Genetic Counselling Research at the BC Psychosis Program

By Prescilla Carrion and Ashley DeGraaf

Genetic counselling is, according to the National Society of Genetic Counsellors, the process of helping people understand and adapt to the medical, psychological, and familial implications of the genetic contributions to disease. Psychiatric genetic counselling is a specialized field of genetic counselling that aims to help people with a personal or family history of mental illness understand the causes so that they may better adapt to and cope with the illness. This involves providing information about the environmental and genetic causes of mental illness and discussing evidence-based strategies for promoting mental health such as lifestyle modifications, nutrition, managing stress, and the role of medications. As this conversation unfolds, the genetic counsellor addresses the psychological impact of the illness and the information shared, provides support and suggests resources. If desired by the patient, the genetic counsellor can also discuss the chances of recurrence of the disorder in the family

Psychiatric genetic counseling services in British Columbia are available to all residents of British Columbia with a personal or family history of mental illness through The Adapt Clinic in the Department of Medical Genetics at BC Women’s Hospital and are fully covered by the BC Medical Services Plan. In 2015, an evaluation of The Adapt Clinic by Inglis et al. demonstrated that psychiatric genetic counseling enhances empowerment and self-efficacy in people with psychiatric disorders and their family members. Empowerment can be defined as one’s sense of control over an illness and hope for the future, while self-efficacy is one’s confidence in the ability to manage an illness. In other words, the study suggests that psychiatric genetic counseling gives patients and family members a greater sense of control over the illness and hope for the future, as well as increased confidence in managing their illness.

Prescilla Carrion and Ashley DeGraaf are certified genetic counselors at UBC Hospital who have been integrated into the BC Psychosis Program to provide psychiatric genetic counseling to patients and their family members through research.  Prescilla Carrion is a UBC genetic counselor and clinician investigator within the UBC Institute of Mental Health Centre for Care and Research. She is leading this research aimed to build evidence for psychiatric genetic counseling among patients with treatment-resistant psychosis and their family members.  As the principal investigator on the study titled “Evaluating the value of integrating genetic counseling into mental health services,” she is using validated clinical outcome measures to assess the impact of psychiatric genetic counseling in this population and aims to identify whether similar increases in empowerment and self-efficacy in mental health management can be observed and maintained as compared to the findings in the evaluation of The Adapt Clinic. She has also developed a survey, in collaboration with Drs. Jehannine Austin and William Honer, to assess clinician perspectives on how genetic counseling may have impacted the care they provide to their patients and interactions with the family members with the goal of understanding how best to engage mental health clinicians in recommending genetic counseling for their patients/clients. This research will provide the first outcome data on the effect of genetic counseling for inpatients with treatment-resistant psychosis, and on outcomes of genetic counseling when integrated into a multidisciplinary mental health program outside of a medical genetics clinic setting.

If you have a personal or family history of mental illness and are interested in psychiatric genetic counseling, you may self-refer to The Adapt Clinic by calling Angela Inglis at 604-875-2726, or Emily Morris at 604-875-2000 ext. 6787, or you may request a referral through your family doctor, psychiatrist, or other mental health clinician. A searchable directory of genetic counselors and genetic counseling services in Canada and the United States is available through the Canadian Association of Genetic Counsellors and the National Society of Genetic Counselors.

Pharmacology research projects getting underway at BCPP

Dr. Ric Procyshyn, a UBC pharmacologist and researcher, is the principal investigator in two research projects underway at BC Psychosis Program. The goal is to recruit 50 patients for each study, and participants must give voluntary informed consent.

The first study, titled A Pilot Study to Determine if Pantoprazole Modifies Steady-State Plasma Concentrations of Orally Administered Psychotropic Medications, will look at the effects of proton pump inhibitors (PPIs) on the absorption and blood levels of psychiatric medications. People who smoke, are overweight, or take clozapine are prone to gastroesophageal reflux disease (GERD), hence many people with schizophrenia end up receiving PPIs. Patients at BC Psychosis Program with gastric reflux who would benefit from treatment, and who are taking valproic acid, lithium, or a second-generation antipsychotic, will receive the PPI pantoprazole for nine days. During this time, plasma concentrations of the medications as well as gastrin, a digestive hormone, will be obtained. If the medication benefits a patient, treatment can continue.

