34:57] The problem with the with temperament research is it's it's questionnaire based and where you're giving the questionnaire to the parents to describe their child. So it's a bit relational. So you have to take that with a grain of salt. But what I take from it is this idea of goodness of fit. So if you have a child who is temperamentally really challenging, not sleeping well, not settling easily, not easy to soothe and you're secure, but maybe not the most secure because secure attachment, again, is on a continuum. You might not be the best fit for that child, and you may respond in such a way that is not as sensitive or attuned because it's not a great fit because the child is a little bit more challenging. That being said, you can have a child who's temperamentally really easygoing and you put them in the wrong situation. They're going to end up insecurely attached because they're not getting their needs met because all infants and children are going to have needs, even the most easygoing ones.

  Lucy: [00:35:57] And that's great. I mean, I think we've talked a lot about different, different types of attachment. And I guess in an extreme sort of case, I'm also curious about detachment or what happens to a child that does not attach to an attachment figure.

  Dr. Diane: [00:36:12] It's extremely rare and it's in these rare situations. So most children attach because it's a survival thing, right? It's just whether they attach securely or insecurely and even the disorganised ones, one can construe them as having an attachment, a bond as well with the caregiver. Despite the maltreatment or bizarre behaviour of the caregiver, children who are removed from the situation, if if they had a good enough attachment with the primary caregiver that they lost, they may suffer, they will suffer and they may be more prone to things like depression and they may show lots of signs of distress, but they have a template for what an attachment relationship should look like. And they have a work internal working model that adults can be trusted and lost, but they can be trusted. And so they're much more likely to be able to form a new attachment with a good enough attachment figure. The ones that have had, you know, very deprived situations, either from the children that were studied from the 1990s where they were in in orphanages that were overpopulated with rotating roster of caregivers and no sense of primary caregiver or children who are in and out of problematic foster homes and high risk situations. Those children are very disorganised and they would be that that small subset of the population. And those are the ones where we know from some limited data, but promising that good enough foster placement as opposed to bad foster placement or good enough attachment. Adoption, adoption. Adoptive families where the parents have secure attachment and it's a stable environment, can have a corrective influence and shift the child towards something that's approximating security or even to security.

  Chase: [00:38:17] It sounds like attachment in a broad sense is an individual's first sort of internal working model of someone else. I'm wondering, like, does this map onto what we think of as like empathy or even just the way we think about others? It almost sounds as if if you can't sort of develop that first primary attachment with a caregiver, that it sort of impedes you the rest of your life in terms of creating an attachment with other people. Is that fair to say, or is that a little bit too abstract?

  Dr. Diane: [00:38:55] Well, it's fair to say that, like your earliest attachment relationships do set the template for what your expectation is in relationships. And I know there's Mickalene and Florian have looked at romantic relationships. I believe that's the folks that have done that and and correlating it with your attachment style as well. So yeah, it has a profound impact and it can be you can have corrective experiences through adoption, through an important relationship with a loved one or a teacher or through psychotherapy where you can shift, shift that template and get a new, more corrective experience. But yeah, it has this profound impact. But there was something else that you said that made me think of something else which has now slipped my mind about attachment.

  Chase: [00:39:53] I was just commenting whether it might does it map onto what we think of as a sort of cognitive empathy or empathy?

  Dr. Diane: [00:39:59] Right. Right. So empathy and empathy is in there. But to me, empathy and correct me if you disagree, but to me, empathy is sort of feeling for somebody else. And I think that in the. Attachment literature. We're talking about something even bigger than that, which is it's feeling like having a sense of what somebody else is feeling. But it's also in the context of my relationship with that person. So knowing that my behaviour, how I'm feeling affects my behaviour, which then affects how somebody else feels, which then affects how they behave. So yeah, like empathy to me is wow, I really get how so-and-so is feeling. But mentalization, which is another term that we use in the attachment literature, or my reflective capacity or my ability to internalise what somebody else is feeling or what I'm feeling is about also the relationship. I'm not sure if that makes sense, but it goes beyond empathy. Not only can I empathise or figure out what that person is feeling, but I also am aware that I maybe created some of that and that if I change how I'm behaving, which may mean me needing to figure out how I'm feeling, then I can shift the whole relationship.

  Chase: [00:41:19] Right? And that whole process seems to kind of necessitate a really high level of emotional intelligence. And I wonder if. I'm not sure if this is known, but is there some sort of component of emotional intelligence or sort of social intelligence that plays into whether people are good at developing attachments with their infant? Because it seems like sort of a complicated process that could be quite difficult if you if you aren't able to really pick up what your infant is needing and being able to develop all these models. It sounds like a complicated process.

  Dr. Diane: [00:42:02] It sounds complicated, but I'm not a I don't know how to. I'm not a psychologist, so I don't want to speak to stuff that is out of my area of expertise in terms of measuring emotional intelligence. But it is something that has been studied with people of varying intelligence. And it's it's not something that's necessarily so I'm making it sound much more conscious and explicit, but it's more on an implicit level that the parent can consider, Oh, maybe his diapers wet or maybe she's cutting a tooth or maybe she's cranky because she didn't get enough sleep or it's a new situation. Like, you don't have to be that super smart to take those things into consideration. You have to be curious, open to the possibility that there might be multiple reasons why the child why a child is in distress. But I don't know that you have to be super clever or anything like that.

  Chase: [00:43:07]  I think that that is clarified because I think the laying it out is something that's sort of implicit or something that kind of naturally happens in human child rearing makes it, I think, a bit more understandable because, you know, when we do kind of talk about it in an intellectualised sense, it does sound like a very complicated process, but it is something that every Parents is kind of capable of in a natural sense, like they can learn to do these things without being a highly emotionally intelligent individual is kind of the sense that I'm getting from you.

  Dr. Diane: [00:43:44] Right. And like, you can get people who are very intelligent, who have no curiosity, and I'll have parents will say, well, why do you think he chose to do X, Y or Z? And the parents, like, I have no idea. And that sort of that an avoidant kind of lack of curiosity about the mind of somebody else and a shutting down of of feelings around in particular distressful behaviour, distressing behaviours, and then the more preoccupied ambivalent attachment system the parent might is more likely to say, well he, you know, he's they'll have this very rigid idea of the my child did this to just piss me off and can't I mean I said this earlier just they can't entertain the possibility that there are multiple, multiple, multiple options and often more than one thing that might be going on. And again, it doesn't have to be that complicated and you don't have to be that smart to think it could be one of a few things that might be causing the child to be in distress.

  Lucy: [00:44:53] I'm just kind of also curious about what you mentioned around the implications of attachment in romantic relationships. And I'm wondering if you work with couples and parents and you're kind of noticing two different attachment styles between the parents and and how you manage that or or how you explore that within the scope of therapy.

  Dr. Diane: [00:45:12] Right. So reflective family play, this approach that we developed at our centre where we took some of the mentalization based therapy and said, Hey, we don't have something for this for a whole family and to work on couples stuff. It was explicitly developed in order to try to work on couple co-parenting issues and some of these differences in parenting styles. And for sure you can have parents who have different attachment styles and children will actually attach differently to the two different parents based on that. And that can create some of the conflict in our relationship around co-parenting. And so, I mean, often in co-parenting, a lot of the work we do is just sort of identifying and labelling these differences and then looking for ways to find complementarity. And instead of saying this is this is a problem and it's a difference that's insurmountable to rather say, hey, let's capitalise on each of your strengths and your differences to find some sort of complementary way of co-parenting this child or these children. But I'm not sure I answered your question. Lucy.

  Lucy: [00:46:22] No, that's great. I mean, I guess I was just thinking about my couples therapy case right now and how I could apply some of this theory into kind of managing these two with the couple that I'm working with two vastly different ways forms of attachment and ways of relating to each other. And I guess I was just curious about that and how it would help me with my specific situation. 

  Dr. Diane: [00:46:48] For sure. And I sometimes call talk about the match made in hell, which is typically the kind of preoccupied, maybe borderline mom or wife and the female part of the partnership, if it's a heterosexual couple. And then the dismissing avoidant or maybe even slightly autistic male in the partnership. And I think of that as a match made in hell where she just keeps up regulating and upping the ante in her pre-occupied way to try to keep him engaged. And he keeps avoiding and dismissing and escaping. And it can be very frustrating to see. And again, naming that as a difference is half the work and getting them to recognise that they have this difference. And at our site we do adult attachment interviews with both parents and so that helps us understand where that behaviour, that attachment style comes from. And then we can talk about whether you have this template of X, Y and Z and you have this alternate template of showers and, and that can be challenging for the two of you. Let's talk about that.

  Lucy: [00:48:00] Thanks, Diane Chase, do you do you have a final question?

  Chase: [00:48:03] I do. I just just wanted to put it out there because I know at the beginning, Diane, you mentioned that attachment is really become kind of the purview of popular culture. And in some sense, like I've seen multiple books about it, podcasts mainly out of California about it. I'm wondering like, what do you think are the most common misconceptions you see out there regarding attachment? And is there anything you'd like to kind of dispel for us before we close here?

  Dr. Diane: [00:48:35] I think my top peeves are that when people sort of use attachment and bond or relationship interchangeably and say things like they've got a great attachment because they were playing so nicely together in the waiting room, attachment. The attachment relationship is not about facilitative behaviour, so it's not about their ability to play. They might be able to play really well together and then the child gets distressed and the parent freaks out or is unavailable to the child. So attachment is again, that thing that you do when you're in distress and it's not the same as loving and playing and feeding and all those other great things and teaching great things that parents need to do to help their children survive and thrive. But they're different. And then I the other issue is like confusing attachment to literally needing to be inseparable from the child and having the child attach to at all times and not being able to kind of set clear limits and boundaries. One of the things children need to learn how to do is how to manage their own distress. And one of the ways parents help children learn to manage their own distress is by responding in an attuned and sensitive way. But I said earlier that you wouldn't want a parent who is 100% attuned because that doesn't really leave the child any breathing room to to actually live with some distress and learn how to manage their distress for themselves. And I have one colleague who talks about benign neglect and that that children sometimes need a little bit of benign neglect. They need to learn how to self-soothe a little bit. Obviously, this is not something we recommend in situations where there's a history of trauma or disorganised attachment or even avoidant attachment. But this idea that children need to always be sensitively dealt with and be literally with their parents constantly and attached to them constantly is is a misuse of the terminology. Attachment theory is really about what is what do you do when a child is distressed. So if a child and that whole thing coming back full circle to what Bowlby said, which was there's two poles to the whole thing. So if the child's attachment system is activated, they need to seek that primary care giver. But if the attachment system is not activated, then they should be free to explore their environment. And being able to explore your environment is the other pole of attach the attachment continuum.

  Chase: [00:51:10] It sounds like what you just spoke about kind of maps onto the concept of being a good enough parent, one who is attuned to their child sufficiently, but also gives them that space where there might be periods of distress that the child does have to learn to deal with in some sense.

  Dr. Diane: [00:51:27] Yeah, you were really paying attention, Chasee When we were talking about this stuff.

  Chase: [00:51:33] That's right.

  Lucy: [00:51:35] This is excellent. I mean, I think we've all definitely expanded. I mean, at least Chase and I am speaking for me specifically around expanding on some of these concepts of around attachment that we sort of, at least for me, have kind of always thought of it in a very sort of solid, specific way and now have a much more sort of elaborate way of thinking about it. And thank you for also dispelling some of those misconceptions about attachment. And I think this also will kind of better inform the way that we approach patients with different attachment styles, and it may alter the way that we were able to engage with them in therapy, but also sort of in a clinical and sort of assessment sort of context. I guess just to wrap things up. Dr. Philip, I always sort of ask the expert if there's any sort of words of wisdom or any advice or any thoughts about attachment or psychiatry in general that you'd like to share with our audience, which composed of young learners.

  Dr. Diane: [00:52:34] I think I love attachment theory. I think it's this profound piece of psychological theory that has influenced the last 30 odd years of mental health thinking. And so I recommend that trainees in psychiatry consider learning more about it and maybe even learning about the adult attachment interview if you're more of an adult psychiatry person, because I think it's it's a great clinical tool and there are folks who've written about using the adult attachment interview clinically because it's a laboratory thing to and so it's not something you need to go and get training in because that's like an 18 month conversion process and religious conversion process to learn how to to become a coder for the AEI, but rather there's lots of stuff now, lots of people writing about how to use the adult attachment interview, the A.I. clinically. So I think it's just so useful to have that lens when you're thinking about shifting people, people's. Psychosocial experience through psychotherapy. And I, I really love the work of the group in the UK that does mentalization based treatment, and I think I would recommend reading some of phonics and dating and stuff.

  Lucy: [00:54:23] Thanks. So thanks, Diane, for your expertise and Chase for joining me. And stay tuned, guys. We'll have another episode for you shortly. Bye.

  Chase: [00:54:44] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Lucy Chen and Chase Thompson. This episode was audio edited by Alex Raben. Our theme song is Working Solutions by All of Music. A very special thanks to our incredible guest, Dr. Diane Philip, for serving as our expert on this episode. You can contact us at the psychedpodcast@gmail.com or visit us at psychedpodcast.org, As always, thank you so much for listening.

Episode 24: COVID-19 and Medical Learner Wellness with Dr. Deanna Chaukos

• Episode 24: COVID-19 and Medical Learner Wellness with Dr. Deanna Chaukos

  Alex Raben: [00:00:08] Welcome to site, the educational psychiatry podcast for medical learners by medical learners. In today's episode, we're going to be covering wellness and Covid 19. For today's episode, we are very happy to be joined by Doctor Deanna Chacos. She's a staff psychiatrist at Mount Sinai Hospital in CL psychiatry. She's also, in terms of the Department of Psychiatry at University of Toronto. She's the wellness lead and an associate and the associate program director. So, Deanna, welcome to the show.

  Dr. Deanna Chaukos: [00:00:44] Thank you so much for having me. I'm very glad to be here.

  Alex Raben: [00:00:47] We're glad to have you. Uh, I'll be the host today. I'm Alex Rabin. I'm a Pgy five in psychiatry here at University of Toronto. I'm joined by three co-hosts today, and they're also the brains behind this episode. And I'm going to go through them one by one. So, grey, you you, um, quarterback this episode. Grey Mechling here is a CC3. Uh, and welcome to the show.

  Grey Meckling: [00:01:11] Thanks, Alex. It's great to be here.

  Alex Raben: [00:01:13] And we're also joined by William Caffyn, who's also a CC3 here in uh, at the med school in Toronto. And we welcome you as well.

  William C: [00:01:23] Thank you, Alex. Happy to be here.

  Alex Raben: [00:01:25] And last but not least, we have Randy Wang, who is also a CC three at Toronto. Welcome, Randy.

  Randy: [00:01:32] For having me. Alex.

  Alex Raben: [00:01:33] Thanks for being here. So before we jump into this very important topic and very timely topic, as we're all currently going through this pandemic as a global community and trying our best to cope with this and, um, and maintain our wellness, I want to go into the learning objectives we have for this episode. So this episode, we're really trying to get an idea as a group, uh, as to, uh, what wellness is and how it's affected by Covid and what we can do about that. So by the end of this episode, you, the listener, should be able to, number one, define wellness and burnout and their importance in medical education and how that relates to Covid 19 in our current time. Number two, understand strategies on how to maintain your wellness and prevent burnout, particularly during this difficult time we're in. And number three, understand strategies that you can use to help maintain or help others maintain their wellness and deal with burnout. So without further ado, why don't we jump right into questions? And we am. I'm going to throw to you because I know you. Uh, for our first learning objective, you did some looking, uh, research into what wellness means and what burnout means. And I'm wondering if you could define those things for us and how they relate to to each other. And then, uh, doctor Chacos could could also add to that as well.

  William C: [00:03:14] Yeah. For sure. Um, so wellness is a time that I often heard, and it wasn't it was interesting for me to kind of find a definition for it. Uh, so according to the World Health Organisation, uh, wellness is defined as a state of complete physical, mental and social well-being and not merely the absence of disease. Um, and although it's a good definition that highlights that wellness is not just absence of disease, it has received a lot of criticism, um, because it describes wellness as a state rather than a continuum. So you're either well or you're not. Another definition that I found, it was proposed by the National Wellness Institute, and it defines wellness as an active process through which people become aware of and make choices toward a more successful existence. And that seems to be, uh, that definition is more is used more because it describes wellness as an active process rather than just a state.

  Alex Raben: [00:04:08] So I'm hearing that it's not just the absence of disease, it's it's something more than that and that we have to work at this thing. Um, but we're we're used to in psychiatry, working from the DSM. How does this relate to that? Uh, that that large tome that we tend to work from? And why isn't wellness language used in that book, do we think, I wonder, Doctor Chacos, if you could maybe speak to that or elaborate a little bit about this definition and why it's not in the DSM or not, something we talk about as much in psychiatry? Psychiatry.

  Dr. Deanna Chaukos: [00:04:47] Sure, I think. I think it's not in the DSM because the DSM describes pathology. And when we talk about wellness, I think, um, as William described, it's it's a pursuit. It's a pursuit of good health, physical and mental health. And it includes the behaviours and attitudes that are necessary for that. And so I don't think it's included in the DSM because it's. I think in many ways, as most medical specialities, psychiatry is no different. We describe the pathologies that we treat in a very specific way, and unfortunately the pursuit of health isn't included in that. Hopefully our practices include that, but unfortunately the DSM doesn't.

  Alex Raben: [00:05:42] Right. That makes sense. And, um, we we chose to focus this episode on wellness and Covid, and I've seen the wellness perspective used a lot. Um, in other documents on social media around staying well during this time. Why do we think this perspective is helpful when thinking about Covid versus something like DSM, or another way of looking at the array of impacts that Covid could have on people and medical learners.

  Dr. Deanna Chaukos: [00:06:16] So I think it's important to talk about wellness right now, because we are all experiencing an extraordinary stress in an extraordinary time, and our stress response as a result, though it might feel. Completely uncomfortable. I don't think that there's anything pathological about that. Um. Having said that, I think we need to keep an eye out and recognise when our stress response in a chronic way starts to cause additional negative consequences, and that's hugely important. But as we think about the general populace experiencing this stress, I think it's probably more helpful and more adaptive to talk about wellness. I also think burnout is part of that, especially as we as we consider our medical students and residents and other physicians. Um, I think burnout is a really important concept for us to consider as well.

  Alex Raben: [00:07:26] Right. So the wellness perspective is particularly helpful because it normalises that this experience that really we're all going through, and that having stress and maintaining wellness are across the board important in this time. Whereas pathology may, may or may not come and it should be looked out for. But really the wellness perspective is more broad and it covers a lot more ground. And it helps us think in that more positive way of looking at health from a positive lens, um, which makes it useful in terms of how we can deal with this together as a, as a community. Danny also mentioned burnout there at the end. And, um, I'm wondering if I could shoot it back to you because I know you had looked into the definition of burnout and what that means. And then, you know, Doctor Chacos, you could you could, uh, elaborate on that perhaps as well.

  William C: [00:08:24] Yeah. For sure. Uh, so, Bernard, uh, when I looked for definition, it was defined as a state of emotional exhaustion, depersonalisation, and decreased feelings of personal accomplishment. Uh, so that's how Bernard was defined.

  Alex Raben: [00:08:40] And, um, doctor Chuck, you as a wellness lead, I'm sure, encounter this these concepts, uh, sort of in real life or in real time or whatever you want to call it. How do they, like, take that? Or if we take that definition, how does that actually apply? Like in the real world, what do you see with people who are burnt out?

  Dr. Deanna Chaukos: [00:09:02] Thanks, Alex. Um, well, I think we all, we all encounter burnout in our practices. Um, I think that, statistically speaking, burnout is something that we will all experience in our careers medical students in their early careers, residents and and physicians as we go through practice. Um, the one thing that I would add to William's, um, definition is that. All those three components of burnout, those are experienced in a work environment. So burnout specifically describes a phenomena in the work environment. And that's really important because it also should should clarify for us how we tackle burnout. Um, because burnout is a work environment problem, we should be tackling it in the work environment and looking to the environment for solutions. Um, so we had talked about the DSM as psychiatrists clarifying the difference between burnout and, for example, other types of distress that a physician might experience, like anxiety or depression is super important because we know that we have evidence based treatments for anxiety and depression, right? And those treatments occur at the individual level. Um, whereas burnout is something that we know occurs in someone's professional context. And though there's a lot of overlap between these types of physician distress, anxiety, depression or burnout, um, we need to be clear about what we're trying to solve.

  Dr. Deanna Chaukos: [00:10:44] And when we tackle burnout, we need to tackle it as a community. So you had asked me about you had asked me about how we encounter it in our medical environments. I think we encounter it, um, in a very real way. I think that we can each reflect on what we look like when we feel burnt out. Um, we can identify how our stress response impacts our interactions at work. Um, our emotional responses, whether it's through having a shorter fuse than usual, feeling less fulfilled by the interactions that we have with with patients, um, whether it's experienced as sort of an emotional numbing to the work or a depersonalisation, um, or a decreased sense of personal accomplishment with what we do. Burnout. Burnout, I think. Is such a big problem because it gets at the reason for why we're all here, and it it can minimise those rewards that we that we experience from the work that we do. And so, um. Similarly, I think many remedies for burnout are coming together as a community. Um, so that we can tackle the stressors in the work environment that propagate it.

  Alex Raben: [00:12:12] Yeah, I think that that's a really important piece to add there, that burnout is dependent on the working environment that you're in and that community as well. And, you know, as the title of this episode, you know, is about Covid and that has had a huge impact on everyone's environment. And we're talking today about medical learners and residents and medical students who may be in in the hospital where things have changed, uh, drastically. How has Covid impacted these concepts? For medical, for residents, for for people, uh, for medical students?

  Dr. Deanna Chaukos: [00:13:00] Certainly. Um, so I think I think that Covid well, I guess I, I think it's important for us to talk about the types of things that contribute to burnout at baseline, because many of those are exacerbated in the context of the pandemic. So so if we if we look at what are the main themes that contribute to physician burnout for for trainees and physicians alike? Um, some of those include that we work in potentially inefficient work environments. So that can include anything from a clumsy electronic medical record to lack of an electronic medical record, or all of the paperwork that, um, now comes along with the patient encounter. Another theme is inadequate support. So for trainees. Um, I like to talk about the responsibility expertise gap. That is a natural part of training. So I usually say to the pgy1 when they first come in, the only difference between you on day one of Pgy1 and you six months ago is that now you have a whole lot more responsibility. And if you don't have the support that you need in that new role, that can be that can be a source for burnout and trainings. Um, another main theme for physicians and trainees is loss of autonomy or lack of control. This one, I think, is probably one of the major contributors to burnout in the context of the pandemic. We feel an immense lack of control and uncertainty about the future. And for healthcare workers and trainees who are on the front lines, that is only exacerbated. Um. Another one of the main themes is problems with work life integration. I don't say work life balance because it never feels like a balance, but the way in which we can integrate our personal lives and our work lives, that can be a source of burnout. And then, of course, loss of meaning in the work. Um. And so as we talk about the pandemic, I think recognising that physician burnout and trainee. Medical student and resident burnout. Those were immense problems that required a lot of attention before the pandemic, and so many of those are only going to be exacerbated now, right?

  Alex Raben: [00:15:41] Right. Thank. Thank you for taking us through. Um, a lot of the different elements of burnout and how things can impact our wellness in the workplace, and also how those things may be exacerbated further in Covid. You know, I'm also just reflecting on my own time as a trainee during this, this moment in in time and how these might apply, like you mentioned, you know, inefficiency, loss of autonomy, work life integration and loss of meaning in the work. Um. You know, I think, you know, just thinking about that inefficiency piece, I think that we've had to have so, so much shift in the way we communicate now, uh, in our clinical lives. That I think it's showing areas where the communication. Um. Maybe could have been improved before, and now it's like we're trying to figure out how to how to make that work. And that's definitely been at times a stress stressor for me personally, where you don't know where to get your information necessarily. And I think that, um, great efforts have been made to, to improve that and make such a difference for one's wellness, to know what's what's coming as best you can in a time of such uncertainty.

  Alex Raben: [00:17:02] Um, you know, loss of meaning in the work. Um, I know a lot of colleagues and, and I think even myself, uh, thinking about what? You know, what does psychiatry, what role does psychiatry play in this pandemic? And some of my colleagues are being redeployed to areas that they, um, you know, did not set out to train in. And they may be on medical wards now. And, you know, what does that work mean to them? Is it different than their previous work? Uh, does it change the way they viewed their previous work? Lots of questions, I think arise from that. Um, just reflecting on my own experience and what I'm hearing from my colleagues. But I see so many. Yeah, so many things. Um, I also wanted to just open it up to the medical students as well, because I'm wondering how this has been impacting on you guys. Like, if you've noticed, um, any of these things. Um, any of these similar challenges during Covid times for you and your colleagues?

  Randy: [00:18:06] So from what I've been hearing from my friends and a lot of what I've been feeling, my personal experience would be, it's just been really difficult for us to see everything that's happening in the world and what our resident friends are going through, and to not be able to do much. So we've been at home now for the past month or so, and sometimes you just feel so helpless, feeling like you should have a role in fighting the pandemic or contributing whatever you can. But at the same time, we're not allowed to go to hospitals. We don't have the expertise to help. So that's been really difficult. In addition to that, I think a lot of us have that kind of personality where we really been in control our entire lives. You know, that sense of having control and trying to maintain it, um, has really helped us, you know, get into medical school and to succeed so far in our training. Uh, so to all of a sudden have something this of, you know, this proportion happen to us. It's just shocking. So that uncertainty is definitely and lack of control is really hard to live with.

  Dr. Deanna Chaukos: [00:19:13] Alex, I wonder I want to I want to hear from um, more from the students as well. I, as Randy was speaking, I think one of the concepts that you haven't asked me about, but I think is so important and infused in her response, is that, um, resilience is another component of what physicians bring to the table. And I think it's a worm that's gotten a really bad reputation in medicine. Um, because some feel that this worm has been used to put the onus of burnout on the individual physician instead of addressing the systems issues that propagate burnout. Um, so some people will say, you know, if only I think I think the reason why it's gotten a bad reputation is because is because it's understood that if only we were resilient as physicians, then we would not be burnt out. But I don't think I think this can't be further from the truth. Resilience is about having been through some hardship and persevering and thriving, such that you are able to generate meaning or become wiser or stronger from the experience. And medical students, residents and physicians represent a group that holds so much resilience. Um. Randy described that the medical students have been out of their clinical rotations in the past month. Um. But what I've heard the medical students have done in that time, you know, they were at risk for such a huge loss of meaning. U of T medical students have offered up their services to frontline workers, um, helping people with anything from like babysitting to picking up groceries, to helping all of these frontline workers who felt so scattered in the face of this pandemic to help them run their households and feel secure that their responsibilities outside of the hospital are are being attended to. What a resilient adaptation, right? Um, not only were med students at risk for losing this this source of meaning. Um, they actually helped frontline workers cope with the burnout risk that they were at.

  Alex Raben: [00:21:35] Yeah. Terrific point. And something that definitely needs to be highlighted in this episode is just the amazing work that you guys, you guys are doing. Um, in this time with such a shift. Yeah. Thank you. Um, and I think we are going to spend like, some time at, like in the third sort of section of this, really talking about that altruism and, um, the impacts of it, uh, across the nation and I'm sure across the world as well. Um. I'm getting a little emotional even thinking about that. So thank you guys. Um, I wanted to turn now to ways in which we can, like, I think this is a nice segue into ways in which we can make the most of this situation. Um, and ways in which we can, uh, care for ourselves, ensure, ensure we're keeping our wellness, preventing burnout in ourselves. And, Randy, I know that you, uh, did some research on this, and so I wanted to hand it over to you to kind of take us through some of the highlights, and then maybe Doctor Chacos can elaborate on some of those things. Yeah.

  Randy: [00:22:45] Of course. Um, so while there aren't many studies on pandemic specific wellness strategies for medical learners, um, I did find a lot of literature on medical learner wellness in general. Uh, so there was a really good systematic review from 2013, uh, that showed that meditation was, um, a significant stress reducer and that was shown across all the reviewed studies. Um, and in addition, I saw a study of first year family medicine residents, and the authors found that adequate sleep, physical activity, maintaining nurturing relationships, and spending time in nature were all protected from burnout. And then on the flip side, uh, they found that alcohol consumption was associated with higher prestige, stress, emotional exhaustion and depersonalisation. Um, so beyond what medical learners can try to do for themselves, I also read that, um, what government policies, um, how those can be changed to preserve wellness as well. And there was a study from the Lancet that suggested keeping lockdown as straight as possible, actively sharing information. Um, ensuring that there's always a good supply of household um, supplies and encouraging virtual communication amongst communities, and paying special attention to health care workers, that those strategies on the government level could also really help the population preserve wellness during this time.

  Alex Raben: [00:24:26] Thanks, Randy. Uh, doctor Chacos, did you have anything to add to that list? Sure.

  Dr. Deanna Chaukos: [00:24:33] Um. Actually I as I was listening to Randi talk about the different strategies, I wonder if it would if it would be helpful to think about strategies in response to some of the some of the. Problems that the pandemic has presented to us. And so, um, I've used this model before. It comes from one of my members, my mentors, Doctor Greg Fricchione, who talks about stress from an evolutionary biology perspective. And so I think it would be really helpful to think about pandemic stress in this context. So basically, as mammals, we're constantly trying to avoid separation threats. This is also an attachment perspective. Um, and as humans, our evolutionary resilience is that we seek attachment solutions. And many of the ways in which we stay well represent these attachment solutions. Um, so common separation threats for mammals, um, include loss of home and security. The pandemic, for example, has resulted in lost jobs for many people. Financial insecurity, um, another separation threat that we experience as humans is separation from health and the pandemic. Um, for health care workers, for medical students and residents who are who are on the front lines, um, not only have fear of being separated from their own health, but the health of their loved ones, and that represents another separation threat, separation from loved ones, from community, and from our sense of purpose. And so if we think about all of these limbic fears that we're experiencing as humans and as physicians right now, um, it's huge. This pandemic is causing us to experience separation on all fronts.

  Dr. Deanna Chaukos: [00:26:36] Um, and so a lot of the things that we can do to remedy this very real threat, um. Comes from the attachment solutions. And so Randy talked about solutions like mindfulness. Um, mindfulness allows us to reconnect with purpose. It might also allow us to keep our head where our feet are. And think about what can we do in this moment to connect with the loved ones that we are physically separated from? Um. Similarly, I think that a lot of a lot of the stress right now comes from that separation, um, that we're physically distancing from our loved ones, and we're also working in different work environments that that make it so that our interactions with work colleagues are different. And so we're being forced to find new ways to connect, um, new ways to, to feel a part of the communities that we normally are a part of. Um, for for many of us, I think especially, um, the medical students who maybe moved to Toronto for medical school, many of the medical students and residents live alone. So many of the ways in which they connected with one another and stayed well before are not available to them right now because they can't go out for dinner after work, they can't meet their loved ones for brunch on the weekends. And so we need to really think about how do we continue to connect as a community when most of our coping strategies in that realm, um, might not be available to us?

  Alex Raben: [00:28:27] Yeah, I think that's a really great point. This feeling of disconnection and how it relates to attachment and our, you know, our evolution, frankly, um, this is in us and it's important that we maintain it in some way. Um, how are people doing this? Uh, how are people maintaining connection? What are we recommending for medical learners with respect to this? And, you know, if any of you guys want to jump in with what strategies work for you, that'd be great too.

  Dr. Deanna Chaukos: [00:29:02] I'll jump in while everyone is thinking about their own strategies. I think. I think now more than ever, maintaining connection is is hugely important. And so the example I know we're going to hear more about what the amazing medical students are doing. Um, but I think we've seen lots of lots of evidence of resilience from health care workers and from community members during this time. So we talked about one. Um, trying to find purpose where perhaps you were at risk for losing that purpose. I think we're seeing. We're seeing as you said, Alex. Um, these, these examples of our peers who are really stepping up. Um, whether it's to volunteer to be redeployed. Um, whether it's the care with which we see people. Um, caring for their patients on the front line, recognising that our patients are also separated from loved ones because they're not able to have they're not able to have visitors in the hospital. Um, and the tenderness and the compassion that we witness in each other, I think it's important to take a moment and notice those things. Um, one of idoukal psychiatry. So I've been in the general hospital lately, which in many ways has been a gift because I get to connect with my colleagues and see, see a lot of the positive.

  Dr. Deanna Chaukos: [00:30:34] Testaments to resilience in our peers. But one of the social workers that I work with created a Covid bingo game. And she gave it to all of our peers. And the way that it works is that you have this bingo card, and on the card it has things like witnessed an act of kindness today, um, or observed someone give a air high five to a colleague. Um, or. Took a walk outside during a peaceful moment to get some fresh air, so it also includes wellness behaviours. Um, but what this card has done is it's required us to connect on something light-hearted. It's required us to to engage in humour. Um, one of the squares on the card was observed creative or unique ways of community members wearing masks. Um, and so I think like as, as health care workers, we see lots of very creative ways of wearing masks, including masks that are hanging around people's ears as they walk down the street. Um, and it's important that we engage humour as one of our most resilient, um, behaviours that we have as humans because, you know, we need to take the work seriously and, and learn how to be flexible with ourselves at the same time.

  Alex Raben: [00:32:03] Know for sure. Yeah. I'm hearing, um, again, that sense of connection in there as well, along with the humour. Right. Having that back and forth and that sort of reciprocal moment and recognising those the great achievements and compassion that is happening right now, in addition to all the strife and difficulty. Um, yeah. Great. You had a point.

  Grey Meckling: [00:32:29] I think there's. Yeah, there's just one thing that I could add, maybe to this discussion about how to maintain and support a sense of connection through this very difficult time. And one thing that I've been doing, and I've noticed a lot of my peers as well doing, is taking this opportunity of sheltering in place to really reach out to people that we may not have spoken to in a little while. I think there's very, um, or a lot of people feel like being inside can be very challenging. But, you know, a lot of us have moved on to zoom, and we're reaching out and scheduling meetings with other people. For example, I, I had a Skype call with some friends from high school just a week ago that I hadn't seen in a while. And so, oddly, as we are all sheltering in place, there has been sort of this different sense of community that we've been able to build online. And that's one thing that I've found really helpful during this time.

  Alex Raben: [00:33:32] Such a good point, grey. And I've noticed that in my own life as well. Randy, it looked like you had a point to raise as well.

  Randy: [00:33:39] Yeah, I was just going to echo what grey said, um, that I've been using this time to really connect with a lot more people who, I guess, you know, in the midst of all the busyness of medical school that I really neglected to do so. And some of those might just be my classmates who. Yeah, I used to see them a lot, and we used to talk a lot, but that was, you know, only in the context of academic things and clinical duties. But now we really get to open up to each other more. And you really do find that we do share so many similarities and just being able to talk to each other about, you know, the pressures we face during Covid, this, uh, expectation to stay productive during this time, it's, you know, just talking about it with someone who's going through the exact same thing. That's been really therapeutic for me.

  Alex Raben: [00:34:29] Yeah for sure. So if I can summarise some of the things we've talked about in terms of helping with our own wellness as, as medical trainees, a lot of it has come down to connecting with others. Um, and this may be in different ways than we're used to, but it can still be meaningful. And it shows us even perhaps as grey you were mentioning in Randy as well, like other opportunities we may not have taken advantage of before, like reaching out to friends we haven't spoken to in a while. Uh, I also heard mindfulness. Just being aware of ourselves and what we're doing. Nature getting outside exercise in a physically distanced way. I know that has been particularly helpful for me. I'm fortunate to live close to trails where I can, you know, go out for a run and in a physically distanced way. And that really helps me reset, um, communication, just making sure we're, um, checking in and getting our, our information from trusted sources. Um, and then I think there was also a piece of staying away from the more maladaptive ways of coping, like alcohol, drugs, uh, things like that. Um, I've heard speaking of sort of information, I've seen a lot online around people talking about limiting their social media or their media consumption and that being perhaps a helpful intervention. Doctor Shawcross, do you have any thoughts on that as an intervention in this case?

  Dr. Deanna Chaukos: [00:36:04] I've heard a lot of people describe that as well. Alex, one of the things that I've been involved in at Sinai, um, and I've feel it's been a great honour to be involved in this is resilience coaching of frontline health care workers. And in the early weeks, when the uncertainty I think about the pandemic was at its peak, one of the things that nurses and physicians talked about was that part of self-care was limiting consumption of some of the media about the pandemic, because there was this sense that other countries had been through what we were going to go through, and the anticipation of that was hugely anxiety provoking. Um, meanwhile, you're here in this moment trying to handle the stressors of this moment. And so I think limiting consumption and putting a boundary on that. I think maintaining healthy boundaries in general is another self-care behaviour that we haven't talked about. Um. Randy brought up that there's a big pressure to feel productive during this time for people who for the medical students who are sheltering in place or for other individuals who are working from home. Um, there have been studies that look at how people are working on their computers for more hours a day now, because the natural boundaries on work have disintegrated. And so thinking about self-care, yes, it's about exercise and healthy eating and sleep. Those are so important. And also maintaining healthy boundaries on something that, you know, work is a good thing. It gives us passion. It's a distraction, and we need to make sure that we have boundaries on that as well. Um, and boundaries on our consumption of the media right now.

  Alex Raben: [00:38:07] Yeah. I think that that's a really good point, right? That it can be viewed as, uh, from a boundary perspective. Like at what point do you say enough's enough and I move on to something else? It's sort of that work life integration or balance or whatever you want wanted to discuss it as, um, if we're doing all of one thing all the time, that's not going to really keep us in a very balanced position. Uh, and I think just speaking personally, I felt like early on a lot of that for myself, like wanting to do more and looking for more and more opportunities. And then at some point it became a little bit too consuming. Um, and I had to find a, uh, a balance there. And that was, that was helpful. Um.

  Dr. Deanna Chaukos: [00:38:52] Another, I think because now as we as we have progressed from the early weeks of the pandemic, we're now also getting to a point where the stress is becoming chronic. Um, and we talked a little bit about this and some of the helpful coping. But now more than ever, I think we need to really learn our own stress responses so that we can recognise what we each look like when we're stressed. Um, you described some maladaptive coping and how how those behaviours can be really harmful to an individual. Um, if we know our early signs of stress, the idea is that if we can recognise those, then we can maybe do something pre-emptively to intervene. Um, and attend to wellness. So like, for example, am I somebody who manifests stress? Um, cognitively, do I have a lot of self-deprecatory thoughts? Um, am I someone who manifests stress physically as muscle tension or fatigue? And when you're chronically stressed, it's important to also notice that stress response for what it is as a response, not as self. Um, because if we are chronically stressed for several weeks, it can be really easy to identify how we're feeling and how we're behaving as part of us. Um, and and not intervene appropriately with the wellness behaviours that we've been talking about with the self-care and the connection. Um. And then of course, noticing what about our stress response is particularly harmful drinking too much, eating too much. Um, and of course, the anxiety and depression that we're at risk for when we are chronically distressed.

  Alex Raben: [00:41:00] Right. So really pay paying attention to the stress levels and also our response to them and not forgetting that this is still stressful. It's like it's as you say, it's almost becoming kind of our new normal in some way, but it's not normal, if that makes sense. It's very stressful. And so to not take that for granted either, um, and trying to reflect on how our adaptation to stress may be helping us or potentially hurting us.

  Dr. Deanna Chaukos: [00:41:31] And having a stress response doesn't mean that we aren't also resilient. I think that resilience is sometimes equated to being made of Teflon, and that's not the case. Resilience isn't pretty. The path to resilience is experiencing the distress of this moment and of the pandemic. Resilience is, you know, being able to to actually sit with how we're all feeling right now, which is not not good. We are all so stressed by this. Um, and. I think a lot of the self-criticism that can arise from feeling chronically stressed can sometimes make us think that we're not doing this right. We're not handling it right. Um, and I just wanted to point out that the emotional experience of persevering is not a necessarily a positive emotional state. Um, but it doesn't mean that that you're not doing it right. Um, or that you're not doing everything you can in the moment.

  Alex Raben: [00:42:47] Right. Which I think is a hugely important point, because we can add almost an extra layer of stress by being self-critical around this and, and thinking we're, you know, we're not doing it right. And that can spiral us, uh, in a negative direction, perhaps. And just being kind to ourselves and recognising we're all doing the best we can. Um, grey, I want to I want to turn over to you, because for this sort of third section or last section of our time together today, which is how do we take these lessons of what we know about wellness and how Covid has impacted us, and how we can help ourselves as medical trainees in this time? Um, and, and take all that and how do we help others, um, or our colleagues or like, how do we, you know, take what we've learned here and, um, put it to action in an altruistic way. And we had already discussed how you guys, as medical students, are doing this on a grand scale in this country and in others as well. Um, and, um, yeah. How do we what lessons have we learned there? Yeah.

  Grey Meckling: [00:44:00] Alex. So I agree, it's a hugely important topic, and I think it's important to recognise that we can all play a role to help maintain everyone's wellness, especially in the clinical environments. And if we see others who are maybe struggling with burnout, there are some important steps we can take. So we'll be referencing a number of articles in the show notes. There was one that I found from the Canadian Medical Association, and they recommended a really nice approach. And so if you want to help someone with burnout, they recommended first noticing the signs of burnout. The signs and symptoms of burnout in our colleagues. And those can even be subtle things. We touched on some of them earlier, and I would encourage people to review those so we can really pick up on them in other people. And then if you do notice that people are struggling with burnout, there's this nice acronym. Um, it's called help. And so this acronym is really geared at providing peer support. And so the H is to really just ask someone, how are you doing? The E and the acronym is to remember to be empathic and show understanding. The L is to listen non-judgmentally and state your concerns about the situation or their wellness. And then the P is to plan the next steps. And that's really a key piece, um, either to encourage them to seek formal support or ask how you can help. So I really like that acronym. Um, I think it was a good place to start, and that would maybe be one tool that we can use to help people deal with burnout.

  Alex Raben: [00:45:35] Yeah that's great. And I like how it gives you sort of a practical approach in the moment with a colleague, because I think that's where this may come up. Right. You're having a discussion, you're trying to connect with your colleagues and then you find out, oh, this person is maybe not doing as well as you had thought, or there's something that comes up as a concern. And this gives you sort of a, an approach to how you might tackle that. Uh, Dina, did you have anything to add to that approach? Like what? What what's your approach when you see someone like a resident in your office who's maybe struggling? Um, in this time.

  Dr. Deanna Chaukos: [00:46:13] I think it's very similar to what grey described. Um. We, as I said at the beginning, statistically speaking, we've all experienced burnout and it's different for each of us. And so I think approaching our our inquiry to our colleagues with humility and with curiosity, meaning we want to understand what what we're each going through. Um, it can be really hard to initiate those conversations in medicine, because it's not traditionally the culture of medicine to allow for this kind of connection. And so, um, in my role, like one of the things that I think about a lot is how do we change the culture? How do we make it so that it's intuitive and natural for us to reach out to each other and check in to see how we're doing? And I think part of how we do that is by sharing ourselves, um, that burnout is this universal experience. Um, and part of the reason why it is, is because we see such challenging and painful, um, things in the work that we do. We bear witness to suffering. And so I think for us to take care of each other as a community is a really important culture shift. I think the ways that we can make that part of the culture is by making systemic changes to the learning environment. Some of some of how that's done is just by having conversations like this. Um, but making making these conversations a formal part of the medical school curriculum, um, which it has been over the past several years. Um, or having curricula that create a space for residents to connect with each other about how they stay. Well. Um, which naturally opens up an opportunity to talk about how the stresses of the learning environment impact us in different ways. These types of initiatives. Um. Are not going to necessarily change the experience of burnout on the individual level, but my hope is that over time, they'll change culture such that the learning environment can support more people to be. Well, um, does that make sense?

  Alex Raben: [00:48:48] That makes a lot of sense. And it actually kind of feels like it ties back into that topic about resilience and how it's not necessarily pretty. And it can be, um, quite challenging, uh, for individuals. And the reason I say that is because, um, I think in this culture of medicine, sometimes we, we think of resilience as being as you were putting it, Deanna, being Teflon, and that if you're Teflon, you'll be okay. And so, you know, people who are in that, uh, mode of thinking are probably not going to be reaching out for help if they're starting to feel burnt out. Um, and so having these kinds of conversations, having an integrated into the, into medical education, I think is hugely important for shifting that idea to one where people can feel free to reach out more and, you know, go through this Help acronym that, uh, grey nicely talked about. Because if you don't get to that first part of the acronym, that how how are you feeling? And you can't really get an an honest answer to that, then you're not going to really have much impact, unfortunately for that person. Totally.

  Dr. Deanna Chaukos: [00:49:58] We need to we need to challenge the culture of heroics and stoicism. Um, you know, wellness, it's wellness as a pursuit in medicine needs to be a dialectic, because so many of the things that we need to do to stay well are challenged or threatened by the busy schedules and the rigorous work that we do. And so we need to infuse some flexibility in how we approach burnout and well-being as physicians. Um, sort of living the full catastrophe.

  Alex Raben: [00:50:34] For sure. This culture change also made me think about these amazing initiatives that our medical students are doing. Um, you know, they've taken this difficult time and turned it into an amazing opportunity, uh, to be altruistic and to show, uh, such compassion. Uh, I'm wondering, grey, if you could, um, maybe speak more to that because I know you, uh, had had done some looking, like, looked into that. Sorry for us.

  Grey Meckling: [00:51:04] Definitely. And this is another thing we'll link to in the show notes. And we touched on it a little bit earlier, but as you say, there are just so many amazing initiatives that have been popping up really all across the country. I think every medical school now has numerous student led initiatives. And, you know, some of them are things we briefly touched on. There's students who are setting up Google Forms for child care, for, um, doing grocery runs, doing coffee runs and all these sorts of things. Um, some of our colleagues at the University of Toronto have also been collecting and donating PPE to local hospitals. Um, you know, collecting them from dentist's office that may be closed or any other health care setting that may have extra resources. So those are two really amazing initiatives. And I read about another one, um, where University of Toronto students were starting this program to stay connected with seniors. They were offering a call line, um, because there's a lot of seniors who are, of course, very vulnerable, and they may be sheltering in place at their their residential home. So just all of these different, um, resources, I think, really are an initiatives rather really are helping maintain this sense of wellness within the public and really among some of the most vulnerable, um, groups.

  Dr. Deanna Chaukos: [00:52:25] It's amazing. It's really terrific. Um, when I read about some of these initiatives, actually, the way that I learned about the U of T initiative was from a physician Mom Facebook group that I'm a part of. And so many, so many people were so relieved. Um, and and touched by what the medical students have done locally. It's had a huge impact.

  Alex Raben: [00:52:53] Yeah. Thank you guys. And and yeah it's just unreal what you guys are doing. And I and I've heard other initiatives across the country as well. I think out in Alberta they were medical students there were helping with testing and increase the capacity substantially and just unreal. Uh, the way that you guys have tackled such a difficult situation. Um, and, you know, in terms of a wellness, an additional wellness point, just recognising this, I think, is, uh, as you were saying, Dana, just recognising the good that is coming from this is so important.

  Dr. Deanna Chaukos: [00:53:24] Yeah. The silver linings, I think noticing, um, noticing the things that we can feel gratitude for, we haven't talked about that as a, as an adaptive perspective yet, but I think, um, this initiative really manifests that.

  Alex Raben: [00:53:42] Definitely. Um, grey, I want to go back to your acronym, the Help acronym, which is the, you know, how how are you doing, the empathic stance, the listening non-judgmentally to the person and then creating a co-creating a plan with them. And I want to go down to that last point, the co-creation of a plan. What are the practical things we can advise someone to do, or we could help co-create with someone? What are the resources they have at their disposal? I know we have a lot of international listeners and listeners out of province, so a lot of these will be probably more specific to Toronto, but I imagine that other jurisdictions have similar opportunities. And so hopefully that it's still something that's worth going through for for those listeners who aren't in Toronto.

  Grey Meckling: [00:54:33] Yeah. Thanks, Alex. So one approach I found in the literature was to maybe think about addressing burnout or stress really in the acute phase, and then also thinking about sort of a longer terme plan to prevent burnout over the course of, say, a residency or over the course of a career. And so really, in the immediate phase, I read about something called psychological or mental health first aid, which may be useful in an acute setting. And I would love Doctor Chacos to elaborate on that a little bit more. And then maybe in terms of follow up and more long terme strategies, there was a lot of the same recommendations that we would use for ourself. We could recommend for other people. So these are things like staying well by eating, sleeping regularly, having a good diet, and all of the strategies we discussed earlier, um, that Randy pointed out so well. And then just finally, in terms of specific resources, I think each medical school or most, if not all in the country would have their own wellness offices. Residency programs, have wellness offices. And so those websites would be really important resources that people could turn to. And we'll we'll put some of those in the show notes. And I really encourage people to look up those, those resources in their, in their local jurisdiction. And then there's professional organisations that are putting out a lot of material, especially as it relates to Covid 19. So these are things like the Canadian Psychiatric Association, the American Psychiatric Association, Cam, for example, the centre for Addiction and Mental Health in Toronto. And so there's just a lot of resources that are available online now. And um, Doctor Chochos, if you had any to add or respond in this, um, in this conversation, that would be great.

  Dr. Deanna Chaukos: [00:56:22] Thanks. Great. Those are are terrific resources that you've described. Um, you asked about psychological first aid, which I think is particularly relevant right now in the context of the pandemic. And if I try and summarise the principles of psychological first aid, it's basically to help to help individual individuals experience a sense of safety and security. And so that can be fostered by providing important information. So at the beginning of this pandemic, a lot of people had fears about, um, adequacy of PPE or supplies of PPE, for example. And so the Toronto hospitals, um, were able to provide their frontline workers with information about this, trying to help people understand, um, as much as they as they want to know about what their what their concerns are. And obviously, there's a lot of uncertainty with respect to the pandemic. Um, that can't necessarily be answered, but creating spaces where people can have their questions attended to is really important. Um, doctor Bob Maunder and and John Hunter have our attachment resource researchers and also have done some amazing work about health care workers under pressure from the SARS epidemic. And they've created a video that's called coping with Covid for Health Care Workers. And in the video, they talk about, um, dealing with the problems that can be dealt with and problem solving those. Um, so, for example, getting your questions answered about PPE, then for things that don't necessarily have an answer, attending to the emotional response, um, and developing coping strategies for those difficult emotions. And then the third part of the video talks about connecting to meaning and finding a way to feel purposeful in a setting that perhaps threatens your connection to meaning otherwise. And so the solutions that the medical students have found at U of T and across the country is an amazing example of that. Um, I can send you the video if you'd like. It's it's a really helpful resource. I think the other pieces that you, that you talked about really hit those three areas that we've talked about today self-care and maintaining healthy boundaries, recognising early signs of stress. Um, and then the connecting to meaning piece.

  Alex Raben: [00:59:18] That's terrific. And I think. And, um. And I think that some of these things are also summarised in an infographic that, uh. Uh, here producer here at U of T and Diana. Were you involved in that, I think?

  Dr. Deanna Chaukos: [00:59:31] No, I'm just a huge fan of it, so. Yasmine Nasser Zahedi and Nikita singal were involved in developing this, this gorgeous infographic that is geared towards residents and has been shared broadly because of how useful it is. Um, that infographic does a lot of psychological first aid principles. It gives residents information about safe donning and doffing of PPE. It answers a lot of questions that people have with respect to fears about the pandemic, and it also provides coping strategies for some of the difficult emotions that we're all feeling in response to the pandemic.

  Alex Raben: [01:00:16] Yeah, I thought I think it's an excellent resource. And, um, um, Nikita, who co-created this, uh, is also part of the podcast and helps us with our infographics. So I know she does a wonderful job on these and so talented. Yeah. So talented. And we'll we'll be sure to link to that in the show notes. Um, a lot of Toronto specific stuff, but I think also very, uh, broad uh, applications as well. So please have a look. Um, we am I wanted to hand it over to you just as we're nearing the end here, because we had reached out to you guys, the listeners, um, to get a sense of how Covid is impacting you because you're also, uh, medical learners. And, uh, William, could you speak to that? And I know we had one person actually, uh, write in and maybe we could, uh, paraphrase some of what they had said to us and see if how we feel about it and what, you know, comes of that.

  William C: [01:01:18] Yeah. For sure. Uh, as you mentioned, um, we here at psych, we post a question to our lovely audience, uh, to kind of ask how Covid 19, the pandemic, has impacted their wellness, uh, if at all. And, uh, we ask this question on various platforms, Facebook, Twitter and Instagram. And not surprisingly, uh, we we saw that wellness was affected by the pandemic by a lot of our listeners. Uh, I think depending on the platform, from Instagram to, uh, Facebook, for example, it ranged between 70 to 100%, uh, of our audience listeners has impacted where the wellness was impacted by the pandemic to different degrees. Uh, and at least 70% of the respondents on Twitter ranked that as being moderately or significantly, uh, affected in terms of their wellness.

  Alex Raben: [01:02:09] So thanks for, um, for, um, for that. Yeah. I will talk more about this response that we got from a listener who wrote in to us. And yeah, please do write in if you have thoughts of how your how you know, how you're coping or strategies that have been helpful for you, feel free to write in to us. We always love to hear from you and get your feedback. Psyched podcast at gmail.com. So this listener, um, would like to remain anonymous, but I'll read some of her, uh, or paraphrase some of what she wrote. Uh, and what she had said is that even prior to Covid, she had been struggling. She had been in a difficult personal, uh, relationship. And she was seeing a psychologist. And essentially, when Covid hit, that office shut down. Um, and she was struggling even more because of that and didn't want to start over with someone new, which, you know, is a difficult thing when you're in therapy and you've formed a really close relationship with someone to move to someone else's, it's a challenge. Um, she, however, also, uh, found time to focus on the positive, uh, and doing things that she enjoyed.

  Alex Raben: [01:03:25] And she had come to accept a lot of, you know, what was going on and that some days will be okay and some days will not be okay. She wrote us back as well, a few days later, to just say that she had done some thinking about her disabilities. She had some physical pre-existing disabilities and how that might impact her in terms of Covid. And, uh, she had she asked the question, you know, um, you know, because she has these disabilities, if she were to contract the virus, would her life be deemed worth saving? And that was kind of a chilling thought that she had and something that was bothering her at that time. I'm just wondering, you know, hearing from our our listener. Who's, you know, struggling and also showing signs of resilience, I think. You know, I guess what do we what do we make of her experience is this, you know, a common one, uh, and how might we help her? What what advice would we give to her?

  Dr. Deanna Chaukos: [01:04:27] I think she brings up so many important points. Um. The first being that because communication has changed in its nature now. Um. There are so many individuals who are struggling with the fact that they can't access their health care providers, though I, I hope that most clinics are finding ways to connect virtually with their patients. Some might not be able to, and that's a huge additional stressor. I think another important. Point that the listener made is, is the experience of moral distress that that many physicians and individuals, um, might be experiencing as a result of the pandemic she brought up. The fear that. That when resources become scarce, would society be forced to make um. And in the example that she brought up the unsettling and morally distressing idea of of deciding whose lives are are to be saved over another. And I think that is is such a painful consideration. Right. Um, and it's one that I think physicians are worried about, of course, individuals. Um, who are who are coping with any number of, of, um, things right now are concerned about. It's pointing out. Aspects of our society that were problematic before the pandemic that are becoming problematic in a new way now. Um, specifically around, uh, prejudices, um, and disparities in our communities.

  Alex Raben: [01:06:34] Yeah, absolutely. It it really ties in all the things we were talking about, right? That, you know, of course, life has its struggles, uh, even outside of a pandemic situation in this, this, uh, woman was experiencing that. And then it was compounded by what was going on, and, and just the change in dynamics that she had to face there. And these larger moral questions, existential questions as well. Um, and, uh, you know, I think, uh, as we were talking about before, like a lot of the strategies we were talking about, I think could easily apply in her situation, right, that she could have access to these resources as well, you know, paying attention to these new ways in which she can connect with others, uh, looking for those virtual opportunities for help. Um, even if it isn't what she had before, it may be something that can still provide care and provide for her wellness.

  Dr. Deanna Chaukos: [01:07:34] At a systems level. I think it's also really important to point out that, um, this is important in the pandemic, but also for medicine in general. If we're aiming to create a culture of wellness that's also about creating safe environments free of intimidation and harassment, environments that support individuals regardless of race, gender, ability and socioeconomic status to thrive. And so if we think about wellness, Maslow's hierarchy of needs is applicable to write. Wellness can only be achieved when all of our other basic needs are met. Um, so safety and equity is part of that, right?

  Alex Raben: [01:08:14] Absolutely. And, grey, I think you had a final question you wanted to end on, uh, so that we're ending on a positive note and looking forward to the to what comes in the future.

  Grey Meckling: [01:08:29] Yeah. Thanks, Alex. So maybe on a final note, we were wondering if there are any opportunities or new developments, maybe reasons to be optimistic that are coming out of the Covid 19 pandemic in terms of mental health, wellness and burnout in general. One example that I can think of might be the increased media attention, for example, on health care worker wellness. So did you have any thoughts on that, doctor Chacos?

  Dr. Deanna Chaukos: [01:08:58] Yeah, I think there's a few things, um, individually in my practice, a few of, um. My patients, and I know colleagues have described this as well, have mentioned that connecting with their providers virtually has actually created, um. A different kind of connection and comfort that if you're able to connect with your providers from home, an environment in which you feel safe and perhaps more reflective, it's allowing for a different kind of care to be fostered. And so I do think that we'll continue to learn about the ways that we've been providing care through telemedicine and virtually, um, in these more flexible contexts. I think that we'll learn that it might actually be more patient centred in some examples, not all, but in some. Um, I think that we're learning a lot from, um, from a psychiatric perspective, at least from these resilience coaching efforts that have been developed. Um, I told you a little bit about the one that I'm involved in at Mount Sinai Hospital, led by doctor Bob Monder and Doctor Leslie Weisenfeld, basically attaching psychiatrists to frontline health care units, um, to provide principles of psychological first aid and support. Um, and I think that I think that by attending to frontline health care worker wellness, as people are going through the pandemic is hugely important and shining a light on well-being in a way that maybe hasn't been done before. And cam is also doing that by creating a self-referral process for frontline health care workers to access. Their own treatment. Um, and I can send the link for that as well, so that you all have it. Um, I think there are going to be silver linings, and the fact that we're looking for them is part of our adaptive coping as well.

  Alex Raben: [01:11:17] For sure. And yeah, and on that note, I do truly hope that this episode serves that purpose as well. Right? That I certainly feel, uh, nice and connected in this moment, seeing all of you on the screen and being able to have such an interesting and engaged conversation. And I hope the listener is able to feel that as well. And, and, you know, I hope that these recommendations and reviewing all of this, uh, serves that purpose, too. I want to thank all of you for being on the show, and I want to thank you guys for creating this episode. Uh, and of course, thank you to the listener, as always, for listening. We'll see you next time. Psyched is a resident initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was led by Grey Mechling and also produced by Alex Rabin, Randy Wang and William Sufian. This episode was audio edited and hosted by Alex Rabin. This episode was co-hosted by Grey Mechling, Randy Wang, and William Sethian. Our theme song is Working Solutions by Olive musique. A special thanks to our incredible guest, Doctor Deanna Chacos, for helping us navigate through this very important topic. You can contact us at any time at Psyched Podcast at gmail.com or visit us at Psyched Podcast. Org. Thank you so much for listening.

Episode 23: Autism Spectrum Disorder with Dr. Melanie Penner, Dr. Yona Lunksy and Dr. Mitesh Patel

• Episode 23: Autism Spectrum Disorder with Dr. Melanie Penner, Dr. Yona Lunksy and Dr. Mitesh Patel

  Alex Raben: [00:00:00] Hi, listeners, this is Alex. This episode on Autism was recorded prior to the COVID-19 crisis. Before we jump into the episode, we wanted to take a moment to recognise the extraordinary efforts of the global community, which has come together to face this pandemic. This includes the tireless work of medical learners like you from around the world. Thank you, guys. Not just for listening, but for the service you're providing people in need. Stay safe and keep well. We plan to continue to make episodes to the best of our ability in this trying time, and we hope you will continue to listen. In addition, we've added to this episode's show notes an additional resource for how to help people with autism during the COVID-19 crisis. In less serious news, this episode had some technical difficulties and so you will notice a drop in the audio quality in the last 10 minutes or so. We apologise for this, but felt it was more important to release the episode blemishes at all than to not release it. As always, we hope this episode will enrich your learning.

