A Family Caregiver Listens to Gerrit van der Leer

Gerrit van der Leer

By Susan Inman

Gerrit van der Leer, BC’s Director of Mental Health and Substance Use, was the closing speaker at the recent sold-out conference at Vancouver General Hospital on Bringing Cognitive Remediation to British Columbia. Van der Leer has decades of experience in developing recovery-oriented programs for people with severe mental illnesses; these include BC’s Early Psychosis Intervention (EPI) programs and Assertive Community Treatment teams.

A ground breaking resource that’s been developed for the EPI programs is the Dealing with Psychosis ToolkitIn the section on “Understanding Cognition,”the Toolkit contains essential information about the common cognitive losses experienced by people with psychotic disorders. These problems include difficulties with attention, learning and memory, critical thinking skills (e.g., planning, organizing, problem solving, abstract thinking) and social cognition. Too rarely do clients, families or many clinicians learn about these cognitive problems.

The Toolkit also contains numerous cognitive adaptation strategies that can help people manage these cognitive problems. Adaptation strategies are a useful component in cognitive remediation (CR) programs, but CR programs have a much broader mandate. Much of the conference described common components of evidence-based CR programs. These components include intensive, supervised computer based work designed to improve cognitive functioning in areas such as processing speed and concentration, and also include professionally facilitated small group discussions. These sessions operate as bridging mechanisms designed to assist clients to bring their new skills to meeting the challenges of daily living, education and work.

Van der Leer expressed his support for incorporating cognitive remediation into BC’s psychosocial rehabilitation services. He discussed the kinds of next steps that need to occur and reminded the audience that these had also been discussed earlier in the conference in a presentation by Dr. John Higenbottam and Dr. Tom Ehmann.   Policy documents need to be developed that address which populations should be included, what kinds of sites should be selected for delivery of services, which remediation programs should be used, how staff should be trained and how programs should be monitored for fidelity and outcomes.

Van der Leer also reminded audiences that cognitive remediation programs are basically inexpensive and relatively easy to implement.

We learned that BC’s new Ministry for Mental Health and Addictions is looking for input in developing a new whole-of-government approach for responding to mental health and substance use. There are vital roles for ministries involved with health, corrections, housing, education, transportation, and children and families to play in developing comprehensive strategies.

As a family caregiver, I’m hoping that certain key issues can be addressed. Here are just three of these issues:

  • BC (and Canada as a whole) needs improved mental illness literacy programs. Inadequate knowledge among the public leads to inadequate responses to psychotic disorders like schizophrenia and bipolar disorder. For instance, delay in treatment of psychosis leads to worse outcomes, and families play a crucial role in getting health care for their family member. Furthermore, inadequate psycho-education programs for clients lead to relapses that are expensive for the health care and criminal justice systems. People are better able to accept and manage their illnesses when they understand them.
  • Many programs training credentialed mental health clinicians do not require any science-based curriculum on psychotic disorders. This is one reason that clients, families and many clinicians have not been learning about the cognitive losses associated with these illnesses; it’s these losses that are considered to be a major factor in ongoing disability.
  • Though contemporary neuroscience and psychiatry no longer blame parents for the development of schizophrenia and bipolar disorder, this blame is still common among other clinical practices. It is an obstacle in creating the kind of cooperative relationships that need to exist between family caregivers and clinicians in order to best help people who develop these illnesses. Standards of training need to be raised. As well, mental health authorities need to provide professional development to help staff learn new ways of interacting with family caregivers.

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BC Hosts the First Canadian Conference on Cognitive Remediation

Randall White and Susan Inman

An audience of more than 200 people, including mental health professionals, family members and service users, gathered to hear local and visiting experts discuss cognitive remediation. The Bringing Cognitive Remediation to British Columbia conference on Oct. 14th at Vancouver General Hospital was a sold-out event.

Dr. Bill Honer, the Head of UBC’s Department of Psychiatry and the Jack Bell Chair of Schizophrenia Research,, welcomed the conference participants. He explained how cognitive losses in people with schizophrenia are distinct from the cognitive problems impacting people with intellectual disabilities and Alzheimers. For instance, cognitive loss in people with schizophrenia is malleable; a UK study of patients who had suffered severe cognitive impairments found that in most, their cognitive function dramatically improved over a five-year period. Dr. Honer also emphasized the value of medications in treating schizophrenia and their importance in preventing relapses.

