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.
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).
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
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
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.
Professional, Clinician, Researcher, etc. $100 + GST
Family Member $50 + GST
For a full schedule, speaker bios and to register, visit www.bcss.org
Saturday, October 14, 2017 | 8:30 AM – 4:30 PM
Paetzhold Education Centre | Vancouver General Hospital
899 West 12 Avenue, Vancouver, B.C.
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.
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.
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
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
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.
Toll Free: 1-888-888-0029
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.
“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.
The Danish have comprehensive data bases that have allowed wide-ranging epidemiologic findings. A group from Denmark and the UK interrogated Danish national registries to create a cohort of 8624 people with schizophrenia born after 1955 and who were at least 18 years old as of 1996. The registries allow for determination of ICD diagnosis and inpatient treatment for schizophrenia, but not treatment-resistant schizophrenia (TRS), which is not a diagnosis recognized in ICD or DSM. To determine which patients were treatment resistant, they applied 3 criteria:
- Treatment with clozapine
- An 18-month period during which a patient was treated non-concurrently for 6 weeks with 2 distinct nonclozapine antipsychotics and subsequently required admission to hospital (clozapine eligible)
- 90 days of polypharmacy, i.e. treatment with two or more antipsychotics
Although the use of clozapine may be the best proxy criterion for treatment resistance, the investigators estimate that only a third of Danish patients with TRS receive clozapine, hence the need for other proxy criteria.
The total number of treatment-resistant patients as fulfilled by any of the 3 criteria was 5900. The largest group was those who received 90 days of polypharmacy (n = 3773), which is the least specific criterion. The researchers used a Cox proportional hazards regression to compare the patients who met any of the TRS criteria to those who met none and found the following characteristics more prevalent in the TRS group:
- Younger age at onset
- Residence in less urban area
- Hospital admission at time of diagnosis
- Comorbid mental disorders
- Paranoid subtype
- Early parental loss
- History of substance use disorder
- Receiving disability benefit
- Any psychotropic medication prescribed during the year preceding diagnosis
- At least one suicide attempt
Sensitivity analyses examined the subcohorts of clozapine-treated plus clozapine-eligible patients (n = 1703). This combined group was more likely to have educational attainment beyond primary level but had the same likelihood of receiving a long-term disability benefit as the non-TRS group.
Characteristics that did not differ in the broad TRS cohort (n = 5900) compared with the non-TRS cohort included:
- Season of birth
- Paternal age
- Living with a partner
- History of a violent offense
The recognized risk factors for schizophrenia such as sex and season of birth did not distinguish TRS in this Danish cohort, but urban residence is a well-known risk factor which surprisingly was less common in the TRS subcohort. Other known risk factors that could not be explored in the registry-based design include birth complications, prenatal infections, and duration of untreated psychosis. The data presented however point to a more severe illness from the outset as reflected by medication use prior to, younger age, and hospital admission at the time of diagnosis.
The strength of the study is its size, which the population-based method permits, but this is also a basis for its weakness, namely the inability to precisely define a cohort of people with TRS. Unfortunately, none of the factors identified here would allow a prospective determination of TRS, i.e. who should receive clozapine. For that we require patient-specific biological markers.
Wimberley T, Støvring H, Sørensen HJ, Horsdal HT, MacCabe JH, Gasse C. Predictors of treatment resistance in patients with schizophrenia: a population-based cohort study. Lancet Psychiatry. Published online Feb 24, 2016. Abstract
Neurostimulation techniques are a growing aspect of psychiatric treatment especially as advances in pharmacotherapy have slowed down. Although electroconvulsive therapy (ECT) remains the best studied and perhaps most efficacious form of neurostimulation for treatment-resistant psychosis and mood disorders, it is invasive, requires considerable resources, and remains stigmatized. tDCS by contrast is noninvasive, requires few resources, and has never been portrayed as a form of punishment in novels and films. Although its efficacy for psychosis is yet to be fully established, evidence is accumulating. Because tDCS is relatively easy to administer, controlled experiments with active and sham treatment groups are feasible.
tDCS involves the passage of an electrical current of 1-2 milliamperes across the cerebral cortex by means of 2 electrodes placed on the scalp. To diminish auditory hallucinations, electrodes are placed on the left fronto-temporal region; for negative symptoms, bifrontal placement has been used. The treatment is typically given for 20 minutes twice a day for at least 5 days. Adverse effects are minimal but may include tingling or itching at the site of electrode placement and short-lived somnolence.
According to a review by Mondino, Fecteau and colleagues, 32 studies have examined the effects of tDCS in schizophrenia. Most studies involved patients who were also receiving medication, and several case reports have described safe combination with clozapine. For auditory hallucinations, 14 studies exist including 2 randomized controlled trials (RCTs) which included a total of 54 patients. One RCT found a 30% reduction in treatment-resistant auditory hallucinations after 10 sessions, significantly greater than in the sham-treatment group. The second RCT, however, did not find a significant reduction in auditory hallucinations. The treatment parameters differed between the studies, which confounds interpretation; for instance, in the positive trial, subjects received tDCS twice daily whereas in the negative trial, tDCS was once daily.
In the review, the authors also describe investigations of tDCS on such parameters as functional MRI, auditory and motor evoked potentials, and cognitive measures including executive function. Questions yet to answered include the appropriate duration of each tDCS session, 20 minutes being the most usual; the total duration of treatment, i.e. days or weeks; and the placement of electrodes. The duration of beneficial effect is uncertain, although data to date suggest it may endure for several months, and the role of maintenance treatment requires considerable investigation.
Mondino M, Brunelin J, Palmc U, Brunonid AR, Pouleta E and Fecteau S. Transcranial direct current stimulation for the treatment of refractory symptoms of schizophrenia: current evidence and future directions. Current Pharmaceutical Design. 2015;21:3373-3383. Abstract
On July 19th, 2014, Dr. Randall White was invited to speak at The Western Washington Chapter of Physicians for a National Health Program’s Ninth Annual Public Meeting. This year’s theme was: “Health Care is a Human Right: Making it Real in Washington State.” As a physician who has practiced both in Canada and the US, Randall brings a unique perspective to the table. Dr. White is a known advocate for health care equality, and stresses that financial access to health care is a major source of inequality. He says “Inequality has greater effects on Health Care than the actions of doctors and caregivers. In Canada, Health Care is a human right.” He goes on to encourage his American colleagues to continue to strive for universal health care.