Episode 19: Applying Mental Health Legislation with Kendra Naidoo

• Episode 19: Applying Mental Health Legislation with Kendra Naidoo

  Alex Raben: [00:00:00] Hello, listeners, this is Alex here. Welcome back to Psyched for the month of July. Instead of one episode, you'll be getting five. That's because we're going to be doing a special mini-series in which we cover clinical skills in psychiatry. So in the past we've tended to cover specific disorders or illnesses. But these five episodes will focus on approaches and competencies that will help you in your training in psychiatry. We hope that you will enjoy. We are recording.

  Bruce Fage: [00:00:39] Welcome to PscyhEd, the Educational Psychiatry Podcast for Medical Learners by Medical Learners. If you're return listener, welcome back and if it's your first time, thank you for joining. We're going to be focusing on something a little bit different today. We're going to talk about some of the ways in which psychiatry interacts with the legal system and some of the specifics regarding mental health legislation in Ontario. Your host today are Dr. Alex Raben, a fourth year psychiatry resident at the University of Toronto, and myself, Bruce Fage, a fifth year psychiatry resident here at U of T. We are thrilled to be joined today not by a psychiatrist but by Kendra Naidoo, legal counsel for the Centre for Addiction and Mental Health in Toronto. Kendra is a graduate of UBC Law School and went to University of Toronto for her undergraduate degree. I've had the privilege of learning from Kendra at different points throughout my residency and she is extremely helpful. She's an expert on mental health law and empowers us to provide the best possible patient care. Kendra, we're happy to have you here.

  Kendra Naidoo: [00:01:35] Thanks very much for having me. I'm delighted to be here. It's always a pleasure to work with you, Bruce and Alex and all of our medical learners and navigating these complex and nuanced issues and mental health law.

  Alex Raben: [00:01:46] Thanks for being here, Kendra. This is Alex. Should we go over the objectives for today? Okay. So number one, we'd like to review some of the history behind mental health legislation in Ontario by the end. We'd also like to ensure we have a discussion about involuntary hospitalisations, including criteria relevant to the legal forms involved in that. Number three, we're going to review capacity assessments and processes for substitute decision-making. And finally, number four, we will talk a bit about consent and capacity boards. So, Kendrick, keeping in mind that most of our listeners are not lawyers, maybe you can start us off by providing an overview of mental health law in Ontario. What are the relevant pieces of legislation?

  Kendra Naidoo: [00:02:40] Sure. So there are two pieces of legislation that are most central to mental health law in Ontario. The first is the Mental Health Act, and the Mental Health Act governs hospitalisation in psychiatric facilities, admissions to those hospitals and what happens while people are there. They also provide for community treatment orders. The second piece of legislation is the Health Care Consent Act. This applies to all treatment, whether it's medical, physical or psychiatric. The Health Care Consent Act governs the principles behind obtaining consent to treatment, assessing capacity to consent to treatment, as well as identifying substitute decision makers and the rules that govern those decision makers.

  Alex Raben: [00:03:21] So so it's the Health Care Consent Act, as well as the Mental Health Act together that are the two main pieces of legislation involved in psychiatry in the law.

  Kendra Naidoo: [00:03:31] That's correct.

  Bruce Fage: [00:03:33] So, Kendra, within psychiatry, we often work with people who are experiencing significant mental health concerns, and sometimes there are very serious safety issues. For example, someone may be extremely depressed and at high risk of suicide or experiencing psychotic symptoms, which severely impaired their ability to take care of their basic needs, like food and shelter. Thus, there are times where we as doctors are compelled to use the Mental Health Act to detain people involuntarily in hospitals. I think it's one of the more challenging and stigmatised aspects of mental health services for patients, their families and providers. It can be wrought with emotion and personally it's a part of my work that is both necessary but very challenging. One of the goals of this episode is to demystify and provide some basic information about involuntary hospitalisation. Can you tell us about some of the process?

  Kendra Naidoo: [00:04:23] Sure. So one of the most common processes to initiate an involuntary hospitalisation is called an application for psychiatric assessment, and it's commonly known as a form one. A form one can be completed by any physician as long as they've examined the person within the last seven days from the day it's signed. The form one is authority for seven days for that person to be taken into custody, usually by the police and taken to a psychiatric facility for an assessment. Once they're there, the psychiatric facility is authorised to detain the person for up to 72 hours in order to conduct that assessment. There are criteria that have to be met before a physician can fill out one of these forms. And this is recognising that it's quite an extraordinary power for a physician to have. Those criteria are commonly known as the box and the box B criteria. The box A criteria have most a past or present test and a future test in the box. A past present test. The person must have threatened or attempted to cause bodily harm to A person or B currently threatening or attempting to cause bodily harm to another person or to themselves. They must have behaved violently or be behaving violently at the time, or causing someone else to fear bodily harm from them. Or they have demonstrated a lack of competence to care for themselves. In the future. Test the physician must be of the opinion that the person is likely suffering from a mental disorder that is likely to result in either serious bodily harm to another person to themself, or what we refer to as serious physical impairment, which is harm that might come to the patient but isn't intentionally brought upon.

  Alex Raben: [00:06:14] So if I can summarise what you're saying, there is this form one and that is the legal form that allows a physician, once it's filled out, to compel someone to come into hospital for a psychiatric assessment. And there are two sort of branch. There's a box A and a box B criteria. And of the box A, there's kind of two branches, the past and present test and the future test. That's right. In the past and present test. That's like talking about the risk that we're trying to avoid by filling out this form.

  Kendra Naidoo: [00:06:52] Right. So it refers to the condition of the person in the current state that is giving rise to concerns and also requires that there be a future risk of harm either to the patient or to themselves. So both components are necessary to fulfil the box a criteria.

  Alex Raben: [00:07:07] And the present risks includes three things so harm to themselves, meaning like a suicidal risk, let's say harm to someone else. If, for instance, if someone was threatening someone else or acted violently towards someone else. And then number three is more about their ability to care for themselves when they are mentally ill.

  Kendra Naidoo: [00:07:32] Right. So the serious physical impairment criteria might come up if, say, someone has a co-occurring medical condition like diabetes or heart condition, and because of their mental illness, they're not able to care for that and so are at risk themselves of medical harm because of that.

  Alex Raben: [00:07:51] Well, we're talking about that risk. Is there an element of degree? I recall at some point being taught it has to be imminent risk. It has to be of a certain severity. But I also know that the like it doesn't seem that the form really lays that out clearly. I'm wondering what, from your perspective, that level of risk needs to be.

  Kendra Naidoo: [00:08:14] There's no requirement for imminence, but the harm does have to be likely in the sense that it is going to occur in what we in law call a reasonably foreseeable time. That's hard to put a cut-off date on that likely criterion, but we would be thinking about it in orders of magnitude in terms of days or weeks or a few months. But if we're getting into many months, six months or into the the into years, then that's probably too far away to be likely in terms of the severity of the harm. It does require that it be serious bodily harm to themself or others, which is defined in law as harm that is more than trivial, or that the physical impairment, the medical consequences to the patient be significant.

  Alex Raben: [00:09:08] Is it possible for you to give us an example of what might be considered trivial?

  Kendra Naidoo: [00:09:11] Sure. So if an individual, say, were to lightly push an otherwise perfectly healthy adult, that would be considered a harm that is likely trivial. Now, if someone were to seriously push a very small child or a frail elderly person, then that could rise to the level of being more than trivial. But things like pushes or light contact would generally be considered trivial.

  Alex Raben: [00:09:43] Okay, that's that's helpful to understand.

  Bruce Fage: [00:09:46] And so, Kendra. You mentioned that there's also a box B. Can you tell us about Box B and some of the differences with Box B and Box A?

  Kendra Naidoo: [00:09:53] Sure. So Box B is newer than Box A, It was put into the legislation in the year 2000 in response to concerns that you really do have to reach quite a high threshold before you can get to the box eight criteria. And sometimes it can be beneficial to intervene sooner so that people can get the help that they need without getting to the point where their safety or the safety or others are at risk. So the box B criteria contains a number of criteria. It requires that the person be found or believed to be not capable of consenting to their own treatment. And their substitute decision-maker has consented to treatment. And we're going to talk about that a little later in the podcast. It requires that they have a history of mental disorder and that they have previously been treated for that mental disorder and experience significant clinical improvement with treatment. It further requires that there is a likely risk of one of the harms. We've already talked about serious bodily harm to self or others or serious physical impairment, and contains this additional criteria where there could be a likely risk of what we call substantial mental or physical deterioration. So in essence, if someone has a history of being treated and improving with treatment, if they're not capable and there's consent to treatment and there is a likely risk that they will suffer substantial mental or physical deterioration, then the box B criteria can be invoked.

  Bruce Fage: [00:11:26] So it sounds like one of the major differences between Box A and Box B is that in box B, you have that, I guess, extra potential risk where it includes substantial mental deterioration in addition to the criteria that are outlined in Box A And also you have to have been treated before and shown benefit from the treatment. Do you like is there any guidance on how you might define substantial deterioration?

  Kendra Naidoo: [00:11:56] So the case law has said that when we're talking about substantial mental deterioration, that means the person is likely to become more profoundly symptomatic. And that use of the word substantial refers to consequential or considerable deterioration. This inevitably requires a level of clinical judgement on the part of the physician who's assessing this and is going to have to be looked at in light of the particular patient and how their symptomatology plays out. But for a particular patient, if they're likely to become more profoundly symptomatic, then that would be considered substantial mental deterioration.

  Bruce Fage: [00:12:40] I think you've touched on something that is very challenging within the work that we do in that there is this element of clinical judgement and sometimes it's hard to know exactly what the actual risk is likely to be and we want to support people and use the least restrictive means possible when we're helping them get well. And we also want to be safe and make sure that people don't come to significant harm. When a doctor fills out a Form One, what happens next? What's the process for moving forward with that?

  Kendra Naidoo: [00:13:11] So the form then gets sent to the police, and the police have seven days to find the person and to bring them to a psychiatric facility once they arrive at the psychiatric facility. The as I said, the facility is authorised to detain them for up to 72 hours for the purpose of getting a psychiatric assessment. So the whole idea behind Form One is that a physician in the community and it's often a family physician, sees that there are things going on with the person that likely requires a psychiatric assessment and the Form One is a mechanism by which they can have them brought to have that assessment. By the end of that 72 hours, the psychiatric facility has to do one of three things. They either decide that the person does not need to be admitted to a psychiatric hospital and discharges them, or they decide that the person. Needs to be admitted to a psychiatric hospital and the person is willing to stay and so they can be admitted as a voluntary patient or if the person needs to be in hospital and is not willing to stay, then they can be admitted as what's called an involuntary patient. An involuntary admission is initiated by completing a Form Three, and the Form Three requires that the person meet either the box, say, or the box B criteria. If that happens, then the person can be detained for up to two weeks on the Form Three, and by the end of the two weeks, if the person continues to require an involuntary admission that can be renewed with a Form Four and then there are subsequent renewals that can occur.

  Kendra Naidoo: [00:14:53] There are a lot of procedural safeguards that come with these kinds of involuntary detentions. The patient has to receive written notice of their detention by way of what's called a Form 30. The forms have to be filed and reviewed by what's called the officer in charge. The officer in charge is the person in charge of the psychiatric hospital. Every hospital does that process differently. So it's important for physicians and learners to get to know the particular processes in their hospital. But the point of that is to make sure there's someone in the hospital administration who's making sure all of the right procedural safeguards are being carried out. The physician also has to give notice of the detention to a rights advisor, and rights advisors usually come from the office of the Psychiatric Patient Advocacy Office, which is an arm's length, arm's length branch of the Ministry of Health. The rights adviser will meet with the patient, explain to them that they're being detained and the criteria on which they're being detained and inform them of their rights, including and importantly, their right to consult with a lawyer and their right to apply to a tribunal called the Consent and Capacity Board, who will convene a hearing to review their detention and decide if the doctor's decision to have them detained was correct.

  Bruce Fage: [00:16:10] So thanks, Kendra, for that explanation, it sounds like after a doctor fills out a Form One, the patient can be brought to hospital and detained for up to 72 hours. And they also are issued something called a Form 42 at that time, which notifies them that they're on a Form One that's right. At the end of the form one period, one of three things can happen. They can be discharged home. They can be admitted to the hospital voluntarily, or they can be admitted involuntarily on something called a Form Three. And it sounds like there's a similar process where you notify the patient with the Form 30. But at that point you also get a rights adviser involved to help advise a person of their right to consult with a lawyer and contest the finding.

  Kendra Naidoo: [00:16:52] That's right.

  Bruce Fage: [00:16:54] And when you say psychiatric facility, what do you mean by that?

  Kendra Naidoo: [00:16:57] So psychiatric facilities are designated by the ministry under the Mental Health Act. They're often commonly referred to as Schedule one psychiatric facilities, because that's the part of the legislation that they're in. It's very easy to find out if a hospital is a psychiatric facility or a Schedule one facility. Googling Ontario Ministry of Health Schedule one psychiatric facilities will pull up the list. There's approximately 80 to 90 of those facilities in Ontario. Most of the major hospitals are psychiatric facilities. It's the smaller community or rural hospitals that may not be designated.

  Alex Raben: [00:17:36] I'm just putting myself in the shoes of some of our listeners in Ontario who have a who are in medical training right now. And I'm trying to think about where they would come across this kind of legislation or where they would bump up against it. And I guess for them it would mostly be in the emerge where they would potentially be putting people on form ones, possibly if they're doing family medicine, they would see it in their office as well, although potentially less frequently than than in the emerge. So if they are seeing someone in the emerge, they would be filling out the Form One as well as doing the 42, because they are simultaneously asking for the assessment and starting the detainment in the hospital, assuming they're working in a Schedule one facility. Would that be true?

  Kendra Naidoo: [00:18:30] That's right. So if they're in an emergency department in a schedule one psychiatric facility, they do the Form One and the Form 42 at the same time, as you say, applying for the assessment and starting the detention at the same time, if they're not in a Schedule one psychiatric facility, then they fill out the form one and that non-schedule one facility then needs to transfer the patient forthwith or as soon as they can to a schedule one facility. And when the patient arrives at the schedule one facility, the receiving physician there will fill out the Form 42 and that's when the 72 hour detention commences.

  Alex Raben: [00:19:09] Gotcha.

  Bruce Fage: [00:19:11] And what if there's no need for 72 hours? Like what if you finish the assessment early? Can the Form one be stopped before the 72 hour limit?

  Kendra Naidoo: [00:19:19] Yeah, it can be stopped at any time when the assessment is complete, and that would either occur by discharging the patient, filling out a Form three for the involuntary admission, or just cancelling the Form one and documenting that the patient has agreed to remain as a voluntary patient.

  Alex Raben: [00:19:35] And kind of riffing off that. Bruce Like, I think we often find ourselves in situations where we're not entirely sure on day one, and so we may. And so even though you've a psychiatrist or a psychiatry resident may have seen someone on day one, they can also kind of continue the assessment onto the second and third day if need be.

  Kendra Naidoo: [00:19:57] That's absolutely right. As long as they get it done and make one of those three decisions before the 72 hours expires.

  Alex Raben: [00:20:03] Right.

  Bruce Fage: [00:20:05] What about if a family member has concerns about their loved one and the their loved one refuses to go and see a doctor?

  Kendra Naidoo: [00:20:14] So. If they can get them to say, go see their family physician, any doctor can fill out a Form one if they've seen the patient in the last seven days. If they are refusing to go see a doctor, there isn't a doctor available. There is something called a Form two, which is a justice of the peace. Order for examination is the official name of the form. Justice of the peace for those that don't know is another kind of judge. You can go see a Justice of the Peace 365 days a year in any courthouse in Ontario, and they don't work 24 hours a day. But you can always call the courthouse to find out what the hours are for the justice of the peace. The process is to go to the courthouse, ask to speak to a justice of the peace, to get a Form Two, and then whoever has gone there can swear information before a justice of the peace that either the Box A or the Box B criteria or both have been met. And they need to give specific information to support that finding. If the justice of the peace is satisfied with the information, then they'll issue one of these form twos that get sent to the police, who then have seven days to go and find the person, pick them up and bring them to a hospital for examination.

  Kendra Naidoo: [00:21:31] It doesn't authorise the hospital to detain the person. And that's a big difference between a form one and a form two. So when the person arrives at the hospital, they have to be assessed as soon as possible and then a decision will be made about whether to admit them voluntarily. Is more psychiatric assessment needed so that they can do it. And if that's the case, they would do a form one and start a 72 hour detention at the hospital. For anyone going to get a Form Two, it can really be anyone. There's no stipulation on who it can be. It's often friends or family members, but it can be members of a care team, neighbours, any kind of supports that a person has in the community, they have to swear the information under oath, which means it has to be true and it's really helpful to give the justice of the peace all of the information that you have, including information about how to find the person, because the police only have seven days. And so the more information you can give, the better to ensure the success of the form.

  Alex Raben: [00:22:33] And then I think there's also the third option, where someone is brought in voluntarily to a hospital, which is if the police are called because they have certain powers under the I think it's the Mental Health Act, I could be wrong about what part of the legislation, but they you can correct me, Kendra, but then they have the power to bring someone to an emergency department. By that sort of third option. Is that not?

  Kendra Naidoo: [00:23:01] Yeah, that's absolutely right. It is. Under the Mental Health Act, the police have their own discretion if they're called to a scene and when they arrive, they believe that somebody appears to be suffering from a mental disorder and is either at risk of causing harm to others or not able to care for themselves. They have their own discretion to decide to take someone into custody, into a psychiatric facility. An important thing to note about that is that police forces generally won't invoke that power unless they actually observe the behaviour giving rise to the risk of harm. So it can be a very powerful thing in the moment. If there's a crisis, call the police and they have the ability to take someone to a hospital. But if by the time they get there, the person is quite settled and they're quiet and they're not exhibiting any of the behaviours that give rise to a harm, the police might at that point say that they're not going to exercise their discretion. And that's where the form too can be a very useful tool for friends and family members. Right?

  Alex Raben: [00:24:04] So just like in any normal life situation, if you feel at risk or something is happening, that's an emergency. You would call the police if your loved one is not doing well, but there's not an acute emergency that would warrant the police coming, then you could fill out a form, too, to get them seen.

  Kendra Naidoo: [00:24:21] Absolutely.

  Bruce Fage: [00:24:23] So thanks, Kendra, for outlining some of the processes that relate to involuntary hospitalisation in Ontario. I'd like to shift the conversation a bit and talk about another area of psychiatry that intersects with the law, its capacity and specifically capacity to consent to treatment of a mental disorder. Sometimes patients and their providers will disagree about a diagnosis. So for example, a psychiatrist may make a diagnosis of schizophrenia and the person might not agree that they have the diagnosis and may not want treatment. What happens in these situations?

  Kendra Naidoo: [00:24:54] So the first thing to think about in those situations is whether that person is actually able to make that decision. In other words, are they capable? When we're talking about capacity, it's important to remember that capacity to consent to treatment is treatment specific. Everyone is presumed capable of making their own decisions about their health care, and if they are to be found not capable with respect to a treatment, there has to be a particular treatment that is proposed. That treatment has to be discussed with the patient and they're given all of the necessary and relevant information and then their capacity to consent to that particular treatment assessed. There are two branches to the test for capacity, and that's legislated in the Health Care Consent Act. The first branch is whether the person is able to understand the information that has been given to them. And the second branch of the test is whether they're able to appreciate the reasonably foreseeable consequences of a decision or a lack of a decision about that particular treatment.

  Alex Raben: [00:25:58] Can you take us through those two branches? Like what differentiates between understanding the proposed treatment versus appreciating it?

  Kendra Naidoo: [00:26:10] Absolutely. And I think one of the things to bear in mind is that the emphasis is on their ability to understand and their ability to appreciate. It's quite a significant thing to take away someone's right to make their own decisions about treatment. And so we only do that where they really lack the ability to make the decision. As for the two branches, the first branch of the test, the ability to understand, boils down to a basic cognitive capacity test. Do they have the ability to process, retain and understand the information that's been given to them generally? So it doesn't have anything to do with how they view their own situation or how they apply the information to themselves. It's about generally are they able to take in process and retain information in the context of someone suffering from schizophrenia? A classic example of that is someone who's able to recognise generally that there are people out there who may suffer from something that resembles schizophrenia and those people might benefit from, say, antipsychotic medication. It's in the second branch of the test that we focus on. How does the person take that information and apply it to their own circumstances? So that starts with an investigation of whether the person is able to recognise that they are affected by the objective manifestations of their mental condition. So the mental condition will manifest itself in terms of symptoms and behaviours arising from those symptoms. Are they able to recognise the possibility of those symptoms and those behaviours? It's important to note that the patient does not or the person does not have to agree with the diagnosis or the label that we put on their condition. They don't have to agree that it's an illness. They don't even have to cast it necessarily in negative terms.

  Kendra Naidoo: [00:28:01] But when we think objectively about how that illness is manifesting in terms of symptoms and behaviours, are they able to recognise that they're affected by them? If the answer to that is no, if they're not able to recognise that they're affected by the manifestations of their condition, then they're not capable and they fail the second branch of the test. If they are able to recognise that they're affected by the manifestations of their condition, then we go on to an examination of their ability to appreciate what we call the parameters of the decision. So the nature of the treatment, what is it? Is it a pill, is it a needle, Is it surgery? Are they able to recognise the possibility that that might benefit them? Are they able to recognise the potential consequences of not taking the treatment? And if they are, then they are considered capable and if they're not, if they are not able to recognise the potential benefits or the consequences of not taking the treatment, then they're not able to appreciate the consequences of their decision. So once we've decided that they're able to recognise the manifestations of their condition, it really turns to an analysis of whether they're able to weigh the information. They don't have to weigh the information the same way as their healthcare team. They may ultimately come out the other end with a decision that we consider to be ill-advised or not in their best interests. But it's not about what it's in their best interest. It's not about whether they agree with their physician or their healthcare team. If they're able to weigh the information to recognise the possible risks and benefits, then that person is capable.

  Alex Raben: [00:29:44] Of making any decision whether we agree with it or not, just like.

  Kendra Naidoo: [00:29:47] Right. With respect to that particular treatment. Yeah.

  Alex Raben: [00:29:50] So the. Um. When we kind of lay it out in legal terms, it I think there's a lot to take in there, but it certainly can seem clear cut. But in reality, I think, Bruce, maybe you would agree. I think it's anything but Maybe it would be helpful for us to propose an example of when this might apply and kind of think through that as a group. I suppose we could think of someone with schizophrenia who, well, we would label him as schizophrenia, but who, let's say when they become unwell, they get worried that their brother is trying to harm them. So then they, you know, try to protect themselves, maybe at times are violent towards the brother because they think that they're going to hurt them. And so when we see that, we point that out to them, we tell them the diagnosis and let's say the understand piece of that is that they understand this illness of schizophrenia exists. They understand that it can cause paranoia. But then we move. Let's say that's true. We then have to move to the appreciation. And let's say they recognise even that they're paranoid. But when we propose a treatment like an antipsychotic to help with that, they say no, that's not, there's no chance that could help me. Would that, what would, would that case be a lack of appreciation if that's true.

  Kendra Naidoo: [00:31:29] Well, I think you'd have to drill that down. So, you know, when you're having the when you're doing the capacity assessment and having that conversation with the person, you'd want to, as you've said, not only tell them about the diagnosis, but explain it to them in reference to the symptoms and the behaviours and be mindful of the labels that we're putting on things. So you may tell them we believe that you're paranoid. And what we mean by that is that you sometimes believe things that are not true. For example, this belief you have that your brother is trying to harm you and that has resulted in you being violent against him. So there is a certain aspect of how you frame the information in your example. If the person accepts that, yes, sometimes I believe he's trying to hurt me and maybe that's not true. But no, I don't want to take that anti-psychotic medication. You then want to get into a discourse about why not. Right. And exactly take a look at the patient's reasons for refusing the medication. If it's because they know that in the past they've taken medication and gotten better, but have, for example, experienced significant side effects, then that may reflect an ability to weigh the risks and benefits of the information. But if they're showing signs that the illness itself is interfering with the decision-making process, so they, despite a history in the past of improving with medication, if they're adamantly denying any improvement and you talk to them, remember last time you were in hospital, we gave you this medication and you were able to go back to work and we discharged you from hospital and you were doing great.

  Kendra Naidoo: [00:33:11] If they're still adamantly denying that, then that may be an indication that they're not able to weigh the information. Right. The last piece that's really critical because we as we said, we're focusing on the ability to understand and the ability to appreciate not actual appreciation and actual understanding. We have to ask ourselves, why did they lack this ability? Why don't they understand or why don't they appreciate? And we need to show that it's because of the mental condition itself. There are a lot of reasons why somebody may not actually understand or appreciate information. If there's a language barrier, for example, if they have particular communication difficulties that mean they can't take in complex ideas and need it to be presented to them in simple, concrete terms, maybe they have a poor relationship with the physician and that interpersonal difficulty is getting in the way. Those are all reasons why they may lack understanding or appreciation, but have the ability, if the information was presented to them in a way that was consistent with their learning needs. So you have the final part of the test is getting to the point where it's the illness itself or it's the condition itself that is interfering with the decision-making and not other factors that could be mitigated.

  Alex Raben: [00:34:27] Right. That's helpful because that helps me understand this word ability and why that's so important. It's you have to go to the necessary lengths to make sure you're testing the ability. And it's not for other reasons.

  Kendra Naidoo: [00:34:40] Exactly.

  Alex Raben: [00:34:41] And it also sounds like it really does require some drilling down and some time you have to spend some time on this to really understand the capacity of the person you're you're seeing.

  Kendra Naidoo: [00:34:55] I would agree with that completely.

  Alex Raben: [00:34:57] Yeah. And then I guess we've talked about appreciation a bit more than understanding, and perhaps that's because it's the one that comes up a bit more often. But are there like what kind of cases would we see that might involve debt understanding peace.

  Kendra Naidoo: [00:35:14] So someone might lack the ability to understand, for example, if they have extreme memory deficits. So when you tell them something within a couple of minutes, they're not able to recall that information if they have extreme thought disorganization. So they can't process the information that you're giving them. The other time it may come up is if the person's mental condition leads them to be so disregulated or agitated that they cannot sit and sustain a conversation for any meaningful period of time. And that's because of the illness that may reflect an inability to understand because they can't taken the information. So it's really referring to cognitive deficits that prevent them from receiving or retaining the information.

  Alex Raben: [00:36:01] Right.

  Bruce Fage: [00:36:03] So it sounds like it's a really high bar to deem somebody incapable to consent to treatment. And I think within mental health, we want to support people to make the best decisions that they can and work with them to develop a plan to meet their goals, to make sure they're living the kind of life that they want to live and helping them manage symptoms. Once you if you think somebody is incapable, what practically happens? Are there forms? Who do you have to tell?

  Kendra Naidoo: [00:36:34] So it depends on the setting that you're in. If the finding of incapacity is being made in a psychiatric facility and it relates to a psychiatric medication, so medications to treat the mental condition, then they have to receive what's called a Form 33. And that's a formal notice to them that a finding of incapacity has been made and they have a right to retain a lawyer. They also have to receive rights advice similar to the rights advice that's provided for an involuntary detention. And they have the rights adviser will meet with them, explain what it means to be found, not capable of consenting to that particular treatment. And they have a right to apply to the consent and capacity board for a review of whether they meet or don't meet that two-part test for capacity.

  Bruce Fage: [00:37:20] And if they are found to be incapable and the ECB upholds that finding, who decides?

  Kendra Naidoo: [00:37:29] So then a substitute decision maker is identified, and neither the health care team nor the patient get to choose the substitute decision maker. There is a hierarchy, a list that is set out in the Health Care Consent Act that determines who will consent the high from starting from the highest ranked. It's a guardian of the person. So that's appointed someone appointed as the decision maker by the court, followed by a power of attorney for personal care, then someone that has been appointed by the ECB. And then after that we get into family members. So first a spouse or a common-law partner, then a parent or a child, then siblings, and after that, any other relative.

  Bruce Fage: [00:38:14] And what if the person doesn't have anyone available in their life who could provide that consent?

  Kendra Naidoo: [00:38:20] So if none of those people exist, then the Office of the Public Guardian and Trustee, which is an office of the government that is specifically designed for decision making, they will become the substitute decision maker.

  Alex Raben: [00:38:33] What happens in that period where you've found someone is incapable of making a treatment decision and they've decided that they disagree and they are going to appeal to the ECB, the consenting capacity board. Can you can you start the treatment? Well, we're waiting for the ECB. Can you look what what happens in that period while you wait for the ECB to decide one way or the other?

  Kendra Naidoo: [00:39:05] So if the patient has indicated an intention to apply for to the CCB (Consent Capacity Board), then no new treatment can be started for the next 48 hours. When I emphasise new treatment, because if they have already been on treatment, then that treatment can continue, provided you have the consent of the substitute decision maker. But you can't start any new treatment in the category that they've been found incapable for until 48 hours has passed at 48 hours. If they have not applied the consenting capacity board, then the new treatment can be commenced. If they have applied to the ECB, then the new treatment cannot be commenced until after the ECB has rendered their decision.

  Alex Raben: [00:39:49] And what qualifies as indicating that they want to go to the ECB?

  Kendra Naidoo: [00:39:54] It's I'd say it's a relatively low bar. Not everybody is sophisticated enough to voice the words I want to apply to the ECB, but in the process of providing them rights advice, following the finding of incapacity, it will be explained to them that there is this tribunal who reviews these decisions and they will be asked, Do you want do you disagree, and do you want to challenge the physician's finding? And it's really any statement by the person that they want to exercise that legal right. So they might say, I want to go to the ECB, but they might say I want a lawyer or I want to challenge or I want to appeal. And that would all be indications that they want to exercise that legal right. So something that sounds like that.

  Alex Raben: [00:40:38] Right. And then they have 48 hours to make that decision. After that be able to start the treatment.

  Kendra Naidoo: [00:40:47] Right.

  Alex Raben: [00:40:47] Gotcha. And what about stopping treatment.

  Kendra Naidoo: [00:40:50] If the treatment is not medically recommended or is otherwise harmful to the patient, then absolutely, you can stop it. Okay. Yeah.

  Alex Raben: [00:40:58] So let's say you go to the ECB. What happens then?

  Kendra Naidoo: [00:41:06] So the ECB will render a decision within one day of the end of the hearing and they will either confirm or revoke the finding of incapacity.

  Bruce Fage: [00:41:19] And is there any step after that? Like what if the patient disagrees with the finding of the ECB?

  Kendra Naidoo: [00:41:25] So any party to a hearing before the ECB and it could be the health care practitioner if the finding was overturned or it could be the the person who's subject to the finding. If the finding was upheld, either party has a right to appeal the decision to the Superior Court of Justice, which is the next level of court, and then the Superior Court would review the decision and decide whether it was reasonable. If the person does file an appeal of the ECB decision, then that new treatment cannot be started until the appeal has run its course and the court has rendered a decision.

  Bruce Fage: [00:42:04] And I imagine that can take a while.

  Kendra Naidoo: [00:42:06] It can. It varies by region, but it's not a very fast process wherever you are in the province.

  Alex Raben: [00:42:15] And let's so let's say that you have a patient and they've exercised their right to go to the ECB. You've you've put forth the treatment of anti-psychotic and now the ECB has found that actually they are capable of making a decision around that and but but they're involuntary. So now what do you do in that scenario? Because they're you're holding them in hospital, presumably to treat them. But now your hands are kind of tied in a way.

  Kendra Naidoo: [00:42:48] That's a very challenging clinical scenario. And I'm glad you raised that point because it's it's an important aspect of the fact that, as we talked about at the beginning, hospitalisation is governed under the Mental Health Act, but treatment is governed by the Health Care Consent Act, which means you can have people who are incapable of consenting to treatment but don't meet the box or Box B criteria and so cannot be detained in hospital. Conversely, you can have someone who is meeting the Box A criteria and so involuntarily detained but is capable and so refusing treatment. At that point it becomes a case of clinical judgement. If you cannot treat the person, what is the purpose of the hospitalisation and what is the goal of the hospitalisation? Maybe because the person is capable, maybe you can work with them to bring them around to consenting to the particular treatment. Maybe you can look at what is it about the treatment that they are objecting to? Is it the side effects? Is it that they don't want a needle and would prefer to take oral? Is there some kind of compromise that you can arrive at? And if they are adamantly, capably refusing that treatment, then you would have to consider what is the goal of this admission and should it be continued. And I would certainly encourage all medical learners, obviously, to speak to their staff and consult with the administration of the hospital on those kinds of decisions.

  Alex Raben: [00:44:22] Right.

  Bruce Fage: [00:44:22] Yeah. Thanks, Kendra. I think I think that's a really great point in that the loss is perhaps a bit more black and white than the clinical reality in any capacity assessment needs. If you're a psychiatrist or a resident or a medical student who's working with a patient who's admitted to the hospital and voluntarily and you're trying to do a capacity assessment, you really need to do a thorough assessment and understand the person's values and their perspective and their rationale for making whatever decision that they're choosing to make and really trying to help support them to make the best possible choice for them. So it is important to look at all of those things that you mentioned and not simply take away somebody's right to to decide for themselves if you don't like the choice that they're making.

  Kendra Naidoo: [00:45:11] Absolutely.

  Alex Raben: [00:45:13] So, Kendra, sorry, you were mentioning that that was the way of making a finding of incapacity if you're in a hospital. But what happens if you're in an outpatient rotation or you're seeing someone outside of hospital?

  Kendra Naidoo: [00:45:25] So if the finding of incapacity is made in a non-schedule one hospital or in the community or it relates to non-psychiatric treatment, then there is no form 33. The physician documents their assessment in the finding and then the physician has to deliver rights advice. So that involves informing the patient of the finding of incapacity, informing them that that means a substitute decision maker will be making the decision for them, informing them that if they disagree with the identity of their substitute decision maker, they have the right to apply to the ECB for a different substitute decision maker and informing them that if they disagree with the finding of incapacity, they have a right to apply to the ECB for that. If the person indicates that they want to make either of those applications to the ECB, the physician then has an obligation to assist the person in making that application. How far you have to go to assist is really going to depend on the individual person. If they're able to do it themselves. It may involve just pointing them to the ECB website or helping them print off the form. But if they have more functional impairments or the physician believes they wouldn't be able to do it themselves, it may be all the way down the spectrum of filling out the form with them and faxing it off to the ECB, and that delivery of rights advice should be documented. And the person doesn't see a rights advisor from the PPO.

  Alex Raben: [00:46:54] Right. And on the topic of helping the patient get rights advice, I've also seen like calling up the rights advisor and like being there with the phone and that kind of thing as well.

  Kendra Naidoo: [00:47:07] Absolutely. If the person is not in a psychiatric facility, the rights advisors won't come and see them. So that's where the physician may call the ECB with them or help them fill out the form and fax it. But if they're in a psychiatric facility, any time a patient wants to speak with an advisor or have access to their legal rights or wants to speak to a lawyer, if they don't have one, then helping as much as you can to facilitate their access to the rights adviser is the best thing to do.

  Alex Raben: [00:47:34] Right. So the big differences are no form 33 and you as a physician or as a health care team, have to help facilitate the rights advice.

  Kendra Naidoo: [00:47:45] Right? You deliver the rights advice.

  Alex Raben: [00:47:47] Okay. You you actually deliver it? Yeah. I have a question around documentation, because often, I mean, it's always important to document it a medical legally safe way. And in particular when things go to the ECB. Your notes are often used as I don't know if evidence is the right term, but it's used it's reviewed in the ECB. So how should residents and medical students document capacity and also like involuntary making someone involuntary?

  Kendra Naidoo: [00:48:22] Often and thoroughly. I think, you know, the best thing you can do to set yourself up for the ECB is to be really familiar with these legal tests. And when you're doing these assessments, document them in relation to the legal tests. So when we're talking about involuntary detention, being very thoughtful in your documentation about which on which criteria am I relying, is it the box or the box be criteria? Your documentation should reflect that. It should reflect are we relying on serious bodily harm to others, serious bodily harm to self serious physical impairments? Here is mental deterioration. And what are the factors or the indicators or the evidence that have led me to that decision? When documenting a capacity assessment, it's very important to document all of the information you have given to the patient because otherwise you're exposing yourself to an allegation that you cannot possibly have assessed their ability to understand and appreciate information if it hasn't been given to them. So all of the information that you've given to the patient and their responses to that information. Right. Another tip is to write your documentation using the language of the legal tests. So the test for involuntary detention requires a likelihood that the mental disorder is likely to result in one of the harms. So language likely is really important. Avoiding words like might or could or may because the legal threshold is a likelihood. Similarly, when you're doing your documentation of a capacity assessment, avoid terms like patient disagrees. They have schizophrenia because of course they don't have to agree that they have schizophrenia. So documenting in accordance with you've you've informed them of their symptoms. If you've expressed to them the manifestations of their illness, remember to document it in terms of a mental condition and not do what I just did, which is refer to it as a mental illness or a mental disorder mental condition. And remember, that key is ability to understand and ability to appreciate, not actual understanding or actual appreciation.

  Alex Raben: [00:50:39] Right? That makes a lot of sense. And then springboarding from that. Still on the topic of documentation, another thing that comes up for medical learners and it's happened to me the other night, I was on college campuses messing up, filling out a Form One because it's kind of a it's a long ish form and there's lots of tick boxes and things that can be forgotten. Why are we so finicky about that and what happens if we do mess up?

  Kendra Naidoo: [00:51:12] So it's a three-page form, but in the context of evenings, I know in the emergency department things are very busy. There's a lot of boxes and a lot of lines to sign and things can go wrong. I think we are really invested and certainly the consent and capacity board is really invested in seeing those forms being filled out, right, Because the powers that the legislation confers on physicians to impact people's rights is so profound, right? There is no other area in our law or in our society outside of the criminal law where an individual person can sign a piece of paper and have somebody detained. So the the information on the form is critical for the patient to understand what is happening to them. It's critical for an evaluation of whether all of the right steps were met. And so it's very important that those films be filled out correctly. That said, things happen. People, you know, counting hours is sometimes complicated. People make typographical errors and things happen. If there's an error on the Form One, the best thing to do is to fill out a new form one deliver a new form 42 to the patient and try to be mindful of not extending the length of the detention because we made an error. So if a Form One is filled out and the error is not discovered until 48 hours later, we fill out a new form one at that 48-hour mark rather than counting. From 72 hours from that 48 hours, which results in a five-day detention. Being mindful that we should be still making that decision about discharge, admit voluntary, admit involuntary within the original 72 hours to be respectful of the rights of the patient and not unnecessarily delay their detention and their access to the legal rights that they have.

  Alex Raben: [00:53:15] So you would backdate it to when the form was originally filled out. Would that be the way of handling that?

  Kendra Naidoo: [00:53:23] Well, when you when you sign the form, the date and time of your signature would be the date and time that you signed the form. I see. But you could write on the there's a portion on the form that says date and time detention commenced. You could write 48 hours ago. Right. And then I would also recommend just putting a little notation that says form redone because of typographical error, just so that it doesn't look like you didn't sign the form until 48 hours after the detention commence. Just so anyone looking at the face of the form can sort of identify what happened and why the dates are a little skewed.

  Alex Raben: [00:54:00] That makes sense. And just for our listeners, because these forms can be a bit tricky, especially at first to get used to filling out. And it's hard for us to describe all the various boxes in an audio format. We will link to a visual walkthrough in our show notes. This was done by a psychiatrist here at IMH, Dr. Patricia CAVANAUGH, and I think it will help you guys to learn how to fill them out.

  Bruce Fage: [00:54:27] So, Kendra, thank you so much for taking the time to meet with us and share your knowledge. Involuntary hospitalisation and capacity assessment can be very challenging aspects of providing psychiatric care. I think certainly for patients and their families, but also the mental health care teams that support them. I think it's extremely important that patients receive due process and that their legal rights are respected and I'm glad that you are around to help us navigate that process. Thanks so much for coming in.

  Kendra Naidoo: [00:54:53] Thanks for having me.

  Bruce Fage: [00:54:54] And thanks to all of our listeners. We'll see you next time on PsychEd.

  Alex Raben: [00:54:57] Thanks, guys. PsychEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced by Bruce Phage and hosted by Bruce Fazio and Alex Rabin. Audio editing was done by Alex Rabin. Our theme song is Working Solutions by Olive Music. A special thanks to Kendra Naidoo for serving as our expert on this episode. We look forward to your comments and feedback and you can contact us at Info@psychedpodcast.com or visit us at Psycedpodcast.org. Thank you so much for listening!

Episode 14: Diagnosis and Treatment of PTSD with Dr. Dana Ross

• Episode 14: Diagnosis and Treatment of PTSD with Dr. Dana Ross

  Lucy Chen: [00:00:03] Hey there, podcast listeners, this is Lucy Chen. I'm a PGY4 for psychiatry resident at the University of Toronto. Today, I'm going to be hosting an episode on post-traumatic stress disorder. I'm here at Women's College Hospital with Dr. Dana Ross, who I had the pleasure of working with as a PGY2 psychiatry resident, and also attended some of her interesting trauma workshops. So maybe without further ado. Dr. Ross, maybe you can tell us a little bit about yourself and your work with trauma and treatment and diagnosis.

  Dr. Dana Ross: [00:00:37] Absolutely. Thank you for having me. So my name is, as you said, Dr. Diana Ross, and most people call me Dana. And so you're most welcome to as well. I am working at Women's College Hospital in the trauma therapy program, which is an outpatient trauma therapy program, where we see people who have a history of childhood trauma and that can be all kinds of trauma. So sexual abuse, physical abuse, neglect, abandonment, psychological abuse, all of that kind of a thing. And we do a lot of group work and then we do some individual as well. And in terms of my background, I did my medical school at the University of Calgary and I came and did residency at Queen's University for my first year and then came to Toronto to finish my residency here.

  Lucy Chen: [00:01:19] That sounds great. So maybe I'll right now cover some of the objectives that we're targeting for this episode. And Dr. Ross really kind of created some specific objectives, so it'll help us with guiding the episode. So the objectives are to cite the prevalence and incidence rates of post-traumatic stress disorder or PTSD. Recognise the clinical features of PTSD using DSM five diagnostic criteria. List five Common Risk Factors for the development of PTSD. Identify three neurophysiological mechanisms underlying PTSD. Differentiate the three stages of trauma therapy. Describe evidence-based pharmacological and psychological treatments for PTSD. So we're covering a lot. So we'll do our best. So, Dr. Ross, why don't we start with, like, I guess, like the prevalence rates or how common PTSD is, how common trauma is?

  Dr. Dana Ross: [00:02:22] Absolutely. So when we talk about prevalence, there's a lot of different studies on there's sort of a wide range of figures. And we'll talk a little bit about why that is as well. So we know that although about 50 to 90% of the population may be exposed at some point in their life to traumatic events, most people don't actually go on to develop PTSD, which is an interesting thing to think about. And I think later we're going to circle back around to talk about some of the factors that actually contribute to developing PTSD. So what we do know is the lifetime prevalence of PTSD ranges from about 6.1 to 9.2% and national samples just in the general population in the United States and Canada. And within one year, the prevalence rate is around 3.5 to 4.7%. And as I was mentioning it, it can be difficult sometimes to get an accurate rate there. And one of the reasons for that is that people may have symptoms of PTSD for many years before they actually seek treatment or they may have sub-syndromal PTSD. So the prevalence rate of PTSD may actually be underreported. So we do know that the prevalence of PTSD is considerably higher among patients who seek general medical care and among persons who are exposed to anything like a sexual assault or mass casualties, including, of course, war, national natural disasters and in refugee populations. And of course, in the veteran community. Different studies show prevalence of PTSD is somewhere between 10 to 30%.

  Lucy Chen: [00:03:50] Mm hmm.

  Dr. Dana Ross: [00:03:51] We also know that the lifetime prevalence of PTSD is higher in women than in men, and it's higher in the presence of underlying vulnerabilities such as adverse childhood experiences. We'll talk a little bit more about what that exactly means down the road and if people have comorbid diagnoses as well. And I think one of the most important things we need to know is that it's extremely common for people in mental health settings to have a history of trauma which may or may not include a diagnosis of PTSD. And so when we're working with people in the health care field, in mental health, I think it's very helpful for us to be holding a sense of that prevalent.

  Lucy Chen: [00:04:28] This also it makes me think about like what's considered a trauma or like how I suppose in DSM five, it's something very specific, but lots of people will say, Oh, that was so traumatic for me. Or, you know, we talk about PTSD in a sense that it kind of it's just general symptomatology in response to trauma. But maybe we can better define and clarify that understanding of what a trauma really is.

  Dr. Dana Ross: [00:04:53] Absolutely. It's a great conversation in the field. I think what is trauma and also just in a wider society. It's a great conversation that's going on. And so certainly I don't have the the one and only definition of trauma, but let's break into it a little bit. So if we look at the definition of trauma in the DSM five, we can start with that criterion, A, which is that exposure to actual or threatened death, serious injury or sexual violence in one of the following ways. And they include directly experiencing, witnessing, learning about it happening to others or experiencing repeated extreme exposure to the details. So for example, police officers, officers and that kind of thing. And so that's sort of the formal definition. But if we talk and think a little bit about the the less formal definition of what is a trauma, it can be anything from a single experience to multiple experiences. And it's often something that just completely overwhelms the individual and their ability to cope, to integrate things like ideas and emotions that are involved around that experience. And it can take a really serious emotional toll on those who are involved, involved in that kind of a trauma. It can have an impact on things like a person's identity, their sense of self, and really result in negative effects in mind, body and soul and spirit. Really often there are four elements that are identified in trauma.

  Dr. Dana Ross: [00:06:15] So one was sometimes it's often or often it was unexpected. The person was sometimes unprepared for the trauma. There was nothing that the person could do to stop it from happening. So that sense of helplessness or lack of control and again, just the traumatic events were beyond that person's control. So those are more not formal definitions, but often I find key components of traumatic experiences for people. But certainly the scope of trauma and what is or isn't trauma I think is a larger conversation for us as a again, as a society and for us within the field of trauma as well. But it encompasses a wide variety of experiences like physical abuse, sexual, emotional violence, abandonment, neglect, of course, domestic violence and trafficking, all kinds of things around significant invalidation neglect that can happen. Harassment, discrimination. We see a lot of things around class and race, sexual orientation, age, religion, disability, gender, things like, of course, war, refugee populations, economic stress, mental physical illnesses, natural disasters. And then I think it's important when we're thinking about trauma to that, we think about it broadly. So trauma can be an experience of the individual, but it can also really be propagated and experienced through organisations and institutions. It can be embedded in cultures and communities, take place with service providers and families as well.

  Lucy Chen: [00:07:46] This concept of like sub-syndromal PTSD, and I also think about invalidation or, you know, someone growing up with a really sensitive temperament to sort of parents that were a poor fit or and I wonder about like how that manifests. Like it's not sort of like a serious threat to their life, but they I guess I'm curious about this idea of like complex PTSD or like some of these other sort of manifestations of PTSD that are not clear cut, but they clearly are distressful. We clearly see it.

  Dr. Dana Ross: [00:08:19] Absolutely. So in the DSM five, right now, we have PTSD, but we don't have complex PTSD. And so those who work in the field of trauma are pretty familiar with the idea of complex PTSD. However, because that, especially in my identity, is actually what I see. And so the diagnosis of diagnosis of complex PTSD is actually in the ICD 11, which is that international classification of diseases 11th revision, and it really defines it as arising after exposure to an event or a series of events of an extreme, extremely threatening, horrific nature. And what they really underscore there is that it can be prolonged. It's often about repetitive events that were difficult to escape or impossible to escape. It can cover a whole bunch of stuff like childhood abuse, repeated childhood sexual, physical abuse, torture, slavery, genocide, domestic violence, and all of the core symptoms that we find in PTSD are under that umbrella of complex PTSD. But it adds a few other things in there that I think are really important. And one of the things that we really see a lot with complex PTSD is really difficult abilities to regulate affect.

  Dr. Dana Ross: [00:09:28] So moods are up and down and all over the place, and that can be really disruptive for people in their sense of who they are and their sense of their ability to function and their day to day life. It also encompasses a lot around sort of beliefs about oneself. A lot of people hold this idea in complex trauma of I'm worthless or I don't have value, and so it really hits those kind of core components of self. Other things that it touches. And I think this is one of the most important things we see as well here, is that it leads to a lot of difficulties in relationships, not just the relationships with self, which we've touched on, but also relationships with others, boundary issues, issues around trust. People can get into repetitive patterns of behaviours and relationships that are really rooted in past trauma. And so that's a lot of the work that we do here. And there's a whole bunch of stuff around dissociation, forgetting cognitive impacts. And again that kind of identity disturbance piece I think is a big one.

  Lucy Chen: [00:10:30] Yeah. And I suppose it's naturally kind of leads into us into a discussion about like the DSM five criteria for PTSD, which I think covers spans like five pages or like really if you we have it like next to us right now, like it's kind of daunting sometimes when we kind of look through the criteria to be able to then make sort of a confident diagnosis of PTSD. So maybe you can give us some tips on how to navigate that.

  Dr. Dana Ross: [00:11:01] Yeah, absolutely. I think the four symptom clusters are really important to just have a handle on the number one thing being avoidance. So avoidance of anything that reminds you of the trauma, that brings up emotions, feelings, people, places are avoided. And it's sort of the bedrock of trauma in some ways because on one hand, we're very happy that people have that ability to avoid because it allows people to live, to survive, to get through their day to day and not be completely overwhelmed and not functioning because of the experiences of trauma in their life. At the same time, avoidance really helps PTSD stay stuck because if you're not sitting with those emotions or body sensations or experiences, there's no chance to process them and to move through and past them as well. And so the other categories are that re-experiencing of past traumatic events like flashbacks, that kind of a thing. That's an important category as well. And then the other categories are negative changes on cognition and mood, which is a lot of people will say, you know, I have a lot of trouble holding on to positive emotions. I'm really stuck in those negative emotions, or sometimes I'm hardly feel any emotions at all because they're so shoved down, because they're so painful and so overwhelming.

  Dr. Dana Ross: [00:12:22] And then the hyperarousal symptoms are probably something we see a lot of as well, which is holding that kind of tension and stress, being really concerned about safety, all of those kind of things. And so one of the mnemonics we can use is traumatic to remember some of these things. So the T is for trauma, which is reminds you about that criterion. A The R is for re-experiencing, the A is for avoidance. The U is for Unable to Function, which is a criteria for all of our disorders. The M is for the one month criteria. So for PTSD we want to have those symptoms lasting for more than a month. A is for arousal, Two is for two specifiers; so there's Depersonalisation and Derealisation of specifiers. And I think we'll talk about that in various ways over this podcast. And then I is for illness, so it's not due to an illness, substance or general medical condition and C changes in cognition and mood.

  Lucy Chen: [00:13:23] So just to summarise, so there seems to be so there's four symptom clusters that we can organise PTSD into in terms of symptomatology. So one of them is intrusion symptoms, the other is avoidance, the other one is negative mood and cognition. And the fourth one is arousal and reactivity. And it sounds like dissociation symptoms. They can emerge in PTSD, but we sort of indicate the existence of them through specifiers.

  Dr. Dana Ross: [00:13:51] That's correct. And so that's a new one for DSM five. We didn't actually see that in DSM four. Tr And what they're talking about there is really there's a big prevalence of dissociation in people who've experienced trauma and dissociation in its most simple way of understanding it I think is about disconnection. So it's disconnection from your self, disconnection from others, disconnection from the world, and that can look like a lot of different things. But two of the really common ways that people dissociate are depersonalisation, which is that disconnection from yourself. And so when I'm talking to people about what that looks like and feels like, people will say, I actually feel sometimes like I'm floating above myself and just watching what's happening. Or they'll say, I feel like and actually I'm actually just a brain walking around. I don't even feel a sense of connection to my body or I don't feel anything below the neck or I feel just not real. That's something that's not to the point of being psychotic, but there's a sense of unreality to their being in. The world and then do you realisation is that disconnection from their surroundings, from the world? People describe that sometimes as it's like I'm watching a movie of my life but I'm not participating in it or people will say there's like a fog between me and the world or like a pane of glass. Everything is sort of happening. I can see it, but I'm not in that flow of life. There's no vitality in there for me.

  Lucy Chen: [00:15:17] And so in PTSD, are all patients supposed to have like one of each symptom cluster. So what I have here is that it has to be one or more of those intrusion symptoms, one or more of those avoidant symptoms, and two or more of the negative mood and cognition symptoms and two or more of those arousal and reactivity symptoms.

  Dr. Dana Ross: [00:15:43] Yeah, that sounds correct. And there's under those I think you'll go through the criteria in more detail. So there's it can look very different for different people because there are a number of symptoms that fall under the DSM five criteria. But I think those having something from those categories in the number that you said, I think that's fairly accurate to what we see.

  Lucy Chen: [00:16:02] And just in terms of timing to I wonder about like the one month of of symptomatology compared to someone who would kind of maybe have some of these symptoms after a traumatic event only lasting, you know, a couple of days or a few weeks. And maybe this leads into this idea of a risk factors. But what makes someone predisposed to having these symptoms for longer and really turning in and manifesting us as this disorder?

  Dr. Dana Ross: [00:16:30] Yeah. So we think about when we're less than a month, we think about acute stress disorder as a possible diagnosis, and then after a month, we're thinking more about that PTSD. So there are risk factors for developing PTSD and those are numerous, but there's different studies that show a little bit of slightly different things. But some of the things that come up are a female gender, the age of the trauma. So if people are younger age, they're more likely to go on to develop PTSD. Being separated, divorced, widowed, having previous trauma, of course, increases your risk of then developing PTSD as well. Having a lot of history of general childhood adversity, adversity, which we'll talk a little bit more again, having a personal or family psychiatric history, poor social supports. And I think there's probably a number of other things as well. But those are the things that kind of come to mind.

  Lucy Chen: [00:17:25] We were sort of indicating that, you know, the five most common risk factors for the development of PTSD. So we talked about sort of childhood adverse events. I guess it's I guess like thinking about PTSD in the sense that it's so it's also it's so comorbid with multiple other DSM five sort of diagnoses. How to tease that out is sort of is MDD sort of a predisposition to PTSD? Does PTSD lead to more MDD? Are substances, I can imagine substances kind of perpetuating avoidance of certain traumatic events which can maybe lead to more PTSD. I suppose it's quite complex, but maybe if we can kind of maybe outline five particular common risk factors for the development of PTSD.