  Alex Raben: [00:01:18] Welcome to PsychEd, the psychiatry podcast for Medical Learners by medical Learners. I'm Alex Raben. I'm a PGY-five in psychiatry at the University of Toronto, and I'll be the host of this episode. And today, we're going to be learning all about Autism Spectrum Disorder from an understanding of what it is to how we can help people with this condition. I'd like to introduce the panel to you, the people joining me in the room today. I'll start with my co-host, Sabrina Agnihotri, who is a PGY one.

  Sabrina Agnihotri: [00:01:50] Yes.

  Alex Raben: [00:01:52] Excellent. And but Sabrina also has a PhD where she studied Fetal Alcohol Syndrome and so has some background in neurodevelopmental disorders. And she'll be bringing that expertise to this episode today as well. And then to Sabrina's right, we have Dr. Mitesh Patel, who is a child, as well as a forensic psychiatrist at Camh, and he works with young offenders, homeless youth, as well as people with neurodevelopmental disorders. Do I have that correct, Dr. Patel?

  Dr. Mitesh Patel: [00:02:28] Yes. And also in the adult forensic system as well.

  Alex Raben: [00:02:31] Oh, great. And then to his right, we have Dr. Yona Lunsky, who is a psychologist who works also at Camh, and she is a Professor of Psychiatry and actually has done a number of teaching sessions for my cohort of residents. And we've certainly appreciated those and wanted to get her on the show. She also does research into various neurodevelopmental disorders, including Autism Spectrum Disorder. So welcome, Dr. Lunsky.

  Dr.Yona Lunsky: [00:03:03] Thanks. Happy to be here.

  Alex Raben: [00:03:05] And last but not least, we have Dr. Melanie Penner, who is a developmental paediatrician from the Holland Bloorview Hospital, also here in Toronto. And she is a clinician educator, so she wears a clinician as well as a research hat. And in both those worlds, she works with people with autism. And in her research she works specifically looking at the services and program evaluation around Autism Spectrum Disorder. Welcome, Dr. Penner.

  Dr. Melanie Penner: [00:03:35] It's great to be here.

  Alex Raben: [00:03:37] All right. So it's wonderful that we have such a panel of experts this episode. I don't think we've ever had so many in one room. Just just to give everyone an idea of the scope of this episode. I think it's important that we go through today's learning objectives. So for this episode, by the end of the episode, the listener will be able to, number one, have an understanding of the neurobiology and epidemiology of autism. Number two, be able to tailor their diagnostic interview for autism spectrum disorder in a way that improves the accuracy of their diagnostic assessment, as well as being empathic and aware of issues in this condition. Number three have a familiarity of the impact of autism spectrum disorder on the people with this condition, as well as their families and the interdisciplinary and bio-psychosocial approaches involved in caring for people with autism spectrum disorder. So with that in mind, I'd like to start off first by getting a sense of this condition. And my first question for all of you is what is autism spectrum disorder? What does that mean? I know it's a DSM diagnosis that's in the Neurodevelopmental chapter, but if we can, without going into diagnostic criteria, is there an easy way for people to understand this condition? Is it one thing? Is it multiple things? I'll leave it there and maybe we can start with you, Dr. Patel.

  Dr. Mitesh Patel: [00:05:10] Yes. Autism spectrum disorders is really an umbrella term. What that means is that it captures a lot of different kinds of presentations or ways of thinking. And the way that I like to think about autism and explain it to parents, for instance, is that autism is really a different way of thinking, a different way of seeing the world. And sometimes that way of seeing the world can lead to incredible strengths and talents and abilities that no one else could even ever have or fathom having. And at other times, it can lead to difficulties both in interacting with others. So some of that social communication stuff, but also sometimes there's some behaviours like repeating certain sets of behaviours or really being really focussed on certain things. And at times individuals who are diagnosed with autism can face incredible challenges.

  Alex Raben: [00:06:03] Right. I'm wondering if other people on the panel wanted to add to that definition.

  Dr. Melanie Penner: [00:06:08] It's so interesting. I had kind of jotted down some notes that said so many of those same things. So just a different way of. Interacting with the world. Thinking about both inputs and outputs in that different interaction. So inputs can be difficulty with the sensory environment that can cause a great deal of distress for autistic people and then outputs that may look a bit different than what we may be used to seeing. So different ways of expressing things like joy by, say, flapping your hands and jumping up and down different types of outputs in terms of how autistic people engage with other people.

  Alex Raben: [00:06:51] Is there a preferred way of talking about this condition.

  Sabrina Agnihotri: [00:06:56] Even referring it to a condition like like do you guys have any feedback for us and our listeners in terms of how that language comes across to you, too?

  Dr. Mitesh Patel: [00:07:08] Yes. Yeah. I think it's immensely important that we stay away from labelling people according to their diagnosis. And something that I've often pushed for and tried to do within my own practice is not label individuals as like this is a schizophrenic individual. For instance, we might say this is an individual who has been diagnosed with schizophrenia in the same way when it comes to autism. I think it's really important for families and patients in particular to hear that, that there's a difference in learning. We term this autism. There can be a difference in terms of how they interact with the world. And I tend to try to stick to an individual who has been diagnosed with autism or has met criteria for autism versus saying the autistic individual.

  Dr. Melanie Penner: [00:07:48] So I'm going to kind of jump in with some some things that I've learned from listening to the autistic community. And you'll notice that I'm tending to use identity first language a little bit more. And that's something that I actually picked up from actually Twitter, from listening to more autistic self advocates who at least for some of them really find something important in claiming that autistic identity for themselves and to acknowledge that it kind of it impacts their whole state of being. I think the approach I'm taking in a clinical environment, particularly when now I'm dealing with youth or young adults, is to actually ask them what their preference is for me to refer to their autism. And so some don't seem to have a preference. And then those who seem to be a little bit more kind of in that savvy community of thinking about disability and how autism kind of interplays with their life and society. A lot of them are kind of requesting identity, first language.

  Dr.Yona Lunsky: [00:09:07] It's so interesting, right, because we really do hear different things from different people. So I would agree with this idea of, you know, talking with people to see what they're comfortable with. But even how we talk about it outside is going to make a difference to people. And I know I've also made a shift because I work primarily with adults to use identity first language around autism. So to talk about autistic people and then, you know, families would be like, well, why? Why do you do that? You know, or like clinicians, what do you doing? Like, don't you realise like and it's like actually I do and I'm now going and so so educating people say you may notice, right? So sometimes I'm going to say autistic people. And that's because some people have said they really have a lot of pride in their autism. They're really excited about that and they've asked us to speak in that way. We don't feel kind of, but that's okay. Whatever works for you, I will do that. But that's why I sometimes use that language. So kind of helping people to understand different perspectives. And I think with families too, even if their families have younger kids, just encouraging them. There's so much interesting literature now to read about that people are writing from their own voice. People who identify as being autistic write about what these things mean and why they're using that kind of language. So some nice things, I think that residents are clerks could just be reading to sort of get more aware of because it's changing. It's I think it's even different from two or three years ago. Certainly is different than six years ago. And it may be that in two years we're having a different conversation again.

  Alex Raben: [00:10:28] So right. So much nuance there I'm hearing and a couple of different types of terminology that may be preferred by different people. And so it's really just important to be aware of these issues, check in with people and keep up with this as well, because as you say, it can change over time. With all of that said, there is this standard definition that we do have in the DSM five, and I'm wondering if we can work through that, because although as we've clearly spelled out here, this is not just about a DSM five diagnosis like with any of these diagnoses, we're talking about people who are very multidimensional. But we also use the DSM five as an important tool in our practices. And so I think it is important for us to unpack that for our listeners who are going through this large diagnostic manual in their clinical rotations. So can we talk a little bit about that? What is the DSM five criteria? How does one meet that? And then I think we can also get into how we actually ask around that and make the diagnosis.

  Dr. Mitesh Patel: [00:11:40] In my work in forensics, it's actually really important that we know these criteria quite well because they do end up coming up. And I think for all of us they come up quite a bit and just knowing. But I think what's really important to remember is that when we're talking about developmental disabilities or neurodevelopmental conditions, in this particular case, autism, it's important to remember that this stuff starts in childhood. Early childhood, there has to be evidence of symptoms or concerns that come from the early childhood period. So some may come to their family doctors later in life or to their paediatricians or even to nurse practitioners or whoever else they might be meeting and say, Oh, I think I might be autistic. That often takes a long assessment. And really going back to interview biological family members, for instance, to find out what could potentially be going on there. So I believe that that's criterion C is that the symptoms are present from early childhood. Criterion D is that there is this impairment to functioning on an everyday basis. And so that is important as well, that this is not something that just simply goes by and it doesn't cause any impairments. I think the other two criterion I believe are much more important being criterion A and B, and I imagine others can speak to this much more.

  Dr. Mitesh Patel: [00:13:02] But just in brief, the first criterion or criterion A is difficulties with reciprocal social communication and social interaction. What that means is that there's this general difficulty with understanding other people's emotions, having difficulties expressing their emotions, or being able to communicate in that context. And the second criterion or criterion B is that there's a restricted or repetitive patterns of behaviours, interests or activities. And so that could involve stereotypical or repetitive behaviours, highly restricted or fixated interests. And this is really why a lot of children come to clinical attention for us, I would say, is that that's one of the main challenges, at least in my practice, that I see a lot of. But also just in terms of the social reciprocity and understanding what's going on there, I would also point out that in autism, there's a lot of advancements that have been made in terms of identifying the severity of the illness or if we call it an illness or the condition. And I think that's really important is that things have changed so that now we're actually identifying them by how impaired the individual mate might be.

  Dr. Melanie Penner: [00:14:17] Yeah. So. So I think within those kind of big A and B criteria. So, so there are two main domains of symptoms. So the first one is that social communication. So within those there, there is the sort of social emotional reciprocity. And like Natasha was saying, that's a lot of like the back and forth interaction piece. So kind of reading the situation appropriately and responding in the way that is generally expected. There is difficulties with nonverbal communication. And it's interesting because when I'm seeing young children, it's often the verbal communication that is presenting as the main reason for concern. But then as we look into it there, it's a broader difficulty with communication. So not only is perhaps the child not using their words to communicate yet, but they may not be using other strategies as well. And I see a lot of parents who are sort of doing a lot of guesswork about what it is their kids are trying to ask for. So within that nonverbal category, we're looking for things like eye contact pointing, use of gestures like nodding or shaking your head, you know, your use of facial expressions. Are you expressing how you're feeling on your face and beyond that? Are you also directing that to another person? And then the third criterion within that kind of social communication group is the development of relationships.

  Dr. Melanie Penner: [00:15:55] So there we're looking at the earliest relationships being the caregiver relationship. So how is the child pulling the caregiver sort of into play, their siblings perhaps into play, whether they're doing that rich, you know, back and forth, imaginative play. And then as they are getting older, how they're developing peer relationships. So I think it's important to note as well  within those social communication criteria, there are lots of things that can give you social difficulties. So autism is not the only one, but it is certainly one of the the ones you should be thinking about if you have a child who's presenting with those difficulties and then, yes, the restricted repetitive criteria. So that's where we see the some of the what we call stereotyped behaviours. So that's where we see things like lining up of toys, flapping of hands, repeating speech. We can see insistence on sameness. So kids who really want things to be like the same way every time, difficulty with transitioning from one thing to another. We can see intense or unusual interests. And so kids who get really obsessed with something and then those sensory difficulties that we've already sort of alluded to. So those can be both things that are extra alluring from a sensory perspective or things that are really aversive from a sensory perspective.

  Alex Raben: [00:17:28] What I've heard and I'll just summarise sort of the criteria that I heard, which were these two big domains of what we might call a criteria, social deficits or difficulty with social communication or a difference in social communication. And then B was, which was restricted in repetitive behaviours that it had to be impairing and that it had to start in childhood, that this is a neurodevelopmental disorder, it starts young. How do we conduct ourselves in the interview that allows us to make this diagnosis? Does that involve collateral? Does it? What are the components of an actual diagnostic assessment?

  Dr. Melanie Penner: [00:18:08] So to me the it you definitely need input from various sources so your history with the people who know that person best including perhaps that person depending on how you know what their age and developmental level is and and how they are able to contribute. I think collateral information is almost always helpful. Some of my really young ones who aren't in Day-care yet, it's, it's hard to get collateral information but once they're in Day-care or school, that's really, really helpful information because that is for children and youth, their sort of main occupation. So we definitely care about how they're doing in that environment. And then there should be some form of observation and interaction. And to me, that's so, you know, watching the child or youth is not really enough. They're you. You do need to be able to interact with them, whether that is with a standardised tool or otherwise and to to see what that interaction feels like. I think it's interesting though, sometimes you can have the effect of being a very good playmate. And I'm thinking of one case that I had where, you know, very bright boy who loved the idea of talking to an adult for an hour, like just loved it, and then afterward asked if I did birthday parties. So. So sometimes we can. We can accidentally select for making things. Things seem a bit rosier than they might in the real world. But those are generally the main components that I would think about.

  Alex Raben: [00:20:11] And you also mentioned Scales. We had a listener write in with some questions. And actually, Connie Lutton, I hope I'm pronouncing that correctly. She's a social worker who works here at CAM in the Slate Centre. And one of her questions for us today was whether there were brief scales people could administer as a way of screening for for autism.

  Dr. Melanie Penner: [00:20:34] So there are definitely, I think, of the tools in a few different buckets. So there are screening tools. There are screening tools that are based on questionnaires and then there are a few for really young kids that are based on a short interaction. And then there are diagnostic tools and again there are diagnostic tools that are more based on a questionnaire or interview, and there are some that are based on an interaction in terms of the diagnostic tools we are often thinking about. So in the interview sort of category, there's the autism diagnostic interview revised, which is fairly lengthy takes, you know, and does take a lot of training. But if you are looking at something that's that's sort of considered among the most reliable tools, that's what you would be looking at. And then for the observation and interaction sort of part of diagnostic tools and that the sort of main one that people often think of is called the AIDS or autism diagnostic observation schedule. And that one definitely takes a lot of training. You need very specific materials for it. It's important to know that depending on where you are making your diagnosis, you may or may not need specific tools to make that diagnosis. So where we are right now in Ontario, you do not need a specific tool to make a diagnosis that differs quite a bit if you go to a province like B.C. so it's important to know where you are and what the eligibility requirements are for diagnosis so that kids and families can access services based on how you've done the diagnosis.

  Dr. Melanie Penner: [00:22:20] Probably the most important point here is that you're not going to find a score or a number that's going to make or break this diagnosis. It's a clinical diagnosis. And though I think the temptation is to find these ways to put to attach scores and numbers to it at the end, it's still based on clinical best judgement. And, you know, different types of cases may require different levels of kind of testing and  kind of semi-structured interactions and things like that to come to that diagnostic conclusion. But at the end of the day, it's not based on a number, it's based on really rich information of that child, their context and support. Sorted by what you've seen in your clinical environment with the caveat, I would say that, you know, we do these clinical assessments in a strange place, like we make people come to a clinical place. They have to play with a strange adult. And so and I think we need to be aware of, of that limitation, particularly when we're kind of coding and scoring these types of interactions as well. That context is really important. And so I always try to really prioritise the descriptions of that child in the real world, recognising that my ability to kind of mimic that in my clinic is going to be limited even though I am a good playmate.

  Alex Raben: [00:23:58] So what I'm hearing is that there's no replacing an actual clinical assessment and if there's a suspicion, there are tools available to you. But ultimately, someone probably needs to assess in person, get an A, get a fulsome assessment. I think part of why Connie was asking this question is she works at Slate, which is a centre here at CMS that works with people who have early signs of schizophrenia. And she was explaining that oftentimes it's not clear to her whether the person in front of her has actual schizophrenia or may be developing schizophrenia, or if this is more of an autism spectrum disorder. I'm wondering, are there other things that mimic ASD and what are they what do we have to look out for when we're trying to narrow down the diagnosis?

  Dr. Mitesh Patel: [00:24:47] There are many other, many other conditions that can sometimes be confused for aspects of autism or presentations that they might have. Going back to what was mentioned about schizophrenia, autism can be comorbid with schizophrenia. That is incredibly important to remember. And when that happens, the presentation is can be very complex and it can be a bit more difficult to tease out what is psychosis versus what is an underlying interest that an individual may perceive it upon. Does that meet criteria for a delusion? Is there an aspect of paranoia tied into that? Are these things then connected? And oftentimes they are all connected, so it's really difficult to put people into these neat boxes.

  Dr.Yona Lunsky: [00:25:37] Are there certain symptoms that you guys can think of from your practice that jump out to you as the most distressing to a patient?

  Dr. Mitesh Patel: [00:25:45] Absolutely. I think one of the most difficult challenges for many youth, at least with autism, is bullying. And as soon as you start mentioning that question or raising aspects of it, the first thing that comes to mind is youth who are bullied for being different or not understanding what other people are trying to communicate and being subject to extreme amounts of bullying. But that's something that comes to mind. I'm not sure if that was your question, but yeah, no, that's what I that's what comes to mind for me is that that's one of the most distressing things. And OCD is very comorbid in terms of autism. And so there can be a lot of distress with having to keep that sameness, as was mentioned. And also a lot of the anxiety symptoms that come along with that.

  Dr. Melanie Penner: [00:26:35] Yeah, I agree with all of those. The only other thing I would add, I think, is that the sensory symptoms can be very impairing. So for people with a lot of sound sensitivity, going out in public can be hard. Using a public washroom can be really hard between the like automatic flushing toilets and the like blasting hand dryers. There are lots of parts of the environment that are just not built with the needs of autistic people in mind.

  Dr.Yona Lunsky: [00:27:09] Yeah. Even just, you know, your regular kid's birthday party with all the screaming, the happy birthday and the terrible thing that happens at the end of the happy birthday singing, which is the applause, you know, with the blowing out the candles and kind of that sudden like that is very jarring. So then you don't want to be at a birthday party, right? Or then you don't want to go to a sports event or all kinds of things that are really, really difficult.

  Alex Raben: [00:27:31] Right. So quite a number of aspects of the illness can have can evoke distress. And part of it also seems to be at times the mismatch between people who we might call neurotypical versus people who have autism spectrum disorder, focusing on this sort of neurotypical word. I'm wondering if we can take a step in the direction of understanding the etiology of autism spectrum disorder. And I imagine this is there's a lot of question marks out there still. But what do we know about the differences in their brains and and how this and how this condition comes to be?

  Dr. Melanie Penner: [00:28:14] Lots of looks around the table.

  Dr.Yona Lunsky: [00:28:16] This one was the one cause of autism.

  Dr. Mitesh Patel: [00:28:20] I think if we knew that, we wouldn't be here.

  Dr.Yona Lunsky: [00:28:23] I was just going to say, I mean, I think it's really a cluster of symptoms or characteristics with so many different aetiologies. So we're learning more about those things. We no longer think, for example, that it's caused by how mothers raise their infants or their children. Right. So the refrigerator mother kind of phenomenon, we recognise that's not true and we know there's a certain biological sort of component to it, but it's not, it's not as clean cut as maybe we were hoping as we sort of advanced all of our, you know, expertise around understanding things like genetics and, you know, the sort of the actual anatomy, what's going on in the brain itself. It doesn't always look quite so different from some other neurodevelopmental condition.

  Dr. Melanie Penner: [00:29:08] Yeah. So, I know some of the people who are doing the kind of cutting edge biological exploration in this area are starting to say things like the autism's so is autism as we know it really at a biological level, more a collection of rare disorders that present in a similar way from a from a behavioural perspective. And then the concept as well of neurodevelopmental disorders. I mean there are very fuzzy boundaries between our diagnostic buckets as we've already discussed. Right. Kids don't fit neatly into one bucket or often even two buckets. And so there's also a lot of work going on right now to re-examine these diagnostic categories that we've created and say, well, do these actually really hold up if we put them under scrutiny? And so I think of my colleague of TYCHE and agnostics work with the Province of Ontario Neurodevelopmental Disorders Network platform where they are. This is exactly the question they're taking on. They're saying if we take if we enrol a whole bunch of kids with various neurodevelopmental disorders, run them all through the same sort of phenotyping platform and look at their underlying biology, what would this tell us about the integrity of our diagnostic constructs? And so far, the results are showing that there is that the borders that we've constructed are quite hazy between these conditions.

  Alex Raben: [00:30:50] Right. So there's I think although we're in the early stages of understanding the ideology, it seems like it's really ideologies at this. From what we understand at this point and a lot of that understanding comes from genetic testing and things of that nature. Is there a role for that kind of testing diagnostically today? Is there a role for other types of testing in our assessment of someone with potential ASD?

  Dr. Melanie Penner: [00:31:22] So right now genetic testing in the form of chromosomal, microarray and fragile x testing is offered to families post diagnosis. And so we're not using it at this point to detect autism. It will be interesting to see, I guess, how the field develops that way. Right now, though, it's used, is more to see if we can find an underlying genetic condition that is that we think is associated with the autism. And there are various results we can get along those lines and a lot of grey areas. So. So I counsel families that it's generally about a one in ten chance that we're going to find something associated with the autism. When we do that testing, sometimes we get a genetic mutation back and it's a variant of uncertain clinical significance. So we don't know what that means. It hasn't been described in the literature as being associated with autism. And then sometimes we get a normal result, which may mean that there's not anything that we can detect that is that is a mutation. But it also may mean that just the type of testing we're doing right now, which is microarray testing as opposed to like a whole genome or whole exome sequencing, is not picking up things that a granular level that we would be able to find otherwise. So it's going to evolve and it will be interesting to see where we move as a field.

  Dr.Yona Lunsky: [00:33:07] Yeah, I was going to just say it's still, I think, a really important message, you know, for clinicians that it is good practice to figure out, I think, if there is a cause, what it is because with certain things like for example, let's say it's fragile X and we didn't pick that up before. Well, we know a lot of things about people with Fragile X. We know about different medical things to look for, stuff that's going to happen over the course of development. We also know what that means in terms of other people in the family. Right. So there are conditions. I mean, Fragile X is hereditary. That's a particular one. There's other conditions as well where it's going to give us ideas of things that we want to be watching, whether it's about how that person's going to communicate best stuff we know about people's language with that kind of condition, medical stuff that's going to come into play, psychiatric things that may involve repair likely over time. So it does help us, but it's helpful, I think, to talk with families about why genetics is important and what we might find and what we might not.

  Dr. Melanie Penner: [00:34:00] Yes, exactly what to expect.

  Dr.Yona Lunsky: [00:34:03] There's one other again, thinking about adults and thinking about what people are talking about these days. It is important we can talk about what we're doing with our young children and our families when we think about genetics and autism, certainly things that I've read or that I've learned from autistic adults talking about this, there's a real fear around that. So if we look at, for example, how we understand genetic screening in another disability, so in Down's syndrome, we can actually test that prenatally. And what that's done, and especially in terms of how we counsel people when we notice that prenatally is sometimes there's an option or even sometimes in how we explain it and encouragement, you know, to abort that fetus. Right. So there can be fears or concerns around why are we doing genetic testing in autism? So people don't understand that it might be to help understand if this is the underlying cause. Here's some good things we could do to help address some of the things that might happen with that underlying cause. So it can feel like, well, we are doing that screening or we want to understand more about genetics because we're trying to not have autism or autism is wrong or autism is bad or this is something we want to get rid of. So it sends a certain messaging for people who are working really hard to take pride in who they are, about what we think of that condition. So with everything we talk about, I sort of hear this sort of perspective around working in the child area. And then I think, well, how is that perspective different when we're working with adults? And I think as people who may work both with children and adults, to have that recognition that something that makes so much sense for one group may have different sort of implications or meanings for another group and to be sensitive to that.

  Dr. Melanie Penner: [00:35:33] Mm hmm.

  Alex Raben: [00:35:35] Yeah, for sure. And just I mean, even in this room, we don't have all groups represented at the table in terms of this discussion. I think we should acknowledge that as well. But we are doing our best to keep that in mind with all of this. And it's a perspective I didn't think of with respect to the genetic testing and how that could be interpreted by someone who identifies as autistic. At this stage, though, it sounds like from what you're saying, the genetic testing is not diagnostic. However, it can be helpful in terms of treatment decisions down the line for people with autism spectrum disorder. Using that as a launching pad. Perhaps now we should turn to treatment and how we can help people who are suffering with autism. We talked a little bit about comorbidities. We've talked a little bit about some of the particularly distressing symptoms. And so we have a starting place, I imagine, of targets for treatment. But if we think broadly, what are the general considerations here when we're trying to help people with this condition?

  Dr. Mitesh Patel: [00:36:49] I think one of the the main challenges in working with individuals who meet criteria for autism is that it can be immensely difficult for them to navigate the world. And as they enter adulthood and something I see a lot in adults, is there social determinants of health are so much poorer than others potentially. And there's a large prison population that may meet criteria for ASD or autism spectrum disorder and just haven't undertaken the diagnostic testing because they didn't come from a family that could have questioned that diagnosis. I see a lot of children at the Children's Aid Society of Toronto that may meet criteria, but again, until they've come into care, haven't had that opportunity to potentially undertake assessment. There's lots of homeless youth who meet criteria for this diagnosis and they face incredible challenges trying to figure out applications for housing money. Many of them are targeted and preyed upon by predators who are either after their money most often. And there's also a sexual predation upon this population. And so it can be immensely difficult for these individuals. And so when we think about treatment, I think it's also important to think about what we can do to help intervene and assist individuals. And many of these individuals are our highest-risk populations. And so when we think of high-risk youth, when we think of high-risk adults, this neurodevelopmental community in particular comes to the forefront in many instances because they are facing very unique challenges, and they they can often become targeted by others, something we haven't really talked about much. And maybe I'll start the treatment discussion. There is what we see a lot of in clinical practice, especially if you're a child psychiatrist.

  Dr. Mitesh Patel: [00:38:38] One of the main things you see is conduct disorder amongst youth. And so when you have an autistic child who comes in with some conduct sort of behaviours, it's often because of what we call poor frustration, tolerance, which is having difficulties understanding all the frustrations that they might have or understanding what's going on around them. And so if you don't have the same kind of perspective on the world around you as others might expect you to have, obviously that's going to be super frustrating. Right. And for some of these children, it can be difficult to let out that kind of frustration. And other people might get hurt when they try to let out their frustrations. So some might behave in an aggressive manner or a hostile manner to let out some of that pent-up energy or pent-up frustration. And so oftentimes that's the focus of treatment, is how do we target these behaviours that are of major concern. Potentially others might be getting hurt in the home or that child might be hurting themselves. Did what we call self-injurious behaviours or SEB that happens predominantly in this community in terms of Seb in general and there are treatments for that. A lot of it is behavioural therapy. There are some medications that can be tried as well that have been shown to have some benefit. But I think it's really important to focus first and foremost on what we can do to help assist that individual navigate the complex social array that we have before them, depending on their age of development.

  Dr. Melanie Penner: [00:40:03] Yeah. Some of my sort of first principles around thinking about treatment goals are thinking about what gets in the way of everyday life. So what that question of function and I think in the past a lot of autism treatment was focussed a bit more on the idea of removing autism or making the autistic person look normal. And so treatment could be focussed on things like getting rid of hand flapping, even though that hand flapping in and of itself may not be harming another person or harming that person. And so I think increasingly the goals of various types of treatment are starting to move towards an idea more of improving function. And with that, I think there's also an emphasis on goal setting. So what is what are that family's goals at this moment as they get older? What are the child and youth goals? And then what are the the young adult, the adult schools to work on? Because I think if you're starting from that place of what does the family really want to work on what's going to or that does the autistic person want to work on? That's going to make the most difference in their day to day life. I think that's where that's where we're going to do the most good.

  Sabrina Agnihotri: [00:41:35] And what does family involvement look like in the paediatric world versus the adult world in terms of treatment goal setting?

  Dr. Melanie Penner: [00:41:44] I think ideally, it's it's a continuum of change as according to the autistic person's sort of developmental, you know, level at that period of time. So we would want to see, you know, some degree of things of enhancing and encouraging as much independence as is sort of reasonable in that situation. Certainly when they're really young, obviously it's a lot of talking to parents. When I'm seeing adolescents, I am trying to do more of that. You know, let's kick your parents out for a bit if that's if that is kind of developmentally appropriate. And I'm going to ask you to tell me what your medications are. I'm going to, you know, ask you about how school is going. And the disclosures that I get during those times are really, really important. And so I think sometimes we think about it in kind of a stepwise fashion, but ideally it's more of a continuum.

  Dr.Yona Lunsky: [00:42:56] Yeah, I think one of the big differences is that when we're doing our adult based work, we sort of forget all that stuff around more family-centred care. That's so obvious in terms of our training when we're working with children. So kind of finding that balance in adulthood is really important. And certainly from a family perspective, you know, whether it's an adult sibling or parents, they will talk about how it feels to not be included in care decisions. So if I am not the best person at articulating, you know, a full context of a situation and people are only listening to my story or I'm not very good at remembering something that happened in my therapy session, for example, or just reflecting on memory of when certain behaviours or symptoms were going on. When I'm giving a history, then the clinician doesn't have all the information, but sometimes I think families are kind of left out of that because we have a sort of model of how we work with adults. So we have to figure out how we blend those two models in a respectful way as possible, sort of promoting autonomy and independence, but also a little bit of interdependence and sort of seeing where that is.

  Dr.Yona Lunsky: [00:43:54] I think it's easy for us to do that with kids. It's harder for us to figure that out with adults, and sometimes people don't share the same perspective. So like, I don't want you to talk to my parents because actually I'm really mad at my parents right now and they don't understand me. I understand me. So how do we respect that with a young adult or an adult, but is there something kind of to learn from that? And sometimes I think therapeutically, if you can sort of help that person potentially appreciate or better understand why they don't want the conversation to happen with family, that could be really informative and there could be something they can learn as a family together if you can sort of bring people together around some of that stuff. So don't shy away from it. I think just because it seems like you're supposed to work in a certain way based on that person's age.

  Dr. Mitesh Patel: [00:44:36] So I tend to work primarily with children who have lost their families or there's been a there's been so, so many challenges within the family that it's fallen apart or their supports have fallen apart. And I think there's three main issues that that come up with that. So the first is a lack of support for those family members that it can be immensely challenging to have a child with special needs that requires so much more attention than other children in the home, for instance, it can lead to immense amounts of frustration, substance abuse challenges, involvement by external agencies, investigations, etc., etc. And it can be immensely challenging, particularly if the child engages in externalising behaviours or ends up getting into trouble with others or there's legal involvement. The second thing is around Psychoeducation, so really understanding what the needs of their child are, and that is do I understand what kinds of resources this child will need as they move forward? And the third is a lack of infrastructure, actually, and I don't say that lightly. When I see a homeless youth, for instance, it is immensely difficult to identify what kind of dedicated services are actually going to be available for that individual. Many of the services we have, they're dedicated and designed for people who can interact well with that system, who can actually advocate for themselves or say, Hey, this is what I want.

  Dr. Mitesh Patel: [00:46:04] You know, I've got this odious application. I need to get it filled out. I'm going to go find the doctor to get this done. You give a form to an autistic individual has no understanding of what that involves or how they would go about booking an appointment or try to get someone on board to maybe assess them and fill out a form that is so challenging. And our system just isn't really well designed for that. And so I see a lot of youth in shelter where we're scrambling to get as many workers on board to help them. Some of these frontline workers do amazing amounts of extra work just to help these kids out and these youth out. And you. I think it's it's always surprising to me when I bring other people into a shelter setting just to see how many of these youth have developmental challenges or meet criteria for autism and are now homeless and have lost all their family supports. And you just see this look of complete concern on almost every worker's face because we don't know what to do and people are trying to get them as much assistance as possible. And it is difficult.

  Alex Raben: [00:47:12] It's it strikes me that we often talk about the biopsychosocial model in terms and approach to treatment of various kinds of conditions in psychiatry and in medicine in general. And I think almost everything we've mentioned so far has been in that social category. So it's almost in reverse, the social psycho-bio approach, perhaps. And, you know, in terms of that social bucket, what I've heard from you guys is understanding the goals, both from the family's perspective and the individual's perspective, working with families to ensure that they are involved in care, but also that the system surrounding them is supporting them in order so that they understand what's going on, so that they don't feel overburdened, which could lead to the ultimate outcome of that individual becoming homeless or not really having that family support and further social determinants of health worsening from their. So that really stuck out to me. I'm wondering if there's anything else in that bucket we should be discussing in terms of what a learner might want to know in terms of helping people with this condition, or if that or if it's a bit too hard to know the specifics around that, because I often find that with social with the social bucket is you need to know very minute services in your area. So I'll just leave it there if there's anything else in social we should cover. But then I was thinking we could move in more specifically to psychological and biological interventions as well.

  Dr.Yona Lunsky: [00:48:49] I think just to mention on the social side that there are a lot of we talked about a lot of the problems and a lot of the challenges, but it also means there's a lot of things we can do. So we can if we can set up infrastructure that makes a big difference. If we can give either that autistic person social supports, that match what they're looking for or their families, that's really important. There's again, we've talked about the sort of movement for, I think, both youth and adults in terms of feeling like they belong somewhere and connecting with other people who see things the same way they do. So there can be a lot of power in terms of peer-based kinds of supports and connections, and sometimes that's in person, but sometimes that's virtual. So there's a lot of support that people connect with through technology. So understanding, for example, a young person who's spending a lot of time gaming and thinking about how problematic that is, but if there's a whole community of people playing that game with them that they can only connect with through that game, that's actually a really important social support for them. So we have to think about that. Or there might be for adults a way of sort of communicating, reading, talking about their experience, and they might be doing that through Twitter, for example, or through Reddit or so, kind of recognising that there are things we can do socially and also in terms of meaning poverty. You talked about housing, which is obvious, so huge, so important, but also having something meaningful that you do during the day. So some of our treatments are really trying to figure out how we can give things for people to do that, make them feel good about themselves, and that gives them meaning. So it's a really important part of intervention.

  Alex Raben: [00:50:16] Right? So not forgetting those sort of low-barrier ways we can improve, potentially improve people's social lives by acknowledging the groups that they can find and connect with online or in person in addition to broader social programs to help with housing and poverty. I think that's very important. That said, I'm wondering in terms of psychological treatments, what is available for people with ASD.

  Dr. Melanie Penner: [00:50:39] So yeah, so I think the most commonly discussed form of therapy is ABA or Applied Behaviour Analysis. And ABA I guess similar to autism is a very broad term that covers a lot of stuff. And so I would say some of the core elements of ABA are that it sort of works with the idea of motivation and how you keep people motivated to learn skills that might be more challenging for them. But there is a lot of breaking things down into very small component parts and then teaching them sort of one piece at a time and a lot of repetition built into that. And it's done. It's supposed to be done in a in a somewhat systematic way, often involving some data collection to sort of track progress. And the evidence base is interesting. So there was a recent meta-analysis that was published of different early interventions for autism, and they actually found that the quality of evidence for many of these ABA programs is not that great. So very little in the way of randomised controlled trials. And this is it's hard to study these types of interventions in a very, very rigorous way in the types of study designs we see when we're doing, you know, double-blind, placebo-controlled drug trials, for instance. But I do think that that it is it does pose a challenge to the research community to think about how we can generate the best possible evidence, control for bias as much as possible to generate the type of evidentiary support that we ideally would like to have for these interventions.

  Dr. Melanie Penner: [00:52:45] In that meta-analysis, the sort of standout that had the best evidence supporting it was something called naturalistic developmental behavioural interventions or NDB models. And we have so many abbreviations in our world, as you can probably tell, and this is sort of the newest sort of iteration I think, of where ABA is and is going where so. Naturalistic refers to applying the intervention in the child's natural environment. So taking it out of a very clinical space, because when it's done in a clinical space, then you have to the child has to then make the leap to applying those skills than in their regular environment. So the idea is by applying the teaching in their regular environment, you eliminate that step developmental. So the RD in MTBI refers just to the fact that we're thinking about the developmental domains and the developmental skills that were kind of wanting to focus on at that age. And so again, previous models were maybe a bit more focussed on kind of table-based tasks, academic type tasks. And these NDB models are starting to move a little bit more into saying, okay, like what are the domains in terms of social interaction, in terms of communication that we want to work on? The behavioural reflects that this is still like a behaviourally based model. So that's that is the kind of I would say where the field is sort of going with those types of interventions.

  Dr.Yona Lunsky: [00:54:37] Just to add from psychological thinking and about adults that we would be thinking about different things for adults, we wouldn't be thinking so much. What are the interventions for autism psychologically? But we might be thinking, what are the interventions for depression or for anxiety? And, you know, it's we're in an earlier stage because most of the research done on autism is done on kids. So it's much less done on adults. But we are learning that many of the things that we do in the general population might also have some use in terms of psychological interventions, especially if that person, for example, has speech and is able to do a more psychological kind of therapy. But there are certain things we might want to shift or change. So and again, Autism's, not everybody does well with the same thing. So one person might really appreciate the sort of scientific inquiry or approach that you use sometimes in CBT, where you take a thought and you think about it and you look at the evidence, but someone else might find it incredibly impossible to capture what an automatic thought is. 

  Sabrina Agnihotri: [00:55:36] Can you give us a few examples of the more biological treatments?

  Dr. Mitesh Patel: [00:55:39] Yes, in a lot of the work that I do focussed around youth who are facing some challenges, some of that can be externalising behaviours and so we may treat that with low dose third generation antipsychotic medications. Abilify has shown some evidence in that regard. 

  Alex Raben: [00:55:57] And by externalising behaviours you mean things like aggression.

  Dr. Mitesh Patel: [00:56:01] Yes. Or even self-injurious behaviours. Yeah. There is some evidence as well for using some other agents related to opioids for self-injurious behaviours. That evidence is somewhat limited. It's a difficult area to treat, but as I've indicated, as has come up here before, many of the symptom concerns that come forward are related to mood and anxiety. And so when we've exhausted psychological approaches and social approaches to treat these underlying issues, we may turn potentially to biological agents. And in that case, we are looking at typical agents that we would use in others, including SSRI medications or other antidepressants. This is in my practice, it's not a population that I typically use benzodiazepines, and I have a very not good experience. And I wouldn't do that anyhow with youth. But even in adults, I find that it's just it's not it doesn't have the same effect even in short-term cases. There's a lot of looking at what the comorbid symptoms are. Is there a poor sleep? Is melatonin going to work, for instance, just to facilitate some improved sleep? And if that happens, is there improved mood and anxiety symptoms? Usually that's the case even when it comes to aggression and hostility. We look at those things as well. There is a specific population that may have certain focussed sets of interests and even engages in some sexualised behaviours which isn't overly common, but it can happen. And so sometimes we look at some medications to help with that too. But I don't want that to be the focus of this and I don't want people to walk away thinking that that's what we're treating for and that's what we have to do. These are very specific cases and I think the rare cases, but I think for some of us that practice in certain areas, we end up seeing so much of one thing that we start to think like, Oh, maybe this is more prevalent than we thought. But no it's not.

  Dr. Melanie Penner: [00:57:45] Yeah, I would say the one well a couple I would add , ADHD commonly occurs with autism. And so we have a lot of kids who are and teens and probably adults who are started on ADHD medications, so stimulants. Alpha agonists. At a max teen. And the other thing to think about from the biological sort of component is co-occurring medical conditions. And so there I think we have to be thinking about. Seizures, which we know frequently occur in autism. Sometimes side effects of seizure medications have a big impact on the presentation that we're seeing. Constipation. I don't think I'd be allowed to be a paediatrician and be interviewed here without mentioning constipation. So but, you know. That's something that you can make you very irritable thinking. Thinking about, particularly for autistic people who don't have the best ways of communicating with us. I think we need to be extra careful that we're not missing things. And so one of the one of the toughest cases in our clinic was a dental abscess that that had been missed. And that was a big source Of pain. And so those are the things that you just don't want to miss. Right. So it's important not to just chalk up the behaviour to autism. But to make sure that you're, you're doing a good review of systems as well to make sure that those medical co-occurring conditions are considered too.

  Dr. Mitesh Patel: [00:59:36] That's immensely important, particularly in autistic clients, especially those that don't have the ability to communicate. In fact, they can't tell you if they're experiencing pain. And so oftentimes in psychiatry or child psychiatry, we're working very closely with paediatricians to have the child undertake a fulsome assessment. Even the dentists will get involved to look for this kind of thing, which is why it's so important to have these multidisciplinary teams working together for these clients, which also presents infrastructure challenges because it can be difficult to get all these players around the table in the same place for some of these youth. 

  Dr. Melanie Penner: [01:00:16] And I think often it's a virtual table that we're talking about. Right? And it does. I think the issue comes. In sort of who's running point on this, who's coordinating all of this information, synthesising it, making sure that all of the boxes are checked off? Because you're right, it's we don't have infrastructure such that everyone sort of sits around the same table to discuss these cases. So there's a lot of behind the scenes work, I think, that probably all of us are doing to coordinate things for our patients. 

  Alex Raben: [01:00:55] So there's a lot there. I'm going to because we've come closer to the end of our time together. I'm going to try my best to summarise the treatment, but there's a lot to summarise. But I think, as I was saying in the beginning, it sounds like it's an almost reverse social psycho-bio approach with social considering factors of social determinants of health, large issues like poverty and homelessness, but also considering the person's social circle, their family supports and ensuring those are as healthy as they can be to support this person in the psychological pathway. We have ABA applied behavioural analysis and this is a behavioural type of therapy that works with positive reinforcement to help with the core deficits that relate to ASD, such as social reciprocity and things of that nature. And then the last section is biological interventions, which from what I was hearing, really don't target the core symptoms if you will, of ASD.

  Alex Raben: [01:02:04] But rather target the comorbid psychiatric conditions and medical conditions. And it's important to recognise both and recognise that there could be overlap that a biological or a medical condition may be causing a psychiatric or mimicking a psychiatric reaction. Leading that person to be aggressive, for instance, and that we do have some medications that help, such as atypical antipsychotics that can help with externalising behaviours and then SSRIs if there's a comorbid depression. I also heard the subtext was that no one does this alone. This is a team working around this individual, ideally a team of professionals, and that's not necessarily an easy team to coordinate all the time in our current health system, but one that is paramount to the treatment of people with this condition.

  Alex Raben: [01:02:59] As sort of a last hurrah, I'm wondering if you guys have any resources you would recommend for clerks or early residents that would allow them to delve a bit deeper into this topic.

  Dr. Mitesh Patel: [01:03:14] Autism Canada.org has a ton of information. I think that's a good place to go but also just I think reading from Journals and seeing some of the newest information that comes out, it's also very helpful and getting a lot of clinical exposure. I think that's the main thing is if you can shadow or do an elective or do a rotation in some of these areas, we haven't talked too much about dual diagnoses, but that's a big area to do this in. And I think you'll find across psychiatry, many practices end up working with individuals who have autism or diagnosed with it.

  Dr. Melanie Penner: [01:03:52] I think my advice is to actually seek out first-person accounts of autism. I think that's where some of my best sort of hidden curriculum learning has happened. So, you know, there is a very rich, nuanced discussion of autism happening every day on Twitter. There are lots of books written. So Yonas mentioned Temple Grandin. One of my favourites is Look Me in the Eye by John Elder Robison. And then for a really nice sort of overview of the history and kind of politics and sociology of autism. The book Neuro Tribes by Steve Silverman is excellent. Great.

  Dr.Yona Lunsky: [01:04:46] I would actually echo a lot of I think recognising different people are looking for things at different times, but so important, I think, to understand people's experiences themselves. And also if you're interested in supporting families, understanding also families experiences and being familiar with the different stories because there isn't just one. And so it's helpful to understand the perspective of autistic adults, the perspective of parents or siblings, of people who are autistic at different ages from different times. The more you can read, the more you can learn, right? And the more you see people and interact with people, I think is also I mean, there's even a huge difference that people who are listening to this right. Now, who are clerks or early residents, were brought up at a different time than I was in terms of who was in your school and who was in your neighbourhood, right? So that's already making a difference is probably people, you know, that you can talk to. I think that could be really helpful as well.

  Dr. Mitesh Patel: [01:05:36] I just want to echo that Look Me in the Eye book that was actually required reading for me during my residency by one of my supervisors, and I'm so glad he pushed for that. That was at the Maples Institute in Vancouver, which is a Child Custody Centre and Youth Forensic Centre. But it definitely helped to, I think, educate me a lot about the perspectives. And yeah, I think there's so many things to do. There's movies to watch as well. Yeah. So I think there's lots of ways about learning about this, right.

  Alex Raben: [01:06:06] And now a podcast episode. Thank you guys so much for being here. We really appreciate it and for taking us through various aspects of autism spectrum disorder and for giving us some resources to move forward with. So I just want to thank you all again and thank you guys for listening. And we will. Talk to you next time. Bye bye.

  Alex Raben: [01:06:35] 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. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Weam Sieffien, Gurnaam Kasbia, Sabrina Agnihotri and Alex Raben. This episode was hosted by Alex Raben and Sabrina Agnihotri. Audio editing by Jordan Bawks and Alex Raben. The accompanying infographic for this episode was created by Weam Sieffien and Nikhita Singhal. Our theme song is Working Solutions by Olive Music. A special thanks to the incredible guests Dr. Melanie Penner, Dr. Yona Lunsky and Dr. Mitesh Patel for serving as our experts for this episode and providing us resources for our show notes. You can contact us at podcast at gmail.com or visit us at Psych podcast dot org. Thank you so much for listening!

Episode 22: Psycho-Oncology Assessments with Dr. Elie Isenberg-Grzeda

• Episode 22: Psycho-Oncology Assessments with Dr. Elie Isenberg-Grzeda

  Jordan Bawks: [00:00:05] Welcome to Psych, the psychiatry podcast for Medical Learners by Medical Learners. This episode is an introduction to the subspecialty of psychosocial oncology. It's a big topic, and today we will focus mostly on how to approach assessment in patients with cancer. I'm your host today, Jordan Box, a fourth year resident in psychiatry at the University of Toronto, working at Sunnybrook Hospital. And that's where I've met my guest today, Dr. Elie Isenberg-Grzeda. So why don't you introduce yourself and tell us a little bit about yourself and your training background and how you came to be interested in psychosocial oncology?

  Dr. Elie Isenberg-Grzeda: [00:00:44] Sure. So first of all, thanks for for having me and for setting this up. So, as you know, I'm a psychiatrist here at Sunnybrook. My subspecialty training is in psychosocial oncology or psycho oncology, depending on which jurisdiction you're in. And, you know, essentially, I trained as a psychiatrist in residency at Albert Einstein College of Medicine in in the Bronx in New York, having really no idea what I wanted to do afterwards, other than maybe something HCL related. And one of my supervisors at the time, CL psychiatrist at my hospital, had suggested that I check out a program at Memorial Sloan-Kettering Cancer Centre. It's like a freestanding cancer hospital in New York City that they have a great CL fellowship program there. And even if I didn't want to work in cancer, it's a great training and the sort of thing that's generalizable to to other areas. So I said, sure, I went to check it out and I absolutely fell in love with it. I fell in love with the place and with the work and with the people and just really felt like a rich, interesting, stimulating area to to work in. So so that's where I trained for for psycho oncology. And for anybody who doesn't know what that is. I mean, essentially what we're doing is we're looking at the really the interface between mental health and cancer. You know, we treat patients, we treat their families, sometimes treat or support the oncologists. Yeah. And so that's the work that I do here at Sunnybrook at the Odette Cancer Centre.

  Jordan Bawks: [00:02:30] Cool. And before I guess we go any further, I'll just make sure that we outline our objectives for today, which are really pretty self-explanatory, which is that we want our listeners to become more comfortable with the sort of unique aspects of a history assessment formulation related to patients who have history of cancer. And our hope through this episode is that after listening to it, you'll feel more comfortable both doing consults and follow ups because we're going to cover a lot of different unique areas. Ever since I've done kind of some electives in psychosocial oncology, it actually opened up areas to talk about my other patients, like when I talk to people about meaning and about impact of illness, like although we'll sort of talk about this as though this is stuff that's specific to cancer, I think kind of like you hinted at with your fellowship at Sloan-Kettering. You know, the sort of the mindset that we bring to doing a psychiatric assessment in patients who have cancer is one that we can apply in multiple settings. So moral story is we want people to learn a little bit about that kind of mindset. So this the outline for today is that we're going to cover some of these unique areas of the assessment. We have about ten of them. And then we're also going to spend some time towards the end talking about diagnostic issues in psychosocial oncology. But before we kick into that, I wanted to let Dr. Elie Isenberg-Grzeda to talk about a little bit about the history of psycho oncology, because it's an interesting one.

  Dr. Elie Isenberg-Grzeda: [00:04:15] Yeah, for sure. And so, as you know, I find this area, the history of psycho oncology or psychosocial oncology very interesting. It's I mean, the history of medicine in general is is really interesting. And this is no exception to that rule. Cancer care in the 20th century is very was very different than than cancer care the way it looks right now in the 20th century. I mean, basically at the start of 20th century, you know, essentially cancer care was in its infancy. It was a very kind of rudimentary surgery based. A type of way of of treating people. And, you know, the surgeries were really not very well refined. Anaesthesia really was not very well refined. And so people kind of had these. You know, these tumours that were taken out and what felt like kind of barbaric procedures that, you know, would send us running if we were kind of given the option for those today. And so cancer itself was seen as something really, really scary and generally really, really untreatable. It was the sort of thing that came with connotations of. Of nihilism. Basically, cancer was synonymous with death. And if you could somehow avoid that fate from the cancer, then at the very least you'd be and you'd be left off with, again, some really disfiguring, barbaric, pretty awful surgical treatments and eventually maybe radiation. And then chemotherapies came about and. And anaesthesia techniques got a bit better and combined treatments came about. So chemo and radiation or surgery followed by chemotherapy or. And so slowly what happened probably around maybe mid 20th century is that there started to be a little bit more of a window of possibility when somebody was diagnosed with cancer beyond just death or suffering this inevitably barbaric, awful, torturous treatment.

  Dr. Elie Isenberg-Grzeda: [00:06:47] And. And so then cancer went from this thing that represented. Death and basically really awful potential outcomes to something that that maybe had a bit more breadth in terms of possible outcomes and people could start to talk about it a little bit more. Certainly there was still a lot of stigma, but maybe a little bit less so. And eventually maybe around 1960s, 1970s, there was this kind of confluence of factors where you had better treatments. People were starting to survive a little bit more than they had been. Breast cancer, of course, one of the most common cancers, and that coincided with the time of women's liberation movements. Sexual revolution. You know, the idea of things that were taboo coming out of the woodwork. And so even the word cancer, which wouldn't have been allowed to be published in many newspapers up until well into the 1970s, slowly started kind of making its way into more lay media. And so people started hearing the word more. Again, less and less stigma associated with it over time. And what happened when you had more people surviving, more people talking about it? People becoming very interested in advocacy and awareness and sort of social responsibility. It is as a field. We started seeing patients going through this type of diagnosis and treatment. And. Starting to need more care beyond purely the the actual cancer treatment. The surgery, the radiation, the chemotherapy. And in the way that this had happened in other areas of health care as well, is we started seeing psychiatrists, psychologists, social workers, nurses and even some oncologists start to take more of an interest in.

  Dr. Elie Isenberg-Grzeda: [00:09:13] Really the whole person. Beyond, let's say, the cancer itself. And what that meant was trying to understand what the impact was on people on their lives and. In as much as cancer caused distress. How we can actually help those people. And so that area of really the interface between health care, medical care and psychiatric care, body and mind essentially started to get looked at by more clinicians and researchers. And oncology was by no means the only area. I mean, certainly well into the 1980s, you know, there were many HIV psychiatrists, for example. But something about cancer psych oncology probably had to do with funding models. And again, just advocacy about cancer in general at the time really did help build a psycho oncology into what's probably the biggest of these subspecialty areas that that kind of rest at the interface of of medicine and and psychiatry. And so. You know, the field grew again. Cancer treatments got even better. Patients started living even longer. Many patients ended up surviving from their cancer. The cancer treatments issues of survivorship started to get looked at and again, the field continued to grow. There are professional associations. There's the American and the Canadian associations of psychosocial oncology. There's the international association. These are anywhere between maybe ten and 30 years old, depending on the associations. So, you know, not new, new, but certainly not associations that have been around for hundreds of years, like in some other areas of medicine.

  Jordan Bawks: [00:11:21] So what I'm hearing is that as cancer treatments progressed. Longevity increased. Also, morbidity increased as people lived with kinds of consequences of treatment. Some of the stigma softened to the point where people were kind of allowed and encouraged to start talking about it. Advocacy groups sprung up to sort of advocate for the well-being of people living with illness or diagnosed with illness. I always like to have that kind of context. Where is where is the field at now? Like what? What are the current things that psych oncology are grappling with? Where does it see itself?

  Dr. Elie Isenberg-Grzeda: [00:12:11] Yeah, that's a good question. So right now, and I'd say this is probably true for me the last ten or 15 years or so is we really seem to be in the era of distress and distress screening. And, you know, there's very good data out there to show that that we continue to really not pick up on people's distress all that well, generally speaking, in the oncology setting. And so there's been a lot of work done by research groups into creating distress screening tools that looks at not only psychological distress, the things that, you know, in psychiatry we tend to talk about and think about all the time depression, anxiety, but also physical distress, spiritual or existential distress, distress around social or practical concerns. And so really, where we are right now is in the era of distress screening. And and we're sort of veering into the era of how best do we then help people who screen high on their distress, on their distress screeners, for example.

  Jordan Bawks: [00:13:21] And like what role psychiatry would have in that? Because I imagine that I mean, this is certainly a bigger conversation than we're able to have just on this podcast today. But, you know, a certain degree of distress, I imagine, is a sign of actually psychological health in the face of certain diagnoses.

  Dr. Elie Isenberg-Grzeda: [00:13:39] Yeah, Yeah, that's absolutely true. I mean, the overwhelming majority of people will experience distress around the time of diagnosis and it's completely normative and the overwhelming majority of them will have their distress levels decrease right back down to baseline can take weeks sometimes, but that's the general pattern. And so you're absolutely right. Do we need to call psychiatry? Do we need to call anybody, frankly?

  Jordan Bawks: [00:14:03] And I imagine that that's one of the things that's on your mind when you're seeing people is to what degree is this sort of transient, expected healthy reaction and to what degree may this distress be, for lack of a better word, pathological or stock?

  Dr. Elie Isenberg-Grzeda: [00:14:20] Yeah, exactly.

  Jordan Bawks: [00:14:22] So maybe that's a good Segway to talk about the different areas to consider when interviewing somebody in a psycho oncology kind of setting the sort of unique aspects of the history. And just to be clear, if this is the first time that you're joining us or you're new to a psychiatry rotation, you probably want to go back to some of our earlier episodes on some of our basic diagnoses to to get familiar with the basic kind of aspects of a psychiatric history and a symptom screen. We've done episodes on the psychiatric interview. That would be a great place to start. So the areas that we're going to cover, I'm just going to quickly list them off. So we're going to talk about cancer history, beliefs about illness, physical symptom, burden, body image and sexual identity. Coping /mental health. Family and supports work and life disruption, disclosure of illness, religion, spirituality and death and dying. And in our show notes, I'll try and earmark the times that we are touching on each of these unique areas. But for now we can just go into them one at a time and spend a couple of minutes on each. And what are the kinds of questions you ask about and why they're important to you? So starting with cancer history, what are your typical openers? What are you really trying to find out?

  Dr. Elie Isenberg-Grzeda: [00:15:49] Yeah, so cancer history and this is an interesting one because this is basically also very generalisable to other areas of these kind of like medical surgical areas that overlap with psychiatry. We want to have a good understanding of what the medical situation is, plain and simple. And what's interesting about this is sometimes when I'm reviewing a case with a resident, we could be sort of well into the history before I actually hear about what type of cancer the patient has, why they're in hospital, what sort of cancer treatments they're receiving currently and. You know, of course, when we think about a psycho oncology consultation, when we think about it, psycho oncology assessment, the cancer piece is really front and centre. You sort of can't extricate that from the sort of overall situation. And so usually that's the sort of thing that we'll want to find out about basically right away what type of cancer the patient actually has. Many most patients have one type of cancer. Some people have the unfortunate reality of having two completely unrelated. So the type of cancer they have when they were diagnosed, what sort of treatments they've received, treatments come like a variety of different shapes and sizes and flavours, and there's chemotherapy, radiation surgery. And nowadays you hear people talk about targeted therapies and essentially having a good understanding of what treatments the patient has had, what those treatments have been like for them. Some of these are extremely onerous, some of them are painful.

  Jordan Bawks: [00:17:38] And what the treatments mean is also sometimes interesting to to get a sense of as well, like is this something that people are understanding is going to cure them? Is it something that they're understanding is to improve their quality of life and or whether they even know that at all? Like I encountered patients who like, yeah, they don't know. And that's distressing in itself. And I guess kind of like what you're saying is that the cancer history is almost like the skeleton by which we drape everything on. And I often that's advice that I give to junior residents when I often try to keep in mind as well when I'm interviewing any patient is to get if you can try and get a clear sense of what's been going on in someone's life and the most stressful thing that's been going on in someone's life, then it gives you an opportunity to both really understand that person and create timelines for things. So when you're hearing about something like Low Mood, it's like, well, in a setting of psycho oncology, did you know, was the low mood there before? You know, right at the beginning, Is it thereafter? Was it thereafter the chemo? Was it there after the surgery? Was it, you know, and by having those different time points, that gives you that kind of structure to jump around?

  Dr. Elie Isenberg-Grzeda: [00:18:58] Yeah, totally.

  Jordan Bawks: [00:18:59] Do you have like do you have a typical go to line? Is there any magic to this? Or like, how do you usually open this up?

  Dr. Elie Isenberg-Grzeda: [00:19:06] Well, so in reality, just by nature, by virtue of of the work that I do here as a consultant at the cancer centre, I always have access to the patient's chart. I've already seen the diagnosis. I have some sense of that kind of skeleton framework. I will usually tell the patient that, you know, that I received the referral from Doctor So-and-so and that I have some understanding of their cancer, their cancer journey thus far, and that I've read through the chart and I've read through their paperwork that they've done for me and but that I want to hear in their own words what the cancer journey has been like for them up until this point. If that's too vague, sometimes I'll ask people. So take me back to when you were diagnosed, and I can definitely say my experience. I don't even have to say diagnosed with cancer, Right? If you say to somebody, take you back to when you were diagnosed in this type of setting in the psycho oncology world, they they know what you're talking about.

  Jordan Bawks: [00:20:10] Our next area here is beliefs about illness.

  Dr. Elie Isenberg-Grzeda: [00:20:15] Yeah. So when we were talking about beliefs about illness, I mean, you know, this can sort of go two ways. Some people interpret this as illness understanding, which I think you were alluding to before. You're talking about does the patient know whether or not the treatments are curative, intent or not? And so there's an illness understanding or an understanding of treatments that are being offered sort of illness, understanding or awareness or health literacy. It kind of all lumps together. But I think what we're getting at more with this idea of beliefs of illness are how does somebody actually think they got cancer? And ultimately. I won't say always, but maybe almost always people have some sense, some belief. Sometimes it's completely rational. Sometimes they'll even tell you, I know this is irrational, but. But everybody, or almost everybody has some. Belief about where or how or why they got cancer. In my experience, it's often not rooted in scientific evidence. Many people are are well aware of that and they'll say, I know this sounds like garbage, and everybody tells me this isn't even possible, but I know it's because of that trip we took that time and and there was that that sort of like chemical smell in the hotel room. And and I know it had something to do with.

  Jordan Bawks: [00:21:43] And why why do you find that important to hear about or know about?

  Dr. Elie Isenberg-Grzeda: [00:21:48] Well, so sometimes it gives a sense of who the patient actually is, kind of what their own just sort of background is, what their relationship is with science, what their relationship is with their doctors or their treatment team, the extent to which they might require some. Myth busting, the extent to which they may or may not even be open to myth busting. And for some people and I tend to see this more. With people who have a real. Sense of control. Sometimes delusionally. So. A sense of control in their lives in the world and how things work. That consequences follow actions. Those types of folks that that sometimes there can be a sense of guilt that goes along with it. I know this. This has to do with that year that I had in that, like that really stressful job. Had it not been for that, then I wouldn't have. And so sometimes that can also be an area of of focus. Something worth exploring to see if you can try to help alleviate the person of that guilt, or at least of the distress that comes with it.

