12th Annual Pacific Psychopharmacology Conference

12th Annual Pacific Psychopharmacology Conference Banner

Dr. Randall White will be co-chairing the 12th Annual Pacific Psychopharmacology Conference which will will take place on September 21st, 2018 at the Pinnacle Hotel Harbourfront, Vancouver. This popular annual conference features a wide range of topics presented by renowned speakers, with a focus on pharmacological interventions for people with mental health problems.

Key Speakers at the 12th Annual Pacific Psychopharmacology Conference

One of the keynote speakers will be Dr. Don Goff., an expert on schizophrenia from New York University.

12th Annual Pacific Psychopharmacology Conference Dr. Jon Goff

Some of Dr. Goff’s recent publications include:
1) “The Genetics of Endophenotypes of Neurofunction to Understand Schizophrenia (GENUS) consortium: A collaborative cognitive and neuroimaging genetics project.” Read it here.

2) “Association between catechol-O-methyltransferase genetic variation and functional connectivity in patients with first-episode schizophrenia.” Read it here.

3) “Association of Hippocampal Atrophy With Duration of Untreated Psychosis and Molecular Biomarkers During Initial Antipsychotic Treatment of First-Episode Psychosis.” Read it here.

Another highlight of the event will feature Dr. Lakshmi Yatham, the Regional Head of Psychiatry and Regional Program Medical Director for Vancouver Coastal Health and Providence Healthcare. He is also a Professor in the Department of Psychiatry at the University of British Columbia.

12th Annual Pacific Psychopharmacology Conference Dr. Lakshmi Yatham

Dr. Lakshmi Yatham’s presentation will cover the CANMAT & ISBD Guidelines for the Management of Bipolar Disorder. Read and learn more about the recent publication of the CANMAT bipolar disorder treatment guidelines here.

Join Dr. Randall White and many other experts this September for the 12th Annual Pacific Psychopharmacology Conference, and register today! 

Clinical Trials Test a Psychedelic Drug as a Cure for Depression

The largest-ever clinical trial of a psychedelic drug will soon begin in Europe and North America to find a cure for depression.

Psychedelic Drug Chemistry

The psychedelic drug is psilocybin – the active ingredient in magic mushrooms. The target is treatment-resistant depression. In the episode 27 of the After On Podcast, listeners are introduced to George Goldsmith and Katya Malievskaia. They are a married couple whose startup – Compass Pathways – will soon launch the largest triple-blind clinical trial ever of a psychedelic drug. The drug is psilocybin, an active ingredient derived from psychedelic mushrooms. And the condition is treatment-resistant depression. A condition that affects over a hundred million people worldwide. The term “treatment-resistant” implies, it lacks a cure.

While this may sound implausible, the individuals that have been drawn to this company’s work is quite remarkable. Their Board of Directors includes Thomas Lonngren, who spent ten years running Europe’s equivalent of the FDA (the European Medicines Agency). Also on their board is the former Chief Medical Officer of Bristol Meyers Squibb – one of the world’s largest pharmaceutical companies. In addition, they have raised roughly $20 million for their company from some extremely savvy investors.

This podcast showcases Katya and George’s their expansive knowledge in medical research. Their efforts are focused heavily on the drug approval process. Also, they have designed their trial in consultation with the top drug regulators of multiple countries.

Psychedelic drug as a potential cure for treatment-resistant depression

Katya and George express their strong sentiments against treatment-resistant depression. They describe how the illness has severely afflicted an individual very dear to them. Listeners will learn about Katya and George’s backgrounds, along with their motivations. As well as, the trial they are architecting and their company: Compass Pathways. The discussion the long clinical history certain psychedelics and other recreational drugs have had, and the major promise several of them are now showing against a diversity of afflictions.

Click here for some helpful resources on how to support individuals with depression or other mental health issues.

Understanding Schizophrenia and Psychosis with Randall White

May 24th marks the National Schizophrenia and Psychosis Awareness Day.

On Thursday May 24th, Dr. Randall was featured on Breakfast Television in a segment to change how individuals talk and think about Schizophrenia and Psychosis.

Explaining the difference between Schizophrenia and Psychosis.

Psychosis is a generic term of a mental disorder. It occurs in several conditions, and schizophrenia is one of them, in addition to bi-polar disorder along with other brain diseases. It is a rupture with reality. People with psychosis are often paranoid with thoughts of other people trying to harm them. Other symptoms include hearing voices and as a result these individuals do not perceive the world as others typically do. They perceive the world in an augmented reality, which can be extremely scary. Also with schizophrenia, there are components of basic human function that are taken away from individuals. For example, they can lose the ability to connect with people emotionally, begin to feel withdrawn, or even lose certain cognitive abilities. These include but are not limited to the ability to plan for the future and memory function.

Highlighting common misconception about aggression for individuals with Schizophrenia and Psychosis.

There is a common misconception that people with psychosis are dangerous and aggressive or violent. While that can happen, it is actually pretty rare. People with chronic mental illness are more likely to be victims than perpetrators.

Treatment and Rehabilitation plans for patients with Schizophrenia and Psychosis and their families.

As far as treatment goes, medication is used to control the voices, scary ideas, and the anxiety. However, a patient’s recovery process is also dependent on additional factors beyond the medicinal treatment. In order for individuals to regain their basic function and ability to relate to other people, services such as counselling and cognitive remediation are crucial to aid in the recovery process. This can help with patients’ memory and problem solving skills. Another big factor is support from peers and families. Mental illnesses like Schizophrenia and Psychosis can affect entire families. It is crucial to get as much support from the whole family, if possible. As this has been shown to significantly impact the individuals healing process.

Click here for a list of helpful resources and organizations for individuals impacted by Schizophrenia and Psychosis.

Research Study: Health Professional Mothers of Adult Children with Schizophrenia

Research Study

The University of New England School of Health is looking for health professionals to participate in a research study. The health professional must be a mother of an adult child who has been diagnosed with schizophrenia.

The purpose of the research study is to look at these mothers’ stories to see how they have negotiated care for adult children with schizophrenia.

Participation will involve:

  • Answering questions on the phone to see if you meet the inclusion criteria
  • Signing a consent form with your agreement to participate (with the proviso that you can withdraw at any time for any reason)
  • Participating in an interview in which the audio will be taped.

The research is conducted by PhD student Debra Klages from the School of Health at the University of New England.

For more information about participating in this study, please contact Debra Klages by email at dklages@myune.edu.au. The principal investigator Professor Kim Usher may also be contacted by kusher@une.edu.au.

 

Ms. Debra Klages RN, BScN, Cert Case Mgmt., M Adv Nurs Prac (Mental Health), MACN

Study Title: Health Professionals as Mothers of Adult Children with Schizophrenia

This project has been approved by the Human Research Ethics Committee of the University of New England (Approval No HE17-028, Valid to 23/03/2019)

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

By 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.”

Dr. Chris Bowie

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. Alice Medalia

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.

Drs. John Higenbottam, Tom Ehmann, Christopher Bowie, Alice Medalia, and Regina Casey

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.

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.