  Dr. Dana Ross: [00:18:15] Sure. Do you want me to talk about comorbidity a little bit in there as well?

  Lucy Chen: [00:18:18] Yeah, that'd be great.

  Dr. Dana Ross: [00:18:20] Let me start there and then we'll we'll kind of see where we go. Yeah, I love talking about comorbidity, actually, because I think it's really the bedrock of psychiatry generally, and certainly it's the rule in PTSD rather than the exception. And so when we look at comorbidity comorbidity rates, we can see that in the National Comorbidity Survey. It suggests that 16% of people with PTSD have at least one existing psychiatric disorder, but actually 17% have two, and up to 50% have three or more comorbid psychiatric disorders when they have a diagnosis of PTSD. So again, when we're working with people who've experienced trauma, who have a diagnosis of PTSD, we really need to be thinking about what else might be complicating that picture, adding to either increasing the risk of developing PTSD or just being more morbid and making that more of a complex picture. So in terms of comorbidity, we know that substance abuse is really a high rate of comorbidity with PTSD up to like 60 to 80%, depending on what studies you're looking at. And that can be all kinds of different addictions, but substance abuse, alcohol, cocaine, whatever it is, we have to think about that as a way to modulate some of the symptoms of PTSD, some of the feelings, some of the body sensations and stuff like that as well. And so when we're asking about PTSD, we want to always be asking about substance abuse, depression as a huge one. Again, depending on the study, it can be up to 65% of people with PTSD who have comorbid depression and anxiety, social anxiety, panic disorder. Those are very common and I'd say clinically, a majority of people that I see who have trauma also have anxiety and depression both now and often throughout their lifetime. There's a whole bunch of other stuff too; brief psychosis, somatization disorder, eating disorders can be really aligned with that as well. Pain disorders, Dissociative disorders, of course, and personality disorders, including BPD, can be associated as well.

  Lucy Chen: [00:20:30] You know, and it makes me think about these are all manifestations of how people end up coping with trauma like or maladaptive coping, rather. I can see how so many people there's such a diverse range of ways that people can end up sort of like maladaptive, trying to handle what they've experienced.

  Dr. Dana Ross: [00:20:50] Absolutely. I often think about and I think there's a discussion in the field as well about even the title PTSD or post-traumatic stress disorder. Because when we see people and they've been through these horrific experiences in their life, the way that those symptoms are coming out and the behaviours that people have make complete and total sense given their history and their experiences and they make sense as a way to self protect, to cope, to be able to function. And so if we look at the disorder of PTSD through that lens, it really isn't in some ways a disorder. It's actually a very human, very understandable way of coping. But PTSD gives us a framework for understanding it. And of course, it can be very helpful to have a diagnosis, to do research and to lead treatment as well.

  Lucy Chen: [00:21:36] Yeah, that sounds like it'd be so helpful for someone encountering someone with PTSD, kind of having a trauma-informed approach, but understanding where those avoidance symptoms are coming from that it's really it's for it's for survival, it's for self maintenance. It's being able to to sort of navigate what they're going through and maybe being able to understand that and kind of communicate with the patient could be a window into better being able to relate with these patients.

  Dr. Dana Ross: [00:22:01] Absolutely. I think a lot about when I'm sitting with somebody and they're telling me what they're struggling with, thinking about what are the advantages and disadvantages of the behaviour, the thought process, the way that they're dealing with emotions because there's something protective in there, there's something that makes sense and I think it's our job together to try and figure that out. And when you're taking away that kind of judgement or and you're sitting in that again, trauma-informed kind of way, which means really holding the idea and the knowledge about the prevalence of trauma, knowing how common it is in patient populations and holding that in mind when you're doing interviews, when you're designing spaces, all of those kind of things. But if we can sit with people from that kind of a lens, this work just becomes even more interesting, even more collaborative. And I think this I can't even think of another way to look at it at this point in my career.

  Lucy Chen: [00:22:52] I suppose that's kind of also leads us into this idea of like how people manifest trauma in their body and like what's really happening in neuro physiologically. And I guess this idea of like hypervigilance and I think about the HPA axis, but there clearly is some underlying neurophysiological sort of understanding of PTSD.

  Dr. Dana Ross: [00:23:16] I think that's a great question because what we're learning more and more in the field of trauma is exactly how much of trauma is really held in the body and experienced in the body. And so that can look like a lot of different things for people. A lot of people are really dealing with tension throughout their body and with pain that gets either brought up or exacerbated by all of that tension, by all that stress that people hold, a lot of people hold a lot of the abuse that they've experienced in their body. And so a lot of people are very also disconnected, not having sensations or feeling any kind of connection with their body. Of course, it impacts people sexually as well. If you have a difficult relationship with your body, especially if you have a history of childhood abuse, I actually forgot what your question was now.

  Lucy Chen: [00:24:04] The sort of the underlying neurophysiological underpinnings, underlying PTSD.

  Dr. Dana Ross: [00:24:09] Yeah, absolutely. So I think there's a couple of things to think about are a few things that we can think about when we're thinking about neurobiology. So there's kind of four areas of the brain that I tend to think about. I think about the hippocampus, the amygdala, the prefrontal cortex, and I also think about the brain stem. So what we know is that when we're really feeling threatened, the body releases stress hormones, including things like cortisol, adrenaline, and those are really going through the body and having a profound impact. And so what we know from research is that something like cortisol can actually damage cells in a part of the brain called the hippocampus that's really responsible for laying down and integrating memories. And so often when people are really struggling with memories and. Trauma. There's actually a way for us to kind of understand why that might be. We also know from research that people on imaging have had a smaller hippocampus, and that can also contribute to difficulties with learning and memory, because that's a big centre for those two important functions. But what we do know is that the more we're learning about the brain, the more we're learning about neuroplasticity, that we can make changes in the brain through medications and through psychotherapy. And there's a lot of hope in the field of trauma because of that. We also think about the amygdala a lot and we talk about the amygdala in psychoeducation when we're working with patients as well.

  Dr. Dana Ross: [00:25:30] So we think often about in a very simplified way about the amygdala as a fire alarm in the brain. And so when people are triggered or stressed that amygdala is firing fire and firing and really taking over the show, and what it does is it kind of shuts down our frontal lobes, which is where we're thinking, planning like kind of more rational, logical kind of stuff. And when people are triggered, they often report, you know, I can remember what my skills were. I barely remembered my name. Sometimes I don't even know where I am. And I'm just completely overwhelmed by this emotional, physical response to being triggered. And the amygdala, when it's kind of taking over in the brain, can be largely responsible for that as well. And so what we're thinking about when we're thinking about learning skills, all of those kind of things, learning strategies and techniques to work with patients, we're thinking about how can we calm and soothe that amygdala, get that frontal lobe back online or those frontal lobes back online, and help that person be able to access both their emotions and their rational thought at the same time. And the other big area that we think about is the what we call the survival responses, which is like fight or flight freeze collapse. Most people are pretty familiar with fight-flight, which is that urge to either lean in the anger or the fight, or sometimes to run away. And sometimes we'll have people just get up in the middle of a group and kind of leave because it's such a strong urge.

  Dr. Dana Ross: [00:26:58] And the freeze response is sometimes not as familiar to people. So that's a really high energy state along with the fight-flight, where people are really experiencing those high stress hormones, but they're feeling actually frozen. Sometimes it's literally they can't move and they're frozen. But inside it's this high energy, frightening, overwhelming kind of environment. Or sometimes people are actually you wouldn't even know they were in a freeze response. But inside they're feeling that experience. And then the collapse is a low energy kind of state where everything kind of goes into that collapse or feigned death kind of state. And those are four ways of being four reactions for survival responses that we see a lot when we're working with trauma. And so having even just a basic understanding of that allows us to organise our skills and some of the emotion regulation techniques and body techniques we use with people with trauma. And we can really be thinking very specialised for each individual. Are we working with a fight, the flight, the freeze collapse? Is the amygdala really taking over? How much is this person holding this trauma in their body versus are they in a more of an intellectual place? And so all of these kind of things and understanding bring in the neurophysiology helps us personalise the treatment. I think for people.

  Lucy Chen: [00:28:14] For sure.And for me just hearing this right now, it's helping me to kind of take me through the DSM five and really understand I give meaning to some of those symptom clusters, like the idea of the fight-flight freeze kind of maybe leading to some of those hyper arousal symptoms. The idea of sort of the amygdala sort of shutting off the frontal cortex, maybe leading to some of those cognitive symptoms or sort of the dissociation perhaps also as well.

  Dr. Dana Ross: [00:28:39] I like that you brought in that cognitive piece because I actually think we don't talk enough in the field of trauma and working with PTSD about the impact of trauma on cognition. So when I'm actually seeing people for consultations, one of the most common things I'll hear is when I say and what I was. One of the main things that you're struggling with, people will say, I actually think I have Alzheimer's or I think I have dementia. It's such a profound impact on their cognition. So people will say, I can't remember words. My memory is just shot. I used to be able to read. I can't read anymore. I had a conversation with my friend on the phone yesterday and I didn't even remember what we talked about, all of those kind of things. So memory, recall, focus, attention is really negatively impacted as well. And you can imagine if you can't do all of those cognitive functioning skills, how difficult it is to go to work, have a job to do, any kind of activities, go to school, to just function at all in your day to day life. And so I think the profound impact that PTSD has, especially when it's also always, not always often associated with depression and anxiety and those co-morbid things like substance abuse and all of those other things we talked about. There are multifactorial reasons. Why people are really struggling with cognition when they've had experiences of trauma in their life.

  Lucy Chen: [00:29:58] And do you see those symptoms reverse through trauma therapy?

  Dr. Dana Ross: [00:30:02] Absolutely. And I think that is a really important message of hope for people. That's when that amygdala settled, when the body isn't going into that fight, flight freeze, collapse response automatically, when people are feeling more in control of their their body, their feelings, their emotions, that there's more room for that frontal lobe, again, to be present, more room to feel kind of in control, to have access to all the memory centres, to have access to thinking and planning and being focussed and all of those things. So I really see people progress through our program and absolutely see changes that are very positive in that arena of cognition.

  Lucy Chen: [00:30:47] And this also it makes me sort of better understand why they're stages of trauma therapy and that the first stage really is about finding safety and then then kind of feeling safe enough to progress through through the rest. But maybe you can better sort of outline what the stages of trauma therapy really look like.

  Dr. Dana Ross: [00:31:06] Absolutely. This is something we explain when we're working with patients. And it's also something that is really important for us to hold as clinicians and when we're doing education as well. So I'd say back in the day, going back in the 30 or 40 years ago when people were thinking about trauma, they often thought about we should jump into it, get into those memories, really tease all that apart in order to kind of have a cathartic experience and really discharge some of that emotion, some of that body sensation. But what they found in the field was that a lot of people, when that happened, they got worse, their symptoms got worse, they regressed. They were feeling much more triggered, actually weren't functioning as well. And so it was pretty obvious pretty quickly that that wasn't a great way to go. And so what happened in the field is this concept of three stages. And so the first stage, as you mentioned, is really about safety and stabilisation. And when people are doing that phase, which in my opinion is really the biggest piece of work that people do, is they're working on things around safety, around housing, around they're working on people if they're struggling with suicidal thoughts or self-harming behaviours, we're really working a lot around affect regulation in that stage. So we're doing a lot of skill-based work and really increasing people's toolboxes in terms of what they can do to self-manage as well. We're doing a lot of psychoeducation in that phase and we're doing a lot of alliance-building as well. A lot of people who are coming into therapy or treatments of any kind who have a history of trauma, have had negative experiences just interpersonally generally or in the health care system.

  Dr. Dana Ross: [00:32:49] And so that's a period of time when we're really working on building trust, having people come in and feel safe in the environment, which is sometimes for some people, they've actually never had that experience of feeling safe in a space with another person in their entire life. So that's a really actually important and big piece of that work. And so the safety stabilisation is about building people's skill set and toolset and self-understanding, self-awareness. And what we see is people's symptoms really go down. People are starting to function a bit better and a lot of people actually don't have to go on to the other stages because they're functioning better, their life is looking better, their relationships are functioning better. And so we see a lot of people in our program who don't go on to the other stages. They're ready to go after stage one, which again, can be a varying amount of time for months to many years for people. It's a very big piece of work that that stage, stage two, we're looking at what we call remembrance and mourning, what we find with people who have histories of trauma, especially we work with people with complex trauma who have histories of child abuse is. That people have missed out on a lot of opportunities in their life because of their traumatic experiences and the symptoms that they've had. And so people do a lot of work around mourning and stage two, which is about opportunities lost, relationships lost. Who would I have been? Who could I have been if I didn't have this trauma in my life? And there's a lot of grief that has to be processed in that stage.

  Dr. Dana Ross: [00:34:18] It's also can be about doing more memory work. And we're not ever digging for memories or looking for memories. We're working with whatever people come with. People can do profound pieces of work in trauma with very limited memories of the traumatic abuse itself. So we don't need to dig for those memories. But some people, when they finish stage one, really feel there's more work to do. There's some sticky pieces in there, and there's something for some people as well around having their story, their narrative witnessed by another human being, by having that validation and that empathy around that and by processing some of those details and some people need to do that work. And that can be very powerful, very important work for people as well. Stage three is about reintegration. So stage three people are starting to move out of trauma therapy. We're really focusing on your support system, getting back into life, redefining who you are. Sometimes when people start trauma therapy, they feel like they are their trauma and they've lost or never had a sense of self. So what we want to see over that course of trauma therapy is people really come in to a stronger sense of who they are, have a stronger foundation under their feet, be able to set boundaries and have healthy relationships and to go and pursue whatever it is that they want to pursue in their lives and be whoever they want to be.

  Lucy Chen: [00:35:39] That's really interesting, this idea that most of the work or a foundational piece of the work is really stage one and that not everyone sort of progresses to stage two. And I find that sort of difficult sometimes when we were in this setting, when we're seeing patients in the emerge or sort of these one time encounters or these limited sort of the limited scope sometimes in which we're able to see patients. And I wonder how we can best help those patients or and figure out who who does progress to stage two and how we can better connect them to resources.

  Dr. Dana Ross: [00:36:10] Absolutely. So one of the things I think we try to do here at U of T is really build more about trauma into the curriculum. And I think that's so important because I know when I did my training, I came and actually was at women's college during my residency and learned a lot of the stage one skills and the ideas and approaches and theories. And what I found was when I then went on call or was in the emergency department, I felt so much more equipped to work with people who are struggling from trauma, not just trauma, but just struggling in general, which is most people who come to the emerge. But I had models. I had tools that I could show and work with, with people who are coming in. And I felt like it was a much more effective approach for me as a resident because sometimes we're so busy, sometimes we can't give as much as we would like to give in terms of time. And so having tools and skills and handouts that you can give to people can be rewarding, I think not just for patients but for us in our work as well. Having said that, in terms of identity-identifying stage one and working with that, most people haven't had a lot of access to trauma work.

  Dr. Dana Ross: [00:37:22] And I think there's a real lack of trauma treatment in the community. And we need to have more people who are trained in doing trauma work in stage two, trauma work in particular, and often people who have really complex histories of trauma and need longer term work, which is of course a problem in our system as we're working on access and and trying to hold all of those principles in mind. One of the biggest pieces that you can do, just based on what we talking about, is have that very basic understanding around the neurophysiology, which I often find when I explain to patients it can be actually transformative for people. A lot of people will say, I feel like I am just a black box of chaos inside. I'm a mess. Everything is. I'm clearly a terrible person. I can't control myself. All of these kind of self judgements that come up around that. When people start to have a real understanding, just the basics of neurophysiology, of trauma and stress, it can be a real shift in decreasing self-judgement and feeling validated and then understanding how and why we apply tools. Because some of, for example, a grounding tool might be to look around the room and name everything that's blue, and sometimes people will think, Well, that's a bit Mickey Mouse.

  Dr. Dana Ross: [00:38:37] I'm kind of looking for a bit more than that. But when we have explained that background neurophysiology, we can say, Well, let's stop and think about that for a moment. If you're taking a moment stopping when you're feeling overwhelmed, looking around the room, you're actually moving your head, moving your eyeballs, you're searching out something that is blue. You have to think about what? Is that colour blue. And then you have to think of the name of the object. You have to say it out loud. There's multiple, multiple steps in that. And that is all about bringing the body back online, calming down from the bottom up, we would say, and top down using turning on that cortex and turning on those frontal lobes to be able to name things, to be able to see the colours, look around, interact. And so we really are using the full body to try and get people more regulated. And so I think when we know some of those really basic neurophysiology pieces, it's very helpful for us to then do some very basic grounding kind of skills with people, and that can be quite useful.

  Lucy Chen: [00:39:34] Yeah. And I think about instances of, like, patients or even myself when I'm in a crisis sort of mode and I can't speak right. It's very hard to find language to represent how you feel or the state of mind that you feel. And it sounds like these are sort of strategies to reconnect with some of the language.

  Dr. Dana Ross: [00:39:55] Yeah, a good point. So one of the big things that can happen with people with any kind of trauma is when you get overwhelmed by it or triggered by it, it takes you back into the past. It takes you out of the here and now. And so people are often in an internal state where they're not here, not present, not taking in the information. And so we are bringing people back into the present. Often people are in a nonverbal state or lost in emotions and feelings that don't have necessarily necessarily words and language that go with them. And so having some of these tools can be really helpful. So one, for example, tool I use a lot is I have people build just a little box at home by a box and put things in it like scented oils or photographs or letters or photos, pictures, that kind of a thing. So it's like a grounding box because when we're really overwhelmed, it's really hard for us to remember, to think about our skills, to remember the steps involved. But when we have kind of a grounding box, we can just grab it. We have it. We don't have to put a lot of thought into it. So it's good to have skills when you're really triggered that work and skills when you're less triggered and you might be able to do more cognitive kind of things.

  Lucy Chen: [00:41:03] That's great. So we've covered a lot of ground in terms of describing stage one, which is safety and stabilization. Stage two, which is..

  Dr. Dana Ross: [00:41:13] Remembrance and mourning.

  Lucy Chen: [00:41:15] And processing a lot of the trauma that sort of residual work from after sort of finding for finding that sort of foundation and grounding and stage three, which is kind of reintegration back into society. So I'm curious now about sort of some of the pharmacological options in treatment of PTSD and then sort of, I suppose, like what's most evidence based.

  Dr. Dana Ross: [00:41:39] Absolutely. So we don't have as much research as we would love to have in PTSD. And a lot of it, we have to really look at it like like everything. We have to look at the source of it. A lot of our research on PTSD is done in the military, in the States, and we're very happy and very grateful that that work is being done. But it doesn't always overlap and speak to the patient populations that we're working with. Having said that, there is a very strong research looking at first-line treatments that are pharmacological for PTSD. So what we want to start with and work with are first-line SSRI. So sertraline, fluoxetine and paroxetine are the recommended first-line agents and there's a first-line snris venlafaxine which is also first-line. And so those are really our go to medications when we're working with PTSD that have evidence behind them. There are other medications that we can use, but they're not as evidence-based as we would like. And so we're we might be using a second generation antipsychotic like quetiapine or risperidone. But again, the preliminary studies there are very entry-level. And I think if we're making decisions around what we're going to be doing pharmacologically, we want to really start with those first line four options.

  Lucy Chen: [00:42:58] And we think about those options. Are we sort of targeting something specific? So I can see sort of for the anxiety, the depression sort of piece using the SSRIs or using the SNRI as well. But I think about is it also addressing the hyperarousal? I guess I'm trying to break it down by symptom clusters.

  Dr. Dana Ross: [00:43:19] It's such an interesting idea to think about really, because as we already talked about, the coma, the rate of co-morbidity is so extensive that it's sort of hard for us to really be as precise as we would like to be. But if we're meeting with someone who has PTSD and by chance, you know, likely has some anxiety and depression, then it also is just very convenient that we have these SSRIs and that's an area to use as well. So I think what I see shift for people with PTSD who are using those first-line options is a decrease in the hyperarousal, which is a big, big component. And so sometimes. I can come with a bit of relaxation in the body as well and a little bit less focus on concern on safety and being aware of safety issues around you. So I would say it kind of takes down the stress level, the hypervigilance kind of stuff and also of course helps with the anxiety that goes with all of that and some of the low mood that goes with having experienced trauma. And that's just a high comorbid condition with that.

  Lucy Chen: [00:44:23] And I suppose I'm wondering and I don't know if there's is there like in terms of antipsychotics and, you know, it's not first line, but treatment for dissociation or those two pieces.

  Dr. Dana Ross: [00:44:38] We don't really have pharmacological treatment. That's good for dissociation. So that we're really targeting with with the psychotherapy component. In terms of the anxiety, we'll sometimes use benzo but very judiciously and we're really worried about again, we just talked about how high the comorbid rate of substance use disorders is. So we want to be holding that in mind. I find I will use a benzo maybe once or twice a week with somebody when they're experiencing a significant trigger, particularly at the more early stages of treatment. But that's not something that has a lot of evidence. And again, we want people, I think, not to be overly reliant on those because of the risk factors that go with them as well.

  Lucy Chen: [00:45:21] Yeah, and I think that you kind of emphasize this, but yeah, the psychological treatments for really targeting specifically the dissociation with multiple aspects of PTSD. Is there sort of like categories of psychological approaches or ways to organise those psychological approaches to PTSD?

  Dr. Dana Ross: [00:45:38] Absolutely. So we've got some evidence-based treatments that are in that arena. So we have things like prolonged exposure. We have EMDR, which is eye movement, desensitisation and reprocessing therapy if cognitive processing, therapy or CBT. There's also a lot of evidence around cognitive therapy or CBT and some evidence for narrative exposure therapy outside of those evidence-based interventions, which are all good and great to know. There's also some things like sensory motor psychotherapy, which really focuses on the body and how trauma is held in the body. I use a lot from DVT. A lot of the skills that you learn around there are just essential and basic, I think, for all of us to know. Psychodynamic psychotherapy really underscores and underlies, in my opinion, all of the therapeutic interventions. So that's also a good one to know. It's good to know a lot about or at least a little bit about the attachment theories because those are very prominent in a lot of the complex trauma as well, and art therapy, some of the creative therapies and there's a type of therapy called Seeking Safety in which looks at trauma and substance use specifically, and it's a group therapy and there's a manual for that. And so I've done that one before and I've found it to be really well thought out and effective.

  Dr. Dana Ross: [00:46:56] When we're thinking about psychotherapy treatments, we really want to also be thinking about different cultures. We want to be knowledgeable and respectful of different cultures. We really want to be thinking about the cultural meaning of symptoms of illness, cultural values of the patient, the patient's family, and trying to hold in mind what is the cultural context in which the treatment occurs? How might that affect the treatment course, the development and expression of symptoms? And we also really want to be holding that. We know that there are higher rates of trauma in certain communities like the LGBTQ+ community with an indigenous communities, refugee populations and of course in other cultural, racial, minority communities. So we really want to be holding that lens and all of our treatment and interaction and psychiatry, but of course with PTSD and trauma as well. So I think those are the main ones we certainly in our program use. I would say we don't do a formal prolonged exposure, but that is built into much of what we do. A lot of us are trained in EMDR, CBT. We do a CBT. I do a cognitive therapy group here that I that I love. I think it's a great group and we do a lot of relational kind of work and body work as well.

  Lucy Chen: [00:48:05] Maybe if you could take us through the perspective of a patient going through this program and what it would look like for them in terms of their schedule or kind of the progression through the program.

  Dr. Dana Ross: [00:48:15] So in our program we're really working on, we just redeveloped it and we're really holding in mind access and equity in those kind of principles. And so what we have people go through now is kind of two pathways into the program. One is into our day treatment program, which is called Wrap or Women Recovering from Abuse Program, which is about eight weeks, Monday to Thursday, 9 to 1. And there are really working in all of those modalities during that intensive period. The other pathway is through our groups and that are more individual groups. So once a week, like an hour and 45 minutes, so people will come through the program, they'll do our foundational trauma group, which is eight weeks and we're really focusing on skills, on psychoeducation, on understanding models and theories of trauma, and we're really focussed on the here and now. So we're not talking about details of trauma at all in those groups. And that again, is that foundational. As people move through that, they can then stream into either focusing on healing through the arts, through the body, through the mind or through relationships. And so there's some choice to personalize and their pathway there. And then as they move on and through the program, eventually they can get to individual stage two therapy and or stage two groups as well. And when you're in stage two, you can talk a little bit more about the details of trauma. So people really need to be ready for that stage of work because like all therapy and like all trauma therapy, but particularly in stage two, it can be really harmful if people aren't quite ready to be in that stage. And that's why stage one is so important.

  Lucy Chen: [00:49:49] It sounds like a lot of stage two is exposure.

  Dr. Dana Ross: [00:49:53] I think so. I think in some ways I think everything we do in psychotherapy is a form of exposure, right? When I'm thinking about working with trauma patients and groups and individually, I'm thinking about sitting with emotions that you're not comfortable sitting with. And how can we start to do that in bite-sized exposures that aren't overwhelming and that aren't going to make things worse? Right. But a lot of times people will come say they're really in a state of anger. I'm really thinking automatically, well, where is their sadness? Where's their grief? Or if someone's coming in a really collapsed state of depression, I want to know where their anger is. And so what we're doing through that is really sitting with and teasing apart people's ability to sit with their physical body, with their emotions, with their thoughts and with their sense of self, and through any of those kind of pathways of treatment or any of those modalities, I think we're very slowly exposing people to those things that they've been avoiding. And again, avoidance being one of those core components of trauma and PTSD. But we have to be thoughtful. We have to personalizing that to the person in front of us. But I think exposure therapy really underlies everything in some ways.

  Lucy Chen: [00:51:01] Yeah. Well, thank you so much, Doctor Ross. I mean, I'm wondering if you have any sort of lasting sort or sort of anything, any tips or any ways that you suggest that we could be better, I guess, like health care providers in general in managing and treating patients who present with trauma.

  Dr. Dana Ross: [00:51:23] So I think there are more and more training opportunities, both online and workshops. There's a lot more that's getting built into curriculums and medical school and in residencies as well, which is fabulous. There's usually a local resources where you can get more education or they might have good handouts and that kind of thing online a lot. There are so many organisations that have so many good infographics and stuff like that. Then when I go online and I just kind of pull them and we find them really helpful here as well. So basic grounding skills I think should be in the foundation of everybody's toolkit as a clinician, as a care provider, even if you're not doing therapy directly. And that would be around knowing kind of breathing skills, deep breathing, some basics around how to bring people back into the here and now if they're in either hyper that hypo arousal state. And then DVT is a good one. If you have that opportunity, mindfulness can be really helpful. Understanding some of those basic concepts like transference, counter-transference, reenactments, all of those kinds of things. We've talked about a little bit about the neurobiology of trauma. So again, I think that's a bedrock of the approach there as well. And then there's a lot out there about this concept of trauma-informed care, which is really care that is really rooted in principles around things like safety and trust, choice, collaboration, empowerment, having a respect for diversity and for our common humanity.

  Dr. Dana Ross: [00:52:54] And I think those principles are things we're trying to really think about all the way through. From the moment we have contact with somebody through the moment, they walk through the door while they're in the program, while they're in the room with us, and while they're exiting the program as well. And so those are principles that we're always working on. We never reach a pinnacle of trauma informed care. We're always learning and seeing where our blind spots are and kind of moving forward. I think the best advice that I got in terms of how to learn more or when people are feeling really intimidated by working with trauma or asking about trauma, is from one of my mentors who said, you know, when in doubt, just be a human being. And in that moment we can just sit with people and just name what's in the room. So that was overwhelming. I can see that emotions coming up for you. Wow. That's an incredible amount of things that you've been through, all of those kind of things. And so a lot of just basic principles of being a human being, basic principles of psychotherapy. It can take us a long way.

  Lucy Chen: [00:53:52] Thank you so much. Any sort of access to every sort of interview, but any lasting or sort of suggestions for young learners in navigating sort of their potential sort of interest in psychiatry or trauma therapy or PTSD or anything related to the field?

  Dr. Dana Ross: [00:54:10] Sure. First of all, I'm just going to put a plug in for coming into trauma, coming into the PTSD field. I think if you're interested in the mind and the body and taking a real holistic lens to people, this is just a phenomenally interesting area to specialise in. And if you look at that, again, rates of comorbidity, you're going to be seeing everything, you're working with everything. So you're both a specialist and a generalist at the same time, which is very exciting. Everything is every patient is unique and diverse as they are in any area but in trauma and PTSD. With all of this comorbidity as well, you're really getting a lot of combinations of symptoms of people struggling with different things. And so I also find that in trauma, we have a lot of really effective treatments, a lot of really effective interventions and skills. And so it's also a very rewarding area to work on, to see people move through, get better and really be functioning in a way that they maybe didn't even think that they could. And so it's a very gratifying area to work in. And the people that we work with, the patients we work with, are just incredible human beings as well. I think if you're interested, there's definitely a lot of books that you can read and I can provide some a list of that. Maybe you can go on the website.

  Lucy Chen: [00:55:22] On the show notes. That'd be great.

  Dr. Dana Ross: [00:55:23] Great. And I'll provide a link to an article on how trauma impacts the brain that I wrote as well. That kind of summarises some of that neurobiology. But certainly, you know, reaching out and finding out what the opportunities are coming to workshops. There's two conferences I tend to be interested in and go to. One is called the through an organisation called the ISSTD or the International Society for the Study of Trauma and Dissociation. And the other one is ISTSS and it's sort of similar, but I'm not going to try and spell it right now. So those are two great opportunities to really network and to learn and get in on the ground floor as well.

  Lucy Chen: [00:56:06] Thank you. Such a rich sort of episode to really understand the foundations of trauma and diagnosis and treatment. Thank you so much.

  Dr. Dana Ross: [00:56:14] Thank you for having me.

  Lucy Chen: [00:56:15] Thanks. Take care.

  Jordan Bawks: [00:56:18] Psyched is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not meant to be representative of either organisation. This episode was produced and hosted by Lucy Chen, audio editing by Jordan Bawks. Our theme song is Working Solutions by Olive Music. A special thanks to Dr. Dana Ross for serving as our expert this episode. You can contact us at info@psychedpodcast.com or visit us at psychedpodcast.org. Thank you so much for listening. Catch you next time!

Episode 31: Understanding Psychodynamic Therapy with Dr. Rex Kay

PsychEd+Episode+31+-+Understanding+Psychodynamic+Therapy+with+Dr.+Rex+Kay.mp3: Audio automatically transcribed by Sonix

PsychEd+Episode+31+-+Understanding+Psychodynamic+Therapy+with+Dr.+Rex+Kay.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Jordan Bawks:
Welcome to PsychEd, the Educational Psychiatry podcast by Medical Learners for Medical Learners. If you're a return listener, welcome back. If it's your first time, thanks for checking us out. Today's episode is an introduction to psychodynamic psychotherapy. Your host today are yours truly Jordan Bawks, a fifth year psychiatry resident at the University of Toronto. And I'm also joined by Anita Corsini, a social worker who works in Knowledge, Translation and Exchange at the Centre for Addiction and Mental Health in Toronto. She's a new member of our team and I'm excited to have her co-hosting with me today. She's been working behind the scenes for a number of months now. Our guest expert today is Dr. Rex Kay, a staff psychiatrist at Mount Sinai Hospital and an assistant professor at the University of Toronto. He is the U of T Psychiatry Department modality lead for dynamic psychotherapy and a graduate member and faculty member of the Toronto Institute for Contemporary Psychoanalysis. He's an award-winning teacher of both undergraduate medical students and psychiatric residents. And on top of all that, he's a pretty nice guy who has a stunning book collection, which is a way to win affection in my heart. So I'll let our two colleagues introduce themselves. We'll start off with you, Anita.

Anita Corsini:
Yeah, I'm really excited to be here. I think you might have mentioned this, but I am a social worker and I work in Knowledge, Translation and Exchange at the Centre for Addiction and Mental Health in Toronto. My official job title is education specialist, and what that means is I develop online training curriculum for therapists and other mental health professionals. Previous to that, the majority of my frontline experience has been working as a counsellor with adolescents and young adults in the field of mental health.

Jordan Bawks:
That's awesome. We're super happy to have you. Knowledge translation is the name of the game in podcasts, so welcome to your first episode. And Dr. Rex Kay. Why don't you tell us a little bit about yourself, your clinical interests, a bit of your kind of training history and your, I guess, your relationship and interest in psychodynamic.

Dr. Rex Kay:
So first of all, Jordan, Anita, thank you so much for inviting me to be a part of this Knowledge Translation indeed, the project is so important that it feels like it should have been around for a lot longer than it has been, and I'm really delighted to be a part of this. So thank you for inviting me and I'm looking forward to talking to you. I am a psychiatrist, I trained at the University of Toronto and psychoanalyst, I trained at the Toronto Institute for Contemporary Psychoanalysis. And as Jordan noted, I'm modality lead for dynamic psychotherapy. What's a little misleading about that is that what I fundamentally am is a general psychiatrist. I trained as a child psychiatrist while I trained as a child psychiatrist. I was told that the definition of a child psychiatrist is somebody who used to treat children. And I'm guilty of that. I used to treat children. Now I work with transitional age, older adolescents, young adults as much as I can. But I've got a general practice ranging from mid teens to mid 80s, and I treat a wide, wide, wide range of psychiatric illnesses. Um, quite happily using whatever comes to hand that's going to help somebody.

Dr. Rex Kay:
Prominently among that for me is dynamic psychotherapy. But I see myself and I would hope that I am seen as fundamentally a general psychiatrist who uses dynamic psychotherapy a lot, along with whatever else I can. My interests are, I'd have to say, first and foremost, education. I spend a lot of my time teaching. In any given month, it can be up to a quarter of my time is spent teaching in one capacity or another, and I love it. I have a long standing interest in creativity, both in terms of the standard creative arts output, but creativity in living and in work and a strong interest in the arts. I am co-founder of a literary journal devoted to issues of medicine and health Ars Medica. I encourage all of you, here comes the shameless plug. Ars Medica do a search for it. We're very proud of it. It's been going for about 15 years now, and I am proud to also be a co-developer. Along with two colleagues at Mount Sinai of Narrative Competence Group Psychotherapy, a program that uses the writing of narratives in treatment. That's my background.

Jordan Bawks:
Fantastic. We'll expect some royalties if you get any extra subscribers to Ars Medica, but we'll work out those details later.

Dr. Rex Kay:
I'll take it up with my co-editors.

Jordan Bawks:
All right. So I'll quickly go over our objectives for the episode today. Psychodynamic psychotherapy is an enormous topic that you can only do so much with in 60 minutes. And so I would encourage listeners to take this as a kind of teaser. We want you to be familiar, you know, when after listening to this episode, when psychodynamic psychotherapy comes to mind, we want you to be able to sort of have a recognition of what that is, what that means, the kinds of patients that you're going to be that are going to be treated in psychodynamic therapy. So here's our explicit kind of objectives. So first off, listeners should have a sense of what psychodynamic therapy is and a bit of an idea of how it works. Number two, we want you to have an idea of who it's for, what kind of problems it's for, and a bit of a sense of the evidence that supports its use. And third, I hope that by the end of the episode you can compare and contrast psychodynamic therapy to other psychotherapies because there's a large degree of overlap. And that's something that we'll talk about towards the end of our time together today. So let's start at a pretty high level. Rex, why don't you walk us through what is psychodynamic psychotherapy?

Dr. Rex Kay:
You're starting not only at a high level, you're starting at probably the hardest level you possibly could have. And I just want to note that, you know, you're starting at the hardest level you can and I will remember that because apparently I'm only a pretty nice guy. Let me answer that, Jordan, by actually moving up one level, because whenever I start talking about psychodynamic psychotherapy, I always find I'm starting a little bit too late in some ways. I want to talk about psychotherapy because it's very easy to lose how audacious the idea of psychotherapy actually is in and of itself. Uh, if we, if we go back historically, people probably since language developed. Have gone to other people with problems that we would broadly put in the emotional range. Typically what we expect are people giving advice, what we would call counselling, maybe doing teaching something educational. Often religious leaders would provide a moral slant on it. All of those factors are to some extent or another part of all psychotherapy. We haven't abandoned that, but the notion of all psychotherapies is that in some way we can help people with mental illness and mental anguish and suffering. Just by helping them talk through their problems, feel more deeply. Understand more deeply. And change. And that's audacious. And and it's remarkable.

Dr. Rex Kay:
And it's only a century and a third old in formal sense. Uh. And it is still, to me, a remarkable human endeavour. And that applies to all psychotherapies, short term, long term, very brief, performed by psychiatrists, psychoanalysts, social workers, psychologists and anybody else that I think we have to start by appreciating that what the attempt here is to use language, relationship, experience together to effect change in the horrible, horrible toll of mental illness and mental suffering. So bringing down from there what is psychodynamic psychotherapy, a lot of what psychodynamic psychotherapy is overlaps with other forms of psychotherapy. But here's my best way of trying to summarise it for you at a basic level. It's about pattern recognition. That people will suffer. And suffer not just anguish, but suffer diagnosable mental illnesses as a result of their patterns of behaviour. Their patterns of being able to process inner experience, emotions, outer experience, process their thoughts and the characteristic patterns at times leads to tremendous suffering, which at times leads to maladaptive behaviour and attempts to cope. So what psychodynamic psychotherapy is about at its most fundamental level is helping somebody gradually elaborate these patterns, collaborate with them in exploring where the patterns come from, to give somebody the chance to alter those patterns and reduce the suffering and illness.

Jordan Bawks:
Well said. And somehow you didn't even mention Freud.

Dr. Rex Kay:
That was an error, but the sentry was the reference.

Jordan Bawks:
That's wonderful. So what I'm hearing in that is that, you know, before we begin even to talk about psychodynamic psychotherapy, it's important to to really root ourselves in the psychotherapeutic endeavour, which is to help people with suffering and including when that suffering reaches the point and fits the sort of pattern of a diagnosable mental illness is to through relationship with another, through talking with another try and. Transform that suffering or alleviate the symptoms associated with the disorder. I mean, I'm not doing justice to your explanation, but talking to the key points that I heard there. If you could speak even more to like what's unique to, as you see it, psychodynamic psychotherapy, like what are the aspects of a therapy that are the hallmarks of, of psychodynamic? How would I know that I was watching somebody doing psychodynamic therapy as opposed to watching somebody do CBT?

Anita Corsini:
Can I just kump in there?

Jordan Bawks:
Absolutely.

Dr. Rex Kay:
Please do, because I really don't want to answer that question.

Anita Corsini:
You're not off the hook, Rex, But I had a quote that I wrote down and it's kind of speaking to Jordan's two questions, right? And it is I read in chapter one of this book, it was maybe the first line. "The dynamic treatment is hard to describe but easy to understand when you watch it unfold". So not only Rex, did you do a superb job of explaining what it is you were actually did an incredible job at describing it. But now I think that Jordan is asking you to help us imagine how it unfolds in the therapy room and wonder if you can.

Dr. Rex Kay:
So I have a feeling that we're going to elaborate on the answer to that question throughout the duration of our conversation. Um, so let me give you just 2 or 3 initial ideas. One. Psychodynamic psychotherapy takes place in four different time frames or spaces. We attend to. The early experience that somebody had. It's a developmental model. It says that early experience shapes those patterns we were talking about. Shapes the characteristic ways that people process experience, internal and external. So we talk about the early experience. We talk about the lived life experience from those early days until the person walks into the office. Again, looking for the patterns, the characteristic development and how that life altered those patterns or reinforced those patterns. We talk about the current lived life, What has happened to the person in between the last session and this session? And explore those And then and this is probably the chief hallmark of dynamic therapy. We spend a lot of time also looking at the relationship in the room. We look at what's unfolding between the for generic purposes. I'll refer to patient and psychiatrist. We can talk about patient and therapist, client and therapist, but we look at what's happening between the two people in the room as a source of understanding pattern. We do that. We refer to this as the transference and countertransference the therapeutic matrix. We do that not because Freud said it was important. Freud said a lot of things were important, some were, some were not. We do it because all of experience and as increasing studies have emerged from a wide range of fields, we know that he was right in supposing that early experience shaped the relationship in the room. But that in and of itself isn't enough to justify it. We do it for two other reasons.

Dr. Rex Kay:
We talk about what's happening in the room because it's happening live in our patients. They're having the experience now. There's no filter. There's no time to reflect. There's no time to revise. It also live for us. We are participants in the process. We are experiencing something. We are observing something. Because it's live between the two of us. Something else is going on that's really important. And for that, I turn to the neuroscience. That's when something is experienced emotionally and intellectually simultaneously. Then the brain is most open. The the the limbic lobe on the right side wherein rides the affect the sense of self, a sense of empathy is engaged. The frontal cortices of the brain. The rational, logical thinking in the upper left is engaged. And what we know from the neuroscientists is that when multiple parts of the brain are engaged, is the time when rewiring has the best chance of happening. But it's also the time when we can explore the patterns most clearly. So we're looking at those four times early childhood lived life current life relationship in the room as a way of seeing how they play into one another and form one another and can help us and the patient together elaborate on those patterns. So if you see a conversation that is focused on affect and experience and looking at those four different timeframes in emotionally charged, meaningful relationship. You were looking at what I would call a dynamic process. I will quickly add that that can unfold in cognitive behavioural therapy, in interpersonal therapy, in acceptance and commitment therapy, in group therapy, in couples therapy. There's no exclusiveness. But in psychodynamic psychotherapy, we are deliberately setting out to court that kind of process.

Jordan Bawks:
Yeah, I think that's. Uh, that's lovely. I mean, looking at those different kind of spaces that we work in. And I'd say it's a pet peeve of mine when I hear people have described psychodynamic therapy to a patient of mine or a patient who is referred to me for psychodynamic therapy as a then in their therapy as a therapy where you're exclusively going to talk about the past. Now, there's no doubt that that's important, right? Like people are shaped fundamentally by their life experiences. So we need to get a sense of that, to get a sense of who they are now and the way in which they respond to things. But. My sense of the literature and my experience is that the therapeutic change happens most in the relationship, in the live relationship and the examination of that experience in that relationship.

Dr. Rex Kay:
Jordan let me add to what you just said, because another of the misunderstandings of psychoanalysis, psychodynamic psychotherapy, is that it is mother bashing, it's parent bashing and or blaming. If we tone the word down a little bit and think I'd like to clarify that while we absolutely see those early years and early experiences as profoundly shaping and all of the evidence supports that, the purpose of understanding that. Is not to wash our hands of the affair because we have discovered that it was Dad's fault. Mom's fault. The only purpose of looking back like that is to help somebody transcend. We are looking at the ways in which an individual made sense of their early experience. We believe with some evidence that there is a rough approximation between what people remember and what happened. There's enough corroboration, but it's only a rough approximation. What matters most is the way you made sense of your childhood, the way you made sense of those experiences, the way they shaped you, given your temperament, your other experiences. And we're doing that to help you transcend the patterns, not so that you can simply lay blame.

Anita Corsini:
Yeah, I kind of feel like it's emerging. For me, that part of what I'm hoping for this episode and I feel like it's already happening, is that we are going to debunk, I think, some of the misconceptions. And for me, I don't think I mentioned this at the top, but I'm really new to psychodynamic therapy. I was aware that it was existing, that it was in the aether, that it was foundational. But in terms of really understanding it, this working on this episode has really sort of like, um, illuminated a lot of things for me. And I feel like even debunking my own misconceptions like through this conversation. And I think that's, that's one of the big ones that then and their idea that sometimes people bring the assumption that we're only going to talk about the past and it's everything that you've said has kind of challenged that notion.

Jordan Bawks:
I'm going to put you on the spot. Anita, What are some of the other misconceptions that you either came to this episode with or things that you really wanted to understand? What's the dirty rumours about psychodynamic psychotherapy on the street?

Anita Corsini:
Mm Um, no disrespect, Rex.

Dr. Rex Kay:
None. None taken!

Anita Corsini:
Some of the things that came to come to mind for me are, like, outdated, out of fashion. These are these are all words I'm using that have negative connotations. Like inefficient.

Dr. Rex Kay:
Those are good. I'm glad Jordan put you on the spot. Feel free to come up with more. But but I want to I want to address a couple of those ideas quickly and in a way that might surprise you. Uh. There was a time not all that long ago. When think the early claim that you just made from the street was becoming true. Psychoanalysis had succeeded a little bit too well. And by the late 70s, early 80s had become a bit of an out of step dinosaur. And if it had not evolved, I would not be an analyst today. There was a. An attack on psychoanalysis for multiple directions from the Psychopharmacologists a term I don't love, but the people using medication and the rise of medication from cognitive behavioural therapists, from the neuroscientists, from the philosophers, from the psychologists, from the feminists, from queer theorists, and from the memory researchers, from the from all of these sources, there was an attack. I would love to say that the field dealt with that in a very open non-defensive way, but the initial response wasn't. There was actually a double initial response, though the outward facing response was, you know, it's the standard Vietnam line.

Dr. Rex Kay:
You know, you weren't there, man. You don't get psychoanalysis. And if you did, you'd know that you're wrong, which is a horrible argument and fundamentally not true. The second line of response, though, was to stimulate a period of creativity within the field. Between the late 70s and early 90s, that was astonishing. And psychoanalysis revamped itself without abandoning its core principles. It recreated itself. Taking in the input from all of those fields. Neuropsychoanalysis over the last 20 years has been a really hot topic of research influencing treatment, attachment theory, serious research coming out of the psychologists. It is incorporated Feminist theory, queer theory, Post-structural theory. There is a wide range of responses to these very legitimate attacks that has produced. A different version of psychoanalysis and psychodynamic theory. That still holds onto for me a lot of the gold that goes all the way back to Freud. But made it a much more vibrant and meaningful field. So fair criticism. But I like to think that it's the criticism itself is now largely out of date.

Jordan Bawks:
And I'll jump in to talk a little bit about the evidence base, because I think this is also a misconception about psychodynamic psychotherapy, including psychoanalysis, is that it's not evidence-based or that it doesn't have a robust evidence base. And I think this will also bleed into answering your question about efficiency, which I think is a very valid question to be asking in, you know, from a systems perspective. Um, uh, so I'll briefly, um, there are a couple of pretty comprehensive and high level reviews that I'm going to link in the show notes. Um, Leichsenring I'm going to butcher their name, unfortunately, but it's a giant in the field of psychodynamic psychotherapy, and there have been a number of high quality studies published in The Lancet. There was a Cochrane Review. There was a pretty rigorous meta analysis in the American Journal of Psychiatry, all within the last 5 to 7 years that have shown that psychodynamic therapy is equal, in effect, size to most other standard interventions and may be superior in some situations. One situation where it actually looks like it's superior to other kinds of treatments is in the treatment of what they call complex mental health disorders. So these are personality disorders, people with chronic mood anxiety conditions or people with multiple disorders and in comparison to treatment as usual, to medications, to shorter-term psychotherapies, a variety of modalities, long term psychodynamic psychotherapy as defined by more than a year of weekly treatment, shows superiority in outcomes for those kinds of situations.

Jordan Bawks:
Um, and then the other kind of piece of this is that I, I think one of the things that happened as well is that a lot of psychodynamic psychotherapies were semi-manualized and so made themselves a bit more amenable to treatment. So there's also a pretty robust evidence base for those short-term psychodynamic therapies as well. And you know, a debate around the manualization of therapy is beyond the scope of our talk. And I think there is something that's lost in that setting, but it's also something that was necessary for psychodynamic psychotherapy to sort of prove itself on the same playground as something like CBT, which I think at this point in time it's done extremely convincingly. And I think for me as a, you know, a psychiatry resident who's about to graduate, who is a real, I'd like to think a student of psychotherapy, like I train in CBT, mindfulness, acceptance, commitment, etcetera.

Jordan Bawks:
I think the place where Psychodynamics kind of separates is in some of these situations where people have failed multiple other therapies, you know, they end up in this complex category. They failed sometimes like 10 to 15 medications. I'm talking about chronic conditions and people who've had neurostimulation treatments who haven't gotten better. And, you know, this is an evidence-based intervention for these people where there are almost no evidence-based interventions. And so when we talk about efficiency in the health care system, there's a lot of talk right now about a stepped-care model that we sort of start at the lowest level of intervention. And to me, just based on the evidence, psychodynamic therapy has a place either in the sort of early steps when you're looking at it like you can short-term psychodynamic therapy as being a non-inferior treatment to CBT, and we can look at patient preference and go from that. And once we get to the higher steps, the higher complexity and chronicity, then I think psychodynamic therapy has a robust evidence base to deserve to stand on those treatment steps when there really is not a lot of other stuff that has that kind of evidence base.

Dr. Rex Kay:
Jordan that was really well summarised and nothing in there that I don't agree with. I'd like to provide a slightly different perspective and this addresses the efficiency question too, and it does address the stepped treatment model. But I want you to start by imagining what people come out of childhood with. That's a temperament, a fit between a child and parent or parents. An early experience. Produces. A character, a personality, a way of being, characteristic ways of being in the world. And what we know is, you know, the biography of Jim Morrison, No one gets out of here alive. No one gets out of childhood unscathed. But what we can say is that some people are more damaged by that combination of temperament, fit and early experience than others. The patterns that we talk about can be luxuries for people who suffered sufficient trauma and sufficient adverse childhood experience that the damage done to their capacity to process inner and outer experience, to manage the complexities of just living can be extreme. Now those people go through life and life happens to them. Life can be physical illness. Life can be life events. And life can actually be the onset of a psychiatric illness that isn't directly related to the features we just talked about that are more genetically or biologically driven.

Dr. Rex Kay:
For those people who came out of childhood relatively unscathed. When life happens, they can often get back on track with nothing but themselves or a close friend or partner. Maybe a little bit of advice from a family doctor. Maybe a single visit to an emergency room or a single visit or a few visits to a psychiatrist. They may require a short-term treatment. They may require medication, but they're likely to do well. For those people. For whom early life was damaging. When life happens, it can be astonishingly difficult. And what we what I think of and what evidence suggests psychodynamic psychotherapy is at its best dealing with is helping those people. The complex problems that the desperately suffering damaged individual who may have a psychiatric diagnosis, who may have a physical illness or who lost a job or a partner. And for those people. We can move through the steps, but very often there is nothing else other than long-term intensive psychotherapy, which I think of typically as being based in dynamic principles, but drawing on everything that the practitioner is capable of drawing on to help from all schools of thought to try to help these people get through.

Jordan Bawks:
So you've hinted I mean, both of us have hinted at this already. Who are the kinds of patients that when you see you think this person needs or deserves psychodynamic therapy?

Dr. Rex Kay:
So part of the answer to that question is contained in what I just said, which is usually somebody who's tried other things. Very few of the patients who come to me come to me without having tried other treatments, medication, shorter term therapies, other approaches. There has to be a level of suffering. Uh, not just of. But of suffering in order to justify a longer term treatment. Psychodynamic psychotherapy itself typically lasts 2 to 3 years. Psychoanalysis itself, a fuller, longer version still only typically lasts four and a half years. We talk a lot about the commitment of time of the psychiatrist. Efficiency comes in there, Anita. We talk about the expenditure of the health care dollar of Doug Ford's taxpayers of Ontario, which is a perfectly legitimate standard. What often isn't talked about, but is very much in my mind is the commitment we're asking of our patients. If somebody is going to come and see me once or twice a week for three years, two years, four years, that is an enormous commitment of time and it's a commitment of emotion. Though the therapy is often useful and often enjoyable, it's also often very hard. We're asking a lot of our patients in order to justify that there has to be a level of suffering. And by and large, there should be an attempt at other solutions that hasn't worked. That's not quite the spirit of what you're asking, Jordan, But that's the background to what I think is really important is a consideration.

Dr. Rex Kay:
A patient who shows little or no curiosity about their own past life and the possible connection to current issues does not scream psychodynamic psychotherapy. A patient doesn't want to do that, but yet wants help is still fully entitled to help. Should probably try other things. Before, if at all, trying a commitment to psychodynamic psychotherapy. Uh, somebody equally. Who? Uh. Has little or no proven capacity to form a relationship. Little image in their mind. That a relationship can benefit them. Should probably try a shorter term psychotherapy or medication or other treatment. Before trying psychodynamic psychotherapy, because the one thing I can promise you is that that therapy is going to be very difficult for them and probably for the practitioner. But if nothing else is working, I deeply believe that for those most unfortunate of people, psychodynamic psychotherapy is rapidly going to become the only game in town, the only treatment that can provide an experience in which a first beneficial relationship can occur. Providing a vantage point for those patients to start exploring their life and their responses and their patterns and begin to change. So ironically, the most difficult patients are also often the ones who scream psychodynamic psychotherapy most, whether they've experienced physical trauma, sexual trauma, relational trauma. They often end up screaming once other treatments still have been tried and failed. Anybody have a thought?

Anita Corsini:
Think Yeah, I was totally reacting to the word trauma because that was like the question that was on the tip of my tongue as you were talking. Just about like complex almost seems sometimes like a euphemism for having like a trauma history. And I just know that, you know, often, you know, adults who have had like adverse adverse childhood experiences, trauma histories and, you know, can have the most difficulty just, you know, dealing with day to day life, as you were saying. And then so then my question was, you know, I haven't come across that in any of the reading I've done so far. But in terms of thinking about patients who might be most appropriate and, you know, having had that early trauma history or, you know, significant series of traumatic events that processing, I wonder if that's possible in dynamic therapy. It seems to be beneficial.

Dr. Rex Kay:
The evidence would tell us there are some really valuable and really helpful, trauma centric therapeutic approaches that are creative and thoughtful and very moving, even to read about when they don't work or when they only get somebody so far is really when dynamic therapy should kick in because they tend to be shorter term and very nicely focussed and often are very helpful. When that hasn't worked is when you ask for the commitment to a longer term therapy if you can get.

Anita Corsini:
So transference and countertransference are sort of key concepts in psychodynamic therapy. And I'm wondering, Rex, if you could talk a little bit about what they are and if you could offer some examples of how they play out within the therapeutic relationship.