  Jordan Bawks: [00:23:06] Yeah, that I know you've we've talked about this in other kinds of settings when you've given this talk. It also follows with a kind of moralistic like Western attitude that we kind of grow up with. Good things happen to good people, bad things happen to bad people. So if I have a bad disease, it must be because I was a bad person. Yeah. And I've seen people really grapple with that, either believing that they were a bad person or trying to understand it, sort of like people with strong, certain spiritual faiths. I don't understand how this could have happened to me in this with the beliefs that I have.

  Dr. Elie Isenberg-Grzeda: [00:23:50] Yeah, that's exactly right.

  Jordan Bawks: [00:23:52] Moving on into physical symptom burden. You know, it's funny. This is actually one that overlaps also with some of our depression and anxiety screening symptoms. So this is always a tricky one. I've found and I've had junior residents or medical students sort of ask like, I don't even know why I'm asking about their energy. Like, of course they're fatigued, they have cancer. Like, of course they're nauseous, they're getting chemo. But at the same time, it's important to know, like just because we can't know the validity of the sort of symptom for depressive diagnosis may be in question. Does it mean that we still not important to know about what the kind of symptoms that that person is living with and to what degree they're bothered by those things?

  Dr. Elie Isenberg-Grzeda: [00:24:38] Yeah, exactly. So all of that is an extremely important reason to ask. I mean, these are all important reasons to ask and might get information that, like you said, will really help you understand the person and understand their experience. Another reason to ask these questions is because not everybody actually gets optimal symptom management, and we happen to be extremely lucky at this hospital. I think my colleagues in palliative care and parenthetically the palliative care docs are really the ones who who treat people's symptoms. They're really the experts in symptom management here and elsewhere. But at this hospital, they're really excellent. And and I think the oncologists are also really good at picking up on people's physical symptoms and knowing when to refer. But even with that, not everybody has optimal symptom management, not everybody who's been seen by the symptom management experts when they need to. And sometimes even in psychiatry and psycho oncology, we might be picking up on something that nobody's really asked about yet. And it's not that uncommon that I actually end up making a referral to palliative care.

  Jordan Bawks: [00:25:59] Because you're picking up on pain or nausea or something like that. And that's something we can do something about, right? Pretty quickly, Yeah. Next up, we have the area of body image and sexual identity.

  Dr. Elie Isenberg-Grzeda: [00:26:15] Yeah. So these areas are are really huge in the in cancer care and the cancer world and. I mean, let's face it, human beings are sexual beings and we all have body image. You know, these sort of internal representations of what our bodies are like and how they appear and how we feel sort of in our bodies. Sexual health is like a really big part of that, and sexual identity is a really big part of that as well. And so breast cancer, prostate cancer, colorectal cancers, right. Are three certainly on top five most prevalent cancers, maybe even top four lung is in there somewhere. Right. So breast, prostate, colorectal, these are cancer areas that really cause huge, huge impact on people's identity, on their sort of integrity of their of their body and in a way that really affects sexual organ, sexual functioning as well. We also happen to live in a world or in a society at least that sometimes a little sexually averse and stigmatising. And people don't always ask their doctors and they don't always share symptoms that they're experiencing. The oncologists don't always ask their patients. And so sometimes what happens when people are experiencing sexual sort of body image or issues related to sexual identity or sexual functioning during or following cancer is that they can, a, be experiencing these really unpleasant symptoms or experiences and then be actually kind of left with it alone in a very isolating, unnecessarily isolating way. And so issues related to body image, identity, sexual health, sexual functioning are critical. They're like a core part of the human experience. They're a part of the experience of cancer care. And so we really need to. Be better about, you know, asking.

  Jordan Bawks: [00:28:32] Yeah. Leaning into those kind of questions because I think it is, you know, people are it's already hard to open up to somebody that you've never met before who's kind of a stranger to you. And so to expect the majority of our patients to volunteer that kind of like aspect of their lives that's often so private, it's unlikely. I think it's a good reminder for us to that we should be the ones to open up these conversations and can play a role in kind of normalising these conversations and identifying these areas. At least just so someone else can hear about it and understand it and empathise with them. And they're pretty common experiences to.

  Dr. Elie Isenberg-Grzeda: [00:29:18] Well, that's it. And so not feel so alone. And patients will often say that is they didn't realise that this happens to everybody or this is so common. Or one thing I would definitely suggest to to trainees is really just to practice asking, even if it means starting like just practising in front of the mirror or, you know, in like a study group kind of thing, throwing around different questions, different ways of asking and literally getting comfortable with the words coming out of your mouth. Mm hmm. I mean, the last thing the last thing a patient wants is for their doctor to ask a really important question in the most awkward sounding way.

  Jordan Bawks: [00:30:02] Do you have any problems with, you know, that thing that people sometimes do? Yeah. Yeah.

  Dr. Elie Isenberg-Grzeda: [00:30:10] So don't do that. Yeah.

  Jordan Bawks: [00:30:12] Yeah.

  Dr. Elie Isenberg-Grzeda: [00:30:13] I'll usually actually start off just by asking about intimacy, you know, And I'll sort of normalise by saying that, like cancer and maybe certain cancers have a way of really, you know, negatively impacting on people's intimacy and, you know, has that been an issue for you? And, and usually people know what we're getting at with that. Sometimes they don't. And then I'll make it a bit more explicit and literally just use the words sexual functioning. Mm hmm. You know, might ask about intercourse and penetrative sex and and sort of the list goes on and on. But ultimately, what I'm trying to do is sort of start by something that's maybe less stigmatising, that's normalising for people, and eventually sort of building up to questions that that might feel a little bit more uncomfortable, but that are important nonetheless. Mm hmm.

  Jordan Bawks: [00:31:05] And this I'm just going following along in your slides and was cued to something sexual intimacy versus relationship intimacy. And I believe we had a talk this year by a couples therapist that you had brought in, and she was sort of mentioning that for many couples, they sort of rely on their sexual intimacy as a way of sort of being close and supportive in the relationship and getting through rocky patches. And when that is vulnerable or disrupted because of a treatment, then you don't have that thing to go to and rely on to stabilise the relationship. It's important to find other ways to navigate around that. So this is something that kind of is, for lack of a better word, intimately related to attachment and relationships and social functioning between partners.

  Dr. Elie Isenberg-Grzeda: [00:32:03] So yeah, and you know. We could sort of talk about this issue at length. But, you know, suffice it to say that that even when sexual intimacy takes a real hit because of cancer or cancer treatments or anything in between, there is still a degree of physical intimacy that isn't. You know, truly sexual, something like hand-holding, hand-holding or cuddling or a sort of physical closeness with one's partner that. You know, I often hear patients say seems to get something about the hand-holding, feels stronger, more loving, more tender, special or different than it did before. And so there is a. Really an ability to actually kind of further grow one's intimacy in a in a couple, even if true sexual functioning is impaired or sort of sexual closeness is kind of prohibitive, that there's still a way to to actually really kind of build upon and improve physical intimacy and closeness among partners.

  Jordan Bawks: [00:33:34] Mm hmm. And that's also another opportunity for a pretty early work. Like, that's not something that requires weeks and weeks of intensive psychotherapy, right? Like, that's stuff like basic psychoeducation and encouragement, normalisation that you can make an impact on. Yeah, on a pretty short basis. This is another good general area of assessment asking about coping.

  Dr. Elie Isenberg-Grzeda: [00:33:59] This is where we try to get a sense of how somebody is actually managing. And usually what I'll do is I'll ask sort of up until this point, what I would have been asking about was about the illness, about aspects of function or dysfunction that have come from the illness. So sexual functioning, for example. But now what we're doing is we're talking about coping and adjustment and how somebody is actually managing with the diagnosis or the treatments and the sort of emotional distress that that comes with it. And I usually yeah, I usually just ask in a very kind of open ended way and almost always that's enough to sort of spark enough conversation around these issues that, you know, that I can get a good sense of how somebody is coping. We can then sort of whittle it down all the way through the most kind of checklist we review of systems if if needed, but we often don't really need to to get there.

  Jordan Bawks: [00:35:04] Mm hmm. And when you say open ended, you're not I take it you're not sort of saying, how are you coping with that? You're rather than that you're saying how are you coping with your symptoms? How are you coping with your sexual functioning? How are you coping with that diagnosis? So it's tying it to those kinds of concrete things that the person's already told you that they're struggling with.

  Dr. Elie Isenberg-Grzeda: [00:35:26] Exactly. So relating it back to what they've told me exactly. You know, in the cancer world, generally, if I had to go for kind of one thing and one thing alone, what I would ask is how are they coping with the diagnosis? Yeah, that's usually just in my experience, sort of where where the money's at.

  Jordan Bawks: [00:35:43] Yeah, I find this question. You know, it's funny because, you know, we reference this as like a bread and butter thing we could do in our sleep as psychiatry trainees. And, you know, this is, this isn't actually something that I felt like I was good at until recently, like how useful this question is. You know, you can kind of use it to try and get symptoms like or are people withdrawing or are they not eating or are they? But I find this really helpful to to also look at people's kind of attachment styles, like, you know, is this the kind of person that's going to be talking to their partner like late into the night about this or just the kind of person who's going to pretend like nothing's happening? Is this the kind of person who is going to be looking up on the Internet like over and over and over? Are they going to be going to reach for natural health products or supplements or really, are they trying to rigidly control their diet or their medications? I find these kind of coping questions to be like really rich from a formula, like a formulation kind of perspective, just even in the way people kind of answer them sometimes. Like, what do you mean, coping? Like.

  Dr. Elie Isenberg-Grzeda: [00:36:51] Yeah, no, totally. These are like really, really like high yield questions and whether we think long attachment lines or personality inventory lines. I mean, either way, this question and the way people approach illness coping style really tells us a lot about who they are and actually about how they're going to manage moving forward as well.

  Jordan Bawks: [00:37:15] Yeah, Yeah. And then how we can adapt ourselves to perhaps like kind of meet them where they're at. Right. But like when you see kind of a particular coping style, you might want to adapt. Like if this is someone who kind of downplays their distress a little bit, then you're going to want to maximise their sort of sense of autonomy in this process and not go to too quickly for the emotions. And the other thing I find coping really helpful for is to normalise stigmatised areas like areas of coping, like people cope through being angry, they cope through drinking, they cope through withdrawing and avoiding and some of those things can be shameful. And so I find sometimes the coping language as a helpful way to get into that. You know, it's this sounds so hard. I am I, I imagine that you must get really desperate to deal with these kinds of feelings. And no wonder you've been drinking more.

  Dr. Elie Isenberg-Grzeda: [00:38:20] Mm hmm.

  Jordan Bawks: [00:38:20] No wonder you've been getting so angry. No wonder you've been pulling away from your friends. It takes away the shame. If we can connect that behaviour to their underlying pain or distress.

  Dr. Elie Isenberg-Grzeda: [00:38:31] Yeah, totally.

  Jordan Bawks: [00:38:32] So the next couple of sections, you may most naturally fit into a personal history asking about. So the first one is asking about family and supports.

  Dr. Elie Isenberg-Grzeda: [00:38:45] Yeah. So family and supports are always important, but they are particularly important I think in psycho oncology when people are often. Been getting treatments that they. Almost just can't do without some sort of support in their life. You know, a lot of radiation treatments require five or six weeks of coming to the hospital every day for 30 or 35 treatments in a row. Even if you can actually make it to the hospital on your own, like who's at home taking care of the kids and. Right. And often people can't make it to the hospital on their own. They really do need help. So it's not to say that people are doomed if they have no family or other supports, but it really makes things more challenging for them. And so having a good understanding of who this person's family is, if we're going to support people, where do we add kind of that extra cushioning, that extra padding?

  Jordan Bawks: [00:39:53] So how do you usually phrase questions like who? Who are your supports or who's supporting you through your cancer? Who's in your life? Yeah.

  Dr. Elie Isenberg-Grzeda: [00:40:02] So sometimes I'll, I'll say, yeah, any of those I mean often I'll ask people, I'll say, who do you have in your life to help support you through times like these? Usually once they've identified people that that they see as supports, I'll kind of ask them, you know, in what ways these people help. So what is the actual support that they give? You know, is this somebody who drives you to appointments? Is it somebody that you can call to vent to if needed? You know, is it somebody who will keep their phone on and let you call them if they if you get a fever and have to come into hospital? Is it you know, this also gives people the opportunity to talk about family members that might actually create more stress or distress in their lives that, for better or for worse, are very much part of their families. And as far as kind of doing an inventory of what the current context is, it's still really helpful to know who are the players in somebody's life that might sort of add to the stress rather than help alleviate some of that. Mm hmm. So it's really getting an inventory, I would say, of who's around, who's around and what they're capable of.

  Jordan Bawks: [00:41:15] Yeah, it reminds me a little bit of interpersonal therapy, the sort of interpersonal inventory where you're like, who is the closest? Who is. Who do you talk to when things are really bad? Like, who can you go to? Yeah. What are the people that you've told and maybe bring in meals or babysit or, you know, and this also, I think this is an area that also lends naturally to a big topic that I have found really interesting and challenging and working with this population around disclosure. So who knows exactly and why if people don't know, why not? And what's that like? And that's a very intense area for some people.

  Dr. Elie Isenberg-Grzeda: [00:42:03] Yeah, So that's a really, really good way to put it. It's intense. And, you know, the idea of disclosing the illness, who have you told and what have you told them is such a critical one? When when we work with folks going through this type of thing, because, number one, by not telling. Right, by not always disclosing, it's basically the equivalent of really having to keep a secret of putting pieces in place so that nobody spills the beans, so to speak. And that's incredibly stressful for people. On the other hand, if one is to disclose to their friends, their family, their kids, their parents, whomever, that's equally stressful. And so I think no matter how you slice it, there's this is a it's a very intense kind of stress laden topic that in most cases that I've been involved with tends to need some handholding, some support, some guidance, some education. It's not rocket science. I mean, essentially what we want to do is we want to be as open and transparent as possible, certainly with the people who are closest to us, people who will otherwise know and find out. You know, I think a big piece of this conversation involves what do we tell kids? Mm hmm. And so in a hospital like this, we don't it's an adult hospital. We don't treat kids here, but we treat a heck of a lot of patients who have their own kids and who often present with a lot of stress around this very topic of do I tell my kids and and what do I tell them? And the general rule is openness, transparency, honesty.

  Dr. Elie Isenberg-Grzeda: [00:43:57] Better to explain to them now why you're telling them something then? To have to explain to them later why you didn't tell them. And that includes using adult language, even for young kids. You know, a lot of parents want to protect their kids. All well-meaning parents want to protect their kids. And sometimes parents have a misunderstanding of of how best to protect them. And so they think by kind of hiding information from them or not telling them or sort of sparing them until they really have to know. And, you know, usually comes from the way they were taught implicitly or explicitly and how to deal with these situations. But invariably, what ends up happening is kids will find out from maybe an oldest sibling or a cousin or an aunt or opening the mail. We're seeing an email or picking up a phone call or sometimes from the backseat when mom or dad drives the other parent to the cancer centre. And if a kid is old enough to read, they can read the sign that says Cancer Centre.

  Jordan Bawks: [00:45:13] And also that kids are exquisitely sent. I mean kids are wired to. Breed their parents. Most cancers. Cancer treatments are going to have a visible impact. It doesn't matter how hard we try. You know, there's like infant literature that, you know, pre-verbal kids can pick up on moms who have been experimentally stressed or not stressed before they walk into a room. So that's you know, that's the kind of language I sometimes use, is, you know, how do you know that they know something's going on, Right? And so bringing bringing your children into that. To me. I know it's a sign of kind of respect, transparency, of collaboration, of openness, because kids have really active imaginations.

  Dr. Elie Isenberg-Grzeda: [00:46:09] Yeah. I mean, so at the end of the day, really what we know is that kids just do better when the parents are open with them. And I think it's for exactly the reason that you're alluding to is that kids have. Incredibly wild and creative imaginations. Even when they know that a parent has cancer, there's a way for them to imagine or fear that the cancer is worse than it is. Even if a parent's dying, there's a way for a kid to imagine that it's worse than it is. Maybe they're dying in pain, maybe they're dying and there's an afterlife and something bad is going to happen to them after. Or maybe they're dying and the kid is. And I'm next. Yeah, exactly. Yeah. So openness.

  Jordan Bawks: [00:46:54] And that's that. Ever since I learned this, it's really stuck with me is like the language as well is so important, right? To say like mommy or daddy is sick, like really loads sickness for someone who doesn't really understand it. All of a sudden, you know, the same word you're using for someone with the sniffles is the same word that's related to this horrible thing that you're witnessing that's stealing your parent from you. And so that the use of that language is so important to create a different category that allows the child to still be sick, just to interact with others who are sick and know that it's a different thing. Yeah, and there's an evidence base for this, right?

  Dr. Elie Isenberg-Grzeda: [00:47:38] Certainly there's a lot of literature out there, including different sort of age categories and kind of developmentally, typically at a given age category, what kids are able to comprehend and sort of what language to use with them. And usually as a general rule, from about the age of five onwards, we'd recommend just open, honest adult language, not euphemisms like sick or booboo.

  Jordan Bawks: [00:48:05] Or yeah, it's important for me to keep in mind when I, you know, sometimes I'll hear this and or I'll be thinking about this and think, okay, well, the right thing to do is for them to disclose. And I always have to be careful to hold that as well, because people go they go through their own process at their own pace. And, you know, obviously, if somebody hasn't told their child, they're doing that with the best of intentions. And if you're going to be able to work with somebody, they need to be able to know that you respect them, where they're. At Where they're coming from, and not to be judgemental about what they're doing or not doing or saying or not saying.

  Dr. Elie Isenberg-Grzeda: [00:48:38] So that's a really excellent point, is that so I will always praise a parent and reflect to the parent that they are trying their best to be a good parent and I'll usually ask them if they're interested in hearing what the experts say. And I tell them, Look, I'm not a child psychologist, I'm really not. But, you know, certainly I have lots of patients and I've studied this. And and there is a sort of commonly accepted sort of best approach. Are they interested in. Hearing what that is and sort of the aspects of what they've done already that that are really in line with that. Do they want to wait for another time or is this a conversation they don't want to have at all? Like, you know, really trying to to respect where they're at rather.

  Jordan Bawks: [00:49:27] Than just sort of dropping your exclusive knowledge? Well, you know, what's best is Yeah, yeah, yeah. Meeting people where they're at. So important in our field, the next area is work and life disruption.

  Dr. Elie Isenberg-Grzeda: [00:49:43] Yeah. So this is also a big area. I mean, this comes up a lot during active cancer treatment. So somebody diagnosed and they go in for whether it's surgery, chemo or radiation and and their bodies recovering and there's a period of time. Maybe a month, maybe six months, maybe a year, depending on the type of treatments, the type of cancer, where they might just simply not be able to go to work either because they've too many appointments and they're coming in for treatments too often, or the treatments really make them feel quite sick with side effects or get rid of their energy and they just can't sort of peel themselves from from bed. And and so that's one big area. And the other big area is this idea of returning to work after the cancer has resolved. Right. So somebody is done with their cancer treatments. They're in a phase of the journey that we most people would probably call survivorship. And the question of when to return to work, will I be able to return to work? Am I going to have the mental Energy and capacity to to really do the job that I used to do. Am I going to feel as alert? Am I going to be able to multitask? Will people be able to rely on me the way that they used to? These are questions that that almost invariably people have at some point. They become stickier for certain people. There are some people where the question is sort of resonates more with them and they have trouble kind of shaking it and where the issue of returning to work becomes the focus of the treatment, it becomes the focus of the pathology, if you want to call it that, although that might be a strong loaded term, but certainly the focus of the treatment.

  Jordan Bawks: [00:51:32] So this might be a big focus of distress for certain patients.

  Dr. Elie Isenberg-Grzeda: [00:51:36] Yeah, so focus of distress and there are actual sort of treatment interventions, programs that that are geared towards helping people get back to work.

  Jordan Bawks: [00:51:46] Well, I can't help but think of Freud's old saying right, that like, like his definition of mental health was to be able to work to love. So that's a fitting.

  Dr. Elie Isenberg-Grzeda: [00:51:58] Yeah.

  Jordan Bawks: [00:51:59] Then we're our last two kind of areas of assessment are ones that I think are somewhat unique to psycho oncology, or at least where you access the most kind of readily. One of them is the first one is religion and spirituality. How do you usually open this up in your assessments?

  Dr. Elie Isenberg-Grzeda: [00:52:22] Yeah. So, I mean, as far as religion is concerned, usually I'll, I'll start by normalising and actually this is probably something I do for, you know, for, for everything that I ask about is I'll, I'll try to normalise it and so I'll say, you know, for some people religion is a way that kind of helps them get through tough times, including through illness and, and through cancer and. So what role does religion play in your life? Something like that. Usually that's a good opener to let me know if religion is something that is important and the extent to which, you know, plays a role in the patient's life. Many people cope through tough times in life by drawing support from their religion, whether it's the people that they interface with. So, you know, parishioners or congregants, people in their religious community, or whether it's drawing on support from God, whatever God means to them. And for people who do do that, for people for whom religion does play that role, it is a big enough role that we'd be missing an aspect of who this person is if we don't ask about it. And so I'll be the first person to admit that sometimes even that question can kind of turn people off a little bit. There are people who are very anti religion and who are sort of, you know, turned off or at least quickly dismissive of that word and sort of all the connotations that it brings up for them.

  Dr. Elie Isenberg-Grzeda: [00:54:11] But again, in normalising it, usually even those people understand kind of where the question comes from, why we're asking about it. And I think appreciate the opportunity to appreciate the fact that we're sort of thinking about people as whole people. And so religion and spirituality, I mean, first of all, you'll find tons of different definitions on these. But the definitions that I tend to subscribe to are the following is that religion essentially is the stuff of divinity. Right. There's usually we're talking about something that's related to God, that there's often an organised aspect to it. Spirituality. It deals with the the essence of something bigger and greater than us. Not necessarily God based, right? It's not necessarily in the realm of divinity, but it looks at and thinks about something bigger than us as individual human beings. And so there are people who many people who will say, well, I'm a very spiritual person, but I'm not religious. I don't subscribe to a certain religion, I don't have a God, but I'm a very spiritual person. I feel like there's something sort of bigger than than me. There's. The idea of purpose. And purposefulness. And that's often associated with religion and the idea of a purposeful world. So a sort of God driven or higher power driven world, that there was a purpose and intention, usually as a concept that. That people think about when they think about religion. And it was sort of God based religion.

  Jordan Bawks: [00:56:23] And so I guess that kind of circles back to that earlier phenomenon I was referencing where people can sometimes sort of in if they have a belief structure in which there's a purpose to life and life's events, then they can be kind of sometimes put in a spin of what is the purpose of me having cancer?

  Dr. Elie Isenberg-Grzeda: [00:56:42] Yeah, yeah, why did I get cancer? Or for the really religious folks, Why did God give me cancer? This is the true essence of the phrase. Why did this happen to me? Right. Has a real flavour of purposefulness, as though there was some reason that this happened, that it. That there's a purposefulness to me having cancer. So whether or not people realise it or rather not, people mean it in this way, there's, you know, those, those questions are the stuff of religion.

  Jordan Bawks: [00:57:13] And I think this, you know, I've also encountered patients who have become more interested in spirituality and religion when faced with like a cancer diagnosis. People have said, you know, I never really thought about it until now. And my take on that is that it's related to our last area of assessment, which is around death and dying.

  Dr. Elie Isenberg-Grzeda: [00:57:37] What cancer almost invariably does, as you've pointed out, is it really makes people think about death and dying and thinks makes people think about their own mortality and love it or hate it. We are mortal beings, right? We are animals, and we are doomed to suffer the same fate as all animals, which is that we are going to die, all of us at some point, and human beings. You know, the sort of cruel irony is that we have the the the cognitive capacity to really understand our own awareness, right? To have an awareness of our own existence, the fact that we're alive now, that we won't always be so we have this cognitive capacity, but in the bodies of animals, right, the same animals that will end up dying if we get hit by a car, if we get cancer, if our heart stop at the ripe old age of whatever, if we get the wrong infection. Right. So we we are animal species that happen to have this really complex, high level brain functioning that allows us to be aware of our own existence. So there is a sort of almost cruel irony joke to it. Death, of course, is inherently scary. It's a scary concept almost universally so. And as a society, we've done a really good job at trying to avoid death as much as possible. So it's no wonder that we have you know, we're we're a culture of heroes, basically have the, again, very understandable need to sort of to sort of dismiss death from the realm of possibilities until we can't. And so sometimes, whether it's, as you said, some sort of cardiac event or in this case, cancer. All right. Sometimes that's just enough to really trigger people's sense of their own mortality and gets people questioning sometimes things that they have never questioned before.

  Jordan Bawks: [00:59:50] Before we move on to sort of distress as a diagnosis versus depression, how do you ask how do you ask your patients about this?

  Dr. Elie Isenberg-Grzeda: [00:59:58] So when it comes to working with cancer patients, in my experience, almost always people have thought about death and dying. They've almost always asked their doctors, or at least thought about asking their doctors. And so it's usually not the first time. If I were to ask about it. It's not usually not the first time that somebody has thought about this. And so in some ways, it's not as high pressured of a question or high risk of a question. And so usually I'll just ask people point blank if this is the type of disease where they've had to start thinking about death and dying, or is the type of cancer where they've had to start thinking about death and dying. There are times when it's the answer is obvious, right? And if it's obvious enough, I might not ask that question. There may have been other questions that come up. Usually I'll ask people if they've thought about asking their oncologist about prognosis, because again, it's on many people's minds. And oncologists don't always have the skill set to talk about prognosis in the way that's most effective and most meaningful for patients.

  Jordan Bawks: [01:01:22] What what would that look like, an effective and meaningful conversation?

  Dr. Elie Isenberg-Grzeda: [01:01:25] Yeah. So, you know, generally speaking, what patients what we've what we've all learned to ask is how long do I have? Right. It's what we hear people say in movies and TV. And maybe we've heard parents say or it is how long do I have? It's probably the worst question for somebody to ask, because essentially what that implies is that you have to have a crystal ball and that doesn't exist. And so it's sort of a meaningless question that can only get a sort of meaningless. Unhelpful answer. And inasmuch as that's the case, generally speaking, all that's going to do is sort of push the oncologist into a corner and they're going to usually say, well, you know, I can't answer that. You know, I can't answer that crystal ball. And so maybe, you know, when the time comes, I'll let you know. Don't worry. I'll let you know when we start talking about that. And so what's much more effective than that is, is actually asking what a best case scenario looks like and what a worst case scenario looks like. And, you know, with generally speaking, the oncologist should be able to quote sort of a median. Right. So 50% of people will be alive at this point. Let's call it ten years. And based on that, there are some calculations that they can do to essentially capture probably 95% of people kind of under what looks maybe like a bell curve.

  Dr. Elie Isenberg-Grzeda: [01:02:54] And to the right, there are some patients who will be these miracle cases, and maybe to the left, there will be some unfortunate people who died because they got hit by a car or for whatever reason, that was just completely unanticipated. But most people will fall between these two. Best case and worst case scenario. And there's the likeliest scenario as well, which is going to be something hovering around the median. But the reason patients find this this information more meaningful is because it allows them to have something to hope for. That's realistic if they're hopeful people and it also allows them to prepare for the worst if needed. And at the end of the day, knowing that knowing that we don't have crystal balls and that we only live in a world with as good information as the information that we've got, then what people really want is they want to be able to retain hope for something and also to prepare for worst case scenario so that they know that they're as ready as they can be. And then my job becomes or any of our jobs becomes about figuring out, well, how do we help support somebody? How do we help get them as ready as they need to be if that were to happen? And so ultimately, as far as kind of meaningful, applicable, useful information is concerned, that's generally speaking, what patients will find to be most useful. Yeah.

  Jordan Bawks: [01:04:22] And so you can also even kind of guide them in that process if they're not.

  Dr. Elie Isenberg-Grzeda: [01:04:26] Sure that's exactly it. And that's usually what I'll do is I'll tell them if they haven't yet had the conversations about prognosis or or if they haven't been satisfying and kind of gotten them the information that they're looking for, go back to your oncologist and ask it in this way. Best case scenario. Worst case scenario, Likeliest scenario. And then what do we have to do to get me ready for the worst case scenario?

  Jordan Bawks: [01:04:50] Yeah. Yeah. We've we've talked about a lot of different aspects of the assessment when we interview patients with a cancer history. How does all of this trickle down into questions of diagnosis? How do you synthesise a diagnosis? What's the use of the diagnosis? What are the relative pros and cons to having one, not having one?

  Dr. Elie Isenberg-Grzeda: [01:05:16] Yeah. And so you're talking about a DSM diagnosis. And so I think the overwhelming majority of patients that we end up seeing, if we were to sort of map their symptoms onto a diagnosis, it would be adjustment disorder, right? I mean, that's going to be the probably the most common and understandably so. There's a small percentage of people who will have a pre-existing psychiatric diagnosis, and in some cases the cancer then becomes something that might tip them over the edge, might mitigate their sustained remission, and or it might be something that seems almost inconsequential that the stress and trauma and burden of the psychiatric diagnoses that they've had throughout their lives just kind of dwarfs the cancer diagnosis. But generally speaking, it's actually that's kind of a small slice of the pie. What we tend to see a lot more is people who come in with what almost seems like normative distress. And it's a word that really, over the last maybe 20 years or so, has been a real push to try to use that term distress rather than the more pathologizing DSM diagnoses actually is a way of trying to get more people, more help. There was a thought that perhaps if we use diagnoses, if we say you're suffering from major depressive disorder and there's something more stigmatising about it, people might be less likely to to look for help, oncologists might be less likely to to sort of buy into that. And so distress was also kind of this user friendly word.

  Dr. Elie Isenberg-Grzeda: [01:06:59] But I think it also is a really great word to use. And as much as it sort of sums up the experience, I think for a lot of people, which is that there's this unpleasant emotional experience that they're that they're experiencing that can be mapped on to either psychiatric symptoms, physical symptoms, concrete kind of social, practical concerns, existential or religious concerns. And thinking about it that way then allows us to formulate and to then come up with a treatment plan that sure might include antidepressants or but it might actually be more tailored to some of the sources or foci of distress that the person's experiencing. And so, for example, if the emotional distress, psychological distress that they're experiencing is because they don't have any close family members to help take care of them as they're recovering from chemotherapy and well, So then the answer isn't going to be antidepressants. It's going to be maybe trying to see if we can hook them up with some home visiting nurse services, if their distress is about the finances, financial burden that they're going to have to incur by coming for radiation every day over the course of six weeks and the cost of parking that they have to pay and the fact that they're going to be missing work while they're coming here. Then again, antidepressants might not be the answer. The answer might be. And helping them with whatever sort of resources are out there to allow for compassionate, you know, funding finances.

  Jordan Bawks: [01:08:43] So I guess that ties back to these kind of specific areas that we're including in our histories is, you know, we're seeing people with a high degree of distress. And that distress may be in areas that we're not always tuned to as psychiatrists. Like I can imagine, you know, seeing somebody in doing an Capps depression screen and a gad screen and a panic disorder screen and a bipolar screen and a psychosis screen, and, you know, you could do a 45 minute assessment and miss like so much like you miss the core areas of distress. And, you know, maybe that person doesn't meet criteria for DSM five diagnoses, but that doesn't mean they're not in distress. And also that by doing a good history that covers these kinds of areas, we find places to intervene with them.

  Dr. Elie Isenberg-Grzeda: [01:09:35] Yeah, and that's really what we want to always, right, is, is the whole purpose of formulating period is to know how to actually have that effect. Are management or.

  Jordan Bawks: [01:09:45] Are you sure that it was just to impress supervisors.

  Dr. Elie Isenberg-Grzeda: [01:09:48] Well, there's that too. Yeah.

  Jordan Bawks: [01:09:52] So, you know, this is such a huge area and I hope that we can come back and talk about it more. I think one of the things that I'd like to be able to revisit is treatment. You know, like, how do we take all this information and how do we make decisions about medications? And I know that there are some kind of relatively unique medication decisions and in psycho oncology and also some unique psychotherapies. Absolutely, psycho oncology. So I do hope that we take the time to come back and take a look at those.

  Dr. Elie Isenberg-Grzeda: [01:10:29] Yeah, I'd love that.

  Jordan Bawks: [01:10:30] All right. Super. Any closing thoughts or comments? One of the things I'm actually wondering is you want to make an argument for why psychiatrists should do some training in this area. Like what? Why this has been meaningful to you? Why you think it's helpful for the general psychiatrists?

  Dr. Elie Isenberg-Grzeda: [01:10:53] Yeah. I mean, so so it's an interesting point about the training, because on the one hand, we can say that, you know, the recent stats about what do they say one in two people will end up getting cancer at some point in their lifetime. And I mean, this is like huge. And so you can argue that, well, every psychiatrist should be trained in how to do this. On the other hand, you could also say, well, this is becoming so common that psycho oncology won't even really need to be a thing, meaning it's own subspecialty area, because frankly, cancer is just going to be so darn common. Personally, I think that this is one of the most, again, enriching, stimulating areas that I could ever imagine working in. You really. Connect with people in a way that, you know, that really kind of enhances the human experience. Like my human experience. What people want at the end of the day is to feel understood, to feel like they matter. Sickness and illness really get in the way of that. And, you know, I think the work that we do in psycho oncology is on the one hand so skilled and sub specialised and niche in so many ways. But on the other hand is also just plain, plain old good work, just connecting with people in a human way, trying to understand their experience, helping them understand ways in which they do matter. And you know, there's never a day that goes by that I'm not stimulated. It's, I think, just part of what happens when you work in this in this type of setting.

  Dr. Elie Isenberg-Grzeda: [01:12:41] And, you know, we work with patients and their families, we work with the oncologists. It's just really there's so much breadth to it. I think the one very sort of kind of expert you almost just can't really get good at if you're not trained is the existential piece. And it could be that if we do connect again and talk about treatments and and all that, maybe we'll take a look at that as well, is, you know, understanding people in the human experience and the type of existential distress that people can experience when they're faced with something like this, like cancer, knowing what to ask, how to ask it, how to address it, and how to sort of help re ground people when they're so they're in such existential crisis, I think is a very kind of skilled process without being trained in it. You really just can't do it all that well, all that skilfully. So that would be one my one pitch in terms of whether everybody should be trained in this or not, I'd say everybody should be trained in that. And I think that is part of the work that is also then generalisable to other areas of of psychiatry, other areas of consultation liaison psychiatry, other areas of medicine in general. And it's rich. It's really like one of my favourite parts of my day is when I'm doing that type of existential work.

  Jordan Bawks: [01:14:08] Well, I, I hope we do find the time to do that and trust that we will. I'll be around Stony Brook for another six months, even though I'm leaving the service. Try and come back and do more of that.

  Dr. Elie Isenberg-Grzeda: [01:14:20] You're going to be missed.

  Jordan Bawks: [01:14:21] Yeah, I'll miss you guys too, but I'll see you around. And now our voices will live forever in the internet.

  Dr. Elie Isenberg-Grzeda: [01:14:28] Awesome.

  Jordan Bawks: [01:14:30] So thanks so much for giving me your time this afternoon.

  Dr. Elie Isenberg-Grzeda: [01:14:33] Yeah, you're very welcome.

  Jordan Bawks: [01:14:35] Look forward to hopefully having you back.

  Dr. Elie Isenberg-Grzeda: [01:14:37] Great. Thanks, Jordan.

  Jordan Bawks: [01:14:38] You're welcome.

  Jordan Bawks: [01:14:41] 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 organization. This episode was produced, hosted and edited by Jordan Bawks. He therefore takes credit for any and all imperfections and errors. Our theme song is Working Solutions by all Means. Special thanks to the generous Dr. Elie Isenberg-Grzeda 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. Catch you next time.

Episode 21: Motivational interviewing with Dr. Wiplove Lamba

• Episode 21: Motivational interviewing with Dr. Wiplove Lamba

  Dr. Lucy Chan: [00:00:05] Okay. Hey, listeners, this is Lucy Chan speaking for this month's episode. We're excited to travel to Quebec City to be at the Canadian Psychiatric Association's annual conference. Alex and our experts were able to find a small meeting room in the Hilton Hotel to discuss the ins and outs of Motivational Interviewing, otherwise known as MI. Alex also volunteered to undergo some MI himself, and we're hoping to get a sense of his experience, and we hope that it will also benefit you in your understanding of Motivational Interviewing. So let's get started!

  Dr. Alex Raben: [00:00:50] Welcome to PsychED, the Psychiatry podcast for medical learners by medical learners. Today we're going to be doing an introduction to Motivational Interviewing or MI. This is a special episode because we are actually at the 69th annual conference for the Canadian Psychiatric Association or the CPA in beautiful Quebec City, Quebec. And I'm joined today by three experts who presented at the conference on MI for over how long? It was a number of hours, and I joined for some of it and it was wonderful. I'm going to get them to introduce themselves to you now and we'll start.

  Dr. Wiplove Lamba: [00:01:32] So my name is Wiplove Lamba. I'm a psychiatrist who works primarily in addiction in Toronto, and I've been in practice for now about five, six years after finishing actually probably closer to seven since finishing my fellowship. I was first exposed to MI in residency and then in my later years, that's where I actually learned the skills. I was lucky enough to have a mentor, Tim Guimond, who was running the MI clinic and we had about six observed interviews using the MITI Scale and it was after that I really felt I could bring in that language because in psychiatry, I thought were so good at the diagnostic assessment and MI is a slightly different skill. And around that time, I also realised that a lot of people don't have this training and so how do I learn to guide others and picking it up? And so there were some great people at Camh that Carolyn Cooper and Stephanie and Tim Gordon who really helped me pick up those skills there through running workshops.

  Dr. Alex Raben: [00:02:35] Great, and Marlon.

  Dr. Marlon Danilewitz: [00:02:37] Hey there. My name is Marlon Danilewitz, and I'm a PGY-5 psychiatry resident at the University of British Columbia, and I'm also an Addiction Medicine fellow. For me, my experience with MI came through in that context of the Addiction Medicine Fellowship and having taken a few courses there. And it was really a fundamental part of my training that helped me to work with populations in Vancouver and the Downtown Eastside who really struggle with drug addiction. So that gave me a tool to engage them and also provide for me a way of resilience in working with some really challenging groups. And it's been a fundamental part of my training and it's something that's inspired me to continue working with that population. And it's been a tremendous experience now to present at this conference with such a great team of other collaborators and so awesome to be here today.

  Dr. Alex Raben: [00:03:34] Great. And last but not least Anees.

  Dr. Anees Bahji: [00:03:37] Now, my name is Anees Bahji. I'm a fifth year psychiatry resident at Queen's University, and most of my experience with me has actually come from working with Wiplove. But I was lucky enough to get to do concurrent disorders work in PGY-2 with Nadeem Mazhar. He was our former program director and he was an addiction psychiatrist and he really emphasized how important MI is as a core skill to being a good psychiatrist, even if you don't do addictions. And I also heard about this book "Getting to Yes"aAnd it actually turned out to be more or less about motivational interviewing. So I realised if I could learn that skill, I might be helpful in getting to yes outside of psychiatry. So, over the past couple of years I've done a few workshops and seminars and I've been able to get a little bit more experience with learning about MI and also being able to teach it to other people across the training spectrum.

  Dr. Alex Raben: [00:04:37] That's great. So we have a wealth of experience between all of you and from different areas of the country as well. So that's great to have all of you here today. So thanks once again. And as you know, I'm Alex Raben and I'll be hosting today's show. Before we dive right in, I'm going to start with the learning objectives. So by the end of this episode, you should, number one, be able to define MI or Motivational Interviewing and describe its utility number to appreciate some of the techniques that are used in MI to increase motivation. And number three, be able to use in the real world some of these techniques or start to use them with your patients. Okay. So now that we've done introductions and done the learning objectives, let's jump into the questions and anyone can feel free to jump in. But my first question is essentially, what is MI? How do we define it? And how is it separate from other types of psychotherapy? What defines it?

  Dr. Wiplove Lamba: [00:05:46] This is a great question and makes me wish that I had my slide deck. I mean, there's a lot of different definitions that are out there and I don't know the current most recent one. For me, motivational interviewing is really about the language of change, how we work with someone to bring out in them, evoke in them the reasons to make those changes where they're in the driver's seat and we're a bit more of a guide in some kind of way. Luckily, Merlyn has the definition here in front of us, and I'm just going to read that out so our learners actually get that. So this one is motivational interviewing is a collaborative, goal oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual's motivation for and movement toward a specific goal by eliciting and exploring the person's own argument for change. So it was similar to what I said, sort of that I think for medical school you definitely need a clear definition, especially if you're asked a question on a test of some kind.

  Dr. Alex Raben: [00:06:57] Yes, exactly. So as you said, it sounds like it has to do with contributing to that person's change, but they're the change that they already have in mind for themselves, is what I was hearing in that definition. But I wonder, I'm going to push a little bit, because I wonder how that differs from other types of psychotherapy, where a lot of the time we are saying or we are doing that for some degree of change in the person. What makes MI unique or what is different about it? Do you guys think compared to something like psychodynamic therapy or CBT?

  Dr. Anees Bahji: [00:07:34] So the really cool thing about MI is that its theoretical foundations are a bit different than other forms of psychotherapy and I'm not sure if even calling it MI psychotherapy is fully appropriate because it's probably more of a conversational style. That is then also similar to psychotherapy because it's a therapeutic style. So one of the things about MI is this idea of ambivalence and it also has to do with the Festinger's theory of cognitive dissonance. So where it strikes a chord in difference from other psychotherapies is that you're not using that theory or that principle outside of MI. It's sort of unique to me where you're trying to help the person work with their inner ambivalence to promote change. The other is that you're also thinking about the stages of change models. So that's the Prochaska & DiClemente transtheoretical model. So those two elements are really at the heart of of the foundation of MI. And that's unique to MI from other forms of psychotherapy.

  Dr. Alex Raben: [00:08:45] Right. So it's, as you say, a more of a perhaps conversational or a style of conversation in some ways, but has some commonalities. But the theoretical underpinnings are different in that it works really with the ambivalence and the stage of change. Is that correct? 

  Dr. Anees Bahji: [00:09:07] I think it's a pretty good way of putting it.

  Dr. Alex Raben: [00:09:11]  Maybe this also gets at some of the same thing, but what do you think motivated the creation of MI? What was the niche it was filling that other therapies or ways of being in the room with people were not accomplishing?

  Dr. Wiplove Lamba: [00:09:31] For Motivational Interviewing, it was really heavily influenced by Bill Miller and he was trained in psychoanalytic psychodynamic psychotherapy. But most of his work was done using Rogerian therapy from Carl Rogers was a very humanistic approach. In the eighties, he wrote a paper and then Steven Rollnick and I can't remember if he's from New Zealand or Australia read that paper in the early nineties and started doing that therapy on his own. And then randomly he was at a conference and he saw Bill Miller and he's like, "Hey, I'm doing your therapy". And he's like "What therapy?" And then it's like, "Oh, that paper you wrote a while back." And then it started to get a little bit of momentum in that context. Bill Miller's style really came from New Mexico, where in the addiction world AA has taken over, and AA is phenomenal. For some people. It's very top down, higher power and there are certain people and I suspect some of the people that we see with some maybe some oppositional trades people that need to have their own reasons for sort of doing things where it wasn't working. And so it really was something that developed in I don't want to say opposition maybe in parallel to AA that was separate but I think was really shaped by the psychodynamic psychoanalytic with a huge emphasis on Carl Rogers. And whenever I've seen Bill Miller speak, he has like ten slides just talking about Rogerian therapy. 

  Dr. Alex Raben: [00:10:51] So was it born out of addictions management and treatment then?

  Dr. Wiplove Lamba: [00:10:56] Yeah, so both Miller and Rollnick were using it for alcohol use disorder when they started using it and then it slowly evolved to other areas as well. And Anees and Marlon, feel free to add anything at any point because I'm sure both of you have unique things to contribute for any of these questions.

  Dr. Anees Bahji: [00:11:15] There's some early videos where you can see Carl Rogers interviewing a patient named Gloria, and those old videos are on YouTube. And really, it was sort of as I was saying, it's really born out of this Rogerian skilful, reflectful listening and there's very little advice giving in that style. So it's a very interesting style. And I think a lot of psychiatry residents, we watch those videos just to get a sense of where it came from. And you can see how it was shaped further with Miller and Rollnick's applications.

  Dr. Alex Raben: [00:11:50] Right. And this makes me think of the idea of the spirit of MI which I know is a very central concept to the essence of motivational interviewing. Can we talk about that? What does that mean, the spirit of MI?

  Dr. Marlon Danilewitz: [00:12:07] I think there's like a number of ways to talk about like the spirit of MI. And one of the ways we work in MI is using different mnemonics. So perhaps in this context to share one of those. So the mnemonic for the spirit of MI is "PACE". P stands for Partnership, A stands for Autonomy, C for Compassion and E for Evocation. And it's a great acronym because it gets across the context of what MI and what it's not, and that it's a partnership, a collaborative experience between the client and the therapist, and not a hierarchical form of communication where we're pushing one particular message and the autonomy gets at that really what's happening here is in the control of the individual and that we're working with them, their strengths to help get to towards the answers that lie within them. See, the compassion aspect deals with the fact that this is really an empathic therapy where a lot of genuineness and reflection and validation affirmations come and help to provide such an important aspect. And the last part, the E for Evocation reflects that the core answers lie within the individual themselves, that it's not about providing for them external information, that the message is within you. And that's really, I think, what the heart of MI and the spirit. And I think what would be most useful for learners is getting the spirit.

  Dr. Alex Raben: [00:13:48] And thank you for unpacking that, Marlon. And I think that's quite helpful in terms of understanding a little bit beyond the definition, what MI is actually about. And so as you were alluding to, there's lots of acronyms in MI and this is the first "PACE". So Partnership, Autonomy, Compassion and Evocation. I think I got that right? Okay. I'm getting the thumbs up. So that's something that can be helpful to to keep in mind. And later on, we're going to be doing a demonstration of MI. So keep these the spirit in mind while we go through that. Okay. So Wip, something you mentioned was that, the origins of MI was really around the treatment of alcohol use disorder. So I'm imagining that you use MI in that disorder? But are there other patient populations we use MI for? Like if I have someone who's in front of me who's depressed, is that an appropriate therapy?  Who is MI tailored for in terms of patient population?

  Dr. Wiplove Lamba: [00:14:54] For me I believe it can be used in any clinical encounter. And every year, if you look at the number of publications in PubMed, they just keep going up and up. And so it includes medical management adherence and other disorders as well. There was a great study out of a group from York where they did an RCT comparing CBT alone versus MI plus CBT for Generalized Anxiety Disorder. And the group with both did phenomenal compared to the ones who just had the CBT piece for it. For me, it's sort of what Anees was saying earlier, where it's more of a tool for engagement. It's a way to have that dialogue and it's a way to potentially set the stage for some structured kind of treatment. It's almost a special way of gift wrapping it in some kind of way. And even when you talk to Bill Miller around it, he'll usually just do two or three MI sessions with someone and then they'll move on to whatever else it is that they plan on doing. So it's almost like this complement thing as opposed to a separate thing for some people.

  Dr. Alex Raben: [00:16:05] So if I'm understanding correctly, rather than other types of psychotherapy where you have a course and it may for CBT for instance, be like 12 to 20 weeks, you meet once weekly for an hour. It sounds like MI is a little bit less structured and is actually more of a style of talking to people that you can incorporate in your day to day and perhaps do a couple of sessions.

  Dr. Wiplove Lamba: [00:16:31] Yeah, absolutely. It's a bit of a starting point for engagement to get them on to board to other kinds of treatments.

  Dr. Alex Raben: [00:16:41] Is there a recommended length for a session if you can even have kind of a session in MI or what would the literature generally do in that instance?

  Dr. Wiplove Lamba: [00:16:54] So I'm not really sure about the answer for the ideal time frame for MI. Once you go through the training, you almost incorporate that spirit and sprinkle it in for a lot of different things. There is clear evidence for MI for HIV risk, diet, exercise. There's stuff for groups and stuff as well. That's there. I just remember hearing Bill Miller speak maybe he'll do three sessions for about 30 minutes to an hour and then have the person move on to whatever the next treatment is for them.

  Dr. Anees Bahji: [00:17:35] Maybe one thing I could add,  I've noticed in the literature is that there's MI and then sometimes it gets operationalised into this Motivational Enhancement Therapy and then that can be turned into a module or I've seen it incorporate into some randomized controlled trials. So even some of the research out of Toronto where they're doing treatments for Cannabis Use Disorder, where they're testing a pharmacotherapy and they might have adjunctive motivational enhancement therapy which is actually it's still MI based. So it can be used in that way quite well but it's based on MI.

  Dr. Alex Raben: [00:18:11] Right, so MI seems to be quite flexible in terms of time frame and how you incorporate it. And then some people will take that a step in a different direction and they'll formalize it a little bit and call it something slightly different. That makes sense to me, and I think that's quite different than other psychotherapies. So it's interesting. If we now turn to how we actually do MI, I'm wondering like, what does it look like when you're doing it on someone? What are the techniques you're actually using in that encounter that make this conversational style, so to speak, different?

  Dr. Wiplove Lamba: [00:18:56] The key ingredients for Motivational interviewing is for basic interview skills, and they love acronyms and motivational interviewing, and so they use the "OARS" acronym for this. So when you're watching an interviewer, the things that'll be coming out of their mouth, if they're doing MI or Open-Ended Questions, Affirmations, Reflections and Summaries, and it's almost like a recipe where you can pick the dose and the amount of each one's those to use and the ways to use them as well. When you hear these words, they're really straightforward, considering the complexity that we're used to doing as health care providers. It's also something that doesn't always come naturally because in medicine we're so good at getting a focused history, figuring out what the problem is. We're not used to having this dance and dialogue to elicit more things.

  Dr. Alex Raben: [00:19:50] So that's helpful to have another acronym "OARS" Open-Ended Questions, Affirmations, Reflections and Summaries. Can we unpack what each of those words mean? I know they sound somewhat self-explanatory, but I think there's probably a bit of meat to each of those.

  Dr. Wiplove Lamba: [00:20:07] So closed-ended questions would have one or two answers: What is your age? When did you start school? To make them open-ended would be more like: Can you tell me a bit about yourself? Tell me a bit about how school was like for you? Things like that. There will come points where you will need to direct them more, but that's just sort of a way to start. For me, affirmations are one of the key skills for Motivational Interviewing, and when I'm doing a psychiatric assessment, I'll sprinkle those in throughout any time. Someone talks about a skill, something they've worked for all affirm it in some kind of way with the statement that was really important to you. "You really care about your mother", "Your health is something that you really want to work on". And then I stop and then I wait and I see what comes up then. It's surprising how many of our patients get such little encouragement and how many of them that it's hard for them to see their accomplishments at their values, and sometimes they'll even say stories. I see a lot of people with depression and for some of them certain days, it's a huge accomplishment to get out of bed. And when they hear that, it can sometimes hit them because it is a huge accomplishment on some days to get out of bed. Reflections are probably the most challenging skill, at least for me they were to pick up. And these are statements that we use and there's various different kinds, simple and complex. Simple have to do with repeating what the person is saying, paraphrasing, getting the gist and the complex are where we're sometimes strategic on the statements we take and give back. Sometimes we can add emotion to it, sometimes we can add extra meaning to it as well. Summaries are almost like a bouquet of reflection, so it's almost like you hear the full interview and then you selectively pick the points that you want to share and bring out and repeat for them to hear as well. And it's also a way that people can really feel heard.

  Dr. Alex Raben: [00:22:11] Thank you. That makes a lot of sense. The one that sometimes gets me is affirmations. But if I understand what you're saying, it's rather than just reflecting, you're actually putting a positive you're emphasizing the positive of what that person is doing with the statement you're making. Is that what differentiates an affirmation from just simply reflection?

  Dr. Wiplove Lamba: [00:22:31] I mean, affirmation. People do say it's a type of reflection. I see it's commenting on something positive in them. And the key thing about that is because, I mean, you could praise anything someone does, you can say, "Oh, I like your hair" or "I like your jacket", "I like" whatever it might be. You want to find something that's a genuine praise and feels authentic from  within when you when you do it. There are certain people where it's not hard to get out of bed. And if you don't believe it's you think it's really easy for them to talk about and you say, "Oh, it's so great that you came in saying you go to bed", people are really good at picking up the nonverbal and the inauthenticity that sometimes comes with it as well. Usually we really try to affirm the strengths and values, especially when the person's less ready for change as well.

  Dr. Alex Raben: [00:23:14] Gotcha! And I understand there's two kinds of reflections broadly anyways, simple and complex. What are what's the difference between those two things?

  Dr. Marlon Danilewitz: [00:23:29] Yeah. So I think that really gets to an important aspect. So I think simple reflections have to do with just repeating back kind of the virtual statements kind of parroting back, whereas more complex reflections get beyond just what was said in the content and get to perhaps some of the underlying emotion values it brings together more than just what was at the surface level.

  Dr. Alex Raben: [00:23:57] Can you give an example of those, like what would be an example of a simple reflection versus a more complex? 

  Dr. Marlon Danilewitz: [00:24:06] So if someone said "I had a rough day" and yet said back to them "it sounds like your day was pretty lousy". That might be more in keeping with a simple reflection, whereas taking into account what they were saying before, you might respond back with a complex reflection saying "It sounds like you've had a really challenging day and it's really had an impact on your relationship with your wife at home, and it's really seeming to be overwhelming for you".

  Dr. Alex Raben: [00:24:41] So you take it one step beyond. You make some inferences when you're doing a complex reflection.

  Dr. Marlon Danilewitz: [00:24:46] Yeah, you kind of have to take a little bit of a leap with a complex reflection, and sometimes you're right on the money and sometimes you may be a little bit off. But it also helps to, if you're able to follow with that, develop a stronger rapport with the individual.

  Dr. Alex Raben: [00:25:03] So to kind of summarize what we have so far, we've defined what MI is we talked about the spirit which is "PACE" Partnership, Autonomy, Compassion and Evocation, evoking what the person already has inside of them to help them with change. And then we talked about the "OARS" acronym, which is how one actually talks in the room with the person using Open-Ended Questions, Affirmations, Reflections and Summaries. But how do we know we're accomplishing what we're setting out to accomplish, and what are we trying to set out to accomplish with MI if that makes sense? How do we measure our our success? How do we know where we're going?

  Dr. Wiplove Lamba: [00:25:49] What a fantastic question! So when we're doing workshops on MI, I mean, we can cover the didactic within an hour. It's all done through experiential exercises. And once people learn the skills. But what the therapist says, eventually they start picking up what they're listening for in the conversation. And the thing that we listen for is something called "Change Talk". And there's different kinds of change talk; there's Preparatory Change Talk, there's the Action Change Talk and there's also an acronym as well. I feel weird sharing all these acronyms because the learning happens through the experiential exercises when you're training, it doesn't happen for memorizing the acronyms. And I know that from my own learning, I memorized the acronyms I wasn't doing it by and then I go through the experiential I get it. So, Preparatory Change Talk is about desire to change, ability to change, reasons to change and need to change. And so whenever you hear somebody say something like "I want to", "I can" "if this then that", "I need to", "I have to". These are the things that you want to try to encourage. And you can even go further for the Action Change Talk, which is commitment, activation and taking steps. One thing to remember is that Change Talk is that there's opposite end of it as well, which is Sustained Talk. And they're two sides of the same coin. And the whole goal that you have when you're working with someone is you listen very carefully what they say. You're very strategic and the reflections and things that you respond with and you really want to soften the Sustained Talk. So Sustained Talk could be like "I need to smoke", "I have to smoke to sleep at night" whatever it might be. So soften the intensity of that and then amplify the other side of it where it's like "I really care about my health", "I can't be coughing every night", "I want to play soccer with my kids".

  Dr. Alex Raben: [00:27:42] That makes sense to me. So there's with ambivalence, we haven't really talked about ambivalence too much, but my understanding is that it's kind of a conflict in a way or there's two sides to the coin, as you're saying. So one side of yourself may want to continue doing the thing you're doing, and then another side of yourself does not. And the Change Talk would be heading in one direction, the Sustained Talk would be heading in the opposite direction, and they can be at different levels of intensity. So sort of preparatory, I'm thinking about that versus action like "tomorrow I will do this".

  Dr. Wiplove Lamba: [00:28:19] Yeah. And there's also this thing in Motivational Interviewing where it's like I believe as I hear myself speak. And so there's something that happens when people start to verbalise those things inside. We have all that stuff. I mean, I'm sitting right here. We got some of this hotel dessert in front of us and I'm going in both directions the entire time. Part of me is like "Oh, I'd love how it tastes right now. I'm really tired. I need some energy". And then I'm thinking about, like, how I've started some cardio. I've convinced my wife to let me pay for a trainer short term. Every time I eat this stuff, it shows on the scale. And both those sides are going very well. And it's almost like by verbalising the part that's important to me, I'm more likely to do it. And the great thing about Motivational Interviewing is that a lot of the research they've done, they actually have psychotherapy researchers where they code the words that are being said. And they find that at the end of the interviews, if you have more Change Talk, the person is more likely to make the behaviour change as well and there is some literature in that regard to.

  Dr. Alex Raben: [00:29:16] So that does seem to be part of the driving force of MI is getting some of that Change Talk, I see.

  Dr. Wiplove Lamba: [00:29:22] And preferably around the end of your interview as opposed to having that Sustained Talk at the end. So say if we're talking about this dessert thing and we finish off and the last thing I'm saying is that, "Oh, it looks really good" and I walk out, I'm going to be more likely to have it. But if as you walk out, I'm thinking more about my health, how I don't want that sugar crash afterwards, I'm going to be more likely to not eat something when I leave.

  Dr. Alex Raben: [00:29:45] Right. I know we talked about the process of MI already but how do we get more change talk? What are some specific techniques that allow us to drive that Change Talk? It sounds like ensuring we get it at the end of an interview is helpful, but are there other ways to support that?

  Dr. Wiplove Lamba: [00:30:06] When we go through workshops, there's all these questions that we typically do that try to evoke things in people in some kind of way. There's one question where they it's like this imagination question, a dream question for the future "What would you like that to be in some kind of a way?". Maybe I'll let Marlon or Anees share a little bit because I know they've talked about this recently.

  Dr. Marlon Danilewitz: [00:30:34] So, I think that's a great question. And there's like a whole variety of ways you can do it and I think it depends on the individual. Things that I've tried before that are perhaps helpful is one like what's called like an Importance Ruler. So speaking with the person and helping to put on a scale, so to speak, where they might say their motivation is on a scale between like 0 to 10, their confidence with changing on a scale of 0 to 10 and then engaging them in a conversation around where they might fall on that scale in terms of eliciting the reasons why it wasn't lower or higher to create some kind of curiosity with where they actually lie. And that oftentimes elicits new reasons for wanting to change and helps to generate more insights into what's going on internally. Other things that are helpful or kind of considering where things might be in a few years from now, or looking back of where things were before and helping people to kind of get a better sense of what their internal values are and their goals are. That also helps to sharpen people's motivation.

  Dr. Alex Raben: [00:31:47] Gotcha! And just going back to your ruler question, Marlon, because I learned this just recently from you guys. It kind of matters which direction you say that question, right? So you ask them to rate themselves on a scale of how important it is to them. And if I say a five, then it's better to ask why not a four than it is to say why not an eight, isn't it? Or am I maybe I'm missing that up?

  Dr. Marlon Danilewitz: [00:32:16] Yeah. So I think you're right on the money. So sometimes it's helpful to ask people why not a lower score in particular, because that often helps them to consider what is actually motivating them to get back to their core values. Whereas if you were to ask people why not a higher number, so to speak, in my attempt to kind of occupy the conversation over obstacles or barriers or reasons why it's not the most salient value for them at that particular moment.

  Dr. Alex Raben: [00:32:50] More ustained talk too potentially. 

  Dr. Marlon Danilewitz: [00:32:53] Right. Well, I'm glad you took away something from our show.

