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.  

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!

Partnership: People with schizophrenia, family members and clinicians talk about schizophrenia

Schizophrenia is a long-term but treatable brain condition. 1 in 100 people worldwide live with schizophrenia.

Dr. Diane Fredrickson is a psychiatrist who treats psychosis-related conditions including schizophrenia.

Gerhart Pahl is the father of four sons—three of whom it turns out suffer from schizophrenia.

Bryn Ditmars has a form of schizophrenia known as schizoaffective disorder.

Schizophrenia occurs most commonly between people between the ages of 15-25. It is the result of physical and biochemical changes in the brain. Symptoms may include:

  • Disordered thinking
  • Changes in emotion
  • Bizarre behaviour
  • Catatonia
  • Paranoia
  • Hallucinations
  • Delusions

60% of people with schizophrenia live with their families. Recovery takes time, a team, medication, and a healthy lifestyle.

Research has improved with brain imagery, but a cause and cure are still unknown.

Statistics about schizophrenia and suicide:

  • 50% attempt suicide.
  • 10-15% of people commit suicide.
  • Self-harm is more common than harm to others.

50% of people with schizophrenia have anosognosis, a condition in which they don’t know they’re ill. Early psychosis intervention (EPI), early diagnosis and treatment improve outcomes.

Stigma contributes to discrimination, which limits access to education, housing and employment. The media contribute to perpetuating myths that create skewed perceptions and unfounded fears.

The B.C. Schizophrenia Society (BCSS) Partnership Program provides mental health literacy. To increase your knowledge, book a presentation.
Call 604-270-7841
Toll Free: 1-888-888-0029
Email: community@bcss.org

Dr. Xavier Amador Talk on Helping People with Mental Illness at Cambridge, MA

Dr. Xavier Amador
President and Founder
The LEAP Instititute
(Listen, Empathize, Agree, Partner)

Dr. Amador lays out pathways to build trust, heal relationships and partner with someone who is suffering from mental illness but is resisting help.

“I’m going to tell you a little bit about something that is very important to me from a professional perspective… but is also very personal. I have a brother with schizophrenia who really is the one who gave me the title for this talk and book by the same name: I’m not sick. I don’t need help.

“This is a very very common problem. I will talk about just how common it is”


Dr. Xavier Amador, founder of The LEAP Institute giving a public talk on how to help people with mental illness who don’t realize they are sick. Sponsored by the NAMI (National Alliance on Mental Illness) Cambridge Chapter. The lecture was given on the evening of October 2, 2012 at the Cambridge Public Library in Cambridge, Massachusetts.

For more information, visit leapinstitute.org.

Anosognosia

Anosognosia

“I think that’s exactly what he had. I believe that my son Chris, over the course of repeated breakdowns, lost his capacity to understand his illness so he went off his meds. That’s when we lost him for good. He never took meds again. He ultimately chose to take his life rather than take medication.” — Cathy Weaver, Austin, Texas

People with anosognosia have a real neurological condition caused by damage to the brain, most likely in the frontal and parietal lobes.

Because of this condition, they can’t recognize that they are sick.

Anosognosia is associated with many diseases.

Some people with strokes, brain tumours, Alzheimer’s disease, and Huntington’s disease suffer from this same lack of insight.

It’s very clear that about half the people with schizophrenia and roughly 40% of people with bipolar disorder have some degree of anosognosia. In other words, they don’t recognize their own illness. We recognize this for Alzheimer’s disease but we seem to have trouble recognizing that this is also common for people with schizophrenia and bipolar disorder.

Russell Weston is one tragic example. Mr. Weston came to Washington D.C. to “save the world from cannibals” and killed two Capitol Police officers while in this delusional state.

Weston was not taking medication because he did not believe he was sick.

County judge, Polly Jackson Spencer developed the first-of-its-kind outpatient commitment program in Texas. She saw the devastation caused when the severely mentally ill are too sick to seek treatment and end up trapped in a revolving door of incarceration, homelessness, hospitalization and victimization.