Dr. Rex Kay:
Yeah, absolutely. They are central ideas and they've evolved. Transference began as Freud's concept that people make false connections between people in their past and people in their present, which is a perfectly fair way of thinking about it. But to Freud, it seemed to imply that the transference, feelings, the feelings that a patient has for their therapist are in some way not real to the relationship with the therapist. They are simply transferred from their past. Uh, this is a case where I'm going to give him his due. He fought hard trying to argue that a transference feeling was false because it was just a recreation of the past and it didn't apply in the present. And as hard as he tried, he ended up shooting down his own argument. And I just want to make this point because I think that it's it's it's so underappreciated even today. Uh, for Freud in the end. The important point about transference is ethical. Freud noted that we as practitioners, as psychiatrists, can anticipate that for many of our patients, as they work with us, the patients will experience strong emotions about us. Not all, but many. Some of them might be unpleasant for us to experience. What Freud argues. Is that as somebody experiences these feelings, we have an ethical obligation. To use that experience of our patient for their benefit, no matter truly how unpleasant it may be up to limits of personal safety, but that the idea is that an individual based on their past is, we hope, going to experience us as an emotionally significant person in their life.

Dr. Rex Kay:
And as such, their old patterns will be reactivated and as the emotional significance of this other person who is in the room with you. Listening struggling as that intensifies, often the feelings will intensify. And that it is our job to not make that go away. But to use that to help our patient. Similarly countertransference which Freud did not develop at all well. Countertransference initially referred to the feelings that the therapist has about the patient. And usually to the early gang, indicated that the therapist hadn't been properly analysed or therapist that went away a long time ago. And now what we see is countertransference. Is the experience of being the other person in relationship with our patient. And it's a source of information. So transference are the patterns that the patient brings into the room intensified by the gradually increasing meaning and importance of the relationship with the therapist. Countertransference can be. My bringing my issues into the room. If that's the case, I need to address that myself and do something about it. But very often counter-transference is me experiencing something that I can use to help me understand my patient. And again, the ethical obligation. Is to use that to benefit the patient.

Jordan Bawks:
I'm glad we're talking about Transference Countertransference because to me this is one of the most useful contributions of psychodynamic thinking that applies in almost all clinical settings, even outside of psychiatry, because it's natural that we're going to have feelings that are arising when we see patients and patients are going to have feelings that are arising as they see us and about us in particular, and having an understanding of the dynamics of transference and countertransference allows us to use those, as you said, to the patient's benefit. I'm wondering, Rex, do you have a clinical example to bring this to life for us?

Dr. Rex Kay:
Okay. Let me preface my comment by saying that I'm going to tell you a rather sketched out clinical story. Mm. But I have the permission of the individual involved to tell this story, even though it's very sketchy and there's no identifying features. I want to reassure your listeners that I have explicit permission from the original to tell this story in teaching. Um, here's a common experience for a lot of people in the healthcare world, whether they're in any area of healthcare world. I'm working with somebody who. Rejects every single idea I propose. Uh, practical idea. Uh, perspective. Interpretation, whatever it is I have to offer. Is rejected. So we can see a characteristic pattern, perhaps. But what matters here, I'm going to talk about the Countertransference at this point. What matters is that I become aware that I'm not simply frustrated. That either I'm not good enough, I'm not putting forth useful ideas or frustrated that this person is shooting down all of my ideas. I begin to feel. Like. My university made a mistake in admitting me to a medical program, let alone a psychiatric or psychoanalytic that I should never have engaged in this work because I'm utterly incompetent, that anybody would be able to do a better job than I am doing. And I'm feeling quite worthless. Fortunately, that's not an experience I have all that often.

Dr. Rex Kay:
And I begin to feel like that's an interesting response on my part. It takes a little while to gain control of my own emotional state, but as I do, I start saying it's interesting that I'm experiencing this so intensely. So I start attending to the way the patient is rejecting my ideas, suffering, individual. And yet they're rejecting my ideas. Not with a sense of sadness. I wish my doctor could come up with good ideas. Not with a sense of despair. Oh, no, he can't help me. He's not coming up with anything useful. Not even quite with the sense of frustration. He's rejecting my ideas with what I can only describe as a sense of glee. And malice, and I start reflecting on what I know about him. And the way he had described and I've known this person for a little bit of time and the way he described. His parents as being really quite supportive and very encouraging and. Having high standards for their children and for him always wanting him to do his best and always encouraging him to be the best person he could possibly be. Which sounded to me like pretty good parents and that he experienced them as pretty good parents. But I'm starting to wonder about somebody who is rejecting my ideas with this intensity and begin to generate an hypothesis based on my countertransference of feeling so belittled.

Dr. Rex Kay:
And so incredibly incompetent. And I start thinking about two things. One is, I think is there evidence that this is how this person feels as he goes through life? I generate an hypothesis that my countertransference may capture his lived experience. It's not the way he narrated his life. But over the time that I've known him, as I reflected on it, I start to think. He's got a narrative of his life, but it could easily be connected to this kind of feeling that he's avoiding and warding off. And then go back and think about the parents and look at other authority figures in his life. And I look for parallels there as well. How has he described bosses? How has he described teachers? And I begin to generate some hypotheses. Don't say anything because they're just hypotheses. But over time, I'm listening in a slightly different way. I'm exploring his rejecting feelings towards me in a different way. And I'm asking different questions. Over time these things don't happen quickly. Over time, together, working together, it's such a fundamentally collaborative process. We gradually come to recognise that the way he experiences me is a way that he's experienced bosses and teachers in the past.

Dr. Rex Kay:
That he did experience his parents exacting standards as standards that he could never live up to. He did not see his parents particularly as attacking, he said, but they were impossible to live up to and it made him feel horrible. But then we so we've done really good work. We're laying out a pattern that he is now talking about benefiting him. In his lived experience that he is slower to anger. Slower to ascribe malice to others. But then we take one more step. And this is more transferential. That we start looking at the moment when he becomes attacking. And we start looking at the moment that came just before. And how he heard me and how he experienced my suggestions. And what emerges is that. He didn't experience my suggestions as possibly helpful ideas that would benefit him in life. He experienced my suggestions as evidence of his failure to have thought of those ideas himself and enact them. He experienced me not as saying, Hey, why don't you try X? But he experienced me as saying, Well, aren't you stupid for not trying x? Why the hell haven't you tried X? And as he experienced that repetition of the childhood experience of not living up to even though my tone was mild, as his parents were, he knew what I meant. He turned the tables on me. And he stopped being himself in the presence of what he experienced as a judgemental other. And he became the judgemental figure and I became the attacked other. Now that unfolded over months. But that can give you hope. And again, I recognise it's an inadequate summary, but I hope that gives you a little bit of a feel for how transference and countertransference can play out in effect change.

Jordan Bawks:
I mean, if you could summarise months and months and months of dynamic work in only five minutes, I know that you were short changing us and leaving out the richness of the work, but I think there's first off, that was a helpful illustration of transference and countertransference, you know, looking at the way in which the patient was transference, being the way in which the patient was experiencing you, the countertransference, and how you were able to use that experience of you as a way into his world, into his life, in a way that was helpful for the both of you working together and also how you were able to use your own experience with him also as a way into his life that wasn't immediately apparent. And along the way, I think you've kind of hinted at, um, you know, a question that's implicitly throughout this whole podcast is how does psychodynamic therapy work? And when I when I listen to that story, I hear it come through. Like there's that sort of almost relentless attention to the patient's experience. Their thoughts, their emotions, their inner world. Um, that is so important for the work that you do together.

Dr. Rex Kay:
Let me step back in, because for time's sake, I left out the last piece, but. But I think that for your listeners, it's important to hear this as well. Uh, he experienced me as being attacking. My professional identity, of course, is someone who would never be sharply critical or attacking of a patient who is suffering and coming to me for help. But doing my job and taking my job seriously involved really looking hard at myself and wondering if when I said, Why don't you try X? At least some of the time. My frustration with his typical rejecting behaviour wasn't creeping into my voice and I decided that it was, and I talked to him about that. Uh, because I think it did. And I think that his response was based on his transference. But it was also responding to a level of frustration. That he heard in me accurately. Now, that's hard. That's hard as a therapist to own. But jerking with a patient's reality and denying that piece is counter-therapeutic. So at some point it was necessary for me. I felt. To explore his response, to explore mine, and to own up to the possibility that at times he was hearing frustration, which was very meaningful to him. So that's the last chapter. And think think it's necessary to round it out in that way.

Anita Corsini:
Like Jordan, you were just pointing out that sort of very close and sensitive attention to the patient's inner world or what the patient is bringing into the room. And it sounds like, Rex, you're also drawing attention to paying close attention to what's happening in that relationship, What's happening between the both of you? In terms of affect, in terms of emotionally, but also sort of cognitively as well.

Jordan Bawks:
All right. So I want to just take a step back and kind of summarise where we've been and check in on our learning objectives. So number one, we wanted people to have a sense of what psychodynamic therapy is and how it works. And I think Rex, through that example, through our kind of discussion throughout, I hope that we've given our listeners a taste of that. I'll make an aside here to say that psychodynamic therapy and writing is extremely diverse. There's a sort of an enormous richness to psychodynamic thinking. And so this is really a taste. This is like a flight and it's like a flight in comparison to a beer hall. And so my hope is that you like what you've had so far and you want more. Secondly, we talked about who it's for. We talked about the evidence base. Our third objective was around contrast and comparing psychodynamic psychotherapy to other therapies. And I think we've done a decent job of that. I mean, just to make it explicit, I mean, I think the things that are common to all therapies is that we're attending to the therapeutic relationship, the working alliance. I think what psychotherapy psychodynamic therapy adds to that. It is a sort of explicitly looking at investigating, talking about the therapeutic relationship rather than just sort of relying on a warm, supportive stance that's going to facilitate a good therapeutic bond. Um, I think we've talked about the ways in which psychodynamic therapy pays attention to patterns. Patterns from the past to the present, from outside relationships to the therapy relationships looking at these kinds of patterns, um, looking at patterns of emotions, thoughts, and in relationship to other people and relationship to the therapist. Um, and you know, it's funny actually, the more I get into all psychotherapies, the more I see tons of commonalities that I think many psychotherapists do these things in very similar ways. Like in cognitive therapy, there's maybe just people are a bit more explicit, like they're actively talking about it with the patient, someone's core schemas, their core beliefs, the assumptions that they have. But I think psychodynamic therapists do that anyway. You're looking at the way in which people interpret the world think about themselves. It's just a sort of slightly different language and a slightly different frame. Um, so now I want to kind of take a step back. This wasn't explicitly in our objectives at the very beginning, but I think this is something that we want our listeners to leave with. I want our listeners to leave with. This is why I fell in love with psychodynamic therapy. Um, that psychodynamic therapy, something about psychodynamic theory, psychodynamic thinking feels really relevant to general clinical work. Like there's always some aspect of a clinical encounter where I kind of lean on what I think of as my own psychodynamic training and principles. And Rex, you're a few years further down the road than me in this path, and I'm wondering if you can talk about the ways in which psychodynamic thinking influences your general psychiatric care.

Dr. Rex Kay:
Yeah, a few years down the road. Jordan, way back in my childhood when I was about your level, I decided that I wanted to train as a psychoanalyst, not because at that time I envisioned doing psychoanalysis at all. Uh, but because I felt that I needed to understand these principles in order to be the kind of psychiatrist that I wanted to be. That's what pulled me into the Analytic Institute initially. Along the way, I discovered that very long term intensive treatment is useful for some patients, and I still believe that and my experience goes with that. But I wanted to be a really good psychiatrist who used psychotherapeutic principles. You could be a tremendous psychiatrist without studying in an analytic institute, but the way I envisioned the work and what I felt drawn to do this seemed to be the route for me. What I feel all good psychiatrists have learned are the basic principles that we've been talking about today. They may not explicitly think of them as psychodynamic, but a lot of them do. Most every psychiatrist that anybody works with today has been trained at least somewhat in these principles and uses them. But if they weren't trained in their residencies, they were trained by their patients. That in order to do the work well, you simply have to learn to attend to the meaning that a patient is drawing from what their life is affording them. The meaning that a patient draws from handing over a prescription for an antidepressant. The way in which a patient is experiencing affective states. And when they learn to and enhances the work. If you can attend to what's happening in the room. As even a consultation progresses. And it is my strong belief that every good psychiatrist.

Dr. Rex Kay:
It does use dynamic principles, but we also all use including the analyst cognitive behavioural principles, dialectic behavioural principles. Systems thinking developmental thinking that mental illness is a vicious, multi-headed beast. And those of us who work with mental suffering and mental illness need to be able to use everything that we possibly can to help and that these principles, I find, achieve their greatest value not in the hands of people treating patients directly with psychodynamic psychotherapy. But in the hands of people using the principles in their general psychiatric work and their general therapeutic work, whatever mental health profession they come from.

Jordan Bawks:
Yeah, I'm. You're preaching to the converted here and I guess you literally you are because you converted me over my residency training that and now I take this work on for myself as one of the reasons I was eager to take this on is that for me, you know, again, not that this is entirely unique to Psychodynamics, but that the things that psychodynamic thinking emphasise, which is seeing the individual, seeing the person as an individual, paying attention to their past experiences, the value of attending to their relationship with you, the value of attending to their emotion. And the you know, this is, I think, one of the late developments of psychoanalysis relatively, that you hinted at that sort of transformation in the 80s and self psychology is how valuable it is to just to empathise to enter the patient, to make a really concerted effort to understand the patient's world and their experience and how healing that is, how stabilising that is, that those are things that I have gained from my psychodynamic training and things that have really greatly enriched my psychiatric work.

Dr. Rex Kay:
Let me pick up on one thing you just said, Jordan, And this will illuminate the cross-fertilisation between psychotherapies. There was a time, and I can still slip into the language of saying that there's a tension in psychiatry. There was a sociologist who wrote a book about psychiatry called of Two Minds that American psychiatry is of two minds, and the minds are along a kind of biological orientation, a psychological orientation. We can talk about a tension between the desire and the need to see people in categories to make psychiatric diagnoses. And that's an extraordinary, valuable pursuit. Starting in 1980, Bob Spitzer and the DSM proposal was incredibly important and remains incredibly important because it's trying to establish categories that we can compare. So we need to make diagnoses and put people in categories, and that's crucial. The other pool that can be called attention is in seeing every individual as an individual. And focusing on their individuality as a person with a unique history and a unique way of experiencing the world. And we can call that attention. But my colleagues in the dialectic behavioural therapy world have helped me recognise that that's not attention. It's a dialectic that the two live together and they actually benefit one another at their best. And that it's actually our job to not choose between the two, but to constantly be integrating and seeing from the two perspectives and integrating what we see to the betterment of the patient.

Jordan Bawks:
Yeah, I totally agree with that. Rex, I'm going to ask you an annoying question, which I've been doing all episode, putting you on the spot with these hard, monolithic questions. But we like to ask at the end of our episodes, our experts if they have any recommendations for interested listeners who want to learn more. If you were to recommend a resource, a website, a book, or even just kind of a general idea to our listeners if they wanted to learn more about second and psychodynamic thinking or therapy, where would you direct them?

Speaker4:
Oh, that's such a hard question.

Jordan Bawks:
I know.

Dr. Rex Kay:
The literature is, as you noted, a complex literature, but it's also an enormous literature. So it's rather difficult to recommend general texts. Probably the best single volume. And Jordan, you could put this up on the website is Jeremy Safran's introductory book. Uh, as a single volume describing the therapy in about 150 pages. The best introduction to theory is probably Stephen Mitchell and Margaret Black's Freud and Beyond are a fascinating introduction to attachment theory, which also helps understand from an evidentiary base. The role of early experience is Robert Karen's Becoming Attached, which looks at the history of attachment theory, but in the process of doing so and it's a fascinating story and he tells it very well, but in the process of doing so, he helps review the literature of just how early experience shapes later. So there are three places that people could start, but I would also encourage people, especially in the field, who are interested. In any given Non-covid year there are six or 8 or 10 people coming in to speak on broadly psychodynamic themes to various groups. Through the Toronto Institute of Psychoanalysis, the Toronto Institute for Contemporary Psychoanalysis, the Child Psychotherapy Institute, the Ontario Psychiatric Association. There are multiple websites that people can keep an eye on. What I would encourage people to do, if they're interested, is grab and follow in exactly the same way that we try to do as therapists. Follow your curiosity. Don't try to start with Freud and work your way up or study the classics. My strong encouragement is to read what is interesting to you and read it until it's no longer interesting and see if that leads you somewhere else and follow your curiosity.

Jordan Bawks:
Wonderful. I'll make my own plug to add to those resources, which I would generally agree with is to try and find your own Rex Kay wherever you live. Look up your local Rex Kay. Can you tell Rex that I'm trying to get you back for another episode?

Dr. Rex Kay:
Where you're going about it the entirely wrong way.

Jordan Bawks:
But truthfully and I'll chop this up with audio. Um, I would also encourage people to look up their whatever your local institution is and try and find a mentor. A mentor if you can so like if you do clinical work asking around in your local clinical department for people who have psychodynamic training or they do psychodynamic therapy is the best way to learn. As much as I love books and podcasts is to is through real relationships. And so I strongly encourage you to ask around for your local psychodynamic expert or trainee or whoever's keen and go through that exploration together. So I want to thank you guys both. Anita, well done your first episode. Rex, thanks so much for joining us and tolerating all my questions and admiration.

Dr. Rex Kay:
No disrespect, Jordan, but Anita, coming at this from the outside, uh, stimulated my questioning mind and I think really facilitated this discussion. So thank you. And Jordan, as always, thank you just for being Jordan.

Jordan Bawks:
Can't be anybody else. Thank you for listening to PsychEd the Psychiatry Education Podcast, by medical Learners for Medical Learners. Our theme song is by Olive Musique. I want a special thank you to our guest expert today, Dr. Rex Kay. Post-production was done for this episode by Jordan Bawks and Anita Corsini, and we hope to have you back on our podcast sometime soon. Take care.

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Episode 10: Treatment of Schizophrenia Part II with Dr. Albert Wong

• Episode 10: Treatment of Schizophrenia Part II with Dr. Albert Wong

  Alex Raben: [00:00:08] Welcome back to PscyhEd, the Educational Psychiatry Podcast for Medical Learners by Medical Learners. I'm Alex Raben and I'll be your host today. This episode is the second of four in our series on schizophrenia treatment. If you haven't listened to episode nine, the first episode in this series, I would recommend you go back and listen to it because this episode builds on ideas that are in that episode. For this episode, we sat down with Dr. Albert Wong, a psychiatrist and research scientist who is an expert in schizophrenia. He is also heavily involved in our education at U of T and is known for challenging our views on psychiatric illnesses in a way that I believe gives us a deeper conceptual understanding. It is my hope that we have replicated some of that experience for you in this episode. This episode also uses a slightly different format than past episodes, in that I was joined by three medical students in their first, second and third year. The intention of this format was to provide the medical student perspective, but I think in that aim we failed somewhat. Partly because the conversation became pretty high level and partly because I just wasn't used to balancing such a large group. I really wish we could have had more of the medical student voice in this episode, and I apologise to my colleagues for that. But either way, I think there's some great information that you guys can benefit from in this episode and I hope you'll enjoy it. And please let us know what you think of this format so that we can continue to build and learn with you. So there is some overlap between this episode and the last one, but I think it takes a deeper dive in a number of the concepts.

  Alex Raben: [00:01:47] So by the end of this episode you should be able to, number one, conceptualise antipsychotic drug categories in an unconventional and clinically relevant way. Number two, have an approach for choosing an antipsychotic medication for a patient and be able to consent that patient to treatment. And number three, understand the limitations of our understanding of schizophrenia and our current treatments and some of the problems that remain to be solved in this area of psychiatry. There is also one concept I'd like to clarify before we jump into the interview, and that is extrapyramidal symptoms or EPS. So these are side effects that can occur with antipsychotic medications and they're essentially disruptions in motor functioning due to the global dopamine blockade caused by antipsychotics. In other words, these are involuntary muscle movements that happen because of the medications. There are three main types that happen acutely or more acutely. These are dystonia, Parkinsonism and akathisia, and then one that occurs months to years after treatment has started called tardive dyskinesia tardive because it happens late. So I'll go through each of these in turn. Dystonia is a sustained involuntary muscle contraction. So the muscle essentially gets stuck and it can be quite painful. It can happen to any muscle group, but often involves torticollis of the neck. Second is Parkinsonism, and this is similar to in Parkinson's disease. So there's rigidity, limited arm, swing tremor, masked face. However, it's usually symmetrical because the drugs affect both sides of the brain, unlike in idiopathic Parkinson's disease. And then there's akathisia, which is a subjective restlessness that will often occur with also a physical restlessness, but not always such as pacing or not being able to sit still.

  Alex Raben: [00:03:50] So for this one, you need to ask about the patient's subjective experience, because if they don't have that, it's not akathisia. And finally, there's tardive dyskinesia. This is the late occurring one, and it's a hyperkinetic movement, usually jerky, rhythmic or slow and sinuous. And this can also involve any part of the body, but often will involve the face and tongue muscles. We also need to briefly review the case of Muhammad because we use it again in this episode. So recall from last time that Muhammad is a 19 year old man who lives in his parents house and was brought to the emerged by them for acting bizarrely, he was admitted to the hospital and received a provisional diagnosis of first episode psychosis, likely related to schizophrenia. He was showing signs of psychosis both at home and in the hospital and had delusions that people were spying on him. And this had something to do with the electrical wiring in his home. At one point, he even tried to tamper with the wiring in his home, and he has no training on how to do that safely. Okay. So that's all the background you guys need. So without further ado, let's jump to the interview. I'm just going to introduce everyone who's in the room today. So as you know, I'm Alex Raybon. I'm a third year resident at the University of Toronto. And our expert guest today is Dr. Albert Wong, and I'll have him introduce himself to you.

  Dr. Albert Wong: [00:05:35] I'm a psychiatrist at Camh, and I also have a lab. I do some neuroscience research.

  Alex Raben: [00:05:39] Great. Thank you. I'm also joined by three medical students here at U of T, and I'll have them introduce themselves as well.

  Sabrina Agnihotri: [00:05:47] I'm Sabrina Agnihotri, a CC3 at U of T.

  Yunlin Xue: [00:05:50] I'm Yanlin Xu, and I'm a second-year medical student.

  Theresa Park: [00:05:55] I'm Theresa, and I'm a first year medical student.

  Alex Raben: [00:05:59] Great. Thank you all. So as before, we're going to sit down together as a treatment team and discuss antipsychotic medications for the treatment of schizophrenia, and especially as they apply to the case of Mohammed. So why don't we start with general principles of antipsychotic treatment for schizophrenia? Whoever would whoever would like to jump in.

  Sabrina Agnihotri: [00:06:32] So there are so many medications that you could choose to start for a first episode of schizophrenia. Where do you even start?

  Dr. Albert Wong: [00:06:42] Okay. I mean, I think a few things here. The first thought that I would have is that it doesn't really much matter in first episode which antipsychotic you pick because all of them will be likely to be effective. Any of them will be likely to be effective. So first episode, schizophrenia, for whatever reason, probably because it's at the beginning of the illness, it responds very quickly and very easily to most antipsychotic medications at fairly low doses. And I think but, you know, one of the reasons why you're having this educational session is because it's unclear if it was very obvious which medication to pick in this instance, then we wouldn't be having this conversation. So what is the controversy, do you think? I mean, you all have said the same thing. So what's the controversy then? Why are we having this session?

  Yunlin Xue: [00:07:35] Um, potentially the side effects. Okay.

  Dr. Albert Wong: [00:07:38] So that doesn't really affect the choice of antipsychotics. I mean, they all have side effects. So what do we. I'm just trying to clarify what it is that is the subject of debate, really. What is the controversy that's in this field that we really need to talk more about? I mean, in the end, we have to choose one medication. But in getting there, we might think a lot in the background about the issues at hand. So from my standpoint, I think there's it's confusing because there's a significant mismatch between treatment guidelines and the literature. You know, there are a number of studies, very well conducted studies comparing various typical and atypical antipsychotics, and they typically find no difference among these two categories. So why is it that we keep on saying that we should pick atypicals? That's one question. And so, you know, I think it's hard for people because the treatment guidelines say atypical. But then if you asked what is the advantage of an atypical antipsychotic, then I think it's difficult to say. And even more upstream question is what is it that distinguishes typical from atypical antipsychotics?

  Alex Raben: [00:08:46] So I think there's even controversy about around that. But it would be the different receptor profiles. So a typical is more purely D2, whereas an atypical has the five H to a blockade as well.

  Dr. Albert Wong: [00:09:04] So I think that's one criteria. A common one that's been advanced to categorise antipsychotics into typical versus atypical. And I would argue that that makes no sense. So the reason I would say that is because there are so every antipsychotic has only one therapeutic target, and that is the dopamine D2 receptor. And so far there has been no medication that's been discovered that has antipsychotic effects that we use clinically that does not bind significantly to the dopamine D2 receptor. So that's the first thing. If you then look at the dose of antipsychotic that's used clinically, that reflects only one physical property, which is the affinity for the dopamine D2 receptor, which is just another way of restating what the earlier statement was. So there is, of course, a dose response curve here. And in order to achieve the same response with a different drug, you need to occupy the same number of dopamine D2 receptors. So because of that, I think really there's no it doesn't make any sense to talk about typical versus atypical because there are some drugs which are considered typical because they're old drugs like chlorpromazine or clozapine, which are given in fairly high doses, you know, in the hundreds of milligrams. And these medications are given in that dose because they don't have a very high affinity for the dopamine D2 receptor, whereas other drugs, old drugs that are considered typical, such as Haloperidol or drugs that are considered atypical, such as risperidone, are given in very low doses somewhere, you know, under ten milligrams.

  Dr. Albert Wong: [00:10:37] So at least an order of magnitude lower, in some cases two orders of magnitude lower than drugs that are given at high doses like quetiapine and chlorpromazine and clozapine. So in my mind, the the low potency drugs such as Quetiapine, chlorpromazine and Clozapine share much more in common with each other versus the drugs that are high affinity such as haloperidol and risperidone that are given in fairly low doses because they have very high dopamine D2 affinities. And the reason I'm making this point is because while some of these drugs may bind to other well, all of these drugs bind to other g-protein coupled receptors that are evolutionarily related to the dopamine. Dopamine receptor system. They do so in proportion to their affinity. So if a drug has got a low affinity for dopamine D2 receptors, in order to achieve therapeutic occupancy, you have to give a whole bunch extra, which will then end up binding to histamine receptors, adrenergic receptors, serotonin receptors and so on. And so the side effects from low potency drugs mostly come from these off pharmacological target effects. So for example, the sedation comes from histamine. Sexual side effects can come from the serotonin, cardiac effects come from alpha adrenergic. In contrast, the high potency drugs like Haloperidol and risperidone, because they bind so tightly to the dopamine D2 receptor, there may main side effects come from a pharmacologically on target, but anatomically off target effect.

  Dr. Albert Wong: [00:12:08] In other words, they bind to dopamine receptors, the D2 receptors wherever they are, including parts of the brain and body where we have unintended effects for the purpose of antipsychotic use for the treatment of psychosis. So the obvious one is extrapyramidal symptoms that come from binding to the dopamine D2 receptors in the nigrostriatal tract. So you really can't get out of this. The drugs that are high D2 potency are going to have side effects that relate to D2 occupancy in areas other than what we intend for therapeutic effects. Whereas the drugs that bind to receptors other than the dopamine receptors are going to have their side effects from that and they will include sedation, weight gain, sexual dysfunction, etcetera. So in my mind, this distinction between typical and atypical, at least based on off target binding to the serotonin receptor, whichever subtype including the 2A1 really has nothing is not useful as a category because again, there are drugs that have almost no binding to this serotonin receptors that are considered typical or there are drugs like that that are considered atypical and vice versa, drugs that don't bind very strongly to D2 and bind to a whole bunch of other receptors, some of which are classified as typical and some of which are classified as atypical. So I don't see that there is any pharmacological basis for that notion.

  Alex Raben: [00:13:26] Right. So you're saying that rather than distinguish antipsychotics based on first and second generation or atypical versus typical, you would rather categorise them as low potency and high potency because that is more useful in figuring out what their side effect profiles are going to be.

  Dr. Albert Wong: [00:13:45] Exactly. So I think the first and second generation category is based on the time at which the drugs were first brought to market. So that's perfectly reasonable way of looking at drugs. There are old drugs and there are new drugs. And that is, you know, I'm not sure how clinically useful that is, but that's certainly something that people think about. It's certainly important to drug companies in terms of which drugs are making money or not. So there is that first generation, second generation idea, and that's not a problem. But I don't think that it matches with typical versus atypical. I think that's part of the problem that atypical drugs really are marketed as such, but they don't necessarily have anything pharmacologically different than drugs, which are so-called typical. So to me, it's a conflation of a number of ideas, which is quite confusing. And this is what is partly why we're trying to clarify this today.

  Alex Raben: [00:14:34] Right? So I agree. It's it is a confusing subject. I wonder if we might turn to the medical students because I know that's a lot to kind of all take in at once. Are there any questions you guys have about what was just discussed?

  Sabrina Agnihotri: [00:14:51] I think the way that they package antipsychotics to us as CC threes is exactly like that. The atypical versus typical and the side effect profiles and. One of the things that they stress to us is that Atypicals are superior because they don't cause movement disorders. And I've actually heard that that phrasing used. And so as a CC3 going through psychiatry, the rotation, like I was surprised to learn that it's not that they don't cause movement disorders, that the risk is lower. So I wonder like why it gets packaged to us like that.

  Dr. Albert Wong: [00:15:29] Yeah. So I think there's a number of issues here. I think there is. So to to borrow from Donald Rumsfeld, there are known unknowns and there are unknown unknowns. What we. What we don't know for sure is what the long term risk of all of these drugs is in terms of causing tardive dyskinesia, the long term movement disorders. And part of that is because we don't prescribe antipsychotics the same way now as the as they used to be. So there used to be prescribed in much higher doses generally, not always, but generally. So we see a lot more patients today, older patients who have been on antipsychotic medications for decades who have tardive dyskinesia. We think, again, we don't know for sure because we can't do you know, we can't do a randomised clinical trial and prospectively assign someone to a very high dose versus low dose antipsychotic and see how they do in 30 or 40 years. That wouldn't be ethical and we wouldn't we're not interested in doing that. But it means that there's a gap in our knowledge. So it's hard to compare what the risk of long term treatment with antipsychotics is between the older and the newer drugs. So if we want to consider first injection second generation simply as a time category. Time on the market kind of thing, it's hard to compare. So the older drugs will look worse for sure because they were given in a higher equivalent D2 occupancy doses. So that's a fundamental problem with our data. However, what we can do is, look, there are many good clinical trials looking at active treatment of different antipsychotics in a patient population that are part of a clinical trial.

  Dr. Albert Wong: [00:17:11] So that is a prospective, randomised controlled type of study. And in those cases we don't see differences in tolerability or efficacy. So that's, that's sort of the bottom line. You know, the reality is that unlike other areas of medicine, there have been really no new targets. Well, for for antipsychotic treatment. There has been no new targets since the original antipsychotic, which was chlorpromazine, that was developed in the 1950s. It binds to D2 receptors, and every antipsychotic that's come out since then also has dopamine D2 receptors as the target. Now, there's nothing necessarily wrong with that, except if you compare that to other areas of medicine. So if you imagine, say, in cardiology, so I'm not sure exactly which were the first category of Antihypertensives was it beta blockers or diuretics? But certainly now we have, you know, many, many different categories of cardiac drugs that work on different biological targets in the treatment of schizophrenia. We have still only one target. So I think it's really important to keep that in mind. We're not talking about the choice between an ACE inhibitor, calcium channel blocker, a diuretic, a beta blocker. Et cetera. In the treatment of hypertension, we're talking about the selection of an antihypertensive just within the category of, say, beta blockers. Which beta blocker should we try? So in other words, the, the the choice we have is very limited and we're looking at very, very fine distinctions between drugs that have the same pharmacological target.

  Alex Raben: [00:18:43] Right. So what I'm hearing a lot of is that these are all equally effective with the exception of clozapine for treatment resistant schizophrenia, which we'll get to in another segment.

  Dr. Albert Wong: [00:18:57] But I agree. I mean, just, you know, just as a quick point, you know, I only I think the only atypical antipsychotic is clozapine. Right? So if we want to talk about differences in efficacy, that's the only one, right?

  Alex Raben: [00:19:10] So then we are forced to make decisions based on side effect profiles, which, as we were talking about, is more a low potency, high potency question. I know that the CPA guidelines at least used to recommend starting with a second generation for the reason of avoiding the EPS, the Extrapyramidal side effects, because people who are first episode are at a higher risk or people who are naive to antipsychotics are at a higher risk of developing EPS symptoms. So would you like is it better to pick a low potency antipsychotic first based on that principle?

  Dr. Albert Wong: [00:19:51] I would say that it's best to choose a drug based on an individual patient's symptoms and their complaints. Right. As we said earlier, if you give risperidone at higher doses, people will get EPS versus an atypical such as with a typically classified as an atypical like QUETIAPINE, for example, it's a fairly new drug compared to Haloperidol. And Quetiapine never causes EPS because it causes sedation before it causes EPS, which is the same for the drugs, other drugs that are high given in high doses. So I would say you should choose a drug based on the patient's symptom profile. So if the patient, for example, is complaining of insomnia, then you would choose a low potency antipsychotic. It will because it will most of them bind quite a bit to histamine H1 receptors and like Gravol, like Benadryl, they make people really drowsy. And that's. A bad thing if you don't want to be drowsy, but if you're having trouble sleeping, that's great. Also, if that person happens to in addition to their psychotic symptoms, has a lot of anxiety, primary anxiety or secondary to psychotic symptoms doesn't really matter.

  Dr. Albert Wong: [00:20:54] All of these treatments are symptomatic. So I think it's important to keep that in mind. We don't know what causes schizophrenia or any other kind of psychosis except in some very rare examples when people have some structural disorders, structural brain disorders. But because we don't know that, we're just treating the symptoms. And so if there's a side effect which happens to also mesh with a patient's complaint that actually improves one of their complaints, then you would choose that. And conversely, of course, if somebody, for example, already has a problem with being overweight, you would try to avoid a drug that increases their weight further, for example. So, you know, you can't. But because each drug just comes the way it does and it has its pattern of side effects, we may not be able to find the best drug for everybody. And we still pick the best drug for everybody. But it may not be optimal for some people. They might just have a combination of symptoms which fits perfectly with a particular one particular antipsychotic, and that's great. But that may not be the case for everyone.

  Alex Raben: [00:21:54] Great. Sabrina, you look like you have a question.

  Sabrina Agnihotri: [00:21:57] Does the fact that some of them have injectable forms come into play at all with your decision?

  Dr. Albert Wong: [00:22:02] Absolutely.I think, you know, the discussion here, you know, we started with some sort of more basic pharmacological ideas. But really clinically, I think the the considerations are just pragmatic, very practical. And so that's a good that's one, you know, area that has a practical aspect to it. So if somebody has a problem with compliance or some people like having depots instead of taking pills every day, you know, it's just like with birth control, you know, some women don't like to take a pill every day. They want to have an injection. You know, it depends on the patient. So it could come from the patient. You know, they prefer a pill versus an injection. They prefer, you know, once a month or once every two weeks. That's it. Or it could come from, you know, the family who are concerned about compliance and convince the patient or perhaps from the treatment team as well.

  Alex Raben: [00:22:51] One question that comes to my mind, especially for our audience members who are trying to remember all the side effects of these drugs for later consenting patients. To them, how do we keep how do we remember those in a way that makes sense?

  Dr. Albert Wong: [00:23:11] Yeah, I wish I could draw something because when we have this discussion in a clinical situation, I usually draw a picture. So if you imagine a spectrum from left to right and on the left side, we can just doesn't matter. Arbitrarily. We can say the left side are high potency drugs that are given at low doses and on the right side are drugs that are low potency, that are given at high doses. So the ones on the right side are the ones are going to have sedation, sexual side effects, weight gain, cardiac effects from all of the non dopamine g-protein coupled receptors that the drug will bind to. Conversely, the drugs on the left side, like Haloperidol and risperidone, are mostly going to cause the dopamine related side effects. So prolactin elevation from the tuberoinfundibular system and extrapyramidal symptoms acutely from nigrostriatal tract and tardive dyskinesia in the long run from also from the nigrostriatal tract. So I would just sort of put drugs into three categories low, medium and high dose or in other words, high, medium and low potency. So basically the drugs that are given in the hundreds of milligrams, those are the ones that are low potency and those are the ones that are going to cause sedation and cardiac effects and so on. And those are the ones in the middle that are given somewhere between 10 and 100mg. So things like olanzapine, for example, loxapine, they fall in that category. And then there's the drugs that are high potency that are given at less than ten milligrams. So just sort of really three orders of magnitude and the ones the tens and the hundreds of milligrams. And so I would just I think that's enough of a of a guide for a clinical scenario because there's enough interindividual variability and people have idiosyncratic responses. You can't predict those things. They have changes, differences in metabolism, differences in illness and so on. So I think that level of general categorisation is enough, basically low, medium and high, and from that you can get a good idea of what the side effects are that the patient is likely to experience.

  Alex Raben: [00:25:07] Great. Thank you. I'm wondering, maybe we could touch a little like drill down a bit more into the high potency side effects so the D two related side effects, because they are, as you put it, are anatomically more anatomically related. Could we go into that a little bit how how those relate to the anatomy? Because I find that helpful.

  Dr. Albert Wong: [00:25:34] So, you know, we don't know how antipsychotics work, so we don't know for sure where the therapeutic effect is, but we think. That it's got to do with. But we know we can infer that it's from the dopamine D2 receptors. So there are four main dopamine tracks in the mammalian brain. There's there are two tracks that originate in the ventral tegmental area, which is just ventral to the substantia nigra and that's in the midbrain. So that's why it's called. So these two tracks are called the Mesocortical and the Mesolimbic dopamine tracks. So they project from the ventral tegmental area in the midbrain. They project forward into parts of the cortex and the limbic system. The second tract is the tuberoinfundibular, which is the one that goes from the hypothalamus pituitary and regulates prolactin secretion in an inverse way. So more dopamine, less prolactin. And then there's the Nigrostriatal tract, which is the track that degenerates in Parkinson's disease. It originates meaning that the neurones in this track live in the substantia nigra and they send their axons into the striatum. So that would mean that the caudate, the Globus, the Globus, Pallidus and the Putamen.

  Dr. Albert Wong: [00:26:46] So, you know, so that's the list. So if you go back, you know, the mesocortical dopamine tract is one that we think is involved in higher thinking, obviously because it involves the cortex, the mesolimbic tract, it's mainly a projection to the nucleus accumbens, which is the track that we think is involved in reward. And this is the tract in which, for example, cocaine and amphetamine act on to prevent the uptake re-uptake and sometimes promote the release of dopamine. And so that's why drugs like cocaine and methamphetamine are so addictive because they derail the brain's mechanism for determining what is rewarding and what is not. And that helps to guide behaviour with normal physiological inputs. But if you take a drug that just specifically activates the reward pathway, then of course this drug will be highly addictive and of course it'll distort behaviour. And then the tuberoinfundibular tract, of course prolactin is involved in lactation and if you block dopamine D2 receptors with antipsychotic, then you will increase prolactin.

  Alex Raben: [00:27:47] Because you're cutting that dopamine break.

  Dr. Albert Wong: [00:27:48] You're blocking the right and you're blocking the receiver for that break. And then the nigrostriatal tract, you know, the, the Corticospinal voluntary movements tract, you know, the pyramidal tract, so-called, it originates in the cortex, of course, and the motor cortex, and it goes through the internal capsule which flows through the globus pallidus the bottom and the caudate through the striatum before descending into the spinal cord to control voluntary movement through skeletal muscle. The fluency of normal voluntary movement comes from essentially motor subroutines that are stored in the striatum. So when you learn a new activity like playing a sport, at first it's very stilted and awkward because one is thinking consciously using the cortex about every small movement. But when somebody gets good at a sport, then of course they don't think about these things. They think about more advanced things like the strategy, you know, what kind of move they're going to use to fool their opponent. They're not thinking about the individual movements that you do when you start off. And that's because those automatic motor programs are now stored in the striatum. So that's why when people get Parkinson's disease, when their nigrostriatal tract degenerates, they become so awkward. They have difficulty initiating movement because that those those motor subroutines are lost. And that's why they seem so that's why their movements are so impaired. So. So you wanted to drill down into each system, Is thatwhat you're thinking?

  Alex Raben: [00:29:08] Yeah. No, that's great.

  Dr. Albert Wong: [00:29:09] Um, maybe just one point. As I was just thinking about it, you know, part of the reason why antipsychotics are so unpopular among patients, why it's so difficult to get people to take them and why compliance is so bad is because they're blocking the mesolimbic cortical, the mesolimbic dopamine tract. So many of the drugs that we prescribe in psychiatry have some street value, especially the benzodiazepines. Even sometimes the anticholinergic drugs. People abuse these drugs. They find them, they like to take them on their own and you can buy them on the street. There's a price for them. You can't sell antipsychotics on the street. That tells you something about them. These drugs are profoundly unpleasant to take because they block the very system that's rewarding. So not only do they themselves are not rewarding, but they make everything else in life not so rewarding as well. So it's kind of like an anti-cocaine. It's like not fun to take.

  Alex Raben: [00:30:03] Right. So that's part of the side effect profile as well.

  Dr. Albert Wong: [00:30:04] Right. And it's unavoidable that, you know, we have found a system in the brain which is very effective for modulating psychosis, but it's also the same neurotransmitter that's used for signalling reward expectancy. And so when you block the system, it has this very unpleasant side effect, which is there's no way to get around it.

  Alex Raben: [00:30:26] Because that's where we think the target is.

  Dr. Albert Wong: [00:30:29] For because the dopamine D2 receptor is found in these different anatomical tracts and it has different roles in each tract. The brain doesn't have this problem because when you release dopamine in the reward pathway, it doesn't it can't get to the other parts of the brain. I too, can't find its way to the pituitary. It doesn't get to the cortex. It doesn't go to the striatum. So the body is fine because it can segregate these neurotransmitter signals in different pathways. And this is a common problem in pharmacological and pharmacology in the treatment of illness. You know, we can, even if we have a very good target for treating that illness, if that target is found in other parts of the body or brain, then you're going to have side effects because you can't Right now, we don't have the technology to get that drug only to one brain area and not the others.

  Alex Raben: [00:31:16] To summarise again, low potency, you're going to have those off target side effects.

  Dr. Albert Wong: [00:31:23] Yeah so I think the main off target side effects would be from the other g-protein coupled receptors. So there's the muscarinic acetylcholine receptor. So that's where people get dry mouth, blurry vision, they can get constipation, that kind of thing. Histamine H1 receptors are the main origin of sedation. The serotonin receptors, the, you know, that are the off target targets of the antipsychotics cause, you know, a bunch of changes in neurovegetative functioning, including sexual dysfunction, perhaps also dysregulate appetite. And then the adrenergic receptors are where the cardiac side effects mostly come from. So, I mean, this is a broad generalisation, but I think for the purpose of this and you know, at this level of training and trying to understand where the clinical, you know, to organise things clinically and to think of where side effects come from, that's where they're coming from.

  Alex Raben: [00:32:11] And how do we mitigate some of those side effects?

  Dr. Albert Wong: [00:32:16] Well, there's really no way to directly mitigate them.

  Alex Raben: [00:32:22] Like, um, I guess what I was thinking is, um, like we do a lot of investigations for, for the low potency. Like we will monitor weight gain and metabolic parameters. And then for EPS we'll do scales and that kind of thing.

  Dr. Albert Wong: [00:32:41] Yeah, I mean, I think but in the end we have no real way of treating these. I mean, the only side effect that we have a good treatment for, I would say maybe there's two with akathisia. We can give benzodiazepines, but that's not a great long term solution. And with extrapyramidal symptoms, we can give an anticholinergic drug. Benztropine benztropine procyclidine sufentanil. So, you know, just as a connect this back to what we're talking about earlier with the high potency drugs because they're purely D2 drugs, you get the EPS, you get the Parkinsonism. The reason that low potency drugs don't give you Parkinsonism even at the same level of D2 occupancy is because they also bind to the muscarinic acetylcholine receptor. So they have like a built in side effect pill that you're taking with it. It's like a, you know, like a combo. It's not. But you know, and you can think of it that way. So but, but your point about, you know, how can we mitigate these side effects? I don't think you can. You can choose a drug that has less of the side effect. That's a problem. But in the end, we really have no treatments for any of these side effects. I mean, you know, you can think of symptomatic things. I guess you could, you know, for erectile dysfunction. There's Viagra, which, you know, I'm sure you get all kinds of spam every day. So if you want to buy some cheap Viagra, you know where to get it. But, you know, in terms of things like EPS, you know, you can give anticholinergics. So that's that's probably the only one we can really treat. But things like sedation, I mean, we have no treatment for that. Definitely wouldn't use some kind of stimulating or activating medication in the context of psychosis.

  Dr. Albert Wong: [00:34:07] So that's out. And then the weight gain, I mean, the majority of the population doesn't exercise already and has, you know, problems. You know, in North America obviously has a very high proportion of people who are overweight and obese. So it's already a problem in general in society for which there is no good solution. So in somebody who's got schizophrenia, who may be having metabolic side effects from the antipsychotics, you have obviously added a whole other layer of problems. Somebody who has negative symptoms and has problems with motivation and may have difficulty organising their behaviour in the first place. Plus they may have psychotic symptoms. And then now you also want to try and get them to exercise and watch their diet. Plus they're usually in a lower socioeconomic strata. You know, that's a really big challenge. So that's why it is a serious problem. But, you know, we have really not a lot we can do about it. I think, you know, the, you know, one, you know, to step back for a minute, what we really need are is a is a better understanding of the illness and better drugs, like a different category of drugs. Like we're still stuck with beta blockers for treating hypertension kind of thing. We need to go beyond the beta blocker. We need to go beyond the D2 receptor. We need new treatments for schizophrenia. And then we would have options because if you hit a completely different receptor system, then you're going to get completely different side effects. Maybe, maybe not be completely different, but they will be definitely from a different cause. And then you have something that you can you can do, you have something to play with. But right now, we've basically we don't have much.

  Alex Raben: [00:35:32] Sabrina, do you have a question?

  Sabrina Agnihotri: [00:35:34] Well, it sounds like a lot of these drugs are targeting the positive symptoms in schizophrenia. What about the negative symptoms? What is like are there pharmacological treatments for the negative symptoms of schizophrenia?

  Dr. Albert Wong: [00:35:46] Not really. I mean, I think sometimes I mean, there are studies that show that there are some effect on negative symptoms. But I would say that overall, it's either very weak or nonexistent. The bottom line is that we don't do very well at changing the course of illness and schizophrenia. We're very actually not too bad at treating psychotic symptoms. Of course, here, you know, there are many patients who are refractory and who, you know, are noncompliant. But for the majority of patients, most of the time, antipsychotics do have an effect on reducing their symptoms. But what we aren't able to do is change the overall outcome of the illness, and that mostly has to do with their cognitive and cognitive symptoms and negative symptoms for which we really don't have any good treatments. And just to point out that we don't have a good way of treating cognitive symptoms in any disorder, in any context, really, whether it's schizophrenia or not. So, you know, think broadly back to the original conception of schizophrenia by Kraepelin as dementia praecox. You know, that highlights the fact that even 100 years ago it was noted that the primary feature of this disorder that gave its name was actually the dementia. It's just that it was a kind of dementia that came on earlier in life than senile dementia, which was obviously the other main kind of dementia. So it's been well known in some ways it's been kind of I wouldn't say it's forgotten, but it's been overlooked. It's been de-emphasised in this quest to come up with a really effective treatment for the psychotic symptoms. I'm not saying that psychotic symptoms are a great thing to have. It's just that. It's only a it's only part of the picture. And in fact, the psychotic symptoms are not the main determinant of outcome.

  Yunlin Xue: [00:37:29] So can you go through the pathophysiology of negative symptoms and why it's hard to treat them compared to the positive ones.

  Dr. Albert Wong: [00:37:38] You know, I don't think we know. Well, first of all, we don't know what causes anything in in any major psychiatric disorder. Right. So we don't know what causes psychotic symptoms, nor do we know what causes negative symptoms. I think this is a great this is a major challenge for our field. It's very difficult to develop rational treatments without knowing the cause. All of the you know, there are many cases in medicine where treatments are discovered by accident. And then from that, something more is learned about the illness for which that treatment is usually given. So, I mean, we do we have learned a lot about psychosis in the sense that we now know how important dopamine is. Dopamine is clearly a modulator of psychotic symptoms. And we know that people can get psychotic sometimes when you overstimulate the dopamine system, when there's too much signalling to the dopamine system, say with crystal meth, methamphetamine, that's sort of a common clinical presentation. And conversely, of course, if you block the dopamine D2 receptors, you can reduce or get rid of psychotic symptoms in regardless of the original cause. But that's not really that's just a proximal cause. We don't know what the upstream distal cause is. And schizophrenia is likely not to be an illness per se, but it's a collection of different things that end up with the same presenting symptom.

  Dr. Albert Wong: [00:38:54] It's a very crude way of categorising things in medicine, you know, in terms of just looking at symptoms. So in psychiatry, we do not yet know what the cause of different types of psychosis is. Mostly, you know, occasionally again, if somebody has a stroke with a sudden onset of psychosis or they have a space occupying lesion or, you know, something like that, then we can presume that the psychosis originated from that etiology. But it still doesn't really tell us what the pathophysiology is because brain lesions in many different brain areas can cause psychosis. So there is no sort of psychosis area. It's not it's a non-localising, non-localisable abnormality. And that's partly what puts it in the realm of psychiatry. Some people would argue that that's what distinguishes neurology from psychiatry and neurology. They have focal localising symptoms and therefore there is a lesion somewhere. Even if there's more than one lesion, say, in multiple sclerosis or, you know, some kind of autoimmune other autoimmune disorders. But still there are lesions that can be identified in psychiatry. We don't have that. Two people can have what seems like a similar presentation and they may have, you know, lesions in different parts of the brain or no lesions that are discernible at all. So the answer is we don't know. I don't know and we don't know.

  Alex Raben: [00:40:05] I'm thinking about Muhammad, our patient. If he were here in the room or his family, you know, given the conversation so far, he may not be too thrilled about being on a medication like this. What are the ways we can how do we frame this to patients to help them with that?

  Dr. Albert Wong: [00:40:24] I don't know if I would try to frame it for them. I would be straightforward with the patients. It's not a good option. We don't have good options. We need better treatments for schizophrenia. I would be frank about that. I am frank about that with my patients.

  Alex Raben: [00:40:35] And yet it's necessary. Is that fair to say?

  Dr. Albert Wong: [00:40:42] Well, I don't know, you know. There are patients who I mean, I think, you know, we see psychosis as being something which is abnormal. And I think that it is a reflection of some brain dysfunction. But, you know, we have trouble framing the situation and selling this treatment to patients because we know we're not selling them a great deal. If this drug was going to make their life better and and have, you know, not that many side effects, then we wouldn't have this discussion. It would be simple. But the fact is that it's not a great option. We don't have a great treatment. Again, if you have if you have transient psychosis for some reason, then it's different because the drug these drugs are good for treating psychotic symptoms. So if you show up in the emerge and you've been smoking a whole bunch of crystal methamphetamine and you're super psychotic, and for the day or two that it takes that to clear, you get some antipsychotic and then you're much calmer and, you know, then that's, I think, a great outcome. But if you have schizophrenia, if you have this chronic psychotic disorder, you know, it's not again, the antipsychotics do not improve the outcome overall. At least not very much. So I think it's a difficult sell. Now, there are cases where there are patients who are otherwise fairly high-functioning. If their psychosis is controlled, they can do well. And I have some of those patients who I first saw in first episode, and I've been following them for many years now, and they're doing quite well. They're the exception. So there are cases like that. So it's not hopeless. But these patients also have very good insight about their symptoms and they're able to comply. And all these other factors are there as well. But in terms of like when you have somebody who is in a first episode like this, this case we're talking about, I think you have to be honest. And for them to be prepared for the likelihood the outcome is going to not be so good. You should be truthful about it.

  Alex Raben: [00:42:41] Sure. Yeah. What would you say if Mohammad said he only wanted psychosocial interventions and he was not interested in trying medication? I'm just thinking about the guidelines. Like I think NICE says that you should recommend you should strongly recommend medication or something along those lines because therapy alone is not as effective.

  Dr. Albert Wong: [00:43:14] I don't think therapy is going to do anything for the psychotic symptoms as bad as they are. I think that's a treatment we've got. But I very I understand why patients don't want to take them at the outset and also why they don't comply with them after they've even started on them. You know, it makes sense to me why they're doing this. You know, there are some drugs which people really want to take which we never have to convince people to take. And actually, we have to try and convince people not to take like opiates, like benzodiazepines. There's a number of drugs in medicine like this. And then there are drugs which people really don't want to take that we have to convince them that they should take. And then there are drugs that people don't want to take, but they take because they know that they have to in drugs that have unpleasant side effects like chemotherapy and cancer. This kind of thing. So, you know, we have the unenviable position of trying to push treatments which are fraught with bad side effects and which have a really limited spectrum of efficacy. They treat part of the illness, but not actually probably the most disabling part of it. So it's difficult. So again, I don't try to sell them. I'm honest about it and make people let people make their own choices.

  Dr. Albert Wong: [00:44:22] You know, there's also this idea of which, you know, I think the evidence is still kind of indeterminate about whether chronic antipsychotic treatment is really the way to go. You know, people could say that, for example, if there are other examples in medicine where there are illnesses that have relapsing-remitting course, in which case we treat just the relapses and when the symptoms remit, we also stop the treatment. So for example, autoimmune disorders are a good example where we might use intermittent steroid treatments. So knowing that our treatments are symptomatic, you know, this is a bit of a heresy. But, you know, because all the treatment guidelines say you must use antipsychotics and you must keep keep patients on these antipsychotics. And it's true that sometimes when patients get psychotic, then they lose the insight about their symptoms and then don't comply with antipsychotics. So certainly you would lose you know, you would you wouldn't be able to treat those patients. You would lose those patients. But there are you know, the question in my mind is for an episodic illness, you know, so some people have chronic psychosis. It doesn't really seem to go away. But other people seem to have episodes of psychosis that come and go. Why? We're using a treatment that's there all the time for symptoms that are not there all the time. I'm not sure that there's a good rationale for that, but that's not the orthodoxy.