  Dr. Alex Raben: [00:32:58] No, it was very helpful. And I think you guys summarised nicely at the end. You had all of us take away something. But I guess I've taken away two things now. We've spoken a lot about what MI is in the abstract and we've tried to use examples here, but what I'm thinking might be most helpful for our listeners is to actually do what we call a real play and demonstrate live or I guess this is recorded, but we'll try to do one take, we'll see how it goes. How this actually works in reality, what it sounds like. So I am volunteering myself to do the real play. So I'm going to bring something that I'm ambivalent about to the group and then Wip is going to be doing the actual MI and a Anees and Marlon are going to be evaluating and listening in to allow for a more fulsome debrief at the end. So we can point out some of the techniques to you guys. Are you guys ready?

  Dr. Wiplove Lamba: [00:34:13] Sure. Let's try this out. And Anees and Marlon, are you going to be using the "EARS" Exercise or the MITI? Okay, perfect.

  Dr. Alex Raben: [00:34:22] So, we're referring to some scales here that we have on a piece of paper that can allow us to get a better assessment of all the times, reflections we're used or affirmations and that kind of thing. And my understanding is this is actually used in the training for MI as well.

  Dr. Wiplove Lamba: [00:34:38] So the MITI Scale is used in the research. So there's this motivational interviewing, a treatment integrity that was developed by Moyers in New Mexico. And for all research studies, they use those scales, they're available online. But the ones we're doing are they're basically going to be tracking the stuff that I say, the open-ended questions, affirmations, reflection, summaries. And this is something we'll do in workshops so people can practice those things.

  Dr. Alex Raben: [00:35:05] And I guess we should also mention "frequency" there. Is there an ideal frequency to how many reflections versus questions?

  Dr. Wiplove Lamba: [00:35:15] Yeah, so they say a good Motivational Interviewing is about 2 to 1 reflections to questions. And if you're Bill Miller or I guess Carl Rogers, it's like 4 to 1. I still remember some interviews I've watched with Bill Miller and the patient says everything and he's not asked a single question. And I'm like, his ratio might even be higher than that 4 to 1 that we sometimes say.

  Dr. Alex Raben: [00:35:37] Right. And for the listeners, we will link to some of these assessment sheets so that if you want, you can pause the episode right now, download them and kind of mark along with us. Or you can just listen in and see if you can pick up reflections and affirmations and summary statements and open-ended questions on your own. All right!

  Dr. Wiplove Lamba: [00:35:57] Alex, thank you for meeting with me today. And this is an opportunity for you to talk about something that you want to change in your life. It could be something that you used to do and want to do again, or it could be something that you sort of imagine yourself doing down the road, right?

  Dr. Alex Raben: [00:36:15] So for me, the thing I would like to change is my use of caffeine.

  Dr. Wiplove Lamba: [00:36:22] Your caffeine use?

  Dr. Alex Raben: [00:36:23] Yeah, I'm quite addicted, I think to caffeine. I drink quite a bit of Diet Cokes, Coke Zero throughout the day, some coffee as well. And previously I went a year without caffeine and then I've kind of relapsed in the last year. And I'd like to go back to the old way, but it's difficult.

  Dr. Wiplove Lamba: [00:36:46] Yeah. So you keep drinking it for the taste.

  Dr. Alex Raben: [00:36:49] Not just the taste. I do enjoy the taste, but I think it's more the caffeine and avoiding the withdrawal of the of stopping. It's kind of both.

  Dr. Wiplove Lamba: [00:36:59] You actually get withdrawal when you don't have it.

  Dr. Alex Raben: [00:37:02] Yeah, pretty significant. Like I know some people don't quite understand that because I don't know, maybe genetics, but I do get quite substantial withdrawal. And so it does make me quite irritable for a number of days, quite tired, lethargic, headaches, the whole kind of nine yards. And so I really can't function very well. So in the past when I've quit, I've actually quit on vacations because I don't need to function at a high level, obviously.

  Dr. Wiplove Lamba: [00:37:34] So when you're like a nice resort or you can sleep in, irritability doesn't affect you or your family.

  Dr. Alex Raben: [00:37:39] Well, it may affect them slightly, but it's not going to be like irritable at work where I need to be cool and collected.

  Dr. Wiplove Lamba: [00:37:45] You like to be on when you're at work, you want to be sharp and on and productive.

  Dr. Alex Raben: [00:37:48] Exactly. Yeah.

  Dr. Wiplove Lamba: [00:37:52] What are the things that make you really want to stop using it?

  Dr. Alex Raben: [00:37:59] Well, cost is one thing. I know that individual cans of coke or coffee is not that expensive, but in the long run, it does certainly add up. I also just don't like the idea of being kind of under the thumb of a substance. I'd rather, because I know when I've quit in the past, I actually feel better. So it's really not a great feeling to know you're just kind of staving off withdrawal in some ways. I guess I do get some pleasure from drinking it, but those are the reasons I would want to stop.

  Dr. Wiplove Lamba: [00:38:38] Yeah, you really want to be able to control your day, choose what you do and when and you don't like having to count the hours before your next caffeine hit, so to speak.

  Dr. Alex Raben: [00:38:48] Like before coming here today to record this, for instance, I had to have a Coke Zero because I knew I would be too low energy if I didn't, which is kind of a bit of a, I don't know, ball and chain or something like this.

  Dr. Wiplove Lamba: [00:38:59] So when you have no caffeine at all, you can't actually function at all at work.

  Dr. Alex Raben: [00:39:06] Not function at all. But it's difficult. And if I were to go like days, like if I were to go a day without it, I would be pretty miserable and irritable. Then, my work might suffer and I don't want that to happen.

  Dr. Wiplove Lamba: [00:39:22] What did it take you to get to the point where you had those moments where you're caffeine free and you actually feel like you're functioning better?

  Dr. Alex Raben: [00:39:33] I think it was like an opportunity. The other thing was that it was around New Year's, and so it was a resolution.

  Dr. Wiplove Lamba: [00:39:40] And you had to follow through and finish it. 

  Dr. Alex Raben: [00:39:42] It was a symbolic time of year. And because it was the vacation over that period and I didn't have any like I wasn't even going on a trip. It was a staycation. So I knew I could just kind of stay in and have some lazy days and just get through it. And then once you're once I was through it, then it was immediately much better. I still had some cravings, but I could kind of deal with that for the most part.

  Dr. Wiplove Lamba: [00:40:08] And you're able to stay away from caffeine for a full year?

  Dr. Alex Raben: [00:40:12] Yes. And then I'm trying to remember why I relapsed. I think it was probably being on-call and not getting a lot of sleep and then, you know, allowing myself that one drink of caffeine to feel a little better and then it just kind of snowballs from there.

  Dr. Wiplove Lamba: [00:40:32] I'm really interested in hearing about what it's like for you when you're off caffeine, maybe like the second or third month when you talk about your overall life being different.

  Dr. Alex Raben: [00:40:44] Well. I mean, I'm saving money. I'm not going to Starbucks every day, which, again, adds up. I'm. My energy is actually higher, sleep is better.

  Dr. Wiplove Lamba: [00:40:57] You sleep better without caffeine?

  Dr. Alex Raben: [00:40:58] I think so.

  Dr. Wiplove Lamba: [00:41:00] Just not for the first week. But once it's clear, you sleep better.

  Dr. Alex Raben: [00:41:04] Yeah, exactly. And then I just don't have to have it. So if I'm in a rush to get somewhere, I don't have to plan my day around ensuring that I can get some Coca Cola or I can get a coffee or something like this.

  Dr. Wiplove Lamba: [00:41:22] So, you have more freedom when you're caffeine-free about where you go and when you're not really forced to take certain routes in certain places, you can explore a little bit more.

  Dr. Alex Raben: [00:41:33] That's true. 

  Dr. Wiplove Lamba: [00:41:38] How exactly did you work through that withdrawal? It sounds like you're at home. You didn't have work. How did you get through that?

  Dr. Alex Raben: [00:41:49]  I was literally on the couch writhing and sweating. And not quite so bad. But it was a lot of Netflix, a lot of just like lying on the couch. Some just naps during the day. It was not very productive and it was kind of miserable. But because I had no obligations, it was helpful. Also, my girlfriend at the time was supporting me in this endeavour. And so team effort.

  Dr. Wiplove Lamba: [00:42:24] So on a scale of 1 to 10 where ten is like the most and one is at least, how important is it for you to get through that withdrawal and be caffeine-free?

  Dr. Alex Raben: [00:42:35] It's funny because I think I would have put it as a lower number prior to this conversation we're having. And actually I did the same real play at the session yesterday. We didn't get very far because we didn't have much time, but I put the number then at three out of ten and now I'd probably say about a 5.

  Dr. Wiplove Lamba: [00:42:56] And why is it a five and not like a three? Where to?

  Dr. Alex Raben: [00:43:01] Well, it was helpful to hear myself and  kind of reflect back to me the things I like about it, particularly the freedom piece. I don't think I think about that very often that I am kind of shackled in a way by it.

  Dr. Wiplove Lamba: [00:43:15] Not having to go here and there at certain times and plan your whole day around it. 

  Dr. Alex Raben: [00:43:18] I don't like to have that extra thinking on board. It's distracting.

  Dr. Wiplove Lamba: [00:43:25] And what do you think it would take for you to get up to six or seven in terms of the importance?

  Dr. Alex Raben: [00:43:30] It's interesting because it's almost like dependent on time of year or like if I had vacation coming up shortly, I would feel, I think, more confident or more I would prioritize it more. But I think because I know I still have a few months before a vacation that I'm prioritizing it less.

  Dr. Wiplove Lamba: [00:43:49] It's almost like your last hurrah. And then when vacation comes, you're going to stop.

  Dr. Alex Raben: [00:43:53] I guess so. I mean, like I said, I do enjoy aspects of it. I do like the taste. 

  Dr. Wiplove Lamba: [00:43:59] On a scale of 1 to 10, how confident are you that you can cut back on your caffeine use for 10 is unbelievably confident and 1 is like not at all.

  [00:44:09] Now it would probably be about three or four. But again, it kind of depends on the timing. If I was coming up to a vacation and I knew it wasn't going to be a busy vacation where I was doing a lot of things or going somewhere where there's really good coffee or something. Then I would be much more confident, maybe like an eight or nine, even because I've quit the one time I've talked about already, and then I've also quit in the past.

  Dr. Wiplove Lamba: [00:44:36] So the number would jump up if you were in an environment that made it easier to do.

  Dr. Alex Raben: [00:44:40] Yeah, exactly.

  Dr. Wiplove Lamba: [00:44:42] And you can't think of any ways to bring some of those principles in now.

  Dr. Alex Raben: [00:44:47] No, I guess I can like I guess there's like long weekends coming up. So that would be one possibility. Thanksgiving weekend is coming up. So here in Canada, Thanksgiving is in October for our international listeners. I could see that being possible opportunity and I will be going home with family and whatnot. So I could perhaps enlist their help as well. And then I guess another thing that you kind of made me think of is like because work is such a driver of this, if I can find work at the moment, I'm sort of getting a bit more used to my rotation and if I have no call for a little bit, perhaps that would also be helpful, if I planned around that.

  Dr. Wiplove Lamba: [00:45:37] Right. So you've talked about a lot of things today. You talked about briefly what you like about caffeine, the way it's almost like this ball and chain. It sort of captures you. You don't like the withdrawal you go through and you don't have it. And it's tough to have to think almost every few hours when you're going to get your next caffeine piece. You've been through this before, right? You made a decision. You picked a date. You were able to do it for a full year with a little bit of support. And part of you wants to go back to it. You just haven't figured out when and how. Yes. And there's clear things about this current pattern that bothered you and upset you to the point that this was the one thing that you're like "This has got to change".

  Dr. Alex Raben: [00:46:16] Oh, it's a really good point. I think that this was the thing I chose and I chose it twice in a row, technically. So clearly it's one of the things on my mind and one of the things I'm quite ambivalent about. And I think the when in the "how piece" you just said makes a lot of sense. I think I am still figuring out "the when and the how", and that's the big piece I have to work on.

  Dr. Wiplove Lamba: [00:46:38] What do you see as the next steps in this?

  Dr. Alex Raben: [00:46:42] I well, I can see myself, at the very least looking at my calendar and seeing what are my next call shifts. When are there longer weekends or opportunities where I have slightly less work or I might be able to chart out a period of time where I can just go through the irritability and the withdrawal and all of that.

  Dr. Wiplove Lamba: [00:47:06] I want to thank you a lot for sharing these kinds of things. And from a personal standpoint, I love to hear how it goes down the road at any point that's there. Thank you for putting this on the air.

  Dr. Alex Raben: [00:47:20] Well, same to you. Thank you. All right. So why don't we debrief that? 

  Dr. Anees Bahji: [00:47:34] So we kept track of the "EARS". So, a few elaborating, exploring questions were used. There was a few affirmations. But the thing that's really important here is that they're all interwoven with each other. So there was times when you can combine multiple different techniques. So, I think at the very end, one of the things that really stood out was when he said, you did this for a whole year. So there was a bit of affirmation built in there that you're really building on that previous success that you had had with that attempt and then building some confidence that you may be able to experience that again.But that was also partly a more complex reflection at the same time, because it was building on something you had said previously. There was a few things that were combined.

  Dr. Alex Raben: [00:48:30] Yeah. That made me feel really listened to as well because it seemed like you followed along the entire story you brought back, even the reference to the ball and chain that I had kind of thrown out there. You brought that back towards the end, and I think it was like little touches that made me feel quite listened to and supported.

  Dr. Marlon Danilewitz: [00:48:50] I'm also very happy to report that for Wip, the reflections definitely outnumbered the collaborations. And what I think was also quite interesting was that you really had a good base of engagement early on, and towards the end of the conversation, the questions that were posed really helped to move ground and to by asking the ruler question to assess your level of confidence, it really helped to evoke a sense of change talk there, which I think really shone through.

  Dr. Alex Raben: [00:49:27] And you brought up engagement, Marlon, so maybe we can elaborate on that a little bit because how does that play a role in MI? Because in this situation, we already know each other from before and the engagement was kind of good from the get go. But I could imagine scenarios where you don't have good rapport with someone and you're trying to use these techniques.

  Dr. Marlon Danilewitz: [00:49:54] So, I think that's a great question because oftentimes in our clinical interviews, we spend a lot of time on the questions and getting the content. But developing rapport and engagement is such a fundamental aspect of my in a successful interview. And it really sets the stage that only through having a solid foundation of engagement can you start to begin to move on to the next stages. And that's really an integral part of my is that knowing that where the person's at and their readiness for change and where they are at any particular moment.

  Dr. Alex Raben: [00:50:29] Right. And we've talked about this on past episodes. Just for the listeners reference, our episodes on the Psychiatric Interview really focussed on that because building rapport is so fundamental in psychiatry, all the things we do. And I guess the same is true in using me as well.

  Dr. Wiplove Lamba: [00:50:46] Yeah. And from what I remember about the evidence MI, it tends to work really well when people are bit more oppositional traits when they're quick to anger and it's quite effective at bringing you down that level of anger in our case, because we know each other, we've worked together before. I suspect if I took a non-MI approach, if I took it direct, it might even have an impact, especially because you know what's coming from a good place. MI is one tool of many and there are situations that do require us to be direct as well. And I don't want people to think that we're coming in and say "Oh, I use MI all the time". I have a suspicion that if we did a different interview that wasn't my based or was a bit more direct, you might have gotten something from it as well. It would have been a different experience for sure but just to think about that for the relationship. One thing I did want to comment on quickly is just that with these interviews, at least when I've been recorded and people have scored me on the MITI, I tend to do okay in terms of reflections, I do okay in terms of listening Change Talk. The thing I'm not that great with is a softening Sustained Talk piece. And there was a couple of times that you made a few sustained talk questions, and I just went over like that. The only reason I'm bringing this up is that just like any psychotherapy, there's levels of which people can improve. And with Motivation Interviewing because they're so careful about tracking the language when they review you, they're actually very specific about which things you could do differently and how.

  Dr. Alex Raben: [00:52:12] Right. Now that makes a lot of sense. We can all obviously continue to improve in these techniques. And I think you brought up the point that it's not the be all, end all. It has a time and place that there are other techniques that one can use with patients. And sometimes advice giving can be helpful. You know, thinking outside of the doctor-patient relationship, good friends are often in a position where they can give that hard advice because you've had years of building a relationship with that person. So that's just an analogy in a way. But to emphasize the point that advice giving is not a part of me, that's actually sort of counter in a way to the spirit.

  Dr. Wiplove Lamba: [00:53:01] Yeah, unless you ask for permission first. I have that little trick there so you can still be a doctor and ask for permission. A little twist in the MI book for health care.

  Dr. Alex Raben: [00:53:12] Right. And that would be sort of the autonomy, peace of the spirit, making sure they're okay with you, giving them some facts. I guess I'll just give a bit of my subjective experience in terms of a debrief. I mean, I found that to be quite helpful. And as you saw, my rating scale even had changed from yesterday to today. And particularly pinning me to thinking about next steps was helpful. And I didn't think I would get there. I thought I was too entrenched. I really do appreciate that because it is, I think something I will potentially do or consider, which was not something I expected coming into this today. I hope it shows the power that MI has to the listeners. Was there any other comments any of you had in terms of that interview before I ask sort of the final question?

  Dr. Marlon Danilewitz: [00:54:14] I'm just excited to see whether you come with a coffee to next academic day.

  Dr. Alex Raben: [00:54:20] Yeah, that'll be the true test, right? Maybe we'll do it. Update in the next episode. All right. Well, I have one  final question for you guys, because I want to make sure we're bringing it back to the junior learners. What do you think a clerk or a junior resident ideally should take away from from this talk? Where can they start to use MI? Sorry, it's a double-barrelled question, but how can they access resources to learn more as well?

  Dr. Wiplove Lamba: [00:55:01] I think all of us have our favourite resources and you'll find MI is very individual in terms of how it's taught. There is a British Medical Journal article that's six things you can do in the medical interview that are MI adherent includes things like the Importance and Confidence Scales. It includes ways to give advice in my adherent way, and it covers the guiding principle and it's available for free online. And the British Medical Journal also has a two-hour free CME that covers some of the basics. This is something I would strongly recommend practising. You could do it at any point in the interview you could do when you give the treatment recommendations, you could do it to try to elicit more things. It's really important that people try it out and figure out for themselves if it works or not, because we tend to do things that we believe are effective, you know? And for me, I wasn't sure if it would work at first. Some of these skills, they seem so basic. It's only when you have those experience of responses that are there as well. So those are my thoughts. But usually what happens for people in medicine, it's usually when they're working for three or four years, they're seeing the same patients over and over again that aren't getting better. That's when the motivation comes, because in medical school and residency, you're just learning how to be a good doctor, right? And there's so much content, so much practice, all that kind of stuff. So those are my thoughts.

  Dr. Alex Raben: [00:56:31] And Marlon.

  Dr. Marlon Danilewitz: [00:56:33] There's always the book Motivational Interviewing by Miller and Rollnick. There's also a great opportunity in the community at large through training those who are extra keen to pursue excellence in MI.

  Dr. Alex Raben: [00:56:48] How do people access training? That's online?

  Dr. Marlon Danilewitz: [00:56:51] Yeah.

  Dr. Alex Raben: [00:56:53] We'll make sure to put these resources in the show notes as well.

  Dr. Wiplove Lamba: [00:56:57] Yeah. It's the Motivational Interviewing Network of Trainers. They have a national  conference every year, one year it's in North America, the next year it's somewhere nice to visit. And it's really how to get to that next level of MI. A colleague of mine who taught me a bunch was actually three years below me, and he went there when he was a resident and he got really quite good at MI quick by attending those intensive workshops.

  Dr. Marlon Danilewitz: [00:57:25] I think the last thing is just practice.

  Dr. Alex Raben: [00:57:27] Yeah. Get the experience. That's terrific and I agree completely. Thank you guys so much for taking time out from the busy schedules here, your busy schedules at the CPA conference and I'm taking you away from dinner and the lovely day outside now, night outside in the beautiful city of Quebec City. I really appreciate that and hope to have you back at some point as well.

  Dr. Wiplove Lamba: [00:58:01] Thank you.

  Dr. Marlon Danilewitz: [00:58:03] Thank you so much.

  Dr. Anees Bahji: [00:58:05] Thank you.

  Dr. Alex Raben: [00:58:05] Take care. That's all for now. Listeners, we're going to sign off and we'll see you next time. Thank you all for listening. If you can, I suggest you stick around for some important announcements about our new email, our new infographic initiative, and to hear about my progress since the episode was recorded over a month ago, we first of all have a new email psychedpodcast@gmail.com. Our old email is no longer operational, so please send all your comments and questions to our new email. In terms of our next update.

  Dr. Alex Raben: [00:58:52] Thanks to our newest member, Nikhita Singhal, who is a first-year resident at the University of Toronto in Psychiatry. We now are making infographics to accompany our episodes. The first one being with this episode on Motivational Interviewing. These are meant to allow you to refer back to key concepts from the episode, using a quick one-page graphic available through our show notes for that episode or on our website Psychedpodcast.org. We hope that you'll find them useful. Finally, a bit of an update since I did the real play with Dr. Lamba on this episode. Although it sucks to admit I have yet to make a meaningful change in my caffeine use since the episode was recorded a little over a month ago. However, I did take some actions towards change. I did look at my calendar and I looked for opportunities to set a quit date.

  Dr. Alex Raben: [00:59:52] Also, since listening to the recording during the editing of this episode, I have noticed I've started to think about change again in this area. And so we'll see where that leads me and I may share some updates as we go. I think for me, this highlights how difficult change can be in general and for our patients. And it's given me a new renewed empathy for our patients that find themselves in similar situations, but with drugs and other behaviours that often have a far greater impact on their mental health than caffeine. I hope that you'll reflect on this as well. So that's all for updates.

  [01:00:36] Now let's go to the end credits. 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, audio edited and hosted by Alex Raben. Lucy Chen provided our episode intro. Our theme song is Working Solutions by all of music. Nikhita Singal created the infographic to accompany this episode. A special thanks to our incredible guests, Dr. Wiplove Lamba, Dr. Anees Bahji and Dr. Marlon Danilewitz 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 20: Understanding rTMS with Dr. Jonathan Downar

• Episode 20: Understanding rTMS with Dr. Jonathan Downar

  PsychEd+episode+20+-+Understanding+rTMS+with+Dr.+Jonathan+Downar.mp3

  Christina: [00:00:02] Perfect. So have a seat. We're going to do something called Automotive threshold on you today, which is basically we're going to be using the magnet on your head to see at which amplitude your arm. So it's uncomfortable. I won't say it's painful. We're going to be using about 0.2 pulses per second. So 3 to 1.

  Alex Raben: [00:00:57] Welcome to PsychEd, the Psychiatry podcast for Medical Learners, by Medical Learners. Today's episode is on rTMS. Repetitive transcranial magnetic Stimulation,  rTMS is a type of neurostimulation therapy for the treatment of depression. It falls in the same category as ECT or electroconvulsive therapy. And although it's not as well known as ECT, rTMS has steadily become an important option in the treatment of depression, which is why we've decided to focus on it. In today's episode, Henry Barron had a chance to sit down with Dr. Jonathan Downer, a world expert and leading researcher on rTMS, and his clinical fellow, Dr. Jean-Philippe Miron. Not only that, Henry also recorded himself experiencing some non therapeutic levels of rTMS. To give you some idea of how treatment feels from our patients perspectives, let's go over the learning objectives. By the end of the episode, we hope that you'll be able to, number one, understand generally how rTMS is conducted and some of the theory behind how it works. Number two, understand where rTMS fits in the treatment algorithm for depression. And number three, appreciate the benefits, side effects and drawbacks of our rTMS and how it compares to other depression treatments. So without further ado, let's jump in.

  Henry Barron: [00:02:24] All right. So why don't we start with introductions? So I'm Henry.  I've been behind the scenes doing some audio editing, and it's a great privilege today to be here with Dr. Jonathan Downer. Maybe if you could introduce yourself.

  Dr. Jonathan Downar: [00:02:38] Sure. Absolutely. So my role here is as a clinician scientist with the Department of Psychiatry at the University of Toronto and the director of the rTMS Clinic here at the Toronto Western Hospital. By way of background, so my Ph.D. 20 years ago was in functional MRI of a network that turned out to be the Salience network. After that, I did my MD in Calgary and I'm doing my residency training here in Toronto before starting the clinic here about eight and a half years ago.

  Dr. Jean-Phillippe Miron: [00:03:04] So my name is Jean-Philippe Miron. I'm a fellow here at the rTMS Clinic at Toronto Western. I'm doing a two year fellowship. I did my residency in psychiatry at the University of of Montreal.

  Henry Barron: [00:03:18] Great. So maybe could you get a bit of background on what rTMS is and how it works?

  Dr. Jonathan Downar: [00:03:25] Sure. Absolutely. So our rTMS is repetitive transcranial magnetic stimulation. It's a treatment that uses a magnetic field generator that makes a powerful, focussed magnetic field that is as strong as the one in an MRI scanner. So 2 to 3 Tesla, but focus into an area that can be as small as the size of a dime by applying these focussed magnetic pulses to the surface of the cortex, it's actually strong enough to induce action potentials in the tissue. So classically, if you place the stimulator over the motor cortex, over the area that moves the thumb and you apply a few pulses, you'll actually see the person's thumb move. And if you go high enough, you can get the whole arm to move in it sufficiently high intensities and durations, it's powerful enough to induce seizures, although we generally try and avoid that for therapeutic purposes.

  Henry Barron: [00:04:07] Great. And how are you using it to treat mental illness?

  Dr. Jonathan Downar: [00:04:10] Great. So for the last 20 years, rTMS has been applied to regions like the dorsolateral prefrontal cortex, which have been shown to be underactive in things like major depression. And by bringing somebody in and doing hundreds of simulations per day, day after day after day, over a course of anywhere between 15 and 30 to 40 sessions, a person can improve all the way to remission from depression. What's nice is that the mechanism is completely distinct from that of standard antidepressant medications. So even people who fail the large number of antidepressant medications have an equally good shot at remitting on rTMS overall current remission rates and the published literature and the most recent studies are about one third of people achieving full remission, one third of people showing nothing at all, and one third of people showing somewhere in between that maybe a 40 to 60% improvement.

  Henry Barron: [00:04:56] Awesome. What are the drawbacks or side effects adverse effects with rTMS?

  Dr. Jean-Phillippe Miron: [00:05:03] So they're actually pretty advantages compared to medication. So medication obviously has a lot of neurological side effects dizziness, for example, GI side effects, nausea, stomach upset, you know, and in long term, there's weight gain, loss of libido. And the great thing about rTMS is that is it does nothing of these things. You know, there can be pain during the treatment. But usually, again, I'm pretty forward with patients. I tell them, you know, yeah, there is some pain involved. I'm not going to lie to you. But I reassured them by saying, you know, it's only a few first sessions are the toughest, but then people, they get used to it pretty quickly. And it's not treatment limiting. You know, when you do again, when you study the dropout rates because of the pain are extremely low. I did a chart review recently, about 200 patients who are using probably the most painful protocol. None of them dropped out because of the pain, even though they report pain. But so most people are able to power through this. There can be headaches and fatigue afterwards, but these are usually time limited. So our TMS is really great in that sense.

  Henry Barron: [00:06:06] What about any long term effects? Have there been any studies that show that there may be or might not be long-term effects with our TMS?

  Dr. Jean-Phillippe Miron: [00:06:15] So there's been no long, long-term studies done. Maybe there are some people working on that, but there's no evidence that it would bring any like long term harm. For example, I think that some people might be scared of our rTMS because of that. We use electromagnetism. You know, it's like I power lines and, you know, magnetic field. I think it's important to say that there's never been any solid scientific evidence that magnetic fields can cause cancer or harm in the human body. So there's no known actually long term side effects. And if some people sometimes report, oh, I'm feeling worse at the beginning with with TMS again, it's usually time limited after a few sessions is going to go away and we know evidence of arm in the long term so far that we know of.

  Henry Barron: [00:07:04] All right. So if I'm a psychiatrist and I've got someone in my office and I'm trying to decide whether or not to refer them for our TMS, how do I know whether I have a good candidate sitting in front of me?

  Dr. Jonathan Downar: [00:07:14] Okay, great question. So when you're looking at a patient, generally our TMS is reserved for treatment resistant depression at present. So that's. Usually a person who's failed at least one adequate dose and duration trial of medications. And more commonly people have failed two or three or five. So anybody who's failed at least one medication, the remission rates that are published for RTMs begin to exceed the remission rates published for sequential additional medication trials. And so if you have a patient has failed at least one antidepressant and they live relatively close to in our TMS clinic, it's worth considering if they failed a lot of antidepressants, then, even if they live far from our clinic, it might still be worth considering. So our rTMS is sort of beginning to occupy a position in the treatment algorithm that sits after medications and therapy. But before you proceed to Ect, Right. How would you say that our rTMS fits in with ECT? Because I think a lot of times people think of neurostimulation and sort of the end of the line and ECT being as effective as it is. How do you think the two compare?

  Dr. Jonathan Downar: [00:08:15] Well, so they sit on different ends of a spectrum of I guess efficacy versus tolerability. So some treatments are less efficacious, but they're very tolerable, others are very efficacious, but they're just not as tolerable or they're invasive or they're costly and so on. So ECT has a higher invasiveness than RTMs because it requires anaesthesia, because it does involve seizure induction and because you have side effects of memory disruption which are troublesome for many patients and distressing for many patients. And then on top of that, the access problem is there. So even if everybody in the world with treatment resistant depression wanted to come for ECT, the reality is that our ECT capacities are limited by our time and the availability of anaesthesiologists and so on. So, so ECT has advantages and disadvantages. rTms is much more tolerable in the sense that it's less invasive and not needing anaesthesia. The seizure risk is very low. You're not trying to induce a seizure, there's no memory impairment. In fact, people have tried to use it to enhance memory. The effects are weak but not negative. And on top of that it says, I say it's more accessible, so you don't need over time, it can be done on an outpatient basis in a few minutes of treatment. The wait lists are shorter. It's potentially something you could scale up to have in every hospital, every clinic in the world if you really wanted to. And the cost is coming down all the time.

  Dr. Jonathan Downar: [00:09:34] So it may eventually be something you can do at home. I think it's unlikely we're ever going to have ECT at home for people. So our rTMS I suppose is better in terms of access and tolerability and side effect profile and invasiveness. So that's why it's something that I think we try after medications and therapy have failed. But if it doesn't work, then you can proceed on to I want to clarify that our rTMS is not the same as ECT light. It's just the difference in remission rates. It's different kinds of patients who do well. On our TMS, we find that our TMS is particularly effective in the cluster B patients, even the borderline trade patients who are, you know, have lots of impulse control difficulties and struggle with cognitive control over and above their depression. Whereas with ECT you tend to get better effects, particularly in psychotic depression and in catatonic depression. Our TMS does not do well for psychotic depression. In fact, patients with psychotic illness are generally the ones who do most poorly on our TMS. So it's not just that our TMS is like a milder version of ECT. They're actually treating different groups of people, and the people who do well in our TMS often have trouble tolerating the side effects of ECT. Whereas the people who don't respond to our TMS with psychotic depression often do very nicely. And so I believe they're targeting different networks and different populations.

  Henry Barron: [00:10:52] One of the drawbacks to TMS is the fact that the effect doesn't last forever. It seems to go away in patients depending on how fast they respond and and other factors. But it seems to go away after about four months on average. So I think the question that some people have is if this is a temporary solution, how can we make it more long lasting and more sustainable for people?

  Dr. Jean-Phillippe Miron: [00:11:13] Yeah, so that's a good question. And I think people do kind of they kind of bit the whether they're surprised by the fact that it's not lasting forever. But I just explain to them, well, there's nothing in psychiatry that we do that unfortunately lasts usually lasts forever. You know, if you stop medication, you stop therapy, your your relapse rate are going to increase. And with our TMS, we don't have solid data on Canada, the long term stability or long term benefits. But like you say recently, the meta-analysis are kind of showing us that it's a bit similar to like it's maybe a 50% relapse rate at six months, something like that. Um, so what I tell people is that, well, it's normal, first of all, and if you do have a relapse, you come back, we do a second round of treatment and then we can do what we call maintenance RTMs and it's maintenance. Rtms is actually much less intensive than you would believe. You know, the kind of standard maintenance RTMs that we do is about one session every two weeks. So it's it's kind of convenient. It's like.

  Henry Barron: [00:12:12] 5 to 10 minutes of stimulation every.

  Dr. Jean-Phillippe Miron: [00:12:15] Every two weeks can be enough on a general level it can be. But again, we don't have good studies on long term data for for RTMs. We're going. Maintenance. But again, if it worked once, there's no reason to think that it doesn't work again and can be used long term.

  Henry Barron: [00:12:30] Great. And how is  rTMS changing or is it changing the way we see psychiatry and the way we practice psychiatry?

  Dr. Jonathan Downar: [00:12:37] Well, I think it's certainly having an effect in terms of patients who sat in that that 2% of the population sits in that difficult treatment resistant depression category. So these are people who fail to respond to medications and therapy, but maybe aren't ready to go to ECT or can't access ECT. In Ontario alone, that's hundreds of thousands of people. And in the city of Toronto, that's probably over 100,000 people. So it's a new treatment option for folks like that. The other thing is that by looking at the basic science of  rTMS, we're learning about what it's actually doing to get people out of depression. And what we think is happening is that it's not actually treating the depression directly. Rather, when you place it over the standard areas like the dorsolateral prefrontal cortex, probably what we're doing is we are strengthening the integrity of one of the brain's 17 major networks. And this particular network is called the Salience Network. What we believe it does is cognitive control, the ability to self-regulate your thoughts and your behaviours or your emotions. And by applying  rTMS, some but not all patients with depression have a more general problem with cognitive control. You can recognise these patients because they have a lot of cluster B co-morbidities and impulse control comorbidities. So we find that the best patients for TMS are the ones who have yes, they have depression, but they may also be on the bipolar spectrum or they may have binge eating or they may have ADHD symptoms or a little bit of PTSD or a little bit of OCD.

  Dr. Jonathan Downar: [00:14:00] In fact, the salience network turns out to be underactive across most axis one disorders. They're all different, but they have a common trans diagnostic deficit of cognitive control. When you apply the treatment the patients report that they have, they actually generally report that, "yes, my mood is improving. But what I really noticed is I have more self control. I have better ability to resist the urge to binge eat. I notice I'm more focussed in conversations. If I want to stop thinking about something, I can stop thinking about something." And the ones who have previous experience of therapy, like cognitive behavioural therapy or DBT, they'll often say in the past they have theoretical understanding. "I know what I'm supposed to be doing, it just doesn't work." And then when you restore the integrity of their salience network with RTMs, then they'll come in and they'll say, "Oh, you know, I started using my CBT techniques and they work now." So we think that's what RTMS is really doing. It's strengthening cognitive control, and the best patients to send for our tests are not just the ones with depression, specifically the ones who have a variety of different diagnoses and co-morbidities, whose common element is a lifelong, pervasive trans diagnostic deficiency in cognitive control.

  Dr. Jean-Phillippe Miron: [00:15:07] I think it's really making our conception of mental illness shift a lot because we go from thinking more in maybe psychodynamic terms or maybe in terms of the neurotransmitter theories of depression. We're shifting from that more to brain networks and brain connectivity, and we're getting closer to actual clinical neuroscience. There's some resistance, especially in the psychiatric field, I find, even though there's been many randomised controlled trial, but there's this there's still a lot of sceptical psychiatrist. Slowly it's opening up. But I think a lot of especially clinicians, they kind of feel that we think that RTMs are going to be the one solution and that's it. But I see RTMs as a solution when it's combined to other things such as therapy and medication.

  Henry Barron: [00:15:58] Great. So what do you think is next in the area of RTMs? What's exciting and up and coming?

  Dr. Jonathan Downar: [00:16:05] Okay, so there are a few different areas where RTMs is progressing. It's actually quite quick progress right now. I think we may be finding ourselves in a sort of golden era of Neuromodulation in the same way that, you know, back in the 1950s to seventies, we were sort of in the golden era of psychopharmacology. So one area of discovery is more cost-effective treatments. In the old days, RTMs was quite a long duration session, so you had to bring the person into the chair for anywhere between 30 and 60 minutes per day. For example, the FDA protocol originally approved in 2008 for depression, is a 38 minute protocol. Now that means that the machines can't treat very many people each day, and that keeps the costs up and the waitlist long and the capacity is low. One of the big advances of 2018 was a large Canadian study called three D, and in the three D study, the Canadian centres, of which we were one of the three ones, we tried out a new kind of stimulation pattern that mimics the brain's theta rhythms, and it's called theta burst stimulation. And the main feature of theta versus stimulation is induces plasticity very efficiently in the brain.

  Dr. Jonathan Downar: [00:17:12] So you get the whole job done with 600 pulses in 3 minutes instead of 3000 pulses over 38 minutes. The big question wasn't whether it did better than sham. The question is how did it do? Or to standard of care. And the three RD study was designed to assess that. What it found was that the three minute treatments were every bit as effective and numerically superior, although not statistically superior to to the standard conventional treatments. So you didn't get better outcomes, but you did get an ability to get the same outcomes with just 3 minutes of treatment. That means the appointments can be reduced to just ten or 15 minutes. And so that means that every machine in the world can treat many times more people and as a result, the cost per treatment can come down quite a lot. So I think more countries and more jurisdictions and more individuals are going to find it to be an affordable treatment. They're also going to notice the wait list is four or five times shorter than it was before.

  Henry Barron: [00:18:02] Another thing that I've seen in this clinic is the idea of maybe bringing RTMs to the home, making it cheap enough for people to afford and do on themselves.

  Dr. Jonathan Downar: [00:18:12] Mm hmm. So that's actually that's one of the up and coming things that I think is going to be necessary to make RTMs a real sort of viable alternative to medications for a large number of people. One thing you say about medications, whether you love them or you hate them, they're very convenient. You don't really have to spend a lot of time doing them. You don't have to come into the hospital for them. They're just there for you at home. So we've had a longstanding goal to try and figure out how to get the brain stimulators home to the patients instead of the patients to the stimulators. It looks like there may be ways to do protocols that are maybe a bit longer, like 8 minutes long, but are extremely safe and simple to do, maybe safe and simple enough that we could teach people to do them at home, just as we teach people on exactly their own insulin or to do other kinds of care on themselves. The devices that used to cost 200,000. Now have some versions that are as little as 10 to $15000. And so there's a possibility that if you take out a loan every five years or so that we might be able to get the daily costs of the treatment down to as little as 5 to $10 a day. So $5 a day. RTMs at home achieving superior effects of medications while having fewer side effects and a superior safety profile. Since you can't overdose on your RTMs machine, it can be programmed to lock you out so you just use it once a day, or only according to the prescription. So this is one of the things we're looking at. And I think bringing our TMS home to people, which may be possible in the next 4 to 5 years, I think that would be a real game changer, especially if the cost can come down.

  Dr. Jonathan Downar: [00:19:42] Other things that people are looking at now that the treatments are just 3 minutes long. A lot of people are looking at doing multiple sessions per day. Now, if you just give people our TMS back to back to back with no gap, the extra pulses don't seem to do very much. But if you give the brain an hour or two to recover between sessions, it might be possible to do more than one session per day. So it's possible that you may not have to wait a full 24 hours between sessions that for some people you can actually do multiple sessions a day. In Belgium, Chris Bakken is a professor who's looking at four times a day or five times a day. Stimulation. Paul Fitzgerald in Australia is looking at three times a day stimulation. Other folks have looked at five times a day stimulation. And and in Stanford, Nolan Williams is looking at ten times a day stimulation. So people are trying lots of different parameters out. We've tried we've recently completed a trial looking at twice a day versus once a day with some very careful controls built in to control for a placebo or a non-specific effects. And it looks like doing two three minute sessions back to back doesn't speed things up. But if you put a 60 minute gap in there and you do the stimulation 60 minutes apart, then the TMS may work faster. For some people, it doesn't seem to achieve an overall higher remission rate, but at least if you are going to respond, then you'll respond more quickly.

  Henry Barron: [00:20:58] Great. One of the things that I also think was really helpful potentially for the people who are trying to get RTMs to work for their patients was you have a checklist approach to when RTMs doesn't work, What factors should you try to address?

  Dr. Jonathan Downar: [00:21:13] So in general, the rule we've found is that if you get to 15 sessions or usually three weeks of stimulation and you haven't achieved at least the 20% improvement, then that particular protocol is unlikely to keep working. Something is up. We have a checklist of about six things you need to look at, and that includes see whether you've got the right diagnosis, whether the patient may be on some medications that block RTMs like the Gabaergic medications like benzodiazepines, Pregabalin and Gabapentin anti-epileptic medications like the motor gene and and Topiramate are also reckoned to potentially block the plasticity of RTMs. Then you have factors inside the room. Maybe the person couldn't tolerate the stimulation, so you couldn't turn up the intensity high enough you have outside the room factors. Maybe the person's getting better coping capacity thanks to you work on their salience network. But if they're in a really stressful situation, like they're still working in a job or they're being harassed or they're still living at home in an abusive relationship, then it might be very hard to see what's changing. Aside from that, it's possible that you're targeting the wrong circuits or you're targeting the person's salience network. But in fact, their pathology is coming from a different network in the brain. So now looks like in depression some people have a lack of salience network and a lack of cognitive control, but not all patients do.

  Dr. Jonathan Downar: [00:22:30] Others may be having other networks that are driving their symptoms, and so sometimes moving the coil to a different spot on the brain will actually will give you another 25% remission on top of the one third we see on the first run. However, when all those things fail, we have to acknowledge that. We believe that about one out of three people, no matter where on the brain, you stimulate them. With our TMS, you can always activate them, you can always get the action potentials. But some people don't show plasticity, so they don't get a durable effect from the TMS and we don't know how to test for those people yet and we don't know what to do about it when we see it. So that part is a diagnosis of exclusion. But if we see a non responder, we generally go through that six point checklist to see if we can spot what's going on. If there's something to fix, we fix it. If not, we try a different brain area and if we try out a few brain areas and nothing's work, then at that point we would declare a failure and we would work on the assumption that maybe they just don't have the plasticity from our TMS.

  Henry Barron: [00:23:23] Great. And then sort of a last question to wrap up. Do you have any words of advice for budding psychiatry residents or medical students who are interested in the field?

  Dr. Jonathan Downar: [00:23:32] Sure, absolutely. I'd be happy to say so. I mean, as a clinician scientist, I can say that there's there's a lot of reward to it because you have scientists who are doing the research and publishing the papers, but often not in direct patient contact. And then you have MDs who see a lot of patients, but they don't always have time to read the scientific literature. Clinician scientists have to have a foot in both in both worlds. So they're seeing patients and they're working in clinics, and they're also reading the science literature and becoming familiar with it. But clinician scientists ideally do a lot of translational work, so they're looking at results from the literature and saying, How could we turn this into a treatment? In my example, it would be the case of saying, Well, our patients were suffering a waitlist problem with our TMS because the sessions are too long. But fortunately, having read the literature, we would hear about these treatments like theta bursts that were being used pre clinically and motor cortex, and we noticed they were only 3 minutes long. And so the translational question becomes, well, how do the these three minute treatments compare in in real world patients to the 38 minute treatments? So that would be the sort of translational question that a clinician scientist can ask. The reward of being a clinician scientist is that you see your research being directly translated into better patient care, and that's a very rewarding thing to to experience. The downside, of course, is that you're sort of working two jobs. So you'll see the joke is that clinician scientist is 75% clinical in 75% research. So usually you're you're spending a lot of evenings and weekends catching up on the science work you didn't get to do during the daytime.

  Dr. Jonathan Downar: [00:24:58] And so you do have to find some question that you're so passionate about that you're willing to give up some of your free time and that you could be spending with friends or family to sit down and work in the lab and try and build the treatments. So that's the downside of it. As for is this, you know, is this the career for you? I recommend that when you're early in your training, the best thing to do is take areas that you think you might be interested in and do some rotations in them. But then if you think you've established an interest, don't forget to also look at other areas to really confirm that that's what you want to do. See if you're interested in, say, clinician scientists and psychiatry, go in and shadow a clinician scientist for a while and maybe do a rotation with them, but also look at other areas of medicine, look at other areas of psychiatry and do other rotations there. You may find that one of those just speaks to you more, that you're more passionate about it, or you may find that none of those areas are interested. And now you can be really confident in your decision that you've sampled a lot of different areas and you're sure that out of all those areas, this one particular one is the one you want to do. So I think that's what I can say is really once you think you know what you're interested in, try other things as well, just to be sure.

  Henry Barron: [00:25:58] Great. It's been a pleasure having you on the show, Dr. Downer, thank you so much for your time. I'm sure that everyone's going to really appreciate the words of wisdom that you imparted.

  Dr. Jonathan Downar: [00:26:07] Fantastic. Thanks for having me on the show and I hope it goes well. Cheers.

  Christina: [00:26:22] Okay, So now that you know a bit more about RTMs, we thought it would be nice for you to understand a bit more from the patient perspective. So here's Henry getting a bit of an understanding about what that feels like.

  Henry Barron: [00:26:38] Okay. So, uh, do you want to just introduce yourself briefly?

  Christina: [00:26:43] Hello, I'm Sonia Goldberg, and I'm one of the RTMs techs at this clinic.

  Henry Barron: [00:26:48] Do you think we should do, like, actual. I just don't want to, like, zap the microphone.

  Christina: [00:26:54] Or the microphone. Yeah, we can maybe put the microphone over.

  Henry Barron: [00:26:58] Yeah, I could. I could turn it up to, like, Max and maybe, like, put it over there.

  Christina: [00:27:02] I just don't want to break your microphone, honestly.

  Henry Barron: [00:27:05] Yeah. Just go like this.

  Christina: [00:27:13] Yeah. Okay, perfect. So have a see. We're going to do something called a modem threshold on you today, which is basically we're going to be using the magnet on your head to see at which amplitude your arm moves. Okay, so it's uncomfortable. I won't say it's painful. We're going to be using about 0.2 pulses per second.

  Henry Barron: [00:27:35] Okay.

  Christina: [00:27:36] So it won't be very quick and it won't be like a treatment.

  Henry Barron: [00:27:39] So it's not going to hurt at all. It's just going to be like.

  Christina: [00:27:41] It'll be uncomfortable.

  Henry Barron: [00:27:42] Okay.

  Christina: [00:27:42] All right. It'll feel tingly and weird and uncomfortable. And depending to where which amplitude we get, there may be a little bit of pain involved, but I don't anticipate there being too much.

  Henry Barron: [00:27:52] Cool. Okay.

  Christina: [00:27:53] So what we're going to do is we're going to have you have a seat. Sure. Remove anything bulky from your pockets or your lap. Okay. Sit down. Lean back a little bit. Head forward. Arms on the armrest and palms facing up just as loose and relaxed as possible. Cool. Are you comfortable like this? Okay, so we're going to get started. We like to start at an amplitude of 35. And what I'm going to do is I'm going to take the coil and I'm going to place it halfway between the top of your ear and the vertex of your head. And we're going to start there and just move around to see where we get a stronger impulse.

  Henry Barron: [00:28:34] Okay. So you're looking to see how much how strong the magnetic field has to be for my for my hand to twitch, right?

  Christina: [00:28:40] Correct.

  Henry Barron: [00:28:41] And so that's sort of like you're testing to see if it's going to be strong enough to actually affect my brain.

  Christina: [00:28:47] Yes. So we're going to we're going to be trying to stimulate your motor cortex because it's about the same depth as the area that we're trying to stimulate to treat you. Okay. So we're going to start at 35. Just tell me if you feel pain. That's above a seven or eight and then we'll stop. Okay, great. So 3 to 1. So that's us ramping it up to 35.

  Henry Barron: [00:29:16] Okay, so I'm getting like a tapping feeling out of my scalp. Yeah. And like, my face is twitching a little bit.

  Christina: [00:29:21] Too, so that's totally normal. You're going to feel some twitching. I want you to tell me when you feel twitching in your arm. Okay. I'm going to move up a little bit. Okay. Okay, so I see some movement in your arm since we're stimulating the left side. I'm going to see movement in the right. Okay, So is that very painful?

  Henry Barron: [00:29:43] It's hard to describe. It's kind of the first couple of ones were kind of shocking. But after that, it it's not as bad. It just kind of feels like someone tapping really hard on my head.

  Christina: [00:29:53] I guess that's how most patients describe it. So that's what the motor threshold is like. The treatment itself is going to be a little bit faster paced, but it's only 8 minutes and 24 seconds for a one hertz treatment.

  Henry Barron: [00:30:08] Oh, wow.

  Christina: [00:30:09] So six trains of 60 seconds, one pulse per second, 30 seconds off between each train.

  Henry Barron: [00:30:16] Awesome. Cool.

  Christina: [00:30:17] Okay. Well, thank you for coming for treatment.

  Henry Barron: [00:30:19] Thank you. Thanks, Christina.

  Christina: [00:30:33] PsychEd is a learner driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Henry Barron. Alex Rayben voiced the introduction. Audio editing was by Henry Barron and Alex Rayben. Our theme song is Working Solutions by All of Music. A special thanks to Dr. Jonathan Downer and Dr. Jean-Philippe Miron for serving as our guest experts on this episode. And thank you to Ksenia Gorenberg, who provided our TMS technical expertise on the episode. As always, we'd love to hear your feedback and you can contact us at info podcasts or visit us at Psych podcast. Org. Thanks so much for listening.

Episode 19: Applying Mental Health Legislation with Kendra Naidoo

• Episode 19: Applying Mental Health Legislation with Kendra Naidoo

  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 18: Assessing Suicide Risk with Dr. Juveria Zaheer

• PsychEd Episode 18: Assessing Suicide Risk with Dr. Juveria Zaheer

  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 17: The Psychiatric Interview with Dr. Juveria Zaheer

• Episode 17: The Psychiatric Interview with Dr. Juveria Zaheer

  Dr. 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. Okay. So we are now recording. Welcome back to Psych everyone, the psychiatry podcast for Learners by Learners. We're here today to talk to you about a very important topic, the psychiatric assessment or the psychiatric interview. Normally, our episodes focus on a particular disorder or mental illness. Today, we're going to be focusing more on skills. And this is one of our most important skills in psychiatry is the interview. And today we are joined by Dr. Juveria Zaheer, and I'm also joined by Lucy Chen, who's my PGY-5 now colleague. And I'm Alex Rabin, your host today, also PGY five here at U of T and Dr. Zaheer or as she likes to be called, Juveria, someone who is a cornerstone of our education here at U of T. And we're very lucky to have her with us today. She is a staff psychiatrist here at CAMH. And she's works in the emergency department and is also the education lead, if I have that correct in the emergency department. Juveria, would you like to share anything else about yourself? I know you also do research as well.

  Dr. Juveria Zaheer: [00:01:56] Yeah, that's exactly right. So I'm a clinician scientist here at AMH. My clinical work is focussed in the emergency department and I do education in the emergency department. I get to meet all of the learners as they come through in PGY one. And I also do research largely on suicide and suicide prevention.

  Dr. Alex Raben: [00:02:12] Great. Lucy, if you could just say hi to our audience.

  Dr. Lucy Chen: [00:02:15] Hi guys! I'm here.

  Dr. Alex Raben: [00:02:17] You guys all know Lucy. The learning objectives for this episode are that by the end of this episode, you, the listener, should have a clear understanding of number one, have a clear understanding of the goals of a complete psychiatric interview, the general structure and content that should be covered in an interview. And number two, feel comfortable to begin to use techniques that will help you conduct a professional, compassionate, empathic, efficient and accurate interview. And number three, be familiar with techniques you can use to facilitate information gathering when you're in a more challenging scenario. All right. So now that we have the learning objectives and the scope established, let's launch right into the interview itself or this topic itself. I should also say that my research for this episode I used to references, in particular the Shea- Psychiatric Interviewing, The Art of Understanding, Second Edition book, and the Carlat, The Psychiatric Interview, Fourth Edition pocket Book. We'll put the details of both these in the show notes. We don't get any kickback for talking about these books. This is not an advertisement, but these are two books I've personally found helpful. The Carlat book is short and sweet and it gets to the points and the Shea book is more in-depth and has some more advanced techniques. So, if you're interested, check those out. Okay, let's launch into the questions now. I think maybe the first question for us in this room is what is actually the purpose of the psychiatric assessment? Why do we do this in the first place?

  Dr. Juveria Zaheer: [00:04:00] I think the psychiatric assessment, exactly as you said, is the most important diagnostic and therapeutic tool that we have in psychiatry. I think people are often waiting a long time to see us, and when they get into that room, they have often no idea what's about to happen or they may have had challenging experiences in the past. So in its original form, people are sitting there with you and you have a responsibility to make them feel comfortable, to build rapport, to build an alliance, and to create the space where you can get that really accurate information in a really rigorous way. The the interview can help us diagnose. They can help us formulate, we can put historical information into context. So from your chart review or any other information that you have, you can ask about it and clarify. And you can also do some work to support people emotionally, to help regulate them or to provide them with hope or some context or an explanatory model for what they're going through.

  Dr. Alex Raben: [00:04:54] It seems that we would define it sort of as the most important tool in our toolbox. And obviously one of the objectives would be the diagnosis and coming up with a formulation about the person and then a plan. But it's also useful to get historical points from that person down on paper to build an alliance, because this may be the first time someone is even seeing a psychiatrist. And there's also a room for emotional support and some sort of supportive therapy work. One other thing that I thought was nice that I think is in the Shea book that he mentions, is this "installation of hope idea" which I thought also made sense and can be a nice way, particularly to end off an interview. I don't know. Lucy, did you have any other thoughts to add to that?

  Dr. Lucy Chen: [00:05:47] I think it just important to emphasize that the utility of a psychiatric interview isn't strictly for data collection, that there's many opportunities for therapeutic work. And the intention behind a psychiatric interview allows us to have a clear sense of the picture of what's going on. But that therapeutic alliance also allows us to get more data and more of a sense of what's going on.

  Dr. Alex Raben: [00:06:08] We'll talk more about that therapeutic alliance when we get to the process part. I've divided up this idea of the assessment into two conceptual ideas, one being content of the assessment and the other being processed. If we do focus on content, I guess it's important to have a structured way to asking your questions, having a sense of where you are in an interview. We often get taught a fairly prescribed structure to our interview, and we're going through our training. Now, this may vary by school or city, but we'll give you the Toronto version here. I'm wondering if we can review together the major components and rough order of these components for a full assessment.

  Dr. Juveria Zaheer: [00:06:59] Absolutely! I would want to add to thinking about the purpose of the psychiatric interview. I also think if we're going to be suggesting a treatment plan, the psychiatric interview gives us an opportunity to better understand people's goals and people's past experiences, to co-create a plan that actually makes sense for them rather than a sort of a laundry list stemming from diagnosis only. I think Lucy's point is really well taken in terms of the psychiatric interview. I think it's important to start with a confidentiality disclaimer or a discussion of the limits of the assessment and the limits of confidentiality in the Emergency Department or in an outpatient setting or in an inpatient setting, for that matter. You want to be familiar with the reporting guidelines for your province or for your state? So in the emergency department where I work or at CAMH, we want to make sure that people know that if they disclose any information around unsafe driving, that there's a mandatory report to the Ministry of Transportation. We also let people know that if they have children and children are potentially at risk based on the content of the interview, we are mandated reporters to the Children's Aid Service. Then we also talk about if people disclose violent ideation towards someone else or thoughts of harming somebody with an intent or plan, or if they disclose suicidal thoughts that are beyond the scope of what can be managed as an outpatient, there would be a duty to follow up or potentially think about next steps. I think it's really important, though, because people can come in and they can be nervous that if they say I'm having suicidal thoughts, that they're immediately going to be, in their words, locked up or have their rights restricted. So, it's important to do a little bit of normalizing around that, that often people will have thoughts of suicide. Disclosing those today doesn't mean that we're going to end the assessment or we're going to act in ways that you're concerned with. We just want to know, we want you to feel safe and know what the limits would be.

  Dr. Juveria Zaheer: [00:08:51] Then moving on from the confidentiality, we always want to know who somebody is that we're interviewing. I think we always teach our clinical clerks or medical students or our first-year residents, get a really strong ID which consists of age, marital status, where the person's living, how they're supporting themselves. Do they have any children? Do they have any religious connections? I think one of the challenges, and I'm sure residents have had in medical since have had this experience is, you go in and the person is saying "Isn't it all right in front of you? Why are you asking me these questions?". Sometimes I think it's important to be transparent about what you know. So, "Mr. Smith, I see here that you're 54-years-old and that you're married, is that correct?" That way people know that you're thinking of them and that you're not just going by the book or by the list. The next piece we would want to know is the reason we have a referral and or the chief complaint. We always package those two together and sometimes in a perfect world, they're the same. The reason that the family physician or the emergency physician referred to you, is the same reason that the client feels that they're being interviewed by you. Sometimes it can be different, and I think it's really important to clarify those two pieces. So "Your family doctor sent you here because they're wondering if you have a diagnosis of depression.

  Dr. Juveria Zaheer: [00:10:06] I'm wondering what you were hoping for today" or "What is most concerning for you today?". That way you can compare the two and triangulate the two. Then we move into the history of presenting illness, which is really important. I know that sometimes for learners and for experienced psychiatrists, it can be really challenging to know where to start. If somebody tells you, I've been depressed my entire life, how do you differentiate between a past psych history and a history of present illness? We can talk about that a little bit through the course of the podcast but in general, the history of present illness is the story. It's what's happening. What brings you here? How are you suffering? How is this affecting your life? When did this all start? We talk about we want to give people narrative space. They've been waiting a long time to tell you this story. They've been practising potentially in their minds what it's like to tell a psychiatrist or a psychiatry resident or a medical student their story. I think giving them some space listening actively, one of the strategies that I use during my HPI's and I tend to be a little bit impatient, I'm emergency physician, so we want to do things really quickly. I ask myself to pause and to count to three during the HPI.

  Dr. Juveria Zaheer: [00:11:17] If someone says "I feel like I've been depressed for the last three months and things are just so terrible right now and I don't know what to do", it can be easy then to jump in with an empathic statement or to try to clarify or to continue with your review of symptoms. I sit there sometimes and I say, okay, Juveria one, two, three. That gives them the space to tell you more. We always want to make sure that we understand what's happening with them, but we want to very rigorously review the symptom clusters as well. I know that you have other podcasts that go over this, so I won't go over in too much detail. But you want to focus on mood and on anxiety. Sometimes the anxiety piece can be missed. We focus so much on the depression, but we also want to make sure that we screen for anxiety disorders as well in our interview. We want to screen for psychosis, potential organic causes, any medical issues, any recent TBI, seizure, safety and also want to think about addiction in this section. I think sometimes we can save that and not place it in the HPI because we will screen for it later. But I think it's important because it could be really contributing to what you're seeing now.

  Dr. Juveria Zaheer: [00:12:27] If you do a quick screen there, you can ask for more details later but if alcohol use or opioid use is driving the current presentation, you don't want to miss it. You don't want to be caught out in your stressor or more importantly, clinically, by leaving it till the sort of later in your assessment under that rubric and then thinking "this really colours the HPI". You want to ask about recent stressors. People's narrative models aren't the DSM-5. They're going to say X happened, then Y happened, then my sister was sick, I lost my job and I had to go to school. People have a narrative and it's really important to honour that. If you can, even in the HPI, it's nice. We can talk about that a little bit later in terms of ways to build rapport, so I'll leave that for now. Safety. We talked about SI (Suicidal Ideation), HR (Harm Risk) but we want to think about violence more generally than that, driving children, any other risks as well as any recent treatments. "You told me that you came to your family doctor about six weeks ago, you said you've had depressive symptoms for three months, tell me what you guys have done in the last six weeks". People are always trying their best, so to reiterate that and to say "What kind of treatments have you had? What's worked? What hasn't the past?". Psychiatric history is a little bit different than the HPI.