Susan Inman, a family caregiver and the conference co-chair along with Dr. John Gray, spoke about “Why and How This Conference Came to Be.” She highlighted, as did others during the day, the lack of awareness among clients, families and many clinicians of the well-researched cognitive losses that frequently accompany schizophrenia. Following a meeting with Dr. Alice Medalia, the Director of Columbia University’s Lieber Recovery Center, Susan had herself become more aware of the extensive progress in developing evidence-based cognitive remediation programs. Through attending the annual Cognitive Remediation in Psychiatry conferences at Columbia University which Dr. Medalia initiated 20 years ago, Susan realized how many countries have received assistance from Dr. Medalia in developing cognitive remediation programs; these include France, Norway, Denmark, Portugal, Japan, and Australia among others. Canada doesn’t yet offer these programs as a part of psychosocial rehabilitation services.

Susan described the two-year collaborative process among representatives from the BC Schizophrenia Society, the BC Psychosis Program, the BC Early Psychosis Intervention program and Psychosocial Rehabilitation BC that led to this first Canadian conference on cognitive remediation.

According to Dr. Chris Bowie, Professor of Psychology at Queen’s University, the cognitive losses in schizophrenia and bipolar disorder are present from the first episode. They affect many domains of cognition such as attention, memory and executive function, and they can be severe to profound, especially in schizophrenia. They predict functional impairment and difficulty in school and employment, and may be manifested by such problems as being slow to complete tasks, being forgetful, an inability to multitask, and appearing socially awkward. Dr. Bowie called these losses “prevalent, pervasive, pernicious and persistent.”

Cognitive remediation is a means to improve these deficits through cognitive activation, strategic monitoring and generalization or bridging to daily life. The latter, according to Dr. Bowie, is crucial and seems to require the presence of an engaged therapist; having a patient do computer training alone is not enough. To this end, he has tested an enhanced form of the therapy called action-based cognitive remediation which involves the clients in activities that are more akin to real-life tasks; preliminary results suggest better retention in treatment and better outcomes compared to more traditional CR including higher likelihood of being employed six months after the end of treatment.

In her presentation on “How to Make Cognitive Health Services a Part of Mental Health Care,” Dr. Alice Medalia explained how cognitive remediation (CR) is an evidence-based, recovery-oriented treatment that helps people become more functional. Among other illness-related cognitive deficits, it addresses working memory, attention, processing speed, problem solving, reasoning, and social skills as well as motivation.

Dr Medalia described the CR programs she has set-up in New York State. They typically involve computer-based activities for 45 minutes and a 15-minute discussion that focuses on bridging skills to the clients’ goals for improved functioning in their community. Although programs usually involve twice weekly sessions for 15 weeks, the duration is adjusted to the clients’ needs. The groups include 6 – 8 people and use rolling admissions so that more experienced clients can help those who are new to the training. Staff, who usually have a master’s degree, are actively involved in both the computer activities and the discussions.

Dr. Medalia trains staff to use a cognitive lens to understand their clients. Usually staff have not previously received training on recognizing and responding to cognitive difficulties. She emphasized that CR training is flexible and can be adjusted to a variety of populations in various settings.

Two panel discussions in the afternoon considered current and future efforts in offering cognitive remediation to British Columbians.

Dr. Tom Ehmann, who helped develop BC’s Dealing with Psychosis toolkit, described the section on “Understanding Cognition.” The toolkit focuses on compensatory and adaptive strategies. Compensatory strategies use existing cognitive strengths by, for instance, identifying and using an individual’s learning preferences. Adaptive strategies use environmental aids such as a day-timer or post-it signs. The areas addressed include attention, learning and memory, critical thinking (e.g., planning, problem-solving, organizing) and social cognition. The toolkit includes a self-assessment checklist which helps individuals identify the kinds of difficulties they may be experiencing.

An overlooked impairment in mental illness is social cognition, the mental processes underlying person-to-person interactions. Dr. Amy Burns said that people with schizophrenia have marked deficits in such domains as

  • Emotion processing
  • Attributional style
  • Social perception
  • Theory of mind

These deficits are related to other symptoms of the disorder including negative and positive symptoms of psychosis, depression and anxiety. Social skills training is a treatment that has shown a strong effect for improving recognition of facial emotions and social perception and significant if lesser effect on other domains.

