Genetic Counseling Research at the BC Psychosis Program

By Prescilla Carrion and Ashley DeGraaf

Genetic counseling is, according to the National Society of Genetic Counselors, the process of helping people understand and adapt to the medical, psychological, and familial implications of the genetic contributions to disease. Psychiatric genetic counseling is a specialized field of genetic counseling 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 counselor addresses the psychological impact of the illness and the information shared, provides support and suggests resources. If desired by the patient, the genetic counselor 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.

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.

Schizophrenia is not a progressive brain disease

DSC_0072 1 (2)Despite Emil Kraepelin’s early characterization of dementia praecox, the disorder or disorders that we now call schizophrenia are not characterized by dementia, or inevitable loss of cognitive ability and function. Dr. Robert B. Zipursky, Professor of Psychiatry and Behavioural Neurosciences at McMaster University in Hamilton, Ontario, said that psychiatrists may share Kraepelin’s impression of a malignant illness because of the clinician’s illusion, which arises from the biased sample of patients that psychiatrists treat, i.e. people with chronic, relapsing illness and multiple co-morbidities who come to hospitals (1). According to Professor Zipursky, who spoke at the 9th Annual Pacific Psychopharmacology Conference in Coquitlam, BC on September 18, 2015, available studies indicate that about 70% of people with first-episode psychosis will achieve remission within a year; he defined remission as having positive symptoms no greater that mild in severity and negative symptoms no greater than moderate in severity.

First-episode psychosis includes patients with various diagnoses including bipolar disorder, schizoaffective disorder, brief psychotic disorder as well as schizophrenia. Patients who achieve functional recovery, however, represent a smaller group, especially in those confirmed to have schizophrenia. In long-term outcome research, 20% or fewer of people with schizophrenia meet criteria for recovery defined as sustained remission of symptoms and success in social relations and competitive employment.
Some psychiatrists have concluded that this long-term functional impairment is due to progressive cognitive deterioration which may occur with untreated or chronic positive psychotic symptoms. A related hypothesis is the “neurotoxicity of psychosis” which posits that persisting psychosis leads to ongoing loss of cerebral tissue as manifested by enlarged ventricles and cortical atrophy on neuroimaging, accompanied by worsening deficits on neuropsychologic testing. Consequently, many clinicians working in first episode psychosis accept that the duration of untreated psychosis is an important determinant of long-term outcome.

While he acknowledged that deficits in grey matter volumes observed with MRI are more prominent in chronic patients, Dr. Zipursky asserted that many factors may contribute to this such as sampling bias; concurrent substance use including cannabis, tobacco and alcohol; lack of physical activity; and chronic antipsychotic therapy. The latter is controversial, but he cited a meta-analysis of longitudinal MRI studies in which change in grey matter volumes was correlated with antipsychotic exposure but not illness duration or severity (2). However, he emphasized that relieving suffering and improving function are the goals of treatment, not specifically increasing cerebral volume, which is affected by various factors mentioned before. Furthermore, Dr. Zipursky showed compelling evidence that following a first episode of schizophrenia, antipsychotic discontinuation is by far the most important cause of relapse.

Duration of untreated psychosis (DUP) has a small correlation with treatment outcome, likely accounting for less than 5% of the variance in clinical outcome measures, and questionable association with cognitive functioning and structural brain measures, according to Dr. Zipursky. He presented evidence that it is a risk marker for poor outcome in schizophrenia as opposed to a causative risk factor. “It’s not certain that it relates to improving outcomes, but it does relate to reducing suffering,” Zipursky said.
He concluded that to improve outcomes and promote functional recovery, antipsychotic medication is crucial but so are psychosocial interventions to manage substance use, educate families, provide adequate housing and income support when needed, and engage patients in vocational rehabilitation and supported employment.

References

Zipursky RB, Reilly TJ, Murray RM. The myth of schizophrenia as a progressive brain disease. Schizophr Bull. 2013;39:1363-1372. Full text

Fusar-Poli P, Smieskova R, Kempton MJ, Ho BC, Andreasen NC, Borgwardt S. Progressive brain changes in schizophrenia related to antipsychotic treatment? A meta-analysis of longitudinal MRI studies. Neurosci Biobehav Rev. 2013;37:1680-1691. Full text

A Meta-Analysis of CBT for Medication-Resistant Psychosis

A team of BC psychologists has performed the first meta-analysis of cognitive-behavioral therapy for medication-resistant psychosis. The 16 published studies that met their inclusion criteria comprised 12 trials and 639 individual patients. Medication resistance was defined as inadequate response of positive symptoms to at least one medication at adequate dose and duration, or treatment with clozapine. All the trials entailed assignment to either individual CBT for 10 to 24 sessions, or to a control intervention such as treatment as usual, psychoeducation or befriending. Four trials lacked masked raters. Outcome measures were typically PANSS or BPRS, and most studies had a follow-up assessment 3 to 18 months after completion of treatment. Based on pooled outcome data, effect size was derived with Hedge’s g.

For improving positive symptoms, the effect size of CBT compared to control intervention at the end of treatment was 0.47. At follow-up 3-18 months after treatment, the effect size was 0.41. Among studies with an outcome measurement for general psychopathology, such as depression and anxiety, the effect sizes were 0.52 at treatment end and 0.40 at follow-up. According to the researchers, excluding studies without masked raters did not significantly change the effect sizes.

This meta-analysis yielded a medium effect size for time-limited CBT in medication-treated patients with residual positive symptoms. The results suggest improvement may be maintained beyond a year. These were not necessarily treatment-resistant patients as typically defined, although some were on clozapine. Research on other important outcomes such as hospital admission, psychosocial functioning, and suicide would help determine the place of CBT in managing treatment-resistant psychosis.

Reference

Burns AM, Erickson DH, Brenner CA. Cognitive-behavioral therapy for medication-resistant psychosis: a meta-analytic review. Psychiatr Serv. Published online 1 Apr 2014. Abstract