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!

Exercise-associated hippocampal plasticity and hippocampal microvascular plasticity in chronic refractory schizophrenia patients

RANDALL - WIN_20150331_130356Donna Jane-Mai Lang, Alexander Rauscher, Allen E Thornton, Kristina Gicas Geoff Smith, Vina Goghari, Olga Leonova, Randall F White, Fidel Vila-Rodriguez, Wayne Su, Barbara Humphries, Aaron Phillips, William Honer, Alexandra Talia Vertinsky, Darren E Warburton. Poster presented at 15th International Congress on Schizophrenia Research, Colorado Springs, Colorado. March 29-April 1, 2015.

Abstract

Background: Hippocampal deficits are a commonly reported finding in chronic schizophrenia patients, and may contribute to severity of illness. Regular exercise is thought to remediate both hippocampal volume reductions and neurovascular flow to this region.

Methods: Seventeen chronic refractory schizophrenia patients were enrolled in a 12-week exercise intervention trial. Clinical assessments (PANSS, SOFAS, Hamilton Anxiety Scale (HAMAS), Calgary Depression Scale, Extrapyramidal Symptom Severity Scale), physical assessments (BMI, resting heart rate (RHR), blood pressure (BP), VO2 Max) and 3T MRI data (3D structural MRI, susceptibility weighted imaging) were ascertained at baseline and 12 weeks. Repeated measures ANOVAs with total (L+R) hippocampal and total hippocampal venule volumes expressed as ratios to total brain volume and total hippocampal volume respectively. Additional correlational models were applied.

Results: Patients had a significant increase in total hippocampal volume after 12 weeks of exercise (F(1, 33) = 6.8, p. = 0.019. Total hippocampal venule volume was not significantly increased after exercise (F(1, 33) = 0.17), although the overall increase in venule volume was 7-7.5%. A significant positive relationship between absolute change in total hippocampal volume and absolute change in hippocampal venule volume was observed (r = .52, p. = 0.04). Patients exhibited reduced symptom severity (p. = 0.0005), improved social and occupational functioning (p. = 0.0004), and a strong trend for reduced depression severity (p. = 0.06) at the end of the 12-week exercise intervention. Measures of BMI, RHR, BP and VO2 Max were not statistically different at 12 weeks, however exploratory investigations revealed a potential, but statistically nonsignificant relationship between improved VO2 Max capacity and reduced HAMAS score (r = -.44, p. = .067).

Conclusion: We observed exercise-associated hippocampal volume increases after 12 weeks of regular exercise in chronic refractory schizophrenia patients, as was previously reported by Pajonk et al, 2010. Moreover, these changes in hippocampal volume were correlated to changes in hippocampal venule volumes. These data support the hypothesis that regular exercise offers remediation in both hippocampal tissue volume and hippocampal microvascular volume in chronically treated refractory patients. Relationships to other clinical measures still remain to be clearly established.

Dimenhydrinate (Gravol) abuse worsens schizophrenia

We just published a report in the Journal of Clinical Psychopharmacology of a woman who abused dimenhydrinate for years. Only after she had sustained abstinence from this over-the-counter remedy for nausea did her psychosis respond well to treatment. Read the case report.

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.

Brazil: The Use of Nitrous Prusside for Schizophrenia

nitrous prusside, schizophrenia, mental health

In 2013, Drs. Jaime Hallak, Joao Paulo Maia-de-Oliveira and associates in Ribeirao Preto, Brazil, published results from a randomized controlled trial of intravenous nitroprusside in schizophrenia. Two Canadian researchers from the University of Alberta collaborated on the trial. This study was the first to find that sodium nitroprusside, a treatment for hypertensive crises, has a rapid and prolonged effect on both positive and negative symptoms in patients with acute psychosis. The presumed mechanism is enhancement of nitric oxide in the central nervous system, which may modulate the NMDA receptor-cGMP pathway. In normotensive patients, nitroprusside has minimal effect on blood pressure, and cyanide accumulation is a theoretical concern but occurs only after 72 hours or more of continuous infusion. In treating schizophrenia, the infusion dose is 0.5 mg/kg/minute for four hours.

In the initial trial published in JAMA Psychiatry, Hallak’s team used the Brief Psychiatric Rating Scale and the negative subscale of the Positive and Negative Syndrome Scale (PANSS) as outcome measures. A significant effect on certain components occurred within the first two to three hours of treatment, and improvement endured for four weeks. All the patients were also receiving an antipsychotic other than clozapine.

I met with Jaime, Joao Paulo and their team at the University of Sao Paulo Hospital in Ribeirao Preto and was able to observe a treatment. When I first met the patient, whose infusion had begun 10 minutes before, she appeared anxious and tended to avoid eye contact. When I returned 90 minutes later, she was engaged in an art activity and was eager to show me what she had created. She smiled broadly and even tested her English vocabulary a little. The researchers said that they often see an improvement in the patients’ affect over the course of the infusion, and they are trying to find ways to measure this more objectively. Although data are still limited, the effect in treatment-resistant patients tends to be more delayed.

Further studies of nitrous prusside in Ribeiroa Preto are underway, including for treatment-resistant patients, some on clozapine, and on neurophysiologic effects as detected with fMRI and event-related potential. Because the benefits of the treatment begin to wane after four weeks, they are planning a controlled trial of weekly nitrous prusside infusions for four weeks followed by 60 days of observation.
Reference
Hallak JEC, Maia-de-Oliveira JP, Abroa J, et al. Rapid Improvement of Acute Schizophrenia Symptoms After Intravenous Sodium Nitroprusside: A Randomized, Double-blind, Placebo-Controlled Trial. JAMA Psychiatry. 2013;70:668-676. Abstract
Photo: Left to right: Dr. Jaime Hallak, Dr. Joao Paolo Maia-de-Oliveira, Juliana Almeida (audiologist), their patient and her mother

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.