Drs. Mahesh Menon and Ivan Torres described a pilot project to offer CR to patients at the BC Psychosis Program (BCPP), a residential treatment centre for treatment-resistant schizophrenia (TRS) at UBC Hospital in Vancouver. Two studies have examined cognitive losses in patients with TRS compared to those with more antipsychotic-responsive psychosis and had conflicting results: one study found the cognitive deficits in TRS were more severe whereas the second study did not find a difference. This needs further investigation, but no reason exists why people with TRS should not receive CR.

At the BCPP, CR is based on the software Scientific Brain Training Pro, but the emphasis is on linking the exercises to functional goals such as returning to school or work by using strategies to promote generalization to daily life tasks. The approach is multidisciplinary: the groups are run by a psychologist and an occupational therapist, while nurses and rehabilitation workers remind patients to do homework and prompt them to use the strategies day to day.

According to Dr. Todd Woodward, CR is meant to improve the trait of psychosis related to inefficient use of neural networks that underlie cognitive functions. Metacogntive therapy (MCT), a form of cognitive-behavioral therapy, is intended to target the state of psychosis that underlies cognitive biases that favor development of delusions and hallucinations. MCT is a group-based, interactive program with 8 core modules; the material is presented such that participants can experience cognitive biases during the session that are then discussed in relation to everyday life. These biases include jumping to conclusions and not integrating disconfirming information when trying to understand a situation. Drs. Woodward and Menon, along with a collaborator from Europe, have a clinical trial of CR and MCT underway in Vancouver with mental-health outpatients. Since May, 2014, they have enrolled 320 subjects; more patients will be enrolled during the next 12 months.

The second afternoon panel, “Next Steps in Implementing Cognitive Remediation in BC,” started with a presentation by Dr. John Higenbottam and Dr. Tom Ehmann that emphasized that cognitive remediation is an evidence-based practice. They pointed out that, in fact, most people with schizophrenia do not have access to the full range of evidence-based practices that help manage symptoms and improve psychosocial functioning.

Drawing on their experiences in establishing various provincial programs, they identified the elements that lead to success. They also raised numerous questions for the panelists to discuss including which populations should be targeted, where services should occur, how fidelity and outcomes should be monitored, and how staff should be trained.

Fellow panelist Dr. Regina Casey led an activity with the audience that encouraged them to identify in their family member or their clients the kinds of cognitive difficulties they witness that are impeding recovery.

The final presentation of the conference was from Gerrit van der Leer, Director of Mental Health and Addiction in the BC Ministry of Health. Director van der Leer sees cognitive remediation as a best practice and he explained the steps necessary to incorporate CR into the mental health system. He spoke of the work he envisions in developing a business plan, standards of practice guidelines, and performance measures. He suggested that each health authority should have an opportunity to learn about cognitive remediation and have regional planning to develop services in their districts.

Over 150 people submitted conference evaluations. The evaluations, which were very positive, included responses to a question about how participants witness cognitive losses impacting people’s abilities to move forward with their lives.

One family member described both the common losses mentioned by many and also wrote poignantly about the impact of the losses. The commenter said their family member’s cognitive losses “affect every area of his life. Money management, daily life – hygiene, food, social interaction. Moving forward with work, school, relationships. The med stabilizes him but he needs help in functioning in daily life. He would be homeless or dead without family help.”

A clinician cited issues described by other professionals: “I work with people with chronic mental illness and could write a book on all the ways this impacts my clients. Isolation, homeless, addiction and alienation are all effects of cognitive decline.”

The videotape of this conference will soon be available on the website of the BC Schizophrenia Society: www.bcss.org

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Bringing Cognitive Remediation to British Columbia

Bringing Cognitive Remediation to British Columbia

Saturday, October 14, 2017 | 8:30 AM – 4:30 PM
Paetzhold Education Centre | Vancouver General Hospital

899 West 12 Avenue, Vancouver, B.C.

People living with schizophrenia and other psychotic disorders often develop profound and
disabling cognitive deficits. Even more than positive or negative symptoms, cognitive deficits can impair daily functioning and are a major factor in chronic disability and unemployment. (Hurford, 2011)

Come learn more about these cognitive difficulties and about evidence-based cognitive
remediation programs. Hear about an efficient strategy for training staff to deliver programs, and hear from people in B.C. working on related initiatives.