  Dr. Juveria Zaheer: [00:13:46] I think about the past psych history narratively and I try to create a timeline in my mind. I start with a service utilization history actually, and people have different approaches. For me, service utilization is something that I can really hang my hat on and then I can explore around it. If you say "when was the first time you were depressed", it gets a little bit muddy. When was the first time you saw a psychiatrist or came to a healthcare provider for mental health issues? Then did you feel well? Didn't you feel well? What happened next? "What happened next" are sort of the three best words you can use in one of these assessments, because you want to really make sure that you're really steady and clear on what's happened. You want to understand how many hospitalizations a person has had, how many emergency visits, and how those visits tend to cluster over time. So if someone's had three depressive episodes and they only really visit emerges or family doctors before that, it's really important for us to know, so we can get kind of a template.

  Dr. Juveria Zaheer: [00:14:49] But the really important thing to remember is that a lot of people who have mental health issues don't get treatment and they can't access treatment. They've been suffering in silence, having issues with stigma. After you do your service utilization history, then I'll go back and say "I'm so glad that you were able to seek care" and comment on whether the experience was positive or negative and say, "I imagine, though, that there have been times where you have felt X (depressed, anxious, distressed). Have there been times where you felt that way and you haven't gotten care?". Then you can see if you can understand those periods and understand whatever functional impairment came along with that. You want to get in your past psychiatric history and a really good history of past suicidal behaviour. Some people might spread it into two different areas, but if you're in that past history, it might be a nice place to get that history of suicidal behaviour. Right afterwards I'll say "You told me what was going on in your life at any point in that narrative or story. Did you have suicidal ideation or do you have a suicidal behaviour?". We'll talk about that later for sure. A past medical history is really important and you want to make sure that you get that next.

  Dr. Alex Raben: [00:15:59] I wonder if we can pause here just because these sections we've covered are a lot of the more psychiatry specific sections. There also are some of the trickier sections of the history, particularly the HPI as you were mentioning. It can be hard even for more advanced practitioners to know exactly what should go in there, and I don't think there is any right answer, so it's probably not helpful for us to completely parse it out but  since we covered so much ground, I think it's helpful to kind of mull that over a little bit. One of the things you mentioned is that someone can come in and say "I've had depression my whole life". What is a strategy a learner can use that would allow them to create understand the more recent story in that scenario?

  Dr. Juveria Zaheer: [00:16:49] I think that's a great question, and there are a lot of process components to it in terms of reading the person in front of you, knowing what they're going to respond to and what they're not going to respond to. In general, from a content perspective, there are several things you can do. You can say "Dr. Jones referred you to us about a month ago before you asked for that referral or before Dr. Jones put that into place. How long before that had you been having difficulty? I'm so sorry to hear you've had depression your entire life. Would you say that this is the worst it's ever been? If it is the worse that's ever been, when did things start to slide downhill?". You want to find whether they're very clear demarcations or whether they're more artificial. You want to find something to demarcate. You can also guess and test a little bit. If they say that it's probably been really bad for three months, you can get some information in your HPI. One of the questions I like to ask is "What if I had met you four months ago? What did life look like for you then?". That's a way to guess and test that you're making sure that you're actually cutting at the right place. People who have histories of trauma or people who've had longitudinal mental health issues, psychotic disorders, it might be a little bit more challenging to clear that quickly. In my experience in the Emergency Department, almost everyone can say "You know, if I look back on it, things have been really hard for X". 

  Dr. Alex Raben: [00:18:15] I know in my own going through residency I learned the importance of getting a duration on the chief complaint early on. Then you know that's that demarcation point if someone's able to give that to you.

  Dr. Juveria Zaheer: [00:18:36] Absolutely. I think it should be one of the first things you do in an empathic way. But to get that at HPI and demarcation early allows you to link it to the chief complaint and it allows you not to get lost in the weeds. I think if you're working clinically and you have some time as a resident, if you have someone an hour and a half booked for your assessment versus 15 minutes, these things can be a little bit less urgent. I think always clinically, it's really good to have that demarcation and especially if you're going into a testing situation and into an observed interview, you really want to show your interviewer that you are pretty clearly dealing with a certain time period. I think clients appreciate that structure because otherwise you can imagine if someone asks you to recount your own social history or your own work history, you'd really like to know where they'd like you to start. I think people tend to appreciate that structure.

  Dr. Alex Raben: [00:19:32] As you say, it allows you to tailor what comes next and which we were talking about the review of symptoms such as the mood symptoms, anxiety, psychosis, organic stuff like drugs and TBI, seizure and then safety of course. I think certainly one strategy is just to go through that entire checklist. But I think with time and experience, we tend to actually tailor that a bit more towards the chief complaint. And we may leave out things that are a bit extraneous or may not allow us to be as efficient. How does one move through that review of systems because you could really get lost in every anxiety disorder? Is there a way of touching on things without going too in-depth?

  Dr. Juveria Zaheer: [00:20:23] Absolutely. I think when you're starting, you want to really make sure that if pressed, you would know exactly which questions to ask, if you had to do a very thorough screen of X, Y and Z. I really like your point that the more experience you get, the more you know what you can adapt and what you can leave out. You have your screener, then you have the follow-up questions. I think that's a really good approach to think what is my screener and what are the questions that I ask afterwards? If I would encourage all learners to have a look at a skid, a structured clinical assessment to see what screeners are used even in a research context, because that can really help you figure out what to ask and how not to get lost in the weeds. The other thing I really stressed to my learners is really pay attention to free information. Free information, paying attention to it, coding it and filing it in saves you so much time and it actually is experienced really positively by the client. If I'm giving you my HPI and I said "the last three months have been impossible, I haven't been able to sleep, I haven't been eating. It's really tough to get out of bed to go to work". When you're screening you might not want to say "how is your appetite?".

  Dr. Juveria Zaheer: [00:21:38] I learned so much from my learners and I really appreciate the opportunity to watch them interview. I always take things from my learners to the one thing that I always pay attention to is the look on the patient's face when the person is asked like "Oh, well, tell me, have you had any changes in appetite?" after they said they spent 5 minutes describing how they used to love to cook and they're a chef.  I think you're nervous, right? You want to make sure you don't miss anything. But if you have something in front of you where you can file and tick off, it's also a great way to show the patient you're listening. So that way when you get to the mood to screen, you've told me that in the last few months you're not really enjoying anything, you're not eating, you're not sleeping, I'm wondering about if you've had any feelings of guilt. Then when you move to anxiety, I always ask "Would you say that you're an anxious person? Has anyone ever told you you're an anxious person? Has your anxiety been worse or better in the last three months? Has it been worse or has it been about the same?", if it's been worse "What symptoms of anxiety do you have? Do you have panic attacks? Are you generally a worrier?". You can do these things really quickly and conversationally the more experience you get. With psychosis, if somebody has a very well-organized mental status and they're presenting for depression and anxiety, I always ask about psychosis. But you might not want to go through every single cardinal symptom of psychosis because people can also experience that as pretty stressful if you want to go through each and every single one. So, you want to be careful there. I think there's a couple of places where I stack questions, we always tell you guys don't stack, don't stack, but I always stack for my mania screen only because, a lot of people say "have you ever had the opposite of depressed or whatever?" but it's not super diagnostic. There's mixed episodes and people have a variety of emotions. But to pair sleep with energy "Have you ever had periods of time where X and then that" saves you that whole screen. OCD you can stack as well "recurrent intrusive thoughts of X, Y or Z", that saves you that piece, too.

  Dr. Alex Raben: [00:23:46] Right. The idea being that, if you have these screener questions, then if you get negatives on the screens, so someone is saying "no, actually my mood is fine and  I'm still enjoying life", then by virtue of that, depression is no longer something you really need to delve into as much. So that might save you some time and similar with other types of diagnoses.

  Dr. Juveria Zaheer: [00:24:11] You don't want to go hunting. Someone's telling you what their chief complaint is and you want to really focus on that piece. You also want to make sure that they don't have a psychotic disorder that you're missing. You want to make sure that you screen and pay attention to mental status. Ggain, you don't want to necessarily get lost in the weeds.

  Dr. Lucy Chen: [00:24:27] It sounds like for HPI, how I've done it is that I focus a big chunk of time on the recent context of their chief complaint. Again, that's getting a story of why they came in the first place in terms of the assessment. For me , how I've prepared for STACERs which are clinical exams where you have to do a 50-minute psychiatric interview, that's comprehensive and then create a formulation and plan on the spot. What I've done is, I've also created six horizontal boxes and each of those boxes I've just had just to remind myself, I have a mood, depression, mania,  a psychosis screener, anxiety, substances, and then safety. Then I usually leave the organic stuff actually for the medical history, but I can include that there if it's very relevant. If you have those titles kind of written in these boxes, you won't forget. That's kind of a way to kind of organize yourself when you're approaching  HPI. So the first part is just the story, the context, and then those six boxes to screen for and then that could transition into the past medical, the past psychiatric history where you're asking about recent treatments or what's been helpful in the past or past episodes. Maybe they're presenting with a depressive episode now, but they've had a manic episode in the past. But just for the HPI and having a visualization on the paper could really help you with an approach when you're kind of feeling nervous.

  Dr. Juveria Zaheer: [00:25:59] I will say that I still do that in the emerge. If I see someone instead of writing down every word they tell me evenwhen I'm listening to the HPI, I have my boxes or my rubrics and if I hear "I went to a work and then I felt like I wanted to hide under my desk because my heart was beating so quickly", I can make a flag for myself of "panic". If I say "I've been drinking a lot more and my friends are really worried about me and I feel so socially awkward all the time", I can make those notes in the little boxes and that way when I come back to do my screens, I already have the information there and the scaffold and I can follow up on it. I really like that approach too, it's great.

  Dr. Alex Raben: [00:26:37] We've  went back to HPI there because it tends to be the biggest struggle for learners. I think it's important for us to really flesh that out. We had just finished up past psychiatric history, why don't we get back to the rest of the content of the interview?

  Dr. Lucy Chen: [00:26:53] I just want to highlight, though, for past psychiatric interview, it's also including all past admissions. It includes past psychotherapy. If we ask "have you ever finished a course of CBT", some patients will say "I've done CBT in the past, but it's like I missed half of all of my sessions". So getting a sense of completion of the psychotherapy that they've pursued, any sort of past history of medication trials, a sense of what the dose was and how long they were on the medication some patients will try medication for about a week and then they'll discontinue. So it's not really considered a full course of medication, and that's informative in terms of your formulation and plan for medication options for this patient. Also asking about neurostimulation or past psychiatric treatments in the domain of rTMS or ECT.

  Dr. Alex Raben: [00:27:45] So, treatment is defined quite broadly.

  Dr. Juveria Zaheer: [00:27:48] I think exactly that. In the past psych history, one of the things that you want to do is also get someone's opinion on what happens. If someone said "I did CBT", then first of all "what did you actually do? Tell me more about that", because some people's experiences of CBT might not be what you might consider to be CBT; "I did talk therapy" "what did that look like for you?". I always ask people what helped and what didn't, and asking people why they stopped treatment or  medication is really important if they say "I did 16 sessions of IPT and I felt really great afterwards", that's very different than  "I did 8 and I felt worse when I stopped then when I was doing it". Or before around the medication piece, I really liked how you put it. You want to know when they started what the dose was, what benefit did they have, if any, what side effects that they have? You really want to ask about adherence as well.

  Dr. Juveria Zaheer: [00:28:47] Everybody says "I took it regularly", but to say things like in a typical week "how many doses would you miss" or "would you have to refill? Would you always on time and refilling your prescriptions or was there always some  left over?", those are really useful questions to understand. The other thing I would suggest for is that you think about your assessment is going to be someone's past psych history sometime in the future, right? So,the use of skills is really important. If someone had a past psych history and you can find the chart, you see that they have a bunch of nines on the chart, it's really useful. People might argue, but I think about scales as part of the HPI, having people do a GAD-7 or PHQ-9 is really important as well to understand the HPI.

  Dr. Lucy Chen: [00:29:36] Then with regards to also past admissions, some patients will have several admissions. You can just get a sense of how many admissions in total. At what age were you first admitted? When was the last admission? What was the worst admission and how approximately how many of those admissions were for If the chief complaints relate to depression? Or perhaps if they've had a past history of mania, how many of those admissions were related to mania?

  Dr. Juveria Zaheer: [00:30:01] Awesome! And what was your worst admission? What was your best admission? What worked really useful?

  Dr. Alex Raben: [00:30:05] Then we get into some the part of the assessment that is less specific to psychiatry, the past, medical history there. Are there things in psychiatry were  particularly interested in from this perspective, from the past medical history?

  Dr. Juveria Zaheer: [00:30:21] As a person who does a lot of suicide research, there are certain conditions that are linked with suicide and these same conditions are linked with mental health concerns. To ask about head injury and any post-concussive syndrome symptoms, I ask about seizure as well. It's important to ask a very general review of system, you want to make sure that someone doesn't have a history of hypothyroidism that's undertreated generally physically how are you feeling for women. I always like to ask about their menstrual cycle. I think it's really important as well as contraception, thinking about planning for medications or family planning in the future. I think these are pieces that you probably don't want to miss. Then you think about the medication you want to have an eye on, the medications you might prescribe. A history of diabetes, a history of insulin resistance, these things can be really important as well. Then in your HPI, too, you're going to be asking about what's happening. If someone identifies particular physical changes and physical symptoms, you want to think about that too. If you're working with older people, you want to think about cognition.

  Dr. Alex Raben: [00:31:27] I've put it separately here on my page, the substance use history. Now, we already said that we would often already have screened for this in the HPI. However, here this is more like a past psychiatric history, but for their substance use, I have to be honest that I usually will clump my "substance use history" in with my "past psychiatric history" and just ask about addictions treatments in the past, whether they've been involved in AA (Alcoholics Anonymous) or something similar. Then get an idea of when their use first started and when it became a problem for them as defined by them. Then getting into the details of how much they're using and what that actually looks like. Do you guys have other comments on that? I know I'm not being terribly specific, but those are some of the highlights that I would ask around for sure.

  Dr. Lucy Chen: [00:32:22] I think also critical aspects of the substance use sort of history and context is a history of withdrawal and whether or not there's been any complicated withdrawal with seizures, delirium tremens or have they ever been hospitalized in the context of intoxication or withdrawal.

  Dr. Juveria Zaheer: [00:32:36] I agree. I think you want to take the care with a substance, use history as Alex said, exactly as you would with the psychiatric history. And there are going to be particular things that you really want to be concerned with. I often will ask people "when did you first start using alcohol? Has your alcohol use changed over the course of your life". People will sometimes say "when I'm feeling more anxious and down", "I try not to drink", "I'm not drinking right now". I ask people "when was your use the heaviest", and even people who don't have heavy criteria for substance use disorder will say "when I was in university, I binge drink or X or Y" . Then you always want to ask about other substances even sometimes people are a bit taken aback "But cannabis is legal". I always ask about cannabis specific. Quickly "do you use cannabis, how often". People sometimes forget, they won't consider it to be a drug. You want to ask about cocaine and you really especially now want to ask about opioids. Have you ever used opioids that were prescribed or not prescribed to you? It's a really important question. Then thinking about, as Lucy said, tolerance and withdrawal. The dependence right here is super important. You also want to ask, if you do end up treating this person substance use disorder or referring on "have you ever been on agonist therapy? Have you ever had anti-craving medication? Have you ever required residential treatment?". I think those are pretty important questions to you. Then asking about what people's goals are, especially if they're coming to you for mental health reasons. You want to know when you're taking this history in the past "Has this been something that you need a treatment for? Where are you at right now?".

  Dr. Alex Raben: [00:34:12] Right. Moving to medications. This would be similar to any other medical assessment, although we obviously pay special attention to psychiatric medications. But I don't think we need to spend too long on that section. You would obviously just want to know dose and timing and all of that. If there aren't any naturopathic medications and then of course allergies are important in our field to know about. Now we move on to family history. What do we want to know from a psychiatric perspective in terms of family history?

  Dr. Juveria Zaheer: [00:34:53] It's interesting cause I think the family history, we think of it as something that's a little bit separate, but the family history and the social history and the developmental history are so tightly linked. If someone has a parent with serious major depressive disorder or history of suicidal behaviour, that's going to affect how they live their lives growing up. Then sometimes it can feel a little bit invalidating or you might end up wasting time, might be a little bit less efficient. For the family history, sometimes I will use that to segue way into the developmental and social history. "Tell me about your family. Who's in your family? Who's in your immediate family? Did anyone in your family ever have mental health issues? Did and has anyone in your family ever been hospitalized?" Sometimes, I'll remind people meaning siblings, your parents, your cousins, your aunt's or uncles. Because mental illness has been so stigmatized, you often get a history of an aunt or grandma. And it's a little bit unclear.

  Dr. Juveria Zaheer: [00:35:58] But if you ask "anyone who seemed a bit different or had some challenges", then always ask about substance, family history of substance use too, don't forget that one. Then family history of any suicidal behaviour is really important because that in itself is an independent risk factor for suicide. Then you want to take that information and not just not do anything with it. So finish your family history and use that and make sure you remember that when you're taking your social history "you told me that your mom was hospitalized for depression, what was that like for you?" The last thing I just wanted to say for family history that's really important is if someone tells you "my brother and my mom had bipolar disorder", you want to ask what medications people have been on and what's worked for them. That can guide your own treatment if you know that "my mom had had bipolar disorder, she was in and out of hospital, but she did so beautifully on Lithium and she has been out of hospital since". That can be important to know.

  Dr. Alex Raben: [00:36:54] Now we come to the social and developmental histories, which is another area that is very important to the psychiatric assessment and  larger in terms of number of questions than perhaps any other area of medicine.

  Dr. Juveria Zaheer: [00:37:09] I think about this a lot as an emergency psychiatrist, "if you've ever been to the doctor, if anyone listening or if you guys have ever seen a physician", it can be really tough if you're in an emerge or seeing your family doctor and you feel like they don't know you like they're asking. I'm sure people who are listening often work in health care. Tthat feeling when you go to the doctor and you say "Do I tell them I'm a resident? Do I tell them I'm a medical student?". It's kind of a weird feeling and especially with mental health, if people want to come and they do want to tell you their story, but they also may be feeling a bit nervous to take up your time. This developmental social piece is such a lovely time to actually engage with someone and to understand them and to take what you've learned about them and make sure and show your work. Show them that you remember the things that they've told you so far. I have combined my developmental and social history, so I don't have to go over both separately. My bias is as a general psychiatrist, people who are developmental, who are child models and psychiatrist are going to do a much more thorough developmental history than I would.

  Dr. Juveria Zaheer: [00:38:12] This is the approach that I take. I keep myself to a short period of time and I hit my high points. I start with "tell me where you were born. Tell me a little bit about the people in your family. What was your mom like? What was your dad like? You have siblings, are you close to any of them? What are they like? Did you do you know if your mom had any problems with you when she was pregnant or if she's any substances? Did anyone ever tell you if you walked on time, if you talked on time? Did anyone ever say what kind of baby you were?" Often people will say "I was like a great baby" or "I was so angry and my sister was so calm" This is important information in terms of temperament. "What are your earliest memories of school? Tell me about school. Did you like school? Didn't you? What was tough for you if you didn't like school? Was it the social aspect or was it the educational aspect?". This is a great place to screen for ADHD, developmental disability, cognitive disability. "Were you ever in a special classroom? Did school come easy? Did it come hard? Was your childhood pretty happy? Was there any trauma? Was there any bad things that happened in that way?" You're getting a more organic trauma history than has anything ever had.

  Dr. Juveria Zaheer: [00:39:27] "Is anything bad ever happened to you? Have you ever had physical, sexual or emotional trauma? What was the toughest thing that happened to you when you were high school? Tell me about high school. Tell me about university". Then I go from there to. "When was the first time you had a romantic relationship? What break-ups been like for you? Tell me about your current partner so you can sort of take it through time?  Are you doing now what you thought you would be doing?". Then getting a sense of what work is like for them sometimes as people. "How do people see you at work?". Because people come in and they're telling you about really hard stuff and they might think "if they saw me elsewhere, this is kind of what I'm like" or "what and how do you see yourself? What if I had met you before you got sick? Are you pretty similar? Pretty different?".

  Dr. Juveria Zaheer: [00:40:13] Then I ask. So making sure I get a work history "who are the most important people in your life?" is really important for safety planning and really important for understanding people's perspectives of mental illness. I ask, does that person know you're here? How do they understand what's happening to you? How do they show support? What do you wish that they could know? Because if they say to you "my partner thinks that I need to buck up and medication isn't real" then that's very different than "my partner's sister had panic disorder and did  well on Cipralex". So it's going to really guide how much work you're going to do for psycho-education. It's going to guide your treatment plan. I ask people "What are your goals? Where do you see yourself? I know that this is really hard right now, but what do you believe in? What do you hope for? What were you hoping for today". These are really important questions. So it's like a very whirlwind tour through someone's history. If you're engaged and you use the free information you've given beforehand and you have a structured life history approach, you can get it done really quickly and effectively.

  Dr. Alex Raben: [00:41:22] I guess that's really helpful too. I think you took us a really nicely right through from like the beginning to the end of a social history. It seems you take a chronological approach in terms of starting  with birth and moving from there chronologically, conceptually. One way that can that I find helpful to think about it is sort of the categories; development, work and school and relationships. So how do they function in these different domains of life? These are the domains I want to make sure I'm covering as well so that domain approach mixed in with the chronological approach can ensure you're sort of triangulating and not missing anything important.

  Dr. Lucy Chen: [00:42:08] I think in terms of a focus for a social history, I  will sometimes derive it from the HPI in terms of the stressors that they presented with. A lot of the times the trigger or the stressor was a relationship, break-Up or some family conflict. I'll flesh that out a little bit more in the social history, but I'll sometimes keep on track and I'll flag that it was something that they had mentioned. Then I'll elaborate it on further in the social history.

  Dr. Juveria Zaheer: [00:42:32] There you can almost even work backwards. So I know that you came in because you've had a really difficult time in your romantic relationship. Tell me more about your partner. How are things beforehand? Is this your first romantic partner? Then you can even work backward within that domain and you want to you're not going to focus the same weight on each domain. If someone in the HPI is really challenged by work stress, if they're a resident who has been really traumatized at work, if there's somebody who lost their job and is now or is retired, you want to in your social history focus a lot on that work and identity piece. If they talk about trauma, that's the piece you want to focus on. So, you want to get all of it but different pieces are going to have different weight. It's just like if you met one of your friends or you met someone on a blind date you wouldn't necessarily want, you want to make sure that you talk to them, feel connected, and ask the right questions about why they're there.

  Dr. Alex Raben: [00:43:22] Then I did put the category of "past legal" here right at the end. I have to be honest, I don't have a good spot for this in my own interview. I tend to put it actually right after my HPI, just to remind myself.

  Dr. Lucy Chen: [00:43:36] Sorry, Alex, before we go and dive into the legal, one more aspect of the social history, which is important because I think we didn't talk about trauma specifically and sometimes the trauma for me will come out actually in the social history. I'll ask "is there anything salient that happened in your life" or "was there ever something that was that you consider traumatic in an emotional or mental or physical context or sexual context that was really important, that it really affected you". Then if that's actually flagged, you might have to delve deep into sort of a PTSD screen but sometimes that comes up for me in the social history and I just want to flag that it's something that could be considered.

  Dr. Alex Raben: [00:44:14] I think you flagged something else. That's an important point that you can always go back if you find something in social history that's clearly really important to that person's presentation, you can always go back to your HPI. It does take a bit more time, but if it's crucial, you really should do that.

  Dr. Juveria Zaheer: [00:44:31] The last point about things that we may miss, you want to ask about people's "sexual function and health" too, especially with the medications we prescribe. It's a symptom of depression, side effect of medication. So when you're do something in the social history of my kind of screeners "do you have any concerns with your sexuality right now, with desire or with your sexual experiences?" and that's kind of an open place for people can feel safe to talk about it. With respect to the legal history, I think you're right. It doesn't seem to fit naturally anywhere, and it sometimes comes out of the blue for people. I think we also need to be confident in the questions that we ask. When you're seeing somebody on medicine and you're asking about they're presenting with cardiac and you ask about GI(gastrointestinal), you don't feel shy about it. Of course, this is much more serious and an emotional potentially traumatizing, but if I don't get the sense that it's an issue within the HPI. Sometimes people say "I have these charges" and if someone talks about relationship conflict in the HPI, I'll ask about "intimate partner violence" because that's really relevant for the legal, the violence history I do as part of my suicide risk assessment. So because it's risk, I tack it on after that we can talk about that in the next session and then the legal sometimes comes up in the social history. If it doesn't, I'll say "have you ever had any difficulties or challenges with legal charges". It almost always comes up if you're taking a not a super thorough but a pretty comprehensive social history. But if it doesn't, "have you ever had any challenges with legal charges", and people will tell you.

  Dr. Alex Raben: [00:46:06] So, in the time that we have left, I would like to shift our focus now to process being basically how we actually conduct the interview itself, the ways we are in the room and before we even go in the room, that can set us up for success and ensure we're meeting all the goals of a psychiatric assessment. I guess my first question then would be what would we advise learners do before they even go into the interview room that can set them up for success? If you guys have tips around that or things that you find helpful yourselves.

  Dr. Juveria Zaheer: [00:46:45] I think anyone who's ever worked with me knows that I really believe in the value of a thorough chart review for lots of reasons. One, it makes you more efficient because you have a sense of what's happened before. You don't have to feel like you're in the woods when you're asking the questions. When you're taking the past history, you can make sure that things match up. I think it's really important to review whatever information you have and if there are ways to get more information to get it ahead of time. That's my  big thing. I think we talked a little bit about templates. I think templates are really important. Just like in any industry, there are checklists. Like a pilot doesn't say, I'm so experienced that "I don't need a checklist", experienced surgical nurses don't say "I don't need a checklist". I think having a template and there's some pretty good evidence in suicide risk assessment that shows that a template is particularly useful, especially for junior learners, I think you want to get a sense you want to sort of sit with it, get a sense of what you think is going to happen.

  Dr. Juveria Zaheer: [00:47:50] Sometimes I take notes to myself of what I think I'm going to offer, what I think the diagnosis is. And you always want to see it as just a hypothesis. There's some nice research that shows that being empathic and being a good listener is the best way to avoid cognitive errors in medicine and to be open-minded and to give people narrative space. You also want to say "is there anything in here that makes me nervous or makes me feel a bit strange". I always tell my learners a story "when I was a medical student, I did an elective at CHEO, in the Child and Adolescent Inpatient unit there, which is the Children's Hospital of Eastern Ontario and Ottawa. I knew I was going to do adult general psychiatry, but I wanted to see what it was like. I was maybe 22 or 23 and my brother and sister were 13 and 11, and my cousins were around that age. I dreaded going into work every day because it made me so sad. I think that it was just because it reminded me of my siblings.

  Dr. Juveria Zaheer: [00:48:51] I think that's not unusual as I've become a parent, I have a six-year-old and an 18-month-old. So my experience is of as my daughter calls them, "cool teens" has changed a little bit and I feel like very maternal. So to know  where you're at, if there's anything, if you see someone from the same ethnic minority group or if you see someone who is the same age as you, to  think a little bit about how you're going to feel when you go into that interview to reflect. Then, that's around boundaries, but it's also around  checking on yourself and also, it feels very different to do your first consultation on a Tuesday morning when you've had a week off and you're caught up with your paperwork. When you've been on call all night and you're doing it at 3 am in the morning and you've seen 12 people to be kind to yourself and to kind of reflect to know that you can't be perfect all the time and to maybe take a time, take some time to like have a coffee or to centre yourself. I think can be really useful.

  Dr. Alex Raben: [00:49:46] For sure. When you said call, I immediately thought of myself at 4 am in the morning and I'm not my best or most empathic self. Being aware of that alone is so helpful because you can stop yourself and really check-in around that, so you're doing the best you can at that moment. You also mentioned "feeling of nervousness" and that made me think of the "issue of safety" as well. Maybe we should just quickly touch on that. From my perspective and I'd love to hear you guys recite those, basically, I don't think there's any question that's more important than your personal safety. If you're in the room and you feel unsafe, you just should leave. If it's an imminent risk, press a panic strip or a panic alarm. There's no need to be a hero, stay and try to  get an interview when it's not going to happen in your safety is at risk for sure.

  Dr. Lucy Chen: [00:50:38] Stay tuned for the episode with Dr. Orlowski about managing aggression in your own personal safety during an assessment.

  Dr. Alex Raben: [00:50:45] Context, excellent plug.

  Dr. Juveria Zaheer: [00:50:47] I think about my own sort of role models in this department, whether it's Dr. Lofgren or Mark Goldstein, when I was a trainee and they both said whether it was one on one or formal in a formal teaching session, listen to your body. If the hairs stand up on the back of your neck, if you feel nervous in a room and obviously, sometimes heuristics  can be a function of sort of prejudice or oppression, we don't want to get too carried away with it. On an individual level, if you're in a room and you don't feel safe, you end it because you can always re-group, right? You can, if you start to have that feeling. I always say to my learners, just leave the room politely to say, I'm just going to take a second. Go touch base with your team, maybe come up with a strategy. If you're a trainee, you shouldn't sit with that feeling alone. You can go to your supervisor and say "I'm sitting with Ron and I'm doing an assessment and I feel like he's responding to stimuli and he's he seems a little bit paranoid" and it's your supervisor's responsibility to come into the room with you, to maybe change up your approach, to maybe move the location of the interview. But your safety is the most important thing to every staff member and to your clients as well. Your clients don't want their doctors to not feel safe and they want to feel safe and supported. We would say the same thing to clients. If you're in a room with a person in a position of power and you feel uncomfortable or you feel unsafe, you always have the right to stop things and to get up and to take a break, too.

  Dr. Alex Raben: [00:52:12] I think that's an important point that we have to make here today, and I'm glad we touched on it. I want to shift now to what actually happens in the room. We talked about the idea of a therapeutic alliance or therapeutic rapport being crucial in the interview process as a goal in and of itself, but also as a lubricant. Let's say, for moving an interview along, getting answers to questions you might not otherwise get if someone doesn't trust you. That's a big part of why it is so important. How so? How do we actually build rapport with people? What are some strategies we can use?

  Dr. Juveria Zaheer: [00:52:49] I think I would start by saying, I have a question for each of you guys, I would start by saying that sometimes we think about the ability to build rapport or to be present or to be empathic as a binary trait. It's either you have it or you don't. It doesn't grow or be that it's not relationship specific. I think it's important to take a step back and remind ourselves that these skills can be honed over time and they're all different things in your toolbox. What works beautifully for one person, for one client may work terribly for another client. What works really well when you're awake at 3 pm., works terribly at 4 am in the morning. We would say that I think about rapport as little different techniques and tools that you use, that you have in your bag, that you try out, you guess and test them. Sometimes it works and then you might want to do more in that kind of vein. Sometimes it doesn't. You want to try something else. I think, it's not like someone is an 80% rapport person and someone is a 30% rapport clinician, is a lot of it is fit. There are some universal pieces for sure. But my question for you guys is, do you think that your interview style has changed in five years? Do you think that you've gotten better or do you think that you've become more flexible or what has changed for you in this field?

  Dr. Lucy Chen: [00:54:05] Yeah, for sure. I think as PGY-5s, now we are doing a lot of reflective work in terms of our changes, in  our approaches and being mindful of what's been helpful and what hasn't. I've noticed that I feel a lot more relaxed with knowing some of these sort of components of a psychiatric interview and relying on my own clinical knowledge. So now I tap into more of just my general curiosity, I think that when this innate ability that everyone has, if you tap into your curiosity, you can get a lot of information and the patients actually really genuinely feel heard and then you elaborate from there. So, I think over the course of time, a lot of these things will become more innate. A lot of these things were really sink and they'll become second nature. And then you can relax and take in all the information and just use your curiosity to generate the momentum in the interview for sure.

  Dr. Alex Raben: [00:55:05] I think I would agree with you, Lucy. I feel a lot more confident myself as well and more comfortable in the rooms now. I think it's hard to pin down all the ways in which experience has changed the way I've done interviewing. But one that's relevant, I think, to what we're talking about in terms of the alliance is that I definitely use a lot more empathic statements and reflection, and I blend that in a more seamless way with my interview. I really have recognized the importance of doing that because it just once you have that rapport, you have so much more leeway not only in your questions but also in building that management plan as we were talking about earlier, which is one of the goals of the interview. That is something I place a lot more emphasis on now than I used to. I agree with what you were saying, Juveria that it's not that I was innately not a empathic person before, and now suddenly I've gained that ability. I think it's learning those that skill of how to to use your natural empathy and testing it out that hypothesis testing. So one thing I know, I read in say a while ago and I've I was rereading it recently and I think it's important is the use of empathic statements. These are things where you're trying to guess at someone's essentially subjective experience of what they're going through either in the past or in the moment. You can do that in a way that you convey. You really think you know what's happening or you can do it in a less certain way. You could do it in a complex or a basic way. I think that's an important concept that Shea mentions. As an example, I could just ask someone, what's their experience like if I see they're crying, "why? What's going on for you? I see that you're upset". That's not very presumptuous because I'm actually just wondering what's going on for them. Or I could say "your mother was very important and these tears are signifying that she was the most important person in your life". Now, that might be very empathic, but I may have that wrong. If I have that wrong, it could backfire. So it is about this sort of testing and maybe in the beginning not being too presumptuous and more asking questions.

  Dr. Juveria Zaheer: [00:57:26] I think that second piece you mentioned is a great interpretation for when you're engaged in dynamic therapy. Sometimes we do a little bit of psychotherapeutic work even in the individual assessment. I think the piece that you mentioned about being authentic and I love that combination that you both mentioned of like curiosity and confidence that when you're feeling more confident, things feel more seamless, and when you're feeling more confident in your skills, you can have the space to be more curious. I think I would say that we're so hard on our trainees and we're so hard on ourselves, sometimes we expect you to be to learn all of these skills and to be perfectly empathic at the same time. What I would say is that most people who choose psychiatry care about people, and they are empathic and they're interested in people's personal experiences, but then they're also learning like a ton of skills. So for our more junior colleagues to know that you're still a person, but you need to learn the technical stuff. Sometimes it'll feel like you're getting further away from being a human person, but eventually it will integrate and you'll get there. One of the things that I really do and it  stems from the curiosity with my clients, is I try to come from a place of transparency. I think about the two lines that you mentioned, Alex, you can either be very kind of to the ground.

  Dr. Juveria Zaheer: [00:58:45] "I see that you're crying. I'm very sorry. How are you feeling right now?" Or we can go to the other place of interpretation of "when I'm talking to you, you're thinking about your mother and how she wasn't supportive of you". There's also a third way, which is to be just really transparent. I do this a lot, and it's something that I think so important in psychiatry is to  sit there and say "when I'm sitting with you, it's so it's hard for me to see you so upset. I can't imagine what it's what it feels like for you to be carrying this. I'm wondering when I was listening to your talk, when you started to cry, I'm reminded of when you said this about your mom earlier. I wonder if they're linked. I'm not sure. What do you think?". That's a curious middle ground. Even that transparency can be so useful when they're structural pieces that you can't really control. When someone is annoyed that you're doing this assessment and you're not a staff psychiatrist, and then they're going to have to come back and talk to the staff psychiatrist, to be able to own it and say "I know I'm the third person you talk to. It can't be easy and I don't love coming in knowing that you've been waiting here for 6 hours for me.

  Dr. Juveria Zaheer: [00:59:59] How are you feeling right now?" If I'm certifying someone to say that "I know that no matter what you said, this was going to happen based on other information that I had I know that sucks. I'm really sorry, I wish it didn't have to be like this". To be pretty transparent about what you're doing and why. Often if someone says "am I scaring you" or if they swear, a lot of learners ask what to do in that moment and I think be transparent. Like, "it makes me really nervous when you talk to me like that and I'm not really sure what's happening here" and that I think to be honest, warm and set limits in that sense by being transparent is really useful. One of the things that I read about parenting that I love, that I think applies to all interpersonal relationships, including the physician patient relationship, "don't tell me what I'm thinking" and "don't tell me what I'm feeling". I think that works super well with clients to I think to be curious and to make interpretations, to be there and be present is so great. As Alex said, to not "don't tell me what I'm thinking, don't tell me what I'm feeling", I think that's really great.

  Dr. Lucy Chen: [01:01:09] Yeah, that's such an excellent thing to highlight and put the spotlight on this idea of transparency, because I think any individual or any patient going through this interview with some of the questions was weird, or they're sort of caught off guard like "why are you asking me about that?", I'll often explain to them if I note that if there is sort of like an affective change or there's something that signifying that they're uncertain about or they seem a little bit awkward. About what you're asking. I'll often elaborate and explain why I'm asking about these medications, side effects and the  length of time and the trial, because it informs us on how adequate the trial was and gives us a suggestions on what might be potential options for you that are more optimal.

  Dr. Alex Raben: [01:01:52] I think we've all mentioned something multiple times here, but I'll just make it more explicit for the learners is picking up on that affect in the room. If there is an affect change, particularly a strong affect change like someone is breaking down into tears, we want to pause on our checklist and our content and we want to address where that affect change has come from for I think, a couple of reasons. One, because it's often very helpful for our assessment and understanding the person, but also it does show a true human understanding and an empathic understanding that then feeds back and builds that rapport as well. I think that's something that sometimes I when I'm observing junior learners, I do notice that particularly with the subtle affect changes, they may not pick up on that. Then maybe down the road they do, but it's an opportunity that should be taken advantage of for sure.

  Dr. Juveria Zaheer: [01:02:56] There's a really lovely paper from a million years ago that talked about priests, and they were trying to measure how goodness or reciprocity or altruism. The idea was that if a person pretended to fall in front of a religious clergyperson, then they would be more likely to help than a random passer-by. I think what the study found is that it wasn't about if someone was a random passer-by or a clergyperson, it was about whether they had time or how they were feeling in that moment. I think for our junior learners, I love Alex's point. You know, it's harder early and it's not because it's because you haven't sat with so many people to see these subtle changes. You're learning. It's also because you have a million things in your head that you're trying to keep track of, and you're also trying to be a grown up and trying to be a doctor. And it's really hard to juggle all of these things. It's like we're teaching you how to ride a bike and juggle and we want you to be nice too. So just to know that it gets better and those skills are there and they're going to grow. I like that point.

  Dr. Alex Raben: [01:03:57] Right, maybe. Transitioning from that to kind of our last topic, we could talk about things that we find challenging or things that we generally categorize as maybe more challenging in an interview and how we might deal with that. I don't think we have time to go through all of our scenarios that we have here. But one scenario that is true or that I find particularly difficult. So maybe I'll highlight that one is the patient or the person or the client who is who we're interviewing, who is talking quite a lot. Maybe they're tangential, they're not necessarily answering our questions and it's difficult for us to get out our questions. What do you guys do in those scenarios to help move that interview along?

  Dr. Lucy Chen: [01:04:50] I've actually found that generally people are not offended if you redirect them and say "Hey, Mr. Smith, I noticed that you're very passionate or you're really excited about topping up this topic. But I've got some questions I need to cover in order to better understand the context and serve you better and figure out what's going on. So is it okay if we re-align ourselves with with with the interview?"

  Dr. Juveria Zaheer: [01:05:16] Yeah, I love that. I do that, too. And sometimes I'll even be even more explicit like "I need to ask you these questions. I have six questions. Can I ask you those six questions". Then people will smile and they'll say, "Well, can we come back to this" and I'll say, "I promise we're going to devote whatever time we have left to chatting with this, because I'm really interested". If I am interested, yes. Usually it's always pretty interesting. It's like "I'm really interested. I wish we had more time. Let's do this first and we'll see what time we have left". In that way, it's kind of a more fair, reciprocal thing. The other thing that I try to do is that transparency really helps too "I wish we had more time because I'm in emergency, I have a bunch of people waiting. I do have to get through these pieces because I just need to figure out how there's some things I need to know for us to know where we go next. Do you mind if we move to those pieces?". I noticed you can try the gentle interruption stuff and sometimes it works, sometimes it doesn't.

  Dr. Juveria Zaheer: [01:06:14] Then I think you can get a little bit more assertive. It's like you need to if you smile and you're friendly, it is like you need to stop and then we can go from there. But if someone is experiencing your interrupting as quite invalidating, then I think then there's always room to explore it. So, if it's someone who is maybe not as pleased to be redirected or experiences that or has past experiences of being silenced or has a trauma history or as a marginalized person or had a very different idea of what was going to happen, then I will explore it. Then I'll say "I know right now you're experiencing me as interrupting you and that's exactly what I'm doing" and "I'm so sorry, and I know it sucks. What do you think? How can we sort of move past this?". And so there's times where it works. If it doesn't, then I would say take the time to explore it for a few minutes because exploring it is actually going to help you finish the interview.

  Dr. Alex Raben: [01:07:12] Right. It sounds like framing the timing, what you're trying to accomplish, explaining that can be helpful. If that fails, maybe some gentle interruptions. If that's not working out, then you may have to be more assertive and just sort of keep asking your questions. I also find if I can do my questions more rapid fire, so there's less sort of pauses in an assessment that can also be helpful. Then there is the risk, however, that people might be might feel invalidated by your interruptions. And in those cases, you can always kind of circle back and check in with them.

  Dr. Juveria Zaheer: [01:07:47] I think own it. You know, you are interrupting them and you aren't letting them tell their story and just own it. Yeah. And apologize and say "these assessments are hard because you want to talk about what's bothering you and you've gone through so much" and it's the dialectical behavioural therapy and it's not a "but" and there's so much that's so important here. We also need to get through the assessment, so we can figure out what comes next. Then you can sort of leave it there and let the person take ownership or responsibility of what happens next.

  Dr. Alex Raben: [01:08:20] For sure. I think we we will wrap up. We've covered a lot of ground here in terms of content and in terms of process. Does anyone have any parting thoughts for learners who are going to be doing these assessments on their own?

  Dr. Lucy Chen: [01:08:34] I think it's just about practice, right? I mean, it was a lot of content, guys. It's this stuff. The more that you practice it and emerge context and the outpatient context, the inpatient context, you'll have to get practice. This will become ingrained. It'll become really natural, it'll become just intuitive. And then when you're in the space, you can really relax and all of this content will stick.

  Dr. Alex Raben: [01:08:59] So use our structure as a lattice on which to build your interviews.

  Dr. Juveria Zaheer: [01:09:05] Yeah, I agree completely with Lucy. I think what I would say is that you can't be unstructured if you don't know the structure. The most important thing early is learning the content. Read as much as you can. Read the DSM, read the diagnostic criteria, read a sked practice. Have as many observed interviews as you can see as many patients as you can and always be as empathic as you can. And to know that empathy isn't binary and it's always going to grow and your clients deserve the best of you and they'll get it. But these things take time.

  Dr. Alex Raben: [01:09:39] Great! Thank you both for joining me and with that, we will sign off. Thank you guys for listening!

  Dr. Lucy Chen: [01:09:46] See you next time!

  Speaker4: [01:09:47] 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 organization. This episode is part of our mini-series on psychiatric skills, which are intended to provide you residents with content directly related to the in trustable professional activities or EPAs in our curriculum. Since EPAs are designed to capture core professional psychiatric competencies, we trust our listeners outside what will still find them entertaining and educational. This episode was produced and hosted by Alex Raben and Lucy Chen, audio editing by Jordan Bawks. 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@psychedpodcast.com or visit us at psychedpodcast.org. 

  [01:10:39] Thank you so much for listening. Catch you next time!

Episode 16: Biopsychosocial Formulation with Dr. Erin Carter

• Episode 16: Biopsychosocial Formulation with Dr. Erin Carter

  Dr. 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!

  Dr. Aarti Rana: [00:00:38] Thank you and welcome to PsychED, an educational Psychiatry Podcast for Medical Learners by Medical Learners. Thank you for joining us today in our mini-series on psychiatric clinical skills. In this particular episode today, we're going to be discussing something called the biopsychosocial formulation. This is one of those conceptual structures we use in psychiatry to bring together our biological, psychological and social models of understanding and treating psychiatric illness. Your host today are myself Dr. Aarti Rana, a second-year resident at the University of Toronto. Dr. Chen, I'll let you introduce yourself.

  Dr. Lucy Chen: [00:01:17] Hey there! I'm Dr. Lucy Chen. I'm a PGY4 for psychiatry resident at the University of Toronto.

  Dr. Aarti Rana: [00:01:22] And we're sitting here today in the west end of the city at Saint Joseph's Health Care Centre, joined by Dr. Erin Carter, who will be interviewing today about the biopsychosocial model. Dr. Carter happens to be my current supervisor on my rotation and is an acute care psychiatrist. Dr. Carter, I'll let you introduce yourself and your background and expertise.

  Dr. Erin Carter: [00:01:42] Thank you so much for having me today. I'm Dr. Erin Carter. I'm a psychiatrist at Saint Joseph's Health Centre in the west end of Toronto. I work as an inpatient psychiatrist, so I see people with acute mental illness who've been admitted to the hospital. I work with a lot of residents. I'm interested in education, and I carry a full patient load here but primarily in the inpatient setting.

  Dr. Aarti Rana: [00:02:07] I thought we could divide our discussion today into three parts. The first part, really about understanding what the biopsychosocial formulation is, kind of the who, what, when, where, why of it. The second part, the how. So the tricks and trades of actually doing formulation. And then the third will hopefully get to a sample formulation in real time. We're going to put you in the hot seat, Dr. Carter.

  Dr. Erin Carter: [00:02:31] Sounds good.

  Dr. Aarti Rana: [00:02:33] So let's begin. What exactly is a biopsychosocial formulation for someone who's never heard that term before?

  Dr. Erin Carter: [00:02:39] Well, if you're just starting out learning about psychiatry and training in psychiatry, biopsychosocial formulation is something that we do when we are really trying to understand who a patient is and why they look the way they look in front of us on any given day. And it's kind of a living entity. It's something that changes over time depending on what's going on in their life. But it's something that we use when we communicate with each other. And also just when we think to ourselves as clinicians about what has brought this person to where they are. I would encourage learners to to think about the word formulation. So, it's about making something. It's about building something. So when you do this, you're drawing on the areas of biology, psychology and sociology, and then also culture of the patient before you. You're building on these areas and you're trying to build something, and what you're trying to build is an understanding.

  Dr. Aarti Rana: [00:03:39] So, Dr. Carter, I kind of get that conceptually, but what does that actually look like? So if you're building something, it's not with popsicle sticks, right? Can you tell us what's the actual components of a biopsychosocial formulation? Like if you were to look at one, what would it look like?

  Dr. Erin Carter: [00:03:53] Well, I guess you want to bring it to life. You want to think of a person in front of you, and they are a living, breathing entity and you're trying to capture them at a moment in time. So what it would look like is if you want to start with biology, you would look at what are the aspects of biology that have contributed to who this person is. So is this somebody who has had any sort of biological stressor or even a biological advantage, something that's happened to them in the distant past during the time that they were in utero or in their childhood, their teen years, or who they are now in front of you, what's happening biologically with them genetically? Think about those sort of physical things. So, that's one area then you want to look at psychologically. And I'm going to just start right at the beginning and say that everybody seems to have trouble at the beginning distinguishing between the differences between psychology and sociology. So I would really encourage you to think of psychology as the factors for the patient that are happening internally inside their head, inside their mind, who they are on the inside. Whereas sociological factors, the sociology of it is what's happening outside of them externally. So for example, psychologically, are they somebody who has intelligence or are they somebody that struggles with intelligence? Or another example would be, are they somebody who is psychologically minded? You know, they think about things a lot emotionally, cognitively they reflect on things or are they somebody that doesn't have any sort of sort of psychological minded approach to life? And then sociologically, like I said, those are external things. Do they have housing, do they have finances? Are they in a relationship? So things that affect who they are right now based on what's going on outside of them. And more recently, we've added a fourth dimension, which is we think about culture. Is that something that has influenced who is standing before you right now?

  Dr. Aarti Rana: [00:05:54] That's really helpful. So in summary, a bio component of the formulation is things that have happened to someone's body. So that could include neurologically, developmentally, for example, socially sound. Sorry, let's go back to psychologically. Are things inside the person? Use the examples of their cognitive ways of thinking and then social would be things between them and others or between them and their environment, and that would include culture.

  Dr. Erin Carter: [00:06:27] I think that's very fair.

  Dr. Aarti Rana: [00:06:28] Okay, that's very helpful. And you'd also mention when you said we're formulating who the person is right now, what do you mean by that? So not just who the person is, but why right now? What's the importance there?

  Dr. Erin Carter: [00:06:42] Well, I think when you start out in your training, in psychology, formulating someone is something that you fear often as a learner. It's a pretty big task to bring all these factors together, and it's something that can create anxiety and fear in new learners. But I think over time it becomes something that you love. And it's probably a big part of the reason why you chose psychiatry, because you're actually really interested in all the pieces that come together to make a person who they are. That's all that formulation is. And so inevitably that's a dynamic thing. I mean, that changes over time. The person that you were when you were seven or eight years old and the things that were influencing you, I'm sure we're really different than the person you were when you were in third year university or the person that you are today. They can be really affected by all sorts of different things inside of you, outside of you, biological things. They will all change what you see really on any given day. And so I would encourage people to sort of settle that anxiety or that fear about formulation and really embrace it as an exciting way to look at a person and an exciting way to inform how you're going to understand them and how you're going to help them, and to know that it's dynamic, to know that it's it's going to change and that it's your opinion as someone expresses their thoughts about formulation. It's an opinion. It's not a fact. It's just what I think is happening and what I think I'm seeing. And so, again, inevitably that's going to change over time.

  Dr. Aarti Rana: [00:08:08] I think have a pretty good understanding now of the what a formulation. Dr. Chen, do you have any questions about the formulation?

  Dr. Lucy Chen: [00:08:15] Yeah. And I guess, like, where does formulation happen, where our residents are going to be formulating sometimes where clerks are going to be formulating, I guess how we can prepare learners for the environments where they're going to be might be expected to formulate.

  Dr. Erin Carter: [00:08:29] Well, in a concrete sense formulation, you know, geographically happens any place where you're coming into contact with a patient. So it's important and particularly when you're meeting a new patient or when a patient appears to be changing a little bit that you're working with over time. So you're going to formulate in the emergency room, when you see people there, you're going to formulate in the clinic, you might have a patient that you're following for psychotherapy over a period of a few years. And you're going to formulate and reformulate over time as you get to know them better. And as they change and grow and evolve, you're going to formulate during exams when you have to communicate with your supervisors and with your examiners about your understanding of patients. So I guess that's the concrete answer. But again, I can't resist adding that in a less concrete way. The place of formulation is happening is inside your mind, and it's the exciting place where you are mulling and thinking about what you bring to this case, your understanding of this patient. So it's happening in your mind.

  Dr. Lucy Chen: [00:09:28] Yeah, well, I guess there's mulling sort of process maybe kind of transitions us nicely into part two, which is understanding the mechanics of formulation, basically the how of doing a formulation, presenting it and using it effectively. So I guess before we begin an interview, how can we set ourselves up for success? What's a really good approach to organising the information that we're going to be collecting from the patient?

  Dr. Erin Carter: [00:09:53] Well, I'm going to give you the advice that I would give to a new learner, to a clinical clerk, a med student or a first year resident. But I'll be honest with you, it's the same advice that I would give when you're right at the end of your residency, preparing for your exams. The way to set yourself up for success in formulation is to really do an organised interview with your patient. So I think that people become familiar with what's known as the psychiatric interview. It has different categories. It starts with identifying information and and it goes from there. And, and these are categories that you really want to own, you really want to master these categories. And if you are able to master an organised interview, a psychiatric interview with your patient, if you can do that in an organised manner, you will have all the pieces of information you need to formulate well.

  Dr. Lucy Chen: [00:10:42] I guess taking us through what that is, identifying information, kind of a chief complaint, what brought them in to hospital or to the emergency department were brought them in for a psychiatric consultation. The history of presenting illness, sort of the context and sort of a symptom screen, their past psychiatric history, their past medical history, the medications that they're currently taking, the medications that they've tried allergies to medication or other sorts of allergies, family history.

  Dr. Aarti Rana: [00:11:10] And substances.

  Dr. Lucy Chen: [00:11:13] Substances. So kind of it sort of gets ingrained over the course of time, which.

  Dr. Erin Carter: [00:11:19] A really good there you were on a run you had you don't even have any paper in front of you did very well with those.

  Dr. Aarti Rana: [00:11:23] And it shows how hard it is to be organised about all of those things. Right. In a systematic way.

  Dr. Lucy Chen: [00:11:28] Yeah. And I guess finally just to add to that list is also sort of the past personal history or the developmental history and the relational history to help us get that information for a comprehensive formulation. So how do we elicit that salient information, the most important information needed to formulate? How do we get that out of the patient?

  Dr. Erin Carter: [00:11:48] Well, that's kind of a difficult question to unpack. I think there are several pieces to that question, and I'm going to try to give you an answer that's not too lengthy. But I think that, first of all, for again, for new learners, what you need to really think about is the categories of the interview that you just laid out quite nicely. I would really encourage learners to attempt to set goals for themselves to gain mastery over each of those categories. And so, for example, the first category you may gain mastery over is identifying information, you know, and that's where you find out the person, their name, their age, what they like to be called, what their relationship status is, you know, these kind of very factual pieces of information. And that once you've memorised that, the approach to that category where you don't have to look at a piece of paper to know the questions you want to ask, then you have mastery over that category. So that may be the first one. The next one you may have mastery over is later in the interview, the mental status examination. That's something you do over and over again and again. You want to get mastery of that. There are some categories that are easier to master than others, and there are some that are challenging. Long after you've finished residency and your staff, you're still struggling to master them. I would say that some of the most challenging categories to master are the history of the presenting illness and the personal history. And inevitably, these are also two of the ripest categories for gaining salient information for formulation. So that's okay. You may never have mastery of them because they are particularly dynamic for the patient.

  Dr. Erin Carter: [00:13:17] The history of the presenting illness, which is what's brought them before you like what's really been happening in the past few weeks of the past few months. It's very challenging to get that information in an organised way and you just get better and better at it through practice and observation. Once you're able to do that and get kind of a tight, concise history of the presenting illness, I think you have a lot of salient information for formulating, particularly what were the precipitates of this illness event, this particular presentation, and also what may be perpetuating it, what's causing it to continue? And then I think the personal history, that's a different category that you're getting later in the interview that is going to really help you have an understanding of the predisposing characteristics. So again, you're trying to build up. Why does this person look the way they look today in front of me and it matters what was happening in their childhood or even maybe what was happening in utero. So, a lot of the personal history questions that come towards the end of the interview, do not lose time. Do not lose all of your time before you get to that section, because it's really going to help you to build your understanding of what shaped this person into who they are. So you are going to get salient information from all over. I guess if I had to pick three categories, I'd want the HPI, the personal history and the psychiatric history. And I feel like I could take a pretty good stab at a formulation if I had those three categories. Get them all, but make sure you get those three.

  Dr. Lucy Chen: [00:14:46] But if we were to really kind of simplify an approach to an HPI categories like symptom collection, how can we best sort of comprehensively sort of summarise in HPI for young learners.

  Dr. Erin Carter: [00:14:59] I think I'm going making eyes at your colleague now because I think you're cheating. I think this is a different podcast approach to HPI. But anyway, let's see, I'll give it a stop. So you're asking me really how do you get a tight HPI? That's sort of the question. I think, to be honest with you. That is the enduring question throughout residency is and I find as a teacher working together with learners, with residents, that is something that people struggle to master. And there are so many things that go into to getting a tight HPI. And as I say, I think people continue to struggle with it at times, even as a staff person after residency. But I think that for a learner who's starting, what I would encourage people to do is to really start out with an open-ended question at the beginning of your HPI. You really want to ask the person something that gives them a chance to talk, that gives them a chance to show you who they are and what's concerning them right now. So an obvious open-ended question would be to say to your the patient in front of you "Can you help me to understand what's brought you here today to the emergency room" or to the clinic or wherever they are. Can you help me to understand, what do you think has brought you here? What's happened? What's brought you here? And then hopefully they're going to tell you a story. Hopefully they're going to give you their story. And I think that your job then for the HPI is really just to work together with them to to enable them to tell you their story.

  Dr. Erin Carter: [00:16:28] And you have to recognise that it might not be easy for them to tell you their story. They may find it difficult because of the actual diagnosis that they have, maybe they're psychotic or having symptoms that cause them to be disorganised in the way they think or the way they express themselves. So if you ask them an open ended question like that and they're struggling to answer it, that struggle that you're witnessing, rather than being frustrated by it, you can use that for information. You can say to yourself, well, he's really having trouble organising a timeline, what does that mean? Well, it means something. It means something to me. It may be about his diagnosis, so it's actually helpful. Or maybe he's having trouble expressing his story because he's a super quiet, shy guy. Or maybe in his culture, you don't talk about yourself. You don't tell stories. So, whatever's happening with that first open-ended question is giving you enormous clues as to who this person is. And that's what formulating is about. So all of that, to go back and say that, I would start with an open-ended question and let's see what they do with that open-ended question. Let's see. And then you go to work. Your job is to help them tell their story. So you may help them through guiding the way they're answering your questions. And sometimes they may need closed ended questions, questions following that, because they've got so much to say. You may need to help them become concise or they may be able to you know, you may be able to guide them just through body gestures or through listening.

  Dr. Aarti Rana: [00:17:59] Dr. Carter, you just gave us a really excellent example of what you described as formulation. You started to hypothesise about what you were observing and you included formulation like language. There you said, maybe this is I'm witnessing this because this person is having difficulty organising themselves. So you're talking psychologically inside? Or psychologically, they're maybe shy person, something about their personality. So I thought that was really interesting.

  Dr. Erin Carter: [00:18:26] It's true. We went through the sort of categories there. We considered, you know, a biological reason. Maybe they're having psychosis. But then there are also could be a psychological reason or a sociological reason or a cultural reason. You're already getting hints. And I think it's important that, you know, you are able to be open to what they give you because the patients are giving you clues and telling you about who they are with everything that they say, with the things that they don't say, with the struggle they have in expressing themselves, they're telling you things. And it's your job to sort of settle yourself and calm yourself so that you can see it.

  Dr. Aarti Rana: [00:19:09] So for our listeners, there's there's two pearls, one of which I learnt from you actually about the HPI. One is to share it like a movie. And so I imagine going back to my supervisor later and being able to explain what happened, like a movie, and that helps me figure out what questions am I still missing, whether it's questions about the timeline, questions about stressors or inciting factors. What am I missing from the movie that I'm going to be able to ask about now? And the other one is, I think this has taken me my whole second year of psychiatry to learn, which is when I ask that open-ended question, to actually wait a while and and let the answer emerge, it's very tempting, especially with time limits, to ask the open-ended question, but ultimately treat it like a closed-ended question by interrupting quickly.

  Dr. Erin Carter: [00:19:55] I think that's very true. The HPI, you're right at the beginning of your interview, so you've asked them the identifying information and you've gotten clues from them during the identifying information. You already have a sense in those first 2 minutes when you've asked identifying information, questions, whether this person's going to be a talker or whether they're going to be hard to get information out if they're already giving you clues. But regardless of what they give you, that HPI is at the beginning. You've got some time. And, I would look at that open-ended question and I would I would be very willing myself to let any patient tell me whatever it is they want to tell me for about anywhere from about 3 to 5 minutes, I'm going to sort of play around with the idea of openendedness. And then at the end of that three or 5 minutes, I don't care how early you are in your training. I bet you have some ideas. I bet you have some ideas about what's going on with this person and then you're off to the races, you've got some ideas and I would say, go with that. So now you've kind of given them that first few minutes of openendedness, which also hopefully you're building some rapport with them. They're getting a sense that you're there to listen to them, but then you do need to move on and get focussed because it is a great danger to lose control of the interview. I mean, the interview is a collaborative process, so I don't always like that phrase of controlling the interview or losing control. But there's a tipping point at which you need to help the patient. You need to work together with them to collaboratively provide the information that you need to work with. So, you do need to get a hold of the interview I would say after somewhere in the 2 to 5 minute range, you need to start to get focussed on the kind of questions you want to ask.

  Dr. Lucy Chen: [00:21:36] And I guess in the past personal history, what sort of information are we listening to contribute to that bio psychosocial understanding of the of the patient?