  Dr. Albert Wong: [00:45:43] And we say, you know, we should always keep patients on their on their medications, but I'm not sure that that's the way we should be doing it. So in some ways, you know, we could reduce a lot of the concerns about antipsychotics if we weren't giving them all the time. You know, the issues about metabolic side effects, for example, are not such an issue if the patient is not on it for their entire life, if they're only on it sometimes, obviously that makes it a lot better. Same thing with the tardive dyskinesia, you know, so there is the clinical problem of getting somebody who has become psychotic to restart their antipsychotics. But, you know, we don't really try and address that problem. We don't try and come up with ways to have people on and off antipsychotics just when they're symptomatic. We just try and get them treated with it all the time. So that's why, you know you know, I know you're just phrasing the question in the vernacular way, but that's why we have this feeling that we're trying to sell these drugs to people because they're you know, they do have all these problems. And especially the way that we give it, I think is it just it's not a it's not a good for the side effects.

  Alex Raben: [00:46:41] That kind of leads into my next question a little bit. Time of treatment. I know there's an orthodoxy and then there's, you know, potentially some wiggle room there for the field to try some other approaches. Is there for a first episode, Is there a recommended amount of time someone should be on this to avoid a relapse? Is there what is the orthodoxy and what is maybe the wiggle room?

  Dr. Albert Wong: [00:47:08] Yeah, I mean, the people say, you know, something like a year, but you know, why is it a year? Why is it not 11 months and why is it not ten months? Why is it not 13 months? You know, there's no real rationale for it being a year. Yeah, I would say it depends on the patient. You know, many patients will want to stop their medications after their first episode. Even if they're successfully treated, they will think, and I think reasonably so, that maybe it's just happened once and it will go away. And it does sometimes happen that it's just a single episode. So I think it's reasonable. But at the same time, you know, sort of the flip side of this is that I don't think that being psychotic is good for the brain. And I think that the longer that somebody is psychotic, the harder the more entrenched those symptoms become and the harder they become to treat. And I don't know if that's partly an illness factor. Again, I don't think schizophrenia is an illness. It's a heterogeneous collection of all kinds of different pathologies.

  Dr. Albert Wong: [00:48:04] But in some cases, there may be some kind of disease progression that occurs. Or maybe it's not that. Maybe it's simply a question of memory, that, you know, the longer somebody does something, whether it's playing basketball or the violin, the more entrenched that that activity, that experience is going to be. So the longer somebody spends being psychotic, I think the harder it is for those, especially the delusions, the harder it is for those delusional beliefs to be kind of squared properly with reality. So I don't think it's good for someone to spend a lot of time psychotic for that reason. So, you know, this goes against what I'm saying earlier, but, you know, the point is that there's obviously two sides to this and it's very difficult to decide for each given patient without having any kinds of real predictors of outcome. We don't have any biomarkers, any ways of really predicting how things are going to go, how long someone's episode is going to last, how long they should be on treatment, all these types of things we just don't know.

  Alex Raben: [00:49:03] So yeah, another thing that's on the top of my mind, having just come off of inpatient psychiatry is that, as you were pointing out, this illness or collection of illnesses can often come with a lack of insight and can present safety issues to the patient as well as those around them. So I think that's that's almost like a third factor for why treatment may be important. I'm wondering your thoughts on that.

  Dr. Albert Wong: [00:49:36] So patients who are you know, so for example, you know, you mentioned sort of safety risks. I mean, the majority of people with schizophrenia are not violent. And I think that the main determinants of violence in schizophrenia are the same as they are in people who don't have schizophrenia. And those are for the demographic factors are the obvious ones age, sex, substance abuse. So it's the young drunk man who you worry about punching you. You don't worry about the elderly, sober woman, whether either of them have schizophrenia or not. So, you know, yes, schizophrenia in some cases, especially when delusions involve a specific person and so on, there is an increased risk for violence. But I think it has more to do with the person and how they react to things as opposed to the delusions. Somebody can have the same delusion. They just don't think that violence is a good way of dealing with it. Some people, you know, one patient could think of it that way.

  Alex Raben: [00:50:29] Right. And bringing it back to our case here, Mohammed has delusions around the electrical wiring in his house. Some patients may not even react to that necessarily, whereas he's going around and digging in the walls and grabbing these wires.

  Dr. Albert Wong: [00:50:44] And that's exactly that's that's a perfect way of tying it to this case. And a perfect example that it's an interaction between the patient's symptoms and their personality and their environment. Yeah. So, you know, if Mohammed did not have schizophrenia and he was, you know, it was, you know, kind of handy, it might be good, you know, that he would actually fix some of the wiring problems in his house. But if his psychosis happens to involve something to do with the wiring and he's not trained and in the midst of psychosis in a disorganised state, he decides to rewire the house. And obviously that's super dangerous.

  Alex Raben: [00:51:20] Right. So many, many factors to think about here in terms of outcome, um, not just of positive symptoms, but overall quality of life safety, patient preference, lots of different factors.

  Dr. Albert Wong: [00:51:35] So, you know, you're asking earlier about the, you know, the sort of mandate for treatment. And so, you know, I think you've sort of summarised it well that it depends on the situation. You know, if a patient's delusions involve something that leads to a dangerous behaviour, whether it's electrocuting himself while rewiring the house or something to do with, you know, something violent about targeting somebody else, then these patients, obviously it's a much higher priority to get them treated, whereas somebody who's maybe psychotic and may have no insight, but if they are a gentle, pleasant, calm person, they could be very, very psychotic. You know, I have obviously, we all have patients like this, too, who are kind of quietly psychotic. And although we may try to convince them to take antipsychotics because it relieves their distress, because it takes away the, you know, the bothering symptoms, it's less of a priority, obviously, than somebody who's going to do something that's physically dangerous. And unfortunately, sometimes, you know, patients end up in the forensic mental health system because of the fact that they're doing something that's dangerous to somebody else. Right.

  Alex Raben: [00:52:39] Great. Yeah. I think that nicely highlights the nuances to when to start this treatment in the first place. I want to turn back over to the medical students and see if you guys have questions or things you want clarified because we've spoken about a lot here.

  Sabrina Agnihotri: [00:52:56] Well, I'm actually curious from this discussion, it sounds like our current treatment options, there's a lot of room to grow. And you mentioned that, you know, we're targeting dopamine and why aren't we sort of targeting other areas of the brain, other receptors? Do you have any ideas of like the future of antipsychotic research and use and where we could be going?

  Dr. Albert Wong: [00:53:19] Yeah. So I mean, I'll start off by some shameless self-promotion. You know, I've done some work with Fang Lu, who's my lab neighbour and colleague, and she's a protein biochemist and recently published a paper showing that in a protein-protein interaction between the dopamine D2 receptor and another protein called disc one, that this complex between these two proteins, it's elevated in schizophrenia and that in animal models, if we disrupt this protein complex, it has antipsychotic like effects. Other people have explored, for example, the cannabidiol as one of the cannabinoids. That is not the one that people want to use when they want to get high, but it actually has some anti-anxiety antipsychotic properties. There have been some clinical trials with the Mglur2 three receptor, which didn't work out, but that seemed like a promising avenue, and it may be that there's something there as well. We know that drugs that block the NMDA receptor, which is a kind of glutamate receptor, can cause psychosis. Drugs like PCP and experimental drugs like MK 81 are used as models of psychosis in animals, actually. So there may be something. So we know in other words, there are other receptor systems that also modulate psychotic symptoms and also the GABA system. It seems that, you know, this is partly work that's done by that's been done by Karl Deisseroth, the one of the inventors of optogenetics, showing that it is the GABA receptors in Interneurons that set up the gamma synchrony across the cortex that you see in the EEG that's disrupted in schizophrenia.

  Dr. Albert Wong: [00:54:47] And this may have something to do with the binding of different aspects of experience. And when this doesn't happen properly, then people can start to have psychotic symptoms. And we know that, you know, there's good evidence that benzodiazepines also have some antipsychotic effects, especially when they're combined with dopamine D2 and, you know, the conventional antipsychotics. So I think there are other transmitter systems. So I think that's one promising avenue that could have you know, that could produce some drugs within the next decade or so. I think that that's likely. I hope so anyway. But I think even that's not that would be only a sort of modest goal, I think a bigger ambition. And the ultimate goal would be to figure out what the causes of some of these types of psychosis are and intervene to prevent them. I think especially with brain disorders, ones that are developmental, but even degenerative brain disorders, once you know, the brain does not repair itself very well, it's not like a bone or the liver. So once we start to have problems with the brain trying to ameliorate those symptoms after the fact, I think is always going to be limited in its success. I think the best way of doing this would be to figure out what the cause is and then stop it in its tracks before the symptoms actually start. That would be the ultimate goal.

  Alex Raben: [00:55:59] Great. We're almost at time where we are. At time. I'm wondering if maybe Teresa could ask a question before we wrap up, if you had one.

  Theresa Park: [00:56:09] So you mentioned quetiapine has sedative effects and I've seen Quetiapine used in like young adolescents for sleep issues. So could you talk about the off label uses of antipsychotics?

  Dr. Albert Wong: [00:56:22] Yeah, I think that's a that's a terrible idea. That's a simple answer. Don't do it. Yeah. You know, there are many causes of insomnia, none of which are worth the risk of tardive dyskinesia. It's the I think it's a it's a class-action lawsuit waiting to happen. So just don't do it.

  Theresa Park: [00:56:43] Use antipsychotics only for psychotic symptoms. Nothing else.

  Dr. Albert Wong: [00:56:47] Very simple. Psychiatry is like, you know that joke? Psychiatry is like dermatology. There's a thousand rashes, but only three creams. So that's the way it works. If you're psychotic, you get an antipsychotic. If you're depressed, you get an antidepressant.

  Theresa Park: [00:56:59] So what about like antipsychotic use in general in the adolescent child population?

  Dr. Albert Wong: [00:57:08] Yeah, again, I think if somebody, you know, if there's an adolescent who very clearly has psychotic symptoms, then antipsychotics are a reasonable choice. They're the only choice. So yeah, again, antipsychotics should be used when somebody is psychotic and never when they're not. Okay. And that includes in other areas of medicine. You know, when somebody is delirious in the ICU. Yes, you should give them I.V. Haloperidol. There's no question. Don't don't hesitate in doing it. The chance of them getting tardive dyskinesia is not, you know, not a consideration at that point because the acute delirium is so much more problematic for the brain and for the rest of them, the rest of the body. But, you know, the converse is that if somebody is not psychotic, do not use an antipsychotic. There are many medications you can use for sleep, many of which are quite benign. Quetiapine is the worst choice, especially because the sleep promoting effect of the quetiapine is not coming from the D2 receptor blockade. So that's even worse because you're giving them the risk of TD without even requiring that the target that's going to produce the TD, you know, potentially in the future is not even necessary for the therapeutic effect you're going for here. If you're going for the treatment of insomnia and you're going to use Qeutiapine, you're basically targeting the histamine receptor. So you might as well just give somebody Gravol, which is perfectly which people use for sleep. It's perfectly fine and they won't wake up nauseous either.

  Alex Raben: [00:58:34] Right. But I think we I think we've all I think that's a great question because I think we've all seen off label uses of antipsychotics. And just to that point, choosing wisely for psychiatry came out with a list of guidelines. And that was one of them was a recommendation not to use antipsychotics for sleep until everything else has been tried. Um, so I think we will wrap up, but I think that was a terrific conversation around the use of antipsychotic when to use it, when definitely not to use it, what the side effects are, what the benefits are, and how that maps onto different people in different situations. So thank you very much, Dr. Wong, for joining us and thanks everyone who's come today.

  Theresa Park: [00:59:19] Thank you.

  Alex Raben: [00:59:21] Thank you. And we'll sign off until next time. Thank you.

  Alex Raben: [00:59:34] PscyhEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. This episode was produced and hosted by Alex Rabin, Yunlin Xue, Sabrina Agnihotri and Theresa Park. Henry Barron and Lucy Chen were also involved in producing this episode. Audio editing was by Alex Raben. Our theme song is Working Solutions by Olive Music. And we'd like to give a special thanks to the incredible Dr. Albert Wong, who served as our expert for this episode. Of course, we'd also love to hear from you and you can contact us at any time at info@pscyhedpodcast.com or on Twitter and Facebook at PsychEd Podcast. As always, thank you for listening!

Episode 18: Assessing Suicide Risk with Dr. Juveria Zaheer

• Episode 18: Assessing Suicide Risk with Dr. Juveria Zaheer

  Alex Raben: [00:00:00] Hello, listeners, this is Alex here. Welcome back to PsychEd for the month of July. Instead of one episode, you'll be getting five. That's because we're going to be doing a special mini series in which we cover clinical skills in psychiatry. So in the past, we've tended to cover specific disorders or illnesses, but these five episodes will focus on approaches and competencies that will help you in your training in psychiatry. We hope that you will enjoy!

  Lucy Chen: [00:00:39] Hey there podcast listeners this is PsychEd the podcast for medical learners by medical learners. I'm Lucy Chen and I'm joined by Alex Raben. And today we are officially PGY-5's. Yeah, yeah, we made it through, guys. So today we're going to focus on the clinical skill of suicide risk assessment and we're lucky enough to be joined by DR. Juveria Zaheer again for this topic as she has a great deal of research expertise and clinical expertise in this area. So in terms of the objectives for this episode, we're going to familiarise ourselves with the risk factors and predictors of suicide, as well as protective factors. We're going to learn about the components of a suicide risk assessment, and we're going to learn how to comprehensively document and communicate the risk assessment as well. So without further ado, we'll let Dr. Juveria Zaheer introduce herself and talk a little bit more about her research experience, and then we'll delve right into the episode. We've brought back Dr. Juveria Zaheer. So we already got a little bit of an introduction on her. But Dr. Zaheer, maybe you can refer maybe you can explain a little bit more about your research on this topic.

  Dr. Juveria Zaheer: [00:02:12] Absolutely. So suicide risk assessment prevention is a real passion for me. When I was a resident at the University Toronto, I'd completed my master's in the Arthur Sommer Rotenberg Suicide Studies Unit at St Michael's Hospital, and there did a lot of research on suicide, qualitative suicide research. So understanding the experiences of people who have had suicidal behaviour, people who've died by suicide through suicide notes, clinicians, family members who work with suicidal people. In my fellowship here at the Centre for Addiction and Mental Health, I focused on understanding how we can use big data or linked health administrative data to understand how patterns of service utilisation or presentations or risks differ for different populations, for suicide risk. And also another part of my research portfolio is Best Practices in Suicide Risk Management. So recently worked with the Canadian Armed Forces to write their clinical handbook for suicide risk assessment and prevention. So and I'm an emergency psychiatrist, so risk assessment is the bread and butter of what I do on a daily basis. Initially, my suicide risk assessment approach was very similar to what we were taught in residency to use sad persons to understand the risk factors for suicide, which I think is a really, really important place to start. One of the things that I found really challenging is people often told us, and I think they meant to tell us this in a supportive or a way to reduce anxiety, but that it's you can't predict suicide on an individual level.

  Dr. Juveria Zaheer: [00:03:40] And so it was very tough to reconcile these pieces that were trained in suicide risk assessment, and we can't predict suicide. And so it was something that I really thought of. I thought about a lot. And I think something that guided my research career in my clinical practice. I think understanding the data, reviewing the literature, doing our own work has shown me that although yes, it's very difficult to predict suicide on an individual level, we have very good epidemiological evidence. We have very good clinical evidence about what is risk, what increases someone's suicide risk. We can also use a suicide risk assessment to better understand a person sitting in front of us. And rather than looking at the suicide risk assessment for me as something that stratifying people's risk arbitrarily, their low, their medium, their high, and often we only link it to whether they're admitted or not. And hospitalisation isn't actually an evidence based intervention for suicidal ideation or suicidal risk. And so what we thought about is how do we understand suicide risk in the way that doing a really good assessment can help guide treatment, can help us manage the risk factors that can be modified, can help people keep people safe, and how can we do it in such a systematic way that we can think about suicide risk prevention as more of a public health concern rather than something that we do clinically?

  Lucy Chen: [00:04:55] That's great. So for our learners, where are they going to be expected to perform a risk assessment?

  Dr. Juveria Zaheer: [00:05:01] That's a great question. I think that, you know, there's a lot of data on this topic. So, for example, Kelly Posner, who wrote the Columbia Suicide Prevention Suicide Assessment Scale, she said that in every appointment, everybody should be screened for suicidal behaviour, like in suicidal ideation, even in medical settings. And then on the other hand, you have the Canadian-American guidelines that say that suicide screening shouldn't be done regularly in family practice unless there are resources available or unless it's a high risk group. We're psychiatrists, so, or we're training to be psychiatrists. So we should be doing suicide risk assessments because we are sort of by definition, working with a higher risk group, people who have mental health concerns. It's really important to point out that everybody that, you know, in North America, over 90% of people who die by suicide would have had a diagnosable access one or access to mental health concern. But the vast majority of people with mental health concerns don't die by suicide. It's really, really important that there is hope and that there is a way forward for us. We always want to do a suicide risk assessment. If it is a new assessment with somebody, even if they're saying, I don't have any suicidal ideation right now, the act of getting the historical information and the current risk and the acute risk factors is so useful because then you have a baseline for when you see them later. You always want to do it in an emergency department setting. You want to do it if they're expressing to you that they have new or worsening CI or suicidal ideation, thoughts of suicide, you want to do it. If you're repeating an assessment for someone who's at elevated risk for suicide, or if there's concerns from a health care provider or a family member in your clinical practice, if you do a thorough suicide risk assessment on visit one and you're doing CBT with the client you want to screen every time you see them, and if there's no elevated risk, then you wouldn't repeat this whole process.

  Alex Raben: [00:06:39] You you were mentioning right at the beginning that we there are ways of knowing what puts people at higher risk for suicide or that we know some of the factors involved in that. We also know that hospital admission is not an evidence based intervention for prevention of suicide. So could you help us understand from your perspective, what are the goals of a suicide risk assessment?

  Dr. Juveria Zaheer: [00:07:06] So it's so for me, the goals of a suicide risk assessment are to understand the risk of suicide for that person in the short term and the long term to understand if their risk, their personal risk is changed over time. So is there something that's happening that's changing their risk that needs to be addressed? By doing a thorough risk assessment, we can identify modifiable risk factors. So for example, by understanding if somebody is having suicidal ideation, we can ensure that we're going to do a safety plan with them, which is an evidence based intervention. If somebody is having worsening depressive symptoms or worsening psychotic symptoms that are contributing to their suicidality, then we can make sure that we treat those pieces. So in that case, an inpatient hospitalisation to treat these modifiable risk factors is completely useful and important. If someone tells us that in our suicide risk assessment that they have a specific thought of a specific plan and they have insomnia and they're not sleeping and they're thinking about it all the time and they have access to means we can make sure that the firearm is removed from the home. We can think about Daily Dose prescribing. We can know that compared to their baseline, their risk is higher. So maybe hospitalisation for stabilisation is important.

  Lucy Chen: [00:08:14] And I'm wondering if there's a better way to understand are there components of risk or can we break that down?

  Dr. Juveria Zaheer: [00:08:19] Absolutely. I think and we always we also often think about risk as a negative thing and they're doing a good risk assessment should also highlight the positive factors, too, and the protective factors and strengthen them. I think we can understand risk in a few ways. So one is somebody is historical risk. So what are things that they have on a population level that would put them on average compared to another person at higher risk for suicide? So those could be sort of demographic risk factors, gender, age, history of family history, of suicidal behaviour, of history, of trauma. We also want to understand suicide specific risk factors. And so those include past attempts, a past history of suicidal ideation, a past history of deliberate self harm, which all, even if there's no intent to die, is an independent risk factor for death by suicide. We also want to understand acutely what's happening that is potentially modifiable. So what are the acute risk factors, whether it's mental illness, substance, medical illness, as well as acute psychosocial risk factors, occupation, marital status, financial stress, immigration, stress. And we also want to understand how the person perceives suicide. What are the psychological risk factors? Are they do they feel a sense of perceived burdensomeness? Do they have a sense of exhaustion? Do they feel alienated? Do they have a lot of cognitive rigidity around this issue? And finally, and most importantly, we want to understand warning signs for suicide. So what is happening in the short term that puts someone at high risk for suicide? Are they engaging in suicidal communication, talking to people about dying by suicide? Are they engaging in preparatory behaviour which might mean making plans for suicide, researching ways to die or the other half is getting one's affairs in order reaching out to people. Have they had any recent attempts? And I think we're probably moving as a field to looking at these suicide specific warning signs to predict suicide death rather than relying solely on sad persons, because a lot of those features are quite static.

  Lucy Chen: [00:10:13] Yeah. So can we talk about SAD PERSONS? Because I remember learning this in medical school, this acronym and just memorising it for the sake of memorising it. It's a suicide risk, I suppose other components of a potential suicide risk, that approach that we can take, like maybe we can go through it and then like, what is it? Is it good.

  Dr. Juveria Zaheer: [00:10:32] Enough? Yeah. So I think SAD PERSONS is a really important place to start because I think suicide is it's such a tragedy. It affects people and families and communities and health care providers and it can feel very mysterious because it's an outcome that has social and biological and cultural factors. I think that SAD PERSONS is a great tool for learners because it shows us, it sort of illustrates the depth and breadth of risk factors associated with suicide. We also know that suicide is so, so rare that it's very difficult to predict. It's very it's a small signal. So getting epidemiological risk factors are pretty tough. So you need really, really big samples. So that person is sort of a distillation of the evidence as it exists. And so would you like to go through the risk factors?

  Lucy Chen: [00:11:15] Yeah, sure. Yeah.

  Dr. Juveria Zaheer: [00:11:16] So the essence that person's is for sex. And so in North American constructs as well as in sort of other high ses European countries, Australia, New Zealand women have engaged in suicidal behaviour at a rate of maybe three or 4 to 1, but men die by suicide at a similar rate. So about in Canada it's about I think 3.2 male suicide deaths to every female death by suicide irrespective of this history of behaviour. And then this varies by culture. So until the last decade in China, women actually died by suicide more often than men did. And in several European and several Asian countries, the risk is actually much closer. There's a there's a much lower ratio. As a multi sort of ethnic society, that's really important for us to know. People tend to carry, according to the World Health Organisation, carry their own sort of cultural risk for suicide to their new country for at least two or three generations before it kind of normalises. The second thing that we talk about is age. So I think in general we teach our students that especially for men, the older you are, the higher your risk for suicide. Although, you know, if you look at the Canadian and American census data, I think what we're kind of landing on is that 45 to 64 age is the highest risk, that middle age for both men and women, for men that that risk remains elevated through the course of their lifespan. And, you know, older men are at higher risk than older women, although this isn't a largely Caucasian population.

  Dr. Juveria Zaheer: [00:12:42] So older men, middle aged men and women. And then there's the youth and emerging adults factor. And there was a really disturbing and important paper that just came out in JAMA Psych that showed that the rates of suicide are going up in young people. And so males tend to be at higher risk young males than young females. But certainly that's another high risk period. We'll call that emerging adult. The next risk factor is D is for depression. So again, it's really, really important to point out that the vast majority of people who suffer through major depressive disorder and even who have suicidal ideation do not die by suicide. And there are people with other diagnoses other than depression that are at high risk for suicide. But certainly having suicidality, suicidal thoughts is one of the criteria for major depressive disorder. And so if you're having an episodic depression, a major depressive episode is a risk. People who are treatment refractory in particular carry the highest risk. The next one is P for previous attempts. This is the big one. This is the most important risk factor for suicidal behaviour is a past history of suicidal behaviour. People often ask, you know, what are the percent of people who die on their first attempt? And there's a nice there's a nice paper that says it's probably about 40% of people die on our first attempt, 60% have had recurrent attempts.

  Dr. Juveria Zaheer: [00:14:00] But again, the vast majority of people, even who've had a suicide attempt or we like to say suicidal behaviour if we can don't die by suicide. The next one is E is ethanol. It's a bit of a stretch, but is ethanol abuse? Alcohol can mitigate the risk for suicide in myriad ways. It's really, really important. So having an alcohol use disorder in and of itself raises your risk for suicide considerably, depending on the study you read here in Toronto. According to coroner's data, I think 30 to 50% of people who die by suicide across coroner studies have alcohol on board. So alcohol, like you think about it in sort of different stratified by different classes, right? So having an alcohol use disorder, it's it can have mood related symptoms which can result in suicidal behaviour. The second piece is that when people are intoxicated they may be more susceptible to co ingestion, they may miss, they may misinterpret risk of self harm behaviour, they may become more impulsive, they may become more emotionally disregulated. They may use alcohol as a way to reduce inhibition. Alcohol withdrawal can potentially make people feel agitated or, in the case of delirium, tremens, sort of do things that they wouldn't normally do. And then the last piece I think is a really important one, right, is an alcohol use disorder can have really serious psychosocial consequences. It can affect your job, can affect your marriage, it can affect your relationships. And I think often that's something that we need to really think about.

  Dr. Juveria Zaheer: [00:15:25] The next one is our rational thinking loss. And you know, you want to call it rational thinking loss. We can call it cognitive rigidity. I really like Thomas Joyner's theory; interpersonal theory of suicide, which says that people feel a profound sense of alienation as well as a sense of perceived burdensomeness. The Beck hopelessness scale is a good one. Talking about losing hope, being quite black and white, having a negative view of yourself in the future and the world not being able to problem solve right. Being really in a dark place like thinking of, you know, often when people have unsolvable problems, suicide becomes sort of an awful solution to an unsolvable problem. Even though we know that with appropriate treatment, people's risk can come down considerably and people can live really happy and resilient and well and meaningful lives. I would say the last one is social. The next one is social support lacking, particularly for men being divorced or being socially isolated as a risk factor for suicide. There's some really innovative and interesting work in that area, but when people are alienated, they don't have a lot of social support. Makes it really tough to safety plan. Like if you don't have anyone to call it feels really stressful. And that's something that we can certainly build when we care and work with people who organise suicide plan. So one of my challenges with that persons is this feature here organized suicide plan or p previous attempts on the face of it looks like it has the same weight as something like sex and age, which it certainly doesn't, but.

  Dr. Juveria Zaheer: [00:16:58] It is a great way to remember all of these pieces. So that's the caveat and we'll talk about that organized suicide plan at length I think during the session. No spouse, especially for males, as we discussed and asked, is for sickness so chronic or severe? I think there's there's lots of things that are missing from SAD PERSONS, you know, especially in our, you know, 2019. We always want to think about addiction, right? Opioid use. And there's a really growing body of evidence that opioid use disorder would be associated with suicide risk, things like personality disorders. And here, schizophrenia isn't here. All of these illnesses carry risk for suicide. Trauma, I don't think is on this list. And trauma is associated with, at the very least, an increase in suicidal behaviour, you know, things like LGBTQ2s+ or indeed like being Indigenous. Being an indigenous person isn't on this list. That's exactly right. And so, you know, I think it's a useful feature, but we need to maybe move beyond it. And we really need to distinguish between things that put an individual at risk for suicide over the course of their lifetime versus things that put people at risk for suicide in the immediate in the days or weeks or months coming up.

  Lucy Chen: [00:18:12] So thanks so much for bringing SAD PERSONS to life. I think it adds a little bit more dimensionality and kind of a context for why this acronym is used. I can actually see many categories of SAD PERSONS within the scope of the components of suicide risk in terms of suicide specific risk factors, mental illness or psychosocial risk factors and psychological risk factors. So I see more as a memory aid, but then kind of to stratify that further in terms of what what components of risk assessment were actually assessing for?

  Dr. Juveria Zaheer: [00:18:45] Absolutely. I think it's really difficult to move from not knowing anything about suicide risk assessment to using a formalised template or having a formalised approach without the intermediate step of that person's.

  Lucy Chen: [00:18:54] Mm hmm.

  Alex Raben: [00:18:55] Sure. So how do we move, then, from SAD PERSONS, which is a great memory aid, and it gives us a foundation of some of the risk factors. How do we move from that to a more fulsome risk assessment?

  Dr. Juveria Zaheer: [00:19:08] So I think we want to exactly, as you guys said, use SAD PERSONS as a jumping off point to help us feel comfortable and help us make sure that we don't miss anything. And we want to focus in our suicide risk assessment on a few different areas historical information, current risk, including acute risk factors and warning signs as well as collateral information. So we want to be able to pull everything together. And in our formulation, you know, the you'll hear me talk about this a lot. If you work with me clinically and maybe even today on the podcast. But often medical students and residents are asked by your staff, what is this person's suicide risk? And we say low, medium or high, but we never talk about low, medium or high. Compared to what? Compared to whom? You know, there's no evidence around what makes low, medium or high risk. It doesn't really guide treatment. So doing a suicide risk assessment, that's an evidence based approach with based on understanding someone's risk in the moment and using it not only to come up with low, medium high, which is actually not super useful, but using that information to create a safety and treatment plan. Then we're talking. Then we're actually talking about something that can help people.

  Lucy Chen: [00:20:20] Mm hmm. So I guess, you know, the approach to kind of maybe a successful suicide risk assessment, I guess essentially like we have to talk about kind of maybe the space and kind of the environment of a risk assessment and then maybe also the content of a risk assessment. And then we'll move on to kind of maybe formulation of risk assessment.

  Dr. Juveria Zaheer: [00:20:39] So this is hard stuff to talk about. And I think for a lot of us who work in this field, I'm sure you've had a loved one or a friend or someone who's on psychiatry say to you, well, or even a family member of a client say, "Well, if you ask about suicide all the time, doesn't it make people feel more suicidal?" And we know from the data that a clinician asking about suicide doesn't actually increase someone's risk for suicide. We've done some work in this area. There's a nice qualitative study about or a survey study, I believe, of people's experiences of being asked about suicide. So I think part of the comfort we want to create a safe and comfortable environment. Part of that safety and comfort is our own safety and comfort. This is hard stuff to talk about and it feels really good. And I know a lot of the people listening to call it feels great when you meet someone and they say, I have no suicidal ideation. And then there's like this feeling of relief because first of all, you care about the person and you obviously don't want anything bad to happen to them. But then the second is like, Oh, now I don't have to go through any of this stuff. It saves me a bit of time. I can think about other things. But you know, if you can do a really good suicide risk assessment early, you create the scaffold for which we can understand this person's risk over time, and we can understand this person better and we can show them that we care. And there's lots of different pieces that we're thinking about.

  Lucy Chen: [00:21:51] And maybe diving into the actual assessment. What is historical information? What's a sort of historical what's that that scope? What does that look like? So, you know, I think if.

  Dr. Juveria Zaheer: [00:22:02] We don't go through this process, if we just sort of ask about current suicidal ideation intent and plan, then we miss all of this historical information, which is you look at that person's a lot of that is historical information. So this is a way that we can get all that information up front. You get it up front. And even if the person doesn't have active suicidal ideation, you have it. It's always there for the next clinician or for yourself when you're looking at it. So historical information informs the current state risk assessment and provides context for the current presentation. We will always want to ask about the history of suicide attempts. Again, sometimes you'll hear me say suicide attempts. Sometimes you'll only hear me say suicidal behaviour. I tend to prefer suicidal behaviour because we try to move away from the language of attempts or completion because it's maybe potentially unnecessarily stigmatising. So and I think often people aren't really sure either. There's a lot of grey area between deliberate self-harm and suicidal behaviour with intent to die. So if we want to call it suicidal behaviour with intent to die, it's a bit of a mouthful. But in their history and historical information, I usually cut it by the HPI. So if someone comes to you and we talked about this in our last session before the demarcation, so not in the last two months we'll see a number of attempts, most recent attempt method lethality efforts to seclude an emotional reaction to surviving the attempt. And I often ask for contextual factors as well. The second piece is a history of suicidal ideation, intent or plan or preparatory behaviour.

  Dr. Juveria Zaheer: [00:23:34] This is something that I think before I started using a really formal approach that I would miss, because if someone's presenting with suicidal ideation now we want to know, have they. We often you see when you see a chart chronic SI (Suicidal Ideation) have you ever seen that all the time. And so chronic aside, does that mean that they've had it one day a week for their entire lives? Does that mean they've had it every day for six months? It's pretty vague, right? So I kind of draw out like you think about the person's life history. We say, I know you've been having suicidal ideation. You told me right now because you get that in your HPI write tell me about your life. When was the first time you ever had thoughts of suicide? When when were they there? Are they always there? Do they come and go? And and someone might say to you, I only ever had suicidal ideation in 2011 in the context of a major depressive episode. And now I'm having it again. It's super valuable information. Another person might say, I had my I had suicidal thoughts for the first time when I was seven. And they kind of come and go depending on if I have stressful things happening in my personal life. That's also really important information, right? We also want to do the same kind of process with intent and plan as well as preparatory behaviour. And we can talk about each of those things in a bit more detail if you would like now or we can do that later.

  Lucy Chen: [00:24:47] Yeah, maybe we can elaborate on this topic now. I think preparatory behaviour is something that we're always mindful of, but I guess how to do that robustly or kind of scope.

  Dr. Juveria Zaheer: [00:24:57] Yeah, absolutely. So you know, in our little I think there's a handout that you guys will get to that describes preparatory behaviour. I think this is a really, really important concept and we don't talk about it I think nearly often enough. So preparatory behaviour refers to one of two things. One is are there things that we're doing to prepare for death? So are we getting our affairs in order? Are we saying goodbye to people or are we, you know, maybe selling items off that kind of thing? And then the other half preparatory behaviour is are we like researching methods online, are we stockpiling medications or are we doing rehearsing? So I think preparatory behaviour goes as sort of both of those categories as well as suicidal communication. Are we talking more about suicide? More people talk about suicide before death by suicide than not. And I think people think, oh well, you know, they won't necessarily say anything about it, but everybody who has suicidal ideation, you have to remember, is deeply ambivalent. Right, because there's a part of them that is still alive and there's a part of them that's really, really suffering. And it's important to kind of highlight that piece.

  Lucy Chen: [00:26:04] And I kind of would like to sometimes see suicidal ideation to intent and to plan and to preparatory behaviour a sort of like a spectrum. So I guess it's a little bit more nuanced sometimes the difference between ideation and intent.

  Dr. Juveria Zaheer: [00:26:17] Absolutely. And I think we often think about the really classic presentation. We think somebody gets very depressed, they're functional, they have functional impairment, they start to feel really sad, then they have suicidal thoughts, and then slowly they develop intent and then slowly they engage in preparatory behaviour. And then there's a tragedy that needs to be averted. I think in practice you can think of suicidal ideation as pretty binary in the sense that either you have thoughts of suicide or you don't. And that to me is the biggest jump. You have thoughts or you don't, right? And you think about having suicidal ideation is like going through life with a sunburn. It's like, you know, if you normally take off your shirt, put on your shirt, have someone grab your arm and you don't have a sunburn. It doesn't feel it's fine. That's okay. But when you have suicidal ideation, everything hurts, right? Like you're more sensitive to things and you go, but you cycle between these scales, right? Sometimes you have intent, sometimes you don't. Sometimes you have a plan, sometimes you don't, sometimes like small. And that's why means restriction is so important. Sometimes you can feel so distressed in the context of see that you get closer whether you're intoxicated or you've had, you're feeling isolated. And so thinking about it as less as a continuum and more about like, do they have ideation or not? If they have ideation, getting all of this information and figuring out what makes it better, what makes it worse. Thinking about suicidal ideation is like taking a pain history, frequency, intensity, alleviating factors, associated factors. I think that's probably your best bet.

  Lucy Chen: [00:27:42] Okay. And then now delineate delineating kind of between suicidal ideation, intent and plan and then self-harm.

  Dr. Juveria Zaheer: [00:27:49] Yeah. So again, I think, you know, when I was training, I always thought that this was so binary. But I think for you guys, when you work with people in our emergency department or you do consultation or people with lived experience will tell you it's not that black and white. There's certainly, you know, we call it deliberate self-harm without intent to die. So and that can be cutting, head banging, hitting. Often we focus a lot in the cutting, but there can be other, other types of behaviours that we might be missing. And so, you know, I ask about both separately and there's this kind of non-specific kind of grey area. I think in the middle when I ask about history of deliberate self-harm, you want to be systematic about it. When did the behaviour start? What is the behaviour looking like? What is the frequency? What is the intensity, what are the triggers and is it changing over time? And you also want to understand the person's explanatory model because they want to. They want you to for two reasons. One is you want to be empathic and understand someone's pain and suffering. And it's a behaviour that can be really stigmatised and can feel really shameful. So an open explanation, exploration is really important. And also most importantly, if you understand the explanatory model, then you can actually figure out how to support them and figure out how to replace the behaviour or reduce their suffering or distress.

  Alex Raben: [00:29:06] And then I guess also in the historical information we would get at some of these non-modifiable risk factors that we were kind of going talking about with the SAD PERSONS such as sex and age and those kind of things as well.

  Dr. Juveria Zaheer: [00:29:22] Absolutely. And I usually write them all out early and then when I do my risk formulation, I'll always have it in the same place because that's the stuff you can't change. So it's important to know that we think about high, medium and low risk compared to what and compared to whom and compared to when. This is the compared to whom. Right. It's this is this is who is at a stratified risk of suicide that's higher compared to the general population. And it's really important because we would do that in medicine, too. Who are people who have risk factors for cardiac events or for developing diabetes?

  Alex Raben: [00:29:55] Right. Subsets of the population that have higher risk?

  Dr. Juveria Zaheer: [00:29:58] Exactly.

  Alex Raben: [00:29:59] And then I guess we would move more towards the proximal factors that are putting someone at risk.

  Dr. Juveria Zaheer: [00:30:05] Absolutely. So we call this current risk, and I usually focus on the HPI. So differentiating your HPI from past history is so important for lots of reasons, especially for suicide risk assessment. So we go through the same process. So on the template, I think I call it suicidal ideation intent plan and preparatory behaviour within the last month, but I think within the last month is useful if you're seeing them or or it can be since the last appointment or it can be like during this episode. But you know, it doesn't matter how you differentiate as long as you differentiate, I think. And then I think about it again, like pain intensity, frequency triggers, alleviating and aggravating factors, associated features. The next step is understanding suicidal behaviour, both attempts and deliberate self-harm since the last visit, within the last month in this time period. And then acute risk factors, worsening depression, presence of psychosis, substance use, relationship breakdown, financial stress. I think we sometimes think of suicide as so related to depression that we don't think about the other things that are happening in someone's life. And suicide is a tragic outcome that's so multifactorial. So you want to make sure that you explore these psychosocial pieces and some of those psychosocial pieces are can be quite modifiable or the target of the target for support or the target for intervention. One of the things that I should have mentioned is you always want to ask about access to firearms in the United States.

  Dr. Juveria Zaheer: [00:31:26] Rates of firearm death by suicide are higher than they are in Canada. But you I always ask everybody about firearms because it's a small thing and you don't want to miss it. And I also ask about stockpiling medications or access to medications at home, and then the next one is warning signs. So this is a way you know, this is something that sad person doesn't really get at. Right. This is what is happening now in the in the days or minutes or weeks or, you know, hours before someone is presenting to you, are they more agitated? Do they have worsening insomnia? Really, really important, especially in qualitative explorations of suicide and suicidal behaviour? This insomnia agitation is so important irritability, anxiety, hopelessness, suicidal communication, psychosis including command, hallucinations, planning for carrying out a suicide, a suicide plan, engaging in suicidal behaviour, making arrangements for death, worsening substance use or intoxication. So these are things that you want to take really, really seriously. If you if someone is describing these these behaviours. And then the last thing that I try to focus on and it's something that, you know, it's something that I've had to learn and it's not something that comes very naturally to me, but I think it's really important is suicide narrative is what does suicide mean to them? Is it a function of hopelessness or helplessness? Is it a function of burdensomeness, alienation? What is their explanatory model that's really useful, right? Like if someone is describing all of these things to you and they say, I'm going to do this because I don't think my depression will ever, ever, ever, ever get better then targeting the depression, instilling hope becomes so important if it's because, you know, my wife has left me and I'm going to punish her and I'm going to punish myself, that it might mean that, you know, you might need to bring this person into hospital to stabilise them to do a little bit of family work, because there's something going on here that's really difficult to engage with.

  Dr. Juveria Zaheer: [00:33:21] If it's a sense of perceived burdensomeness, then you can do some interesting family work to bring the family there and have the family say that, you know, we really you're really meaning you really mean a lot to us. We had no idea you were suffering, you know, so there's there's kind of ways that you can work with that narrative. And that's how and then I also I think it's really important to stress protective factors. I don't think we think about that nearly often enough. But what are these person's personal characteristics, their social supports, their treat and capability to engage in treatment, their ability to safety plan? What is it about this person that's keeping them with us that we can harness and work with them to create a robust safety plan?

  Lucy Chen: [00:33:56] It's sometimes so hard to kind of assign weight to the protective factors and versus sort of the weight of. All of the historical context of suicide attempts or suicidal ideation, self-harm history, and then the current risk and then how we balance all of those features. Yeah.

  Dr. Juveria Zaheer: [00:34:15] One of the things that's really helped me is to try to move in my mind, which is a bit challenging as an emergency psychiatrist. Right. But between like, is this person at risk or not? Or do I have to admit them or not? But more moving towards how do I understand the protective factors in the context of safety planning? So rather than assigning them a weight, if I can say that they have tons of suicidal ideation, but they have a loved one who's willing to stay with them. 24 seven They have access to date treatment so they can come into hospital every day. They're willing to start medication treatment. So there are pieces that would and they don't want to come into hospital. It's not really in keeping with their values at the moment. There are pieces that we can definitely work with them to engage in a robust safety planning process and a treatment plan that doesn't necessarily facilitate hospitalisation. But, you know, it's it's a bit of a mind shift. But I'm trying to personally and I think in the teaching that we do try to move beyond like having it be like typing it all into a computer and coming up with like a decision tool. Because I think that's really, really challenging, especially when the decision tool is often around hospitalisation, which again is isn't necessarily the the best proxy for for safety plan. I will also say that like recent hospital discharge or increasing service utilisation is another risk factor for suicide. And we have to whenever excuse me, you see somebody who's being having more admissions or going to the emergency department more, you want to take it seriously and think about breaking that cycle by an admission or another type of treatment modality.

  Alex Raben: [00:35:45] So it sounds like the if we shift a little bit in our mind frame, the risk assessment can be thought of more as a layered understanding of someone's relationship with their suicidal ideation and behaviours and the various factors in their lives that affect that. And you know, just hearing you talk about that, you mentioned multiple times that there were interventions you can actually tailor to each of those kind of things. And so having this layered understanding, I imagine, is really helpful in that way.

  Dr. Juveria Zaheer: [00:36:20] Absolutely. And there's a lovely paper that I'll send to you guys that gets at exactly this. It's we train so long to understand, to do an assessment, to come up with a metric for risk. And, you know, if we can switch that focus to doing a really robust and thorough assessment that serves three purposes, one that engages the client, the second is that it gives us a benchmark so we can compare risk over time to know when things are going sideways or to adjust our plan. And three, it shows us all of our targets for intervention. I think it's it's it's a much more hopeful process.

  Alex Raben: [00:36:57] I think how do we as as learners balance this approach versus what our staff will often ask of us on a call which is kind of like, give us the bottom line in terms of what you think the risk is or what your disposition might be. How do we synthesise all of that to to that point?

  Dr. Juveria Zaheer: [00:37:14] And I hope I really do hope that they're sort of mutually they're not mutually exclusive. Right. And so what I would say is, if I'm reviewing with you guys and it's on call and it's four in the morning and you want to you know, I would say two things. So go through the process and tell me what their suicide risk is. But not just high, medium, low, but compared to X and Y. Right. So you can say I've seen Mr. Jones compare to his A, he has this, you know, demographic risk factors, this sort of warning, these clinical risk factors, these warning signs compared to the general population. I think his risk for suicide is elevated compared to psychiatric outpatients. I think his risk for suicide is elevated compared to other psychiatric outpatients of his same demographic group, you know, a 70 year old white male who's divorced. Even compared to that high risk group, his risk is elevated and I think his risk is as elevated as psychiatric inpatients. So I think he merits a psychiatric admission. The second half is I think Mr. Mr. Jones is risk state. His risk compared to himself is the highest it's ever been. He had a major depressive episode 20 years ago, but never had this intensity of suicidal ideation at his baseline.

  Dr. Juveria Zaheer: [00:38:20] He doesn't have any suicidal ideation. And so I think his baseline risk is, is that the highest it's ever been because he's engaging in preparatory behaviour, he's had recent average visits or recent hospital discharge and I think that understanding. Mr. what do we call him, Mr. Jones, is risk. Here are my treatment targets. So one is I think he has depression with psychosis. So I think that we should admit and consider ECT, which is an evidence based treatment that's shown potentially to reduce suicide risk. And we can also treat his psychosis with X or Y medication to is I think that he has a firearm in the home. So we need to talk to his family about removing that three. We can talk to his doctor about he's had an overdose recently about daily or weekly dispense versus like giving three month. At a time and for I think he has an alcohol use disorder so we can consider safety talks and naltrexone. So you can sort of look at the risk factors you have. And then the fifth piece is he's having a lot of stressors around sense of burdensomeness. His daughters live elsewhere, but seem to me to be very supportive of him. Maybe as part of the process we can engage in family meetings.

  Alex Raben: [00:39:25] So just the same way in which your assessment is very layered, your delivery can also be very layered in terms of what you're putting forward.

  Dr. Juveria Zaheer: [00:39:34] Yeah, absolutely. And if you look at the time, it doesn't take that much more time. I think we you know, the last thing we would ever want to do for our learners who are learning how to be psychiatrists is to make them do things that it's going to take a lot of time with no payoff or no benefit, most importantly to the client. But I think this approach doesn't actually take too, too much longer, and it can come up with a treatment plan that I think is more robust. And I think it's something that probably would be we're going to do a study on it to see how people experience various suicide prevention initiatives like qualitatively. So, stay tuned. But I do think that a client is not going to mind going through this process. And we do know that a safety plan which is also included in your materials, there's a lovely paper in JAMA Psychiatry from 2018 in the summer that showed that a safety plan intervention, which doesn't take very long done in an emergency department, reduces suicidal behaviour in the intervening three months by half. So there are, there are reasons to do this kind of stuff.

  Alex Raben: [00:40:35] Speaking of the safety plan, like I find that particularly useful for me in especially in an emerge setting to do with someone not only because, as you say, it's an effective intervention, but also I find you get at a lot of this nuanced information because I will often just even give a quick explanation of the safety plan and hand it to someone, have them fill it out while I do some other paperwork and whatnot. And when I come back, I then have all this rich information onon the page and it starts a conversation.

  Dr. Juveria Zaheer: [00:41:06] I agree completely. And it shows you who's important to them. It shows what the triggers are. It shows what kind of thoughts they have. It shows you what their reasons for living are. And I think even in addition to what you said, which is so important, it can also serve as a bit of a diagnostic tool. Right. If someone tells you, you know, how many times have you seen somebody who very sadly engaged in suicidal behaviour and was transferred to psychiatry? And they're saying to you, I have, I don't want to do it, I want to go home. But then you give them a safety plan and they can't really tell you anything and they can't really and they're maybe dismissive of it or they're feeling they have they're in so much pain and suffering that they can't really engage with safety or safe living. And I think that to me is maybe an indication that supporting them through hospitalisation might be something that would get them to a place where they feel safer for sure.

  Lucy Chen: [00:41:57] I also want to emphasise a really essential component of the safety assessment is collateral information. And so we touched on it and I was hoping you can elaborate further about this component.

  Dr. Juveria Zaheer: [00:42:08] Absolutely. I think collateral is super important because people remember that suicide is a social suicidal ideation. Suicidal behaviour or death by suicide is inherently a social act. Right. And so if somebody is expressing worry about someone, you know, it doesn't necessarily mean that you have to do what they say, but you really want to be able to understand where they're coming from. I think especially if you had a loved one who was having suicidal thoughts and you brought them into hospital, you would definitely want to be contacted. You would definitely want to be able to say your piece because when people are in a cognitively rigid or inflexible place, they might not be able to tell you what you need to know and engaging in collateral also improve safety planning because then people are on board, you know, because of that ambivalence around suicidal ideation or behaviour. And I think a pretty profound fear of hospitalisation, which I don't blame people for. People might not or might not be in the place where they can tell you how they feel or, you know, they haven't. If you don't go through this whole process, you might not know that they're okay now. But when they binge drink, which they're planning on doing later, the suicidal ideation ramps right up.

  Dr. Juveria Zaheer: [00:43:19] And so I think, you know, you always want to get collateral if the person is risk as such that the collateral is going to make the difference between staying or going, then absolutely. But also, I always ask everybody if I can talk to a loved one and that safety plan is useful. Right. Because then I can say, can you mention that Joe's a support? Can I give you a call? Our child nonetheless. And colleagues do this so well, right? Thinking about people and systems and engaging systems and providing some psychoeducation even for family members about what do you do if I there's a lovely handout. We have one in the military manual that we wrote of. How do you support someone that you love if they're having suicidal ideation? Like how do you give people the tools? So I think for that reason, collateral is really, really key. And also in terms of people's health care team, like with consent or if the risk is so high that you can sort of circumvent consent, you know, if you're someone's. Treating psychiatrists, you'd probably want to know that they came to an emergency department with suicidal ideation.

  Lucy Chen: [00:44:09] Yeah, I just want to emphasize this because oftentimes I've encountered an emerged sort of a patient who minimises all of their symptoms or they say there's nothing going on, you know, you know, my I was told to come in, but I really don't see what the big deal is. And then you sort of get some collateral information from their parent or from a loved one. And there's there's a lot of concern like they've they've witnessed some preparatory behaviour.

  Dr. Juveria Zaheer: [00:44:31] And this is so important because without that collateral in your assessment you would right patient like no elevated risks, no intent, no plan low risk for suicide and you know, for the person's life is sort of in the balance here. And we want to respect people's autonomy and dignity, but we also want to give them the very best chance to alleviate their suffering and to get treatment for treatable conditions. And I think it's really, really important. And like medical legally, you know, you hate to say it, but medical legally as this is not why we practice and we should never practice because we want to avoid litigation. But, you know, the optics aren't great, right? If you know somebody is at risk and you don't get collateral, the optics aren't great if they've had a suicidal behaviour and then you discharge them and right. Low risk, no intent, no plan.

  Lucy Chen: [00:45:16] For sure. Yeah. Like the labelling of those scenarios would be completely different. One case would be sort of not acutely elevated risk at all. And the other case, there's some cognitive rigidity or there are some like lack of ability to engage and we have some more information about preparatory behaviour which would put them at high acute risk.

  Dr. Juveria Zaheer: [00:45:34] Absolutely. And you still may not admit that person to hospital, but you could do a robust risk assessment with recommendations and safety planning and follow up that would give them the very best chance to recover rather than sending them out without anything.

  Alex Raben: [00:45:47] You very imagine a scenario where in gathering collateral, if the risk is high enough, you may not get consent for that. Could you talk about that a little bit more, just so it's clear for our listeners?

  Dr. Juveria Zaheer: [00:45:59] Absolutely. And we should all work within health care systems where confidentiality is treated with utmost respect and our patient's autonomy and dignity is treated with respect. And also people may come from marginalised communities or have trauma and they may not want us to contact specific people who may be perpetrating violence. And you know, it's also interesting because we talk so clinically about suicide risk, but, you know, to reduce risk for suicide as a society, we need means restriction. As a society, we need safe housing, we need freedom from oppression. All of that to say around confidentiality. We want to support people's dignity and their autonomy. At some point, safety trumps confidentiality. And if I'm for my line as an emergency psychiatrist is if I have somebody on a form or who I think about being able to certify or hold and voluntarily, safety has to trump confidentiality. And so in those cases, I'll say, you know, I need to talk to your loved one. And I always remember you can always get information, right? So you don't necessarily have to give information, but you can collect information if someone tries if someone's trying to contact you. And I think people are pretty, you know, of course, imagine being in that situation, being an emergency department, not wanting your partner or your parents to know. And sometimes I'll frame it with people. It's like, I'm not going to call them right now, but I think they're really important for your safety planning. So maybe we'll sleep on it. We'll talk about it tomorrow.

  Alex Raben: [00:47:22] And then you mentioned, um, how we communicate the, our risk assessment is very important and you kind of gave the example of someone communicating it very briefly as in something like no change in risk, say to be discharged. How should we be? I imagine I'm guessing the answer is fulsome, but how do we communicate all of this?

  Dr. Juveria Zaheer: [00:47:49] Absolutely. So the first thing I would suggest for learners is to get into a habit of like communicating the suicide risk fulsomely for everybody. And I have we were going to distribute some case summaries that show like a way of documenting suicide risk for someone who has no elevated acute risk. And so if you get into that habit, you can see it's like three lines in your chart, but it's so valuable and so important because it creates a baseline. I would say that you don't have to you don't have to write a novel to do this effectively. I usually have one line that is the historical risk. I have two or three lines that are the current risk and the warning signs, and then I have a collateral piece, and then I will say risk status, risk state. So their risk status, their risk compared to general population, peer matched demographic group, psychiatric outpatients, psychiatric and patients. The inpatient thing is really key because if someone is at super elevated risk in hospital, like if they have a history of suicidal behaviour in hospital, their risk of suicide in hospital is elevated over psychiatric inpatients, which means you're going to need a higher level of observation, right? So and then then align that is their risk state. So their risk compared to themselves. And then I have my safety and treatment plan. So here are the things that I'm going to do to alleviate their risk. And that's actually your treatment plan anyway. Like a lot of there's a lot of overlap. Yeah, yeah. Your, your, your plan is going to be to treat depression and so you're going to write that out anyway. So it's a way of kind of considering it all in one place.

  Lucy Chen: [00:49:18] And maybe to help our junior learners maybe conceptualise some of these levels of acute risk. Like I guess what would a low acute risk sort of look like? What would moderate acute risk look like? What would high acute risk look like? Just for our learners to have an approach and to how they can best communicate those scenarios.