Keynote speakers:
Dr. Alice Medalia (Director, Lieber Recovery Clinic, Columbia University)
Dr. Christopher Bowie (Director, Cognitive & Psychotic Disorders Lab, Queen’s University)
Dr. Medalia and Dr. Bowie are co-editors of the recently published anthology, Cognitive
Remediation to Improve Functional Outcomes (Oxford University Press, 2016).

Program:

8:00 Registration Opens

9:00 Opening Comments – Dr. John Gray Welcome – Dr. Bill Honer Why and How This Conference Came to Be – Susan Inman

9:30 Keynote Speaker: Dr. Christopher Bowie “Cognition in Mental Disorders: Impairments, Implications and Opportunities for Treatment”

10:45 Coffee/Nutrition Break

11:00 Keynote Speaker: Dr. Alice Medalia “How to Make Cognitive Health Services a Part of Mental Health Care”

12:30 Lunch (Not included)

1:30 Panel 1: “Cognition: A Brief Scan of B.C. Initiatives”

Moderator: Dr. Ashok Krishnamoorthy

Panelists:

Dr. Tom Ehmann “Guided Self-care for Cognitive Problems Associated with Psychotic Disorders”
Dr. Mahesh Menon and Dr. Ivan Torres “Adapting Cognitive Remediation for the Refractory Psychosis Population”
Dr. Amy Burns “Isn’t it Ironic? Social Cognition in Schizophrenia”
Dr. Todd Woodward “Treatment of Symptoms vs. Cognitive Remediation in Psychotic Disorders”
Dr. Randall White “The (limited) Role of Medications in Improving Cognition in Schizophrenia”

2:45 Coffee/Nutrition Break

3:00 Panel 2: “Next Steps in Implementing Cognitive Remediation in B.C.”

Moderator: Monica McAlduff

Panelists:

Dr. John Higenbottam
Dr. Regina Casey
Dr. Tom Ehmann
Dr. Chris Bowie
Dr. Alice Medalia

4:15 Closing Remarks: Susan Inman and Gerrit van der Leer

4:45 Conference Ends

This conference will be of great interest to clinicians, families, consumers, mental health
administrators and educators.

Conference Fees:
Professional, Clinician, Researcher, etc. $100 + GST
Family Member $50 + GST
For a full schedule, speaker bios and to register, visit www.bcss.org
Bringing Cognitive

Remediation to
British Columbia
Saturday, October 14, 2017 | 8:30 AM – 4:30 PM
Paetzhold Education Centre | Vancouver General Hospital

899 West 12 Avenue, Vancouver, B.C.

www.bcss.org

 

Coping With a Loved One’s Opioid Addiction: What Science Says To Do

Coping With a Loved One’s Opioid Addiction: What Science Says To Do

While many factors are blamed as contributing factors in North America’s opioid crisis and overdose, Canadian hospitals and clinics are handing out naloxone kits as a stop-gap measure for at-risk opioid users. But it can be a tricky time at any point to deal with a loved one’s addiction, whether it be to Vicodin or heroin.

What does existing science say you can do to help someone you care about? For over three decades, Maia Szalavitz, author of “Unbroken Brain: A Revolutionary New Way of Understanding Addiction,” has presented the evidence that should play a vital role when weeding through conflicting advice in a field that she states is largely unregulated. Searching out care based on scientific fact as opposed to personal and clinical experience can improve recovery chances.

Her article “What Science Says To Do If Your Loved One Has An Opioid Addiction” is an excellent, evidence-based guide derived from the best research available on addictions, including systematic reviews and clinical medication trials. Szalavitz lays out how to accurately assess the problem, delves into the psychology of addictive behavior, and suggests how to intervene gently. Then, most importantly, she explains how to choose a treatment that is research-based.

Studies suggest that most people with addiction eventually recover, a far cry from the bleak picture portrayed in the media. Recovery from an opioid addiction can look different for different people, but no doubt is rooted in two key aspects: medical assessment and a long-term maintenance program. At least, so says the World Health Organization and the Institute of Medicine, for starters. Read on for more on the science to help you help your loved one on the road to recovery.