  Dr. Erin Carter: [00:21:44] So getting towards the end of the interview, usually when you're doing the personal history, we always called it the social history where I trained. So that's coming at the end of the interview. And I think that at this point,  you think of your categories, you've got your biological category, your psychological category, your sociological category, your cultural category. Well, the last three, I think you're really need some of the personal history to get that. You want to understand how this person experiences the world inside themselves and how they experience their interactions with the world. And you want to have an understanding of how that formed over time. So that's the personal history. You want to go back in time, hopefully to a time before they were having symptoms, before they were unwell. So you really want to get a picture of what did this person look like when they were little, when they were, you know, pre-school or when they were starting school and when they were interacting with teachers and friends? I mean, you know, think about yourself. Think about who you are and how did those things shape you? How did your parents shape you? How did your teachers shape you? Did you have a good experience in school or was school a nightmare for you? Was it a terrible place to be? And how did it shape how you feel about yourself and how you feel about the world? And as you approach adulthood from those experiences, how did it shape the ways in which you're going to be able or not able to get your needs met and how are you going to do that? And so that's why personal history is really important.

  Dr. Erin Carter: [00:23:21] So I'm really but I'm asking simple questions. I mean, those sound like complicated ideas, but I'm really just asking people: I want to ask you a few questions about yourself, can you tell me where you were born? Can you tell me who raised you? Did you move when you were a kid growing up or he always in the same apartment or house? Did you have siblings? W when they say who raised them, it wasn't always a parent. Sometimes it's a grandparent or sometimes it's someone completely outside of the family. And you might ask them about that person. You know, you might ask them if you had to pick a couple of adjectives to describe your grandmother who raised you. What adjectives would you use? And you're going to learn a lot about how they were shaped. So you're kind of wanting to generate a bit of a conversation with them again. And this is also an area where you may be asking them questions about whether or not they had traumatic experiences in their childhood. So you need to connect with them. They need to feel some connection with you. They need to feel that you're interested in what you're asking because you're going to ask them some personal questions that may be about their identity, their sense of who they are, their sexuality, their abuse history. So, you need to maybe put your pencil down and make eye contact and connect with them because you're asking them to share a personal history, emphasis on personal.

  Dr. Lucy Chen: [00:24:34] So, after an interview, we have collated a lot of raw data. So what's the best way to sort of organise all of that data and maybe also be an opportunity to delineate the difference between synthesising and summarising information?

  Dr. Erin Carter: [00:24:48] Okay. You have a way of asking me questions that are very complicated. You're asking me stacked questions.

  Dr. Lucy Chen: [00:24:58] I'm reading your questions.

  Dr. Erin Carter: [00:25:01] Okay. Let's see what we can do with that. So I guess we talked previously about where you will find yourself, like where are you when you're formulating? So I mean, realistically for learners, you're probably going to be formulating for your supervisor or you're going to be formulating for an examiner. But but in time when those that stage of life is over and you're practising, you're going to be formulating for yourself. You're going to be formulating to be able to share and talk with colleagues, and you're going to be formulating for the patient or maybe for their families so that you can talk with them about what you think. So you need to have an approach to be able to do that. But I think in your early years, a lot of times you're going to be formulating for your supervisor realistically or for an examination. So I would encourage you at that point in time to create a grid. There is a grid that is used for formulation that everybody knows about as they begin to move through residency. And it's called the formulation grid. And so this is where we need TV instead of radio. But on the left hand column, going down the grid. Let's actually let's start at the top, going across the top, you're creating a few columns.

  Dr. Erin Carter: [00:26:08] So the first column is the biological column. So you usually write bio, and then the next column is psycho for psychological. Next column is social for sociological. And then the last column is cultural. So you're making those four columns, so that they can run down your page vertically. Then horizontally. this is where the grid part comes in. On the left side of your page, you're going to really create a bit of a timeline over time because we want to know what's happened to this person, for example, psychologically over time or biologically over time. So biologically, we want to know if something happened in utero, we want to know if something happened biologically in their childhood or their teen years. We want to know what's happening now. So you're going to create a timeline down the left side of the column. You're going to start and it's referred to as the four P's. So the first P is predisposing. So what were the predisposing things biologically, psychologically, sociologically and culturally that contributed to this person's presentation today? So I guess an example would be in the biological column. Predisposing would be if this person's mother consumed a lot of alcohol during the pregnancy, that's a biological factor that may very well be affecting who this person is today.

  Dr. Erin Carter: [00:27:25] So, that's just an example. Then the next timeline, the next category after predisposing is precipitating. So, you're looking for a precipitant and it's a precipitant to this episode of illness. And the reason I sort of stress that out with my words is because most psychiatric illnesses are chronic in nature. Let's take a person who has a major depressive disorder. They may have bouts of episodes of depression over time, and they may have times when they're not depressed. And if they come and see me when they're 65 years old and they're depressed, I am going to formulate them based on this episode of depression. So, I'm really going to be focusing on what's happening with this particular episode, and that's why it's important to have a category that's called precipitating in the timeline, because I want to know what factors biological, psychological, etc. I want to know which factors precipitated this episode. So precipitants for the 65 year old with depression might be the fact that they were forced to retire from their workplace. And that sorry, that wouldn't be biological. That would be an external thing. So, that would be a social factor. But a biological factor might be that they had a new diagnosis, something physical had happened to them.

  Dr. Erin Carter: [00:28:44] They've just been diagnosed with stage one breast cancer. And that may biologically be contributing to their mood. So, precipitating is the second. category on the left side. The third P is perpetuating. So what is perpetuating this person's current episode of depression? So it may be perpetuated by the fact that this 65-year-old with new breast cancer diagnosis, who's being forced to retire, is also, let's say, perpetuating is that she's really struggling with sleep. She's got this long standing struggle with sleep, but that's making things worse for her. It's perpetuating things. And then the the final category, my favourite category is the P that stands for Protective. So we don't like to just look at the things that are creating the illness state. We want to look at whether they have any protective factors in any of the biological, psychological, in any of these categories. So that's the fourth one. So you're going to create this grid and then you're going to take the information that you got from the interview and you're going to plug it into this grid because it's really going to help you organise your thoughts.

  Dr. Lucy Chen: [00:30:00] And then I suppose like this grid really helps us with summarising having like a general sort of overview of all the raw content that we were kind of collating.

  Dr. Erin Carter: [00:30:09] That was the second part of your question. You wanted to know the difference between summarising and synthesising. Let's assume that you are going to present your case and your formulation to your supervisor or to an examiner,  your supervisor probably knows a bit about this patient already. And the examiners that you're presenting to, they just watched you interview this person. So, they also know a lot about this patient. So, one of the sort of pitfalls I think early in training is that people really just provide a summary instead of a synthesis. So, they really just kind of regurgitate the information that the patient gave them. They say it in the same order. They use the same language. They just they just tell the person what they heard. But over time, I want you to sort of raise the bar for yourself. I want you to sort of set some learning goals for yourself, which is the ability to distil the information that you've been given into something meaningful. I could just repeat to you all of the things that the patient has told me in the interview, or I could hear them, what the patient said, I could think about them, I could think about how they're connected to each other and the meaning they might have. And I could re-organise them into a more concise and meaningful piece of information before I share it with my examiner or my supervisor or my colleague or even the patient, because I don't want to just tell them what I heard. I want to tell them what I think. So synthesis. I like to think of it as distilling. I like to think of it like you put a whole bunch of information into a cup and you distil it at the bottom. And what comes out is this concentrated, thoughtful, connected idea that relates to each other. And that's what you're being paid for. That's the really fun part, is to think about the meaning and to come up with opinions and ideas and to share them.

  Dr. Lucy Chen: [00:32:02] And maybe before we get to an example, synthesis of a formulation, how would we use formulation? How do we make use of it for management plan and make sense of it?

  Dr. Erin Carter: [00:32:14] So, really the question is why like why are we formulating people? Well, it's important to understand them. And academically it's interesting for us, we like to understand them. But really the real purpose is to guide how we are going to help this person. You know, this person's come before you and potentially in quite a bit of distress, maybe even in danger and they're telling you their story. And now it's your job. It's why you became the doctor that you became. It's your job to help them. And so formulating is the building together and the taking the Plato and forming it into a new shape of understanding that will guide your treatment plan. So, when you have a treatment plan for the person in front of you, there's probably some very acute things you need to do, some things you need to do right away. And that would be what we would consider your short-term management of this patient in front of you. And then there is also a medium-term management and there's a long-term management. You know, you're thinking of the long game also how you can help them. And so once you've got your formulation done, the work is largely done because you have figured out what needs to be addressed for this person.

  Dr. Erin Carter: [00:33:26] In each of the domains we listed, you're not only going to help them with pills. I mean, if it was that easy, you wouldn't need to be in school for so long and everybody could do it. You could just say, this person has a diagnosis of whatever and that equals this pill, and you'd give it to them. But it's not like that. We are looking at a much more complicated understanding of them and by the time you've got that understanding, that formulation, then you should have some ideas about how to help them biologically. So there's the, you know, the pill piece or maybe some sort of intervention like ECT or rTMS. It should help you guide you biologically, but also it's going to help guide you psychologically. What do we need to do for this person in terms of therapy? And what are they going to respond to? Like, what do we know about who they are? Are they going to be open to therapy? And if so, what kind are they going to have trouble with? How to make connections with people, including their therapists? You know, we're going to think about those things so we know how to deliver the therapy or the approach that we're taking.

  Dr. Erin Carter: [00:34:28] And then socially, does this person have some very real things that need help from a social worker or from someone you know that can help them in the community? Because they don't have a safe place to live right now or because they have no money or, you know, some serious determinants of their mental health that need to be addressed that are practical external factors. And if you skip the cultural piece, you might be missing a lot as well, because that may really inform how you're going to help this person. If you just crank off a script, a prescription for this person, and you have no idea of what that means to them or whether they're going to take it or whether in their culture that's something that they're comfortable with. Unless you understand those pieces, then you're only satisfying yourself in your own mind, you're not actually in a concrete way helping your patient. So, once you do the formulation, much of the work is done and it will really guide you in what you need to do for them in each of those categories.

  Dr. Aarti Rana: [00:35:22] Thank you, Doctor Carter. In summary, for the "how" of formulation, it sounds like before you do the interview, being very well organised is quite important and you identify the three areas of the interview that you think are kind of high yield for formulating. You identified the HPI, the personal past, personal history or social history. Past psychiatric history. And then in addition, we talked in detail about the HPI in particular and why that's so important and also takes so long to master. We also talked about what you might do after the interview in terms of organising all of the details you've gathered from the various sections of the interview, in terms of building a biopsychosocial grid with across the top the bio, psychosocial and cultural aspects or factors you're identifying throughout the interview and along the side of the grid, the predisposing, precipitating, prolonging, protective and perpetuating. 

  Dr. Lucy Chen: [00:36:37] Guess they are synonyms.

  Dr. Aarti Rana: [00:36:38] Well, sometimes people actually do that "prolonging" as well. 

  Dr. Erin Carter: [00:36:45] The predisposing is number one.

  Dr. Aarti Rana: [00:36:49] So, this is why you need to do this again and again. And actually draw out the grid too.

  Dr. Erin Carter: [00:36:53] What predisposes you to illness? What precipitated this episode? What's perpetuating or prolonging this episode? I like perpetuating Doctor Rana likes "prolonging". And then lastly, what is protective for this individual?

  Dr. Aarti Rana: [00:37:06] Yes. And then finally, an aspect of "why we do the formulation" in general is really to ultimately inform our management plan.

  Dr. Erin Carter: [00:37:15] Yes.

  Dr. Aarti Rana: [00:37:16] Okay. So moving on to part three, which is our practice case. Dr. Carter, I'd like you to imagine that Dr. Chen and I are clinical clerks. We are in the emergency department. We have just gone and assessed a patient for the first time. And we don't really understand this formulation business. So, you've suggested to us that we do the interview and present the interview to you and that you will teach by example by formulating this patient. So. I'll present the case and then Dr. Chen will ask some follow up questions. This is a 40-year-old male who's presenting to the emergency department with his wife. He lives with her and his two children aged two and four. He is self-employed as a real estate agent. He completed a college diploma in accounting. His chief complaint right now is my mood is going up and down all the time and I'm really stressed. His history presenting illness, things started about one month ago. He abruptly asked his wife for a divorce after he confessed to her that he had been having an affair for several weeks. At the time, he states, he was making a lot of rash decisions in his life. He had launched a new business. He'd made new investments. He was really on a roll financially, and he started to engage in a relationship with a person he'd met. In the last two weeks, he's really been despairing about what happened about a month ago in his life. He has been abandoned by his business partner. He's lost a lot of money that he invested.

  Dr. Aarti Rana: [00:38:43] He feels very guilty about having this affair and also potentially breaking up his family. His symptoms one month ago included reduced sleep 3 to 5 hours nightly, he was really increasing his activities around his investments and his real estate business. He experienced flight of ideas. His energy was high. He described himself as impulsive with respect to financial decisions alcohol, drugs and sex. And he says his mood was all over the place then. Currently, he said, his mood is still all over the place, but mostly he's feeling quite despairing and low. He says his energy and concentration now are very poor. He's eating a lot in all the time. He's gained about £10, actually, just in the last three weeks. His sleep is still quite poor and for the first time he developed passive suicidal thoughts or thoughts that he doesn't want to live anymore. Life would be better or easier if he wasn't living, but he doesn't want to do anything about that. He's not planning to take any action to end his life. And the fact that he's having these thoughts is very disturbing for him. He has no symptoms of psychosis. He does have long-standing history with difficulty falling asleep. And his review of symptoms was otherwise unremarkable. In terms of his substance use, he has no history of tobacco use, he has been someone who's occasionally had difficulty with cocaine use. He'll use cocaine at parties several times a year and has a history as a teenager and in his early twenties of having periods of high amount of cocaine use and other stimulant use. Most recently, he used cocaine around a month ago, he said he went on a binge for about a week around the time all of these things started. He denies any marijuana use. He drinks a glass of wine nightly. In the last few weeks, he's been drinking a lot more, maybe three glasses a night. In terms of a psychiatric history, he had one major depressive episode after college when he had difficulty finding his first job. That coincided with heavy substance use again at that time stimulant use. Three months ago, he was diagnosed with anxiety, just difficulty handling all the stressors of work and two kids at home. And, because of his sleep difficulties and at that time his physician started him on Venlafaxine, which was titrated up to 75 milligrams. He said it started working within a week. It felt great, he had no side effects. He has no history of self-harm, behaviour or any attempted suicides. He's never had any suicidal ideation before now. In terms of his family psychiatric history, there was depression on the maternal side with mom and grandmother, and he has a sister with anxiety. His medical and surgical history are unremarkable. His doesn't have any allergies. He's only on the on Venlafaxine 75 milligrams for the last three months, though he admits over the last month he hasn't really been taking it as much since the cocaine use and the affair. In terms of his personal history, he grew up in Toronto with a single mom, he didn't really describe his relationship with his dad, who left the family when he was five years old.

  Dr. Aarti Rana: [00:41:59] He has one younger sister  who is four years younger than him. He had normal developmental milestones. He reluctantly talked a little bit about witnessing some verbal and physical abuse of his mother by his father when he was quite young, but didn't really want to speak very much to that. He described his mother as being really busy, really engaged and just financially supporting the family. And he doesn't really have any particular fond memories of her or negative memories. And his grades were actually quite poor in school. He struggled with focus, but he managed to graduate on time, and he had some kind of minor difficulties with the law as a teenager, some robbery that was kind of in the context of stimulant use, but none after that. No legal issues after his teenage hood. He describes currently his wife as a real stabilising force in his life. Their relationship has been largely positive until 1 to 2 months ago, and he's really concerned about her judgement and her family judgement. That's what we've focussed mostly on. He says that her family judges him for quote on quote being "white trash" and he feels like he has made a lot of mistakes in his life and he compares that to her life, which has been very different in terms of their upbringing. He's very self conscious about this. He's been very present with raising his children. He says both are healthy and has no concerns there. None of his substance use was around his children at all or ever in the home. And he's done very well financially despite the recent financial losses around $100,000.

  Dr. Erin Carter: [00:43:37] Okay, that's a lot of information. Actually, this is deja vu because this is what we do everyday, because I'm supervising you right now. So you're often presenting patients to me just as you just did. Okay, so what next do you want to talk about how to formulate this patient?

  Dr. Lucy Chen: [00:43:51] Maybe. First, an approach to synthesising the information, a differential diagnosis, and then maybe a formulation.

  Dr. Erin Carter: [00:43:57] Well, I think that's a good point, because it's important when you formulate a person that you are not just formulating in general, you're formulating what is sitting in front of you right now. So and by that, it's usually easiest, you can formulate a particular symptom cluster or you can formulate a diagnosis, you can  choose what you want to identify, what you're going to  anchor your formulation on. But I would encourage, especially new learners, I would encourage you to try to have a differential diagnosis. So a list of diagnoses that could possibly explain why this person is unwell in the way they currently are. And then I would also encourage you to have a preferred diagnosis. So you've got your list with a few ideas about maybe this person has this, maybe they have that, and then you're going to choose one as your lead. And it might not be right. It just has to be your opinion about what you think they have and you have to be able to defend. It doesn't really matter if it's right or not. It's just your best attempt at saying what you think they have and defending it. So, I would say in this instance that my differential diagnosis so the first thing I would do if I was preparing for an exam or I had to present to my supervisor, I just seen this person in the emergency room or in the exam room, and now I'm alone by myself for a few minutes, getting ready to present to my supervisor or to the examiner.

  Dr. Erin Carter: [00:45:17] One of the first things I'm going to think is, what do I think is going on? What do I think this person has? And this presentation is pretty clear that this gentleman has had manic symptoms. So he's had manic symptoms in the context of what actual label, I'm not sure. But I'm pretty sure from this description, he sounds manic. He's spent like he's lost like over $100,000 in the past little while. He's had an affair. He's behaving in ways that are revved up and and not sleeping and maybe a bit grandiose, different than he's been previously. So, he's having a manic episode. In terms of the DSM five, in terms of my differential diagnosis, whether or not I'm going to say that this gentleman has bipolar one disorder with mixed features, or whether or not I'm going to say that this gentleman has substance or medication-induced bipolar disorder, because maybe the cocaine and the alcohol caused it. I'm not really sure. And on my differential diagnosis, I might just be thorough and might also include a stimulant use disorder, and I may include post-traumatic stress disorder, maybe depending on what I got in the interview.

  Dr. Erin Carter: [00:46:23] These are all things that this gentleman could have right now. But I got to pick one. So and really the first two are the one I would be struggling between. Does this guy have like a full-blown bipolar one disorder or does this guy have a bipolar picture that's really being caused because he's been using a lot of cocaine lately? I'm going to go with the first one just because. So, I'm going to go with bipolar one disorder with mixed features. I guess to clarify my thinking, the fact that whether it's the cocaine or whether it's the Venlafaxine that the family doctor gave him for anxiety, it does sound as though he may have been having symptoms before that, before his cocaine increased and before his Venlafaxine increased. The reason he went to the family doctor was because he was having increased difficulty sleeping and increased anxiety. So, I might not be right. I just have to be able to defend it. And, I think that's something I can defend. I'm going to go with bipolar one disorder with mixed features. And I'm going to say to my examiner and my supervisor, I'd like to formulate this patient who I believe is currently presenting with bipolar one disorder with mixed features. I would say to them, I'd like to tell you what I know about this gentleman, and then I'm off to the races.

  Dr. Erin Carter: [00:47:31] I'm basically basically going to be looking at my grid. Now, here's the trick. When you get a little bit better at it, you're going to try to make as much eye contact as you can with the person that you're talking to. Because I'm telling you my opinion, this is where I'm really telling you what I think about this patient. I'm selling it to you and I want you to buy what I'm selling. I want you to believe what I'm saying because again, I might not be right. It's just my opinion. So the first thing I have to do is I have to sort of I have to summarise the case, but rather than calling it a summary, I'd rather call it a synthesis because I just want to distil it. I don't want to repeat for you everything I just heard. I wanted to distil it and the way that I'm going to distil it, this is just my opinion. This is just me as an individual, how I formulated and how I present. But I'm going to start by telling you the stuff that supports my preferred diagnosis. This gentleman may have given me information, all sorts of information in whatever kind of order he chose to give it to me. But I'm going to synthesize it and give it back to you, the examiner or the supervisor in the order that I think is most important.

  Dr. Erin Carter: [00:48:36] I just told you that what I think is most important is bipolar one disorder with mixed features. So, hopefully you have some idea of what that looks like in the DSM-5. Hopefully, you have some idea what the language is and you'll have a gaining mastery of that. I'm going to  model for you what I would say. I'm going to try to use the language of the DSM so that I can connect with the examiner or the supervisor. I'm going to present this case and tell you a little bit about what I know about this gentleman. This is a gentleman who I believe is presenting with a distinct period of abnormally and persistently elevated mood and abnormally and persistently increased energy for greater than one week. The reason I use that language is because I want them to know my supervisor, my examiner, that I know what the DSM-5 sounds like, also the DSM-4. Then I'm going to move on to the B criteria, which is where I get into the symptoms. I know because I know the DSM, I know that I need at least three.

  Dr. Erin Carter: [00:49:37] So ,I'm going to hit those three. I'm going to let them know that this gentleman; he's clearly presenting with decreased sleep with flight of ideas, distractibility, increased goal-directed activities, and some high risk activities in the form of sex and also poor business investments. I might even hit on the negatives just to show them that I really know the DSM. So I may say, there hasn't been any information about whether or not he's had increased talkativeness and whether or not he's had inflated self-esteem or grandiosity. Although, given his behaviours, I think he probably has been grandiose. I'm not going to forget to go on to the C part of the DSM, which is to comment on whether or not it's causing impairment socially or occupationally or educationally and whether or not it could be attributed. His presentation could be attributed to drugs or medications, substances or medication. So don't forget to comment on those. So I am going to comment in my assessment, my presentation of the case that it's difficult to tell whether or not these symptoms are happening independently of the cocaine use and the increased Venlafaxine. That's something I'm going to have to tease out in a future interview. But it certainly is clear to me that this gentleman has caused both social and occupational impairment from his symptoms. By using that kind of language and letting them know in the DSM language, this is what I'm talking about, and then I'm going to quickly sort of synthesize the rest of the information that I was given from the patient in all the different categories of the psychiatric interview, including the next things on my differential diagnosis.

  Dr. Erin Carter: [00:51:02] Again, I would be my number two on my differential was substance or medication induced bipolar disorder. So, I would talk about the fact that he had been having symptoms of anxiety and difficulties with sleep and that his family doctor had increased his Venlafaxine, which of course, we all know could have prompted a manic episode, and also that he's been using more cocaine than usual. Hard to know how to tease that out, we'd need some collateral,I would comment on that as well. I may comment on the fact that, you don't need very much to meet criteria for a mild diagnosis of stimulant use disorder if you're using cocaine, you only need two of the symptoms. So, he probably meets criteria for that too. Do I think it's the most like the most responsible presentation for why he's here? No, I think it's the manic stuff. And that's why I'm focusing on that for my presentation of my formulation. And then lastly, I may quickly comment on the PTSD possibility because of his childhood, he witnessed significant persistent abuse of his mother by his father.

  Dr. Erin Carter: [00:51:55] Okay, I'm done all of that. At some point we're skipping pieces, but we're moving on to the formulation. So, I'm getting to my chart. I have to make my chart. I mean actually write it out in the minutes that you have. So, when I go to do my chart later in this interview, you're going to ask me if I have any clinical pearls, so I'm just going to tell you them right now. The clinical pearls for the formulation chart, in my opinion, is or are that there are some classic things that exist in each category for almost every individual. So, when you're feeling anxious and you're sort of freezing a little bit, go back to the classics. I would encourage you to sit down with a blank grid and at the bottom of the biological column, choose three things that you can almost always comment on for any individual, and you can comment on them in terms of their presence or their absence because it's relevant, something might be present and causing a problem or it might be absent, and therefore it's a protective factor. For example, for biological, you can always comment on family history and that's a biologically, genetically relevant thing. You can always comment on substance use during their developmental years because that's a factor. It matters, in terms of a predisposing or even a precipitating factor for illness.

  Dr. Erin Carter: [00:53:20] So, either they used drugs like cocaine in their teenage years, which is relevant, or they didn't use any drugs and they don't use any drugs. And that's a protective factor, it belongs somewhere else in your chart on your biological column. And thirdly, pain. Pain is a good biological factor you can always address. They either have chronic pain, which matters in terms of predisposing, precipitating and perpetuating, or they are an individual who has no issues with pain, which would be a protective factor. That's just an example. You can choose whatever three you. You could choose things like their physical health, their history of whether or not they've experienced abuse, their sleep history. These would all be things that could go in the biological column for any patient. But, I would encourage you to memorize three, because if you got three, you can always fall back on them for any patient and then for psychological, same thing. Three things you can always comment on. Any person you interviewed, you can comment on their intelligence and that's either going to be protective for them or it's going to be an issue for them that belongs in one of the other three categories. If they have difficulties with intelligence, their attachment history, that's something you'll learn a bit more as you go through your training but whether or not what type, what style of attachment do they have that matters psychologically for all humans. And it's either protective because they have a nice, solid, stable attachment history or they have a disrupted one which many of our patients do.

  Dr. Erin Carter: [00:54:44] So, that would be number two. Number three, I might pick psychological mindedness. Is this person somebody who really gets the idea of mental health, mental wellness, mental illness, therapy? How are they going to do with that sort of thing? What are their thoughts about it? That would be a third thing you could comment on, on any individual for social category, housing, money, education. I'm not saying that these are the three in any one category that you have to have, I'm just giving you examples. Housing, money, education, you've either got it or you don't have it. And, it's either protective because you got it or it's a problem because you don't have it. So, figure out where that goes in the grid. Then culturally, again, I think psychological mindedness is an issue in different cultures, what their feelings about psychiatry and mental health are, and it matters. Do they have a lot of supports because they have a tight cultural history either within their extended culture or even just in their family culture? Religion can be a factor for many people, but there can be other things like language barriers, whether the care that they're getting, are they the kind of person that's going to respond to care within their culture from someone who comes from the same culture as them, or do they need to go outside of that culture? So, I think you should have a few classics for each category and then if nothing else happens, you can try to plug those into your grid.

  Dr. Erin Carter: [00:56:08] Let's try to do it for this gentleman. Biologically for this gentleman, if I look at the three that I mentioned; family history, substance use and developmental years and pain, you can see that for him, family history is an issue. So biologically, the category that would go in is predisposing. He has a genetic family history of both anxiety and mood in his mother and his sister, so that goes in predisposing. He had substance use in his developmental years, that would also be predisposing. Then also substance use for him carries on into precipitating and perpetuating because he's using increased cocaine and alcohol. It may in fact have been one of the major precipitates for this episode, and it's certainly a perpetuating issue unless he stops it pain. I don't think there was any mention of pain. So it's a great example for how this is something you can use and you can put it in a protective factor.

  Dr. Erin Carter: [00:57:00] You know, you can just throw it in there. This is a gentleman who, unlike many of our patients, he has no issues with pain or chronic pain that's actually protective for him. Then I would jump into the psychological category and I said my three were intelligence attachment, history and psychological mindedness. So, you can think about this guy. He's clearly an intelligent gentleman. He has a very successful, self-employed business, which says several things about him psychologically. He's intelligent, that's protective also that he's able to self-start and to manage himself normally. Again, that's protective of his attachment history, that's probably a concern. This gentleman was abandoned by his father, by his abusive father when he was five years old and his mother is quite distant from him. He doesn't have any positive memories of her in childhood. So, I'd really want to understand more about his attachment history. It would be safe when I do the formulation to start a sentence with something like "I wonder". I wonder because it's just my opinion, right? So, when I'm doing the presentation, I can say: I wonder if the abandonment of this gentleman by his father when he was five, by the witnessed abuse he observed of his mother and also by his mother's emotional distance to him, whether that's affected his attachment.

  Dr. Erin Carter: [00:58:16] I wonder what attachment style he might have and how that may have been. Ultimately, a precipitant for him during high stress times with his real-estate business, whether or not it contributed to the fact that he turned to someone he was emotionally not connected to and had an affair with rather than going to his wife, who he has a long-standing relationship with. I wonder if that was a contributor when I jump into the social categories, this gentleman does seem to have stable housing, which is protective, but he's got money problems. He just lost over $100,000 during this manic episode, that's going to be an issue in terms of perpetuating. Then education in the social column, he doesn't have that much education, although he seems to have had enough to do what he needs to do in real-estate. But again, it makes me think back to the psychological column that this gentleman struggled with when he was in school. He may very well have a learning disability or he may have ADHD. He had difficulties in school that were described in the history and that may have contributed to drug use. And the reason he uses cocaine and stimulants. It may also play a role in his psychological sense of himself and why he is so sensitive to the judgement of others, the judgement of his wife's family.

  Dr. Erin Carter: [00:59:38] That may matter in terms of what kind of therapy this gentleman needs also. I'd be thinking about it in that column. Culturally, I don't have too much to say about him. He sounds as though he's at least he's male, and I think he might have said he was Caucasian. I can't remember. But then again, it would be protective in the absence of him because the absence of him suffering, racism or gender issues. So, you would plug all of those things in and then you would try to say them out loud to your examiner or to your supervisor. You want to use words like: I wonder if these are connected. I see this gentleman as having predisposing issues in these categories and say what they are. I think maybe what precipitated this event, he's in a very high-stress job, he was using a lot of cocaine, he was having some anxiety and some difficulties going to sleep. So, his family doctor gave him biologically an increase in an antidepressant which may have sent him up into a manic state. Then perpetuating, I'm looking across the columns. This is a guy that when he's in trouble, might not be able to really ask for help because of some of the things that happened in his early childhood, his fear of judgement from others when he's making mistakes.

  Dr. Erin Carter: [01:00:49] He might have gotten quite far into the episode before he was able to ask for help because of his psychological background. Again, I'm not saying that's a fact. I'm just I'm saying I wonder, and then and then the fact that he really can't sleep and he's struggling to sleep, inevitably that's perpetuated this situation. I'm jumping around between the categories, but I'm just telling you what I think about what's contributed. Then there's a lot to say about this gentleman. At the end, I would be telling my supervisor or my examiners that I think it's important to mention that this is a gentleman who has a lot of protective factors. He's quite likeable, he's really quite bright. He's able to form relationships psychologically with people, as evidenced by his wife. She comments on him being a great parent. So he's really got a lot to work with positively. Those things tell us also that he may very well be able to engage in therapy, and also he's helped seeking. So, we'll look at whether or not he's comfortable with the medication I'm going to prescribe and whether or not he's going to take it.

  Dr. Aarti Rana: [01:01:44] Thank you so much. That really helps paint a very rich picture of him and really interpret his story into a rich picture that could actually be used to relate to him, relate to his family, and also work with him on a management plan.

  Dr. Lucy Chen: [01:01:57] Giving us some tools to be able to approach it in a more simplistic fashion that will really be helpful for young learners.

  Dr. Erin Carter: [01:02:04] Good. I'm glad to have helped. It's been fun. Thanks, guys.

  Dr. Lucy Chen: [01:02:06] Any last impressions or wisdom you'd like to impart on our listening audience?

  Dr. Erin Carter: [01:02:11] Two things. Number one, doing a formulation on paper is entirely different than presenting it. You have to practice saying it out loud because it just doesn't sound good the first few times you do it, and that's the same for everybody. I would really encourage you to get in front of the mirror or get together with one of your colleagues and just practice saying it. I mean, formulate each other and then practice saying it out loud because the art is really in the way you synthesize the information. You do not just want to read columns top to bottom or left to right. You want to dance between them and talk about the interplay between those things with phrases like, I really wonder, and you want to show that you are wondering, you want to sell it. Whether you're talking to the patient or your supervisor or your examiner, this is your chance to really say your opinion about why you think the person is like this and you want to sell it. So, make eye contact, say it. Let them know what you're thinking. "You know, I really wonder about this. I think about how this might impact him. I think he's he's really strong in this area. I do think this was an issue." You are using that kind of language. Don't just read it off a page. Say it like you mean it, like it's yours, like you own it and like you're selling it.Good luck.

  Dr. Aarti Rana: [01:03:24] Thank you.

  Dr. Jordan Bawks: [01:03:28] 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 organization. This episode is part of our mini-series on psychiatric skills, which are intended to provide UofT residents with content directly related to the intractable professional activities or EPAs outlined by our program. Since EPAs are designed to capture core professional psychiatric competencies, we trust our listeners outside UofT, will still find the episodes entertaining and educational. This episode was produced and hosted by Aarti Rana and Lucy Chen, audio editing by Jordan Bawks. Our theme song is Working Solutions by All of Music. A special thanks to Dr. Erin Carter 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 5: Managing Aggression and Agitation with Dr. Jodi Lofchy

• Episode 5: Managing Aggression and Agitation with Dr. Jodi Lofchy

  Dr. 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.

  Dr. Lucy Chen: [00:00:38] Okay. And we are rolling. Hi there. This is Lucy Chen. I'm a PGY four psychiatry resident at University of Toronto, and I'm here with my co host, Arthey.

  Dr. Aarti Rana: [00:00:49] I'm a second year resident also at the University of Toronto.

  Dr. Lucy Chen: [00:00:52] And we're very lucky today to be discussing a very important topic about risk and risk of and management of violence and agitation in the emergency setting. We're very lucky to have Dr. Jodi Lofchy here with us for this interview. Maybe we'll have Jodi first. Maybe you can you can talk. Tell us a little bit about who you are and sort of your experience in this topic.

  Dr. Jodi Lofchy: [00:01:19] Okay. Thank you. And thank you for inviting me to your podcast to be part of the the group of very illustrious presenters that you've had so far, so happy to join in. I am an emergency psychiatrist and I am here at St Joseph's Health Centre as the service head of Adult Acute Care Psychiatry, where I've been since October of 2018. So my background is in emergency psychiatry, and when I finished my residency training at U of T a century ago, many, many years ago, there was no such thing as emergency psychiatry and basically as residents we learned on the fly. I found emergency work fascinating and being able to think on your toes and having to make diagnoses and figure out what's going on when people were so acutely ill and make sure they got to the right place in a humane and caring way, because often it was their first presentation to the psychiatric system and anything we could do to ensure that they trusted our patients, trusted us and would come back for treatment, would go a long way. And so what we could do and emerge was really, really important. But there I was aware that we weren't getting any teaching in this.

  Dr. Jodi Lofchy: [00:02:36] And through my residency years, I was moonlighting. Those were the days when we could do such things because we had general licenses and I was a GP doing locums before my psych residency and I did emergency medicine work during that. And again, I like the acuity of being in the emergency. So after my residency I did a fellowship and this was the first fellowship in emergency psychiatry in Canada. There was no precedent for this. It was only a subspecialty area that had just been sort of evolving in the American than the U.S.. The American Association of Emergency Psychiatry had just started up in the late 1980s, so I completed my fellowship at the place formerly known as the Clark Institute of Psychiatry, and I finished that in 1992 and stayed on there to work in the emergency setting and become the director of that emergency services. Up to 2002, when I moved to UHN and helped create a models of best practice in the PC at Toronto Western Hospital where I worked up until 2018. I'm currently part of the emergency team here, but I also chair the CPA's section on emergency psychiatry for the country. So that's my area.

  Dr. Lucy Chen: [00:03:51] And that's lots and lots of experience.

  Dr. Jodi Lofchy: [00:03:53] And feel free to edit that too long.

  Dr. Lucy Chen: [00:03:57] No, I think that's amazing. Well, you know, I guess firstly, maybe what I'll take us through right now is just a list of the objectives that we're hoping to cover during this episode and we're hoping to fit it all in and we'll do the best that we can to make a sort of create sort of a comprehensive sort of overview of this important topic. So firstly, in our objectives, we hope that the learner can identify risk factors for violence in the emergency department and understand the differences between static and dynamic risks. We're hoping that the learner will know how to take a history for violence and communicate that risk to others. We're hoping that the learner will describe the indications for non chemical interventions in the management of an agitated patient as well as describe some of the pharmacologic interventions in managing the agitated patient and then finally wrapping it up with how to apply legislation regarding risk of violence. So I guess we'll start off with firstly, you know, there's always effort. There's it's really important to mitigate risk of violence in the emergency setting. And for you, Dr. lofchy, with your experience, what's been the most I guess what have been the most common challenges in preventing bad outcomes? How common is it and what have you really seen in your experience?

  Dr. Jodi Lofchy: [00:05:17] Common challenges in the emergency setting are there's environmental challenges, there's the clinical challenges, and then there's the challenges we bring and our team we bring as individuals, working in an intense and unpredictable environment, often doing shift work and perhaps being fatigued. So I always think about it in those three areas of the actual system or environment, the clinical, the patient challenges and then the individual in terms of the clinician and what we bring to the picture. So we do know the in terms of the system, we know the emergency department is very prone to violence, that that we have some stats about that that 10% of psychiatric emergencies involve some sort of agitation or violence and that out of looking in the states where they looked at 3.4 million emergency visits, 1.7 of those visits involved some sort of agitation. And we know it's not just when people have major mental disorders such as schizophrenia or bipolar mania, but the cognitively impaired patient. So we don't know. It's always psychiatric. It could be medical substance related presentations. All these kind of clinical factors impact on people's agitation. We know that our staff whose front line is at the highest risk, and that's typically nurses and security guards. So the environment itself, if it's not designed safely, can lead to bad outcomes. You asked. Those are the kind of challenges that we would want to create, environments that would reduce the risk. We would want to be able to get patients quickly and safely through the doors.

  Dr. Jodi Lofchy: [00:07:01] And we know that if there's increased wait times or crowding and overcrowding in our emergency departments, that leads to frustration and agitation. If we have poor communication with our patients, that can lead to a bad outcome. You know, triage is a pretty opaque concept to the layperson. Many people sit in our waiting rooms and have no understanding why someone else who came in much later than themselves flying through the door quickly. And it's like, Wait, hey, I've been here a couple of hours. Why are they going ahead of me? It's not like, you know, the bakery or the deli where you take a number and you just wait your term and you're going turn and you're going in sequentially. It triage is about prioritising the most acutely ill, and we need to communicate that to our patients who are sitting waiting in the emergency department. I think that the trend towards building holding units such we have, such as we have at Toronto Western and here at Saint Joseph's where right from the point of triage, people go right into a designated area for psychiatric emergencies. That goes a long way in helping to explain the system and explain the process and settle people because they're going to be seen and they're going to be in a contained space that's designed for safety and can hopefully help to settle people and reduce the risk of violence. There's lots of challenges. Lots of challenges. Yeah.

  Dr. Lucy Chen: [00:08:22] And maybe just to summarise, it sounds like what you've talked about is like sort of systemic factors in terms of structure of the hospital triaging, sort of the routines around management and kind of triage. And then you're sort of talking about environmental factors in terms of the space seclusion or holding units, sort of opportunities in terms of containing patients when necessary into a room where where that's necessary. And maybe you can tell us a little bit about what a seclusion room is or for for those who are who are not really that familiar.

  Dr. Jodi Lofchy: [00:09:02] Well, I don't know that there's one definition of that, and I think they're pretty site specific. When we have rooms that people can be separated from a general waiting area that has reduced stimulation where there's not the noise of other people who might be unwell so that people are removed into a quieter space. We also know that lack of sensory stimulation can make people more agitated. And so there's that fine balance of being able to give somebody some quiet space and diminish the stimulation, but also allow them to feel that they can ask questions or that they're being cared for by a team and that the nurses and the the psychiatrist or the emergency physicians will still be seeing them. But we do want if we have to give somebody a time out in a in a way have a place where it is quieter and it's removed from the general melee of the intense, busy, noisy emergency setting.

  Dr. Lucy Chen: [00:10:08] Yeah. So just to continue the summary. So systemic factors, environmental factors, sort of psycho pathological factors with regards to the patient. So in terms of the diagnosis or whether it's sort of an organic cause such as substance, dementia, delirium or head injury, psychotic factors such as mania or schizophrenia or psychosis, or if they have perhaps a forensic history or if they have a diagnosis of autism or sort of personality traits that are more predisposed to violence. So those patient factors as well, and then as well as sort of the train, the practitioner and perhaps their level of training and familiarity in that environment.

  Dr. Jodi Lofchy: [00:10:45] That's right. Or if there's a certain type of patient that creates anxiety or dislike in the clinician, then you may not be coming towards the clinical interaction with patients and empathy. If it's a certain kind of patient that would push your buttons, you need to have that self awareness. And that's part of what goes on in the residency training, is learning how to manage these intense feelings and reactions to patients who at times are incredibly challenging. So knowing ourselves well, knowing when we're fatigued or when we've been too busy all day to even eat lunch and that we're going to be our patients is going to be even more thinly pulled. So we have to just be aware of the factors we bring to the interaction as well with patients who have high risk, who are high risk.

  Dr. Aarti Rana: [00:11:33] And Dr. Lofchy, when it comes to the patient factors, one of the challenges, as I understand it, is these are undifferentiated patients. It's a term we use to say that these are patients where we don't know the psychopathology, right? We might be able to see some of it in that they might appear agitated, but sometimes a very quiet patient can quickly become agitated. So how do you take a risk history? How do you take a history from a patient quickly that actually helps you assess risk along the way? What are you looking for?

  Dr. Jodi Lofchy: [00:12:03] Oh, that's a really important question because that's part of every type of psychiatric assessment. Before we meet the patient, we are given some information about them. So it really is important to see if there's any collateral or past history because we know past predicts future. So if we know that there's been a legal history or that right then and there, the police are bringing in the individual because there's been some sort of altercation. Anything we know about their past risk would help inform our assessment that we're going to do. The police have often put patients into their computer systems and they can tell if there's any charges in the past or outstanding charges at times. So we go online to see if we can get the information from old charts, if they're known to our hospital, that kind of thing. But if somebody just comes in calmly, we're going to do our history, as we would with any emergency patient. Right. And there might be kind of little triggers that go off that say, hmm, I'm concerned about this person, or I'm watching for signs that show that there's increasing agitation. But the actual history taking, we follow the same approach and structure that we would with any emergency assessment. But we're going as we would screen for risk in terms of suicide, we screen for violence risk. So we want to know about an aggression history.

  Dr. Jodi Lofchy: [00:13:19] We want to know if there's been any charges and if so, what kind of charges are these assault charges with or without weapons, that kind of thing? Were they provoked? If we hear there's been a history of violence or unprovoked, this kind of thing, and who's been at risk? We know that those closest to the individual are always at the highest risk, intimate partners, children, that kind of thing. Or was there violence towards complete stranger, something random and much more concern? It's all concerning, but if we can't predict because that kind of thing just is something that's a one off, that kind of thing. What was the individual's response to having been violent? Did they have remorse or was there some sort of minimization or denial of the whole kind of incident and the role of substances. A lot of this doesn't occur in isolation. Many of our patients have comorbidities, and substance is a big part of the emergency presentation, whether it's a current state of intoxication or withdrawal or a current history or past. So if there's been violence, has it been in the context of any kind of substance use? So these are the kind of things that we we explore. We ask about how people manage difficult feelings in a more general way. How do they express their anger all the way from road rage to property destruction to actual physical altercations.

  Dr. Jodi Lofchy: [00:14:44] So we're exploring it in some detail. If we feel somebody is at high risk or we we know something about their history to hear what their past is. We also want to be checking in in the interview itself. How are they feeling now? Are you able to tell me if you're having any of those feelings here today? You're always trying to assess your risk and make sure it's safe for you and your team while you're doing your interview. So it's not just asking these questions and noting down and then coming out and say, Oh, I've got a high risk patient. It's making sure this is not going to be activated because of the stress of being in the emergency setting or having been apprehended or put on a form, whatever the stressor is. Now, that might be provocative. We want to make sure you're safe and that you know how to ask the questions to check on that. Clearly, the aspect of means for violence is important. It's always in our mind, and that's why we're talking about safe environments. But have the patients been searched? We don't know that. If they haven't come in with the police, Police, we would check with them. Have they been searched? Usually they do search them, but it's not typically part of the routine, the automatic role of a security guard in the hospital or a psychiatric assessment psychiatric assistant in some of our hospitals.

  Dr. Jodi Lofchy: [00:16:03] Pa, So we have to understand if there's available means, if they have that, any kind of potential weapons on them or nearby. And then as we're doing our interview, we're looking at the individual and the demographics in terms of are they falling into a high risk group, in terms of being a young male, having been through chaos and dysfunction in terms of their family upbringing? Is there a paranoia in the room in terms of they're feeling victimised or and I don't even mean delusional necessarily, but necessarily but their way of seeing the world that they've been victimised and that others are out to get them. So maybe they need to protect themselves or maybe others have it coming. So that kind of cognitive set. But obviously if there's actual psychosis and persecutory delusions or command hallucinations informing the individual that they must do something violent for whatever reason doesn't necessarily make sense. We want to explore that in great detail. So basically you're doing your regular history and mental status exam, but you're just being alert to who are the individuals in their realm who might be at risk. What does their past history tell you in terms of past experiences? Predict future and what's currently going on now in terms of how active are their psychiatric symptoms that put them at at risk and including states of intoxication or withdrawal.

  Dr. Aarti Rana: [00:17:33] So in terms of a step by step approach, first you might start with the triage notes and say, is there anything in these notes in their presentation, like are they agitated? That makes me worried about risk.

  Dr. Jodi Lofchy: [00:17:44] And the police would hopefully bring in the EDP, the emotionally disturbed person's form, And if they've forgotten to do that, you can remind them or triage can because there's such useful information that the police have about why this person has been apprehended or brought in under the Mental Health Act, in effect.

  Dr. Aarti Rana: [00:18:02] And then in addition, it sounds like, in addition to getting the story from police, also making sure we ask about whether or not the patient has been searched, that's really important. And looking at past records to see what's their history within the emergency department or within past psychiatric assessments. And then in addition to that, looking at the environment that the patient's in before you go in and speak with them, those would all be things. And then in the context of the actual risk assessment, some of the things that you mentioned that I thought were really important are how do we characterise past risk. So is it provoked or unprovoked? What was the context for it? Was there were there any substances involved and what was the degree of impact? So is this was this I hate to say minor because I think even a small minor history of violence is still important, but sometimes there is minor violence versus something major that resulted in a charge of some kind. And the extent of that charge and when that was all of those factors. And once we have all this information, how are we writing it down that we're ensuring the next person really has all of this or that? If we're reading a note from the patient's history that how should it have been communicated to us that we're really prepared to go see this person?

  Dr. Jodi Lofchy: [00:19:20] Well, that's a great question because that speaks to systems and hospitals and the way we communicate between team members and within our own group, but outside our own department as well. And various hospitals have created different systems of highlighting patients who are at risk of violence anywhere in the hospital. And that could be, again, a post op, delirious patient who's assaulted a nurse or been agitated on the ward, not somebody who's been aggressive on an inpatient ward or comes in the door that way. So there's different flags that go on electronically at different hospitals, and everybody should be at the point of orientation, informed of the way the hospital complaint completes these and communicates that this person is a high risk patient. So these days it's being done electronically. We have that on our own system here at Saint Joe's , UHN has a system of a behavioural safety alert, so there's red flags and highlights. If you look on the actual sort of patient list on the here it's sunrise and at at it was the EPR. So all different systems and I can't speak for every single hospital, but I know that's what the trend is to be able to communicate that patients you do need to like kind of be a little hyper alert when somebody has a past history so that it's being indicated throughout the hospital.

  Dr. Lucy Chen: [00:20:47] And Dr. Lofchy, like you've sort of supervised residence in the Emerge before, How would you like that violence risk be communicated to you? So if there's the first year resident there on their first emerge shift, they're kind of encountering this patient, they're collating all this information. How would you prefer to receive that information? What's the kind of organised approach that a resident can take in communicating risk when they're sort of handing over?

  Dr. Jodi Lofchy: [00:21:10] Right. Well, handover is really important and I do think it involves not just the medical handover but the nurses taking care of the patients as well, the whole team. So there are different ways in St Joseph's creating a new interface for safety and incident reporting when there's any concerns about safety issues to the team or between the patients, that kind of thing. What we need to do is integrate it back into the clinical record. So I think there might there's no harm in duplication. Now if all the different boxes are being checked, you just the resident would need to know their system in terms of who should I tell that I'm concerned about this patient, that there they're no needs to highlight it. And maybe the way the orders are written in terms of level of observation or we have here communication orders, just to note that there's concerns, that kind of thing, so that the other team members can read this, that in their own consult note, it's being documented in the impression every resident will write up their note and after doing the history and their mental status exam will do an impression, It will be including a diagnostic impression with the DSM. But it will also be a narrative, a description of the risk assessment and the justification for the decisions they're making at that point for what the disposition is. So you don't just come up with a plan and say, you know, admit on a form or send out the door and and go to crisis clinic. It's like, how did you get to that decision? How have you deemed that safe or appropriate to be able to follow that course? Or what are your concerns that make the admission necessary or the involuntary admission required? So that should all be documented in your impression, so that even if somebody doesn't have time to read the whole note and often we're just saying, okay, what's going on here and what's the plan that it's all clearly laid out in terms of why this person is high risk and why you're choosing the disposition that you are?

  Dr. Lucy Chen: [00:23:08] And I guess just to organise this further, I mean, there's this idea of static and dynamic risk factors and what we're really targeting are the dynamic risk factors. So maybe if we can better highlight what's considered a static risk factor, what's considered dynamic, and then maybe that'll give an approach to organising risk.

  Dr. Jodi Lofchy: [00:23:25] Absolutely. And I think this is a really good way of thinking about any kind of risk assessment and people are more comfortable thinking about this or it's more common to think about this in terms of suicide risk assessment. It's this exact same approach. The concept of static risk factors are being. The historical aspect, things that are more biologically driven, and basically the concept that we can't modify or change the static risk factors, we we inherit them as the patient comes to us through the door. And this is their history and this is who they are and this is what's already happened in the past. So in terms of, you know, men maybe being at higher risk or having had a background of trauma or chaos and family dysfunction, having had past history of substance use, having a psychiatric diagnosis that they come to us with. Those are all things that are. Hardwired to an extent, but not. But we can treat and we can modify the the substance, use the psychiatric illness by engaging with the patient and offering treatment. And then we look at the more dynamic aspects is can this person is there something here that we can treat? And we know there's certain conditions and personality disorders that there isn't a lot we can do in terms of the antisocial personality, and that's why we have the legal system to assist us with that. If there's nothing else treatable that we can offer in terms of a major mental disorder such as schizophrenia, substance problem, mood disorder, etc., the things that we have more of an armamentarium to offer in terms of treatment options.

  Dr. Jodi Lofchy: [00:25:20] So we are looking at the dynamic factors, where can we intervene. So I'm talking about some clinical things, but I'm also talking about social aspects and that's why it's essential we work with a team that we work with clinicians and social workers, and we liaise with community supports that our patients are well connected. If we can assist with that, that's fantastic because we want to help them outside the hospital. If this kind of cross sectional interaction in the emergency department might be the only time we see this person. The difficulties are out there not with us one day in the emerge or one night we want to try and create more of a support system and an infrastructure when they leave the hospital. So those are the modifiable risk factors and working with the team allows us to kind of put a bit of a cushion together and engage the person in treatment. And I'm back to my earliest point is this is the portal of entry, right? This is the the chance that we have to really hopefully engage this person in a positive connection and journey towards the recovery model and hope and wellness and all these things that we can offer, just hope for the future, that we have something to offer so that we can. That's our role in the emergency department, I would say.

  Dr. Lucy Chen: [00:26:39] I guess just generally summarising static risk factors being more historical, generally sort of modifiable and long term risk and dynamic factors being more modifiable. It's more so the short term risk and it offers targets for risk management and risk reduction.

  Dr. Jodi Lofchy: [00:26:54] Right.

  Dr. Aarti Rana: [00:26:54] And it's not only it sounds like the factors that are dynamic, but risk itself is dynamic, right? So you're observing someone and their behaviour may be changing in the emergency department and we can identify those stages of risk or what are those stages and what do we look for to identify them?

  Dr. Jodi Lofchy: [00:27:12] Well, that's very, very important because I mean that we don't just say, Oh, they're low risk because today they're not intoxicated or they want help. And then we we have to see what's actually going on in the department itself, because as we've mentioned already, there's lots of factors beyond our control in terms of the milieu of the emergency setting that can create an increased risk or provoke somebody who may come in the door initially calm. So we're always watching to see how things are shifting or evolving. And we have to I always talk about doing an eyeball sort of visual mental status exam before you even go out or start your shift. You sort of I think the term is an environmental scan. We look around, we see who's there, we see is it crowded, Are people sleeping, Are people pacing? Are they already in a state of potential agitation? So we need to organise our thoughts about who is no like doesn't look to be at any acute risk at this point in time. And who might be escalating because we know that there's a continuum and if we don't intervene at any stage of this kind of escalation, it will just go on and on until something very dangerous potentially can happen. So we want to organise our thinking about who is starting to escalate and what should we be looking for at each stage.

  Dr. Jodi Lofchy: [00:28:37] So the first stage would be just general agitation. These are the patients who might be coming up and banging on the the the glass Lexan glass where the ward clerk or receptionist is saying, When is my turn? When am I going to be seen? I've been here forever. They're starting to get a little upset because they want something or their needs aren't being met. So we're going to watch for motor changes. We're going to see them pacing more. We're going to hear their voice go up. Perhaps they're not able to contain themselves to be pleasant and calm when they're asking their questions. So the volume, the tone, and we're going to just watch for some sort of sort of adrenergic response where they're getting a little more flushed or they're starting to clench their fists and it's hard for them to sit down. So that's the anxiety, the agitation phase. And then we if that is not addressed, if we don't intervene to help de-escalate that, then things can get. More volatile. Somebody can move from anxiety and being agitated in a psychomotor agitation way to actually threatening and verbally threatening and saying if I'm not seen within a few minutes, something bad is going to happen. That's a threat. It may be non-specific, but we just don't ignore that.

  Dr. Jodi Lofchy: [00:29:49] So now we're in a verbal threatening phase of an interaction and we need to actually intervene accordingly. I can talk about management after, but you had asked about what are the things we watch for? So we watch for agitation and this kind of psychomotor escalation. Then we listen to what's going on and if there's any threats, they're now in the second phase of actually threatening. And then the next phase is actually the most dangerous, where we have overt aggression, where it's no longer verbal, it can become physical and anything as a potential weapon. If somebody has come in with belongings, things can get thrown. If we're working in an environment where there's objects that can be picked up or we don't know, again, the worst case scenario, if they have a weapon, if they haven't been searched, that kind of thing. But anything is a potential weapon if used in a certain way. So that's kind of the peak of the curve when things are at the most dangerous. And after that, then people's energy spent and there's a resolution where we can actually all engage. But by the point that point, we're looking at code whites and calling back up and really kind of trying to diffuse the whole setting to keep it safe.

  Dr. Aarti Rana: [00:31:01] Since you mentioned Code White, I think it might be helpful for people to know what exactly happens if we have a lot of listeners who are clinical clerks or first year residents. Some of them have never actually seen what a code white looks like. They've just heard it paged overhead. So can you describe when someone might call a code white and what would they expect would occur?

  Dr. Jodi Lofchy: [00:31:19] Sure. For anybody working in a hospital environment, the code system is standardised, so there's lots of different colours, the whole rainbow and it's any hospital that you're going to work in across Canada, we'll have the exact same code system and what's nice about it, it's standardised, how to access it to you would call, you would dial five, four or five, five, five, five, five and that gets you the code white, which is asking for backup and a code white team to respond immediately when there's an agitated patient. And it doesn't have to be a registered patient, it could be a family member, it could be a concern to other it. It's an individual who's agitated and you need a show of force and a backup team and trained personnel to help de-escalate the situation and back you and your own team up. So when you're working in an environment like the emergency department, you may hear code whites being called. They may be in the General emergency Department, they may even be in the psychiatric emergency department, they may be on psychiatric inpatient wards. But there is a designated code white team 24 seven that will come to assist with with as many people as possible who can provide backup to assist. If you need to now de-escalate the patient, provide chemical restraint or mechanical restraint, get the patient into a quiet place, into a bed, and make it safe for everybody.

  Dr. Lucy Chen: [00:32:47] So now we've kind of got a clerk or a resident who's prepared themselves through a review of the history. They've collated all this information. They've gotten some handover. They're now approaching sort of they're exiting sort of the nursing station and they're heading towards the sort of the the merge department interview room, I guess. Are there things to be mindful of to ensure that we're working in a safe and well equipped environment? Where are things to watch out for? What are things to be mindful of?

  Dr. Jodi Lofchy: [00:33:17] Absolutely. I think this is a great opportunity for medical students and residents to check that the environments they're working in feel safe and that are designed with safety in mind. And the bottom line is, if you're not feeling safe or you have concerns, you bring somebody with you or you organise your space accordingly to be in a place that is set up that way. So ideally you want to go to an interview room that's designed for safety or interviewing psychiatric patients that would have a non barricaded door or have two exit points so that nobody could block you in that you need to know about personal alarms that what your actual alarm buzzer will do. Does it call for a backup team? Does this buzzer that this little button you're carrying around, is that going to call a code white? You need to be oriented to what are these devices that have been provided for you to to access backup? Should there be any need to hit an alarm button? You want to make sure the room that you're going in doesn't have extraneous decorative items that can be thrown that the patients are not bringing in. If they have that suitcase sign of kind of thinking they're staying in the hospital longer, that perhaps they leave their belongings outside the interviewing room. You're. Looking at what they're wearing and if they've got layers of clothes or bulky pockets that may have items in them, you may want to ask that your team together, ask them to empty their pockets, etc., before you go in.

  Dr. Jodi Lofchy: [00:34:45] Sometimes patients when they've been certified and put on form ones are put into hospital gowns already. So that's kind of an equivalent of having them searched and make sure they're not bringing in any extra weapons. You want to set up the room where you're sitting and where the patient sits. And if you have extra staff members or team members with you so that you all can get out of the room quickly and nobody is feeling trapped in a corner. So that is a certain way to make sure that everybody has access out. What I typically do is I don't like a door shut 100%. I like it a little bit open. So you're not fumbling with waiting for buttons and things to open. So and also this kind of illusion of ventilation and air coming in and flow so that we can all quickly get out of the interview room. But it really depends how your department is designed and what the actual physical space is. But you do, especially if you're on call and this is the middle of the night where there might be reduced staffing. You definitely want to check out before you go in who is your backup, who is going to be arriving should you need extra help and how to call for staff or assistance quickly. You also want to look at yourself, what you're wearing before you go in. I always talk about fashion as weapons.

  Dr. Jodi Lofchy: [00:36:01] There's certain things that if you're wearing necklaces or long and dangling earrings, that kind of thing that anybody could grab on to and pull and you're putting yourself at risk. Women who have long hair have to think about that, not having ponytails that could be grabbed or hair that's going to be potentially a weapon if they're on call, males who maybe are dressed more formally. Really, psychiatry is not a place to be wearing ties, especially on call. And I always joke unless they're those quick release ones that you have and that speaks to the lanyards as well. Everybody wears their hospital ID, but I think these days most House staff have quick release with three breakaway points with the lanyard so that even if somebody's pulled from the back, that there's no way that you could be harmed by your own hospital ID. So these are the things to think about before you go in if you're not in an emergency setting, but you're seeing somebody who's a new patient to you on an outpatient ward, you have to go through the same kind of thought process and you really don't want to be seeing new patients. At the end of the day, when there's less staff around, the receptionist may go home at a certain hour and you're still booking patients a little bit later. You save the new patients for early in the day when there's sort of a robust response going to be available should you have any concerns.

  Dr. Aarti Rana: [00:37:24] Thank you. You've really highlighted the importance of preparation and all the things that have to happen before you even go in to assess a patient. And I've still been in situations where despite all of that, I'm in a room with someone and they sometimes very calmly express some kind of violent ideation or for whatever reason that I can't even anticipate during the course of the interview, start to become agitated. So let's talk about de-escalation. The word kind of implies we're trying to bring someone from one stage of risk down to a lower stage. So what is de-escalation? How do we do it?