  Dr. Juveria Zaheer: [00:49:37] It's great. We have in our military manual, we have a table that I adapted from the American Armed Forces Manual that I really like, and I sort of use it myself just so my nomenclature is consistent. The challenge in psychiatry, you know, we want words that mean something. We want them to be reliable, meaning that everybody does the same thing and we want them to be valid, meaning that it measures what we say we're going to measure. My concern around this stuff is I don't think that this is particularly reliable or valid unless we all start doing things the same way. But I think you're going to have to use the wording that we use like as a discipline. So I can give you some examples right now. The other thing I would say is just there's one particular pitfall that I think we all fall into residents, staff, medical students is sometimes we reverse engineer our risk assessment. So if we're admitting someone, we say it's moderate or high, and if we're discharging someone, we say it's low. But I would really strongly encourage you to you know, you can discharge people who are at moderate or high risk for suicide with a safety plan and like targeted treatment. And you can admit people who are at low risk for suicide to manage other symptoms, you don't necessarily have to link the two.

  Dr. Juveria Zaheer: [00:50:49] But the way that we define it in the manual and in the materials that you have is not acutely elevated, is no suicide, no recent suicidal ideation and no history of suicide-related behaviour. So that's like many of the patients that we see low acute risk is recent suicidal ideation, but no intent or to act can control impulses have not engaged in preparatory behaviour, no previous attempts, limited risk factors and some protective factors. So you ask how I write out my assessments. Sometimes I'll just use one of these terms and I'll write down the things that pertain to that patient from this list. It's pretty useful and it's fast to moderate. Acute risk is current suicidal ideation with no intent to act and no recent attempt and no preparatory behaviour. They have warning signs or risk factors and limited protective factors. The next one is high. Acute risk is persistent suicidal ideation, strong intent to act, or a well developed plan or feel unable to control the impulse to harm themselves. It also refers to those who've had a recent suicide attempt or who have participated in preparatory behaviour. They may also be in acute state of mental disorder or psychiatric symptoms, psychosis, agitation, intoxication or have precipitating events and inadequate protective factors.

  Dr. Juveria Zaheer: [00:51:59] And then we always want to talk about the chronically high, acute risk. So these are people who have a history of multiple suicide attempts, acute stressors, including major depressive episodes, substance use or relationship conflict that can increase their risk or recent hospital discharge. And for those people, you want to use an acute on chronic risk assessment model, which is a little bit beyond the scope of what we're doing today, but not really. Right. They have a high risk compared to the general population, but where is the risk compared to themselves? And again, there are going to be times where you are going to discharge someone with high, acute risk because they've had a suicide, they've engaged in suicidal behaviour, they're feeling really depressed. They were intoxicated at the time. They're committed to staying away from alcohol. They really don't want to be hospitalised. They can engage in safety planning. They have follow up within the next three days and the bridging service. They have family who are willing to stay with them. They don't have any psychosis. You could discharge that person safely and in keeping with their values. No prescription drugs in the house, but you just want to document accordingly.

  Lucy Chen: [00:53:04] So thanks for that clarification. I think a lot of the times we're often afraid to make these calls, right? Yeah. And hopefully there's a little bit more context now into getting a sense of what's all the information available to us and how we can communicate that and make sense of that and formulate that effectively.

  Dr. Juveria Zaheer: [00:53:21] Yeah, that's exactly right. Like we I think sometimes I worry that when people see these materials, they say, oh my goodness, now we have to do so much more work and it's not going to help anybody and it's not predictive of death. And what's the point of any of it? I hope by listening or by engaging with the material, we can say this is actually not going to make the assessment that much longer. It's really going to help me and my colleagues and my client because we'll be able to track the risk better over time, and it's going to facilitate better safety planning and a shared common language. And I think that would be the goal of this kind of work.

  Alex Raben: [00:53:57] Make sense.

  Lucy Chen: [00:53:58] And maybe with or for early learners or sort of early trainees, any words of wisdom or advice you can give to them on their first psychiatric rotation or their first day emerge with you?

  Dr. Juveria Zaheer: [00:54:07] Yeah, so I really like this question or lucky enough in the camera merge to have all of our U of T psychiatry residents now come through. So I think 36 PGY-1s every year we have a big call pool too. We have a lot of our wonderful senior residents like you guys who do call and who come back. What I would say for your first day of psychiatry is to be kind to yourself. This is a big field and you're in it because you care about people and you're going to learn so much from your clients and you're going to learn so much from your staff, and people are going to learn from you. And to remember that your decisions are supported by your staff. And all you can do is gather the information that you can and do the best job that you can. Try to always triangulate your data, try to get information from more than one source and enjoy the process because it's it's a learning process. And we're really happy to have you in the field and it gets easier.

  Lucy Chen: [00:55:04] And we've got some tools for you guys, so you'll feel a little bit more sort of relieved or relaxed about having some type of approach.

  Alex Raben: [00:55:11] Yeah, exactly.

  Lucy Chen: [00:55:13] Okay. So that's it. We'll see you guys in the emerge. Take care!

  Speaker4: [00:55:18] PsychEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not meant to be representative of either organisation. This episode is part of our mini series on psychiatric skills, which are intended to provide you residents with content directly related to the trustable professional activities or EPAs in our curriculum. Since EPAs are designed to capture core professional psychiatric competencies, we trust our listeners outside. You will still find them entertaining and educational. This episode was produced and hosted by Alex Raben and Lucy Chen. Our theme song is Working Solutions by All Live Music. A special thanks to Dr. Juveria Zaheer for serving as our expert this episode. You can contact us at Info at Select Podcast or visit us at Podcast Talk. Thank you so much for listening. Catch you next time!

Episode 56: Understanding Trauma and Addictions with Dr. Gabor Mate

PSYCHED EPISODE 56: UNDERSTANDING TRAUMA AND ADDICTIONS WITH DR. GABOR MATÉ.mp3: Audio automatically transcribed by Sonix

PSYCHED EPISODE 56: UNDERSTANDING TRAUMA AND ADDICTIONS WITH DR. GABOR MATÉ.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Nikhita Singhal:
Welcome to Site the Psychiatry Podcast for Medical Learners Biomedical Learners. This episode covers trauma and addictions. My name is Nikhita and I'm a fourth year psychiatry resident here at the University of Toronto. I'll be one of the co-hosts for this episode. I'm joined by my colleagues who I'll let introduce themselves.

Angad Singh:
Hi, my name is Angad. I'm a second year medical student at McMaster.

Sena Gok:
Hi, I'm Sena. I'm an international medical graduate from Turkey.

Rhys Linthorst:
And I'm Reece Linthorst, a fourth year psychiatry resident at the University of Manitoba.

Nikhita Singhal:
We're thrilled to be welcoming our guest for this episode, Dr. Gabor Mate, a retired physician who, after 20 years of family practice and palliative care experience, worked for over a decade in Vancouver's downtown east Side, with patients challenged by drug addiction and mental illness. The bestselling author of five books published in 30 languages, including the award Winning in the Realm of Hungry Ghosts Close Encounters With Addiction. Dr. Mat is an internationally renowned speaker, highly sought after for his expertise on addiction, trauma, childhood development and the relationship of stress and illness. For his ground breaking medical work and writing, he has been awarded the Order of Canada, our country's highest civilian distinction, and the Civic Merit Award from his hometown, Vancouver. His fifth book, The Myth of Normal Trauma, Illness and Healing in a Toxic Culture, was released on September 13th, 2022.

Rhys Linthorst:
Maybe when. Next? We'll talk a little bit about our learning objectives. So the learning objectives today are as follows. By the end of this episode, the listener will be able to, number one, understand the connection between trauma and the development of addictions and other mental illnesses. Number two, critically reflect on current diagnostic and treatment paradigms. And number three, apply principles of trauma, informed care to psychiatric assessment and provision of mental health services. Next, we'll maybe turn things over to Sienna to get our discussion started.

Sena Gok:
Thank you so much, Chris. Doctor Matt, could we start off with how would you define trauma?

Dr Gabor Maté:
Sure. So trauma is one of these words that like the word God, everybody uses, it has a different meaning for it. So it is important to begin with the definition. So the way I'll be using it in this context, trauma means a wound. In fact, wound is the Greek origin of the word trauma. It literally means a wound or a wounding. It's a psychological wound that we sustain at some point in our lives, in my view, most frequently in childhood. And unless it's healed, it has all kinds of consequences for physical and mental health, including what we call mental health diagnoses and addictions. But in my view, it's also shows up in its manifestations in autoimmune disease and malignancy even. That's not a matter of just my opinion. It's scientific research. To give you an example of the latter, who would you say would be the most traumatised segment of the Canadian population? You'd probably agree it's Indigenous women. Indigenous women has six times the rate of rheumatoid arthritis than that of the average population. This is amongst a population that used to have no autoimmune disease prior to colonisation. So I'm saying there's a huge link between trauma and all manner of illness. Um, I'll also say that. Trauma is not what happened to you. Trauma is what happened inside you.

Dr Gabor Maté:
Trauma is not the blow on the head. It's the concussion that you sustain. Two people can sustain a blow on the head. One of them might not have a concussion at all. They're not wounded. But the other one is. So it's not what happens to you. It's what happens inside you as a result of what happens to you. Number one. And number two, traumatic events can take many forms. Most famously, the adverse childhood experiences ACE studies which, if anybody listening has not heard about that should be your first task tonight is to look them up because they've been published in major medical and psychological journals since the 1990s. They show that the more childhood adversity occurs to an individual, the greater the risk for addiction exponentially, the greater the risk of addiction for mental health problems, for autoimmune disease, malignancy, behavioural problems, sexually transmitted disease and so on. These ACE studies, again, are not in the least controversial. They don't show a causal relationship. They certainly show a statistical relationship. Causation has been shown in many other studies, but adverse childhood experiences include ten categories that originally listed physical, sexual or emotional abuse. That's three. The death of a parent, A parent being jailed. A parent being addicted. A parent being mentally ill. Violence in a family, a rancorous divorce and neglect, to which we have to add some social factors poverty and racism, which are also being shown to have traumatic impacts.

Dr Gabor Maté:
And those are what we call the big T traumas, the big T traumatic events. What physicians, physicians barely learn about these, at least not until very recently. What they don't learn about at all is that people can be wounded not by these big T traumatic events, not by just the bad things that happen to you, but also by the good things that don't happen to you. So human infants in utero onwards have certain needs. On birth and after birth in early childhood. They have certain emotional needs. If those needs are not met, the child can also be wounded without anything terrible having happened. Which also means that in this culture. Which is so out of alignment with the needs of children. Many kids are wounded in homes where there's nothing but love, nothing but good intention, no abuse, no big T traumas. But children are still wounded because they innate human needs are not being met. So trauma then, is a wound sustained through either through overt misfortune or through. Essential needs not being met. And then for purposes of this conversation, trauma then shows up. In addictions, all addictions and in mental health conditions, in my view, all mental health conditions.

Angad Singh:
Yeah. Thanks for that definition, Dr. Mate. So I was wondering, beyond the ACE studies, could you speak to the relationship between trauma and addiction and the many ways that they're connected?

Dr Gabor Maté:
Sure. Now, one of the learning objectives that you outlined was critique of the current model. Let me begin with that. Okay. And then I'll revert back to answering your question directly. Because the because looking at the inadequacies of the current medical model of addiction is essential to then leading into the actual nature of addiction. So in this society, there are two dominant views of addiction. By far the most dominant view, the one that is infused into the legal system, is that addictions and some kind of a choice that somebody makes just through ethical lapse, moral weakness, failure of will. And so people then choose to do drugs. And addiction, by the way, is very much in a social mind associated with drugs. And it's a culpable, conscious, deliberate act. Now, I won't spend any time on it because it's complete nonsense. I've never met anybody who ever chose woke up one morning and decided to become an addict. But that's a dominant view. And that's why, by the way, largely why if you look at the jails of Canada, 50% of the women in jail in this country are indigenous. They make up 5% or 6% of the female population, 50% of the jail population. Because addictions are so widespread in the native communities. A lot of. Actions flow from that and then the people are punished. So that's the legal view. Now, the medical view, which is what concerns us here today, is a step forward.

Dr Gabor Maté:
The medical view sees addiction as a disease of the brain, primarily a disease of the brain, which affects behaviour and the sources of it, according to the medical view, is largely genetic. So the US Surgeon General, Dr. Vivek Murthy, published the overview of addiction is maybe six years ago now where 50 to 70% or 40 to 70% of addictions are ascribed to genetic tendencies. Now the medical view is a step forward. Markedly so from the popular choice model, because, number one, if somebody is a disease, at least you, you don't blame them for it. And furthermore, especially if the disease is genetically determined or influenced, who can you blame for inheriting certain genes? So it removes blame and shame, at least ideally, ideally, but not in practice, because a lot of physicians still practice shame based medicine when it comes to working with addicts. Just visit any emergency ward when an addict addicted person comes in and how they're treated by the nurses and the doctors. So theoretically, the medical model. Obviates shame and blame in practice. Not like that. But at least theoretically. Secondly, it provides treatment. So if somebody comes to you with rheumatoid arthritis, you'll treat them. That's good. Number three. When somebody relapses with cancer or multiple sclerosis or rheumatoid arthritis, you don't punish them for it. You don't judge them for it. You accept that that's the part of the so-called disease. So you just treat it.

Dr Gabor Maté:
So these are all steps forward that the medical model offers and they're valuable. But does that mean that they're accurate? No, doesn't mean they're accurate at all. So I'm going to assert for you that addiction is not genetic and it's not a disease. What is it? So we'll do a little test here with our four panellists. I'll ask for your but your honest participation. Maybe I'll draw a blank, but maybe I won't. I'll give you a definition of addiction that I don't think is controversial. And it's the one. Okay. Conflict of interest here, folks. I'm going to mention my books. Okay. So in this book, The Myth of Normal, which is the most recent book that I've written, I gave a definition of addiction. An addiction is a complex, biological, psychological process that is manifested in any behaviour in which a person finds temporary relief or pleasure and therefore craves. But then suffers negative consequences as a result of and cannot give up despite negative consequences or does not give up. So craving pleasure relief in the short term. Harm in the long term. Knack of giving it up. That's what an addiction is. Now, notice something I haven't said. I think about drugs. It could include drugs, certainly cocaine, crystal meth, heroin and caffeine, alcohol, nicotine, opiates, of course. But it could also include sex. Gambling. Pornography. Shopping. Eating. Bulimia. Gaming. The Internet. Cell phones. Extreme sports. Work. I could go on forever.

Dr Gabor Maté:
The point is not the behaviour as such. You can actually take heroin not addictively. Not that I recommend it, but you can or you can take it addictively. You can work not effectively or you can work addictively. You can eat. Not addictively. Or you can eat addictively. So the issue is not the behaviour per se. It's the internal relationship to the behaviour. Does it provide pleasure relief in the short term? Therefore, you crave it causes harm. You can't give it up. You got an addiction. So I'm going to ask my four brave panellists here if, according to that definition, you will acknowledge that any time in your life you had any kind of addictive pattern, just raise your hand and I'm not going to ask you what it was or when. I just I just ask you in general, did you ever have anything like that? Yes or no? Yes. Yes. Okay. Here's what I'm going to ask you. No, I'm not going to ask you what you're addicted to. What substance or behaviour. Nor am I going to ask you when or how long. I'm just going to ask you, each of you tell me what was right about it for you and what was wrong with it. You know what was wrong with it. What did it give you in the short term that you wanted? What did it give you that you craved, actually? So anybody would like to start.

Sena Gok:
I can start with idea of pleasure and distraction.

Dr Gabor Maté:
Pleasure and distraction. Thank you. What else.

Nikhita Singhal:
Made me feel safe? It was predictable.

Dr Gabor Maté:
So the sense of safety. Yeah. Okay. Sense of security. Go on. Thank you. Next. Anybody else? Yeah.

Angad Singh:
I can follow up with a sense of approval.

Dr Gabor Maté:
A sense of approval From whom?

Angad Singh:
From the outside world. Okay.

Dr Gabor Maté:
Thank you. And one more person.

Rhys Linthorst:
Really just sort of a relief from distress, like almost just finally being able to let go.

Dr Gabor Maté:
Distress. Okay. Very good. So pleasure was the first thing that a good thing or a bad thing in itself? Distraction from unpleasant. When do we need to be distracted? When we're in uncomfortable? So it's a sense of comfort. Is that a good thing or a bad thing in itself? Safety, security. Is that a good thing or a bad thing in itself being accepted or approved of by others? Sense of I'm okay. Is that a good thing or a bad thing? We all want it. It's a good thing. Distraction again from distress. Stress relief. Is that a good thing or a bad thing? Clearly in itself, it's a good thing. The lack of pleasure, the stress, the lack of safety, the fear of not being approved of, and the feeling of distress. These are all forms of emotional pain. Hence, addiction is not a disease. It's not genetic, but it actually is is an attempt to resolve the problem of human pain. So the addiction wasn't your primary problem. It was your attempt to solve a problem. The problem of some form of emotional psychological distress. Therefore, if you want to understand the addiction and here's my mentor and if you remember nothing from this conversation, try to keep this phrase in mind. The question is not why the addiction, but why the pain? Now, if we understand why the pain and the question was the relationship between trauma and addiction, the pain is an imprint of trauma.

Dr Gabor Maté:
The pain that you're still carrying. An adult life is an imprint of trauma that you sustained at one point in your life. It's the wound that hasn't healed yet. No. You want this proven? Statistically, if you look at the adverse childhood experiences studies, if a male child had six of those, his risk of becoming an injection using substance dependent person as an adult is not six times greater than the average is 46 times greater. They multiply each other. And I like also to talk about it from the point of view of the human brain. And I wonder if this would be a good time to do that, because certainly it's a manifestation of brain dynamics. But the big mistake made by neuroscientists and psychiatrists is they think the brain is the origin of things. So I would like to discuss the question of it's a brain disease. Let's look at why do addictive substances even work in the human brain? We're talking about substances now for the moment. So let's take the opiates. So I think it was mentioned in the introduction, or if it wasn't for seven years, I was the medical coordinator of the palliative care unit at Vancouver Hospital looking after terminally ill people. So I dealt with a lot of death and a lot of pain. Thank God for the opiates. The opiates are the strongest pain relievers that we have.

Dr Gabor Maté:
We know that. But why do they work in a human brain? The opiates come from opium papaver somniferum the poppy that puts you to sleep. That's the Latin word for it. And it goes in Afghanistan. Why do we find relief from a plant that grows in Afghanistan? Because we have receptors in our brain for opiates. But why do we have receptors from a plant that grows in Afghanistan? We don't. As you will probably all know, we have receptors for opiates because we have our own internal opiate system. And our internal opiates are called endorphins, which simply means endogenous morphine like substance. S. So our bodies are full of endorphin receptors in our guts, in our immune system, in our mucous membranes, in our brains. And in each of these areas, they play different roles. So I'm here now concerned with the role they play in addiction and specifically in the brain. The endorphins. Played three major roles in the brain now. If you want to understand why people crave opiates, you gotta understand endorphins. What do endorphins do? Well, the first thing they do, I've already mentioned this. They provide pain relief. Pain is an essential part of human life. As you know, if it wasn't for pain, we would not be able to protect ourselves. But there has to be pain relief as well. The endorphins help provide that. So in a placebo effect where you give 100 people an inert pill for pain and 25 have complete pain relief, it's their own internal endorphins that are being released that.

Dr Gabor Maté:
So, you know, this is not a it's a real effect. It's actually an opiate that's helping them when they think they're getting an opioid. They're getting their substance, but they won't. Endorphins kick in. So that's the first job. But not only physical pain relief, the emotional pain relief as well, because the part of the brain that experiences the suffering of physical pain is also the part that experiences the suffering of emotional pain, and that's the anterior cingulate cortex. Now pain is felt different areas of the brain, but the suffering is felt largely in the ACC, which is heavily endowed with endorphin receptors so that the first job of the endorphins then is emotional and physical pain relief. Number one. Number two. They help. Experience. They help us experience. Moments of pleasure and reward and elation. So when people go bungee jumping, the higher their resultant endorphin level, the more exalted they are, the more exaltation there is. That's important in human life because human life is full of suffering. We have to have pleasure and reward. Endorphins help to do that. That's the second important role. The third one is the most important, which is a word we never even talk about in medical school. The third rule of the endorphins is to help potentiate a little thing called love.

Dr Gabor Maté:
My love. I mean, the attachment between two human beings for the purpose of caretaking, which is an essential dynamic between mother or parent and infant. So both the infant and the mother have endorphin surges when they're looking into each other's eyes. That's why parents get so addicted to their kids. It's that endorphin high, which is a good thing because otherwise parenting would be a very difficult business. If you take infant mice and genetically you knock out their endorphin receptors, they will not cry on separation from their mother. What would that mean in the wild? Their death. That's how important detachment is. That's how important the endorphins are. And if you ask heroin addicts, what does the heroin do for you? You know what they'll tell you? They'll say, it makes me feel like a warm, soft hug. It makes me feel like. One person told me this in. In a detox facility. I said, What does it do for you? He said, You know, Doc, it's like when you're three years old and you're shivering with a fever. And your mother puts you on her lap, wrapped in a warm blanket and gives you a warm chicken soup. That's what the heroine feels like. Love. That's the endorphin circuitry. That's where the opiates are so powerful. No. Then is dopamine. Dopamine is another little mouse experiment where you put a little mouse in front of a plate of food.

Dr Gabor Maté:
He is hungry, he hasn't eaten, and he will not budge two inches to eat. Why? Because genetically they knocked out his dopamine receptors. Dopamine is essential for motivation, for seeking, for curiosity, for vitality. Dopamine flows were seeking a novel object, were exploring a novel object or a novel environment. Dopamine flows when we are seeking food or seeking a sexual partner. I got news for you. Sex addicts are not addicted to sex. If they were. And it's a serious condition, even though the DSM doesn't recognise it. But that's a whole other picture. But sex addiction is a serious problem for a lot of people. What they're looking for is not sex because it was sex. They just had to marry another sex addict. It'd be okay for the rest of their lives. It's the dopamine hit of seeking that they're looking for and all the behaviour addicts. And I've had my own. Believe me, we're not seeking the object. What you're shopping for or the gambler is not after winning money. Because if they want a big. Role, they'd quit, but they don't get back the next morning and they lose it thereafter. The seeking the dopamine hit the excitement. So all behaviour addicts are actually substance addicts, but the substance is their internal dopamine apparatus. So that's the second circuitry. Of the brain that's implicated in addiction. The third one is stress regulation.

Dr Gabor Maté:
If you talk to addicted people who were clean for a while, then they relapsed. You ask them what happened. Usually something stressful happened. They couldn't handle it. They used the addiction behaviour, whether it's gambling or sex or pornography or shopping or drugs to soothe the stress. Now, our brains, as you know, is medical students, medical people. We do have a stress apparatus and, you know, the hypothalamic pituitary adrenal axis, but we also have the stress regulation. Addicts don't have good stress regulation. They use the addiction to soothe their stresses. As a couple of you have already told me. And finally, there's the impulse regulation circuitry. I'm pointing at it. The right orbitofrontal cortex. And his job is to tell you you may want to do this thing, but it's not good for you. Don't do it. No, babies don't have good impulse regulation or any impulse regulation. But a baby wants they'll reach for it right away. Addicted people are the same thing. What should that tell us? It should tell us that addiction is not an inherited disease but a developmental problem. Certain circuits in the brain did not develop properly. So what we're looking at in addicted people is that these various brain circuits, the endorphin apparatus, the dopamine apparatus, the special litigation circuitry, the impulse regulation circuitry did not develop properly. And I'm going to just spend two more minutes to talk to you about brain development and then I'll stop.

Dr Gabor Maté:
So how does the human brain actually develop? And here's another one of these little secrets that I would wager to say most of you in medical school have never heard about. And I am not critical here of individual physicians, but I'm telling you, your education is bereft of some of the most important dynamics in human life, including normal psychological development, which you probably never heard a lecture about. We just learn about pathology or including healthy brain development. So I'm going to read you an article that's not in the least controversial. It's from the Journal of Paediatrics, February 2012. That's the Journal of the American Paediatric Academy. The article is from the most prestigious centre on Child development in the world, the Harvard Centre on Child Development. Again, it was published 11 years ago now in February. And. I'm going to read you two sentences on brain development. This article, when it was published in 2012, was no longer in use. I'd known about this stuff since the 90s. You know, there was by the 90s there was not news anymore. It was just, you know, being established in the literature. Here's an article from 2012 summarising all that knowledge. The architecture of the brain is constructed through an ongoing process that begins before birth, continues into adulthood, and establishes either a sturdy or a fragile foundation for all the health, learning and behaviour that follow.

Dr Gabor Maté:
I'm going to parse that sentence for you. The architecture of the brain is constructed through an ongoing process that begins before birth. You know what that means. It means that the emotional states of the mother are already promoting and influencing the physiological development of the child's brain. Now I could cite for you X number of studies if you want the references on which I rely. You're welcome to find them in my books, most recently The Myth of Normal. Previous to that, my book on addiction in the Realm of Hungry Ghosts. Previous to that, published 24 years ago, my book on ADHD called Scattered Minds. So the architecture being is constructed through an ongoing process begins before, which also means that the prevention of addiction needs to begin at the first prenatal visit. We have to pay attention to the emotional states of the mother when she's carrying the child. Because stress is depression. Anxiety on the part of the mother will have a physiological impact on the child's brain, including on a number of dopamine receptors, for example. So because before birth continues into adulthood, so goes on throughout childhood. So childhood is a period of being development. And establishes either a sturdy or a fragile foundation for all the health, learning and behaviour that follow. Not some of the health learning and behaviour that follow all the health learning and behaviour that follow. The base of it is established early on.

Dr Gabor Maté:
Okay. Second sentence The interactions of genes and experiences literally shapes the circuitry of the developing brain. So it's experience is acting on the genes. This is called epigenetics. How the genes are turned on or on off by the environment based on methylation and a whole lot of other biological mechanisms, which I'm not smart enough to understand or not patient enough to memorise. But it's genes being affected by the environment. That's why you can have people with the same genes, two animals with the same genes, totally different behaviours if you put them in different environments. So the addiction is not genetic. It may run in families, but so what? Those All four of you here are medical doctors or medical doctors to be. If any, future children you might have go into medicine. Does that prove that the passage of medicine is a genetic disorder? I mean, maybe it is, right? So it's critical. So so these experiences shaped the circuit of developing brain and is critically influenced by the mutual responsiveness of adult child relationships, particularly in the early childhood years. In other words, the biggest influence on the physiological development of the brain, the circuitry, the systems, the neurotransmitters is the quality of emotional relationship with the early environment. Now what happens to a traumatised brain? Guess what? These circuits don't develop. Now you got the template for addiction. That's it in a nutshell.

Angad Singh:
Thanks, Dr. Matt for outlining those normal physiological mechanisms ranging from the brain circuits you outlined that underlie sort of the normal motivation and and attachment mechanisms to the HPA axis and the Neuroendocrinology as well as the genetics and epigenetics. And you sort of hinted at this at the end of what you were saying. But I'm wondering what are the ways that trauma gets encoded into those systems? And then how does that lay the groundwork for addiction and other problems?

Dr Gabor Maté:
Well, first of all, if we look at any development, so look at the development of a plant. If you're growing a plant in your garden, what questions would you have to ask yourself? I'm asking you.

Angad Singh:
Whether the soil is fertile.

Dr Gabor Maté:
Good. That's an important one. What's another one?

Angad Singh:
Whether there's enough sunlight.

Dr Gabor Maté:
Very good. That's 2 or 3. There's one more.

Angad Singh:
Whether you're watering enough.

Dr Gabor Maté:
Very good. In other words, you would take care of the conditions that the plant needed for the development. Same with human beings. Human beings have certain needs, a certain expectations into which they are brought into this world. They include safe, secure attachment relationships. Where the child is absolutely can rest in the awareness that they're accepted and seen and loved for exactly who they are. That's a human need. They have a need not to have to work inside that relationship. In other words, the child shouldn't have to be pretty compliant. Presentable. Good. Corroborative shouldn't have to try to make the parents feel better in their own miseries. Judges rest. Because growth happens during rest. Not doing struggle. That's the second need of the child. The child is a third need. And again, this is a chapter on this and the myth of normal, the irreducible needs of children. The third need is now the great neuroscientist. His name is Jacques Jaak Panksepp PR and SCP. Unfortunately, he died a few years ago before his time of cancer. But he distinguished seven number of brain circuits that we share with other mammals. They include caring love. That's the endorphin circuitry seeking curiosity. That's the dopamine circuitry. Fear. Grief. Anger. These are all essential for human functioning. Now. We asked you about what does a plant need? Irrigation, sunlight and minerals in the soil. Yeah.

Dr Gabor Maté:
Well, the human child needs these conditions. Do you mean the child? Also, by the way, needs free play out in nature. Spontaneous play. Play plays a huge role in brain development, much more important than academic learning. We have a huge circuit in our brain dedicated to play. Cats play. Lions play. Bear Cubs play. Everybody plays because the brain promotes healthy brain development. You know, society free spontaneous play is barely available for kids anymore. They don't play anymore. They play with cell phones. That's not play. So these are the four irreducible needs of children. When they're not met. These circles don't develop properly. The receptors don't develop stress mothers. The kids dopamine circuitry won't develop properly. You know, so. Because don't forget what this article from Harvard said, that the brain develops under the influence of the mutual responsiveness, responsiveness of adult child relationships, particularly in the early childhood years. Now, come to the downtown east side with me in Vancouver, North America's most concentrated area of drug use, where I worked for 12 years. In 12 years of work in the downtown east Side, I didn't have a single female patient out of hundreds who had not been sexually abused as a child. Not one. And what was amazing is that until I asked them, nobody had asked him that before. In most cases. What does sexual abuse do to your child's brain? The stress of it, the activation of the HPA axis, the release of cortisol which interferes with brain development.

Dr Gabor Maté:
Which undermines the availability of dopamine receptors. Which interferes with healthy stress responses. Because the child who is being. Abused. Take an extreme case. Can't generate the healthy stress response because the healthy stress responses to fight or to escape. Can a four year old being abused fight or escape? They actually they have to gut their own stress responses. No wonder. Then later on, they don't know how to handle stress. It's a wonderful volume by my colleague and friend Bessel Van der Kolk called the body keeps the score. On, on on stress. If you want to really know the traumatic impact of severe trauma, read that book. But as I said to you earlier, you don't need those big T traumas. And this is where genetics do come in. Here's what I'm going to tell you. This is true for mental health conditions in general. There's no gene for depression. There's no gene for schizophrenia. There's no gene for bipolar. There's no gene for addiction. There's no gene for ADHD. There's no gene for nothing. Nobody's ever found a single gene. That if you have it, you will have this disease. And if you don't, you won't. Don't believe me, by the way. Look it up for yourselves. Nobody's ever found a group of genes that if you have them, you'll have this or that condition.

Dr Gabor Maté:
And if you don't, you won't. What they have found. As best I could tell, when I did the research last time, a year and a half ago, in preparation for my most recent book, A Large Group of Genes, that the more of them you have, the more likely you are to have any number of mental health conditions. But no specific one. So those jeans are not for diseases. You know what they're for. Susceptibility sensitivity. So the more of these sensitivity genes you inherit, the less it takes to make you suffer, the less it takes to have an impact on you. Now that is inherited, but that in itself does not lead to disease. It's the action of the environment. On sensitivity genes that makes some people much more prone for addiction. Now, you don't have to have those genes to become addicted, but the more you have, the more likely to have any number of mental health conditions. And that's one more thing I want to say. When I was working in the Downtown Eastside, it wouldn't be unusual for somebody to say to me, Hey, doc, I don't get it. But most people, they do cocaine. They go all hairy. But me, I calm down and I cleaned my room. What do you think they were telling me?

Nikhita Singhal:
Self-medicating in a way, I guess.

Dr Gabor Maté:
They were self-medicating ADHD because Hobby Medicate, ADHD is with dopaminergic drugs. You know, Dexedrine, Adderall, Ritalin, methylphenidate. These people were using the stimulus to medicate themselves. People also use these people also tend to use. And so but in the study, statistically, about 30% of of amphetamine addicts or stimulant addicts, nicotine, caffeine, crystal meth, they're actually self-medicating ADHD. And most doctors don't even realise that. And in general, very often the drugs are self. Heroin is a wonderful self-medication for PTSD. Do. Cocaine elevates serotonin levels. Not as long as Prozac does, but it does. People self-medicate depression with cocaine. So very often people medicate. I mentioned maybe marijuana. People sued the ADHD brain with marijuana. I was talking to Prince Harry a few weeks ago. Some of you may have heard that. And I kind of controversially, but diagnosed him with Add because it's in his book. He couldn't pay attention. It was distractable, you know, And and marijuana really helped him because it helps the hyperactive brain calm down. So very often addictions to substance are self medications.

Nikhita Singhal:
So mean so much of what you've talked about. You know, things start in childhood. There's there's something that happens. And it's not necessarily what happened is, you know, how how we respond. There's certain maybe genes that make us more susceptible to respond certain ways. And then thinking about how the addictions are serving some purpose, some function. And we don't maybe take on more adaptive ways of coping with things as we grow up. Bring that. Then maybe to our third learning objective thinking about how can we use this pen to provide better care for people?

Dr Gabor Maté:
Sure, if you believe that what you have in front of you is a person afflicted by some genetic disease which manifests in a certain behaviour. Well, what can you do about anybody's genes? All you can do is manage the behaviour. So to an opiate addict, you might provide some medically assisted help. You know, give them Suboxone or methadone. That's useful. You might put them into a group where they learn better behaviours that can be useful. But you're forgetting or not knowing. Not that you forget it because you never knew it. You're ignoring the fact you're not aware of the fact that underlying those behaviours is trauma. So we need to have a trauma informed view. Of treatment. Now, trauma informed view of treatment doesn't mean that all you talk about is trauma. It means trauma informed. It means that you're informed by the fact that this person of any gender, of any age, when they come to you with an addiction, and I would argue with any mental health condition, if there's time, we can talk about that. If not, we just talk about addiction. Actually, there's a traumatic wound inside them so that any healing program needs to address not just their behaviour, like with cognitive behaviour therapy and dialectical behaviour therapy. You need to address the underlying pain. Now why the addiction, but why the pain? And that pain shows up in self-loathing. in self-blame. In aggression. In. Mistrust in a skewed view of the world, in constant behaviours designed to soothe the pain or to numb the pain.

Dr Gabor Maté:
So let's deal with. And. The ultimate pain is. When you're suffering as a child. Whether it's emotional suffering or physical or both. And you're alone with that suffering. You almost are forced to disconnect from yourself because the pain is too much. And that disconnection from yourself no longer knowing your gut feelings, not trusting yourself, not even liking yourself. That's the ultimate wound. So that trauma informed care would help lead people back to themselves. And let's face it, pain is a part of life. You can't escape pain if you're a human being. You don't have to inflict on inflicted on people. Which incidentally, the medical system often does unwittingly, but it does just by how it treats them. But you have to help them cope with pain. So part of the trauma informed care is how can we help you develop ways of being with the genuine pain of being alive without having to resort to escape from it all the time? So it's healing that traumatic wound. That's the ultimate goal here, which doesn't obviate or invalidate other approaches. And I'm all in favour of, you know, Suboxone and methadone when it's required. I'm not against psychiatric medications. I've taken them with benefit but taken antidepressants and I've taken stimulants for my ADHD. But they're not the answer. They only deal with symptoms.

Rhys Linthorst:
Think that's a really helpful kind of approach to the treatment of addictions and trauma. Dr. Mate And actually noticed in your latest book, The Myth of Normal, there was like a chapter on kind of Steps towards healing, which kind of elaborates on strategies that individuals can use to move toward more adaptive ways of thinking was actually sort of curious, kind of on a broader scale how you see the role of the medical doctor, whether it's the family doctor, the psychiatrist or addiction specialist in regards to the provision of the psychological work versus the prescribing, and if there's any upside or pitfalls to having the same person do both.

Dr Gabor Maté:
Well, I certainly did both. In fact, I couldn't have imagined not doing both. And it's not as complicated as you might think. You know, I'll tell you, for myself and I teach a therapeutic program internationally. We've had over 3000 students now in over 80 countries. It's called Compassion Inquiry. I've never had a day's training in psychotherapy. I'm not saying you shouldn't. I'm just saying. The formal training is not the essence of it. Something else is the essence of it. I'm not saying it's just like that. And I've learned a lot from others and from my clients and so on. But the most important thing is, is what you have to keep in mind. This makes all the difference in the world. Even if you have no factual knowledge. People were hurt in relationship. They were hurt unwittingly. We're not blaming parents here, by the way. Parents do their best. Your parents did their best. My parents did their best. I did my best as a parent. And I'm telling you, I hurt my kids. Not because I meant to, because I didn't know any better. There were stuff I hadn't worked out yet that I invented. And trauma is multigenerational that way. You can see that especially in the Aboriginal community in Canada, just a multigenerational it is, but it's multigenerational. But it means that we were hurt originally in relationship. It also means that we need to heal in relationship. So the therapeutic relationship is the most important thing you bring to your client. I don't care what training you had and I don't care what training you didn't have. Can you see them as human beings? Can you accept them? Can you look at them without judgement? When they come in your office having relapsed yet again.

Dr Gabor Maté:
We feel resentment and frustration and judging. Because if you are. And you're saying to yourself, I got this difficult client. There are no difficult clients. Who's got the difficulty? You've got the difficulty. Look at where that judgement, where that resentment comes from. You don't look at your rheumatoid arthritis patient that way, do you? Where is your judgement coming from? So if we can strive to provide an accepting, unconditionally accepting. I'm not saying to put up with bad behaviour. I'm not saying somebody wields a knife at you. I'm not saying sit there, accept it. You know, I'm not talking that nonsense. I'm talking about their behaviour in their own lives. If you cannot judge them, if you can see the pain behind it, if you can accept them and not only accept them, but see the possibility of wholeness in them. The to that relationship. That's a huge healing influence. And many of you who are listening to this, at some point, I hope you experience this, that somebody will say to you. Dark many years ago or some years ago. I came to your office and you listened and you didn't judge me and you accepted me. And that made all the difference in the world. And it does. So trauma informed doesn't mean like a huge load of training necessarily. It doesn't mean that you show up seeing that person as carrying a wound that can heal and you look at them with compassion and acceptance and you take responsibility for your own reactions. That's the biggest part of it.

Sena Gok:
Thank you, Dr. Mate. You mentioned the impact of multigenerational trauma and that we see within the indigenous population, and especially in women in Canada, highly this impact. And also there are societal barriers that are impact addiction population. Could we maybe speak to these? And I've also read that you mentioned trauma informed care can be applied from our society. Could we could you speak to that as well?

Dr Gabor Maté:
So what are the societal barriers?

Sena Gok:
Yeah.

Dr Gabor Maté:
Well, so let's just own the fact that we live in a society of high inequality. So these barriers are not general. They're specific. Some barriers affect everybody, but some barriers affect some people much more than others. So poverty is a huge barrier. Lack of drinking water. A lot of our native communities until very recently and some even now don't have potable water. We make societal choices as to where we're going to spend our money. We spend our money on sports stadiums, millions of dollars on certain celebrations. We don't spend it on drinking water for our indigenous communities. That's a barrier. But it's an arbitrary one. Which speaks to the values of this particular society. Race is a barrier. Not in itself. In itself, race doesn't even exist. There's no race. Skin colour and shape of lips or nose does not create a new race. Race is a function of a society that in its evolution, dependent on making some people inferior for the sake of enslaving them or of depriving them of their goods and lands. Race is a concept arose only with the rise of capitalism. But that's a huge barrier. Article yesterday or two days ago. The Toronto police are much more likely to be violent with black people than with Caucasians.

Dr Gabor Maté:
What a surprise. That's a barrier. Gender is a barrier. Um, in that there are certain acculturated tasks that devolve onto women more than onto men, particularly being the stress absorbers of everybody. Women have much more risk of of being on psychiatric medications, antidepressants, anxiolytics, and so on. Women have more PTSD. Obviously not exclusively, but there are more prone for sexual abuse in childhood. These are barriers. Class is a barrier to receiving treatment. The Canadian health care system does not cover psychotherapy. One of the reasons I developed my own psychotherapy therapeutic skills such as they are, because as a general practitioner, once I began to recognise the connections between people's emotional states and their mental health or their physical health. I thought, well, okay, I can I can give them the antidepressant or I can give them the anti-inflammatory or the immunosuppressant or whatever they need, but who's going to talk to them about their emotional needs? In the medical system, only psychiatrists are paid to spend money and only in Toronto with their GP psychotherapists. But in B.C. there aren't. Most provinces do not. Emojis are not trained in that way. So then I'd have to send people to psychiatrists. But I hate to tell you. Most doctors are not trained in decent therapy.

Dr Gabor Maté:
That is not even part of their training. They at least wasn't. They mostly deal with hospitalised patients with severe mental health conditions. Therapy barely comes into it. So therefore I had to start talking to my patients myself. So money is a barrier because here in Vancouver, to see a private therapist. You know what? $100 an hour, $150 an hour, maybe more. Well, in a in the East Vancouver family practice I used to have before I worked in the Downtown Eastside, my people were working class immigrants. They couldn't afford $150 an hour for psychotherapy. So these are all barriers. But the biggest barrier is an ideological one. Which is that the medical profession itself doesn't recognise the connections that have been trying to draw for you. You can go to medical school and I hope you'll tell me otherwise today. I hope you'll tell me right now that I'm wrong. But my assertion is that the average medical student doesn't hear a single lecture on trauma. In a way that I talked about it today, the significance of it now. In, at least in the undergraduate years. Tell me if I'm wrong. Okay. I'd like to know that I'm wrong on that one. Yes or no?

Angad Singh:
No, you're not wrong.

Dr Gabor Maté:
Okay. Which means that the biggest dynamic in causing addictions and mental health problems is not even mentioned in medical school. Now, talk about barriers. That's a barrier. All the more. I'm appreciative that you guys are giving me this opportunity to address some doctors in training. I mean, I, you know, am I an evangelist? Yes, I am. I'd really like people to know about this stuff. And you know what frustrates me here? When I allow myself to be frustrated. It's not that the medical practice is scientific, it's that it's not scientific enough. Because what I'm talking about, you know, when I wrote this book, The Myth of Normal, I collected 25,000 articles. Multiple hundreds on trauma and its impact on the brain and the body and unity of mind and body and the connection between addictions and ADHD and everything else. You guys don't even learn the science. And you would call yourself a scientific discipline. So that's the biggest barrier is our ideological blinders Imho.

Dr. Alex Raben:
Thanks so much, Dr. Mate. I haven't introduced myself, but I'm Alex Raben. I'm a psychiatrist from here in Toronto. Great. Um, and I have to say, yes, in my own medical training, I would agree with what Angad was saying there and many of our panellists here today, thankfully, I think in psychiatry training is a bit different and we certainly have had some episodes on trauma, thankfully before, not not the same lens as today. I just wanted to jump in with a question as well that came to me to do with harm reduction because we've talked a lot and in your book you talk a lot about the biological, psychological, developmental, multifactorial aspects of addiction and, and the way trauma layers on top of that. Yeah. But there's also, I guess, this element of the substance or whatever the target of the addiction is. And it strikes me that some of those behaviours may lead to bigger harms than others. And I'm thinking about, for instance, the opioid crisis which is rampant in the country, has been getting worse and particularly in BC. How do, how do we view, how do we make sense of that from this model, right where we see this substance being taken up in greater quantities and causing greater and greater harm? Is there a role here to do something in that realm as well? Or how how does that fit into all this?

Dr Gabor Maté:
Sure. So in this in my previous book, which is in the realm of Hungry Ghosts, Close Encounters addiction, there's a chapter on harm reduction. Um, so I was the physician at North America's at that time only and first supervised injection site which is called Insite or here in Vancouver on Hastings Street, where people could bring their substances of abuse or use and get clean needles and sterile water and a tourniquet and inject under supervision. And if they're overdosed. They'll be resuscitated. The Canadian government In its wisdom at the time, the Harper Conservative government tried to shut it down. Under the principle that we're aiding and abetting addiction. From their point of view, it would have been better to what I'm saying now. The Supreme Court of Canada ruled. Unanimously against them. So now there are other injection sites throughout the country. Not nearly enough. So that's a harm reduction measure. Harm reduction says basically harm reduction says it's not just a practice. Harm reduction is an attitude. And it says, we know that right now you find yourself incapable of not using. So let's. Can we help you use in a way that reduces the harm so that you don't infect yourself or somebody else with HIV or hepatitis C so that you don't develop a brain abscess from a dirty needle? or abscess in joints. Um, so that we can talk to you and you can start to trust us and maybe accept treatment from us because we're not judging you. Harm reduction also includes provision of safer forms of opiates like Suboxone or methadone. But basically it says that while sobriety or abstinence is a legitimate and ultimately the hoped for goal, it's not the only goal.

Dr Gabor Maté:
By the way, there's nothing so unusual about that in medicine. I mean, if you come if you come if you come here as a type one diabetic. Nobody's hoping to cure you. But they are hoping to reduce the harm. By maintaining your sugar levels, insulin levels at an optimal range. By dealing with foot injuries so they don't get infected. But make sure that your kidney functioning stays within normal parameters. These are all harm reduction measures. So it's the same principle. And sometimes people say this is controversial. Well, we shouldn't have harm reduction. I mean, these people brought it on themselves. Let them suffer. There's that attitude which I say I go along with as long as we're consistent. Which means that the next time a workaholic, cigarette smoking businessman shows up in the emergency room with a heart attack, we don't give them a bypass. We kick them out. You're saying you brought this on yourself, not deal with it. You know, but no, we go in there and and we reduce the harm. You know, we give them the medications and if needed, the stent or whatever they need. Well, harm reduction is in the same range. And by the way, nobody stays in addict because of harm reduction and nobody becomes an addict because of harm reduction. So it's just a part of the to me, it's totally irrational. Hopefully it'll lead to abstinence if people trust enough and they enter the treatment system. But unfortunately, there's not a good enough treatment system to enter. So I think. Once you understand trauma, harm reduction becomes a self explanatory dynamic.

Dr. Alex Raben:
Right. Sounds very complimentary. Going back to what you were saying earlier about being able to be a doctor while also providing trauma informed care in that combination being essential. Right. It's not just one or the other.

Dr Gabor Maté:
But listen, Alex, why why also like it's like it was somewhat extraneous, you know, not while also that ought to be part of your work as a physician.

Dr. Alex Raben:
Right? They're there. They're inextricably linked and linked in a sense. And the even the language you use around it can kind of make these false dichotomies. Yeah. Yeah.

Dr Gabor Maté:
Yeah.

Dr. Alex Raben:
Nikita. Maybe I'll hand it back to you to wrap us up.

Nikhita Singhal:
Yeah, I think we could go on for ages talking about it. And thank you so much for, you know, providing us with this perspective, because as as you alluded to, it's not one that we are often, you know, exposed to, although increasingly, I think it's becoming. Know, thanks to your work and others more more in the general awareness. But really, I think, you know, just a quick recap. You covered, you know, trauma and how we can really think about trauma in a broad sense and how that is really linked to not only addictions, all kinds of health conditions, and that the current approaches, the way we think about things doesn't really do the people we serve justice in allowing us to understand and and then to best be able to help help empower them to move past what they're struggling with. And you gave us some really great considerations for ways that we can be trauma informed. And that is our job is to be trauma informed and provide that care. So really, we we thank you so much for for your time and speaking to us. And we think this will be a really helpful for all those future providers out there.

Dr Gabor Maté:
Well, my pleasure. Thanks for the opportunity and the great questions and I'll talk to you again sometime. You take care.

Nikhita Singhal:
This concludes our episode on understanding. Trauma and Addictions featuring Dr. Gabor Mate. Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Sena Gok. The episode was hosted by Sena Gok, Rhys Linthorst, Angad Singh, Nikhita Singhal, and Alex Raben. The audio editing was done by Sena Gok. Our theme song is Working Solutions by Olive Musique. A special thanks to our incredible guest, Dr. Gabor Mate, for serving as our expert for this episode. You can contact us at Psychedpodcast@gmail.com or visit us at Psychedpodcast.org, Thank you so much for listening.

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Episode 12: Treatment Of Schizophrenia Part IV Advanced Principles of Schizophrenia Treatment with Dr. Gary Remington

• Episode 12: Treatment Of Schizophrenia Part IV Advanced Principles of Schizophrenia Treatment with Dr. Gary Remington

  Lucy: [00:00:01] Okay. All right. Okay. Welcome back to PsychEd, the Educational Psychiatry Podcast for Learners by Learners. I'm Lucy Chen, now a PGY4 psychiatry resident at the University of Toronto. I'm excited to introduce to you the fourth episode in our four-part miniseries on schizophrenia, which will be an advanced look at the clinical management of schizophrenia, a discussion on treatment resistant schizophrenia and clozapine. So just a warning, the content in this episode is going to be a little bit more advanced than usual, but it's also ultra interesting. Alex, Henry and I had the pleasure of interviewing Dr. Gary Remington for this episode. He's a researcher and chief of the Schizophrenia Division at CAMH and an author of the 2017 Schizophrenia Treatment Guidelines. His knowledge base on the topic of schizophrenia is impressive and later into this episode, he reveals some fascinating context on the history of clozapine and the idea of ultra resistant schizophrenia and the future of treatment in schizophrenia. But to bring it back to basics, the primary learning objectives for this episode are as follows. One: to know how to treat a first episode of psychosis of schizophrenia. Two: to understand the important components of maintenance treatment in schizophrenia. Three: to know what treatment resistant schizophrenia is. Four: to know about the application of clozapine in treatment resistant schizophrenia and five: know some of the psychosocial interventions involved in treatment. This episode is based on the 2017 Guidelines for the Pharmacotherapy of Schizophrenia in Adults, which we'll include a link for in the show notes. And I thought I would just highlight a quick summary of some of the recommendations in the guidelines that we discuss.

  Lucy: [00:01:46] Firstly, that antipsychotics should be recommended in first episode of psychosis, and we should use the lowest effective dose. We should consider changing an antipsychotic after four weeks with no response to treatment and after eight weeks with partial response to treatment. Maintenance on an antipsychotic should be at least two years or longer. Treatment resistant schizophrenia is failure of two adequate trials of two different antipsychotics and clozapine should be offered to patients who have treatment resistant schizophrenia. Family intervention should be offered in all cases where patients are in close contact with family. CBT should be offered. Social skills training, life skills training and employment programming are also really important to consider in management. So I'll also preface that we used a case from our earlier episodes, episodes ranging from 9 to 11. I'm not going to repeat the case to you, but briefly, it was about a young man named Muhammed who presented with psychotic symptoms that likely reflected a first episode of schizophrenia. He was brought in by his father after he presented with paranoid ideations and was a risk of harm to his father in the context of his psychotic delusions. He was admitted to hospital for stability, safety and treatment. So we can jump right into the episode. And I basically started to ask Dr. Remington about the treatment guidelines and how it's relevant to the case. So let's get rolling.

  Lucy: [00:03:13] I guess firstly, because we're talking about the schizophrenia treatment guidelines, Dr. Remington maybe you can tell us a little bit about the guidelines first.

  Dr. Remington: [00:03:21] Sure. The guidelines have been available, and certainly they're available through a number of sources now, different guidelines. But here in Canada, they've been available now for at least several decades and they were just updated in the last 12 months. The purpose of the guidelines is really to offer clinicians in the community the most up-to-date evidence-based approach to treating people with psychosis, whether it be schizophrenia or one of the other related diagnostic categories. And they walk us through the various aspects of treatment from the very onset of the illness to individuals who move into more chronic stages. They reflect in part, and when we establish the most recent guidelines, they weren't done absolutely independently. I think as most guidelines are now put together, there's an attempt to look at what's happening across other parts of the world and to ensure that the guidelines are similar in terms of not only intent but practice as much as possible one guideline to the next. So, for example, we looked at the the NICE guidelines as, as a comparator, one of the comparators when we put these together.

  Lucy: [00:04:49] And I guess based on in the context of like understanding what the guidelines are in this specific case, we have, you know, a presentation of a first episode psychosis and is there, so I guess in this context, what would be the approach of treating, of treating this sort of presentation?

  Dr. Remington: [00:05:10] Sure. Well, initially and you touched upon it when you detailed the case, obviously what you want is as much collaborative history as possible. So you have the family involved at this point, and it's critical in terms of trying to establish the background in terms of issues that that may have been identified while the individual was growing up. More recent incidents that may have precipitated this particular set of circumstances, shifts in behaviour that have been identified more recently prior to this particular encounter, other issues that that may be playing a role: trauma, difficulties at school, substance abuse, those sorts of things.

  Lucy: [00:06:08] And I guess like, how would you approach treatment in this context and how would you kind of explain that to a patient and his family?

  Dr. Remington: [00:06:15] Well, always, and I think that's the case in psychiatry in general, what you're trying to do is rule out any sort of medical conditions that might account for this particular behaviour. And so certainly at the outset, I think as we do with many psychiatric conditions, the intent is to try to rule out possible medical diagnoses. Although in fairness, in individuals like this, young people who come into the system, it's been established that very rarely will you find an organic cause for the underlying psychosis. But having said that, you usually go through the various routine investigations to ensure that there aren't other medical conditions that may be accounting for it. Particularly more recently, there is, of course, the need to look at other issues like substance abuse, which has now become much more prevalent in terms of pre-empting the diagnosis of psychosis as well. And it's particularly difficult during this period, which is captured in some of our strategies around diagnosis, because oftentimes in somebody who has a comorbid substance abuse disorder, that it may not be clear for a period of time whether or not it was related to the substances or whether it is a primary psychosis. And in fact, it may never be entirely clear on some occasions.

  Alex: [00:07:53] So it sounds like a urine tox would definitely be part of that initial workup. Can we get into more specifics there? What else would be part of that?