Meta-Analysis Conundrums

For patients whose psychosis doesn’t adequately respond to antipsychotics, especially clozapine, treatment options include electroconvulsive therapy, cognitive-behavior therapy, and augmentation with another medication. Investigators have done cotreatment trials with other antipsychotics, anticonvulsant/mood stabilizers, and even the antibiotic minocycline and anti-inflammatory agents such as aspirin. The trials are small in many cases, so meta-analyses allow various trials to be pooled. Two recent publications give some new guidance but also may sow confusion.

One team examined clinical trials of the anticonvulsants lamotrigine, topirimate and valproate added to clozapine. They included 22 randomized controlled trials (RCTs) comprising 1227 subjects; 613 received clozapine alone, whereas the others received, in order of frequency, valproate, lamotrigine or topirimate. The primary outcome was change in Positive and Negative Syndrome Scale (PANSS) or Brief Psychiatric Rating Scale (BPRS) total score. The analysis showed no significant effect for lamotrigine, confirming a previous meta-analysis, but also confirming a prior analysis, topirimate was superior to clozapine alone for reduction in total, positive and negative psychotic symptoms ratings. Sodium valproate, but not magnesium valproate, was superior to clozapine alone in reducing total and positive psychotic symptom scores; it was not effective for negative symptoms. In terms of tolerability, topirimate but not valproate had a significant all-cause discontinuation rate compared to clozapine monotherapy.

One of the limitations of this pooled data set was that many of the patients were not clearly designated as having clozapine resistance; for instance, clozapine serum levels were not recorded. Another concern was that all the trials for valproate augmentation were done in China, and the generalizability to other settings and ethnic groups is uncertain.

The anticonvulsant meta-analysis is one of many that has examined antipsychotic augmentation, which prompted a group led by Christoph Correll to do a meta-meta-analysis. Summarizing this article will not do it justice, so I recommend reading it in its entirety. The investigators looked at 29 existing meta-analyses of trials of augmentation of any antipsychotic with any of 42 medications including, mood stabilizers, anticonvulsants, antidepressants, minocycline, a second antipsychotic, or various hormones such as estrogenic agents. They applied a novel method to assess the quality of the meta-analyses, AMSTAR-Plus Content. Five of the meta-analyses looked at augmentation of clozapine.

In combination with clozapine for positive symptoms of psychosis, only glycine, an amino acid which modulates the NMDA glutamate receptor, had a significant effect size. No treatments showed efficacy in combination with clozapine for total psychopathology or negative symptom scores. In combination with non-clozapine antipsychotics, lamotrigine, estrogenic agents, mirtazapine and a few others showed efficacy.

An important finding is buried in the discussion: “When all this metanalytic literature was compared regarding the quality of its meta-analyzed content, the effect sizes were inversely correlated with the study quality, reducing confidence in these affirmative recommendations.” In other words, many of the studies in this uber-study were small or contained biases, and those studies tended to overrate the effects of the adjunctive treatments. They point out that individual patients may benefit from specific interventions, but the evidence to guide treatment selection is lacking. This leaves the clinician without clear direction for the most difficult-to-treat patients. In an accompanying editorial, however, Wolfgang Fleishhacker suggests that this meta-analysis does not necessarily invalidate all preceding analyses.

References

Zheng W, Xiang YT, Yang XH, Xiang YQ, de Leon J. Clozapine Augmentation with Antiepileptic Drugs for Treatment-Resistant Schizophrenia: A Meta-Analysis of Randomized Controlled Trials. J Clin Psychiatry. 2017;78(5):e498-e505. Abstract

Correll CU, Rubio JM, Inczedy-Farkas G, Birnbaum ML, Kane JM, Leucht S. Efficacy of 42 Pharmacologic Cotreatment Strategies Added to Antipsychotic Monotherapy in Schizophrenia: Systematic Overview and Quality Appraisal of the Meta-Analytic Evidence. JAMA Psychiatry. 2017;74(7):675-684. Astract

The B.C. Mental Health Act Protects My Daughter

The author of the original article, Susan Inman, wrote this piece for the Huffington Post from personal experience. Susan’s daughter has suffered from schizophrenia for the past 16 years, and Susan has seen first hand how involuntary hospitalization and medication have helped her daughter have years of stability.