The second project is A Pilot Study to Determine How Frequency of Administration Modifies Steady-State Plasma Concentrations of Orally Administered Clozapine. Patients on clozapine often receive it once every 24 hours, usually at bedtime because of its sedating properties. However, clozapine has a short half-life and dissociates quickly from the dopamine D2 receptor, so it may work better with more frequent dosing. Patients already on clozapine will be assigned to receive it once or twice a day for 15 days during which plasma concentration of clozapine will be monitored along with effects on glucose, body weight, and symptoms of psychosis.

Dr. Vila receives award at American Psychiatric Association 2014 meeting

Dr. Fidel Vila-Rodriguez, a BC Psychosis Program psychiatrist, received an American Psychiatric Foundation Early Academic Career Award on Schizophrenia Research at the APA Annual Meeting in New York in May, 2014. To learn about Dr. Vila’s research, visit his lab Web site NINET.CA.

Fidel Vila-Rodriguez Joins BC Psychosis Program

FVR_BCPP

Fidel Vila-Rodriguez, MD recently joined the BC Psychosis Program as a staff psychiatrist. Dr. Vila received his medical degree in 2000 at the University Autonoma of Barcelona in Barcelona, Spain and completed a residency in psychiatry at San Joan de Deu Mental Health Services. After graduation, he was an attending psychiatrist at El Prat Mental Health Team as well as a clinical research fellow in schizophrenia. Dr. Vila received his Master of Advance Studies in Neuroscience in 2007 at the University of Barcelona. After coming to Canada in 2006 and graduating from the UBC Psychiatry residency program, Dr. Vila has been practicing in the area of neurostimulation at Vancouver General Hospital and Saint Paul’s Hospital.

Dr. Vila is a Clinical Assistant Professor in the Department of Psychiatry at UBC, and his research interests include understanding the pathogenic mechanisms of and treatment for psychosis and mood disorders. He has extensively published in international peer-reviewed journals and has received many awards for his work including the Tsung-Yi Li Award for Clinical Research, the George Davidson Scholarship Award, and the significant Contribution to Research Award.

Another passion of Dr. Vila’s is soccer. He volunteers as a board member for the Vancouver Street Soccer League, an organization that strives to improve the lives of people with mental illness, addiction, and homelessness through team sports.

Meet Miriam Cohen, new access coordinator

Miriam Cohen has recently joined the BC Psychosis Program as our access and discharge coordinator. Miriam has extensive experience in mental health nursing, and she previously worked at UBC hospital as the coordinator for the Early Psychosis Intervention Program from 2000 until 2003 and continued in that role when the program moved to the community. More recently, she was the program director for child and adolescent psychiatry at BC Children’s Hospital, and she received the Oustanding Nurse Award from BC Mental Health and Addictions Services in 2008.

Miriam received her training at York University and Seneca College in Ontario, and completed her Bachelor of Science in Nursing at UBC in 1996. We are pleased to have her join our team; she already has ideas about improving the referral and admissions process.

Clinical Neurosciences Postscript

The BC Schizophrenia Society has posted a video recording of Clinical Neurosciences 2013 conference online. You can see and hear Dr. Herb Meltzer discussing treatment resistance, Dr. Bill MacEwan on the Vancouver Hotel Study, and even me (Randall White) describing the BC Psychosis Program.

Dr. Leona Adams joins BCPP

Dr. Leona Adams joined the BC Psychosis Program in December. In addition to her role as a psychiatrist with the BCPP, she will continue on staff at St. Paul’s Hospital where she works on an acute inpatient unit, and where she has been involved in collaborative care in the infectious disease clinic.

Dr. Adams obtained her medical degree in 2002 at the University of British Columbia Faculty of Medicine and completed her psychiatry residency at Dalhousie University in Halifax. She is a fellow of the Royal College of Physicians of Canada and a Clinical Instructor in Psychiatry at UBC. In addition to her various activities as a physician, she is a member of the Good Noise Vancouver Gospel Choir. I have attended a number of their concerts and recommend it highly!