“You can’t simply tell someone who has a mental illness and is disorganized in their thinking, ‘Hey, you’ve got a doctor’s appointment in three weeks and it’s ten miles from here, these are the different buses you need to take to get there, and don’t forget to go’ and assume that they’re going to make that. That’s just not going to happen.” —Polly Jackson Spencer, County Judge

Judge Oscar Kazen supervises the day-to-day operations of Bexar County’s court-ordered outpatient treatment program. He meets regularly with patients, psychiatrists, and staff.

“When I sit in that little courtroom, down in the basement of that abandoned hospital, the guy who sits at the end of the chair—that mentally ill patient—didn’t have a choice. He didn’t wake up one morning and say ‘I want to lose my life, I want to lose my sanity.’ These people had no choice in the matter and it’s our responsibility to bring them back to sanity.” — Oscar Kazen, Judge

Anosognosia is the number one reason why people fail to seek treatment.

It’s up to the rest of us to make sure that they are able to get treatment.

Learn more about anosognosia at treatmentadvocacycenter.org

Video by the Treatment Advocacy Center.

Join Dr. Randall White at the 11th Annual Family Conference: From Crisis to Hope

11th family conference poster 2016

Dr. Randall White is pleased to be presenting at the 11th Annual Family Conference in mental healthy and substance services. Please join us Saturday, April 23, 2015, 9:00am-4:30pm in the Paetzold Theatre at the Vancouver General Hospital. Admission is $25 per person, and limited financial assistant for admission cost is available –just contact Becky Hynes via email (or call 604-714-3771 ext. 2300 for details.

Keynote Presentations Include:

  • Access & Assessment Centre (AAC): A New Service for Vancouver Residents to Access Mental Health and Substance Use Services in Vancouver
    • Monica McAlduff (Director, Vancouver Mental Health & Substance Use Acute, Tertiary & Urgent Services)
    • George Scotton (Manager, Vancouver Access & Assessment Centre, ACT & AOT)
  • Finding Clarity in Chaos: Principles for Developing Health and Recovery
    • Dr. Diane Fredrikson (Physician Lead, Early Psychosis Intervention Program, Vancouver Coastal Health)
  • When Treatments are Inadequate – New Hope for Patients
    • Dr. Randall F. White (Medical Director, B.C. Psychosis Program, Clinical Associate Professor, UBC)

Panel Discussions:

  • Support for Families in Need
  • Family Panel: How Families Can Advocate for Improved Mental Health Care

For the complete program schedule, click here!

Have questions about 11th Annual Family Conference in Mental Health and Substance Use Services? Contact Annual Family Conference: Family Involvement in Mental Health and Substance Use Services

11th family conference poster 2016

 

 


 

Fluvoxamine

In some patients, achieving a therapeutic serum clozapine concentration requires a high dose entailing a prolonged series of dose increases. This may be more common among smokers, and people with schizophrenia are more likely to smoke and to smoke more cigarettes per day than the population at large. One short cut to achieving a therapeutic level is adding fluvoxamine, a serotonin reuptake inhibitor used to treat anxiety and depression. Clozapine is converted by cytochrome enzyme 1A2 to the metabolite N-desmethylclozapine, known as norclozapine in clinical settings. Fluvoxamine inhibits this process which shifts the ratio of clozapine to norclozapine upward and prolongs the half life of clozapine. Fluvoxamine also inhibits CYP2C19 and in some people, CYP3A4 as well. The clinical effect is to permit a lower total dose of clozapine, and it may make once-daily dosing more tolerable. Furthermore, fluvoxamine can be used to treat concurrent anxiety and depression while maximizing clozapine serum levels. The evidence for the safety and benefits of these uses of fluvoxamine was reviewed in a recently published article.

The authors identified 24 case reports and series comprising 29 patients, and 9 prospective studies comprising 212 patients; 2 of these were randomized trials. Most patients had a primary diagnosis of schizophrenia, and the rationales for the various studies were diverse.