  Dr. Remington: [00:08:01] Well, you do the standard procedures like blood work, liver function, haematology and so on in order to rule out such things as thyroid conditions and so on. But once again, and we actually published work in that area here at the university a number of years ago, for all the tests we do do, very rarely do you find anything that would truly account for the for the condition that we're seeing in front of us. We don't do imaging routinely here, and probably what we don't pay enough attention to and it's becoming more and more evident, is doing a broad-based assessment for other areas of the illness that actually, as a rule, declare themselves before the onset of the psychosis. So we now appreciate that the first episode of psychosis that we see in individuals who perhaps ultimately get the diagnosis of schizophrenia, it's a bit of a misnomer to use the term first. It is the first episode of psychosis, but in fact, it's the end of the illness. The illness is in its final stages at that point, in as much as as there is a lot happened by that time, that is only picked up often through a thorough history.

  Dr. Remington: [00:09:32] So for example, we often see changes in behaviour in the preceding months and years that involve increasing withdrawal, evidence of academic deterioration, social issues, those sorts of things. And when you look at the domains of the illness now, we talk about multiple symptom clusters and the ones that seem to be embedded when the individual comes to us with the first episode of psychosis are cognitive symptoms and negative symptoms. And going back to my point that I made at the outset, there is, I think, a need to better capture the extent of these as quickly as possible because they become the major factors over the longer term in functional recovery. And to that point, I would add that it's critical when you think of an illness like schizophrenia to distinguish between clinical recovery and functional recovery. Routinely, we assume that clinical recovery, and generally speaking clinical recovery is taken in the context of improvement in psychotic symptoms, translates to functional recovery, and that's simply not the case.

  Lucy: [00:10:55] I guess this makes me think of like now DSM-5. They've included this idea of a range in the presentation of like between like schizotypal personality and schizophrenia. And so I wonder where along that spectrum we begin treatment, where in the guidelines is it appropriate to start an antipsychotic?

  Dr. Remington: [00:11:17] And it's an excellent point. It's a point that we struggle with and the major part of the struggle is the hesitancy to intervene with a drug like an antipsychotic in individuals where you can't even be sure that that's what the illness is going to be. And as you're probably aware that we now talk about this so-called prodrome or clinical high-risk period before the onset of the illness, when we can begin to identify features that would suggest that this person may convert to a full-blown psychosis, but even in the best programs, we still only see a conversion rate of 20 at the best, perhaps in the range of 30%. So with that kind of conversion rate, you have to be very cautious about embracing something like an antipsychotic to treat a condition, in particular because with these individuals, it's not as though they're presenting with a first episode psychosis. It's often much more vague than that. It's a loaded history, perhaps with some unusual changes in behaviour or what we call soft positive symptoms, symptoms like magical thinking, those sorts of things.

  Henry: [00:12:44] How do you know? So you have someone who presents with acute psychosis, you treat them with an antipsychotic. How do you know when to stop?

  Dr. Remington: [00:12:53] Well, you raised a very good question. And indeed, that's the first and probably the most important questions that the individuals and families are interested in. Oftentimes, they're even reluctant to take the medication from the outset, but with resolution of the symptoms, as is so often the case in medicine, there's this notion that the illness has been cured and medication is no longer required. As recently as last week, we were talking about that, and indeed, in the guidelines, you will see that a position was stated whereby individuals who have a clear first episode psychosis are it's recommended that they take the antipsychotic medication for at least a year and a half before there's consideration of possibly discontinuing the medication. Having said that, we in the field actually have concerns about that kind of guideline inasmuch as it's a guideline that's very much influenced by what your primary diagnosis is going to be. So your chance of doing well in the absence of medication, i.e. antipsychotic medications, the general figure that you'll hear reported in the literature now is probably in the range of about 20%. And that's the kind of figure where you would say, well, we need to reassess these individuals and ensure that they do need to be on the medication. Having said that, we believe that that if truly the diagnosis of is one of schizophrenia, that it's considerably lower than 20%. Unfortunately, many people diagnosed with a first episode psychosis, though, have a multitude of diagnoses, some of which have a much higher chance of resolution and I think they load that 20% figure that is now talked about in the literature. So there are conditions whereby you should be considering discontinuing the medication because they are powerful medications and they come with a multitude of side effects. If it truly is a diagnosis of schizophrenia, we would suggest that you're probably going to need to take that medication indefinitely.

  Henry: [00:15:17] How do you know if it's schizophrenia or just psychosis?

  Dr. Remington: [00:15:21] Well, unfortunately, and it's in many ways the the most important question. And unlike so many other fields, we have done poorly in the field of psychiatry in terms of identifying biomarkers or endophenotypes that would firmly establish the diagnosis. So to your question, how do we know? We know based on clinical experience. But as I mentioned at the outset, one of the sort of protective factors that we build into this is trying to ensure that we have a period of time to watch individuals before we say with more conviction that this truly is a diagnosis of schizophrenia. But particularly in the first episode, you can see shifts in diagnosis over the first several years in particular. So the person who came in and looked like a schizophrenic individual may end up looking like a bipolar two years later, or vice versa. So time becomes one of the most critical factors in helping to make that distinction.

  Alex: [00:16:26] So this is a lot for even us to think about, but I so I'm trying to put myself in Muhammed's shoes here. How do we explain, assuming this is true schizophrenia or at least at this stage, we have to believe that it is and we want to initiate an antipsychotic, how do we then explain to him the potential need for this to be a lifelong treatment?

  Dr. Remington: [00:16:50] And oftentimes you try not to put that on the table initially. There's so much to take in at that particular stage that I think we're very cautious about making those sorts of ultimatums early in the course of the illness. And of course, it's not just Muhammad that we have to engage, we have to engage the entire family in particular, if we're going to see a buy in to long term care. So I think it's probably not in best interest to say, well, you have schizophrenia, you're on these medications for the rest of your life. I think we start off much more hesitantly saying this looks like a psychotic condition. One of the differential diagnoses could be schizophrenia. We may not know that for a period of time, but we do know that that the cornerstone of treating psychosis is an antipsychotic medication. So at least for the time being, we would advocate for you taking this medication and then with the resolution of the symptoms, we can begin to look at other options as we move forward.

  Lucy: [00:17:59] And I guess that transitions to a question about how do you treat acute presentation of psychosis and how do you transition that into maintenance or kind of treatment as well.

  Dr. Remington: [00:18:10] And there has been a fair degree of change in that area more recently. When I trained as a resident, for example, we were in a period where we were using incredibly high doses of medication with the assumption that more essentially was better. So at that time, the strategy was one of loading people with an antipsychotic medication with doses that were now, as we look back historically, much, much too high. Now we've taken an almost opposite approach and it's very much a start low and go slow strategy for treating acute psychosis. So, notwithstanding those individuals where they may be really acutely psychotic and aggressive, the strategy now may not even be confined to bringing people into hospital. Oftentimes now it's started on an outpatient basis, but the general agreement is that you can use low doses of antipsychotic and increase them. And why I'm saying that is, and we wrote about this a few years ago, what it's meant from the standpoint of maintenance is that at odds with what we used to do historically, which was to load people with high doses and then several months later begin to titrate downwards. In contrast, what we do is titrate up now more slowly. And it's very likely that the kind of dose that you used in people say, who weren't acutely psychotic and requiring high doses to control their behaviour, is that the kind of dose that you attain to establish antipsychotic control in that strategy probably reflects more of the maintenance kind of dose that you're going to need over the longer term. And as a practical example, let's use a drug like risperidone. When we used risperidone, we might have, and indeed when we did the original risperidone trial here in Canada, the highest dose was 16mg. But now what you would see if a drug like that was initiated, you see somebody started at two milligrams, three milligrams, four milligrams wait as long as possible between the different stages of titration and then once the symptoms were resolved, hold that dose. So it would be more common now to see somebody start at two and end up on four milligrams of risperidone than the old strategy of, well, let's give them 16mg of risperidone and work our way down as the psychosis resolves.

  Lucy: [00:20:52] And did this transition happen as a result of adverse sort of events or...

  Dr. Remington: [00:20:56] Well, we certainly had our share of adverse events. There's no question about that. We had a lot of trouble with with acute dystonic reactions and motor movements and so on. But it actually was driven in large part by work, again, done in part here at the centre, which was in the late 1980s and late early 1990s. We finally had the opportunity to begin to evaluate dosing centrally through imaging. Historically, it always had been done based on peripheral kinetics, but with the opportunity to look centrally at the relationship between these drugs, their dose and D2 occupancy, both here at CMH and at the Karolinska in particular, we were begin to we were able to begin to establish what amounted to very concrete thresholds for D2 occupancy and then link those to specific antipsychotic doses. And it was that kind of information that afforded us the opportunity to appreciate that the kinds of doses we've been using historically were just absolutely out of line. So, so when I trained as a resident I'll give you an example, we our starting dose of Haloperidol was ten milligrams. When we did our occupancy work in the early 1990s, we established that two milligrams of haloperidol crosses the threshold for optimal chance for clinical response, which is around 65% D2 occupancy.

  Dr. Remington: [00:22:35] So we had for the very first time again these data that would allow you to take most drugs, not all drugs, but most drugs, and be able to say if you want to reach that kind of occupancy level, here's exactly the kind of dose that you need. And that in turn translated to a dramatic reduction in the doses that were being used on a daily basis for the treatment of individuals. We can't do that with certain drugs. And so, for example, people will say to me, well, what's the correct, we talked about clozapine at the outset, what's the correct dose of clozapine? I can't tell you the correct dose of clozapine. I can't tell you the correct dose of aripiprazole and I can't tell you the correct dose of quetiapine for different reasons. Clozapine and quetiapine because of their kinetics in terms of K off and aripiprazole because of its partial D2 agonism. But notwithstanding those three drugs, we could literally scan somebody and we have done that with most of the drugs and tell you what the proper dose of an antipsychotic is to optimise clinical improvement.

  Henry: [00:23:51] So let's say we started Muhammad on a smaller dose of some sort of antipsychotic. When do we decide that that antipsychotic is not working for him?

  Dr. Remington: [00:24:00] Good question. And we have to acknowledge that that decision making is being influenced now by the pressures of moving people through. So in 1994, I had a discussion with Pat McGorry, who started the first first-episode program in the world in in Melbourne, and his comment to me when we were talking about our PET data was I'm going to start somebody on two milligrams of risperidone and keep them on it for 30 days. And of course in the best of all worlds, that's probably not a bad strategy if there's no reason to increase the dose. But but in fact, that's not possible in acute care settings as a rule any longer and you don't need 30 days in order to establish whether or not a drug is working or not as a rule. In fact, some of the work, again done out of this particular centre has identified that in the case of antipsychotics, about 50% of the improvement that you see in antipsychotics occurs within the first 7 to 14 days of treatment. So the current recommendation and I think it was based embraced in the guidelines was that you look to whether or not you're getting a response in the first four weeks at a reasonable dose. And if that isn't evident and there's a partial response, you may choose to continue it for another four weeks at least, in order to establish whether that drug is going to work or not. Whereas if you're not seeing any response at four weeks, you're probably very likely not going to see a response with that medication and you might as well move on. Indeed, arguably, you should be moving on and we've not done that very well in past years. And the reason why it's so important to move as efficiently and systematically as possible is the data that suggests that duration of untreated psychosis is associated with poor outcomes. So clearly, you want to get from point A to B in a timely fashion.

  Henry: [00:26:20] So say the medication didn't work at all four weeks in, do we, so we switch to another antipsychotic in the same class? Different class?

  Dr. Remington: [00:26:31] Well, you raise a good point. The classes are not near as clear as when I was working as a as a resident. But you certainly switch to another medication, and most of them are of different classes, depending upon which way you want to define class. But when we published our data, looking at the first two trials before clozapine, we arbitrarily looked at two medications in particular, risperidone and olanzapine. And what you choose should be done in discussion with the individual who you're treating and discussion of the side effects that may occur with a particular drug and what they would hope to avoid and what they're willing to tolerate and so on. So, for example, an olanzapine-like drug, of course, carries a very high load in terms of metabolic side effects, whereas risperidone may be better in that regard, but carries a greater propensity for movement disorders.

  Alex: [00:27:40] So taking this to, I think maybe its natural conclusion, if now we try Muhammed on a second antipsychotic and that doesn't work for him, what do we do now? I mean, I think we learned after two adequate trials, we try clozapine now because that's treatment resistant schizophrenia. But can we be very specific about what exactly is treatment resistant schizophrenia, because we don't, what does that mean in terms of the dose of antipsychotic and how long and...

  Dr. Remington: [00:28:07] Sure. And treatment resistant schizophrenia really evolved through the 1980s, and it arose out of the recognition that these drugs, which were supposed to be a panacea, in fact, weren't. And so by the 1980s, it became clearly evident that there was a significant proportion of individuals with schizophrenia, in the range of about 30%, who weren't responding to the antipsychotics that we had in hand. Now, by the late 1980s, the seminal work with clozapine was done, and it identified that for those individuals, individuals who had failed two adequate trials of antipsychotics, of the other antipsychotics that is, in and adequate in terms of both duration and dose, then they would be deemed treatment resistant and candidates for clozapine. And we actually had data that came out of some of the work done here that allowed us to sit down and talk figures with individuals. So we knew that when somebody had their first break and they were treated with an antipsychotic, that roughly 60 to 75% of those individuals would respond to drug A. Now, if they didn't respond to drug A, regardless of what drug you chose for trial two, your chances of getting a response dropped from that 60 to 75% down to 15 to 20%.

  Dr. Remington: [00:29:44] So we saw this precipitous decline in treatment response. But still, the guidelines are that you don't use clozapine until there's been two adequate trials if they can be tolerated. So we do advocate and I would argue that families, if they were told, well, here's clozapine as your second line treatment or here's another drug, and we can tell you in another 4 to 8 weeks whether or not that drug is going to work, they would probably choose to have the second drug trial before they moved to clozapine. But that said, if in fact you don't respond to that second antipsychotic and of course the odds are relatively low, because you only have about a 15 or 20% chance of responding to drug two, then certainly your odds for response to clozapine, now having met the criteria for treatment resistance escalate considerably. So your chance of responding to clozapine for that third trial would be in the range of about 40 to 50%. In contrast, where if you reached for a third non clozapine drug, the data would suggest that your chance of response with that third agent non-clozapine drug is probably less than 10%.

  Lucy: [00:31:09] Can you tell us a little bit about what like how why clozapine is so special or maybe a little bit about the story of clozapine?

  Dr. Remington: [00:31:18] Clozapine is a very interesting drug. I like history. So I'm going to bore you with just a bit of history.

  Lucy: [00:31:23] Oh, we love it, too.

  Dr. Remington: [00:31:24] Oh, good. Because. Because, in fact, having done a PhD in pharmacology and been in this field for a long period of time, I was trained that it was the hypothetical deductive strategy that would move us along in the field. But in fact, that hasn't worked in the field of psychiatry and clozapine is a perfect example of that. So indeed, the whole history of antipsychotics is a perfect example of that. So chlorpromazine, which was the first antipsychotic available to us, was never synthesised to be an antipsychotic, it was to be a pre-surgical anaesthetic synthesised in 1948 and 1949 serendipitously found to have antipsychotic properties and in 1952/1953 part of the work being done here in in Montreal was what took it to be established as an antipsychotic. Now clozapine has a similar story. Clozapine was synthesised in 1959, was supposed to be a tricyclic antidepressant and through various sorts of circumstances ended up being identified as an antipsychotic by the 1960s and was unique not because they had identified that it was a drug that worked with TRS, it was unique because it didn't invoke EPS at therapeutic doses. It was fast tracked and released in a small group of Scandinavian countries in the early 1980s and a cluster of people died within the first year following its release, later to be established secondary to Agranulocytosis. And it was for that reason that that almost all countries in the world chose to withdraw clozapine at that point.

  Dr. Remington: [00:33:20] But seminal work done in the 1980s, looking at clozapine in those who failed other antipsychotics, allowed it to be resurrected in a lot of countries like Canada and the United States again, with strict guidelines in place that this would be the only population that it would be used in: people who had failed, as the criteria were established, two antipsychotic trials of adequate duration and dose or intolerable side effects that pre-empted adequate trials. So it was reintroduced here in North America in the early 1990s and revolutionised the field because for the very first time we had a drug that was different from all other drugs. But having said that, and I get this question asked of me all the time is, is to your point is clozapine a unique drug in schizophrenia? No, it's not a unique drug in terms of, I don't believe and I don't think the evidence supports that that clozapine will work better in first episode schizophrenia, where it works better is in treatment resistant schizophrenia. Now why would it work better in treatment in first episode schizophrenia is we now have data indicate that roughly 85% of treatment resistant schizophrenia walks through the door with a first episode psychosis. So so people don't evolve into treatment resistance the way we often conjure up that that term, a small percentage of them do but in fact, most people have treatment resistant schizophrenia when they walk through the door with a first episode psychosis. We don't have any biomarkers or endophenotypes to identify them. So as a result, we give them our two trials and then finally say you must have treatment resistant schizophrenia and we should put you on clozapine. And so for those individuals, I would like to see them at first episode get schizophrenia, but we struggle on two levels. One is, as of yet, we can't find biomarkers or endophenotypes that would clearly say you should be on clozapine from the outset because you have a treatment resistant form of the illness. And secondly, we clozapine is of the old sort of phenothiazine type of medication. It's a very heterogeneous receptor binding compound and to try to dissect what accounts for it's unique profile in the treatment resistant population has proven incredibly difficult. And to this day, we still have no idea why clozapine is effective in people with treatment resistance. Now, I should tell you, do I get to still talk for a minute? Okay. So we now recognise that only about 50% of those people who we identified as treatment resistant are going to respond to clozapine. So in the early 2000s somebody, in Montreal interestingly, coined the term ultra resistant schizophrenia and set up some criteria which we have since modified in a paper subsequently but we now recognise that in those who meet criteria for TRS, only about 50% of them will respond to clozapine, a figure that's made worse by the fact that many people will choose not to take clozapine. And if you have TRS and you choose not to take clozapine, again you're running with less than a 1 in 10 chance of responding to whatever antipsychotic they give you. But in terms of the clozapine resistant population or, what Mouaffak chose to call ultra resistant schizophrenia, it's those who now I focus on with most of my time in research because they are the group for which we have no treatment whatsoever. So for all the work that we've done, looking at what should be implemented after clozapine, and you see it in our Canadian guidelines, we actually drew a line in the sand. I think we were the first guideline to do that and we indicated that we would not make any recommendations for what to do after somebody failed clozapine and it was based on the recognition that for all the drugs that have been tried, none, including ECT, which probably ranks up there as one of the better options, has got enough data to say with conviction that there's enough evidence-based research to support moving the treatment algorithm beyond clozapine at this point.

  Alex: [00:38:27] So there's not enough evidence from a guideline perspective to make clear recommendations there. But as a clinician who probably encounters that, what do you do to the ultra treatment resistant patient? What do you do for them? Typically.

  Dr. Remington: [00:38:44] There's endless numbers of strategies, what almost all people do, because it just seems so intuitively correct, is that they try to augment with another antipsychotic. This idea that, well, clozapine doesn't have a lot of high affinity D2, so let's give them a D2, a potent D2 blocker like haloperidol or risperidone in combination or so on and so forth. But indeed, if you look at that, which is by far and away the most common strategy to try to treat clozapine partial responsiveness, there's no evidence whatsoever that adding another and it just it just keeps going on and on because we've tried so many different strategies: mood stabilisers, antidepressants, even glutamatergic compounds. Indeed, if you take a glutamatergic compound and you give it in addition to clozapine, there's often evidence of clinical worsening, interestingly. So we still struggle and unfortunately we haven't, I think we've obfuscated the issue by suggesting that you can do this, this and this after clozapine, when we should have been a bit more frank and honest and said there really isn't any evidence and we need to be devoting a lot more resources to what do I do when Clozapine fails from a research standpoint. So at the very least, we don't expose people to all these trials of compounds that clearly have no evidence for working. Interesting, I mentioned the ECT story. Very nice paper came out of New York in 2014 indicating that ECT might be a useful strategy in people with clozapine partial response but having said that there is only the one RCT to this point and that's probably enough, not enough and that was our position when we put the guidelines together to advocate, well, this is compelling evidence that ECT should be your treatment of choice.

  Lucy: [00:40:54] Do you think in ten years that that's like in terms of ultra resistance, like ECT is going to be a part of the guidelines?

  Dr. Remington: [00:41:01] I certainly could imagine if somebody could replicate that particular trial. As you can imagine how difficult it is to do a blinded, controlled trial with ECT in a clozapine partially responsive individual. But having said that, that's the kind of evidence we need. Or conversely, we need serendipity once again to step in and I think that's probably how the next major breakthrough will occur in terms of moving us beyond clozapine. It won't be through a hypothetical deductive strategy. It'll be somebody, by chance, tries something that doesn't really make sense, but translates to opening up a door that we just didn't know existed.

  Lucy: [00:41:48] And I guess pragmatically, from your clinical practice, how likely is it that a patient stays on clozapine once they've started?

  Dr. Remington: [00:41:56] Oh I just found out some data on that in the last month. So about half of people will stop clozapine in the first 12 months after they're started. So many people refuse clozapine and unfortunately, in many ways that's a kiss of death inasmuch as we just don't have another drug that's clozapine-like. We have olanzapine, interestingly, which was shown in the Catie trial and which was shown in a couple of other projects to maybe be the next best choice. And there was a nice blinded study done with olanzapine 30mg suggesting it might be an option for people who say no, I don't want to take the clozapine. But beyond that, we really don't have any other options for the clozapine story. So for those who say, no, I don't think then what we do as clinicians is, because we are in the business of selling hope and trying to give people every opportunity to improve, is we generally do move through all these hoping that at least you'll have that maybe 1 in 10 chance of responding to a drug that that they haven't yet been tried on. So generally what we advocate is that if you want to continue with strategies in a person who's proven to be clozapine partially responsive or chooses not to take clozapine, that at the very least you be cautious. So what you do is you you choose a drug based on what existing evidence there might be and then circumscribe the trial. That is, make the trial 12 weeks. But rather than just leave that drug hanging, as we so often do in this population so that they end up on 4 or 5 different medications, instead what you do is you quantify outcome. So we strongly advocate using scales rather than just your personal judgement as to whether that added drug helped and then at three months, if there's no compelling evidence to indicate that it's improved, then discontinue it and move to the next trial. I would also point out that when I'm talking about this, I'm talking about psychosis and I underscore that because I'd said earlier on that clinical recovery and functional recovery are independent of each other. And I say that because we only have a drug for one domain in this illness and it's the positive symptoms. So our drugs are antipsychotics, they're not anti-schizophrenia drugs. So we get the people better in terms of their psychosis but what we don't see is that translate to functional recovery. So they follow independent courses and the thinking is that even with resolution of the positive symptoms, the rate limiting steps that account for why functional recovery doesn't fall on the heels of the improvement in psychosis is that you have these other domains, the negative symptoms and the cognitive symptoms that aren't treated by the current medications that we have available. And consequently the individual, because of the resolution of positive symptoms, isn't in the same position to return to their level of functioning that they saw before the onset of the illness.

  Alex: [00:45:38] I don't know if this exactly segues because I don't know the answer to this but do we have, outside of medications, treatment for those functional outcomes, like do our psychosocial treatments, do they touch on that? Can we touch on those topics, how they work?

  Dr. Remington: [00:45:53] Sure. And I will say I'm not the resident expert in non pharmacology, so I start by that caveat. But obviously we've always needed to look for strategies that would take us beyond just medications and you see it in the most recent guidelines, now embedded in the guidelines now are CBT, for example, they're in the NICE guidelines they're in our guidelines. And we recognise that a lot can be done with non-pharmacological strategies and certainly in terms of strategies to help deal with the trauma of having this illness, trying to work with the symptoms that might persist and understanding the illness, an intervention like CBT can be extremely useful. The psychoeducation for the family, ensuring that the families involved, because one of the problems we struggle with is that many individuals, it's just so hard for them and their families to embrace the illness that as soon as we see resolution of the symptoms, there's talk of discontinuing the medication and not requiring further treatment. Supported employment from the standpoint of functioning, for example, is proving to be probably more effective than many of the old rehab strategies that we embraced for a number of years. So there's increasing evidence that and efforts, I think, to look at more innovative strategies that would allow us to improve in these other areas that take us well beyond the medication. Because, again, the medications have not been useful at all. It's not that they don't effect some changes, but the magnitude of the effect size is so modest that it doesn't translate to clinical improvement or functional improvement, as the case may be. So you can imagine, as is the case, that there's lots of interest in coming up with now new classes of medications that would address the cognitive symptoms and the negative symptoms. But at the same time, those are the kinds of domains that can very likely be enhanced with non-pharmacological strategies as well.

  Alex: [00:48:22] Right. So there's no medication that will increase your likelihood of finding a job but if you help someone out with supportive employment, you can potentially increase their level of functioning.

  Dr. Remington: [00:48:33] And indeed, you know, we now, even with cognition, for example, we used to just talk about cognition and in fact, when I trained as a resident, we didn't even bother talking about cognition. We only talked about positive symptoms. But then along came this concept called cognition and by 1990s, it really had gained legs in terms of its potential impact on the illness. Well, even subsequent to that, we now have that further subdivided into neurocognition and social cognition and that opens the door for not only developing unique strategies that are specific to improving people's neurocognitive abilities, executive function, verbal recall, those sorts of things, but we're also now much more sensitive to some of the social cognitive deficits that people struggle with, that are seen from a clinical standpoint in the form of symptoms like social withdrawal, anxiety, social anxiety, those sorts of things. So we have a number of doors now open to opportunities for non-pharmacological strategies that can hone in on these other domains.

  Alex: [00:49:53] Right, it's not just about medications, it's about building our other resources, psychotherapy, CBT and family interventions and all of that is part of the treatment as well. Up until now, we've spoken about this as if Muhammad is nodding his head to all of these treatments and agreeing. But I think we all know around the table that with schizophrenia often comes a lack of insight into the illness itself. These patients can often not realise what's going on or not be agreeable to starting a treatment. How do we help someone who is not having much insight into their illness?

  Dr. Remington: [00:50:35] Again, we certainly want to keep the families involved as much as possible. I don't think there's a single instrument that's as powerful as having the family on board in terms of of trying to to engage individuals. And then, of course, education around what this illness is, and it's such a foreign concept to most individuals, the whole idea of hearing voices or believing that people in the next room are talking about you, those sorts of concepts, it really requires a lot of education around two things. One is the symptoms that constitute this illness and the symptoms that take us certainly beyond the psychosis per se, but also the stigma of the illness. So for all the gains that we've made in mental health, and you can see just how far we've come in the last ten years with major industry embracing support for mental health and so on, we still have not made robust gains in the area of serious mental health issues like schizophrenia. It's still an illness that's stigmatised. It's stigmatised in the literature, it's stigmatised in social media and the movies. And so we have a considerable ways to go in terms of destigmatizing it for individuals who have the illness and for their families and supports as well. So there's a lot of work that needs to be done in that area. But to your point, and it's an excellent one, many people who, and it takes us back to something we talked about at the outset, as soon as their symptoms resolve, the next point to be made is, well, I don't need these medications anymore. And unfortunately, the reality clinically is that you will have to see people through perhaps several episodes or relapses where they've chosen to stop their treatment before they recognise that, from a cost benefit standpoint, they're probably much better off taking the medication. And again, we've tried to to certainly be more comprehensive in offering treatment beyond medication and in addition to that, be much less confrontive around the medication in terms of, you know, the history of using excessively high doses and multiple medications and so on.

  Alex: [00:53:22] I know we're a little over time here. I don't know if we have time for one more question or...

  Lucy: [00:53:30] So concluding question?

  Lucy: [00:53:32] Yeah I guess there's been a lot of public discourse now in the domain of like the effectiveness of antidepressants in treating depression and like it's been on the agenda recently. And I'm wondering what your stance is on antipsychotics and schizophrenia, kind of like one concluding statement about that and then maybe transitioning that to your thoughts about the future of treatment of schizophrenia and what that would potentially look like.

  Dr. Remington: [00:54:00] I would argue that the evidence remains compelling that antipsychotics work for psychosis. But having said that, I would also, touching upon several points we made in this talk, would argue that the current antipsychotics we have falls short of treating the full forms of the illness that we now recognise. I would conclude by saying that schizophrenia is not a single illness. It's a heterogeneous group of disorders that require different treatments and that I think going forward the next big breakthrough that we have will be very much a personalised medicine sort of strategy whereby we acknowledge that there are these different forms of illness, and this is actually where we spend a lot of our time now, and that if we had the capacity, as we do in other areas of medicine, to say, well, this is the form of cancer you have or this is the form of illness you have, that we will do much better in terms of overall outcome by being able to say, well, schizophrenia is not a single entity. You have this type of psychosis and this seems to be the best strategy for this type of psychosis as compared to that or so on. So to your point around the drugs we have, dopamine blocking drugs, which is the prototype of an antipsychotic work for one form of the illness. But we clearly have other forms of the illness that require other strategies, clozapine-responsive patients being one such example. And then those who fall in the non-clozapine response population have to have a different underlying pathophysiology, just by definition.

  Lucy: [00:55:49] Any kind of advice that you have for future sort of potential medical students interested in the field of psychiatry and maybe convincing Henry to go into psychiatry. And what's so special about the practice for you?

  Dr. Remington: [00:56:01] Well, psychiatry in and of itself kind of interested me but schizophrenia interested me a lot. And so I would argue that this isn't, psychiatry is incredibly fascinating, but schizophrenia is even a notch above. I would advocate strongly that if you have an interest in psychiatry, test the waters with schizophrenia and see it, it's so interesting on so many different levels and it's such a disenfranchised population.

  Alex: [00:56:33] Well, thank you so much, Dr. Remington, for sharing your interest and passion about schizophrenia with us and our audience. It was quite the tour, all the way from chlorpromazine, clozapine up until the future, what the future holds in terms of maybe individualising these treatments and not thinking just about the antipsychotics, but also thinking about the other ways we can help people with schizophrenia. I think it was terrific. So thank you so much for being with us today.

  Lucy: [00:57:00] Thank you so much. Thanks.

  Lucy: [00:57:02] Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. This episode was produced and hosted by Lucy Chen, Alex Rabin and Henry Barron. Our theme song is Working Solutions by Olive Musique. A special thanks to the incredible Dr. Gary Remington for serving as our expert for this episode. You can contact us at info@psychedpodcast.com or visit us at psychedpodcast.org. Thank you very much for listening!

Episode 26: Nutritional Psychiatry with Dr. Laura Lachance

PsychEd Episode 26 - Nutritional Psychiatry with Dr. Laura LaChance.mp3: Audio automatically transcribed by Sonix

PsychEd Episode 26 - Nutritional Psychiatry with Dr. Laura LaChance.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Alex Raben:
Hey, listeners, it's Alex here. I just wanted to say how excited we are to have our very first episode coming out of Montreal. This episode on nutritional psychiatry was led by Sarah Hanafi. Sarah works tirelessly behind the scenes as our head of research, and we really appreciate all she does for PsychEd. I hope you'll learn as much about this important and often neglected topic in psychiatry as I did. Enjoy.

Sarah Hanafi:
Welcome to PsychEd, the Educational Psychiatry Podcast for Medical Learners by Medical Learners. In today's episode, we're going to be covering the topic of nutritional psychiatry. My name is Sarah Hanafi and I'm a PGY2 in psychiatry at McGill University. We're very happy to be joined today by Dr. Laura LaChance, who is a psychiatrist at Saint Mary's Hospital here in Montreal.

Nima Nahiddi:
My name is Nima Nahiddi, and I'm also a Pgy2 psychiatry resident at McGill University.

Gray Meckling:
And my name is Gray Meckling, and I'm a third-year medical student at University of Toronto.

Sarah Hanafi:
By the end of this episode, we're hoping that you'll be able to have a better understanding of how we define nutritional psychiatry, that you also develop an understanding of the mechanisms, common misconceptions, challenges and current evidence supporting the role for nutrition in mental health and finally, that you'll be able to apply this understanding to clinical cases in psychiatry.

Nima Nahiddi:
So to start off, Dr. LaChance, we're so happy you can be here with us, although here is virtually. Can you let us know a bit about your professional background before we start?

Dr Laura LaChance:
Sure. So thanks so much, guys, for having me on the podcast today. And you know, I know we were having some scheduling difficulties and Covid obviously didn't help and at a certain point you just need to get on with learning activities, so I'm glad we're able to make this happen. So I'm a psychiatrist. I work at Saint Mary's Hospital, which is a McGill affiliated hospital in Montreal, and my clinical practice right now is in general psychiatry, so I work with patients in the emergency room and the outpatient clinic. I'm also newly the director of outpatient psychiatry here at Saint Mary's and the my focus right now is actually on working in the Mental Health Crisis Clinic so I work with a lot of transitional aged youth in particular through that clinic. So that's kind of what I'm doing now clinically. Um, you know, where does that place me in relation to nutritional psychiatry? So this is my research interest. I graduated from the University of Toronto in 2017 residency program in psychiatry and, as part of my residency I did a fellowship, a research fellowship in the social determinants of mental health and there I focused on nutrition and food insecurity as determinants of mental health. And so that kind of, you know, early on informed my research interest in the field. And I've been doing research in this field since about 2012, I would say. Um, so yeah, I guess we'll get more into specifics. Um, but I'll just add, I'm also doing my Masters in psychiatry right now, so I kind of have a few different hats that I'm wearing.

Gray Meckling:
Okay. Thank you so much, Dr. LaChance, for sharing some of your background. So I think to jump things off in the episode, we're going to just ask if you could define nutritional psychiatry for our listeners.

Dr Laura LaChance:
Yeah, it's a good question and there are a bunch of different definitions floating around if you Google it. So what I choose, the definition that I choose to stick with is nutritional psychiatry is basically integrating nutritional approaches into both the prevention and the treatment of mental disorders and their comorbidities.

Gray Meckling:
Okay. And so that's one question that I had starting this episode, was whether or not the nutritional interventions are really just looking at the mental health disorders or if they're also addressing things like metabolic syndrome that can happen to people who have mental health diagnoses.

Dr Laura LaChance:
I mean, I think it's both because, you know, you're obviously going to have some side effects, quote unquote, of your nutritional interventions, which are going to be impacts on physical health as well. And we know that our patient population has high rates of metabolic illness, cardiovascular illness, so you can't really separate the two.

Gray Meckling:
Yeah. And so being a medical student, this was definitely a new field of psychiatry that I've just been exposed to. Could you maybe walk us through sort of the origin or the history of nutritional psychiatry as a field?

Dr Laura LaChance:
Um, well, I mean, it's interesting because we think that nutritional psychiatry is this new field and, you know, the whole kind of concept of food as medicine is getting a lot of attention and, you know, all the health blogs in the general population and obviously in scientific research as well. And um, when you look at the scientific literature, there are actually a ton, there's been a ton of research in nutritional psychiatry kind of even predating our medications. So I did a meta-analysis of, um, biomarkers of gluten sensitivity in individuals with schizophrenia in 2014 and the reason I mentioned that is because there were research papers where psychiatrists were looking at biomarkers of gluten sensitivity in that patient population schizophrenia back in the 1960s. And so like, you know, they had randomised controlled trials in the, in the standards that were, you know, typical of research at the time where they randomised one psychiatry inpatient unit to a gluten free and a casein free, which is the milk protein, one of the milk proteins that's most likely to cause an allergic reaction. So they had milk free, wheat free, um, wards versus wards that got just like the regular control diet and then they measured psychiatric symptoms and time to discharge, yeah and this is the 60s. And you know, another example would be like Orthomolecular psychiatry, which I couldn't actually put a date on that but the person who most closely comes to mind is Linus Pauling and high doses of vitamin C to treat a number of conditions, including psychiatric conditions. And this is all, you know, really, these are all really old ideas. And so I think nutritional psychiatry was actually popular, um, you know, more than 50 years ago, but is now seeing a resurgence really in the last ten years or so I would say.

Sarah Hanafi:
It's really helpful to hear that background and get a better sense of what, where or where this field has kind of come from in the past few decades. Um, you know, I know for myself, I've heard of terms like inflammation and the immune system is, is possibly explaining some of the link between mental health and nutrition as well as concepts like oxidative stress and the microbiome gut brain axis. I'm wondering if maybe you could touch briefly on some of the mechanisms we're starting to think are involved in the relationship between nutrition and mental health.

Dr Laura LaChance:
For sure, and I'll try my best to be brief on these because each one could be, you know, a podcast in and of itself. So when we think about the different mechanisms that underlie the links between nutrition and mental health, before we get into it, I just want to emphasise that it's a bidirectional relationship. So, you know, we're talking today about how nutrition can impact mental health, but obviously the reverse is also a very important relationship to consider, so how having a mental disorder or your mental health can impact your nutrition. And so kind of taking a step back, like thinking about things like food insecurity, how mental health disorders can impact, you know, appetite, how our psychiatric medications can impact appetite and how that impacts eating behaviour. You know, obviously eating disorders is kind of a separate entity that's beyond the scope of today but so just kind of before we get into the science, looking at, you know, nutrition impacting mental health, just recognising that this is obviously complex and bidirectional.

Dr Laura LaChance:
Um, but so with that, so thinking about mechanisms, so inflammation is certainly one of the, one of the important mechanisms, explaining how nutrition can impact mental health and inflammation is an area of research in psychiatry that's gaining a lot of traction recently. So, you know, a number of meta-analyses have found that there are heightened number, heightened levels of peripheral biomarkers of inflammation, so things like inflammatory cytokines, um, interleukins, TNFs, CRP, you know, those types of molecules in bipolar disorder, in depression unipolar in schizophrenia and we also know that, you know, when we think about the comorbidities that our patients often are diagnosed with like metabolic disorders, cardiovascular disorders, we know that inflammation plays a role there, too. So this is a really important topic and I think for today we're interested in understanding what does diet have to do with this. So try to kind of break it down. So we know there are certain foods or dietary factors that tend to promote inflammation, so those are things like refined carbohydrates, ultra processed foods and also sugar. There are also dietary factors that tend to reduce inflammation so things like vegetables, fruits, fibre, so legumes are examples of sorts of sources of fibre, whole grains, healthy fats like omega-3s or monounsaturated fats and also fermented foods. And so when I'm describing kind of the factors that tend to either promote inflammation or reduce inflammation, I'm describing a dietary pattern that maps pretty closely onto the Mediterranean diet. And, you know, it hasn't been shown yet in psychiatric populations. But if looking at other clinical populations, there's a recent meta-analysis of 50 experimental studies that found that Mediterranean diet can reduce biomarkers of inflammation. So, you know, that's kind of one way of thinking about it as from like a dietary pattern perspective.

Dr Laura LaChance:
We can also break it down so we can look at, for instance, the balance of omega-6 and omega-3 in the diet. So those are two types of fatty acids that are they make up a minority of the amount of total fat that we eat. But in recent years with, you know, how agriculture and the food processing industry has changed, we've seen really major shifts in the amount of relative omega-6 and omega-3 that we consume today relative to 100 years ago. And omega-6 fatty acids tend to be pro-inflammatory, whereas omega-3s are anti-inflammatory. So that kind of imbalance that we see in the diet is another way that diet ties to inflammation. And then the microbiome is implicated there too but I think I'll save that for a bit later.

Sarah Hanafi:
Fair enough.

Dr Laura LaChance:
So yeah, because we'll get to that. There's a lot of overlap.

Nima Nahiddi:
It's really fascinating, this idea of the bidirectionality between, you know, nutrition and then some of, you know, implications of mental health. Do you think that there's common misconceptions about things that are happening in, you know, mental health and the role that nutrition can have? Maybe things that are in the media or things that physicians might think of that could be common misconceptions?

Dr Laura LaChance:
Yeah. So the first misconception that comes to mind is the idea that mental health and nutrition are not related, or that somehow nutrition is not important for mental health. And I'm obviously an early career psychiatrist, but I would say earlier in my career, that's the one that I was really pushing up against. And so every time I would give talks or presentations or whatever, it was always kind of like, you know, newsflash, nutrition is important for mental health, whereas now I find that's already become, um, you know, sort of accepted, at least relative to where things were about five years ago. Um, so I'm happy that there's a growing recognition now that food is medicine and that psychiatry is part of medicine, so that one is a little bit less relevant. What I'm seeing a lot now in terms of misconceptions is this idea around helping psychiatric patients to change their diet is not feasible, in some way, or that it's futile. You know, there's always something else that's higher priority than talking about diet and so I have some thoughts about about that if you guys are interested.

Nima Nahiddi:
Yeah. What is it that that you think is the greatest barrier?

Dr Laura LaChance:
Well, I mean, we know that nutrition is not a huge part of medical training. So there's definitely a piece around lack of knowledge, um, for like perceived lack of knowledge for health care providers. But I don't think you need to have a graduate degree in nutrition to be able to counsel your patients on diet because, you know, we all prepare food for ourselves and eat every day. Um, so, you know, I think it, I think it's more like some kind of barrier that, that we've put up based on, um, you know, what our comfort level is or what like we learned from observing other clinicians. So, you know, other clinicians aren't talking about food, so, so we shouldn't like, I don't, I don't think that there's, um, I don't think it's anything really more complicated than that. And, you know, I see that we talk to our patients about all kinds of stuff. We talk about substance use, we talk about, you know, finances, their innermost private thoughts, past trauma, their sexuality, you know, everything. And so why why would it not be appropriate to also talk about food?

Dr Laura LaChance:
And then, you know, when you think about who is best suited to help psychiatric patients to make these often basic changes in their diet, I think we actually, as mental health professionals, have a lot of tools at our disposal to help our patients make behaviour change because, you know, that's what we do, whether it's sleep hygiene, taking medication, you know, engaging in psychotherapy. Um, so I mean, I think we're actually well suited and, you know, often patients are coming to us with like, okay, well what can I do to take care of myself at this early stage while I'm waiting for the medication to take effect? Or families are asking us, what can I do to support my loved one who's struggling with depression? Well, I think actually preparing healthy food for yourself or your family member is something tangible that we can do that gives some direction to families and patients. And I think we have to remember that these interventions are also very safe. So, you know, I talked earlier about side effects of dietary interventions being possibly improved physical health. And so, yeah, I think we need to kind of take that into consideration as well as we're like, you know, waiting for the perfect research to to guide us in terms of making recommendations for our patients.

Nima Nahiddi:
And being mental health professionals, do you have or can you discuss a bit about some of the research and some of the evidence supporting the role of nutrition in the management of psychiatric illnesses?

Dr Laura LaChance:
Yeah. So, um so I think it makes sense to probably focus a little bit here just because it's hard to give like a broad overview of everything. But if I take depression for an example, which is a condition that like anyone's going to treat, and it's also the condition that has the most advanced literature in terms of nutritional psychiatry. So depression, so there's at least three randomised controlled trials now of dietary interventions in depression, like clinically significant major depressive disorder, and they're all a little bit different. So one was an individual intervention of a mediterranean diet. One was a group intervention of a mediterranean diet with supplemental omega-3, and the other was basically a video with two five-minute follow up phone calls and some information on FAQs and like tips and recipes. And all three of those studies found that the Mediterranean diet, as compared to a control intervention, significantly reduced depressive symptoms. And so these are these are add-on treatments, I think that's an important point that you know nobody's recommending that you don't offer you know the gold standard treatments that we have but it's just like something benefit something additionally that's beneficial because we don't like you know we don't have 100% remission rate for depression with our current treatments.

Nima Nahiddi:
And as you said, the side effects, the side effects are or can be safe when it comes to nutritional interventions.

Dr Laura LaChance:
Yeah, exactly and another sort of piece of literature, so there's, there's been a shift in the field where initially there was a lot more emphasis on studying individual nutrients or individual foods. And then in recent years, to say the last ten years or so, people have been talking a lot more in the literature about dietary patterns and understanding which dietary patterns can either increase risk or decrease risk of depression or be used as treatment. And so a couple of years ago, probably for I don't know, honestly, I think was in PGY2 when I first came up with this idea, um I was wondering okay, so there are these dietary patterns which seem to be helpful for depression, but what are the actual active ingredients here? Like, if somebody wanted to actually design a diet that was going to promote recovery from depression, what foods would be included in that? So I partnered with Dr. Drew Ramsey, who's a nutritional psychiatrist in New York and runs the brain food clinic there, and we conducted a literature review to identify what are the, what are the, we call them "antidepressant nutrients", so which nutrients have the highest level of evidence to support their role in either prevention or treatment of depression? And then we took this list of antidepressant nutrients, and we applied a nutrient density formula and then tried to identify what are the foods that actually have the highest nutrient density of these antidepressant nutrients. And we looked at individual foods, we looked at food categories and the findings were super interesting to me because the foods that came up on top were, you know, leafy greens, seafood, organ meats, other vegetables, fruits and it was really foods that are highly prevalent in traditional diets from a number of different cultures, but certainly foods that are not common in the Western diet. So it was like another, you know, kind of coming at it from coming at the question from a completely different angle and then finding the same answer.

Nima Nahiddi:
And so do you think with the dietary patterns, you know, we should be looking into making new diets with these types of foods in them?

Dr Laura LaChance:
Well, not necessarily. I mean, I think what's interesting about the findings is that I think that they could be like the foods that came up on top could be integrated into any dietary pattern that that's fitting with your culture and preferences. So, you know, like seafood came up on top, for instance and like, depending on what your culture is and what your preference is, you could choose different kinds of seafood. I mean, you know within reason, I think it's I think it's reasonable to sort of shift towards, you know, maybe a certain food that may have a higher nutrient density than another, but I don't think anybody, you know, I think compliance would be a problem if you if you try to be too prescriptive with any diet.

Nima Nahiddi:
Yeah, I can imagine that that would be it would be difficult. Compliance would be difficult with any diet and I think we see that in with a lot of different people. Um, do you have any, any evidence about you talked about omega-3 versus omega-6. Have there been any, any evidence or any studies about those and their roles in the management of mental health disorders?

Dr Laura LaChance:
Mhm. So, um Omega-3s so again, there's probably the most literature in, in depression, although there's a decent smattering of literature in schizophrenia as well, although probably a bit more controversial. So in depression, if you look to the most recent CANMAT guidelines,so C-A-N-M-A-T, which are the guidelines that we typically refer to in Canada to um, you know, guide us in terms of treating depression, omega-3s are listed there as second line evidence, as either monotherapy or as adjunctive therapy. Um, and the International Society for Nutrition and Psychiatry Researchers published in September 2019 a series of specific guidelines for using omega-3s in depression. So basically what's been shown is that for both bipolar depression and unipolar depression, there's there's multiple, you know, 15 plus RCTs to support use of omega-3s as adjunctive treatment. If you have mild depression, you can start with just omega-3s as monotherapy, so by themselves and it's more important that the omega-3s contain a higher dose of EPA relative to DHA, and those are the two long chain fatty acids that are the most bioavailable and usable by the brain. So you want to look for a dose of EPA somewhere between 1 and 2g, so 1000 to 2000mg and depending on which supplement you're taking, that might actually involve taking more than one of those little gels, so you have to read carefully on the label, but that's the dose for acute treatment. And then if you're more in like a maintenance kind of brain health, then you can then it's okay to use to use lower doses, similar as with medication. We have doses for acute treatment and then doses that we would use for maintenance.

Nima Nahiddi:
Similar to any other type of medication.

Dr Laura LaChance:
Yeah. So I treat it as such. And it's the same kind of thing, right? I'll start the omega-3s, you know, assess tolerability at two weeks, think about maximising the dose based on tolerability, wait 4 to 6 weeks to see an effect. You know, same same kind of principles.

Gray Meckling:
So we've been discussing some of the research around nutritional psychiatry. I think the next section we wanted to touch on was really tie things back to clinical practice. And so I'm wondering if you can take us through maybe a common clinical case that might demonstrate some of these principles. For example, one that I saw in the literature and I'm sure there are many others, would be something like iron deficiency and how that may relate to depression.

Dr Laura LaChance:
Sure. So so I mean, I can think of a number of cases. So what I'll share with you is probably just like a bit of a fusion of several individuals. But I tend to think of iron deficiency when I see somebody who's presenting with depression, who has decreased food intake for whatever reason, it may be due to their depression itself as a symptom or there may be other reasons like, you know, food insecurity, dietary preferences, they're restricting a bunch of different kinds of foods and as part of our usual workup for depression, we should be doing a CBC. But I think that in certain, if you have certain risk factors, like somebody who's vegetarian, a woman who's of in their reproductive years, you know, decreased intake for another any other reason I always add on a ferritin with that first CBC that I order because you can see early signs of iron deficiency even before the person becomes frankly anaemic. And often when you think about symptoms, often the person's presenting with cognitive difficulties and low energy, right? A lot of fatigue in in context of their depression. And then I'll basically include adjunctive treatment with an iron supplement as part of the treatment. And I'll also counsel my patients around iron rich foods to increase into their diet.

Gray Meckling:
Right, and so have you seen this play out in any of your patients where prescribing the iron or the ferrous sulphate as an adjunctive treatment has really shown an improvement in their symptoms beyond maybe the standard of care?

Dr Laura LaChance:
Yeah, I mean, I've seen I've seen it a few times. I've presented a few cases at our clinical rounds, which feels like an eternity ago, which was in April. But one person stands out in particular. She's the young woman with bipolar depression and she she looked kind of iron deficient to me. She just looked so tired all of a sudden and she was complaining a lot of low energy, and it was really a change from her mental status before. And she had been following a diet that was, um, like it wasn't vegetarian per se, but she was really focused on weight loss and so her main protein source was chicken breast and a lot of just like basic salads and stuff like that. So her actual intake of iron is down and she's a menstruating woman and she was iron deficient. And so I added that to her treatment for depression. Um, you know, I would never, like if somebody has symptoms of depression, I would never deprive them from the normal, you know, standard of care treatment. So it's challenging in nutritional psychiatry because you never have the situation where you're just treating somebody with a dietary intervention. Um, but, you know, she responded really well and I could see the improvements in her mental status track with, with her ferritin levels normalising. So I mean it's, it's challenging because you don't really have you know, you can't say what did what with 100% certainty. Um but I have been seeing definitely a pattern in my clinical practice.

Gray Meckling:
Yeah, that's great. And it sounds like it can be really important to watch out for these nutritional deficiencies or other dietary factors that may be contributing to people's mental health challenges. One question related to this is I'm wondering if you think most psychiatrists are comfortable prescribing these types of dietary or supplemental interventions.

Dr Laura LaChance:
I think the supplements are a little bit trickier. They're also higher risk. For instance, you wouldn't want to indefinitely prescribe somebody an iron supplement because, you know, you can have toxicity from having too much iron. You know, similarly, if you took four grams of EPA, you know, every day for the rest of your life, maybe you'd be at increased risk of bleeding, for instance. So the supplements are a little bit trickier. So I think we do need to, you know, lean on guidelines, for instance, like the guidelines I mentioned for the omega-3 supplements in depression or looking to clinical, you know, point of care resources like UpToDate to understand how to prescribe iron supplementation for iron deficiency. But I think that the food interventions, I think the beauty of the actual nutritional interventions is that they have such a better safety profile. So really, I think that any doctor, you know, can feel comfortable and I can get into kind of more specifics of how do I assess diet and what do I recommend if that's of interest?

Gray Meckling:
I think maybe for now we can just put a flag in that point, because I wanted to quickly ask you also about psychotic disorders and if there's any evidence or any clinical cases that you can think of that might relate to diet and any of the psychotic disorders.

Dr Laura LaChance:
Yeah. So I published a scoping review on that topic about a year ago and so there is there is a very, you know, plentiful body of research on this topic and I think it speaks to the fact that we still don't really understand schizophrenia very well. The treatments we currently have are limited so it's one of those disorders where, you know, pick a theory and somebody studied it 50 years ago because it's just like, you know, we just really don't, we have more questions than answered than answers. But so for for psychotic disorders, I mean, where to start? So certainly we know from observational literature that individuals who have schizophrenia spectrum disorders follow a lower quality diet than the general population and kind of just summarise it at that. There's a large body of research on omega-3s as adjunctive treatment for psychotic symptoms themselves, but also for metabolic comorbidities in schizophrenia. And there are a couple of RCTs that have found that you can prevent weight gain or triglyceride abnormalities in in individuals with schizophrenia treated with antipsychotics by using omega-3 supplements, so that's kind of interesting. In terms of the effect on psychotic symptoms, it's more heterogeneous. So there seems to be more of a signal in early disease that omega-3s can potentially have an effect as opposed to chronic illness that's less clear.

Dr Laura LaChance:
Um, there are no so there's, there's some, you know, people have looked at probiotics, people have looked at different micronutrients like a bunch of the B vitamins, for instance. In terms of whole diet interventions, so I'm involved in a randomised controlled trial of a virtual care intervention to target diet, exercise and smoking in youth with first episode psychosis. So again, the intervention is, is like it's a compound intervention, it's complex, it has, you know, those three elements. It's not just diet, but, you know, it's an intervention where we follow participants over 12 weeks and we help them make changes in their health behaviours and so I have experience with participants from that research study of just like, you know, experiencing huge changes in not necessarily psychotic symptoms, but mood, energy within a diagnosis of schizophrenia after making dietary changes. Concentration is another big one that comes up, motivation, and so you know we can think about also the comorbidity of depression or of even negative symptoms in schizophrenia as targets for dietary interventions aside from the psychotic symptoms themselves.

Gray Meckling:
Yeah, that's all fascinating and I think I'll just point out to our listeners that we'll link to the scoping review that you mentioned, and I did flip through some of it, it was very fascinating. So that's, the paper is titled Diet and Psychosis: a Scoping Review, and you can find that in the show notes beneath the episode if you want to learn more about that. There's a lot of great information there. So I didn't have any other questions. I wanted to see if Sarah and Nima wanted to jump in with anything.

Sarah Hanafi:
Yeah. Um, so I was, you know, I was hoping to maybe tease out a little bit more of your experience in trying to capitalise on this mode of intervention and what might have been maybe some of the challenges you've encountered. I know you've alluded to, to how perhaps the tide is shifting in terms of the interest in the field, but certainly I can imagine that there's still kind of some progress to be made. And the first one that certainly comes to mind is even just obtaining like the necessary workup, is that something that sometimes you face some resistance when you're ordering certain bloodwork or other investigations for your patients or even, you know, consulting, nutrition?