Susan discusses how provisions in B.C’s Mental Health Act which protect people with severe mental illnesses are currently under attack. This came when a challenge was filed with B.C’s Supreme Court which states both inpatient and outpatient involuntary treatment are violations of people’s human rights. The challenge does not deal with involuntary hospitalisations, rather it proposes changes that would mean people can avoid involuntary treatment no matter how ill they are. Two of the plaintiffs themselves have received involuntary treatment.

Some may feel that the most morally responsible position is to allow people to choose whether they want to be treated, but Susan highlights how this ignores some vital information about psychotic orders. In psychosis, a person loses the ability to differentiate between what is real and what isn’t. Even as some of its symptoms begin to subside, people can be left with anosognosia, a brain-based inability to understand that they are or have been ill.

As Susan argues, mental illness policy changes can be dangerous when they ignore the impact of the most severe mental disorders, such as suicide, aggression or neglect of one’s most basic personal needs. In their challenge, the plaintiffs fail to address the consequences of the changes they propose on people with profound or life-threatening illness. Any policy changes of this nature must be looked at in depth, looking not only at the change itself but also the consequences that will follow.

Let us know your thoughts on the proposed changes to B.C’s Mental Health Act, join the discussion on our twitter page. Click here to read the full article.

This article previously appeared in Huffington Post Canada.  

Evidence for accelerated aging in severe mental illness

A panel of five investigators discussed an emerging concept in psychiatry which integrates findings in epidemiology, pathophysiology  and cell biology. Dilip V. Jeste, Distinguished Professor of Psychiatry and Neurosciences at the University of California at San Diego, described “inflammaging” as the low-level inflammatory tissue derangement that accompanies aging and which seems to be accelerated in people with chronic mental illness, whether major mood disorders or schizophrenia. Inflammaging can be measured by biomarkers such as C-reactive protein (CRP), tumor necrosis factor-alpha, F2-isoprostanes, chemokines, and leukocyte telomere length. The latter, which refers to the tips of chromosomes which slowly shorten over the lifespan, is a well-recognized measure of cellular senescence.

Although psychiatrists seldom examine these biomarkers in their patients, they know that on a population basis, people with schizophrenia have a high prevalence of metabolic disorder, diabetes, and atherosclerotic vascular disease. Compared to age-matched controls, people with schizophrenia and bipolar disorder have a high rate of morbidity and mortality from these disorders, which are partially inflammatory in nature and age-related.

Dr. Jeste and his research team have studied 140 patients with schizophrenia, ages 26-65 with a mean age of 49, half women, and they confirmed the higher prevalence of metabolic and vascular disorders in this cohort. Moreover, in comparison to a group of 120 non-mentally-ill age-matched subjects, they found elevations in six inflammation-related biomarkers including CRP and the chemokine eotaxin-1. In patients and control subjects, telomere length inversely correlated with age, but only in women with schizophrenia was telomere length significantly reduced compared to controls. According to Dr. Jeste, younger women seemed most at risk for metabolic disturbances: they had the highest rates of obesity, insulin resistance, and elevated inflammatory markers. The researchers will follow the cohort longitudinally to observe what they hypothesize is an accelerated aging process.

References

Jeste DV, Wolkowitz O, Harvey P, Eyler L, Nasrallah H. Accelerated biological aging in serious mental illness: are these disorders of the whole body and not of the brain only? American Psychiatric Association Annual Meeting, San Diego, California, May 20-24, 2017.

Hong S, Lee EE, Martin AS, et al. Abnormalities in chemokine levels in schizophrenia and their clinical correlates. Schizophr Res. 2017;181:63-69. Abstract

American Psychiatric Association 2017 Annual Meeting

American Psychiatric Association 2017

Dr Randall White was presenting a research poster at the American Psychiatric Association 2017 Annual Meeting in San Diego, CA.

Session: New Research Posters 1
Date: Monday, May 22
Time: 10:00 AM–12:00 PM
Poster Number: P5-020
Poster Hall: Exhibit Hall A, Ground Level, San Diego Convention Center

Dr White discussing the BCPP findings with Dr. John Kane, who did the first controlled trial of clozapine in North America.