  • Increasing clozapine plasma level
  • Treating negative symptoms
  • Treating positive symptoms
  • Treating depressive symptoms
  • Treating obsessive-compulsive symptoms
  • Reducing metabolic adverse effects

The available evidence for most of these indications is mediocre or poor except for increasing plasma levels; according to the authors, fluvoxamine increases clozapine, norclozapine, and clozapine N-oxide plasma levels in a dose-dependent manner. The data among smokers is supportive but surprisingly limited. One point they raise is that the effects of changing the ratios of metabolites other than norclozapine is not understood. The evidence for reducing metabolic adverse effects is relatively good as it comes from a 12-week RCT, but long-term efficacy is unknown. As for treating depression or obsessive-compulsive symptoms, the authors conclude that it is safer to use an appropriate antidepressant without the pharmacokinetic complications of fluvoxamine given the risk of toxicity if clozapine levels rise abruptly.

Safety concerns addressed in studies include the risk of agranulocytosis and seizures for which there is no evidence of a protective or facilitative effect; the available evidence correlates increasing clozapine dose and not plasma level with risk of seizures. (2) The reports reviewed mention frequent occurrence of common adverse effects including sedation, sialorrhea with drooling, and constipation in fluvoxamine-treated patients. Clinicians and patients should be aware that prescribing fluvoxamine to enhance clozapine effects is not approved by Health Canada or the US Food and Drug Administration.

References

Polcwiartek C, Nielsen J. The clinical potentials of adjunctive fluvoxamine to clozapine treatment: a systematic review. Psychopharmacology. Published online Dec 2, 2015. Abstract

Remington G, Agid O, Foussias G, et al. Clozapine and therapeutic drug monitoring: is there sufficient evidence for an upper threshold? Psychopharmacology. 2013;225:505–518. Abstract

The Canadian Psychiatric Association’s Annual Conference Welcomes Dr. Randall White at its 65th Annual Conference

65th Canadian Psychiatric Association’s Annual Conference banner

Every year, more than 1,200 psychiatrists and other mental health care professionals attend the Canadian Psychiatric Association’s conference to educate themselves on the latest research in the field, exchange ideas, and network with colleagues from across the country. This year, Dr. Randall White is honoured to be presenting a symposium on the diagnostic and therapeutic advances in Schizophrenia along with several of his esteemed colleagues.

As the largest psychiatric professional development program in Canada, the CPA is an invaluable resource. 2015 marks a new direction for its annual conference with several changes to usual programming:

  • Pre-conference courses will be offered Wednesday, September 30
  • Thursday, Friday, and Saturday mornings will each offer an all-delegate keynote plenary
  • The AGM and President’s Gala have been moved to Friday morning and evening, respectively
  • Refreshment stands with coffee and tea will now be available at both venues

The conference will be held October 1st – 3rd at both The Fairmont Hotel Vancouver and the Hyatt Regency Vancouver. For location and room rates, visit fairmont.com/hotel-vancouver and vancouver.hyatt.com/en/hotel/home.html or book online 2015 CPA FHV and 2015 CPA HRV.

Conference Details:

  • Pre-Conference Courses (scheduled on Wednesday, 30 September, 13:00 – 17:00)
    These four-hour sessions were the most highly rated courses from peer reviewers. Space is limited, so register early.
    -Member/Affiliate: $150
    -Non-member: $225
  • Registration Package (CPA Members/Affiliates only)
    Includes three discounted scientific days, admittance to the exhibit hall, daily coffee breaks, admittance to the co-developed symposium, and the option to purchase a ticket(s) to the President’s Gala (all events have limited seating).
    $900
  • Daily Registration
    Each day of registration includes scientific sessions, admittance to the exhibit hall, daily coffee breaks, admittance to the co-developed symposium, and the option to purchase a ticket(s) to the President’s Gala (all events have limited seating).

    Resident & Medical Student Member registrations include all 3 days for $75.