  Dr. Jodi Lofchy: [00:37:59] There's verbal de-escalation. And I guess that technique and approach to de-escalate somebody would apply to those first two stages of pending violence, the agitation, anxiety stage and then the verbal threats. And we use all these verbal techniques to help bring somebody back to a place where they can communicate calmly and clearly, if possible. So the earlier we recognise, the better, because our techniques will vary based on what we're hearing. When you're seeing somebody just calmly talking about some violent thoughts or fantasies or ideation, but there's no signs of motor agitation that's separate from somebody when you're in the interview who suddenly can't sit still and has to get up and pace around and you have to keep saying, are you able to sit down? You can't ignore what's going on. So whatever they're bringing to the interview you have to address. So if somebody is calmly starting to talk about some violent thoughts, feelings, fantasies, ideations, you need to say, are we at risk right now? Do we need to take a break? Are you telling me you're having these thoughts about acting on this now? It's just like suicide. It's one thing to have ideation. It's another thing to have intent. You want to understand the degree of impulsivity, though, that this person brings to the interaction and what their history is. How have they acted on it before? So that's back to the history. So if they're telling you about it, it's more an exploration.

  Dr. Jodi Lofchy: [00:39:27] But if something's going on, that's where we de-escalate, where it's getting more. It's in the room. So verbal de-escalation is always for setting the stage with, you know, an empathic and respectful connection with the patient and already appreciating that they may come into this interview very frustrated that our emergency systems are set up, that they've probably told their story three or four times before they get to you as the psychiatric team. And you may actually have to say, we need to you may actually have to tell the story again once I review with my staff or bring in a senior resident or another team member. So you're trying to appreciate that. I know you've been waiting here a long time. I know you've already talked to a lot of different people. Did they explain who I am and why I'm talking to you now? No, I have no idea who you are. I just want to go. Okay. So the idea is trying to empathise with the frustration and the time they've spent and what they're telling you. I hear that you want to go. You're not ignoring it. But we need to understand why you're here. And if there's any way we can help before we figure out what's going to happen. So it's really important not to make promises that you can't keep. That's a really important rule because that will come back to haunt you If you people are listening to you.

  Dr. Jodi Lofchy: [00:40:48] You would be surprised, even in a state of escalation and yelling and threatening and calling you terrible names, they are listening to what you're saying. So it will come back. Doctor, you said that once I talk to you, I can go now. Why can't I go? Whoa. Now you're worried that they're certifiable. They're not going, so you're retracting. So be careful how you're engaging, what you're promising. Only promise. Things you can carry out. Such as I. We will get through this as quickly as possible so we can make a decision that's good for you and that we can help you as best as we can. So you're trying to engage. You're when people are agitated, they can't hear. It's a little sound bites. You know what it's like when you go to the doctor and everybody comes in with their questions because they know the minute they go out, they're going to forget everything you've said or even with a family doctor. If they're hearing something that is distressing, potentially, you forget because you're so aroused with emotions and affectively charged. So you have to speak in soundbites. You can't give a paragraph, you can't give double barrelled, you know, instructions or saying, do you feel this or do you feel that you have to actually say, I hear what you're saying, end of sentence.

  Dr. Jodi Lofchy: [00:42:00] You're upset. And yes, I'm upset. Obviously, I'm upset. Okay. You've been waiting a long time. I see that. And and many of our patients, again, English is not the first language they have there. Substances may be impairing cognitive challenges. There's lots of reasons why we have to speak very simply, very succinctly, very clearly, and so that we are identifying accurately what's going on. And if we're wrong, someone's going to tell us, no, I'm not upset because I've been waiting. I'm upset because my kids were just taken away. I'm upset because, you know, I just lost my job. I haven't even told you why I'm upset. You're right. We haven't had a chance to sit down and talk. So can we do that? And you know, it's not about can we? Because then they might say no, so I'll take that back. Like, I'd like to be able to do that now. We'd like to be able to talk. It's not asking permission to do your job. You have to say, we need to hear what's going on so we can help you. Right. So the idea is limit setting, empathy, respect. There's a very, very good article from the Beta project Janet Richmond wrote on verbal de-escalation, and she's a very experienced emergency social worker who has written an excellent article on an approach to verbal de-escalation with sort of the ten domains. And that's something.

  Dr. Lucy Chen: [00:43:19] Maybe we'll include that in the show notes.

  Dr. Jodi Lofchy: [00:43:20] Yeah.

  Dr. Lucy Chen: [00:43:23] So thank you. Dr.. So I think we the resident has now sort of attempted to validate, empathise, respect the patient as best they can, understand the circumstances and sort of work with the patient. But this patient's really still continuing to escalate and they're sort of emerging out of stage 1 to 2, progressing really into stage three. They punched a Wall.

  Dr. Jodi Lofchy: [00:43:45] Okay, So now you're no longer verbal, now it's physical. When they get physical, we get physical. So now we're at overt aggression. Right. So I think what happens typically, though, people medicate to early because they haven't really gone through the verbal de-escalation. But I'm not saying you stay in there until it's not safe. You should be able to see it coming. Obviously, if you can't and I can speak from personal experience, having had an assault, significant assault where I didn't see it coming, somebody went from 0 to 100 who is very psychotic. There's times you may not. So you have to be comfortable protecting yourself and your team and getting out of the room quickly. Right. If it's property damage, you get out of the room, it's not you at that point. But that's when you start thinking about, okay, we're not we're beyond negotiation here. We need to intervene physically. So then you ask the questions about medication in terms of your choices at this point. And I think you don't need to know what's going on. We often our patients are new to us. We don't know their histories. It may be a first presentation, a first break. We haven't worked them up properly with what substances are on board, etc., etc. So we have to just kind of can use our skills of observation and the mental status findings we've found already to ask some pretty broad brush strokes about diagnosis.

  Dr. Jodi Lofchy: [00:45:09] Is this person psychotic or not? What is our provisional diagnosis at this point in time? And are we looking at somebody who sort of, you know. Throws their pen or paper work down on the floor versus punches a hole in the wall. How severe is this agitation or has there been an assault? So is this mild agitation somebody starting to pace? They can't sit down, they can't listen to your instructions or has something very potentially dangerous happened. So that's going to help us both with medication choice in terms of what we're choosing as well as the dosing. If there are psychotic features, if they're known to have a psychotic illness, we may start with an antipsychotic and a benzodiazepine. If this person is has no psychotic illness, it may be only substance related or personality related, then we may be choosing to start with a benzo alone. Our choice of route will also be determined by the severity of the agitation. Somebody may actually say, Look, I'm feeling out of control. I need something. Okay, We agree. Would you like to take that by mouth or in a needle form? So there may be a point of negotiation where somebody can agree to take it sublingual. Often when you come up with them with a needle to them, they'll say, Whoa, I want that. I'll take it. I promise I'll take it by mouth.

  Dr. Aarti Rana: [00:46:34] So you may be able to negotiate what route?

  Dr. Jodi Lofchy: [00:46:36] There's a certain point when you can't where it's severe agitation, somebody is at risk, there's an assault, and you're giving an IM because we know it's the quickest onset of action and we can't wait for anything else to kick in. You asked in a question in terms of the earlier questions you distributed, but when we think about mechanical restraint and it fits in, my discussion here is that you would never sort of come in with an IM when somebody is still agitated, hitting walls. You do need to this is where your code white and you have enough people to actually get someone onto a stretcher and put them into mechanical restraints briefly to stabilise or immobilise before you give an IM, because we know that there's a high risk of the wrong limb being an injected if the patient isn't stabilised mechanically before, it doesn't mean they have to stay in physical or mechanical restraints in any kind of excessive way. And that's an important point. We're just doing it briefly to get the medication given in the safest way possible. So yeah, those are some of the concepts of medication. And in terms of I don't know, I don't think for the purposes of time, I don't know how specific you want me to be in terms of choices of of agents, but.

  Dr. Lucy Chen: [00:47:56] Yeah, yeah, yeah, yeah, yeah. For sure, I guess. Finally, just to touch on the last topic, which is how we apply legislation when we have to pull out that form one when this person, this person certifiable.

  Dr. Jodi Lofchy: [00:48:10] And that's a really important thing to think about at the end is about are they in the right place? I mean there's lots of violent patients who maybe shouldn't be. Well, I'm using the word patient, so that infers that there's something medical going on and that we have a role to play. But a violent individual is not always best served in a hospital setting. So the use of the form one is when we have concerns that there's an underlying possible mental disorder that's contributing to the risk and the agitation and the violence, that there's something psychiatric that we need to investigate further. We don't need to know for sure. We just have to have concerns and some observations in our interaction that there might be some psychiatric symptoms or mental status findings that would allow us to complete the form in a valid way, saying that there might be an illness that's contributing. So we would use the form one to complete a fuller assessment to actually make that conclusion about what's going on here and why is this person so agitated when they're threatening harm to themselves or others. But when we're witnessing that there's been agitation or aggression? And one of the aspects of the form, one I think is actually a really good box that you can check off is causing another individual to fear bodily harm. Nothing has to have happened but just your and again, I understand that subjective and we all have different thresholds for concern and anxiety based on many factors.

  Dr. Jodi Lofchy: [00:49:45] But that doesn't matter if you are a physician completing that form. One Any M.D. who's fearing potential violence from this individual can complete the form one, and that would be the risk. And you would explain how you came to those concerns, but you would also have under the future test to explain why you think there might be an illness here that's contributing. So that would allow us up to 72 hours to figure out if there's something psychiatric or if this person remains at risk and requires a longer admission, either as a voluntary or involuntary patient. The other important aspect of the legalities of working with violent patients in the emergency department is our duty to inform, and that if we know that other people are at risk, if there's been threats made towards others outside the hospital or inside the hospital, what is our responsibility to alert the police or that individual? And we typically would inform the police if somebody is being released in the emergency setting, we're usually holding people and we would want to go back to your communication in writing, in our documentation, make sure we're clearly communicating with our inpatient colleagues that before the point of discharge, this risk needs to be reassessed and any other individual, if they remain at risk, there would be that duty to let the police know or the individual know about the risk that exists. So those are the two emergency aspects of the the forms and the legalities that we think about in the moment.

  Dr. Aarti Rana: [00:51:21] And for context for our international listeners. In Ontario, which is a province in Canada, we have a mental health act. I feel like I'm an untested doctor. Lofchy Let's let's see how much I know we have a mental health act that allows us to hold to essentially hold people for a period of up to 72 hours for psychiatric assessment when they are exhibiting behaviour that's putting themselves or others at risk, a potentially or actually witnessed. And also they have to have some evidence of a psychiatric illness.

  Dr. Jodi Lofchy: [00:51:53] And that's the third criteria. Just if you're educating our listeners from afar that that or that there's the evidence that they're at imminent risk for lack of self care, that they can't, they're putting themselves at risk because they're not able to care for themselves.

  Dr. Aarti Rana: [00:52:07] And I want to highlight the aspect of there being some evidence of a psychiatric illness. That part I didn't actually really understand until I got to residency that there was a distinction between just putting oneself at risk for, say, because due to a medical condition. Right, Right. Versus a evidence of a psychiatric illness. And that's really an important criteria in the form. If we're not seeing evidence of a psychiatric illness, we can't actually employ the system.

  Dr. Jodi Lofchy: [00:52:34] That's right. And that's what the point I made earlier about our legal system, that we have jails when people are homicidal, that they should be charged with uttering threats or with assault or whatever the actual violent indication is, if there's no evidence of anything psychiatric going on.

  Dr. Lucy Chen: [00:52:52] So I think those are all our questions for today. Dr. Lofchy, We're very lucky to have. Had you on our show. I guess any lasting sort of impressions or sort of wisdom you'd like to impart on young learners, clerks, young residents in our program and and afar who are listening to this podcast episode right now?

  Dr. Jodi Lofchy: [00:53:12] Well, I think the emergency setting is an exciting place to work, and I think young learners, trainees now are working in environments at the best time possible because you're getting education both as medical students, as residents about the importance to learn about how to assess and manage yourselves with agitated patients that the residents and even medical students are learning self-defence techniques to have physical ways of responding if threatened with assault or put in a dangerous situation. You're getting training that was never available before. So when we look at the stats and we look at the literature about resident assaults and that kind of thing, we need to revisit it because we are now we now have the educational programs in place and providing training that's lowering the risk. And those earlier statistics about residents, you know, maybe frontline people being more at risk, I think we have to think that those numbers are going down and that you're feeling more comfortable and confident to be able to have the tools that you require to work with all patients that you're going to encounter in the emergency department, that our hospitals are more sensitive to what we need in our settings, in the environments that we're designing for psychiatric patients are safer than ever. So I think it's an exciting time to be a trainee and it is exciting time to work in the emergency department. I've been doing this for decades and it never gets boring. It's always exciting. And and in fact, as I sign off, I'm heading down to the emergency department here to see what awaits. So I thank you for the opportunity just to share some of the experience I've had over the years.

  Dr. Lucy Chen: [00:54:51] All right. Thanks a lot. All right, Stay Safe, folks, that's it for today.

  Dr. Alex Raben: [00:54:56] Psych 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 a part of our mini series on psychiatric skills, which are intended to provide you of residents with content directly related to the intractable professional activities or EPAs outlined by our program. 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 is produced in hosted by Aarti Rana and Lucy Chen. Audio Editing by Jordan Bawks. Our theme song is Working Solutions by All of Music. A special thanks to Dr. Jodi Lofchy for serving as our expert this episode. You can contact us at Info@PsychPodcast.com Or visit us at PsychEdPodcast.org Thank you so much for listening. Catch you next time.

Psyched Episode 14: Diagnosis and Treatment of PTSD with Dr. Dana Ross

• Psyched Episode 14: Diagnosis and Treatment of PTSD with Dr. Dana Ross

  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!

Psyched Episode 13: Psychiatric Rehabilitation with Dr. A. Rudnick

• Psyched Episode 13 Psychiatric Rehabilitation with Dr. A. Rudnick

  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 12: Treatment of Schizophrenia Part IV Advanced Principles of Schizophrenia Treatment with Dr. Gary Remington

• Episode 12: Treatment of Schizophrenia Part IV Advanced Principles of Schizophrenia Treatment with Dr. Gary Remington

  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 11: Treatment of Schizophrenia Part III CTOs and ACTT with Dr. Arash Nakhost

• Episode 11: Treatment of Schizophrenia Part III CTOs and ACTT with Dr. Arash Nakhost

  Henry Barron: [00:00:01] Welcome back to Psyched, the Educational Psychiatry Podcast for Learners by Learners. I'm Henry Barron, one of the medical students on the podcast, and I'm going to provide a quick introduction to the episode, and then Alex Rabern is going to take it away with today's interview. This episode is the third of four in our series on schizophrenia. If you haven't listened to Episode nine, it may be helpful to go back and listen to it because this episode builds on it and reinforces those ideas. For this episode, we sit down with Dr. Arash Nakhost, a psychiatrist and scientist at the Lee Caching Knowledge Institute here in Toronto who's an expert on health systems and serves delivery to people with complex mental health and social needs in the community. Alex got a chance to talk to Dr. Arash Nakhost about Community treatment orders, also known as CTOs and Assertive Community Treatment Teams, also known as ACT Teams. Before we get started, I'm just going to quickly go over the learning objectives for this episode of which there's five. So number one is to provide a brief description of the history of ACT teams and CTOs, as well as the challenges in establishing evidence for their use. Number two is to be able to compare and contrast ACT teams with intensive care management teams in terms of their composition methods and respective strengths and weaknesses. Number three is to be able to describe an array of services that teams can help provide its clients, as well as some of the challenges and drawbacks of teams. Number four is to outline the major reasons someone might be put on a community treatment order and describe how a CTO is applied and enforced. And number five is outlined the major challenges in using CTOs as a treatment tool. So that's all the learning objectives for today's show. Now, without further ado, here's Alex with the show.

  Alex Raben: [00:01:40] Today, we're going to be continuing Muhammad's case. And so we'll start with that premise. Before we get there, I want to introduce our expert guests today, Dr. Arash and. He is a staff psychiatrist at St Michael's Hospital.

  Dr. Arash Nakhost: [00:01:54] I'm one of the psychiatrist on the Focus team, which is a flexible set of community treatment team at St Michael's Hospital.

  Alex Raben: [00:02:01] Thank you for being here. So let's start with the case and then we'll have a discussion. Talk about the learning and teaching points we want to go over. If you remember from last time, Muhammad was someone who presented quite young with schizophrenia, and since the last time you've seen him, he followed through with some of the treatment recommendations. He did take his antipsychotic the four milligrams of risperidone for about a year under the supervision of his family. However, about two years ago, Muhammad became homeless. He left the home suddenly and he stopped following up with his outpatient psychiatrist, stopped taking his medications. He's now been admitted for the second time in the past year. This is his third time total, and the inpatient team feels he is suffering from psychosis. He was found by police throwing rocks at a window and has cellulitis in both his feet as he was not wearing shoes outside. And the in-patient psychiatry team has now contacted you. You're working as part of the ACT team and they want you to come by and see if he would be a good candidate for foreign team and for a CTO. And they want your opinion on that. So that's the setup. Perhaps before we dive into the case, though, we should get a better understanding of what teams are and what CTOs are. So that's our goal today is to get a better understanding of that through the use of Mohammed's case. So Dr. No-cost, let's start with the basics. What is an attack team exactly?

  Dr. Arash Nakhost: [00:03:48] So ACT teams or assertive community treatment teams are psychiatric teams that provide care to patients with severe mental illness who are living in the community and they need assistance. They are based on initial work that was done by Stein and his colleagues in the 1970s in Madison, Wisconsin. Initially, what they were trying to do was trying to figure out how to provide care for some of these clients who were being discharged from inpatient units of these hospitals but were not able to stay out for very long. So they would tend to decompensated, come back and need to be readmitted. Now, you also need to kind of put this in some kind of a context in a historical sense, is that they were closing up these massive psychiatric hospitals where people had stayed for for a very long period of time. And now the intention was that people were going to be provided with services in the community. However, they weren't really that many services available. And although many people tend to do well after these big hospital are closed, some patients were not able to cope and they would end up back in a hospital and kind of a revolving door scenarios. So that's where Stein and his colleagues came up with this idea. And their initial plan was the first time, if I'm not mistaken, was called training in community Living is where they were provided with some small amount of money and try to run these teams, which were idea was you would provide rehabilitation and care at the same time to these clients and see how they would do.

  Alex Raben: [00:05:24] Is this a Canadian term or are there other is it referred to other things in other countries?

  Dr. Arash Nakhost: [00:05:29] So initially was called this teaching in community living or TCL team, but eventually the term translated were changed to assertive community treatment teams. They are in existence in many countries in the world. The initial data was quite promising. It showed that they could reduce the number of hospitalisation, maybe length of stay or hospitalisation. They had some initial findings showing that they could do some genuinely successful rehab work with some of these clients, and this led into disseminating all across the US their activities in in Canada, for example, in Ontario we have, I believe, close to 70 teams. They started in Toronto in the 1990s. In other provinces there are teams and are also ACT teams in many countries in the world. And there are also some variations on ACT that's been adopted over time. But the initial success of ACT was actually quite important because what they were able to show is you could actually provide care and support for these patients in the community and they actually developed some fidelity skills, basically looking at what are the elements that you need to havefor an ACT team to  be successful.

  Alex Raben: [00:06:40] You mentioned fidelity in regards to the team, and I've certainly heard that before, but I don't think I've ever really understood exactly what that means. What can you take us through that a little bit?

  Dr. Arash Nakhost: [00:06:52] From what I understand is some initial data coming from ACT teams were quite promising. Then other people try to meet ACT teams and then some of the subsequent data that was coming out wasn't really showing as robust of an outcome. So the question was, are they sticking to the basis of a model or were they deviating too far? And then that led to a number of different fidelity models. Basically, they're looking at parts of an act like how closely are they following the model? And it comes down to things like what is the admission criteria? Do they have a crisis services? So can they provide 24 hour coverage? Are they doing active outreach? How many case managers do you have on a team? What is their case load? What is the rate that you take patients on? An important element of an ACT team is that you have a small case load, but it's also shared. So everybody on a team knows every patient. And then if you think about somebody being an acting, the idea is you can see them up to twice a day if need be. But in average you would see them at least 2 to 3 times a week. And for some people that is basically what differentiates an ACT level of service from intensive case management, kind of a level of service.

  Alex Raben: [00:07:59] You mentioned a revolving door patient scenario being key to why this service was initiated, what actually makes a patient this kind of revolving door patient.

  Dr. Arash Nakhost: [00:08:10] As we know through the literature, many patients with a psychotic illness don't actually have insight into their illness. So what we know is anywhere between 30 or 50% of people who have a primary psychotic illness don't tend to think their symptoms are a sign of an illness. So then it becomes paradoxical that why should somebody take medication for something a problem they don't have? That is what to some extent can lead to the fact that these clients can become revolving door patients. And we know that many patients with this psychotic illness have fairly short readmission rates. So if I'm not mistaken, based on the data from CHI in. Canada. We know that for somebody with a primary psychotic illness after their first admission, the readmission rate within the first year is about 39 to 40%. And in addition to the psychotic illness, you have substance use issues. Then that rate substantially go up, gets closer to 50%. So then it's understandable that why someone like Muhammad can have these these problems, that he doesn't feel that he has a problem. So he's not going to be comply with his treatment. And when he comes out, he's going to get ill. So an ACT team can be helpful in maybe helping him with his compliance by observing him, maybe for taking his medication, by providing him services. It's not just necessarily about being assertive or coercive. Maybe Mohammad wants to go back to school, maybe he wants to get a job. Maybe he's thinking about moving on his own. And that's one of the elements of an ACT services that are important because on an acting, you're going to have a case manager. Typically on an acting, they have a very low case load. So a case manager is going to have anywhere between 8 to 12 patients. Most often ten is the standard number. So this person can spend a lot of time with Muhammad, try to get him actively involved in his recovery. And then as part of that discussion or part of that work that they're going to do together is the idea of medication compliance. So medication is important, but it's just a piece of the puzzle.

  Alex Raben: [00:10:07] You have to think of the bigger social picture as well. I'm hearing I heard insight is one of the main things that you were talking about there. Would Muhammad be someone you might typically have on an ACT team?

  Dr. Arash Nakhost: [00:10:19] Then in general, most teams provide services for people with psychotic illness and then clients with mood disorder, typically bipolar illness. And because of that, Muhammad would be a very common or typical candidate. There isn't a lot of evidence supporting for other clients with other type of illnesses Being picked up by an ACT team reality is that many of these folks just fall through the cracks. For example, if you have significant brain injury with substance use, then you may not be picked up by anybody. That doesn't assume means that they don't need services. It just means that we don't have enough literature to support good candidates for an ACT team.

  Alex Raben: [00:10:54] I see. I see. You've mentioned early on the results were very promising and there's been lots of literature since then. And I actually just read a the newer Cochrane review of ACT teams and the results were not great according to that. But I know that the literature is very nuanced and I'm not nearly as familiar with it. Could you take us through some of like highlight some of the important parts of what's come out in the literature about the benefits of ACT teams?

  Dr. Arash Nakhost: [00:11:21] So I think the way I like to look at it and this may be kind of a more simplistic way of analysing the data is that before ACT came to the scene, there wasn't really much happening. We didn't really know how to care for these patients. We had hospital based method of providing care and it worked for some people, but it failed many others. So ACT came with the idea that you actually have to actively go out. You need to assertively go out, see the patient, provide care with them where they are, seem in their homes, and not just think about trying to medicate people. It's like you need to provide an array of services from housing to rehab to vocational work, all of that, and they actually develop standards for how to do this. And that led to an improvement in my mind, of quality of other services that came on board. So many other teams or many other models of care that came to existence after that adopted some of these scales or some of the things that ACT teams are doing. What it means to have a case manager, whether they're supposed to do things along those lines. So in many ways, ACT raised the level of what standard of care was supposed to be.

  Dr. Arash Nakhost: [00:12:32] It led to the development of what they call intensive case management team. And what we know is that many intensive case management teams basically adopt many of ACT elements. The case managers generally have a higher caseload. It can go up to 20. They may see the patients less frequently. It's not a shared caseload. So you see your own patients, but they have been actually being able to provide very excellent quality of care and then use you get to the point when you see in the in mid 2000 where studies coming from like Netherlands that come from UK, they're not able to show any improvement over ACT. Now you can say that part of it is because the quality of the standard care has gone up. Now there are issues with the studies, issues from the for example, studies from from the UK and the teams that they were selected and how closely did they adhere to the fidelity scale and all that. And part of it is the overall improvement in the quality of the services. Now one of the things that if you look closely at the data, like some of the data coming from Netherlands or even data that we have in Ontario, it shows that yes, ICM teams are pretty good at providing services and maybe you they provide the same level when you look at, for example, rate of hospitalisation or length of stay.

  Dr. Arash Nakhost: [00:13:43] But ACT teams do a phenomenal job, for example, at retaining patients. You know, the drop off rate on an ACT Team is typically very low. You're talking about 2 to 3% when on an ICM team, even based on the studies from Ontario, it can be 25% and that people who kind of fall through the cracks are not showing up for follow up are the ones who you tend to worry about and you think they need to come in. So I think that that's an important element that you can kind of put it in perspective. And I think that's why when you look at the Cochrane Review, initially it used to be an ACT review that was withdrawn and now it's kind of put together as an intensive case management. But for an intensive case management to be successful, they actually need to stick to many of elements that was kind of brought on by ACT teams.

  Alex Raben: [00:14:26] Right. So there's many reasons why the studies may not be showing huge changes.

  Dr. Arash Nakhost: [00:14:32] You know, you can even question is like, is this is the hospitalisation rate or admission rate is the only element you can look at if you're looking at someone's trajectory and the recovery. Now again, I think in some ways ACT has been incredibly important in improving the quality of care, but that doesn't mean that it cannot be improved upon. Or maybe there are ways that things can, can, can move forward because the initial studies from ACT or now for better part of 50 years old, we haven't really changed anything from 50 years ago. You improve on it and it's understandable that some of these things have have changed and improve. And in my mind, for a certain patient population, you always need to have the intensity of act that ICM can't manage some of these folks and can't help them. But there's also much to be said about intensive case management and what it can.

  Alex Raben: [00:15:19] Do, right, And unhinging ourselves a bit from the literature. What in your opinion, do you feel are the benefits? What do you see on a day to day in your clinical experience that really shines with the ACT model in terms of benefits to patients?

  Dr. Arash Nakhost: [00:15:35] I think as a whole put them together with ACT and ICM is the ability to have a case manager who can come out and see you in your own home, that they can look at you as a person and looking at the totality of your issues. So maybe you need help with your banking, maybe you're having issues with your housing, maybe you need better housing, maybe you need somebody to help you get a family doctor. And sometimes some of the clients are overwhelmed with the multiple tasks that they need to do. And in some cases, people have significant legal issues. You may, because of your illness, you may have got into trouble with the law, you may have complicated medical issues, you may have diabetes, you may be there are many, many things that you need to to deal with that it can be quite overwhelming to someone with somewhat limited capacity. And I think that's where the model becomes important in a way that you're not forcing the patient to adapt to your to what your 9 to 5 office are, is like you're adapting to what their needs are. So you go out and you see them where they're at.

  Alex Raben: [00:16:40] Right? And I imagine a lot of that is hard to capture in a study as well. Right. A lot of those benefits are.

  Dr. Arash Nakhost: [00:16:47] Some are. And I think, you know, it's I think that's why you kind of need to look at these longitudinally. And I think, again, part of it is it's not necessarily trying to say, is it act better than it seems that I same. But in fact, I think you need to have a range of services you can provide.

  Alex Raben: [00:17:02] In my own experience on inpatient psychiatry have certainly seen patients come back into hospital. I've seen patients who have been very difficult for our team at St Michael's to connect with by virtue of just the way the city works. And it's hard to find people. I'm wondering what are the what are the challenges that you guys face day to day? And maybe we could do it in the context of Muhammad. What would you anticipate would be difficult in providing Muhammad with care?

  Dr. Arash Nakhost: [00:17:31] So somebody like Muhammad, you know, one of the things at the top of my head when I'm thinking of it is where is it going to be housed when he's going to come up Post-discharge is family going to take him back? Are they interested for him being at home? You know, if he is homeless and if he's not stable, they may not be interested in having him back home. If he has a history of assault at home, they may not be interested to be involved. And that's one of the tragedies. One of the difficulties of working for some of these clients is that over the length of time, as they become more and more unwell, they actually lose their social support. Many of them, for example, with people with schizophrenia, as it tends to affect men in their late teens, early teens, early twenties, they actually haven't really made close friends. They don't have close friends that stay in the picture. So it's kind of becomes very difficult for them to connect to other people. You know, if you look at some of the issues that kind of comes up with with the ACT teams, you know, they tend to have very long waiting lists. Right now, for example, in Ontario, the average length of people staying on a waiting list when active is a year, because a typical length of stay on an acting in most literature is anywhere between 5 to 8 years.

  Dr. Arash Nakhost: [00:18:38] So you build these teams, they're expensive, they are labour intensive, you bring people on, but then you can't discharge them. You can't send them anywhere. They stay there. And sometimes it's challenging to provide follow up for some of these folks, although they may be in a place where they can do better, but maybe they're not well enough to to start going to seeing their GP only or going to have other services. And I think that's part of the problem is that as wonderful an ACT teams are, they can't fix the system if somebody doesn't have adequate housing, doesn't matter what you do, if somebody is having physical health issues and you can't find them, a GP doesn't matter how the case manager is, you're still not providing adequate services. So for Mohammed, another issue that comes to mind is, is he going to be compliant with his meds? Is he going to take his meds, is he going to take oral meds? And then ultimately, if he's not, then would he be someone that he can put in a community treatment order?

  Alex Raben: [00:19:34] You've said, perfectly to our next topic, which is the community treatment order. So why don't we talk again from the basics? What what is a community treatment order? What is the purpose of this?

  Dr. Arash Nakhost: [00:19:47] So community treatment orders have been in effect since basically the 1960s. My understanding is District of Columbia in the US was the first place that put a community treatment order in place and they're currently used in many jurisdictions in the US. I think last count were 44 states have them, multiple provinces have it in Canada, many countries in the Europe, Europe have it, New Zealand, Australia have had it. So I look at community treatment as a tool in treatment of the patients. The idea of them is that it can be a mix of two different things. Some of them are meant to be at least restrictive method of care for the patients. So in some places they say for you to be able to go on a community treatment order, you need to meet criteria for admission to a hospital. In some places it can be preventative. You can actually be pretty well and they can say, you know what, your past history shows that you're not going to follow through with treatment. We're going to put you on an CTO. Many places as a combination of both. And the basic idea is you are going to be obliged to take your treatment, come to appointments, and if you don't, then you can be brought back for an assessment. A very few places allow force treatment, although it can exist or happen in most places similar to Ontario. The idea is you're not coming for your appointment based on your community treatment plan. You're supposed to see your team every week and you're supposed to get your injection every month. You haven't come to your appointment. This week. The physician can issue a form and ask the police to pick you up, bring you to a hospital for an assessment, and then from there they can decide what they want to do.

  Alex Raben: [00:21:24] Right now defining what is treatment. I imagine a lot of it is depo intramuscular anti-psychotic medications because we can give them over a longer period of time and then see people in every couple of weeks. But our other two other treatments fall under this umbrella.

  Dr. Arash Nakhost: [00:21:46] So treatment is actually in at least in Ontario, has been defined very broadly. So if you look at the the health act, it's it's it's fairly broad as what is considered treatment as part of a treatment plan. You can have a number of visits to the office. Some clients may be asked to come daily to take their medication, observed oral medication. Now you're right, intramuscular antipsychotic injections are probably the easiest to monitor, but other elements can be added as part of a treatment. Maybe somebody needs to follow up with their diabetes care. Maybe somebody needs to see their case manager. This amount of time a week placement has been raised as a possibility, so basically asking someone to live in a specific location in Ontario is not that common. But in Quebec I know that placement or placements are a very typical part of a treatment order. When you say what you need to stay in this house or this rooming house or this place for the length of your community treatment order. Now the important question is always enforcement. So how are you going to enforce it and what's the benefit to the patient? Why are you asking for something if you're not going to enforce it or if it's not going to have any specific benefit to the to the to the client.

  Alex Raben: [00:22:58] And just in terms of anti-psychotic medications, I'm thinking about Clozapine as something that would be pretty complicated to monitor but may come up because it is the most effective medication for treatment resistant schizophrenia. Does that issue come up at all?

  Dr. Arash Nakhost: [00:23:14] So we've had from my clinical experience, we've had some success with patients on, well, clozapine or valproic acid or lithium, different mood stabilisers. And we basically make it known to the patient that we expect them to take the medication observed at certain times of a day, and then that we would do blood levels to make sure that they are actually compliant. And again, it really comes down to where somebody is maybe they're initially reluctant because they have no insight or they're not well. But over time, when somebody is feeling better, may they may actually decide that, no, actually, I need this. This is not something that needs to be forced upon me. On a CTO.

  Alex Raben: [00:23:55] Getting back to a similar question we did with the ACT teams, what is the the benefits of this treatment option? What does the literature show and what what? From your own experience, do you feel the benefits are?

  Dr. Arash Nakhost: [00:24:08] So the literature is, I find, difficult to fully decipher just because there's so much variability on, you know, even what did they mean when they say a CTO, you know, what are the terms of enforcement? So there have been two RCTs done on patients or community treatment order versus standard care, one done in New York and the other one in North Carolina. And there was also a study done on in UK on comparing community treatment orders versus extended leave. And these studies haven't really managed to answer the question partially because there are significant shortcomings in all of these studies. So, you know, if you for example, look at this study from New York, it didn't show a difference between CTO and the control group, but the team is quite honest about the fact that the police in New York refused to enforce the CTO. So if you have an order that nobody enforces, then really, what's the point? Similarly, for example, if you look at the study done in in UK, they didn't show a difference between the two things that we're looking at. But because of the restrictions that they had with their ethics, they only could ask patients to participate in the study who had capacity to to consent to treatment. So in many places, if you have capacity to consent, you can't actually be forcefully put on a CTO.

  Dr. Arash Nakhost: [00:25:28] So then then you're looking at a very narrow slice of the patients and there are multitude of other issues. Now, the study from North Carolina was not on the initial group, but on a subgroup analysis. They were able to show that for people who were in a CTO for six months and more, they were benefits reduce hospitalisation, length of stay, less victimisation things along those lines. If you look at the Canadian studies, we don't have a randomised controlled trial in Canada, but four studies have been done. These are small studies, pre post type of study like case controls or just pre post looking at the same patient population and all four have been supportive that they help with reducing the length of stay and the hospitalisation. So my feeling is that CTOs are a treatment tool, they're not a treatment unto themselves. It really comes down to what other services are available, what jurisdiction you're working on, what else is out there, and then ultimately how they're utilised. They're not. Going to answer for everyone. Some clients are not going to do well on them. I don't think we know enough to to say who's going to fail and who's going to work for it. But in general, they tend to be utilised for people with psychotic illness. They tend to be used for some clients with bipolar illness.

  Dr. Arash Nakhost: [00:26:41] And the overall indication is that it works. And I think it works better for someone who is on an intramuscular injection and someone who probably has some some challenges in some other issues. You know, maybe they're not having issues with substance use maybe or other things now as a whole. I think it's a piece of a puzzle. So you can put somebody in a CTO, but if you don't have other pieces, then it's going to be limited outcome. But if you have other pieces to put in and then you give someone time because think about all the challenges that someone like Muhammad may be facing right now, you know, what's the likelihood of putting him on a you know, in some states in the US and a 90 days treatment order is going to do for him, you know, how far are you going to go? He may still be trying to figure out the very basics of his life and he gets out of a hospital. So that's why I think the although the literature is limited, I think six months would be a minimum. You probably need to be closer to maybe a year or two on a community treatment order before you see a difference. And then you need to have other services on board.

  Alex Raben: [00:27:42] Right now. By other services, do you mean ACT teams? Because I could imagine that getting someone to comply you're going to need people monitoring is what is the overlap between ACT teams and CTOs.

  Dr. Arash Nakhost: [00:27:55] So in many places, like for example, in Ontario, often they want you to show that the patient has improved when you're putting somebody on a CTO, and the idea is that you can provide adequate community services. So actually an ideal, although we've done studies, one of the works that I've done on CTOs and was published in 2012 and the clients we looked at, the hospitals that we looked at did not have an ACT teams or ICM team. Now you can say so maybe some of the most challenging patients at some point would be lost to follow up because you can't find them and they just disappear. But I think as a whole, if you look at these clients as high need individuals, then ideally when you put somebody in a community treatment order, then in some ways now you are you kind of binding yourself to them, that you're going to provide the best services that you can. And then having an intensive case management or ICM or ACT teams are essential because then actually help you to put these other places in place. So you you're not just trying. The issue is not just about trying to medicate someone is you're actually trying to help them with housing and education and vocational work. In all other pieces of the puzzle.

  Alex Raben: [00:29:00] Write the important results and correct me if I'm wrong, but that's built into the legislation in Ontario anyways that they need, that they.

  Dr. Arash Nakhost: [00:29:07] Need to have high intensity care. But, you know, I've followed patients on ICM as an outpatient psychiatrist. There are many other pieces of puzzle that are in place. So for example, maybe they are generally agreeable when they're well or they live at their mom and dad and, you know, mom agrees to bring them to the appointment and at the tail end of their hospitalisation, they're starting to kind of get better. And many other pieces were already in place, so they didn't necessarily require the ACT team acting. I don't think it's a necessary element, but for some clients especially hard to serve clients, it's helpful.

  Alex Raben: [00:29:41] So I guess an important question here is would Muhammad meet criteria for CTO? Although we have international listeners and listeners in other provinces, I think it's important to anchor this in something. So we might I think we should go with the Ontario legislation and we don't have to go into super detail about the criteria. But would he meet criteria? Would it be a good idea for him?

  Dr. Arash Nakhost: [00:30:05] So it's it's actually right now in Ontario, the legislation is pretty straightforward. So what do you need to have in the past three years? You need to have either to hospitalisation or having spent more than 30 days in a psychiatric hospital. Now, it doesn't necessarily need to be involuntary. It can be any type of hospitalisation and as long as you meet that criteria, you can come in. The other issue is if you have previously been on a CTO, that can also count. So if Mohamed, if I'm not mistaken, has had three.

  Alex Raben: [00:30:39] Two in the last year, three total.

  Dr. Arash Nakhost: [00:30:40] So then that that is, that is enough for him to meet the criteria for a community treatment order in Ontario and the legislation. And I think this is an important element when you look at different, different legislation, is that the legislation in Ontario is consent based. So either the patient themselves or the substitute decision maker need to consent to treatment. That's not all the same all across provinces. So in some provinces you don't necessarily need the patient's consent to go ahead. You just need the the issuing physicians to agree. And remember, even in all across Canada, it's not it doesn't say needs to be a psychiatrist in some places, for example, in Saskatchewan, if I'm not mistaken. You need two psychiatrist to issue a CTO. In Ontario, the legislation is a physician, although I think if they're looking at the legislation means that even if a GP is going to issue it, they need to do quite a bit of mental health work. But this has actually allowed maybe physicians in a small communities to to issue a CTO if they think it's necessary and again, in some other places.

  Dr. Arash Nakhost: [00:31:45] Again, if I'm not mistaken, like in Alberta, if a general practitioner and a psychiatrist to issue it. And I think the issue of consent is also very important as far as, you know, who can you put on a CTO and what the processes are. My experience working in Quebec was that it's probably one of the most wide reaching kind of community treatment orders you can put in place. They can go up to three years and it really comes down to past history. So even if maybe at the day of a hearing, somebody saying all the right thing, if they had six hospitalisation over the past three years and have got into all sorts of troubles and shown that when they're unwell, a danger to themselves or the public at large, then they may still go on to CTO, where in Ontario it's capacity based comes down to day of a hearing. If the patient decides to challenge your request for CTO and if at that moment they're saying what they need to say and they you cannot issue a CTO right?

  Alex Raben: [00:32:41] So that's definitely a challenge in issuing the CTOs in Ontario. Are there other challenges to issuing CTOs in Ontario? One comes to my mind that there just a lot of administrative work. I recall from my time in the inpatient unit that it took quite a while to get things going. But yeah.

  Dr. Arash Nakhost: [00:32:58] It's so it's kind of I think it's amusing that they call it a community treatment order, but when you look at the mechanics of it in Ontario, at least it's not really done in a way that favours this being done in a community. You need to issue a number of forms. They need to be issued in a certain order. You need to have done your initial assessment before you finish, before you issue your first form four and 49, within 72 hours of assessing the patient. They need to get rights advice. They know the rights advice needs to reach the patient. So I actually find the current legislation in Ontario to be quite challenging sometimes for some certain clients and also the fact that they need to be issued every six months. It makes it sometimes you feel like you're just gone over issuing one when the time is to reissue, because in some cases it can. Realistically, I've had cases when the patient's SDM doesn't live in Canada, so it takes and the current legislation requires the substitute decision maker if it's a family member, to receive rights advice every time. So it's a challenge trying to get somebody in Dubai to get straight rights advice and all the forms need to be signed and the sequence that needs to be signed again. I think it's very important to be patient centred and you affect someone's rights, so they should have the tools at their disposal to challenge if they want to. But the current system in Ontario is very, very challenging and clunky. Mm hmm. Mm hmm.

  Alex Raben: [00:34:25] And it's interesting that the patient's SDM also gets rights advice. I can understand that you are encroaching on the rights of the patient. Therefore they should be allowed to call a hearing. But do you have any sense of the rationale for the SDM?

  Dr. Arash Nakhost: [00:34:39] I mean, a good thing is that, you know, these things are evolving. So the initial CTO legislation in Ontario came to effect in 2000 and they're subject to review every five years. So far there have been two reviews and they have made some changes in the legislation, small amounts. And I think these things were done with good intentions, but I think at some point it can provide in care challenging because somebody can even question the fact that why do you need somebody to be hospitalised twice in a short period of time? Because effectively by putting this some of these barriers, you make it impossible for someone who is maybe a first episode psychosis kid to receive the services. Maybe Mohammad would have been better off if somebody could have issued a CTO three years before. But because you need to meet these specific criteria, you're effectively excluding some of these folks from getting the treatment. And again, I'm not necessarily saying that everybody needs a CTO. It works. For some people it's a tool. But I think with some of these barriers, we may make it more difficult for patients to actually access service. Right?

  Alex Raben: [00:35:41] So let's say we get through all of these barriers and that Muhammad does end up on a CTO. You mentioned earlier that for some people it fails. I know you said you can't predict it, but is there a typical reason why people fail in a CTO?

  Dr. Arash Nakhost: [00:35:55] I mean, I often find it's the, you know, where somebody is in their life and what is it that they need? So one of the clients that comes to my mind that we weren't able to help with the community treatment order is that someone who we had a very difficult time housing because significant substance use issues. And then he kind of started moving further and further out from downtown core because he was being chased away by various dealers he owed money to. And then we couldn't. Help him. And a part of it is that I don't think he also viewed this as a problem. So there was substantial substance use problems. There were housing challenges. He couldn't connect them to services. He was not interested. He had very little insight and he wasn't improving substantially. I think the treatment had helped him. He was less symptomatic and somewhat better, but we didn't manage to bring him to a place where he was well enough to kind of appreciate what was going on. And effectively, at some point he just moved far away from downtown core and was smart enough to not meet with the case managers and basically hide. And then we were not able to renew the CTO. So, as you know, not everybody responds to treatment and some people can have partial response. And, you know, it's kind of hard to think about why would you even try to issue a CTO for someone who is not at all responding to treatment, Like, what's the point of this? And that may be some of the folks that ACT on its own is not sufficient. But then I think if you can provide a package of care that includes other things that people need, then you can have a different discussion.

  Alex Raben: [00:37:31] And can the CTO, even if those that package is not included in treatment, can it be used as leverage for getting that package surrounding patients? Is it a tool in that way?

  Dr. Arash Nakhost: [00:37:41] Not necessarily, no. I mean, it can in some places may, May, may be expedient your access to an ACT or an ICM team. But I don't think on its own, just because you're not acting doesn't mean you're going to get housing. But just because you are on a CTO doesn't mean that you're going to immediately get off the hook from the legal system. Now, I think sometimes it's interesting because one of the things that just came to my mind was this patient that she wasn't really meeting the criteria for a CTO but wasn't well enough. And that was one of those people who hasn't really had that many hospitalisation but wasn't well enough. And then we were trying to work with her for quite some time unsuccessfully, and she had a lot of legal charges for small things, like she wasn't doing anything dangerous to anybody, but she was just getting into trouble. And at some point I think she had a, she had a couple of short hospitalisations. And then right after that, we ended up in jail and then somehow spoke to a court diversion worker and the division court worker said, you know, why don't you go and ask your psychiatrist to put you on a CTO? And then she basically came to my office and she said, you know, I need to be on a CTO, okay? I think now you meet the criteria. She mostly did it in order to kind of appease the legal system because she thought they would send her to diversion and it would help with her case. But she's done beautifully and I am. And she she requested it. And it's funny because I actually had to tell her when we had to renew. I'm like, I really don't think you need this. Just like, No, I need it. I'm like, okay, I renew it one more time, but I really don't think you need this. You're doing really, really well. And, you know, she's quite insightful and has a good sense of what had happened. So it can it can work in odd ways for different people.

  Alex Raben: [00:39:14] It makes sense. We are running low on time. So for my last question, we've talked about a lot of different things, but I'm wondering if you had to choose one thing or a few things that you think would make the biggest difference in the system right now for the patients who are on our ACT teams and on our on CTOs, what would that look like to you?

  Dr. Arash Nakhost: [00:39:36] I think housing is a is a huge challenge. I think adequate financing, I think we are in some ways is force poverty that many patients with mental illness are. You know, what is paid for them to live on on a yearly basis is completely inadequate. You know, you're living in a place like Toronto where, you know, I have patients who, after they paid their cost of their housing and the food, they have like literally $20 to live on for the rest of the month. And I think it's to me, it's kind of backward because my understanding is the cost of a day of an admission to an inpatient unit is about $2,000, and we're paying people like $1,000 to live on. And I think in some extent it's just not necessarily the smartest way of supporting people. I think, you know, the measure of civility in a place for me is how they take care of the least advantaged people. So how do you take care of your elderly, how to take care of your children, how to people who are ill? And I think if you look at it that way, then we need a lot more support. And in an absence of adequate housing and adequate finances, what's the point of some of these things if you can't really look at the patient as a totality of who they are and try to help them? I mean, if you look at somebody like Muhammad right now, you know, he's going to have all sorts of ongoing issues, vocational training, educational needs, financial need, housing. So, you know, yeah, it's good to put him on an ACT and it's good to give him a give me a CTO and maybe you can help me with his med compliance. But if he can't really help me with every other thing that he needs, then I'm not quite sure how patient centre is the care you're providing.

  Alex Raben: [00:41:14] So it's a big question of where we're putting our tax dollars and that kind of thing. Obviously big systems issues. Well, thank you so much. For joining us today and sharing your wisdom about ACT teams and CTOs. I've learned a lot. I'm sure our listeners have as well, and we really appreciate you being on the show.

  Dr. Arash Nakhost: [00:41:32] Thank you.

  Alex Raben: [00:41:33] Thank you. Bye bye.

  Henry Barron: [00:41:38] The site is a resident driven initiative led by residents at the University of Toronto, where affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. This episode was produced and hosted by Alex Rabeon. Our theme song is Working Solutions by Olive Music. A special thanks to the Incredible Dr Arash Nakhost for serving as our expert on this episode. You can contact us at Info@Psych.Podcast or visit us at PsychEdPodcast.org Thank you so much for listening.

Episode 10: Treatment of Schizophrenia Part II with Dr. Albert Wong

• Episode 10: Treatment of Schizophrenia Part II with Dr. Albert Wong

  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 9: Treatment of Schizophrenia Part 1 with Dr. Jason Joannou and Dr. Andrew Lustig

• Episode 9: Treatment of Schizophrenia Part 1 with Dr. Jason Joannou and Dr. Andrew Lustig

  Dr. Lucy Chen: [00:00:05] Okay, we're rolling. All right. Hey there, podcast listeners. Firstly, we'd like to apologise for the delay in releasing this episode on the treatment of schizophrenia. We kind of went down a rabbit hole after our episode on diagnosing schizophrenia. We basically interviewed multiple experts who elaborated on multiple facets of schizophrenia treatment, and we realised really we kind of needed the basics. So that's what we're going to give you today. And we're here and we're back with our two favourite inpatient staff psychiatrists, Dr. Andy Lustig and Dr. Jason Joannou. Welcome back to the podcast!And I'm Lucy Chen, and I'm joined by Alex Raben.

  Dr. Alex Raben: [00:00:44] Hello.

  Dr. Lucy Chen: [00:00:45] And Henry Barron, our trusty fourth year clinical clerk who is multifaceted and talented and has been instrumental behind the scenes in our editing process.

  Henry Barron: [00:00:53] Hey, guys.

  Dr. Lucy Chen: [00:00:54] So we're going to cover three broad objectives and basically they're summarised as the following. So the first thing we're going to have a basic understanding of the psychopharmacology of antipsychotics. We're going to have a clinical approach to treatment based on the 2017 guidelines for pharmacotherapy of schizophrenia in adults. And we're also going to have an idea about the longitudinal treatment of schizophrenia, which will include a discussion about treatment-resistant schizophrenia and psychosocial approaches to care. So let's just start off very openly what are medication treatment options for schizophrenia?

  Dr. Andy Lustig: [00:01:30] Okay. Well, really, the mainstay of treatment for schizophrenia and all of the other psychotic illnesses is antipsychotic medication. Surprise, surprise. So when we meet somebody who has schizophrenia or related condition, we try and get consent and commence an antipsychotic medication.

  Dr. Lucy Chen: [00:01:53] Anything else down the pipeline or is this all we got so far?

  Dr. Andy Lustig: [00:01:56] Well, they are trying to do something. No antipsychotics have been available in Canada since the 1950s. Chlorpromazine was the first antipsychotic medication and there's probably upwards of dozens of different antipsychotics. They all work basically in the same way and down the pipeline then there's been a lot of research in this. They're trying to find a novel mechanism for antipsychotics. A lot of research into glutaminergic modifiers. But there's nothing in the market right now. And, you know, it's been about 60 years. And so far dopamine blockade is the only thing that we've found that reliably is what causes antipsychotic effects.

  Dr. Lucy Chen: [00:02:35] Great. So we'll focus on that for this episode. So specifically dopamine blockade and then all the sort of effects and side effects that happened. So let's start with just talking about the basic mechanism of action of antipsychotics.

  Dr. Andy Lustig: [00:02:53] Sure. I mean, the interesting thing is like, you know, all antipsychotics that are licensed have an indication for this and have shown effectiveness share. One common thing, and that is they're they block D2 receptors. So but these drugs are actually quite messy drugs. So for instance, chlorpromazine, which was the first antipsychotic medication ever that we discovered is actually not very potent at the D2 receptor. It's much more potent at, you know, adrenergic receptors or other things like that. And that's where you get all these side effects from. So what they all share in common is and that's why we talk about high potency, mid potency and low potency medications. So high potency antipsychotic medications are much more specific to the D2 blockade and might have less ancillary side effects for like, you know, anticholinergic effects and things like that. But they also might have more intense D2 blocking side effects. Yeah. So that's kind of the basic pharmacology that it needs to block D2 in order to be an antipsychotic as of today in 2018. And they're actually messy drugs, a lot of them. So they block a whole bunch of other things. And that's where a lot of the side effects arise from.

  Dr. Lucy Chen: [00:04:01] Great And a lot of medical students are going to be exposed to this concept of typicals versus atypicals. Can we kind of summarise what that means for them?

  Dr. Andy Lustig: [00:04:11] Yeah. So, you know, people have hypothesised on what gives antipsychotic agents typicality versus atypicality. I think from a practical point of view, the kind of bottom lines are one that initially there was a belief that atypicals which were newer were better, and there was an early hope and belief that they would target the negative symptoms of schizophrenia, things like decreased energy, decreased affective expression. Those have been very difficult to treat symptoms of schizophrenia. And the initial hope was that Atypicals would target those symptoms as well as the positive symptoms of schizophrenia, by which we generally mean delusions and hallucinations. And unfortunately, that really has not proven to be true. The Atypicals are really no better than the conventional agents for treating any symptoms of schizophrenia, either positive or negative. So the way in which they differ substantially are that the atypicals are more expensive because they're still on patent for many of them. And also the side effects are different. And generally speaking, it's helpful to think of the atypical agents as causing primarily metabolic side effects. So we talk about weight gain, hypoglycaemia, which down the road can lead to diabetes and so on. And for the conventional for the older antipsychotics, we think of more like neuromuscular side effects. So like Parkinsonism stiffness, tremor, tardive dyskinesia, much more common in the older conventional antipsychotic medications.

  Dr. Jason Joannou: [00:05:41] Maybe if I could just add to Andy's response for the typical Stu, I guess they've also been a lot of fierce debate in the literature about what causes that different pockets of psychiatry like Toronto versus other places in the world have competing theories, and the two main ones are that 5 HT 2A antagonism really confers the atypicality to atypical agents. And there's a whole reasons why that's done. But I'd say that's one theory. And the other theory is about a fast of a fast dissociation constant, which is the one that's preferred in Toronto, which has a whole body of literature behind it and reasons. But that would get really complicated going to those. But that's also kind of just the underlying theories behind that. But neither has been proven to there's no consensus there yet. Yeah.

  Dr. Lucy Chen: [00:06:27] Thanks for that clarification. So we're basically talking about side effect profiles being the result of either like fast or kind of binding strength at the D2 receptor versus its kind of dirtiness or rather like hitting multiple different receptors as being the cause of side effects?

  Dr. Andy Lustig: [00:06:44] Pretty much.

  Dr. Lucy Chen: [00:06:45] So I think one thing that also helps with our understanding is the dopaminergic pathways in the brain. So where dopamine exists in the brain and how antipsychotics affect that. So maybe Dr. I'll turn it to you and maybe you can summarise for us the four dopaminergic pathways and how anti psychotics affect each schizophrenia.

  Dr. Jason Joannou: [00:07:08] Nobody knows what really causes it. It's not just as simple as saying it's a defect in dopamine. What we do know is that when we block the D2 receptor, we get some anti psychotic effects. It's a lot more complicated than that. It's not like we know where the lesion is. Like if we were in neurology, we'd be like, where is the lesion? Right? We don't have that clear cut thing. So we're just kind of targeting the whole brain with this. And it would be nice if there was a more targeted treatment and then we maybe wouldn't get all these side effects. So it's important when you think about the pathways that this is really how you get the different side effects that occur and then maybe propose kind of mechanisms of action of anti psychotics as well. So the first kind of classic one that most medical students learn is the substantia nigra pathway, which is related to Parkinson's disease. And it's kind of clean cut and people it's been well delineated. So that's basically just where most of your dopamine neurones in your brain are actually reside in the substantia nigra, about 90% of them or so, and that's in your midbrain. And then they have projections out to your caudate Putamen we call the basal ganglia.

  Dr. Jason Joannou: [00:08:08] That's where you get the tardive dyskinesia, the tremor, the rigidity, the kind of, you know, trap the classic stuff in Parkinsonism, and you start getting symptoms in Parkinson's when you kind of lose about 90% of those neurones. So you can kind of think about blockade as well. The other pathway that's kind of very kind of clean cut and clearly delineated is the tuberoinfundibular pathway. I was nervous about pronouncing that properly, and that's basically the projections from your hypothalamus to your pituitary gland. And another name for dopamine is prolactin inhibiting factor. So what happens here is that by blocking dopamine, it's kind of disinhibition and that can cause breast development or lactation or what we call galactorrhea in men and women actually. So it can be quite a disturbing side effect when you are prescribing this. If you know, men or women are all of a sudden having breast development and are lactating. So that's a common reason for discontinuation with these high potency medications such as Risperidone or Haldol, which are kind of the worst offenders. So that's related to side effects. The other two pathways, really, that's where people postulate a lot of maybe the origins of schizophrenia arrive, as Andy was saying, talking about negative and positive symptoms.

  Dr. Jason Joannou: [00:09:32] That's basically saying that the Mesolimbic system is maybe where the positive symptoms of schizophrenia come because it has to do with your emotional brain. It's very primitive part of your brain. So it deals with emotion, motivation, long term memory, and that is projections from your midbrain. Again, your ventral tegmental area to your limbic structures. And different people have included different structures in the limbic system. Depending on where you read it. It's kind of an old concept, and some people say we should just get rid of it, but common ones. These are the most accepted ones, I would say are things like your cingulate gyrus, your hippocampus, your amygdala, so emotional brain, deep brain, and they think a lot of things, positive symptoms, may derive their origins there. And the fourth one is the Mesocortical system. Again, from the ventral tegmental area to your prefrontal cortex. And people think that's perhaps where the negative symptoms are originated because your prefrontal cortex has a lot of things like working memory and attention. It's a newer part of the mammalian brain. And so this postulated that a defect in that would kind of fit well with negative symptoms of schizophrenia.

  Dr. Lucy Chen: [00:10:45] Great.Thanks for that. It must have been exhausting to kind of go through that. Just to summarise very quickly, the Mesolimbic pathways thought to be relevant to the positive symptoms of schizophrenia. So in our previous episode on diagnosis, that's the hallucinations and the delusions and antipsychotics are thought to reduce the positive symptoms of schizophrenia by blocking dopamine in the mesolimbic pathway. The other pathway was the mesocortical pathway, which is more so relevant to the cognitive symptoms of schizophrenia. When antipsychotics act on this pathway, they can worsen the negative symptoms of schizophrenia by blocking dopamine there. The nigrostriatal pathway is involved in motor planning and dopamine stimulates purposeful movement. So blocking dopamine in the nigrostriatal pathway can be responsible for the Extrapyramidal symptoms or Parkinsonian symptoms that you can see with antipsychotics. And then the final pathway is the tubulo infundibular pathway. When antipsychotics block this area can worsen symptoms like prolactin, anaemia or galactorrhea. 

  Dr. Jason Joannou: [00:11:49] Very articulate Lucy Very.

  Dr. Lucy Chen: [00:11:51] Okay. So I think that'll I think that we'll stop there in terms of talking about kind of the psychopharmacology and maybe Henry, if you want to take the lead on kind of asking questions about the clinical aspects of starting an antipsychotic.

  Henry Barron: [00:12:05] Sure. Yeah. So I wanted to talk to you guys a bit about the actual use of antipsychotics in practice and how we go about treating people with them. So now that we know a little bit about antipsychotics and how they work and also what their side effects are, let's sort of turn to how we would treat someone who comes in, for example, in a first episode of psychosis, maybe to the emergency department, maybe to a first episode psychosis clinic. What antipsychotic would you choose and how do you come to that decision?

  Dr. Andy Lustig: [00:12:34] So as Jason mentioned earlier, there are a lot of different antipsychotics available on the market in Canada, and so they don't tend to differ much or at all really in terms of their effectiveness. So we're primarily driven by considerations around practical matters like route of administration, whether or not the medication is available by long acting, injectable, antipsychotic, side effect, profile, cost availability, things of that nature.

  Dr. Jason Joannou: [00:13:02] Nowadays, actually a lot of them are off patent like olanzapine risperidone and there's generic forms, so they're cheap. So cost isn't as much of a consideration as it used to be. But you know, long term use with typical antipsychotics, first generations, they do have a higher incidence of tardive dyskinesia, which can be irreversible. That's like involuntary movements, usually oral buccal, it can be anywhere in your body. It can be quite stigmatising and debilitating. We're trying to avoid that. Often these people are going to be on medications for years and years and years and the risk goes up with every year up to 50% if you stay on your medication. So that's serious. But also serious is, you know, if you're having, like Andy was saying, like diabetes, high cholesterol for years of your cardiovascular risk is huge. And you're talking about people who usually start their illness in their early 20s. So the full impact of really atypicals we haven't quite seen yet in terms of the long term. So we're trying to I think, you know, again, it comes down to side effects. Like you said, there's no real superior efficacy other than clozapine in treatment refractory psychosis, which I think we're going to talk about later. That's the only one with any kind of superiority in the subset of people with schizophrenia. But the efficacy is all the same. The other problem what I think about is compliance. And so when I was a resident, people said, "you don't prescribe people depo medications until they've failed two oral courses." And nowadays there's several RCTs And we just recently did this in our little journal club here on the at the GPU about the evidence of depo medications in first episode psychosis. And there is some good evidence showing that it improves compliance and outcomes. So I'm very if people are on for it and I say, you know, "you can take this medication once a month, you don't have to worry about remembering it". This might reduce future hospitalisation. That's a good thing and we shouldn't be shying away from it like we used to or like I was taught when I was a resident. You know, some people might argue that it's paternalistic to kind of give an injection and say that you can't make the decision to stop doing it as well. And I can see from that point of view, if someone's willing to do it, I think it's good to offer it to them. I wouldn't, you know, subject somebody to like if it's their first episode of, you know, illness and they don't want an injectable medication, I typically wouldn't pursue that too strongly. But if there's a pattern of non-compliance, rehospitalization and people don't really appreciate that if they don't stay on these medications, things are likely to get worse for them and they are found incapable under the law. Then that's when I would think about, you know, strongly consider a depo medication.