Dr Laura LaChance:
Yeah. I mean consulting nutrition as a psychiatrist is certainly a challenge. Um, but the, I mean, yeah, I really haven't had very much luck with that at all actually in the hospital setting that I work in. So I do feel like I'm kind of on my own a little bit, which is unfortunate. Um, in terms of the workup, I mean, the workup is the dietary history at this point because there's not so much that you can actually order in terms of blood tests. So like I mentioned, ferritin and along with CBC is something that I order for anyone with depression or anyone who has risk factors for decreased intake of iron. Um, and then, you know, if they're anaemic, we can order B12 but, and or folate, but that's like pretty much it, or you can order B12 if there are other risk factors for B12 deficiency. But we're very limited in terms of what actual lab tests that we can do. So the workup at this point is, is the dietary history. Um, and you know, I'd love to see, um, you know, in Ontario for instance, it was really easy to get what's called an Omega-3 index, which is basically a blood test that measures the amount of, so it gives you the percentage of EPA and DHA that's been incorporated into red blood cell membranes and you can use that as an indicator for people, you know, to identify people who would be preferential responders to supplementation with omega-3. You can use that to target the dose because we have, you know, ranges for what the omega-3 index should be between 8 to 12%. But we can't order that here, I haven't been able to find a private lab that can do it and so that would be really that would be really wonderful.

Nima Nahiddi:
For you, what would be some of the questions you would ask your patients in order to get key elements of the dietary history?

Dr Laura LaChance:
Yeah. So it's like really bare bones. So the first thing I do is give people some psychoeducation about the role of nutrition and mental health. So I'll say something like, you know, your brain is an organ just like every other organ and it needs the proper fuels to function and if your brain isn't supplied with the right nutrients, it can't function in the way that it that it needs to. So, for instance, doing things like making neurotransmitters, having your neurones communicate with each other, all of those processes require nutrients to function properly. So then I'll ask people, is it okay if we talk about your diet a little bit in relation to your mental health? Because sometimes people are, you know, they're a bit confused, right? Or they're not used to having mental health professionals ask them about diet.

Nima Nahiddi:
Yeah.

Dr Laura LaChance:
So ask permission, give some psychoeducation and then I'll ask people to start about the number and timing of meals and snacks. So how many meals do you eat a day? How many snacks do eat a day? Do you generally eat food at home or are you picking up food or going to eat at restaurants? So just have like a little bit of a landscape, right? So the person who, you know, doesn't eat anything at all until 5 p.m. and then snacks all night is very different from the person who eats three meals and two snacks a day. So that's the first question. Then I go through, I go for like, biggest bang for your buck. So how many servings of vegetables do you eat in a day? How many servings of fish and seafood do you eat in a week? And how many servings of sugar sweetened beverages do you eat in a day? And like that is, you know, I mean, you can often get find targets for intervention right there. You know, lots of people have many vegetables do you eat? One. How much seafood do you eat? No, none. How many sugar sweetened beverages do you have? Oh, just two, you know, so that's kind of a really easy place to start. And then the next question kind of if I have time and people are actually cooking at home, I'll ask them about what kinds of cooking fats do they use in the house and to try to shift them towards olive, avocado or coconut oil if that's something that's of interest to them. And so that's kind of where my assessment. And then as we've been kind of talking about this, you know, people have like even, you know, the somebody with the most basic food literacy, they usually have some idea of something that they could do better with their diet. So even just from talking about it, I'll ask them, you know, is there is changing your diet something that you feel that you could do? You know, what's your motivation? What's your confidence that you could make a change? And then do you have an idea of something that you could change about your diet? And like that, you know, you don't need a nutrition degree to do any of that.

Sarah Hanafi:
So it sounds like you take almost a bit of a motivational interviewing approach to coax behavioural change.

Dr Laura LaChance:
Certainly, yeah. Yeah. If it's their idea, they're much, much more likely to do it.

Sarah Hanafi:
And you know, you mentioned a little bit how your interest in the social determinants of health is part of what led towards nutritional psychiatry. A lot of the patients that we work with in psychiatry are vulnerable and might have limited access to financial resources or other kind of economic resources. I'm wondering if that's a challenge that you've encountered sometimes for patients who may be interested in adopting diet-based interventions or other kind of physical activity changes, but are limited.

Dr Laura LaChance:
Certainly. So, I mean, one thing is, you know, work with, so collaborate, so, you know, working with our social work colleagues to ask them about resources in the community for nutritious food. There are a lot of different options out there, and we can't possibly know about everything that exists in our environment. So that's one thing is collaborate. Another thought that I have about that is that restaurant food is often much more expensive than food that you prepare at home. So, you know, shifting toward preparing more food at home can often identify a way where you can make an intervention that's cost neutral. Um, I'm currently in the process of evaluating a handout that I created based on the scoping review with one of my colleagues, Dr. Monique Aucoin, about and it's actually Aucoin, not Oakley, I'm not mispronouncing it. And it's a handout that's specifically made for individuals with severe mental illness and there's a section on there about, um, about eating well on a budget. And so certain items like, you know, frozen vegetables or very inexpensive, buying like dried beans and legumes, very inexpensive, um, eggs, another source of complete protein, healthy fats that can be added to many different kinds of meals, many different types of cuisines. So like, obviously there, you know, it's more challenging for sure, but everything else is more challenging also with an individual who is, you know, facing barriers like insecure housing and, you know, substance use and, you know, everything that we see of patients poverty really in general. So, um, I think you just you meet the patient where they're at and you try to make an improvement, you know, in one step. And just because you can't have them, you know, eating a $20 salad from pick a restaurant, um, it doesn't mean that it's not worth trying to make some gradual changes with them.

Sarah Hanafi:
No and I think I think you make a really good point, too, about those opportunities to collaborate and lean on other members within the team or other resources to support our patients and in making these changes within their life.

Nima Nahiddi:
All of, all of this has been really fascinating with the discussion on some of these really basic questions we can ask the patients in order to get really important information about their everyday habits and move forward with these dietary patterns and, you know, really get them interacting with us and becoming better clinicians ourselves. Do you see future directions for nutritional psychiatry? Do you have anything in mind as to what's going to be next steps in the field or what's going to be things to come?

Dr Laura LaChance:
Um, yeah. I mean, so I think this podcast is a really nice next step and examples like it so thank you for giving the topic some attention. Um, you know, I look forward to opportunities for more nutrition education and as part of medical education in general so that we can have nutrition be on our radar as doctors. Um, I think, you know, there's obviously a ton of research to do. We didn't even touch on gut microbiome today, which is a huge, you know, diet is one of the major and most modifiable determinants of the gut microbiome. And I think we're just we're in like we're just in the dark. We don't even understand what a healthy microbiome looks like versus an unhealthy microbiome or what a healthy microbiome is even supposed to produce or how to influence that. So I think that's really going to be a major future direction for the field.

Nima Nahiddi:
So my my knowledge about gut microbiome is quite limited. Do you mind giving us a quick update on like what's when you say that or like what is the current knowledge on the gut microbiome? Because it is something, you know, you read about in newspapers, magazines and I would think it's something that, you know, we would be interested in developing more knowledge about. But do we have current evidence or what's the current knowledge about the gut microbiome?

Dr Laura LaChance:
So, so you know, microbiome as it relates to mental health has a number of important functions. Um, mostly so the microbiome is, is crucial in maintaining that barrier between outside of the body and inside of the body at the level of the gut, right? So we have this gut epithelium or intestinal lining which protects the inside of our body from what's in the lumen of our intestines. And if that barrier is not functioning normally, then, you know, toxins from food, bacteria can translocate, bacterial antigens can translocate across the gut lining and get into our circulation, and there they can cause an immune response. And that, you know, when we talked about inflammation earlier and inflammation being an important mechanism in mental illness, the question of where does this inflammation coming from? Well, a lot of people think that it's coming from the gut for exactly this reason, because the gut lining is not intact. So the microbiome plays a massive role in terms of maintaining that gut barrier integrity. It also produces a number of important molecules like short chain fatty acids, but also neurotransmitters directly, so, you know, of obvious relevance. Um, and it modulates the HPA axis, which is our stress system, which is of also crucial relevance to mental health.

Dr Laura LaChance:
And the gut and the brain are talking to each other. So Sarah mentioned earlier the microbiota-gut-brain axis, and that's a bidirectional means of communication between the gut and the brain, where the vagus nerve is one of the channels of communication but also there are endocrine and cytokine signaling molecules that communicate between gut and brain. So, um, I think like, you know, there's, there's a lot of overlap when you start to dig into these mechanisms but I think what's super important and I think exciting about the gut microbiome is how modifiable it is. And so, you know, you can modify the gut microbiome with, with probiotics, with synbiotics, with postbiotics, with, um, faecal microbial transplant, but also diet is actually coming out as the most potent way of changing your microbiome. So if you change your diet for a couple of days, you can see dramatic shifts in the composition of the gut microbiome. And so I think that's going to, you know, I hope as that field develops, we start to see, um, a lot more attention to, to diet there.

Nima Nahiddi:
It's really fascinating.

Dr Laura LaChance:
I mean, it is and it's just like it's a whole other, you know, like layer of complexity to apply to the physiology that we already understand about our bodies. So it's hard to even wrap your head around it. But we have now we've got at least five randomised controlled trials in depression of probiotic interventions. We've got one in anxiety, we've got two in schizophrenia and like I said, it's early days because I don't think we know what a healthy gut microbiome even looks like, so I don't think we know which kind of probiotic to prescribe. So my response to that clinically right now is we know that you can support a healthy gut microbiome by avoiding things that damage the microbiome, like ultra processed foods and sugar. We can support a healthy microbiome by providing our gut microbiome gut microbiota with lots of healthy food, which is fibre, right, another another word for it.

Nima Nahiddi:
Yeah.

Dr Laura LaChance:
Um, and then we also know that we can consume fermented foods directly so we can eat things like yoghurt, kimchi, sauerkraut, whatever, kombucha, if you will. Um, and, you know, those are all sort of safer things that, you know, are actually probably more cost effective than probiotic supplements anyways.

Nima Nahiddi:
And it's nice that even though, you know, it seems that we're at the tip of the iceberg for, you know, what we know about the microbiome, there's still a lot of things clinically that we can recommend to the patients.

Dr Laura LaChance:
Yeah. And I mean, there's a lot of convergence, right? We've been talking about anti-inflammatory diets. We've been talking about supporting a healthy microbiome and, you know, having lots of fruits and vegetables like, the Mediterranean diet is essentially a template that everything kind of converges in that direction. And I realise that not everybody on the planet is going to consume a mediterranean diet for various reasons. But you know, it's rich in fruits, rich in vegetables like beans, legumes, whole grains, you know, fermented foods, healthy fats, not refined carbohydrates, not sugar. And those are really just like, I think, take home points at this point.

Gray Meckling:
Well, that was great to touch on all those future directions. And I for one, I'm grateful that we've had such an expert on the topic to to chat with, and we can count on you to sort out all of these research questions. The last topic we wanted to touch on was just if you had any tips or advice for for someone who's maybe in medical school or early on in their residency who is interested in nutritional psychiatry, where they can learn more or how they can get involved.

Dr Laura LaChance:
So there is a society that I alluded to that's called the International Society for Nutrition and Psychiatry Researchers, and it's actually probably 50% researchers, 50% clinicians. But they have an absolutely fascinating conference every two years and it just happened in 2019, so it'll be 2021 in Vancouver, actually. Um, and if anyone's interested in learning more about the field, that is where the experts are. It's a group of about, the last conference was about 200 people and it was like, you know, I felt like I was, you know, in Hollywood, like seeing all the stars. And, you know, it was so that's something that I would strongly recommend to anyone who's interested in the field because you'll get the the most kind of cutting edge knowledge. Um, I mean, if anyone, like anyone at McGill who's interested, please reach out to me, I'd love to chat with you and like, you know, we can definitely talk about it. So you're welcome to share my contact info in the show notes also. There's a Food and Mood Centre at Deakin University that was created by Dr. Felice Jacka, who's probably the, um, she's probably the most, I guess, famous researcher in the field. She's the person who actually started the society and she's like kind of the mother of modern nutritional psychiatry, I guess. Um, and so it's called the Food and Mood Centre at Deakin University in Australia and they have a course on food and mood that's free on, through FutureLearn and so if you're wanting to learn more as a clinician or just as a person who is interested in making healthy changes to your life, that's a good place to get really high-quality information. Um, and you know what I would say if anyone's interested, I mean, read broadly and start talking to your patients about their diets. I don't, you know, I don't think we need to wait for that.

Gray Meckling:
Yeah, that sounds like great advice and we'll definitely link to some of those resources in the show notes so thank you for sharing all of that with us. I think I'll hand things off to Sarah now.

Sarah Hanafi:
Yeah. Thank you so much, Dr. LaChance, for joining us for this episode. You know, I think I can speak for our listeners in saying that maybe the takeaway, the takeaway from all of this is that nutritional psychiatry is something that's actually quite accessible. It's something that, you know, in speaking with our patients, we can quickly ascertain opportunities for intervention by not only trying to to work with our patients and meet them where they're at, but also work with our colleagues and finding and facilitating access to to resources. So I think that that gives me a lot of hope as a trainee that I feel like a little better equipped to address some of this when I'm caring for my patients. So we really thank you for your time and for our listeners, keep an eye out for the show notes. We'll make a point of linking many of the the useful resources that Dr. LaChance mentioned today. Thank you.

Dr Laura LaChance:
Thank you.

Alex Raben:
PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sara Hanafi, Dr. Nima Nahiddi and Gray Meckling. The audio editing was done by Dr. Alex Raben. Our theme song is Working Solutions by Olive Musique. A very special thanks to our incredible guest, Dr. Laura LaChance, for serving as our expert for this episode. You can contact us at Psychedpodcast@gmail.com or visit us at Psychedpodcast.org. As always, thank you for listening.

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Episode 13: Psychiatric Rehabilitation with Dr. Abraham Rudnick

• Episode 13: Psychiatric Rehabilitation with Dr. Abraham Rudnick

  Alex Raben: [00:00:10] So welcome to PsychEd, the Psychiatry podcast for medical learners by medical learners, and today we have an episode on psychiatric rehabilitation with Dr. Abraham Rudnick. And this is an interesting episode because usually we, behind the scenes, do a lot of preparation for our episodes and we know a lot already about our topic, and this time we don't really know what to expect. So that's a first for us. Before we get started, though, let's do our introductions. So I'm Alex Raben, I'll be hosting today, and I'm joined by my colleague Aarti Rana.

  Aarti Rana: [00:00:49] I'm Aarti Rana. I'm a second-year psychiatry resident here at the University of Toronto.

  Alex Raben: [00:00:54] Yes, and we're joined today, as I said already, by Dr. Rudnick. Dr. Rudnick, can you give us a bit of an introduction to you, please?

  Dr. Rudnick: [00:01:01] Sure. No problem. And thanks for asking me to do this. So I'm a psychiatrist. I'm also a PhD trained philosopher, and I'm a certified psychiatric rehab practitioner. I'm just now moving into a new position. So moving from Ontario to Nova Scotia to be the Clinical Director of the Operational Stress Injury Clinic of Nova Scotia and a Professor of Psychiatry at Dalhousie University with a cross-appointment to occupational therapy at Dalhousie, which is very relevant to psychiatric/psychosocial rehabilitation, because obviously occupational therapy has a lot to contribute as well as other mental health services.

  Alex Raben: [00:01:44] Great. Thank you for that. And where are you coming from?

  Dr. Rudnick: [00:01:47] So maybe just a tiny bit of preliminary background even before my most recent position. So I was trained in psychiatry and medicine first, then military medicine, then psychiatry in Israel, which goes back to my roots a bit in military medicine. Then I did a fellowship at University of Toronto with a double focus, one in philosophy of psychiatry and one in psychiatric rehabilitation at what was then called Whitby Mental Health Centre, which is now Ontario Shores, and during that I also certified through an American national organisation in psychiatric rehabilitation. And most recently I've been the executive Vice President of Research and Development and Chief of Psychiatry at the Thunder Bay Regional Health Sciences Centre in Ontario, as well as a Professor of Psychiatry at the Northern Ontario School of Medicine.

  Alex Raben: [00:02:45] Great. Thank you for that. So maybe we can start off by unpacking this term, psychiatric rehabilitation, because it's not something that, at least in our curriculum here at U of T we use very often or I've honestly never really heard those two words really put together. And when I think about rehabilitation, I think more physical rehabilitation, like physiotherapy after an injury or something like this. Can you help our audience who may also be like me and not very familiar with this terminology, understand what it's all about?

  Dr. Rudnick: [00:03:18] Absolutely. And I think it's symptomatic in a sense that you haven't heard about psychiatric or psychosocial rehabilitation, those are synonyms, because we don't expose our learners both in psychiatry as well as in social work or even occupational therapy, psychology and nursing enough to this. Psychosocial or psychiatric rehabilitation is one of the four main types of mental health intervention, one being pharmacology, another being psychotherapies in plural, a third being all the types of neurostimulation like ECT, TMS, DBS and so on and the fourth, last but not least, is psychiatric rehabilitation. So it's a whole world of evidence-based practices that focus on facilitating recovery of people with serious or other complex mental illness. Primarily historically, it was focused on people with schizophrenia, but that goes much beyond people with schizophrenia these days. The idea of recovery is a key point. And as you may know, the Mental Health Commission of Canada has highlighted recovery as the ultimate goal of all mental health services for all populations served by mental health services. And so maybe, just very briefly, I'll unpack what does recovery mean because if we understand the goal, we can understand the means to achieve the goal. So there are at least two types of meanings for recovery. One is the more traditional meaning, which is a set of outcomes that's called clinical recovery by people like Mike Slade, and that's about symptom reduction or alleviation, that's about more independent functioning, those types of outcomes. But the second sense of recovery or what's called personal recovery are the processes of recovery, which is about seeking, finding and keeping a meaningful personal life. And immediately you can imagine that that goes much beyond pharmacology or even psychotherapy. It's about the whole person's life. And that's where psychiatric rehab comes into play, because it focuses very much on helping people live the best life they can in their environments of choice. And if we have time, I'll explain a bit more, what does that technical term "environments of choice" mean.

  Aarti Rana: [00:05:55] When you speak about recovery, usually recovery is referring to some kind of injury or event. And so in a physical rehab model, for example, someone might have a knee injury, they might be a military survivor of military combat. I imagine looking at psychiatric illnesses in terms of the concept of recovery would change how we think of the illness itself in some way. So how might someone thinking about recovery think about schizophrenia differently, for example?

  Dr. Rudnick: [00:06:30] So they it's a great question. The idea of recovery is that, as Bill Anthony from Boston University said, we all recover from something in life, be it a divorce, be it unemployment, be it a loss in the family, be it an unaccomplished dream, and people with mental illness, in addition to many of those challenges, also have a mental illness to to address and cope with. So in a sense, recovery is not specific to mental health issues, but in the mental health sector, in the last 2 to 3 decades, particularly from the States and then after that in Canada, Australia, New Zealand, UK and other countries, the idea is developed into a whole social movement saying that recovery's goal is really not just about the adversity we face, it's about society accepting anyone with any kind of adversity and challenge fully. And so in the States it's been fairly political movement that has aligned well with psychiatric rehabilitation but is separate from psychiatric rehabilitation. Although there are a lot of people who straddle both camps. The main leaders of the recovery movement obviously are people who are recovering. So people who have had or still have mental health challenges. Some of the most famous ones internationally would be people like Patricia Deegan, who is a PhD psychologist who has published research on coping with voices for example, as well as on shared decision making in regards to mental health care. Still, according to her public acknowledgement, still receives treatment, still experiences symptoms, but still has a full life in spite of that, and sometimes even partly because of that, because it has brought new meaning and new purpose into her life. So when we say recovery, we don't mean cure. We don't even necessarily mean symptom remission, what we mean is people living a full life according to their hopes and to their abilities.

  Alex Raben: [00:08:46] I have some questions about how we achieve the recovery, but before we get there, I'm having a little bit of trouble with some of the terminology because, right now I'm working in an ACT team, so we are very much recovery-focused and yet I've never really heard this rehabilitation terminology. And you're suggesting there might be actually two camps or a recovery and a rehabilitation camp. Are they different? Is there a lot of overlap? Are they the same? Is it just different preference and terminology?

  Dr. Rudnick: [00:09:12] There's a lot of overlap. The terminology is fairly similar. I would say each country and even each province in Canada would have a slightly different take on that because it's quite contextualised. But by and large, the recovery movement is composed of people with mental health challenges and people who support them. And the psychiatric rehabilitation sector is not an ideological movement anymore, it was decades ago, it's now really an evidence-based set of practices that continues to change based on research generated and helps facilitate recovery based on the visioning of the recovery movement.

  Alex Raben: [00:09:57] So it's like a yin and yang, almost? Okay.

  Aarti Rana: [00:10:00] Could you describe where psychiatrists who are practising psychiatric rehab, where are they working? Are they working in the same hospitals that we would be doing our residency rotations in? Are there specific centres that they work in? Are they working privately and how does their work look different than the work of other psychiatrists who are working with similar patient populations?

  Dr. Rudnick: [00:10:22] So it's a whole mix in different areas of the mental health system. But I would say that there are not many of us who actually do full-fledged psychiatric rehab, partly because there are very few psychiatrists who are certified in psychiatric rehab in Canada, even in the States, not many, but some are, partly because there are more traditional understandings of what recovery and recovery and psychiatric rehab mean by many of our colleagues. And so one of the things I've published about in my research is the notion of coercion in psychiatric rehabilitation. And we all know that legally coercion is sometimes allowed and even required in treatment, in enforcing medications when people are incapable and a risk to themselves or others. But some psychiatrists still think that that is also possible for psychiatric rehab and if you understand the basic definitions of what psychiatric rehab is, which is helping people achieve their life goals, then coercion is by definition not possible because no one can impose life goals on someone else. If they do, that's not a life goal anymore. So there's a logic to this that is a very strong logic and of course has ethical implications. And therefore, other than in very special circumstances like forensic systems where psych rehab is constrained, it is constrained, but parts of it could be allowed in all other aspects of mental health care. It's all about personal choice of the service users. And I think we need a lot more dialogue with psychiatrists and others about how does that look like when there's no coercion, not even an attempt to influence in a subtle, coercive way people's goals in life.

  Aarti Rana: [00:12:20] So I'd like to try to summarise what you're saying. Someone who's practising psychiatric rehab in this way would be working with patients to try to identify their own goals in life and then adjusting what they do as a psychiatrist to help the patient further those particular goals. So the system that we work in would be secondary to what the patient's trying to do with their own life.

  Dr. Rudnick: [00:12:48] Absolutely. And we would be, the whole mental health sector including psychiatric rehab, would be only one fairly small piece in the whole puzzle of a person's life, including the supported parts. And so in that sense, psychiatry can be flipped on its head and looked at as a support, not the lead of the person's life, but just the support that sometimes is needed and sometimes is not whether the person is or is not symptomatic. And therefore the person with the mental health challenge is the driver of their recovery-oriented care.

  Alex Raben: [00:13:27] I was going to ask who defines recovery? And it sounds like from what we're saying, it's the person who's being treated or who has a mental illness. What about like, I'm thinking about my own clinical work, what about scenarios where the person has schizophrenia, and they have negative symptoms and they don't have much motivation to really come up with goals? Is, what would someone who's practicing from this frame of mind do in that scenario? Would they start to work with them to help them think of goals, or would they say no, actually their goal is just to be by themselves and be asocial, and that's how it's going to be.

  Dr. Rudnick: [00:14:04] That's a great question and a segue into the process of psychiatric rehab because there's a structured process to go through. This is not just an art. And so Boston University is an example, their psychiatric rehab centre has published for decades now that approach of, how do you help people who are not clear on their life goals get to the point where there's clarity and then psychiatric rehab can start. Because if the goals aren't clear, then we can't really proceed. PSR, psychiatric rehab, is focused on people's life goals. So there is a process, a preliminary process called readiness assessment and development. So psychiatric rehabilitation readiness assessment and development, it's not exclusive of people. It doesn't say people are not ready to, just helps better understand the clients as well as the providers at what level of readiness the person is. It's structured into a few components. The first and most important probably is does the person have a felt need for change in their life, in any aspect of their life, in what we call environments of choice, be they residential, vocational, educational, social, sexual, health care, environment, spiritual and so on. If they don't, then there's a dialogue. Why not? If it looks from outside like maybe their life is not that great, but it's their choice to change or not.

  Dr. Rudnick: [00:15:32] If they do have a felt need for change then there's another component of readiness, which is are they committed to invest effort, time, sometimes even money into change? We know from behavioural change in general, in the general public, that a lot of people feel a need for change. But when it comes down to committing to that, for example, weight reduction, it's not that easy. And so if a person isn't committed enough, maybe it won't work. And there are a few other components of readiness, such as awareness of personal values and preferences, awareness of environmental possibilities and what's not possible, and eventually also the ability to connect with someone to work on this together. If the person isn't ready enough to put in place a goal for rehab, then there's a structure, that a process that looks very similar to motivational interviewing and often actually uses motivational interviewing to help them explore whether they do want to change their readiness. And so that's one of the interfaces between psych rehab and psychotherapy, for example. There are many other interfaces, so using skills from motivational interviewing can very much facilitate that readiness assessment and development process.

  Alex Raben: [00:16:48] And then along the same example, does at that very early step, does it ever is there ever a point where you say it's the person's mental illness that is preventing them from forming goals and we need to treat the mental illness, perhaps even coercively, before we can get to those goals.

  Dr. Rudnick: [00:17:08] It can happen. From my experience, it's not often that that happens because even if a person is actively psychotic and let's say their goal seems to be delusional, there are ways to break down a goal. And this is coming from human services, not from the health sector. How do you break down, help people break down their ultimate goals into steps to achieve that? And so often during that process, the person realises that, as an example, they may have initially wanted to be an astronaut, but because it's very unrealistic plus they've discovered that their interest is actually in astronomy and not really in being out there in space, that they may actually shift or focus on those interim steps, interim goals and be more than happy with that. So typically, that would be the readiness process where you're exploring why and what in fine detail. As you can imagine, this can take many months to just get to a clear goal for rehab. So it's very time consuming, but that's okay. We know from physical rehab, which is a model for psychiatric rehab, that things sometimes can go slow, but so long as it's clear where they're going towards, it's fine.

  Aarti Rana: [00:18:30] And let's say someone is ready. So they you identify that they are ready, they're committed, and they have a clear goal. What happens next?

  Dr. Rudnick: [00:18:39] So now you start with the actual bread and butter of PSR, psychosocial and psychiatric rehab, which is about identifying what are the skills needed for that particular environment of choice. I'll define what that means in a moment and what are the supports. So the two practical pillars of work practice in PSR are skills and support. And as you can imagine, there are many types of skills: cognitive, emotional, practical, social and many other skills. And similarly, there are many types of supports: social, physical supports, time supports and other supports. And so the planning with the client is to identify, for their environment of choice, what skills they have, what skills they don't have but are needed as well as what supports they have and what they don't and what supports are needed. An environment of choice literally means what setting and what role in that setting the person wants. That's a rehab goal, the environment of choice. An example would be a person wants to be a tenant in an apartment. That's a role in a setting, that's an environment of choice, putting the role and setting together. And that's the goal. That's a very specific practical goal. Now, if they wanted to be a resident in a group home, it's also a residential environment, but it's very different. The role is not a tenant and the setting is not an independent apartment. So expectations for skills and supports are very different. They would have to have many less skills in a group home and many more supports. And most people, when you ask them, prefer it the other way around to have more skills and less support in order to be as independent as they can. And we do have in Canada still a system of many group homes which is called sheltered residential rehabilitation. It's not evidence-based and some people are there for life because they've been there for decades. But most people, particularly the younger population, would prefer to go to the supported housing sector, which is more skills and less support, but there still are supports as needed. And so that's the process you identify together. What are the skills and what are the supports needed for both success but also for satisfaction. And that's part of the complexity of rehab, because we all know from our life and that's the whole exercise of rehab is learning from ourselves, is that sometimes success conflicts with satisfaction. We hope to achieve both in an environment of choice, but that doesn't always happen. So when we're planning psychiatric rehab, we need to flesh out those issues. Could there be a conflict between success and satisfaction for the person. They may not have enough life experience to actually know that in advance, and that's part of our role, to help them think it through and make some tough choices sometimes.

  Alex Raben: [00:21:47] So it sounds like from what you're saying, it's, psychiatric rehab is more of a framework almost where you then can plug in like psychotherapies, for instance, or cognitive psychotherapies, emotional psychotherapies to help build skills and then social supports to help fill supportive needs, rather than it being a single intervention in itself. Is that so?

  Dr. Rudnick: [00:22:12] It's both, you're right, but it's both. It's both that framework where you can input interventions from other practices like psychotherapies, for example, but it also has its own set of skills-building interventions and support-building interventions. I should also add it's not just about building those skills and support, it's also maintaining the effective adaptive skills and supports because skills and supports, even if they're very effective, can easily erode. So if someone is in hospital for a few months, their basic daily activity skills may erode. And we need to be very mindful that long stays in sheltered facilities like hospitals may actually cause some harm. And therefore, if they're absolutely needed for safety, for example, then we need to do active work in those facilities, in hospitals and other facilities to maintain the skills the person is brought into the facility. And the same would go for supports, if someone is admitted to hospital and then they lose their apartment or are evicted and a new apartment is found, we need to make sure that the right supports are in place based on their recovery goals. And so a typical example would be someone is in hospital, they're now finding a new apartment, but there's no laundry facility in the building. So they need to do laundry, if their apartment is located in an area where there is no laundromat anywhere nearby, they may not be able to do laundry. That's a recipe for disaster. And it's very simple, very practical but we have to think of those aspects of life that are critical for people to live a good life.

  Aarti Rana: [00:23:59] In a sense, what you're describing is a deep study of an individual, one at a time in a kind of n-of-one. So you have a whole system that one by one looks at the n-of-one and says, okay, what are the factors that are limiting the goals that this individual has identified for themselves?

  Dr. Rudnick: [00:24:16] Absolutely.

  Alex Raben: [00:24:17] So very personalised medicine already at our fingertips.

  Dr. Rudnick: [00:24:21] Very. And very it could be very low tech because this is really about the interpersonal connectivity between the service provider and the service user. It could be expanded to more people, but the core of the intervention is you and the client. It could be the rehab practitioner and the client if it's not the psychiatrist leading the rehab part, but it could be a psychiatrist, which I found personally to be fascinating work because you actually are invited by the service user to every aspect of their life that they want to consider changing.

  Aarti Rana: [00:24:56] You know, I happen to be currently in a psychotherapy seminar group and we're reading some of early Freud's early papers and he talks about listening to patients and actually listening and seeing what's there with a completely open eye because there was no psychiatry, right? There was no sense of what you're supposed to do. And what you're describing is a little bit of that as well. I wonder if you can speak from your background in philosophy to what you're doing in this model that wouldn't be present in other models.

  Dr. Rudnick: [00:25:29] Yeah, absolutely. I think the first pioneers of psychiatry like Freud and even before him, Kraepelin and so on, were looking at the whole person. They didn't have the intervention means, even Freud initially, to actually make much of a difference in the person's life but they could actually look at the person's life and they did. So from a philosophical perspective, we're talking here about a holistic approach, not H-O, W-H-O- holistic, a whole person, but also a whole system approach. And there's a similarity to physical rehab, again, which was one of the sources of inspiration for psych rehab, which were we're looking not just at the person, we're looking at the fit between the person and their environment of choice. So if you look at the person with physical disability and how rehab work proceeds with them, it's about finding out what their goals are and then finding the fit, based on those goals, between the person and their environment. And if the environment needs to change, such as ramps for people in wheelchairs, elevators for them and so on, so be it, the environment has to change and it's legislated. It goes the same for people with psychiatric disabilities. That's the focus of psychiatric rehab. It's just sometimes a bit more difficult, challenging to figure out what are those technically termed "accommodations" in the environment that would optimally support the person.

  Dr. Rudnick: [00:27:00] But the research is pretty clear. In general, there are many types of accommodations, but two that stand out are social supports in environments of choice and time flexibility. So in the work environment, for example, if someone has difficulty getting up on time because they're heavily medicated or because they have some negative symptoms, an employer who is flexible and accommodating would allow them to come late to work but then finish work late. So they're still working the full workday, but they're just shifting it. And so part of the work of rehab is to not just work with the service users, is to work with their environments. Very well known evidence-based model is called supported employment, specifically individual placement and support, IPS, highly replicated in randomised controlled trials and systematic reviews. And one of the jobs of the rehab practitioner there is to work with employers in general in their region, not even specifically in regards to a particular client, but to help them destigmatize, better understand and learn what supportive accommodations are so that the next client coming their way would be better accommodated.

  Alex Raben: [00:28:15] You touched a little bit on the the literature there and the research, and earlier you said that it's not just about plugging things in,there is an actual sort of codified treatment here. So in my mind, I'm wondering like, is this sort of like CBT in the sense that people have written all this down? There's manuals, people practice in a certain way and then there's research on that. And if so, what does that research look like? What are the outcomes like?

  Dr. Rudnick: [00:28:44] Yeah, absolutely, much of PSR now is manualized. An example would be IPS, supported employment, including fidelity measures similar to psychotherapies, where you can evaluate if a service is working enough to the model, close enough to the model, and they can be rated on that. And the research shows the lower the fidelity, the less effective the service is compared to what's been published in randomised controlled studies. So IPS would be a great example for that. There are practices that are not yet fully evidence-based in psychosocial rehab. For example, in the vocational rehab environment, social enterprise would be an example of a promising practice that has some research to support it, but it's not yet as evidence-based as IPS, as supported employment. But it's promising enough that people are actually doing more research, including randomised control trials on that. One of the challenges in that in the methodology of the research is that doing RCTs on each and every psychosocial intervention is sometimes challenging. And even psychotherapists would argue that for some psychotherapies, because randomisation of course removes choice to some extent and there are some challenges, you can't blind these interventions, the psychosocial interventions. So, you know, compared to biological interventions, they're considered a bit weaker. But there are statistical and other ways to strengthen the studies, including using quasi experimental research, which is not RCTs but if it's done with large enough samples, it can be very, very effective, very helpful, very informative. And so I think a lot of people are recognising that for some interventions, just sticking with RCTs may not be enough, we may need RCTs, but we also may need more creative, rigorous methodological designs in order to demonstrate whether an intervention is effective or not. And I and many other rehab practitioners don't use the term treatment because that's actually very specific to the biomedical approach. We use the very generic term intervention, treatment is one type of intervention, rehab is another type of intervention.

  Aarti Rana: [00:31:07] So if you're a medical student or a resident in Canada and you wanted to have an opportunity to work and do an elective in this model, where would you go?

  Dr. Rudnick: [00:31:16] So you would probably want to look up psychiatrist who are CPRPs or CPRRPs That's CPRPs is an American designation, psychiatric rehab practitioner. CPRRP is a Canadian designation, the Certified Psychosocial Rehabilitation Recovery Practitioner. They're on the websites. Very few of us psychiatrists with that, but we're available. I know some in London where I worked in the past, now in Nova Scotia, I'm there. There are a few others but if it doesn't have to be with a psychiatrist, there are a few occupational therapists, social workers who can supervise that. I would also encourage looking at getting that designation with enough training eventually and also there are courses in psychosocial and psychiatric rehab. So in Canada, the two at least two colleges who provide that online training. One is Mohawk College in Hamilton, another is Douglas College in in British Columbia. There may be others and it's those two are all online. So it's an opportunity to at least get the basics of the training of PSR with many other practitioners, including service users. So patients take those courses too. No one is excluded so long as they can play, it's a fairly nominal, pay, it's a fairly nominal fee and based on that you gradually get a very diverse workforce.

  Alex Raben: [00:32:41] That's great. That's very helpful for our listeners who are who are finding this interesting and want to pursue it further. I'm wondering what does recovery look like? We've talked about that there's some literature, it does show that certain outcomes are improved in certain areas. But as Arthur, you were saying, this is very much an n-of-one process, kind of at the end of the day. Can you share with us what it actually looks like when you see recovery or when you're involved in that?

  Dr. Rudnick: [00:33:10] Absolutely. So first of all, it's ongoing because life changes and so goals may change once in a while. But if a person has put in place goals of, let's say, working a full-time work with this certain amount of wages, that would be vocational recovery for them and it would have to also be a meaningful job. So if they're suffering from the job but earning well, then we have that clash between success and satisfaction. That's not ideal. Sometimes it's necessary, not just for people with mental health challenges, but it's better to try to plan or at least tweak it after that towards both success and satisfaction. And people just tell you, we can use all sorts of sophisticated psychometric tools, psychometrically validated tools and measures for that, but in rehab, actually, the bottom line is pretty simple. Has your goal been achieved? We can just say fully, partly or not at all, that's good enough to know do we need to continue to do rehab work in this particular area of the person's goal.

  Alex Raben: [00:34:14] One area of discomfort for me around this topic is something you mentioned early on where you said that to be coercive, to use coercive means is to really not be in this model whatsoever. But thinking about my own clinical experiences, there's many times where safety is at play and where medicolegally we're responsible to be coercive. How does that fit into what we're talking about here?

  Dr. Rudnick: [00:34:46] It fits well because psychosocial rehab is not a panacea. It can't do everything. There are times and situations where it's where our hands are bound, right. Public safety trumps and that has to be the case. Think about physical rehab. It's not like a physiotherapist can always do their work. If the patient is deteriorating, develops a fever, physio has to step back for a short while at least, and let other practitioners do what they can to help the person. So as everyone in rehab recognises, although the framework is a recovery-oriented framework, there are many other ways of achieving both safety as well as success and satisfaction. There are many service users out there who have never used psychosocial rehab and never will use and don't have a need for that because they have found their own way. Or maybe meds are enough for them and their own coping and own natural supports and that's fine. So really it's just part of the puzzle doing psychosocial rehab. But if we do it, there's no coercion, there should not be coercion involved because then we're not doing psychosocial rehab.

  Alex Raben: [00:36:02] That helps me conceptually wrap my head around that, so thank you. I'm wondering if we can end off with just kind of any, I'm wondering if we can end off with what you would hope that a medical student or an early resident would take away from this, someone who's maybe not considering pursuing this as a career, but is going to be maybe a general practitioner or a general psychiatrist, what would you hope they take away from this podcast?

  Dr. Rudnick: [00:36:33] So I'll use an adult education framework where we look at attitudes, knowledge, skills and awareness. So the very first is awareness, that people are aware that there is such a set of practices that are evidence-based and informed that can help people with serious and other complex mental health challenges. So I'd like people to be more aware, and I think medical students and junior residents should be aware that there is this set of practices that can help some of their clients. And then gaining more information, more knowledge, I think is also important so that at the very least, practitioners, even if we're talking about primary care providers who may not really be in the realm of providing psychosocial rehab services, at least know who to refer to, they're not just aware that there's such a set of practices, they know what's it about and who to refer to if they think there's a need, because these referrals don't have to go only through a psychiatrist. They could go through a primary care provider, through a social services worker, whoever is the right person, because there has to be a very seamless way for clients to access these services and at the somewhat more advanced level, people who want to be general psychiatrists, I think should have some basic skills in not necessarily providing psychosocial rehab, but at the very least facilitating and not obstructing it. The coercion challenge is one of those issues that people need to know what to do and that this is very different from treatment in the cases of people who are incapable, right, to decide on their own treatment. And last but not least, come the attitudes. And so positive attitudes, particularly always keeping in mind that there's hope and messaging that to clients is crucial. Without hope, there is no recovery. And so if there's no recovery, no goal set for that, there's no place for psychosocial rehab. And so I think those positive attitudes, not pollyannish, but real reality-based, positive attitudes that anyone everyone can grow and learn and change based on their hopes and dreams, I think is crucial. It's not just crucial for psychosocial rehab. It's crucial for life, for people in general, but for people with serious mental illness or other complex mental illnesses who often have been traumatised in addition to having their mental health challenges. And we know the rate of trauma for people with serious mental illness such as schizophrenia is so high, both pre morbid and after they develop their illness, without that hope messaged consistently it'd be very difficult to do any work, including medication, including psychotherapy work. And so I think psychosocial rehab and more generally the recovery approach can bring that hope and it's realistic because pretty much everyone can learn, grow and develop towards their own goals if they are their own goals.

  Alex Raben: [00:39:42] So hopefully today we've built that awareness. People can then go from here and learn more about this on their own to gain that knowledge and then going forward, work on those attitudes with hope being one of the most important ones.

  Dr. Rudnick: [00:39:55] Absolutely.

  Alex Raben: [00:39:57] Just as a last note, do you have any resources or one particular resource you would recommend people go to as a way of finding out more about this topic?

  Dr. Rudnick: [00:40:06] Yes. So there are lots of textbooks, including some of mine, and many journals. So the one journal I'll highlight, because I think it has a nice diversity of types of articles, both research and opinions and educational literature about PSR is the Psychiatric Rehabilitation journal published by the American Psychological Association. It's it comes out, if I remember, quarterly, it's quite helpful. And for textbooks I would probably still highlight the William Anthony et al. textbook. It's unfortunately now from 2002, that's the second edition. But it's, from my experience, one of the best for theory of psychosocial rehab and clinical practices. Now, if people want to look at the evidence, not just through journals, but through a textbook, then Patrick Corrigan's 2006 Psychiatric Rehabilitation textbook is a wonderful resource to see what's evidence-based in psychosocial rehab.

  Alex Raben: [00:41:12] Great. So guys, we'll look into those resources and we'll post them in the show notes so that you have access to them. But I want to say thanks Dr. Rudnick so, so much for coming out today. You were originally up in Thunder Bay before and you had wanted to be involved and now you're down in Toronto for the CPA and so we thought we would snag you while you're here and it worked out really nicely. But thank you so much for that talk. I feel like I've learned a lot. Aarti, I don't know about you.

  Aarti Rana: [00:41:40] Definitely. I feel like there's a whole new part of our ecosystem that I wasn't aware of before. And for me, I know a lot of the principles that drew me to psychiatry do rest in the psychosocial part of psychiatry. And so to know that there are further resources I can explore, people I can talk to, to build my training in that area is hopeful, as you said.

  Alex Raben: [00:42:04] So and we hope that you guys, the listeners, have also learned a lot and we will see you next time. Thanks for listening.

  Dr. Rudnick: [00:42:12] Thanks so much.

  Jordan Bawks: [00:42:14] PsychEd is a resident led initiative based out of the University of Toronto. We are affiliated with the Department of Psychiatry at U of T as well as the Canadian Psychiatric Association. The content in our episodes is a representation of our own views and those of our guests. Our special thanks to our guest in this episode, Dr. Abraham Rudnick. The episode was produced and hosted by Aarti Rana and Alex Rubin. Post-production editing by Jordan Bawks. Our theme song is Working Solutions by Olive Musique. You can contact us at info@psychedpodcast.com or visit our website at Psycedpodcast.org. Thank you for listening. Stay tuned for more great content around the corner as we try and meet our goal of a monthly episode for all of 2019. Catch you next time!

Episode 45: Reproductive Psychiatry with Dr. Tuong Vi Nguyen

PsychEd_Ep_45_-_Reproductive_Psychiatry_with_Dr._Tuong_Vi_Nguyen.mp3: Audio automatically transcribed by Sonix

PsychEd_Ep_45_-_Reproductive_Psychiatry_with_Dr._Tuong_Vi_Nguyen.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Nima Nahiddi:
Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. In this episode, we'll be exploring the psychiatric aspects of reproductive mental health. I'm Dr. Nima Nahiddi, a fourth year resident at McGill University. And I'm joined by Arielle Geist, a second year resident at the University of Toronto, and Audrey Le, a first year resident at McGill University.

Arielle Geist:
Hi, everyone.

Audrey Le:
Hi, everyone.

Nima Nahiddi:
We're really grateful to have our guests, Dr. Nguyen, this week to share her expertise. Dr. Nguyen, if you could, please introduce yourself.

Dr. Nguyen:
Sure. So I'm a reproductive psychiatrist at McGill University Health Centre.

Nima Nahiddi:
For this episode. Our learning objectives are the following to define the field of reproductive psychiatry to discuss the possible neurobiological pathways impacting mood and cognition during the reproductive cycle of women, to discuss the influence of sociocultural gender roles on psychopathology, to list the DSM five diagnostic criteria of Premenstrual Dysphoric Disorder. To recall the Epidemiology of Premenstrual Dysphoric Disorder. To describe the steps in the diagnostic evaluation of Premenstrual Dysphoric Disorder. To list lifestyle and psycho pharmacological interventions for Premenstrual Dysphoric disorder and to discuss common mental health concerns during the perimenopausal period.

Arielle Geist:
So I'll start with the first question today. So before diving in today's discussion, could you briefly explain the clinical scope of reproductive psychiatry and what your work entails? Exactly.

Dr. Nguyen:
So reproductive psychiatry is really about all of the mental health changes that occur in a woman's lifetime during reproductive periods, typically around puberty. You start to see changes related to hormones and you can see a significant proportion of women who start to have premenstrual syndrome, 70 to 80% with a smaller proportion that go on to the premenstrual dysphoric disorder. Another stage of life when you have these hormonal fluctuations is, of course, the pregnancy and postpartum period. And then finally you have the perimenopausal period. And there has been talk amongst us, reproductive psychiatrist that psychiatry should also include hormonal changes for men. But we'll see maybe in in ten years. For now, it's pretty focused on women's mental health.

Arielle Geist:
Mm hmm. Since you mentioned hormones, my next question was, how do these hormones, especially in the field of reproductive psychiatry, where the focus is on mostly estrogen and progesterone, how do those hormones modulate mood and the neurobiological pathways that are involved in regulating mood?

Dr. Nguyen:
There's no simple answer for that. I think that when you think about hormones and women hormones, you have to think about the fact that there are classes rather than just thinking about estradiol and progesterone. It's really all of the steroid hormones are linked together. And you can have up to 54 metabolites, maybe more, maybe more metabolites could be discovered. And then you have these three or even four classes. I don't know if you're aware, but it all starts with cholesterol. And then you have one branch that go on to be corticosteroids. You have one branch that go on to be the estrogens, but then you have tons of different types of estrogens, including 17 beta estradiol, the most famous one. And then you have the progesterone progestogen basically progesterone alone and all of these related hormones. And then you also have the androgens like DHEA and testosterone. So all of these hormones change cyclically throughout the menstrual cycle and then very drastically during pregnancy and the postpartum period and of course the perimenopausal period in terms of how they affect neurotransmitters, I would say again, no easy answer, but just in a very broad way, in simplified way, the estrogens tend to regulate serotonin. Well, all of the all of the neurotransmitters, it's really like they're really almost like dirty medications. So they will affect serotonin and norepinephrine, dopamine in different ways. Progestogen also and estrogen suppression tend to have opposite effects. So for example, estrogen tends to be more stimulating to, for example, up the serotonin, serotonin tone and also androgenetic tone. And then progestogen tend to act again, not all of them, but most of them act through the GABA receptor and then they will lead to inhibition or kind of downregulation of the HPA axis, for example. So the kind so more a bit more like benzos androgens, there's a lot of research that remains to be done on androgens, which are really not well studied. But the typical effect is really in terms of activity, mood, lability, competitiveness, things like that.

Arielle Geist:
Thank you. I think you really were able to simplify something that that seems very complicated to. I think many trainees. Next, because of the way that we formulate things in psychiatry, going with the biopsychosocial model, I wanted.

Arielle Geist:
To step away.

Arielle Geist:
From the biological aspects of reproductive mental health for a second and take some time to explore its social aspect. So my next question was about how do you feel that social and cultural type of gender norms affect clinical presentations of this field? For example, how the way that it might affect the experience that mothers who have postpartum depression have?

Dr. Nguyen:
I think there are still many unanswered questions regarding that. And one of the key aspects of the literature is that we still don't know enough about the social determinants of health for perinatal depression. I hope that beyond post-partum depression, we'll start to talk about perinatal mental health disorders. I think PPD has become very famous. Postpartum depression has been recognized by and large by the mainstream media. But then oftentimes we miss the anxiety disorders that present during the period of period the post-traumatic stress disorders, OCD, which is its own different beast as well. And so I think that, yes, there's a lot of advantages to to have more recognition and awareness, awareness of depression. But we must I think it would be more helpful for women if we use a broader term, perinatal mental health disorders. And I think that in the past decade or so, more and more women are delaying fertility or delaying reproduction to further career or other interests that they may have. And so more and more women will have unfortunately, more and more couples will have infertility and fertility problems. And then that kind of opens the door to a whole other area of mental challenges, which is all of the mood fluctuations related to hormonal treatments, IVF IUI, and in addition to the psychological issues of repeated miscarriages and pregnancy complications. So I think in terms of in terms of that social aspects of mainstream recognition and awareness, we've done a lot, but there's still there's still a lot of work to do because some women will still come to me and say, well, I have suffered for two years because I had no idea.

Dr. Nguyen:
I thought they were suffering from postpartum anxiety, let's say, and then not want to present to not want to discuss it with their doctor because it's they felt they were obviously not depressed. So I think that's that's one aspect. I think the other aspect socially that is that is important to mention is that unfortunately, we're still, despite the fact that Hillary Clinton said several years ago that women's rights are human rights or human rights or women's rights, something like that. I don't know if I'm quoting her properly, but I still think that we are struggling to we are struggling to kind of have the political recognition that we that we need. And this is at all levels. Just to give you an example, all of the reproductive psychiatrists currently working in Quebec have really struggled to implement to have even a prenatal clinic. This in the in face of the fact that we know now that maybe one in three women around the period may have a significant period of mental health disorder with all of the uncertainties surrounding COVID, with the fact that most of the child care burden and house chore burden still falls on the woman at home, and that several of them have out of work because of that. Even so, we're still really struggling to establish these these clinics. And there's actually just one, I would say, clinic in the Quebec province that offers psychological help, an experienced nurse and a psychiatrist. Then the rest of us are basically perinatal and reproductive psychiatrists that are working with little support.

Arielle Geist:
Mm hmm. Thank you for all of that wise insight. I have one last question about the social aspect that I think you kind of touched on to. So when I was reading on the literature leading up to doing this episode, some of it suggested that premenstrual syndrome and postpartum depression and such are quite seem to be a bit more culture bound because there is some literature out there that suggests that it's less prevalent outside of Western countries. So I was just wondering if you had any comments to make in terms of how those differences might be explained by cultural norms or whether that even is true, whether or not we do see it pretty prevalent in in all cultures?

Dr. Nguyen:
Yeah, No, no, absolutely. I wanted to mention that too. So it's again, an example of of perhaps some of the biases that are in some of the controversy that always surround women's mental health in terms of of how long it took for the premenstrual dysphoric disorder to make it into the official category of the diagnosis instead of being relegated to the culture bound syndromes. I would say all of the evidence up to now point towards the fact that there are similar percentages, proportions of women suffering from PMDD across all across all cultures, across all ethnicities. And so I would say if you have a multiple choice question, I would say that PMDD is not the culturally bound syndrome. And it it really does seem that there is an overlap between the women who suffer from PMDD and the women who may have bad reactions like disinhibition and aggression with alcohol. So there seems to be something surrounding maybe men alone and the GABA receptor, but there's several biological and particular genetic contributions to this to this illness.

Audrey Le:
Thank you for answering all of those questions. We're going to move a little bit now into premenstrual dysphoric disorder. So this is a depressive disorder that's linked to the menstrual cycle with symptoms presenting in the week before the onset of menses. Before we dive into this further, it might be helpful for our listeners to briefly talk about the DSM criteria for premenstrual dysphoric disorder to get a better understanding of what this looks like. So before asking further questions, I'm just going to run through the DSM criteria for premenstrual dysphoric disorder. So A, in the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses start to improve within a few days after the onset of menses and become minimal or absent in the week post menses, criteria B one or more of the following symptoms must be present, and these include effective lability, irritability or anger or increased interpersonal conflicts, depressed mood, feelings of hopelessness or self deprecating thoughts and anxiety, tension and or feelings of being keyed up or on edge. Criteria C, one or more of the following symptoms must additionally be present to reach a total of five symptoms when combined with the symptoms and criteria B above.

Audrey Le:
These include decreased interest and interest in usual activities, subjective difficulty in concentration, lethargy, easy fatiguability or marked lack of energy, marked change in appetite, overeating or specific food cravings, hypersomnia or insomnia, a sense of being overwhelmed or out of control. And lastly, physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of being bloated or weight gain. Of note, the symptoms I mentioned must have been met for most menstrual cycles that occurred in the preceding years. And the rest of the criteria after this include D causes significant distress or interference with daily activities or relationships. E The disturbance is not an exacerbation of the symptoms of another disorder such as MDD, panic disorder, PDD, or personality disorder. F Criterion A should be confirmed by prospective daily readings during at least two symptomatic cycles, which we'll talk about more detail later in the episode and G. The symptoms are not attributable to a substance medication or another medical condition. So now that I've gone through the diagnostic criteria of premenstrual dysphoric disorder, let's talk about the epidemiology. How prevalent is this disorder and how does it evolve across the lifespan?

Dr. Nguyen:
So in terms of the last estimates, they go between two, it's 2 to 8%. I think if you define it very rigorously with a two month perspective ratings, which not all women are willing or able to complete, then it maybe is 2 to 5% and that is compared to the 70 to 80% of women who have premenstrual syndrome.

Audrey Le:
Thank you. And and how does this tend to evolve across the lifespan?

Dr. Nguyen:
So typically, PMDD, unfortunately, tends to get worse with the years, particularly after having had children, that we we still don't know what exactly in terms of hormonal mechanisms that's due to. But that has definitely been documented in terms of it's getting worse over time.

Arielle Geist:
And again, thinking about premenstrual dysphoric disorder, what's the differential diagnosis that you think about when you're seeing a patient?

Dr. Nguyen:
Oh, you have to think about all of the gynaecological endometriosis, for example, PID (pelvic inflammatory disease), ovarian cysts or ovarian torsions. There's a lot of different gynaecological conditions that you have to think about. I am actually of the school of thought that I don't. I think that disorders can be co-morbid. And so even though I know that in the DSM, it says it cannot be the exacerbation of another condition. We know from family studies that, for example, MDD and PMDD coexist in these families. And so you will have several women who suffer from both. And so then it's really difficult to disentangle. Is it just an exacerbation of MDD or PMDD and MD together? So for me, it's not kind of hard exclusion criteria per se.