    Thursday
    -Member/Affiliate: $320
    -Non-Member: $550
    -Nurse, Research Assistant, Psychologist, Social Worker: $380

    Friday
    -Member/Affiliate: $320
    -Non-Member: $550
    -Nurse, Research Assistant, Psychologist, Social Worker: $380

    Saturday
    -Member/Affiliate: $320
    -Non-Member: $550
    -Nurse, Research Assistant, Psychologist, Social Worker: $380

Attend the CPA President’s Gala!

Friday October 2, 7:00-11:00pm
The President’s Gala is an exceptional four-course dinner where we honour CPA award winners, congratulate our outgoing president, and conduct the exchange of office. It offers a great opportunity in a beautiful setting for networking with your friends, colleagues, mentors, and may even see you on the dance floor. The dress for this event is business attire.

-Residents: $35
-Members/affiliates: $75
-Non-members: $95

Dr. White’s Symposium Details:

Thursday, October 1 at 4:30pm – 6:00pm
Randall White*, MD, FRCPC; Geoffrey Smith, PhD; William Honer, MD, FRCPC; Marnie MacKay, BScN, PhD (c); Serdar Dursun, MD, PhD, FRCPC; Mahesh Menon, PhD, RPsych; Gary Remington, MD, PhD, FRCPC

 

For a complete schedule of the scientific programming, click here.

For updates, follow @BCPsychosis on twitter & use #cpaconference to follow conference highlights.

Dr. Randall White at the 9th Annual Pacific Psychopharmacology Conference

Dr. Randall White is pleased to be attending the 9th Annual Pacific Psychopharmacology Conference this September where he will be Co-chairing the pre-conference and moderating many of the conference sessions. Join us to learn what’s new in evidence-based research on the pharmacotherapy of psychiatric illness.

This year’s conference theme is: Balancing Risks and Benefits to Improved Adherence

The pre-conference workshop title is: Strategies for Managing Mood and Anxiety Disorders in Primary Care at the workshop. The workshop will also cover the following topics in the format of brief presentations with cases:

  • Incorporating Measurement-Based Care for Mood Disorders into Clinical Practice
  • The BC Practice Support Program Adult Mental Health Module: Implications for Primary Care
  • Use of Antidepressants in Ambulatory Settings

Key speakers for the conference:

Martha Sajatovic, MD
Treatment Adherence in Bipolar Disorder
Dr. Martha Sajotovic, is a professor of Psychiatry and Neurology at Case Western Reserve University. She is also a director of the Geropsychiatry Program, and Neurological and Behavioral Outcomes Center, University Hospitals Case Medical Center, and a Willard Brown Chair in Neurological Outcomes Research, Cleveland. Her research focus is on treatment adherence in Bipolar Disorder and Improving Outcomes for People with Schizophrenia.

Robert Zipursky, MD, FRCPC
Improving Outcomes for People with Schizophrenia
Dr. Zipursky is a professor, Department of Psychiatry & Behavioural Neurosciences. ‘s research interests have been in investigating the biology of schizophrenia and its treatment using brain imaging techniques (CT, MRI, PET), the treatment of first episode psychosis, prevention of schizophrenia, and clinical outcomes from schizophrenia. He has served on the editorial boards of Schizophrenia Research and Schizophrenia Bulletin. He is a recipient of the John Cleghorn Memorial Award for Excellence and Leadership in Clinical Research from the Canadian Psychiatric Association and the Michael Smith Award from the Schizophrenia Society of Canada.If you are planning to attend, please introduce yourself to Randall! And if you’re coming from out of town, Be sure to ask for the “Annual Pacific Psychopharmacology Conference 2015” rate or quote booking ID #15906 at time of booking.

Pre-conference Workshop Information
September 17, 2015
Time: 1-4pm, lunch provided prior to course at 12:30pm
Cost: $119 for delegates, $69 for residents, apply a $25 discount if you register for the Sept. 18 conference as well

This workshop will be great for nurse practitioners, pharmacy/therapeutics, psychiatrists, registered nurses, residents and students.

Conference Details:
September 18, 2015
Executive Plaza Hotel and Conference Centre

Social Media:
Follow Dr. Randall White @BCPsychosis on Twitter, use #CPDpppc to follow the conference.