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 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!
Although clinicians and researchers have not reached consensus on diagnosing treatment-resistant schizophrenia (TRS), most of us use the same working definition. For instance, the Canadian Psychiatric Association treatment guidelines suggest that patients who fail to respond to two antipsychotic trials are treatment resistant. Persistent positive symptoms and functional impairment are the essential factors in TRS, and the significance of the diagnosis lies in determining when a clozapine trial is appropriate, a high-stakes decision for an individual patient.
In a paper published in Psychiatry Research (ref), a group of Canadian and Japanese psychiatrists have proposed a definition that takes into account medication unresponsiveness and functional impairment. Based on a literature review, they endorse the widespread criterion for TRS of failure of two different antipsychotics, each attaining a chlorpromazine-equivalent daily dose of at least 600 mg for a duration at least six consecutive weeks. The authors do not specify any particular classes of antipsychotics given the limited evidence that non-clozapine antipsychotics differ in efficacy.
An important factor is how well previous treatment response is documented. The authors indicate that the failure to respond to past trials should be “clearly documented and unequivocal.” The use of quantitative measures such as the PANSS and BPRS is ideal but is rare in routine practice, so instead the authors suggest treatment failure as end-point of CGI-Severity scale of 4 or greater and Global Assessment of Function (GAF) of 50 or less. If the past trials are not adequately documented, failure of one prospective trial would be required to satisfy this criterion.
Once the presence of TRS is confirmed, the authors propose that response to treatment would require a score on CGI-Improvement scale of 1 or 2 or a decrease of 20% on the PANSS or BPRS, along with and an 20-point or greater increase in GAF. They define a partial response as a CGI-Improvement score of 3 or a 10-19% improvement in PANSS or BPRS, along with GAF improvement of 10-19 points.
At the BC Psychosis Program, we are fortunate to have the resources that allow us to employ standardized instruments such as the PANSS, CGI scale and GAF at baseline and at discharge to document patients’ response to treatment. One point of this article is that simply using the CGI and GAF, which take little time, would be very helpful for subsequent care givers in understanding a patient’s response to prior medication trials.
Suzuki T, Remington G, Mulsant BH et al. Defining treatment-resistant schizophrenia and response to antipsychotics: A review and recommendation. Psychiatry Res. 2012;197(1-2):1-6. Abstract
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
With our first patient from Northern Health arriving the week of June 25, the BC psychosis program has reached capacity. We have a total of 25 patients from all health authorities and although Vancouver Coastal has more than its allocation of six, we intend to balance our admissions according to the access protocol and make room for more admissions in the coming weeks.
I’m pleased to report that some key positions are now filled. Our psychologist and psychometrist recently arrived, and our occupational therapist and music therapist are starting their work this week. We can now begin expanding our therapeutic programs.
The B.C. Psychosis Program at Detwiller Pavilion, UBC hospital, admitted its first patients on Feb 23, 2012. As heir to the Refractory Psychosis ward at Riverview Hospital, the program accepted nine patients from Riverview who were not yet ready to go home. Since then, patients have been admitted from Fraser Health, Vancouver Coastal Health, and Vancouver Island. We have space for patients from Interior and Northern Health Authorities and look forward to referrals from those regions. We have a presence on the Web and our referral forms are available for download.
Many people played a role in organizing the program and helping in the transition from Riverview to UBC Hospital. I was selected to be medical director in December 2011 well after this process was underway. I have not even met some of the people who were instrumental in making the program come together in February with the infrastructure and personnel we need to function. Although I risk offense by leaving some important names out, I want to thank certain people for helping me as I took on this job. They include Bill MacEwan whose counsel has been invaluable, Carole Rudko and Derek Lyons for all the work they’ve done in hiring and training our staff, and Leslie Arnold whose vision and personal interest in this project have made it possible. Sean Flynn, Diane Fredrikson and Veerle Willaeys are physician colleagues who are working to make our clinical program excellent. Bill Honer, Laura Case and Soma Ganesan have provided vital advice and support to me and our team. The steering committee, which includes people from all Health Authorities, continues to meet monthly and is our conduit to the province.
Creating a provincial resource in the ivory tower of UBC is a challenge given the distance to places like Campbell River, Terrace and every other town in B.C. where people and families are affected by severe psychosis. The B.C. Psychosis Program needs to be accessible to them just as it is to people in Vancouver. But the benefit of being at UBC is the ability to attract excellent staff and to create a site for significant research on treatment-resistant psychosis.