  Henry Barron: [00:15:44] Now let's turn to sort of the actual specifics of starting and maintaining someone on an antipsychotic. So how long would you keep someone on their first antipsychotic before you decide that you want to try a different one?

  Dr. Andy Lustig: [00:15:59] Generally, I'd say several weeks. So you want to get them to a therapeutic dose of the antipsychotic, and then adequate duration is somewhere in the neighbourhood of 4 to 6 weeks In practice on the inpatient unit. We tend to accelerate that time course a bit, but on an outpatient basis, I think that's what you'd be looking at.

  Dr. Jason Joannou: [00:16:20] We're a little more aggressive with the. Yeah, with the dosing schedule for sure.

  Dr. Lucy Chen: [00:16:24] You guys are more so seeing them in the acute phase of illness where they're very actively psychotic and we need to control symptoms as quickly as possible.

  Dr. Andy Lustig: [00:16:32] That's correct, Yeah.

  Henry Barron: [00:16:35] Okay. And then so if you did decide to switch, for example, because you're not getting the response that you're hoping for, do you have any strategy to switching like, do you choose a typical antipsychotic after trying an atypical or does it not really matter?

  Dr. Andy Lustig: [00:16:51] I would say generally no. I tend to stay within the atypical class. I could see the rationale for switching from atypical to conventional, but I think we tend to be pretty wedded to our atypicals. So yeah, we would we would simply usually choose another one and design a cross titration schedule. Again, I think the rapidity of the schedule would depend on on how unwell the person is so and therefore how urgent it is to complete the cross titration rapidly. And whether you're doing it on an inpatient basis where you have access to them on a daily basis and you can monitor closely for side effects or whether you're doing it on an outpatient basis and you're maybe only seeing them like once a week or once every couple of weeks, which would kind of slow it down. But typically we would just choose another agent and then cross titrate.

  Dr. Lucy Chen: [00:17:44] Can I just ask a quick question about antipsychotic withdrawal? Does that exist? Does it happen? What does it look like?

  Dr. Jason Joannou: [00:17:50] So it's not necessarily withdrawal due to like the antipsychotic effects, though. It's withdrawal due to your all the receptors that antipsychotics are affecting and the rapid discontinuation and your body's homeostasis with that. So the worst offender is Clozapine. If you just stop clozapine right away, it can be quite uncomfortable for people. They can have jitteriness, irritability, problems with their sleep, differences in micturition, things like that. And that's due to it's very anticholinergic medication that you develop tolerance to quickly and lose quickly when you stop it. So it can be uncomfortable. And then when you start it again, it's kind of like methadone or an opioid. You can't start at the same dose. So you have to start from early. So there are withdrawal syndromes and it can be quite uncomfortable for people to stop right away.

  Dr. Lucy Chen: [00:18:40] So therefore the importance of kind of cross titration, which is slowly decreasing the dose of the drug that the patient was on and slowly increasing the dose of the drug that you're switching to.

  Dr. Jason Joannou: [00:18:49] Depends on the setting you're in too, because sometimes if people say, for instance, leave an inpatient unit and the cross titration hasn't been done yet, that may not happen for weeks, months or years afterwards. And then people are on to antipsychotics, which is really not, you know, kind of evidence based or good for them and might have more suffer more side effects. So I actually do that fairly rapidly in hospital and try to minimise the discomfort, but it could be a real problem and I try not to when I'm cross titrating leave it for so long because I don't want that to kind of just inadvertently cause some harm. I would say not in terms of just generally what agents you choose after one's failed. I think, again, it just comes down to side effects and not all atypicals or typicals are created the same. Some have worse or less favourable profiles, like for instance, Olanzapine is a wonderful antipsychotic and works very well. And it just this is anecdotal. There's a great article. It was like, why olanzapine is better than risperidone, is better than quetiapine, is better than what have you, and there's no known efficacy difference. But in practice you will see psychiatrists say like, I like this or I like that.

  Dr. Jason Joannou: [00:19:58] For instance, no one uses Ziprasidone very much anymore because you had to have it with food twice a day, which may decrease the efficacy and it might in a randomised controlled trial be the same, but maybe in real life not quite the same. And there's these other new ones, Lurasidone and Asenapine. And I always say to residents, I say be wary of new things, try them out, learn about it, but like tried and true things that have been on the market 5 to 10 years at least like that have gone through the wringer in clinical practice usually are a bit safer. Yeah. So I mean I try to when I'm doing things, I try to use like less metabolically heavy things. So like risperidone and paliperidone are better than, you know, clozapine or olanzapine in terms of those risks. So I try to, you know, especially in first episode psychosis like Abilify or Risperidone Paliperidone are kind of like of the atypicals, kind of the less burdensome ones. So I try to see if hopefully somebody has a positive response to those before I move to other ones. 

  Dr. Lucy Chen: [00:20:56] So you've treated someone in the acute phase, you've kind of gotten them better on the inpatient unit and they're stable. What does it look like for them in the maintenance period when you're discharging them from hospital? Do you keep them at the same dose? Do you reduce the dose and how long do you keep them on that medication for?

  Dr. Andy Lustig: [00:21:13] Yeah, I think it's a matter, again, of weighing risks and benefits. And essentially there's kind of a safe option and a, you know, riskier option with potential for gain. So essentially, you know, the safe option is to maintain them on the dose of antipsychotic that initially led to the response and the recovery. And generally if you do that, you. I think you have the lowest chance of seeing relapse of symptoms, but that's typically a robust dose that may come with robust side effects. And most people are invested in decreasing the dose of the antipsychotic medication after they're out of the hospital. And as you probably know, many people want to get off the medication as soon as possible. So I kind of have this conversation with them and I say, you know, we can certainly try dropping the dose and we need to be vigilant for the re-emergence of symptoms. I find that most people can come down on the dose, realistically speaking, that the dose necessary to stay well is typically less than the dose that was necessary to get well.

  Dr. Lucy Chen: [00:22:15] And how long do they have to stay on it on that dose?

  Dr. Andy Lustig: [00:22:18] Well, it's controversial. So so I think typical recommendations. People say after a first episode, it should be somewhere like either like a year or 18 months or something like that. But we just recently read a paper and I think this is borne out by clinical experience, too, that says basically, you know, more is better. You know, unfortunately, schizophrenia does not typically go away. And people with schizophrenia who stop their antipsychotic will typically experience a relapse at some point. So I would say after a first episode, again, like somewhere around a year or 18 months, if the person is amenable to stay on the medication, I think that's the safer and frankly, the wiser option. And after a second episode, I think it's a lifetime of treatment is recommended.

  Dr. Jason Joannou: [00:23:03] Yeah. And Andy's referencing a recent American Journal article with a big Finnish cohort. And basically there's no safe time to discontinue. They have all this great registry data in the Scandinavian countries. And, you know, from one year to five years, they're high relapse rates if you stop the medication. So despite many guidelines saying somewhere between 18 months to two years or three years or what have you, I mean, that's more expert opinion than kind of great science behind that. I usually tell patients, I was like, look, if you're tolerating this, well, your life is a lot better. We can try to reduce the dose, but like, if I were you, I'd probably you're most likely going to have a relapse if you stop this medication. So you got to weigh that.

  Dr. Alex Raben: [00:23:48] And for sure, that's good advice. I want to turn now towards Clozapine, which is something we've alluded to a little bit already as being a bit more effective than the others for a subset of people with schizophrenia, at least in the new guidelines. And I think a lot of guidelines would say this as well, that if someone fails two treatment trials with other antipsychotics, that in those cases you should move to using Clozapine because it's shown to be more effective for what we would label as treatment resistant schizophrenia. So these are assuming that it's two good trials of a number of weeks at an adequate dose and that kind of thing. However, Clozapine is an interesting medication for many reasons, and I'm wondering, practically speaking, how that works out in real life, or what's your clinical experience with starting Clozapine?

  Dr. Andy Lustig: [00:24:37] Yeah. So Clozapine has higher efficacy than the other antipsychotics. It's the one notable exception to the previously stated rule of thumb that there's no real significant difference. And unfortunately, that greater efficacy comes at a greater cost in terms of the side effect burden. And so Clozapine has a lot of side effects and it's frankly quite a toxic drug. And so, I mean, typically after someone has two failed trials of antipsychotic medication, we would recommend and propose Clozapine as a third agent. And it's also important to be explicit about the side effects that the person is signing up for. So so Clozapine is kind of the quintessential atypical antipsychotic, and it has the attributes of Atypicality in kind of like in extremis. So so in terms of, you know, we talk about atypicals, we talk about metabolic side effects. And Clozapine has really severe metabolic side effects and it's variable. Some people don't seem to gain a lot of weight on clozapine. But I have seen people that have gained like £80 on clozapine. And in addition to that causes it causes constipation, which in some cases can be fatal.

  Dr. Jason Joannou: [00:25:55] I know that sounds weird, but it's true. You can get a ileus, like your gut just stops working. So you have to it's actually really important to monitor people's poops.

  Dr. Andy Lustig: [00:26:03] You have to be very vigilant about bowel motility for people on Clozapine, it causes myocarditis. It has been linked to sudden death. And as you know, it causes agranulocytosis, which is a precipitous decline in the neutrophils. And so people on Clozapine have to be enrolled in a national registry of everyone on clozapine and they have to be monitored with a complete blood. Cbc's, which have to happen weekly for six months and then bi weekly for six months and then in perpetuity for the rest of the time that the person is on the drug. And so in order to get somebody on clozapine, effectively you really need some buy in from the person because remember, it's an oral agent. It doesn't come in in any injectable or long acting injectable form. So the person has to take it on a daily basis. They have to have the blood work. And if they don't have the blood work, you have to stop the medication. And if you stop the medication, you can't after several days, you can't just restart it. You have to re-titrate it again, which takes some time.

  Dr. Alex Raben: [00:27:11] Right. So I it's obviously the most effective, as you're saying, but comes with all of these side effects and practical limitations that make it quite hard to not convince but it's not an easy drug for someone to decide to go on, essentially. And what I'm also hearing is, although we kind of are in medical school, we all learn about agranulocytosis associated with Clozapine. There's also these other quite significant side effects which are constipation, which again may not think but can cause a deadly ileus. And then I also heard myocarditis. Can you speak a bit more to that? Because that can be scary as well.

  Dr. Andy Lustig: [00:27:48] Yeah, absolutely. So that's, you know, inflammation of the heart muscle and it's often associated with kind of like a flu-like illness and oftentimes pain. And so now here at this hospital, we monitor people with we do their TROPONINS and CRP to monitor for inflammation of the heart muscle. And so we can stop the medication if they're developing that side effect.

  Dr. Jason Joannou: [00:28:14] Yeah. And it's actually no, no one told me about myocarditis again when I was even a resident, no one really talked about it. And then all of a sudden, you know, people were having these sudden deaths and they kind of the myocarditis story has been coming more and more. Australia has really good guidelines on what to do and the timeline and usually happens within the first month of initiation. So you don't have to if you've been on Clozapine for six months or a year, you don't really you're kind of past that window for the most part. And you know, the Australian numbers say something like I think 4% or something like that of people initiation get myocarditis, which is huge. 4% is you know we talk about everyone knows that agranulocytosis that's more like 1 to 2%. And we've been tracking this at CAMH and apparently, like the numbers here are like 7% and that just might be a cohort difference or what have you, but it's not insignificant and not uncommon. So it's actually a super important issue with Clozapine.

  Dr. Andy Lustig: [00:29:13] It also causes sialorrhea like excessive salivary production, which is a nuisance side effect for people, especially at night. People will describe waking up in their pillow is soaked with saliva very commonly.

  Dr. Alex Raben: [00:29:26] And then I'm just using my cheat sheet here. A few other kind of more nuisance side effects would be the anticholinergic and the side effects that come with other antipsychotics. But because it's the prototypical atypical antipsychotic, it tends to be quite extreme in clozapine. So like drowsiness, orthostatic hypotension, those kinds of things. And then also, as with other antipsychotics, there's a seizure risk, which I think is higher in clozapine. But I could be wrong about that.

  Dr. Jason Joannou: [00:29:55] It's very high in clozapine dose dependent, and you really start getting risky once you get above kind of 450, 500mg. Most people, when you're starting Clozapine, if you're doing a first trial, kind of get to 300mg, sit there for a while, see if there's a partial response or a full response, you have a partial response. You might want to increase the dose. Really therapeutic range is from 3 to 900mg. But once you start getting to the 500 milligram range, people really start considering adjunctive, maybe antiepileptic medications like Epival, which has some evidence about efficacy and augmentation, not great, but if you have to choose an anti-epileptic, might as well choose Epival because that's a mood stabilising properties as well. But yeah, seizure becomes a very big issue, one in high doses and obviously in overdose. If people were to kind of overdose on their medications, it can be quite dangerous.

  Dr. Alex Raben: [00:30:53] We've learned that it's clozapine is substantially more effective in treatment resistant schizophrenia. However, it doesn't work all the time. The new Canadian guidelines don't comment actually on what to do after Clozapine if it doesn't work. I'm wondering when you're faced with this clinical dilemma, what do you guys tend to do in practice?

  Dr. Andy Lustig: [00:31:17] That's a tough situation. You know, it depends how they got there, basically, and how much it's not working. If it's doing nothing, then really you can stop it. You should stop it. And if they've been on two other antipsychotics, well then there's lots of other untried antipsychotics. And so you can do trials of other antipsychotics that you haven't yet tried. In some instances, rarely ECT has been used for the treatment of refractory psychotic symptoms. And, you know, some people have psychotic symptoms that don't respond to medication management. That's the case. Then you want to help them move forward with their recovery, given the symptom burden that they're experiencing. And so, you know, we have other modalities which are not the cornerstone, but there is cognitive behaviour therapy for psychosis and other kind of like recovery tools and approaches to help them live the best life. They can with psychotic symptoms.

  Dr. Jason Joannou: [00:32:14] Another strategy. But you've got to tell people what the numbers are or they're not that great once you've failed. Clozapine in terms of a robust response with something else. But people do have idiosyncratic reactions to individual antipsychotics, and we don't know why. Right. Just like we were talking before, if you fail one trial, you go to a different one. We don't know why they fail the first one and they might respond to the second antipsychotic. And the earlier you are on in your illness, the more responsive that seems to be. But that doesn't mean that you can't have an idiosyncratic reaction to another antipsychotic. So I just recently had an experience where I was cycling through antipsychotics for another person who was failing them. He tried clozapine and actually got myocarditis twice. So he had two failed failed trial because of the myocarditis, not because of efficacy, failed a couple of other antipsychotics. We said we're going to retry him maybe on a slower titration schedule that might help. Still happened. And then Haldol, for whatever reason, he's doing really well now. But that's the patient's decision because the numbers aren't great there. And if someone's like, I get all these side effects and I rather just do what Andy said, I think that's a very reasonable course to go. But I also think it's very reasonable to say, look, we don't know why these individual superior effects with these medications happen, but we can just try to find the one that works best for you. Just being upfront again about like what the odds are is is important.

  Dr. Alex Raben: [00:33:44] Dr. Lustig, you you commented on CBT for psychosis and we spent almost all of our time today talking about antipsychotic medications as the cornerstone of treatment and certainly for positive symptoms like hallucinations and delusions. It is. But I'm wondering more now about the psychosocial aspect of the treatment and how that plays into things. The guidelines, again, we'll talk about everyone should get CBT for psychosis, everyone should get a family intervention. How often is this happening? When does this tend to be introduced to treatment and why is it necessary above and beyond antipsychotic treatment?

  Dr. Andy Lustig: [00:34:24] Well, yeah. I mean, essentially the antipsychotic medications are rarely a cure for for schizophrenia. And although there are some instances where people take the medication, have total resolution of their symptoms and just go about their life, that's the exception, not the rule. Most people don't have 100% reduction in in their positive symptoms, and most people have negative symptoms, which again, make it hard to go about doing the things that people want to do in their life. Those things are like, you know, going to school or going to work, cultivating healthy relationships with their family, cultivating romantic relationships, friendships, pursuing extracurricular interests and hobbies, fitness. Those are all the things that healthy people want to do as a part of their life. And those are hard to do with schizophrenia. It's just hard to it's just hard to get out of bed and hard to get ready in the morning and attend to your hygiene and get dressed and and call people and follow up and go to interviews and prepare your CV and all those things that we kind of take for granted become a kind of an extra effort in recovery from schizophrenia. And so a part of cognitive behaviour therapy for it is, I mean, you know, and it's not just cognitive behaviour therapy, it's just a part of recovery is structure and, you know, giving people like structured scheduling and prompts and encouragement and motivation to go about doing these things in their life.

  Dr. Alex Raben: [00:36:01] Right. So there's so much more to the illness that the antipsychotics don't really help with. That's right. And these psychosocial interventions, including CBT and helping with finding a vocation or other things like that, are essential for helping people with just going on with their lives and recovery, essentially.

  Dr. Andy Lustig: [00:36:19] That's right.

  Dr. Jason Joannou: [00:36:20] Yeah. I mean, there's a real risk of kind of isolation, marginalisation with this diagnosis and anything you can do to increase people's supports, their circles, it's going to be not only good for their illness, but just for their lives. And there's a lot of evidence behind that in terms of, you know, people are generally maybe do better in non-urban environments because they're more likely to have friends or neighbours that know them, care for them, check in on them, friends circles, their behaviours a little bit more accepted. Sometimes we know people in kind of developing countries actually are more likely to have a job, more likely to be married, more likely to be part of a community. And those are really important things not to forget. You just can't simply prescribe an antipsychotic and say, Here, that's all you need. See you later. These are the sorts of things that are going to help with all the things that Andy were saying that are really important not only to people with schizophrenia, but just healthy. Controls. Yeah.

  Dr. Lucy Chen: [00:37:14] Yeah. So I guess right now I'd like to just tie everything in together and, like, really kind of maybe provide the context of a case and then maybe have you guys use your clinical expertise in guiding this patient through a first episode of psychosis and how you'd counsel them on really the course, the trajectory of their illness and kind of maybe some counselling around medications and providing them with some guidance around what their life is going to look like.

  Dr. Alex Raben: [00:37:42] Okay. I'll read the case off here. So you are working on an inpatient psychiatric unit and are admitting Mohammed, who is a 19 year old male who was brought to the emerge by his family after two months of acting increasingly more bizarre. He is talking to his parents about Russian spies and has been tampering with the wiring of his home. He was placed on a form one for physical impairment. He almost electrocuted himself and harm to others. On one occasion, he elbowed his father in the nose while his father was trying to prevent him from touching the wiring. He has been relatively calm in the emergency room, but continues to feel like his home is bugged and is wanting help to deal with the spies. He appears unkempt. His speech is somewhat monotone, but otherwise normal. His affect is intense and constricted. He appears to be talking to someone at times when no one is around. He is tangential but coherent. He denies any drug use and his urine drug screen is negative. Basic blood work wasn't impressive and he has no significant past medical history. After a thorough history, including collateral from family doctor and his family, you find out that he has been hearing voices when no one is around and that his uncle has schizophrenia. Also, Mohammed has been followed for a year by first episode schizophrenia clinic for prodromal symptoms, but has never shown true psychosis before now. He has been managed conservatively up until this point. Your team concludes that Mohammed's most likely diagnosis is first episode of schizophrenia with Schizophreniform on the differential. Mohammed does not believe he is suffering from any illness and does not want treatment. So this is something that we haven't touched on too much. But how do you broach a situation like this with someone who doesn't have insight into their illness and doesn't actually want to be on medication at all?

  Dr. Andy Lustig: [00:39:33] Yeah, it's a it's a great case. So as you know, quite typical of the stuff we would see here, I would say. So I think you want to remember that. I think where this conversation is going, I think, is that we're going to talk about a variety of coercive tools that we have at our disposal. But but it's also important to notice that you want to avoid using those if you can. And this is going to be, you know, potentially a lifelong engagement between this person and their team and the system. And we want to work as collaboratively as possible with them. Having said that, so you basically what you would want to do in this instance is there's the two primarily kind of medicolegal issues that that have to be addressed. One is the issue of certify ability. Is this person sufficiently dangerous to justify detaining them in the hospital against their will? And the second is the issue of capacity. You know, here in Ontario, there's a test of capacity that we apply. And is the person able to understand the information relevant to making a decision? Are they able to appreciate the reasonably foreseeable consequences of a decision or lack of decision? We call that the two branch test with understand being one of the one of the branches and appreciate being the other one. And so you want to assess for this guy, should he be here in the hospital? And we would recommend an antipsychotic medication to him. We would work with him to to educate him about our concerns and educate the family and educate him about psychosis and schizophrenia and the medications and try to get him to take the medication.

  Dr. Jason Joannou: [00:40:58] Yeah. And I would just say in Ontario and he said the two decision points are, you know, involuntary detention or capacity. I would just add on the involuntary detention, you can't treat someone who is incapable and doesn't want treatment unless they're detained in hospital. I mean, initiating treatment is very difficult. You could be on a CTO and do it in the community, but like practically speaking, initiating treatment on somebody who doesn't want a treatment if they're not involuntarily detained is most likely not going to happen. The criteria for involuntary detention are safety ones, generally harm to self, harm to others, serious physical impairment, which basically means you don't want to hurt yourself, but you're just behaving in a way that is likely to occur.

  Dr. Alex Raben: [00:41:40] Harm like tampering with electrical wiring in your house?

  Dr. Jason Joannou: [00:41:43] Yes, exactly. Not dressing appropriately for the weather, being disorganised, walking into traffic, those sorts of things. The other criteria is benefit from treatment in the past. And different jurisdictions in Canada have different thresholds for this. Some don't have it. Ontario does, but it's only based on a previous treatment response. So if you're in a first episode psychosis, you can't say that you've had a previous response and we can hold you in hospital because you're going to benefit from this versus if someone's had multiple admissions and tried treatment, then basically if they've deteriorated and lost their capacity, you can treat them in the future, which is, you know, that's a whole podcast on its own about why you would do that. And one of the most frustrating things for I think, providers who want to help people and families who really are seeing their family members suffer, you know, part of the illness is a lack of insight into being ill. So it's very hard to explain to someone like they're very unwell, they're super. We have a treatment that we could do for them. But because there's no like 50% chance in a short period of time, they're going to hurt themselves seriously, someone else or die. They can just be, you know, deteriorating. And you say, I can't do anything. That's a very difficult conversation that we have to have many times with families.

  Dr. Lucy Chen: [00:43:01] So with like maybe Muhammad and his father in the room and his father is extremely concerned, very tearful. How do you talk about treatment? How do you talk about the course? How do you talk about what's going on and make sense of it for very like distressed family?

  Dr. Jason Joannou: [00:43:16] Yeah, I would say. I mean, the first thing is talking to Muhammad and telling him what you think is going on, that basically, you know, your brain is misfiring right now. There's there's actually not all these threats out there. Unfortunately. You have this illness called schizophrenia, psychosis, whatever. You're going to label it that just talking more about the symptoms and the diagnosis and saying we have this medication doesn't come without side effects, but it can make you feel more at ease, get you back to where you were. And we can monitor it closely, especially in hospital, and then support you when you leave with it. That's kind of the general conversation. And sometimes people, you know, even if they're incapable, will go along with it and kind of just do what doctors do. And sometimes people are very vehement. They don't want treatment. So that's kind of where you start. And then when you talk to the family, you know, you sympathise with them, you educate them about the limits of what you can do in hospital under the law, you problem solve with them in terms of what to do. If this were to happen, they can go to the doctor, they can get a form to if there are safety issues, all those sorts of things, and then you try to provide them with any support you can. So there's, you know, a lot of family support usually are very good social workers here on the fifth floor work with families. So and this is a journey they're going to be taking together for a very long time, even though you can't give them what they want, you want to make sure that they feel heard and listened to share their concerns with them as well. The other kind of stumbling blocks sometimes is people say, I don't want you to talk to my family. And then there's a limit about information that can be shared and that that can be very frustrating for families as well.

  Dr. Alex Raben: [00:44:52] So thank you guys so much for that. I mean, just summarising that last piece, I think something I take away is just how important those moments can be for the longer term trajectory, because it is often a life long illness and you have to be cognisant of that while you're giving all this counselling in those early days and moments.

  Dr. Jason Joannou: [00:45:09] Setting the stage.

  Dr. Lucy Chen: [00:45:11] For sure. So thanks so much again for sharing your time guys. We'd love to have you back on the show.

  Dr. Andy Lustig: [00:45:16] Thanks for having us again!

  Dr. Lucy Chen: [00:45:18]  But for now, we're going to wrap up, I guess, any closing remarks or just some advice or kind of insight to give to young learners in the scope of pursuing a field in psychiatry and especially in the context of your practice.

  Dr. Jason Joannou: [00:45:30] Just like any area of medicine, there's going to be challenges and limitations to what you can do. But we I think we do really good work. And even when we're having to use these coercive tools and doing what we think is in our patient's best interest, I think we do make an impact on people's lives. And I feel very privileged to be in the position I am in every day to work with these families going through this and the kind of courage and strength that they show the patients and the families and just trying to help and be part of it is can be a really wonderful experience. It can be very taxing and difficult experience as well. But most things in life that are worth doing can be difficult as well.

  Dr. Andy Lustig: [00:46:13] Yeah, I agree. And I think it's important to celebrate small victories when working with people with chronic psychotic illnesses.

  Dr. Alex Raben: [00:46:21] Great. Thank you, guys.

  Dr. Lucy Chen: [00:46:22] That's a wrap. 

  Dr. Alex Raben: [00:46:23] Psyched is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. This episode was produced and hosted by Lucy Chen, Henry Barron and Alex Raben. Special thanks to Yanlin Zhou and Theresa Park for help with research. Henry Barron provided the audio editing. Our theme song is Working Solutions by Olive Musique. A special thanks to Dr. Jason Joannou and Dr. Andy Lustig for serving as our experts on this episode. You can contact us at info at psychedpodcast.com or visit us at Psyched podcast.org. Thank you for listening!

Episode 8: Diagnosing and Treating Obsessive- Compulsive Disorder with Dr. Nik Grujich

• Episode 8: Diagnosing and Treating Obsessive- Compulsive Disorder with Dr. Nik Grujich

  Dr. Alex Raben: [00:00:01] Hi, everyone. Alex here. Before we get to the show today, I wanted to take a minute to request your help. Here at PsychEd in addition to our aim of bringing psychiatric learning to life through podcasts, we also strive to improve knowledge on how medical learners actually use podcasts. Because of this as a team, we've developed a short research survey to better understand how you, the listener, interact with site. You can find the link to this survey in the show notes or you can find it on our website at psychedpodcast.org. By taking less than five minutes to fill out this survey. You not only help us improve psyched. You help us move research on this important new tool in medical education. Forward and by completing the survey, you will also be entered into a draw for a chance to win $230 in a gift card of your choice. As always, thank you for listening to the show and thank you for taking time out to improve psychiatry education. All right, let's get on with the show.

  Dr. Jordan Bawks: [00:01:21] So welcome to PsychEd, the Psychiatry Education Podcast for Medical Learners by medical Learners. Today we'll be talking about OCD, obsessive compulsive disorder. The objectives for today's podcast are that we want listeners to be able to recognise the clinical features of OCD and diagnose it using DSM-five criteria. We want listeners to be able to appreciate the differential diagnosis and how to conduct assessments to help guide clinical judgement. And we want to talk about the bio-psychosocial treatments for OCD. Today we're joined by Dr. Nick Grujich, a staff psychiatrist at Sunnybrook Health Sciences Centre and a part of the Frederic W. Thompson Anxiety Disorder Centre. Dr. Grujich is an award-winning educator of both medical students and residents at the University of Toronto, and we're very happy to have him on the show.

  Dr. Nick Grujich: [00:02:12] Thank you, Jordan. Happy to be here.

  Dr. Jordan Bawks: [00:02:14] Dr. Grujich, why don't you start by telling us a little bit about your involvement with the Thompson Anxiety Disorder Centre and your interest in anxiety disorders?

  Dr. Nick Grujich: [00:02:22] Sure. It happened kind of organically. When I applied for my job here. There was an opening in OCD clinical work. I guess I was working with Dr. Peggy Richter and not long after we started seeing.. Well, not long after I started seeing OCD patients, she had a tremendous donation that was offered and that's what allowed us to start the Frederick Thompson Anxiety Disorders Program.

  Dr. Jordan Bawks: [00:02:50] Great. So we you know, one thing that I'm always conscious of when I'm teaching medical students is that there seems to be a common mistake when people in kind of the lay public talk about OCD, like, "oh, my friend is so OCD." Usually they're actually talking about OCPD, which we'll talk about later. But Dr. Grujich, can you give us like a plain language summary of OCD to set the frame for today's podcast?

  Dr. Nick Grujich: [00:03:17] Sure. So obsessive compulsive disorder is an anxiety disorder and the symptoms are marked by a intrusive or persistent image that that gets stuck in someone's mind. And as a consequence of that, they feel anxiety and distress related to it, and they typically find some sort of compulsive behaviour or mental ritual that they engage in to try and alleviate the anxiety caused by the obsession.

  Dr. Jordan Bawks: [00:03:43] Okay. It's pretty plain language to me and we'll get deeper into the DSM five criteria shortly before we do. Aarti, do you want to actually we should formally introduce you to the show. This is Arthur's first podcast. Why don't you introduce yourself, Artie?

  Dr. Aarti Rana: [00:03:58] Yeah, Thank you. Jordan. My name is Aarti Rana, and I'm a PGY one in psychiatry, just starting my residency and learning all about OCD today.

  Dr. Nick Grujich: [00:04:07] Fantastic.

  Dr. Jordan Bawks: [00:04:08] And I forgot to introduce myself too. I'm Jordan Bawks. Maybe you recognise my voice from the previous episodes. I'm a PGY-2 in psychiatry, currently working at Mount Sinai Hospital in Toronto. So Aarti, why don't you tell us a bit about the epidemiology of OCD?

  Dr. Aarti Rana: [00:04:23] Yeah.So as we know, OCD is seen with equal frequency in both men and women, and the mean age of onset is around 20 years old. It has a chronic course and it tends to be highly familial. So 10% prevalence rates in the first degree. Relatives of those with OCD, if you have a relative 10% likely to have OCD, there's a high degree of shame related to the contents of obsessions of OCD, which we'll probably dig a little bit further into.

  Dr. Jordan Bawks: [00:04:53] Yeah, I mean, I think that's something that you think about when you're seeing a patient who's like young and they're quite anxious and you feel like something's missing because the contents of the obsessions can be pretty upsetting to people and it can be hard for them to talk about it. Dr. Grujich, any thoughts on kind of like the the typical ages or the types of patients that you tend to really start to suspect OCD early on just based on?

  Dr. Nick Grujich: [00:05:20] Yeah. So generally speaking, OCD starts in adolescence or early 20s. I've seen OCD in very young people as young as five, six, 7 or 8 years old. But OCD can also start later in life. But the mean age of onset is usually in one's 20s. Once you have a diagnosis of OCD or you have the symptoms of OCD, they tend to persist over the course of one's life. What people tend to describe is a waxing and waning of symptoms, which are generally in proportion to stressors and life events that are going on around the same time.

  Dr. Jordan Bawks: [00:05:56] Okay, so why don't we clearly flesh out the DSM five criteria for Ocd? So first this is one that I actually find tricky still to this day. It's the the presence of obsessions, compulsions or both. So you actually don't need obsessions and compulsions to have OCD, so.

  Dr. Nick Grujich: [00:06:17] That's correct. Now, having said that, the vast. The majority, upwards of 90% of people who have one will have the other. So the typical pattern we'll talk about this is that an obsession is followed by a compulsion, and that happens in over 90% of individuals. Now, correct. As per DSM strictly, you don't need to have both. But the vast majority of people that you'll come across will have both.

  Dr. Jordan Bawks: [00:06:41] Okay. And when the DSM five, like when psychiatrists talk about obsessions, we're talking about persistent unwanted thoughts, images or impulses. So these are kind of felt by patients to be intrusive, uncontrollable. They tend to provoke anxiety because they're distressing and they often result in an attempt to ignore or suppress them, which is where we get to the compulsions.

  Dr. Nick Grujich: [00:07:07] Absolutely.

  Dr. Jordan Bawks: [00:07:07] So when we talk about compulsions in the DSM five lingo, we're talking about repetitive behaviours or mental acts. And that was one that I always kind of forget to ask about with patients. But that compulsions don't just have to be physical behaviours. They can be like counting or reciting kind of mantras.

  Dr. Nick Grujich: [00:07:28] Is that right? Yeah.

  Dr. Nick Grujich: [00:07:29] So we call those mental rituals.

  Dr. Jordan Bawks: [00:07:30] Mental rituals. And they're sort of performed, as you said, They follow obsessions. They're performed in response to obsessions, often in kind of a ritualistic, patterned fashion.

  Dr. Jordan Bawks: [00:07:40] And the intention, the kind of the use of them is to reduce the distress that's associated with the obsessions.

  Dr. Nick Grujich: [00:07:46] Exactly is the point. Now, they're not always connected. I mean, we'll talk about specific phenotypes of OCD, but sometimes the compulsion can have no connection with the nature of the obsession.

  Dr. Jordan Bawks: [00:07:57] Okay. So it's not always as clear as fear of contamination and hand-washing.

  Dr. Nick Grujich: [00:08:02] Exactly.

  Dr. Jordan Bawks: [00:08:03] And as per usual in the DSM five, the symptoms must cause distress and significant functional impairment. And the specifier they use in the OCD is that they, the symptoms must take up over an hour of the day. Is that something that you find?

  Dr. Nick Grujich: [00:08:19] So that's an important one because some degree of checking and and cleanliness, if you will, or cleaning behaviour, that's all normal. It's all well within the normal scope of human experience. Ocd becomes pathological or quote unquote diagnostic meeting diagnostic criteria when it becomes functionally impairing and when it actually starts chewing up more than an hour per day.

  Dr. Jordan Bawks: [00:08:43] Okay. And the DSM also has some specifiers. So talking about patients with or noting patients with good or fair or poor insight and sometimes absent insight and almost a delusional level like a quality to them.

  Dr. Nick Grujich: [00:09:01] Exactly. So that was the DSM five edition.

  Dr. Jordan Bawks: [00:09:04] Okay.

  Dr. Aarti Rana: [00:09:06] Yeah. Dr. Grujich, I'm curious. Sometimes you have patients that say, of course, I checked the door five times every night before I go to bed. How do you actually ask the right questions to get at whether or not this is really OCD? What are the screening questions that you're asking people when you have a high suspicion?

  Dr. Nick Grujich: [00:09:21] That's a very good question. Ocd can have many different phases, and for that reason, it's often missed. Primary care physicians and even psychiatrists will often mis misinterpret people's symptoms as a different anxiety disorder or some other illness. So maybe we'll take a moment at this point to talk about different types of OCD or different phenotypes. So the first one that we often see in the media and that people usually ascribe to OCD are obsessions around contamination. So this can be a fear of having HIV or things being dirty or unclean. And that thought gets stuck in one's mind and causes distress. And so the compulsion that's typically associated with that are compulsions around cleaning. So maybe it's undressing when you come into the home and having to wash all the clothes, hand-washing, excessive showering routines and so on. Second common OCD theme is around doubt. So it's obsessional doubt. Did I lock the door? Did I not lock the door? Did I say the right thing when I was speaking to this friend? Is this email correct? Is it going to be misconstrued? And so there's often catastrophic thinking that's associated with doubt, obsessions. And of course, the typical compulsion that would follow would be checking behaviour. So checking doors, checking locks, appliances, checking, rechecking emails, checking and double checking thoughts or reviewing narratives of discussions with friends that's associated with OCD thinking. The third one is a bit of a grab bag where it's a need for orderliness or things to feel just right.

  Dr. Nick Grujich: [00:11:04] And so this is where symmetry counting, superstitious numbers, odds and evens these things can all be part of that grab bag of symptoms. And then the last one, which is very common and often the most distressing, but the one that's typically associated with the most shame are what are called intrusive thoughts that tend to be of violent, religious or sexual themes. So if someone identifies as heterosexual, they might have an image of homosexual act and they can't get that thought out of their mind and it tends to cause a lot of distress. So again, when someone has these types of obsessions, they will come up with all kinds of potential rituals, be them behavioural or mental in nature, to try and reduce that distress. So let me come back to your point actually, in typical, when I see a patient with an anxiety disorder, I'll ask them if they ever get thoughts stuck in their head that caused them distress and that they typically engage in some sort of repetitive behaviour or some thought process to try and alleviate that anxiety and distress. If my index of suspicion is higher, then I might go into specific examples like the themes that we talked about. So I might ask about contamination, doubt, intrusive thoughts or things needing to feel just right type of obsessions.

  Dr. Jordan Bawks: [00:12:31] Okay. I think that Segways pretty nicely into the next set of questions we were hoping to ask you, which is around differentiating like OCD from other common kind of mimickers like the common kind of differential diagnoses that are tricky to tease apart. So for example, someone with like really severe generalised anxiety disorder, what kind of questions or features might you try and find to tease those apart?

  Dr. Nick Grujich: [00:12:58] Good question. So I think right off the bat, like all of our mental health diagnosis, they typically flock together. Rarely will you see someone with pure OCD without a comorbid anxiety disorder or mood disorder or substance use disorder or so on. So I think that we want to try our best to distinguish between the symptoms that are being presented and how to understand the diagnosis. But it's not uncommon for people to have multiple different disorders happening concurrently. So with GAD specifically, there's often this sense of rumination or quote unquote obsessional thinking. But what's different is with GAD, it's more of a broad free flowing type of worry. And the worries are typically around normal, everyday events. So a worry about finances. A worry about relationship. A worry about one's personal health. And they tend to move around and be free flowing. And the worries are kind of consistent with the person's belief they want to be problem solving. And so they see their worrying on some level as advantageous to prevent surprise or to plan and prepare. They also don't describe compulsive behaviours the way someone with OCD might. So, again, it can be difficult to distinguish, For example, if somebody is concerned about where their partner is, they might start checking their phone in a compulsive fashion. Curious when they're going to get a text from that loved one to say that I'm okay. But again, you distinguish that because they see that behaviour as reasonable and rational and it's unique to that one situation that's related to an everyday type of event. With OCD, the patient again, in the with the exception of the low insight OCD symptoms, they typically have a good sense that their worries or their obsessions are irrational.

  Dr. Aarti Rana: [00:15:01] Okay. And how about eating disorders? I mean, that's an instance where someone has a particular kind of obsession and a compulsion response to that, which is to change their eating habits. But we don't call that OCD. Right.

  Dr. Nick Grujich: [00:15:15] So in the DSM, they talk about what is the best fit for the symptom criteria. If all of the obsessional thinking and compulsive behaviour is exclusively related to eating behaviour, then you'd be more appropriately diagnosing an eating disorder rather than an OCD disorder. Now, having said that, people who work in eating disorders populations will be the first to say that OCD is typically a comorbid illness and the two often flock together.

  Dr. Aarti Rana: [00:15:47] Okay. And you had mentioned one of the new DSM five criteria was kind of a psychotic component to the OCD. How do you distinguish it generally from psychotic disorders that might have an obsessive component to them?

  Dr. Nick Grujich: [00:16:01] Right. So again, that could be tricky. Like all things in mental health, we talk about spectrums and continuums. And so there's folks who struggle with OCD that have good insight and can appreciate that their obsessions are irrational, although they continue to engage in the compulsion because that's what relieves the anxiety. But as you move along that continuum towards less insight, that's when it can start feeling delusional. When you look at psychotic disorders, I guess you look at clusters of symptoms. So if someone has schizophrenia, you look for things like negative symptoms, prodrome family history and other components, whereas with OCD, you might not see some of the other associated symptoms that typically come with primary psychotic illnesses. The other thing obviously, is that with OCD, there's the compensatory compulsions, whereas with psychotic disorders related to primary psychotic illnesses, you don't typically see as clear of an association.

  Dr. Jordan Bawks: [00:17:00] Yeah, that makes me think a little bit about like depression. Like sometimes if I'm screening, like I've found somebody who is. I'm working with somebody who has depressive symptoms, feel pretty good about that. And then I'm moving kind of into an Anxiety disorder screen and I let myself slip a little bit and I'll sort of say something, a screening question like, "Do you have any obsessions? Like, do you tend to obsess about things?" Then people will kind of like volunteer in the colloquial sense, like, yeah, I'm obsessing about and sometimes it's in depression. It tends to be like about a loss or about a personal inadequacy. And in those situations, like you don't see the there's no compulsion to fix that. It's just kind of a rumination as opposed to an actual like obsession in the way. Good point. We think about it.

  Dr. Jordan Bawks: [00:17:48] I wanted to quickly talk about tic disorders, trichotillomania, body dysmorphia, hoarding.

  Dr. Nick Grujich: [00:17:56] Sure. So in DSM for OCD, PTSD and and the classical anxiety disorders were in one chapter called the Anxiety Disorders in DSM five. They pluck them out because there was a number of orphan disorders that didn't really have a home. And they had a lot of overlapping components with OCD and of course, with PTSD and trauma-related disorders. So from my understanding, the folks who put together the DSM five purposefully put OCD close to the Anxiety disorders chapter to convey their connection. Yet OCD is now in an independent chapter called Obsessive Compulsive and Related Disorders. So we'll go over the different diagnoses that fall in this chapter. So OCD, of course, hoarding disorder, skin picking disorder, hair pulling disorder and body dysmorphic disorder. So tic disorders are not actually there. Tic related is a specifier as part of OCD because people who have OCD and tic disorders have a different phenotype than other types of OCD. So those are the different related disorders. I guess I don't know how much detail you want to go into them. Theoretically, we could do a whole podcast on each of those independently, but if you can look at them all individually, they all have some degree of fixation on something or some sort of obsessionality with some sort of repetitive behaviours. Again, they're all quite different, but those are the themes that connect them. 

  Dr. Aarti Rana: [00:19:37] One way to understand that better for me at least, would be to go back to this distinction between obsession and compulsion, which I always struggle with, especially when it comes to like mental acts. So you can have an obsession that's mental, but you can have acts or compulsions that are also mental. Can you clarify that distinction a little bit?

  Dr. Nick Grujich: [00:19:59] Sure. Yeah. Yeah. So. So let's take, um, let's take someone who has a violent, intrusive thought. So I have a young child at home and I have this horrible graphic image of me hurting the child. So specifically, let's say it's an image of stabbing my child. Now, I have no wish to do that. Obviously, I love my child. And when that thought comes into my mind, it's very, very, very distressing and anxiety provoking. And I question whether I'm going to do it or not, even though I know I'm not. There's this gnawing question that happens and the distress goes up. You can imagine how a parent might feel if they have that and some of the shame that's associated with that. So I think we'll talk about this later, but it's not consistent with my beliefs. And the term egodystonic comes up. I'll talk about that later. But when I have that thought, I will scramble to try and figure out a way to get rid of that thought. And so if I figure out a mental ritual that I can engage in that alleviates the thought, then that might become a paired compulsion. So a mental ritual might be where I would go in over in my head every time I've interacted with a child and I've not hurt the child or these kinds of reviewing of of mantras or saying things to oneself or reviewing evidence in one's mind. So these are different types. Some people will engage in mental rituals like counting over and over and over again as a way of alleviating the distress related to the obsession.

  Dr. Jordan Bawks: [00:21:43] One of the common differentials that I know medical students often get pimped on that we haven't gotten to yet is differentiating OCD with OCPD.

  Dr. Nick Grujich: [00:21:52] And are they the same thing?

  Dr. Jordan Bawks: [00:21:55] Not quite the same thing.

  Dr. Aarti Rana: [00:21:57] Ocd. Aren't we supposed to all be OCD? .

  Dr. Jordan Bawks: [00:21:59] All medical students have OCD? Yeah. So this is sort of what I was alluding to earlier. And again, not that we have kind of the time today to really go into OCPD, but that's OCPD Obsessive Compulsive Personality Disorder is really unfortunately named because it shares three of the same syllables. And in some respects you can see some of the similarities, like in terms of the tendency to kind of like obsess in the more like colloquial sense to be very detail-oriented to be perfectionistic, to be moralistic, to be rigid, to want to sort of alleviate anxiety through control. That's kind of what I think about when I think about OCPD as a personality disorder.

  Dr. Aarti Rana: [00:22:49] Yeah, kind description of medical students.

  Dr. Jordan Bawks: [00:22:53] Well, we all have traits. And, you know, without this is the interesting thing about personality disorders, which is a soapbox for another time, but is that, everybody has a personality, right? Everybody has personality traits and we in the DSM five, we really characterise a disorder by marked functional impairment. So by that stretch, the majority of medical students, by the fact that they got into medical school by the fact that they continue to attend medical school, don't have ocpd full on, but probably something that a little bit of the traits helps them study for tests and get those bonus marks.

  Dr. Nick Grujich: [00:23:24] I'll give you one clinical example which highlights it. So the patient who comes in and you ask them about cleaning and they say, I clean for two hours a day. So is that OCD cleaning or is it OCPD cleaning? So when you ask them what motivates the behaviour, they'll tell you that they enjoy having a clean house. They like to do this. This is consistent with what their beliefs are and what they want. Whereas the person with OCD will say, I know that this is excessive and ridiculous, but it's the only way that I can get rid of these intrusive thoughts around germs being in my house so they can see the behaviour as problematic. But they can't stop the behaviour because if they don't do the behaviour then they have the painful anxiety, whereas the OCPD is kind of a rigid, fixed, perfectionistic need to be done my way and this is the way I like things done.

  Dr. Jordan Bawks: [00:24:20] And that's where the buzzwords that come in from medical students who are looking to score on their exams and impress their supervisors comes in Egodystonic versus Egosyntonic, which you kind of mentioned earlier. So ego kind of meaning like mind your conscious mind in this sense, it's something that's egosyntonic is something that you feel is consistent with your values. It's something that doesn't cause you like active distress versus Egodystonic is something that feels like foreign to your own mind, something that, yeah, it feels kind of intrusive and upsetting.

  Dr. Aarti Rana: [00:24:52] Let's say this patient has been referred to your office by their GP and the GP suspects they have OCD. Is there anything else in the history that you want to cover that we should be asking about that we haven't touched on yet?

  Dr. Nick Grujich: [00:25:05] You know, without going into too much detail, I think you screened for comorbidity, obviously special populations like youth pregnancy, geriatrics, if there's a bipolar mood disorder, if there's an active substance use disorder, these are all factors that we always think about that might impact our treatment suggestions. You want to look at severity, you want to look at supports, you want to look at whether the person has the capacity to engage in psychotherapy or medications. And you want to start looking at the patient in terms of your bio psychosocial formulation to identify treatments that are appropriate.

  Dr. Aarti Rana: [00:25:43] And speaking of special populations options, what if you have a youth who recently had a throat infection? Oh.

  Dr. Jordan Bawks: [00:25:51] Pandas. Yeah.

  Dr. Nick Grujich: [00:25:52] So which one of you champs wants to talk about that one?

  Dr. Jordan Bawks: [00:25:55] We try to talk about it in the hall before we came in, and I think I botched it, so.

  Dr. Aarti Rana: [00:26:00] Couldn't remember the acronym, to tell you the truth.

  Dr. Nick Grujich: [00:26:03] So there is this this idea that strep infections can cause OCD and there's a very real and and and observed phenomenon around that. I work with adults and so I don't typically screen for that. Sometimes adults will ask me to prescribe them antibiotics because they've heard on TV news programs that antibiotics can treat OCD. However, there is no evidence in the adult literature. It's not in the guidelines that antibiotics are a viable treatment for adults with OCD.

  Dr. Jordan Bawks: [00:26:40] All right. So for listeners who want to go read up about that because they're working with paediatric populations. They can Google paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. And the Wikipedia article looks pretty comprehensive to me right now. I think that the PANDAS acronym there is quite helpful. Lastly, before we wrap up kind of diagnosis and move into treatment. Is there anything that you kind of look for or comment on as part of your mental status exam in patients who have OCD?

  Dr. Nick Grujich: [00:27:16] So sometimes it's obvious, but most of the time it's not. So when I say obvious, I mean someone that engages in rituals when they're sitting in your chair. So if before they talk, they have to engage in a pattern of rituals or before they engage in movements. I mean, these are the kinds of things that are obvious. I remember one patient before they would start talking, they would have to look at all four corners of the room before they could start talking. And so I guess on mental status exam, you keep your eyes open and you look for things, but oftentimes they're subtle. And if they're mental in nature, you'll never get them. So I think that on mental status, the patient with OCD will often come across as globally a bit anxious or apprehensive. But if they do have rich rituals that you can observe, then that's something you obviously comment on.

  Dr. Jordan Bawks: [00:28:07] All right. So let's take a second to pause and summarise what we've talked about so far. We talked about the epidemiology of OCD. We talked a little bit about its natural course. We've talked about the nature of obsessions, that they're intrusive, upsetting thoughts, images or impulses, and we've talked about compulsions which are repetitive behaviours or mental acts that are usually done to reduce the anxiety associated with obsessions. And we also talked a lot about the differential diagnosis and how to distinguish different psychiatric syndromes from OCD using kind of screening questions and  thinking about course and of course, family history factors in there too.

  Dr. Jordan Bawks: [00:28:51] And we spent a little bit of time talking particularly about OCPD, because it's such a common question for medical students and junior residents. So now we'll move on to the treatment of OCD. Dr. Grujich, can you give us an overview of the treatment of the what are the treatment pptions for OCD and how do we choose between them?

  Dr. Nick Grujich: [00:29:12] So your options would be psychotherapy or pharmacotherapy? We'll talk later on about research based or somatic treatments for OCD, but predominantly at this point, the guidelines would recommend either psychotherapy, which is a cognitive behavioural therapy informed CBT model or sorry, a cognitive behavioural therapy model for OCD or medications or a combination of the two.

  Dr. Jordan Bawks: [00:29:39] Okay. My understanding is that psychotherapy is the gold standard treatment for OCD and has like frank superiority over pharmacology alone.

  Dr. Nick Grujich: [00:29:50] So I would agree with that. I think one of the challenges is how does one access good evidence based psychotherapy? If someone is reliant on a public system, they might be subject to extremely long wait lists or just frankly, not find someone available who can provide therapy. Also, issues like language barrier or availability to participate in CBT. The other thing is that CBT is hard work and so not all of our patients are well enough to engage in CBT. So for I guess all of those reasons, the vast majority of patients who have OCD and anxiety disorders will get treated with medications with regards to the medications. Suffice to say that OCD responds to serotonergic drugs and so the guidelines will emphasise specific drugs based on clinical trials and whatnot. But I think that you're in the right ballpark if you start medications with a serotonergic drug. And so for ease of of tolerance and tolerability, we typically start with the SSRI or selective serotonin re-uptake medications, and then we go from there.

  Dr. Aarti Rana: [00:31:02] And how does treatment with SSRIs in OCD differ from depression or anxiety?

  Dr. Nick Grujich: [00:31:07] So with OCD, it tends to respond more to higher doses, and trials often take longer. So in our CANMAT guidelines for depression, they talk about 2 to 4 week trials for depression, for OCD. Those trials can be up to three months and sometimes even longer. So if you are a prescriber working with someone with OCD, you need to be patient and you need to understand that the trials will take time. So that's the first issue. And the second issue is that with anxiety disorders and depression, we start at the lowest dose and we give it time to see whether we've achieved full remission. If there's a partial response, then we would optimise for OCD. We tend to push the medications to higher doses quicker because there is evidence that suggests that higher dosing can be more effective. And oftentimes with OCD, we'll try supra-threshold dose. So, for example, sertraline above 200mg may confer more benefit.

  Dr. Jordan Bawks: [00:32:11] And after we exhaust some of our first line options, what are the second line options that we might bring in? Pharmacologically.

  Dr. Nick Grujich: [00:32:19] So my algorithm follows the Canadian guidelines, which is I'll try one SSRI. If that fails due to lack of efficacy or tolerability issues, then I'll try a second SSRI. And if that also fails, then we got a couple of options. We could try an SNRI, a further SSRI, or we can go to Clomipramine.

  Dr. Jordan Bawks: [00:32:40] Okay. And sometimes I've seen augmentation with antipsychotics. When do you start to think about involving an atypical antipsychotic in the treatment of OCD?

  Dr. Nick Grujich: [00:32:52] That's a good question. Globally, the way I approach psychiatric illness is less is more when it comes to medications. And so I would rather stick with one medication and optimise it as much as possible to try and get as much benefit. If the person still has residual symptoms and has functional impairments as a consequence of residual symptoms or distress, then that's when you consider augmentation. Now, augmentation also includes therapy, so don't forget about that option. But the most evidence in terms of augmentation strategies is adding atypical antipsychotics and Risperidone and Aripiprazole have the most evidence from that standpoint. Now, there's an interesting research that's going on in looking at glutaminergic drugs. And so there are a bunch of interesting third-line agents that in the coming years there'll be more research. But these are drugs like Ketamine or Memantine or Topiramate. So these are interesting things. N-acetylcysteine is another one. So again, it's a serotonergic drug, whether it's an SSRI, SNRI or Clomipramine, there is some evidence for addition of Mirtazapine. And you could think about atypical antipsychotics and then glutaminergic drugs is an option that would be further down.

  Dr. Jordan Bawks: [00:34:08] Okay, so it sounds like there are quite a few well-established pharmacologic options and an algorithm to work through with patients, but it's important to be patient exactly with that process. Now, we talked about exposure and response prevention as being kind of like A CBT Protocol. That's kind of the gold standard of OCD. Can you walk us through some of the underlying psychological factors in OCD and why it makes ERP exposure response prevention so effective?

  Dr. Nick Grujich: [00:34:41] Sure. So let me give you an example. So let's say I'm struggling with doubt obsessions and I leave my house in the morning to get to work and I lock the door. And as I'm walking to the car, the obsession creeps in. Did you lock the door? Did you not lock the door? If you didn't lock the door, someone's going to break into the home and and light your house on fire. Whatever these catastrophic, irrational obsessions are. By the time I get in the car and I'm sitting in the car, there's a high degree of distress because this obsession is unrelenting. And so in the interest of alleviating the anxiety, I'll just say, you know what? Let me just double check. So I'll get up, I'll get out of the car. I'll walk to the door. I'll lock the door again. I'll check it, and then I'll start walking back to the car. Now, we've all done that at some point in our lives, and that's totally fine and totally normal. But when it's OCD, that intrusive thought will creep back. So as I'm walking back to the car, the obsession returns and it causes me the same distress. And so then how am I going to get to work? Because I'll be worrying about this the whole day. So maybe it's just easier if I get up and check. Now you can see that if I do this over and over and over again, this is going to potentially impact my ability to get to work on time or to complete tasks and so on. So the CBT approach which you alluded to, is the behavioural interventions called exposure response prevention.

  Dr. Nick Grujich: [00:36:03] So the therapist and the patient will start identifying all of their obsessions and their compulsive behaviours and they'll rank them in a hierarchy in terms of their capacity to not engage in the compulsion and what the subjective units of distress would be if they don't do the compulsion. Once you've ranked them all in a hierarchy, then you want to start knocking things off the list. So if we're going to use this same example through the lens of exposure response prevention protocol, what I would say is you lock the door, you're mindful about the fact that you lock the door as you're walking to the car once the obsession starts, rather than engaging in the compulsion and reinforcing this pattern, I'm going to say to myself, No, I check the door. I'm not going to double check. So what tends to happen is the anxiety level goes up and up and up, but it reaches a maximum. So the good news is anxiety does not go to infinity. It reaches a peak. At some point it'll plateau off and then eventually we will habituate to that uncomfortable experience and it will go back down to normal. The analogy that I use for my patients, I find it helpful is if you put your foot in a hot tub, your reflex is to pull it out. But if you leave your foot there, your foot will get hotter and hotter, but eventually you get used to it. And then the warm temperature doesn't bother you anymore.

  Dr. Aarti Rana: [00:37:25] And what happens if you've tried pharmacology, you've tried psychotherapy with patients and they're still refractory to treatment? Is there any other options for patients who still have OCD?

  Dr. Nick Grujich: [00:37:40] So usually between the two, you're going to get some benefit. You're absolutely going to get some benefit. I like working with anxiety disorders because I feel like on some level, everyone is going to get a little bit better. Even just psychoeducation is enough to get people feeling better. Now there are people who have problematic compulsions, perhaps even dangerous compulsions that might involve self-injurious behaviour and and real severe functional impairment if that person is really unable to benefit from the first and second-line therapies and psychotherapy, then that's when you might think of somatic treatments. Most of these interventions are experimental in nature, but to name a few are RTMs. There's some trials looking at RTMs, there are ultrasound guided focus interventions. We're doing studies at Sunnybrook looking at that. There's psychosurgery, which is something that was practised a long time ago but is now coming back because we're able to really localise treatment. And so that would include deep brain stimulation for OCD. So again, these are these are all very much experimental interventions, but there is promise in terms of using these types of somatic treatments.

  Dr. Aarti Rana: [00:39:03] So psychosurgery is one of the options that kind of begs the question of whether there's a particular part of the brain or parts of the brain that are implicated in OCD.

  Dr. Nick Grujich: [00:39:12] So research trucks on. But I think at this point we would say orbitofrontal cortex and anterior cingulate cortex and the head of the nucleus. The caudate nucleus.

  Dr. Jordan Bawks: [00:39:25] Okay. So. At this stage. We've talked about epidemiology, we've talked about phenomenology, diagnosis, differential diagnosis, mental status, treatments, psychotherapy, pharmacology, psychosurgery. Dr. Grujich at this stage, is there anything else that you want to talk about to OCD? Think it's important for medical students, junior trainees, anyone else who might be listening?

  Dr. Nick Grujich: [00:39:53] So I'm glad that you pursued this topic. It's fairly niche, but it's not all that, um, um, prevalent, I guess you could say. And I think OCD is one of those illnesses that often gets missed and people who have OCD tend to struggle with it for their whole life in the absence of good treatment. And so I'm glad that you're bringing more light and attention to this disorder.

  Dr. Jordan Bawks: [00:40:17] Yeah, that's certainly our hope with the podcast that we can encourage students to pursue psychiatry, facilitate learners, recognising psychiatric illnesses no matter where they practice. And for the lay public also to learn about mental illness in a way that we hope destigmatizes it and encourages people to seek treatment or help loved ones.

  Speaker4: [00:40:41] So thanks so much, Dr. Grujich, for joining us today. A pleasure as always. Aarti any thoughts after your first episode?

  Dr. Aarti Rana: [00:40:50] No, I think I learned a fair bit about OCD that I probably should already have known. And that's it.

  Dr. Jordan Bawks: [00:40:57] That's the beauty of medicine. We keep learning, keep learning and keep learning. So as always, thanks for tuning in to PsychEd. Feel free to get in touch with us at Psychedpodcast.org or leave a comment on our iTunes page. We welcome any and all feedback. We are actively trying to improve our product. In fact, we actually are launching a survey soon. So if you see that survey link, it should be on our website. Please take the five minutes to fill it out. It will help us create a better product for you, our listeners. The only way we can give the people what they want is if you get those fingers or thumbs in action on the keyboard. This episode of Psyched was written and produced by Dr. Jordan Bawks, Dr. Bruce Fage and Dr. Aarti Rana. Our theme song is Working Solutions by Olive Musique. We would especially like to extend another thank you to Dr. Nick Grujich for making time to help us out with this episode and for providing clinical resources to help write the script. This podcast is made possible by support from the Department of Psychiatry at the University of Toronto and is produced in affiliation with the Canadian Psychiatric Association. The views expressed in this episode do not necessarily reflect those of the Canadian Psychiatric Association or the Department of Psychiatry of the University of Toronto. Another thank you to all the people behind the scenes who make the Psyched Podcast a reality. All of our medical students, residents and staff mentors. Thanks. Catch you soon!