ABSTRACT

Although clozapine is the standard for treatment-resistant psychosis, 40-60% of those treated with clozapine do not have an adequate response as measured by a 20% or greater reduction in the BPRS, PANSS or other assessments. This condition is known as clozapine resistance, ultra-resistance or refractory psychosis. At the publicly funded BC Psychosis Program, at UBC Hospital in Vancouver, Canada, we have developed criteria to identify clozapine resistance (CR) and an algorithmic approach to treatment based on available evidence. This involves assuring adequate clozapine treatment verified by dose and serum level, including addition of fluvoxamine when appropriate; offering ECT to CR patients, and/or antipsychotic augmentation preferably with sulpiride or aripiprazole. All patients admitted since program inception in February 2012 had failed at least 2 antipsychotic trials. A psychiatrist, social worker, pharmacist, nurse, general physician, and neuropsychologist evaluated each patient. All available summaries of previous psychiatric admissions were reviewed, and medical, pharmacological, social and behavioural histories were recorded.

All information is presented at a case conference and a DSM-IV or -5 multiaxial diagnosis reflects agreement among at least 2 psychiatrists and a psychologist. Symptom ratings included the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Psychopathology (GAPS), and the Clinical Global Impression-Severity and Improvement scales (CGI). Clozapine resistance is defined by an adequate trial, that is, at least 500 mg daily dose for ≥60 days; and continued symptoms manifested by PANSS with 2 positive scale items rated ≥ 4 (moderate) OR 1 item ≥ 6 (severe).

Of 114 patients with schizoaffective disorder or schizophrenia on clozapine at admission, 89 had received it for≥ 60 days; 23 were on at least 500 mg; and 20 met criteria for clozapine resistance (i.e., 17 men and 3 women). Of these, 17 had schizophrenia and 3 schizoaffective disorder; the mean age was 39.6 years. The mean PANSS scores at admission were Positive=28.3, Negative=26.2, General=50.0, Total=104.4; the mean CGI-S was 6.3. Of 16 patients with complete data, 8 were offered ECT and 3 accepted a course; the number of ECT treatments ranged 19-46. Of 19 patients discharged to date, 17 remained on clozapine with a mean dose of 463.2 mg; to obtain a therapeutic clozapine level, 6 received fluvoxamine, dose range 37.5-200 mg. Seven patients received adjunctive antipsychotics: 3 sulpiride, 2 aripiprazole, 4 first-generation agents. At discharge, the mean PANSS were Positive=20.8, Negative=22.1, General=40.0, Total=82.9; the mean CGI-S was 5.1.

Find full info on the American Psychiatric Association 2017 Annual Meeting here! 

Long-term benzodiazepine use is associated with increased mortality in people with schizophrenia

What I did before

When psychiatric patients are treated in an emergency department, they are often hypervigilant, manic, or otherwise in an excited, agitated state. The current standard of care to manage acute agitation in adults is using an antipsychotic medication and a benzodiazepine, often loxapine or haloperidol and lorazepam. For patients who have schizophrenia, antipsychotic medication alone often treats such symptoms in the longer term, yet many patients are discharged with a benzodiazepine prescription continue long-term benzodiazepine use possibly because the community clinician hopes to avoid triggering a relapse in discontinuing the medication. As a psychiatrist who has worked on acute and tertiary inpatient units, I have discharged patients on benzodiazepines with the expectation it would eventually be discontinued, but I have also seen many patients for whom it never was.

What changed my practice

Then, in 2013 while at the 7th Annual Pacific Psychopharmacology Conference, I was introduced to research showing that people with schizophrenia on chronic benzodiazepine therapy have an increased risk for suicide and all-cause mortality. I kept these observations in the back of my mind and was further alarmed in 2016 when another article from the same researchers found high-dose benzodiazepine use, but not lesser doses, was associated with increased suicide and cardiovascular mortality.

What I do now

Based upon these studies, I find the evidence compelling that benzodiazepines are contraindicated for long-term use in people with schizophrenia. When appropriate, I continue to use lorazepam for acute agitation amongst other reasons, I also educate patients about the risk of long-term use, including dependence and cognitive impairment in addition to mortality.To raise awareness of this issue among my colleagues, I mention the rationale and include recommendations for tapering benzodiazepines in consultation reports and discharge summaries.

Find the full article here!