Introducing Harish Neelakant

Dr. Harish Neelakant recently joined the BC Psychosis Program as a psychiatrist. He came to B.C. from the United Kingdom where he completed his residency in psychiatry in Newcastle-upon-Tyne in 2006. He has a special interest in cognitive therapy for psychosis and during his residency, he worked under Professor Douglas Turkington, a leader in the field. After his training, Dr. Neelakant worked in an early psychosis program in the U.K. which implemented the use of mobile devices, a complementary multidisciplinary model, care-giver support and collaboration, and primary medical care involvement. Since 2009 he has worked at the South and Midtown mental health teams in Vancouver and with the Vancouver Acute Home-Based Treatment team. In his practice, Dr. Neelakant is interested in prevention of stigma, prevention and early detection of psychosis, and a integrative approach to patient care

Managing a smoke-free inpatient environment for patients who smoke

No Smoking, smoke-free, sign

As more and more hospitals eliminate smoking on their grounds, including Vancouver Coastal Health, health professionals will benefit from reduced exposure to second-hand smoke. At the same time, they have to help patients adapt to forced abstinence. Many smokers with mental illness want to quit but may not be ready to give up tobacco at the time of hospitalization, and taking cigarettes away is another loss of autonomy to which inpatients must adjust. This raises ethical questions among staff, and compounding the ambivalence toward smoke-free policies is anxiety about symptom exacerbation or even aggression related to forced abstinence. One study of a general psychiatry inpatient service found that forced tobacco abstinence was in fact associated with unplanned discharge and seclusion (1). However, research on outpatients with schizophrenia found that acute nicotine abstinence was associated with a transient increase in negative but not positive symptoms (2).

The restlessness and anxiety that patients in nicotine withdrawal experience may nevertheless be interpreted as psychotic exacerbation. A study in an emergency psychiatric setting showed that nicotine replacement is effective in patients with schizophrenia (3). The authors found that compared to placebo, a 21-mg nicotine patch led to a 23% reduction at 24 hours in the Agitated Behavior Scale. This is similar to the effect of a dose of antipsychotic, suggesting that managing nicotine withdrawal may reduce use of sedating medication.

At the BC Psychosis Program beginning November 20th, newly admitted patients are not able to smoke, and it is important for them to be prepared for this when they arrive. We suggest that patients who smoke and are traveling from distant communities by medical transport receive nicotine replacement en route. All smokers at BCPP receive nicotine replacement therapy, and only when they have independent passes off grounds will they be able to use tobacco products if they choose to do so.

References

1. Prochaska JJ, Gill P, Hall SM. Treatment of tobacco use in an inpatient psychiatric setting. Psychiatr Serv. 2004;55:1265–1270. Full text

2. Dalack GW, Becks L, Hill E, Pomerleau OF, Meador-Woodruff JH. Nicotine withdrawal and psychiatric symptoms in cigarette smokers with schizophrenia.
Neuropsychopharmacology. 1999;2:195-202. Full text

3. Allen MH, Debanne M, Lazignac C, et al. Effect of nicotine replacement therapy on agitation in smokers with schizophrenia: a double-blind, randomized, placebo-controlled study. Am J Psychiatry. 2011;168:395–399. Full text

(Photo: flickr.com/hmoong)

Introducing Mahesh Menon

Dr. Mahesh Menon came to B.C. Psychosis Program and the UBC Department of Psychiatry from the Centre for Addiction and Mental Health in Toronto. He did a postdoctoral fellowship the University of Toronto after completing a doctoral degree in psychology at the University of Cambridge in the United Kingdom. His areas of interest are the neurocognitive correlates of psychosis and cognitive-behavioral therapy for schizophrenia.

Dr Menon is serving both as a neuropsychologist and as a therapist for the B.C. Psychosis Program. He has initiated two weekly group therapies for our patients, including a cognitive-behavioral intervention for patients with chronic hallucinations.

As a researcher, Dr. Menon has obtained a number of competitive research grants and published many peer-reviewed articles. In collaboration with his UBC colleague Dr. Todd Woodward, he is investigating a novel psychotherapy for psychosis called metacognitive therapy, which developed from research into the cognitive biases associated with delusions and hallucinations. They plan to compare the efficacy of metacognitive therapy to that of cognitive-behavioral therapy in patients with chronic psychosis. Patients at the B.C. Psychosis Program will be recruited as subjects for the study.