Nima Nahiddi:
I was just wondering how realistic or easy do you find it is for people to do the prospective charts for the two months? Is that something that if you will have resources or with your smartphone, that is very doable.

Dr. Nguyen:
It is doable. I just find that this is this goes back to the social determinants of health, I guess, but it's just very special to me that it's the only disorder which you require. Two months perspective ratings for all of the other disorders are not it's not that hard to to meet the criteria, basically. And I think that for some of our some of our population it is quite difficult. You know, like you have three children, you're trying to get diagnosed with PMDD, you just don't have the time. So it can be challenging for some people. So at least we have the option of being of giving a PMDD provisional diagnosis until the person kind of hands in the two months perspective readings. But typically I really try to encourage them to do it either like you said, on the smartphone or some people just like hard paper copy. So it's it's doable. But I think maybe in ten years there may be changes again to that specific criteria.

Audrey Le:
And thinking of those rating scales. What are some rating scales that are typically used in diagnosing premenstrual dysphoric disorder that you use?

Dr. Nguyen:
They're quite widely available now, particularly given that a lot of women are trying to track their fertility. So you just there are several apps like Overview and several other new apps as well. It's called Fertility. I don't remember, but there are several for both iPhones and Google Samsung phones now. And even if you just do, you don't even have to download an app. You can just do a Google search and you'll see like all of these paper forms, you just have to make sure that the big categories, like the effect of symptoms, cognitive symptoms, physical symptoms are all properly listed, but they're widely available and free.

Nima Nahiddi:
Now that we've reviewed the diagnosis of premenstrual dysphoric disorder, what is your approach to the treatment once you've diagnosed someone?

Dr. Nguyen:
It really depends on the patient. I think most of I think most of reproductive psychiatry is. There's a lot of joint decision because it's such a it's such a personal decision. For example, for PMDD, it depends whether the woman is willing to consider contraception, in which case you could try something like Yasmin for three cycles with four days off. It's important to mention, though, because I see this very commonly, is that you cannot just throw any oral contraceptive pill at PMDD and hope that it works. Several pills, particularly the ones that have more androgen potency, actually can make PMDD worse. One common culprit is alesse, for example, which is quite commonly prescribed. So even though if alesse has very low levels of hormones and so some GP's or some other health care practitioners may think that this is going to be helpful for someone who's suffering from PMDD. It actually is not about the levels of hormones but about the potency and which direction, which of the different classes of the steroid hormones that I mentioned earlier, which the oral contraceptive is offering. And the other thing that people often forget is that you have to prescribe it really three cycles and four days off, which is not the typical regimen for oral contraceptive pills. Usually it's like three weeks on and then you have like a week of sugar pills or placebo pills. But you need to do this to disrupt the cycle and to help in terms of the PMDD symptoms. Another aspect I would say is some women actually come to me already on SSRI, And then I think in that case, it's easy to consider, okay, why don't you try to increase your SSRI during your luteal period? And so the week before menses, this is depending on their perspective tracking this.

Dr. Nguyen:
This can be useful in terms of knowing. Does the woman start to have symptoms right after ovulation, which some women do, unfortunately. So they have like a full two weeks of symptoms that then only start to improve slightly when menses start. Some women only have like three days of symptoms before their period occurs. And so depending on the timing that you can tell them to increase, bump it up a little bit. For example, if the person is on escitalopram, they could go up to 25 or 30 just for that period. What's important to remember is that the mechanism through which the SSRI work for PMDD is not the same as how it works for depression, for depression and anxiety. You have all of these changes at the synapse or occurring the changes in auto receptors 5HT1A But for PMDD, it's really thought to occur through a disruption in the way that the hormones are being metabolized. So again, because there's this communication between the serotonin and just overall neurotransmitter systems and the hormones, basically the if you administer SSRIs or an increased dose of SSRI during this period of time, perhaps it's changing how fast the hormones are being self-rated or converted to different metabolites in a way that then helps women. So there's still a lot of research, kind of more fundamental research that needs to be done in terms of how that occurs. Exactly. But there are now several studies showing that the SSRI are quite effective for PMDD when administered in this fashion.

Nima Nahiddi:
So to clarify for pharmacological treatments, there's oral contraceptive pill and SSRI. And so can you explain in which situation would you choose one or the other or would you recommend one or the other?

Dr. Nguyen:
I think I've touched a bit on that in terms of, you know, depending on the on the patient perspective and what they what they want to priorities. Some women may be in the midst of trying to conceive and so the Yasmin wouldn't be the right choice for them. Some women might have a family or personal history of stroke, pulmonary embolism, deep vein thrombosis and other and have other risk factors such as being over 35 years old and smoking, etc. And in that case, Yasmin and Yaz, that whole category of oral contraceptives actually are associated with an increased risk of stroke and deep vein thrombosis, etc. So there are some exclusions in some cases where I tend to shy away from the Yasmin or Yaz, oftentimes. Also, it may be easier for women who are already on SSRI to just continue on and just change their dosages that way. And then it's less stressful for them in terms of changing medications. I just want to mention also that if SSRI and oral contraceptives don't work, then you can help. GNRH agonist or antagonists are kind of like basically surgical or medical menopause. So this is really a last resort, though. And I would say 70 to 90% of women actually respond to Yasmin or SSRI. And in terms of the study. It does seem that the contraceptives have a slightly higher rate of success. It may be 80 to 90% versus the SSRIs, which are more like 70 to 80%. So like a highly treatable condition.

Nima Nahiddi:
You had mentioned that we should avoid certain contraceptives like Alesse, What is the specific reason why you would avoid that? Just to clarify.

Dr. Nguyen:
So some contraceptives have more androgen activity like you remember, Like the difference, like there's androgen activity, progestogen activity and estrogen activity. So each pill actually has different balances or mixes of of that similar to, I guess, the antidepressants in the different neurotransmitters. So if you have one that acts more on androgen and not so much on the drospirenone or basically it's the metabolite that is in the progesterone category that is part of Yasmin and Yaz, then it's not going to be effective. So some some contraceptives will just be neutral. It will neither help nor worsen the PMDD and then some others will make it worse if they have the wrong mix, if they have too much androgen activity, for example. And then that's why we think that it's Yasmin or Yaz, that has that is efficacious because of that drospirenone metabolite specific to those medications.

Nima Nahiddi:
Thank you so much for clarifying that. Are there any lifestyle interventions that can help with the treatment of PMDD?

Dr. Nguyen:
Unfortunately, there's very weak evidence to support that. Some women will say, I've tried calcium, I've tried B vitamins, I've tried exercise. And I'm not saying like in lots of cases, add on CBT, add on light therapy even could help. There's a lot of different conditions, but it's just that the the evidence behind those complementary therapies is still quite weak.

Nima Nahiddi:
So I'd like to finish our discussion by going to another topic. Mental health concerns during the perimenopausal period. Can you clarify? First, the definition of perimenopausal?

Dr. Nguyen:
Perimenopausal is again, difficult to define because you have so you have menopause, which is one year after the cessation of the complete cessation of menses. So you can basically only define menopause retrospectively because you never know if you're going to have another period at perimenopause. In most of the studies are is thought to represent the whole period of when the ovaries or the follicles are starting to decline up until menopause, which is one year after the last period. And then you have early perimenopause and you have late perimenopause. I feel like for your learning, you don't need to know all the details of that, but just know that the changes of hormones are different in early versus late perimenopause. Menopause in early perimenopause, you can see a lot of erratic changes in estradiol and other hormones, too. I don't want to get too much into the complexities of that. And in the late period menopause, that's when you start to see a profile that is more similar to menopause. So a lot of ups and downs and fluctuations throughout that whole period. And just to mention that some women can start to enter the early menopause around age 40, 45 years old. So it can be quite much earlier than than some of us would expect.

Nima Nahiddi:
And what are some mental health concerns that arise during this time period?

Dr. Nguyen:
It's typically anxiety and depression, but you will also see exacerbations of schizophrenia and exacerbations of bipolar disorder, for example. So again, if you have a patient with bipolar disorder or schizophrenia and suddenly you have treatment resistance, you have to think about asking those questions about the menstrual, the menstrual history and reproductive history in terms of the more common disorders like anxiety and depression. And so what we see is that these perimenopausal mental disorders tend to be more persistent and more comorbid. So instead of just seeing a classical picture of depression, you will see a lot of anxiety, kind of depression with anxious features, difficult to treat, a lot of insomnia. And sometimes the women will describe it as the worst, the worst mental breakdown that she's had during her entire life and accompanied accompanying these mental symptoms. You have, of course, the physical symptoms also. So the hot flashes, the vaginal dryness, there's a lot of discomfort physically that occurred during this time as well.

Nima Nahiddi:
Can you speak about the incidence of depression specifically in the perimenopausal period and perhaps what effect estrogen has in the treatment of depression?

Dr. Nguyen:
I think other than the fact that the depression is often comorbid with anxiety in terms of presentation, I don't see any remarkable features of the depressive symptoms that are different from an MDD at another period of life. It's possible, though, that in terms of psychological and social contexts it's even harder because it's like a woman ageing, her children leaving. There's a lot of life changes also that are different from other periods of life in terms of the hormonal treatment. So I mean, we do consider transdermal estradiol as one of the useful add ons to antidepressant treatment. I don't tend because I'm not a gynaecologist, I don't tend to start with the transdermal estradiol, Some gynaecologists will, and I guess it's for them to comment on how the how they think, how they consider it first line versus second line. For me, I consider it more second line because there are several antidepressants. All of the antidepressant categories have been shown to be effective for perimenopausal depression and anxiety. Maybe with the SNRIs being a little bit more effective, we think because of all of the hypothalamic changes and dysfunction in the noradrenergic nucleus in the hypothalamus that happened with hot flashes. And that may also be may also cause some of the mood fluctuations that occurred during this period. So perhaps a SNRI a little bit more effective, but SSRI is also effective. Mirtazapine is also effective. I wouldn't go so much with bupropion though, because it's too activating and it can increase the anxiety that is often comorbid with perimenopausal depression.

Dr. Nguyen:
And then if that doesn't work, then you can consider something like transdermal estradiol. I think Raloxifene at some point was also discussed. It tends not to be very effective, maybe mildly effective sometimes a bit like how we use Pregabalin for for GAD like it can be effective, but oftentimes more like an ad as an add on. It actually has been studied in schizophrenia. I don't know if you're aware, but in terms of schizophrenia for cognitive and effective symptoms of schizophrenia and Raloxifene, which is a selective receptor modulator, seems to be effective for those symptoms in schizophrenia. And so that's why sometimes we also use it for perimenopausal depression. If someone, for example, has contraindications to transdermal estradiol, I always make sure to have a family doctor or a gynaecologist who is my partner in prescribing these medications. Typically, I've had no issues with people kind of collaborating and getting back to me quickly. And usually it's like at least it takes six weeks of transdermal estradiol and sometimes a bit more six weeks to six months. I would say after that I would be reluctant to continue to prescribe unless I have like an ultrasound or a really good follow up by the the other either family doctor or gynaecologist to make sure that endometrial thickness is not has not change, etc..

Nima Nahiddi:
And these other side effects that you've spoken about, like hot flashes that occur during menopause, do you find that these contribute to having increased mental health concerns?

Dr. Nguyen:
So just like the co-morbidity between PMDD and MDD, sometimes it's hard to disentangle. However, all of the prospective studies have shown that even when you control for hot flashes and all of the physical symptoms of menopause, you still have a peak. So the mental health symptoms do seem to be independent, although of course, the worse, the more anxious you are, the more you can suffer from hot flashes also. So so so there's a bidirectional kind of exacerbation that can occur. But even in a woman who would have very little physical symptoms of perimenopause, you can still have an increased risk of perimenopausal depression, anxiety, as well as exacerbations of bipolar disorder and schizophrenia.

Nima Nahiddi:
Thank you so much for that overview of reproductive mental health. Before we leave, do you have any specific clinical pearls you'd like to leave our listeners with?

Dr. Nguyen:
Oh, I would say I mean, I hope that everyone who listens to this podcast will remember to ask about menstrual history, because that's what I kept repeating throughout the podcast and then strong sexual history. I think these are really key and this is something that we often as psychiatrists feel uncomfortable to talk about and at any life stage, as you can see. So even a woman who comes to you 55 years old. So I have to ask about reproductive history, sexual history as well.

Nima Nahiddi:
Thank you so much, Dr. Nguyen.

Dr. Nguyen:
You're welcome.

Arielle Geist:
Site is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode is produced by Dr. Nima Nahiddi, Dr. Arielle Geist, Dr. Audrey Le and Dr. Rebecca Marsh. The episode was hosted by Dr. Nima Nahiddi, Dr. Arielle Geist and Dr. Audrey Le. The audio editing was done by Dr. Audrey Le and the show notes were done by Dr. Arielle Geist. Our theme song is Working Solutions by All Live Music, and a special thanks to the incredible guests we had today, Dr. Nguyen, for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

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Episode 40: Suicide Epidemiology and Prevention with Dr. Juveria Zaheer

PsychEd+Episode+40+Suicide+Epidemiology and Prevention with Dr. Juveria Zaheer.mp3: Audio automatically transcribed by Sonix

PsychEd Episode 40 Suicide Epidemiology and Prevention with Dr. Juveria Zaheer.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Chase:
Welcome to PsychEd the Psychiatry podcast for Medical Learners by Medical Learners. Today, we'll be taking a deeper dive into talking a bit more about suicide. It will cover additional topics relating to suicide risk assessment, suicide prevention and suicide epidemiology. Today, our guest expert is Dr. Juveria Zaheer. Dr. Zaheer is a clinician scientist with the Institute for Mental Health Policy Research, and she is also the medical head of the CAMH emergency department in Toronto, Ontario. She's also a assistant professor in the Department of Psychiatry at the University of Toronto. Her research integrates both population level investigations with qualitative research on an individual level to better understand mental health service delivery and service outcomes as it relates to suicide and psychiatric care. My name is Chase Thompson. I'm a fourth-year psychiatry resident at the University of Toronto, and I'll be hosting this episode. The learning objectives for this episode are as follows: One, develop an awareness of suicide risk and suicide prevalence as it pertains to the general population as well as psychiatric populations. Two, incorporate additional contextual information into suicide risk assessment that goes beyond SAD PERSONS or other list-based approaches. And three, develop a deeper understanding of how to approach and help individuals with suicidal thoughts and behaviours. Hope you enjoy the conversation.

Chase:
Thank you so much, Dr. Zahir, for joining us today and talking a little bit more about suicide. Just for our listeners, this episode is meant to build on some of the previous topics we've had in suicide, assessing suicide risk, as well as how to manage suicidal patients. But I think that it's important for us to have a little bit more of an in-depth conversation on this topic, given how often it comes up and how important it is to psychiatric practice. So thank you so much for joining us, and I'll just let you introduce yourself. I know you've been a frequent podcast guest at this point. I think this is your third interview, as we discussed earlier.

Dr. Juveria Zaheer:
Yeah. Thanks so much, Chase. My name is Juveria Zaheer, please call me Juveria. I am a psychiatrist at the Centre for Addiction and Mental Health in Toronto, Ontario. I am the emergency department medical head at CAMH. So we are the only standalone emergency department in Ontario and our goal is to provide ethical, evidence-based and dignified care to the people who walk through our doors. And I am also a clinician scientist and my program of research is focussed on suicide and suicide prevention, trying to understand the epidemiology of suicide, the lived experience of people with suicidal behaviour and to bring them together to co-create interventions that work.

Chase:
So I think one of the things that I wanted to touch on, you know, in this conversation is something that you spoke about in the previous conversation you had with us about: we tend to stratify individuals as low, medium or high suicide risk. But, you know, as trainees and residents working in the emergency department, sometimes it's hard, I think, for us to kind of have a more concrete idea of what that means. And we often don't really get taught about some of the statistics around suicide and the numbers or how often this actually happens. So I'm wondering if we could go through that a bit and kind of talk about suicide risk as it pertains to different populations in psychiatry.

Dr. Juveria Zaheer:
Yeah, I think that's a really important question because it's sort of like zooming out to see what the lay of the land is and then we can zoom in to make sure we understand a person's individual risk. So I think if you if you meet 100 people, probably 100 of them have been affected by suicide in some way. Suicide is the leading cause of death for young people and it is a top ten cause of death here in Canada. So when we think about what our rates of suicide, we often put them in person-years. So in Canada, we have 11 suicide deaths per 100,000 person-years, and person-years can feel a little bit tricky. But basically what it means is it's using, it's trying to account for the number of people that you're following and the length of time that you're following them. So I could follow a thousand people for one year and that would be 10,000 person-years. Or I could follow 100 people for ten years and it's the same amount of person-years. So we're looking at about 11 per 100,000 in Canada across the general population. And I know that one of the first things that medical students and residents are taught is that men die by suicide three times more often than women do, about 3.2 times more often in Canada, which is very consistent with other sort of white majority countries, European, North American countries. I think it's really important to point out, though, that women engage in non-fatal suicidal behaviour at a rate about 3 to 4 to 1, and that in itself is a really important treatment target and this gender ratio is quite culturally mediated. So in other parts of the world, that gender gap is much lower and up until about 15 years ago in China, women actually died by suicide more than men do and the rates there are about 50/50.

Dr. Juveria Zaheer:
And I think it's really important when we think about how we stratify risk or how we understand risk, to understand that there are certain things that are going to be more important than others. If you're a clinician and if you have a man or a woman sitting in front of you, the most important thing isn't their gender on an individual level, the most important thing is their history of suicidal behaviour or their current suicidal ideation, or whether they've been recently discharged from hospital. So, for example, in a in a psychiatric population and we consider that to be like anyone who has been admitted, say in the last year, you're looking at 500 suicide deaths per 100 000 person-years. And if we look at like closer discharge, so if you look at people who are discharged within the past week, it's close to 3000 per 100 000 person-years. So the closer you are to a discharge, the higher your risk is. And then I think an area that we don't talk about too much that can be quite frightening and dramatic for folks, for families and for patients and for care providers is that people do die by suicide in hospital. And so one out of every 600 or so psychiatric admissions can end in a suicide death in hospital but it's really important to point out that environmental factors, programmatic factors are so important and this is a really important area where we could reduce suicide risk and there's a lot of variability within institutions based on the kind of care that's provided and the kind of environment that you're looking at.

Chase:
Right. And I know you had mentioned that the gender gap in suicide rate is actually quite culturally mediated. I know you've done some work in this area, and I'm wondering if you could speak to the kind of anomaly that China represented where they didn't have that same gender gap that we see in North American culture?

Dr. Juveria Zaheer:
Yeah absolutely.

Chase:
Do you know what's going on there?

Dr. Juveria Zaheer:
Yeah, I think it's a really big and a really important question, especially when we live in a place like Canada that's so diverse and we know that, for example, my background is Indian Muslim, and although I was born in Canada, my risk is actually more similar to an Indian woman living in India for at least 2 or 3 generations and so understanding suicide risk in different cultures can be really important in prevention. And so, you know, classically when we formulate suicide, so people like Durkheim, Emile Durkheim, who was a sociologist, talked about how only men have the sort of the strength and the decision-making ability to die by suicide. And so it's the idea that non-fatal suicidal behaviour then culturally becomes something that a woman does and death by suicide is something that a man does. And these cultural scripts are so important because for a man who's suffering, who may be socially isolated or who may be not engaging in mental health care, it becomes a script that that makes sense to them and that's really important in suicide prevention. In China, though, up until, you know, the 90s and the 2000s, like psychiatry, is a relatively new discipline and suicide often didn't show up in psychiatry or neurology textbooks. It was more of a behaviour, it was an act of a powerless person in a very difficult situation. And the other thing to to point out around Chinese women in particular is the gender gap where women are dying more often than men is often seen in rural areas because women often engage in the consumption of poison, so rat poison, agricultural poison. And when you, those can be very fatal and so there's if you have an impulsive overdose attempt, for example, the risk of death is quite high. And there's a beautiful quote from some sociological work in China that said, 'when somebody dies of suicide, we don't ask why, we ask who is to blame'. And so we sort of start to see how important culture, gender construction of suicide is in suicide prevention.

Chase:
And the other thing that stood out to me about what you said, you know, when we're talking about the population of individuals who's recently discharged from hospital, the number I think was 3000 suicide deaths per 100,000 person-years, which, you know, is almost 300 times population-based rate. You know, I guess that kind of brings up other issues. Like one might look at that number and think, are we discharging patients too early or what is, is there some sort of lack of risk assessment going on at the discharge period? Or how do you understand that sort of really high risk period right after discharge?

Dr. Juveria Zaheer:
For sure, and I think what you're speaking to is can we develop a sense of therapeutic nihilism that our interventions don't work or our hospitalisation, which is often like the biggest card in your deck for acute care psychiatrist, doesn't work. I think another way of framing it is is a way of trying to be optimistic about the fact that we have a population of people that we know are high risk that we can identify. Often we don't know who's at risk and, you know, in the general community. So is this a place where we can act? And, you know, epidemiological data tells us what's happening. It often doesn't tell us why. And so the other half of my work is qualitative, where we interview people about their lived experiences. And one of the things we've just done, we're doing a study right now where we've interviewed all told 70 people, people who have lived experience of suicidal behaviour, who've been admitted, their family members, care providers. And what keeps coming up in that study is that you're in so much distress, you're in so much pain, you go into a hospital, you get support, you get the right treatment, and when you're discharged, your level of care goes from 100 often to zero. There's a really important paper authored by Paul Kurdyak, who's one of my colleagues, that says in Ontario 68% of people who have a suicide attempt don't have follow up within a month. And so I think as a system, we really need to think about intensive access to care in that post discharge period. So there are things that can work like close-contact follow up, so calling or following up with a person within 24 hours of discharge, higher intensity things than just offering an appointment. So can we meet someone on the inpatient unit, even start psychotherapy with them, have them discharged to the same provider? So I don't necessarily think that it's because hospitalisation doesn't work or that we're necessarily doing something wrong in that piece. I think in all of health care, transitions are so important and cardiac care, if you have an MI, then you go to cardiac rehab and trying to figure out in mental health care, how we can sort of honour the suffering of the people that we're serving and make sure that we don't go from 100 to 0.

Chase:
Right. Makes sense.

Dr. Juveria Zaheer:
And I think and I think the other piece is that, you know, epidemiologically, we're selecting for a very, very sick population. And I think anyone who has you know, it's an honour often to sit with someone on the worst day of their life and they tell you their story and they're in so much pain and you bring them into the hospital to help them. There's you see ten people you may admit two, and they are people who are very, very unwell and they're deserving of sort of very good in-patient care and then transitional care thereafter. And I think that's another piece of it.

Chase:
There's I guess, been some conjecture that potentially with the sort of deinstitutionalisation of psychiatry, the burden of suicide risk has actually kind of moved from, you know, the institution in the past, as we would call it, and now sort of exists more in the community. Do you think that's also plays into that part of the elevated risk in the post-discharge period or.

Dr. Juveria Zaheer:
Yeah, it's a it's a great question. We know that length of stay is a little bit shorter now, much shorter than it was back in the day and we know that very intensive services are less available. I do think, though, that one of the really important pieces around framing suicide prevention is it's not just a psychiatric issue. I think it's more about it's a public health issue and it has public health components, and that's food security, housing security, financial security and freedom from trauma and oppression. And I think as we see a bit of an unravelling of the social net where we see, you know, people who can't get a job out of high school and buy a house and, you know, have supports in that sense, I think that these broader social factors are really important as well. And so I think it's difficult to sort of understand deinstitutionalisation in context versus kind of the broader picture. And I think to a lot of people who are suffering from suicidal thoughts don't necessarily have the kind of mental illness that is severe enough for long term hospitalisation. So I think we always there's always that stuff that gets thrown around that 90% of people who die by suicide have major mental illness. That psychological autopsy studies are fairly flawed. And there's been some interesting work by the CDC and a nice paper in the New England Journal of Medicine that sort of talks about how the intensity of psychiatric symptoms are only one piece in risk prediction and things like relationship breakdown and conflict, things like housing insecurity, things like financial distress or trauma all play a huge role.

Chase:
So I kind of want to switch gears a little bit. So we have this sort of idea as residents and psychiatrists that, you know, one of our primary tasks is to assess suicide risk and to really kind of quantify the risk when we're presenting the case and charting that risk. But I think one of the things that I've learned from you in part, is that there's a lot of other factors about, you know the patient's wishes. What would be best for them in their certain scenario, whether that means hospitalisation or actually returning home and whether they're able to kind of participate in an outpatient plan that you put together for them. And I think you've also spoken about this on previous podcasts, but, you know, sometimes that means that patients who may have a higher, you know, quantitative risk, if we can say that would end up being discharged versus someone who might be lower risk being hospitalised. I just wanted to ask you, like, are there certain cases where, you know, even when an individual seems sort of reasonable, doesn't seem to have overt symptoms on the face of it, but the, you know, the plan you're sort of putting together seems good, but for whatever reason, you kind of have a bad feeling about the case, either from information you've gotten from family or from collateral, and in those cases, you're considering certification. I'm just wondering, like, how do you sort of approach those cases where the patient is actually presenting very well, but the family is very concerned and sort of saying, you know, well, if they go home, then I'm really worried what's going to happen to them, but there may not be like any sort of material evidence so far that the person is at risk.

Dr. Juveria Zaheer:
Yeah, I think that's a really excellent question, Chase. As an emergency department psychiatrist, I think one of the hardest sort of sets of cases you deal with is when there's conflict. In a perfect world, everybody is on the same page that I say to the patient, I think you're deserving of hope and help. The patient understands that and is hoping to come into hospital for initiation of treatment, and the family is on board as well. And as you say, when there's there's lack of consistency in that triangulation, it can feel very difficult. One of the things that I tell myself and I often share with patients and families, in obviously more appropriate language, is that admission to hospital in and of itself is not an evidence-based strategy for suicide prevention. There are things that we can do in hospital that can prevent suicide. For example, if someone's experiencing depression with psychosis, we can treat that psychosis, which would reduce someone's suicide risk considerably if that's what's driving the risk. If someone is intoxicated and having suicidal ideation in the context of that intoxication, holding and being able to sort of understand the person in context and safety plan thereafter would reduce their risk. And so I think that helps me sort of move beyond admission versus discharge. The question of and the other thing I say and I think I said this in our last podcast together as well, is if I'm working with someone and they want to be admitted, I should have a really compelling reason that I don't think that they should be admitted. And if I'm working with someone and they don't want to be admitted, I should have a really compelling reason for bringing them into hospital and engaging in what is trauma and what is quite carceral.

Dr. Juveria Zaheer:
And so the things that I sort of think about in terms of involuntary hospitalisation is trying to hold on to a thread of hope, if someone can hold on to a thread of hope and they want to be alive and they want to engage in care, then there's a lot that we can do to support them. So, for example, safety planning is an evidence-based intervention in suicide prevention. There's a lovely paper in JAMA Psychiatry that shows that we show a 50% reduction in suicidal behaviour post discharge if a safety plan is completed. So a red flag for me is if someone can't safety plan, if they say I have nothing to live for, I don't really I have no hope, I have no one to connect with, that makes me a little bit concerned. Things that can really affect someone's ability to plan or to not be impulsive make me really nervous. We did a study that showed that of people who die by suicide between the ages of 25 and 34 in Ontario, something like a fifth or a quarter of them have a diagnosis of schizophrenia. So for younger folks, having a psychotic disorder is a really big risk factor for suicide, and it's really treatable. Psychosis is treatable and psychosis hurts and bringing someone to hospital to manage that, if someone has psychosis, whether it's an affective psychosis, whether it's a primary psychotic disorder, postpartum psychosis is very high risk. These are people I tend to bring into the hospital because if you're not able, if you think about keeping yourself safe, the psychosis can really interfere with that. Around family work, I think one of the biggest principles in working with families is is radical genuineness and radical transparency. So to be honest and open about what we're thinking, I'll often say to a patient, I'm really worried about you. I'll say to a family, you know, I would really love to keep your loved one in hospital. I'm worried too, and not but, and, here are the limitations of the Mental Health Act. And so I think if somebody I think one of the dangers in risk assessment is say, if I see somebody and they had a very serious suicide attempt. They engaged in preparatory behaviour, so they wrote notes to their loved ones, they've been giving away their belongings, they have a very deep depression that is sort of characterised by decreased problem solving ability, a lot of pain and potentially even some psychotic symptoms and that person has an overdose attempt. They made efforts to seclude themselves, they happen to be found and they come in and they're sitting in front of you and they say, oh, everything's fine, I'm not suicidal anymore. One of the really important things to think about is like, what has changed between now and then? And for this person, not much has changed and there's very much that could be modified. And if you can come up with a way to keep that person safe, in hospital, can someone stay with them 24 over seven? Can we start treatment? Can they come to day hospital and be seen every day? Then you can kind of modify that risk. But if the person says, no, I'm done here, and you know that three months ago they were going to work every day and they were really active in parenting their children. And, you know, they have a family history where someone died by suicide in the same circumstances. That's a situation in which I would certainly certify. If you meet someone who, you know, brings themselves in, I have a very difficult time when someone brings themselves in for care and they're really honest about what they're going through, you know, that's a really good sign that they're able to engage and they're able to share with you what they need. And that's a it's kind of like the the door is open. There's a crack, there's a light where you can kind of connect with them and support them in that sense.

Chase:
For sure. Even sort of talking about, you know, the individual who's brought in by family, who's kind of concerned about suicidality. It sort of, even reminds me of when you see patients who are suffering with addictions and the family brings them in similarly and the person isn't kind of really ready to engage in that sort of care. And, you know, I think we understand that they need help at some level. And but at the same time, in terms of addiction and sometimes suicidality, the person is still kind of in that stage where they're not ready to engage with care or that can make it really hard too when you and the family are sort of on the opposite page as the patient.

Dr. Juveria Zaheer:
For sure, one of my colleagues, Gina Nicoll, who has dual expertise, she has lived experience with suicidal behaviour and is also does research with me, she says something really beautiful. She said, 'it's really important, not like not to just try to understand the plan, but to understand the pain behind the plan'. And so I think sometimes when people are feeling really ambivalent about living or dying or getting care or not getting care to try to focus maybe less on the plan and less on keeping someone safe and more on what's going on in your life that is so painful and what is driving it. Yvonne Bergman often says, one of her lines that is so moving, is when people want to die by suicide and you ask them what they want to end, they don't often say my life, they often say I'm exhausted or I'm a burden or I'm terrified. And sometimes connecting with that emotion and that feeling, it's almost like a motivational interviewing approach, as if we can connect with that person as a person, then it can help us understand how we can get at that underlying piece behind the work. And so I think there's some really interesting parallels with addictions as well. And I think any kind of tools that families have are really useful. In our work with families, so we've interviewed people who who've lost loved ones to suicide and who've supported loved ones in navigating the health care system. People don't necessarily often complain about like, I brought them to the hospital and they weren't admitted. They are really distressed about lack of communication, lack of open communication. They are really distressed about the differences between like confidentiality and safety, like that kind of space there. They get really distressed that the follow up plan makes no sense. Like, oh, you want me to follow up in three months? That doesn't make a lot of sense. And so I think there's instead of getting stuck on admission versus discharge, even with families, to sort of try to understand their concerns and context and try to do whatever we can to make sure that we have a safe discharge plan for someone and that we can help them engage in the supports they need. And if the person isn't ready, then that we have a plan in place that if they're ready, like can we like harness that moment and bring them into the hospital and do what we need to do at that point?

Chase:
Yeah. One thing you stressed is evidence-based care for patients with suicidality. And one of those things is completing a safety plan for that patient. I'm just wondering, is there any sort of particular, you know, diagnostic category that you might consider completing a safety plan, or are they really good for most patients who are having suicidal thoughts or behaviours?

Dr. Juveria Zaheer:
Yeah, I love that question. I talk about safety planning all day. So I think the old term that people often use to use is like contracting for safety. So like if I say like, you promise you're not going to do anything right, there's no evidence for that because you're not actually giving the person any support or skills in that moment. The cool thing about safety planning, you know, you talk about reasons for living. How do I distract myself? Who do I call to distract myself? Who do I call for support, resources that I can talk, I can contact and keeping my environment safe. So a little bit of means restriction in there. Every time you use the safety plan effectively, it's positively reinforcing, which is really, really cool. Although like safety plans aren't a panacea, like there's certain times where it's not going to work and timing is really important. So you mentioned around, I'll come back to the timing piece, but around diagnosis. Suicide safety planning is a pan diagnostic intervention, but there are certain people who may struggle with safety planning. So, for example, someone who's experiencing mania or psychosis, this may not be the right moment or the right time to engage in safety planning, although you can still engage in kind of a modified form of safety planning. We just had a meeting yesterday with our colleagues at the Adult Neurodevelopmental Service, and we talked about how do we adapt a safety plan for people with intellectual disabilities or people with autism. We're doing some research right now where we interview people about their views on safety plans. And so I think that's a really great place to start, is ask someone what do you think about this process? And if someone is like all in on it, then absolutely do it. If someone is kind of ambivalent, sit with them and show them. If someone is like, No, I've done it, this doesn't help me, find an alternative.

Dr. Juveria Zaheer:
The other piece that I mentioned earlier is around timing and safety planning. My colleague Gina often talks about waiting until the emotional bleeding has stopped. It can be extraordinarily invalidating, if I came to you in crisis and you were seeing me and I was saying that my relationship has broken down and I have been staring at a bottle of pills and I feel so alone and I'm not working, and you hand me a safety plan, you haven't even assessed me yet. A safety plan should be something that we come to collaboratively and we talk about the sort of striking while the iron is cold rather than trying to do the safety plan in the midst of crisis. I really like the idea of talking to folks about what works for them, and people are really good about about telling you. And I didn't realise until we started to do the research, but some people say to me, I prefer visual safety planning. Someone said to me once, I prefer a safety plan that's like a circle, so there's not an end to it. Some people say, like, I've been through this enough times that I can do it all in my head, and having a piece of paper isn't helpful. There's something at CAMH called the Hope App, which is really excellent. And for people who are like really good at the Internet, the app might feel a lot better. Often we ask who's important to you and we can photocopy the safety plan and give it to people that they love or give it to their care team too, which is really useful. One of the things I say is if you have like an iPhone, take a picture of it and then do the heart so it goes into your favourites so you can always find it easily. So I think that safety plans, again, they're not going to solve everybody's problems for sure, but they're sort of a tool in your arsenal that can be very helpful. And also it gives us kind of a shared language. So if my outpatient, for example, is struggling, they can say, you know, I've worked all the way through my safety plan and I know I need to come to hospital, and that's very useful and effective to know.

Chase:
I've definitely had the experience of being sort of an earlier trainee and bringing a safety plan to, I believe it was an older gentleman who was having suicidal thoughts, and he did find it to be quite invalidating to actually receive the plan and sort of fill it out with me. So I think I have sort of learned to ask as well if people find that helpful or appropriate or if they've done one in the past before, sort of jumping into completing one at this point.

Dr. Juveria Zaheer:
Yeah, absolutely. Like any time like it's we always talk about how like we always try to find the perfect question or the perfect thing to do, but it's not about the perfect thing to do, the perfect questions but the relationship. And so figuring out what the relationship, that's another Gina-ism. So figuring out what the relationship is is really, really useful and and reading the room before you start with one intervention or the other. And I think in in suicide-safe mental health care, choice is so important. Treating someone with dignity is really important. Not jumping to conclusions is important. Like if someone has been on Mirtazapine in the past and they hated it, then you probably would offer other choices. And so in the same in suicide safe care, if someone doesn't like doing a safety plan, is there something else that we could do that could be helpful?

Chase:
And just on the lines of evidence-based care for patients with suicidality. Are there other sort of treatments that we should be looking towards when a patient is having a high degree of suicidality, maybe across some diagnoses? We could talk about those a bit.

Dr. Juveria Zaheer:
Absolutely. I sort of think about suicide prevention strategies in four large buckets. So the first is how do we create a world where every life is worth living? And that means things like housing interventions, universal basic income, making sure that people are free from trauma and oppression, sort of like one bucket. How do we make the world a better and safer place? The second bucket is around understanding the treatment of underlying mental health issues. So we if somebody has depression, if somebody has schizophrenia, engaging in treatment for those for those illnesses. So we know that lithium, for example, is an evidence-based suicide prevention strategy for folks with mood disorders. We know that Clozapine is an evidence-based suicide prevention strategy for folks with psychotic disorders. So making sure that we know what the diagnosis is and then treating it. DBT, CBT, other types of psychotherapeutic interventions and antidepressants, not individually, they're not like lithium or clozapine, but as a class has level one evidence. Young people are really, really, really responsive to any kind of suicide prevention strategy. So any kind of sort of psychotherapy or higher term support for those young folks. And then the third bucket I think of is like public health interventions that are maybe more specific than the first bucket we talked about. So that's things like means restrictions. So gun control, lock boxes for poisons, bridge barriers that that kind of group of interventions, and then things like positive messaging around suicide and suicide safety in the media. So we think about the Werther effect where suicide can have a contagion effect. The opposite is the propaganda effect where we can talk about suicide in a safe way, show that there is care available and hope exists and help exists, that can be really important. Other types of interventions in that kind of bucket are things like gatekeeper education. So, for example, in the armed forces, if you can train like the generals and the corporals and the people who are kind of higher up to understand mental illness and to be open about it, it might make it easier for other people to get care. This works very well in schools as well, and religious institutions. And then primary physician knowledge and engagement, so like upscaling family docs and other care providers to be able to pick up on the signs of depression and suicidality. And then there's like this last bucket, which is kind of one that I'm really interested in, which is like specific interventions for suicide, often pan diagnostic. So the safety plan is one of them for sure. Another one of them that we're sort of trying to build evidence for is something called close contact follow up. So it's a little bit what we talked about earlier. So if you're getting discharged from an emerge or you're getting discharged from an inpatient unit, like someone will call you or reach out to you or you'll have like more intensive care in that period.

Dr. Juveria Zaheer:
There's also psychotherapies that are specifically designed for suicide prevention. So things like CAMS is a really effective treatment, DBT, CBT for suicidality, these sorts of interventions can be very useful. Family and patient psychoeducation can be very useful as well. And then individual means restriction, so like talking to people about safe prescribing. If someone is, a risk factor for someone for engaging in suicidal behaviour is alcohol, like getting the alcohol out of the house. If somebody is like feeling really unsafe around subways, like avoidance of those things. So it's kind of like safety plan adjacent, like trying to make your environment safe. And then we also, I think in the biological treatments we mentioned things like ECT, rTMS, ketamine, lots of new things with evidence building. So I think basically the principles are how do we create a world that's safe for folks both in terms of like both broadly and more narrowly? How do we make sure we treat the underlying illnesses that are raising suicide risk and reminding ourselves that mental illness is only one part of suicide prevention. And then the third, the last bucket is how do we engage in suicide safe care in terms of suicide specific interventions?

Chase:
And on the note of providing evidence-based care for patients with suicidality. I think sometimes, you know, we hear this sort of comment that like, oh, it's impossible to prevent or or we don't know that this particular intervention, including like SSRIs, even, is known to prevent suicide. And I think sometimes that can make one feel a little bit disenfranchised with some of the treatments we have. And are we even, you know, this patient's coming to me with suicidal thoughts and am I even helping them because I have this supervisor who told me this is this particular intervention has no evidence for reducing suicide. So I guess my question is like, you know, why is it so notoriously difficult to prove that our interventions are effective for reducing suicide? And and why do we have limited evidence on these?

Dr. Juveria Zaheer:
Yeah, absolutely. And as for like the Zaltzman paper that came out in 2016, it's a review in Lancet psychiatry and suicide prevention, SSRIs as a class do have level one evidence in preventing suicide. But you're absolutely right. It's not like I can link this prescription for Prozac with reduction in suicide deaths, because doing an RCT around suicide is very, very difficult because suicide is an extraordinarily rare outcome. So we often use proxy measures like suicidal ideation or suicide related behaviour. The other piece is that but even those aren't necessarily common, especially suicide related behaviour. The other thing is often in studies like people with suicidality are often excluded and so people think we're there too. Even for me, someone who does qualitative work, you know, you have to struggle with IRB to get approved, to even talk to folks who are experiencing suicidal ideation. And I think, too, like suicide is so multifactorial that one of the challenges in working with folks with suicidal ideation is that it's a complex problem that requires complex solutions. But there are interventions that work and hope and help exist. And I think to your initial point, I loved kind of hearing you describe that feeling as a trainee when you're sort of trying to navigate these two messages. So one message is that we can't prevent suicide. We get that in training. We have a terrible outcome and we reassure each other with this statement and it has its benefit in that it can help us feel better when something awful happens. It can be reassuring for families too, who did everything they could for their loved one. But it has, it's problematic in the sense like how do you, it can cause therapeutic nihilism. It can make us like not think as seriously about treating people who are really, really suffering. And then the second one is like, every suicide is preventable and that's lovely because we want to make sure that nobody dies of any kind of illness. And the goal of zero suicide and suicide, perfect care for people with suicidal ideation is so, so important. The problem with that, though, is that it can lead to a lot of distress in care providers and families. It can also lead to really bad outcomes like, are we just not going to see people who we think we can't help? Are we going to put everybody on a form one? It can be, it's really a tough kind of dichotomy to navigate. So like swinging between like therapeutic nihilism to like feeling awful about ourselves and our system.

Dr. Juveria Zaheer:
So for me, the way that I kind of the story that I tell myself is that like every suicide death is an extraordinary tragedy that affects families and care providers and the person whose life is cut short. And at the same time, suicidal ideation is a really important treatment target and people who are experiencing suicidal thoughts are deserving of hope and help, and we do have treatments and therapies that work. And so if it takes all of us to prevent suicide, I individually can't change the way the world is. We can advocate and we can be activists, but we can't change the whole world, but we can do our part. And that makes me feel better. And when I think when I do a suicide risk assessment, my goal is to make the person feel comfortable and safe. To say, I'm so glad you came, and like these these thoughts can often feel really shameful, but to say, like a lot of people have been through what you've been through and they've come through the other side. So stories of hope and recovery can be very useful for people, not in a toxic positivity kind of way, but in a natural and genuine way. And then once the person is feeling safe or more comfortable with you, then how can we understand their risk in context? How do we get all the answers to all the questions, understand their narrative of suicide, understand their risk factors, understand their protective factors, and work systematically to manage the risk factors and to strengthen the protective factors. And that's kind of the approach that I take. So it's less about prediction and most more about like best practices and providing good care. So if I see someone who has alcohol use disorder and when they use alcohol, it makes them at higher risk for suicide, we can do things like taking the alcohol out of the house. We can also help them enrol in addiction services, we can start them on naltrexone, we can introduce them to to other psychosocial rehabilitation models. And so if we can kind of link everything that the person is going through to their suicide risk as like making it higher or lower, and we can both address their suicide risk, but we can also decrease their suffering, which is ultimately the goal and have them live a life with meaning.

Chase:
Right. And I think one of the things, too, that I also came to understand is that, you know, saying that something doesn't have any evidence in preventing suicide doesn't mean that it has been proven not to have any benefit in preventing suicide. It's just that also that we don't have possibly the power of or powerful enough studies to kind of show the effects that we're looking for as well.

Dr. Juveria Zaheer:
Absolutely. And that's the challenge. So we know, if we can understand what the risk factors are across a broader population, then I think it makes sense that treating those individual risk factors can help. And I think the other really important piece is and this is like a plug for for qualitative research, is that understanding. There's no there's no like with like for us without us, right? Like there's no way of understanding someone's lived experience of suicidality and what helps and what doesn't unless we actually talk to folks and have them help us understand what's meaningful or not. So I think like engagement and co-creation is really, really valuable too in this population.

Chase:
So one thing that I think comes up in the emergency department quite often, and we have touched on this topic briefly in our borderline personality disorder episodes, but, you know, there's this, I guess, constant balance that we're trying to strike with some of our patients who have borderline personality. On the one hand, we are concerned about their safety and on the other hand, we're also told that we don't want to create sort of this situation where, you know, the individual comes to hospital and we make them feel safe in hospital and we sort of become a de facto coping mechanism for that individual. And I'm just kind of wondering, how do you balance that care for someone's safety and wanting to be validating, but at the same time sort of taking on the cruel to be kind sort of mantra that others have advocated for in terms of treating borderline personality.

Dr. Juveria Zaheer:
For sure. And the first thing I'll say around BPD is it's a diagnosis that does not have a ton of like construct validity in a sense. Like it's not a it's supposed to be a diagnosis that indicates like a lifetime, pervasive pattern of dysfunction. But we do know that a lot of people who are experiencing other types of major mental illness, particularly people who have a trauma history, can look like they have BPD, but that might not be the most appropriate diagnosis or it may be a comorbid diagnosis. So I think for me, one of the things that helps me is to move beyond like how do I treat someone with BPD to like, how do I use universal precautions from trauma at all times? And so many people who come to psychiatric emergency departments have a trauma history. Many people with BPD have trauma. Almost everyone with BPD has trauma, and the system and having suicidal ideation and behaviour is traumatic in and of itself. It's like threatened loss of life and threatened loss of integrity. And so for us at CAMH, and I think for me personally, it's like, well, how can I understand someone's story? How do I make them feel comfortable? How do I make them feel safe? How do I work with them to build safety and autonomy? I think one of the things that we do is if we have someone who is coming into hospital a lot, it's really important to look at their narrative arc of suicide risk. So, for example, if you have someone who is has come in eight times in the last month but hadn't come in in the three years before that, you know, a diagnosis of BPD or a formulation of 'we don't want to reinforce this behaviour' might not be the most accurate one because it could be that there's an episode of severe mental illness that we're just not treating all the way. If we know that someone is not doesn't get better in hospital or gets worse in hospital, I think it's really worth striking while the iron is cold again, having conversations with this person in the context of safety planning outside of the moments of crisis. There's a lovely paper by Von Bergmans and two of her former patients who have BPD that talk about how different I look when I'm not in crisis. And so if we can engage with people and we do this in the CAMH Emerge often as they engage with people when they're not in crisis with their care teams to figure out what exactly is most helpful in the moment. Sometimes what we do is we want to sort of it's kind of a I'm not a DBT expert by any means, but sort of taking we we live and work in a system where, like there's sometimes suicidality can be seen as a ticket to admission and if you don't endorse suicidality, then you can't get admitted. And so then it ends up that people have to up the ante to get the care that they need.

Dr. Juveria Zaheer:
And I often reflect on the word manipulative, right? Like we often use this. It's a very gendered word, first of all. And for someone like me, if I if I had like a loved one or if I myself was struggling, I could call like 100 people and they would help me, like get the care that I need. But that's an incredible privilege. And if you don't have that privilege, all you may have is the emergency department. And so I think, like we see somebody who has increased service utilisation, one of the strategies we use is to try to strike while the iron is cold. It is very difficult to safety plan or to identify one's feelings or needs when one is in distress. And so if we can work with a patient and their care team outside of crisis, then it can really help us understand what they may need when they are in crisis. For some of our patients, we try to get rid of that ticket to admission kind of construct. And so often in mental health care, it's you're admitted if you're suicidal, you're not admitted if you're not. And then the ante keeps getting upped. Well, you're only going to get admitted if you self-harm in the department, you're only going to get admitted if you have a serious suicide attempt. And so what we try to do is disentangle the reinforcement from the behaviour and to say things that we sometimes we do something called a green card strategy where someone can come into hospital for a set number of days, a set number of times in a six-month period. And we really validate and reassure and support people for coming in before their crisis. I think it's really important to remember that people with BPD do die by suicide and they often die by suicide after periods of intense service utilisation. And so coming into hospital to break that cycle can be very useful. We work when we when we bring people in, I think it's really important to identify goals of admission and so that can be really tough when someone is like really activated and struggling. But to say, you know, we'd like to bring you in, we'd like to review your medications, help you connect with family, try to arrange good follow up, which is part of the problem, right? Like if you go from everything to nothing, that's a huge problem. And I think trying to be open and transparent and honest about, here are our behavioural expectations, what are your expectations of us? What do we think this length of stay is going to be? When people have a lot of trauma, they can't predict their environment and even neutral stimuli can feel very frightening and threatening. So should try to be as as as reassuring and supportive and open as possible, I think is a nice approach. And again, like if I if I'm working with someone and I know that when they come into hospital, things don't get better and they probably know that too, I try to be really honest about it and try to problem solve. And I think the other thing I know you and I have talked about this even on call, where it's a lot easier to be empathic and kind when it's 11 a.m. on a Tuesday and you're just back from vacation than it is at 3 a.m. where there's a full waiting room with 15 people waiting and you haven't slept and you haven't eaten. And so I think for us, it's really important to reflect on our own ambivalence and our own distress and what we're bringing to the encounter, because it can it's a it's a bidirectional process, assessment. And so to be kind to ourselves as well and to check in with ourselves, before we work with folks who are also in crisis and struggling, can be very useful.

Chase:
Yeah. And you know, it also brings to mind sometimes I feel a bit disingenuous telling people, well, you know, the treatment for this is DBT and that's ideally what you should get on an outpatient basis. But in reality, you know, the person may not have any funds to access it and the wait times for publicly available DBT, you know, this is an Ontario based podcast, but I'm sure it's very similar no matter where you are, accessing DBT can be quite difficult. And so admission also becomes the fastest way to speak to someone who may be like first in DBT or able to kind of work with you on your distress tolerance in a really immediate sense.

Dr. Juveria Zaheer:
Yeah, absolutely. And I think that's not a bad indication for admission. I think we need to think about the failures in our system and to be really open and genuine about those failures and then thinking about ways that we can advocate for better access to trauma therapies and better access to DBT and we definitely can't do it alone for sure. And I think I really like what you said about like picking up on those moments of feeling disingenuous and to sort of say like, does the plan I'm giving this person actually make sense? Like in talking to patients in our studies, like I think they would rather hear from us like, look, here's the treatment and the waitlist is going to take a really long time. And I'm so sorry about that. And what can we do in the meantime to help you feel supported, whether that's, you know, an urgent care clinic or other types of support rather than DBT is the way to go, here's a list and then when they call everybody, they realise that nothing is open or available. So I think that that kind of that feeling that you have, that empathy for the person you're working with is so important.

Chase:
Wanted to get your thoughts on another topic that I think is becoming maybe more relevant as we move towards legislation for made for people with psychiatric illness. And this sort of revolves around the topic of involuntary hospitalisation for people who have suicidality or who have had suicide attempts. I guess I'm wondering how you sort of frame that or how you think about the ethics of involuntary hospitalisation for people who have suicidal thoughts or behaviours.

Dr. Juveria Zaheer:
Then starting with the involuntary hospitalisation piece, I think psychiatry is facing a reckoning of sorts where we have to come to terms with our own history of oppression. We need to come to terms with our own systemic racism and anti-black and anti-indigenous racism specifically. We also need to come to terms with the fact that we are how we are the third arm of the law in many ways. We are carceral and so part of this sort of process needs to be understanding the power that we have and needing to understand the experience that people who are being held involuntarily are having. So for me, I think it's really important. There's a few things that I do to help myself understand the ethics of this. I think, as I said earlier, if I'm going to bring someone into hospital involuntarily, I better have a very good reason for it and I better be able to describe that rationale to the person I'm working with. Here's what I'm worried about. And for someone with suicidality to be very clear that it's not a punishment, that these are the goals for you coming in, whether it's collecting more information or providing support or whatever it is. I think that's really, really important.

Dr. Juveria Zaheer:
And I think one of the things that is really helpful around forms and certification is to actually speak with the person about it, asking about past experiences of certification, asking about what it means to them. Like I have people who I say, I'll say, I'm so worried about you and I'm worried that if you were to leave here, you would continue to suffer and your life would be at risk and I think that we can help you here in the hospital. But I also know that being held involuntarily is really traumatic. What are your thoughts? And then people, you have these really interesting discussions about some people will say, you know what, I'd like to come in voluntarily and being formed would be really awful. Other people have said to me, the act of being put on the form is reassuring to me because it shows me that people care about me and I don't, sometimes when the thoughts get really dark, I don't trust myself and so I understand. Other people say, I don't like this, but I know it'll make my family feel better. And so actually having that conversation can be very useful. And I think like owning what we're doing is really, really important.

Chase:
So I know we've taken up a lot of your time already, but I just wanted to get your thoughts on what do you think the future holds for suicide prevention and suicide treatment?

Dr. Juveria Zaheer:
I was reflecting. I was doing teaching for our first year residents yesterday, Gina and I were. And we often ask people like, when was the first time you ever heard about suicide? Like when you were a kid? Like, what was what were those conversations like in your family? And the answers are so thoughtful and meaningful and so sad in some cases. And I feel badly, I'm the kind of person who never thought they would always talk about their kids, but I always talk about my kids. And I have an eight-year-old and a three-year-old and, you know, in my family, we were a muslim family, you know, suicide was haram. We never talked about suicide. We didn't even kind of understand it. And if it happened to someone else it was 'how could they do that to their family?' There wasn't an understanding of the mental health piece. And with my daughters, you know, we talk about how we're so happy that they feel well now and there's going to be things in their life that make them feel worried or scared or happy or sad. And sometimes sadness or worries can stick around even when good things are happening and they can make us not feel like ourselves and they can make us feel so sad and scared. And sometimes for some people they can even make us not want to be alive anymore and if that ever happens to you, we're always here and we'll figure it out together and people get better from this. And so I know it's like a long-winded way of saying, you know, when we think about the future of suicide prevention, it's not my eight-and three-year-old for sure, but I think it's like these conversations that's striking while the iron is cold. It's the work that's done by people like Jack.org. It's like changing the way we talk about suicide and making it easier for people to understand that there is hope and there is help and there are treatments that work.

Dr. Juveria Zaheer:
I think, when I think about the future of suicide prevention in terms of research, I really do think that the future of suicide research is in co-creation and working with people to develop interventions for communities that work and then to test those interventions. And the future of suicide prevention is around accessibility and availability of evidence-based treatment. As you say, we have really good treatments that work, and universal health care means universal access and equitable access. And I'm really interested again in these kind of like suicide specific interventions that that we might not think of because we always think about like diagnostic silos, but I think that's really exciting. And I think the last piece is, is how do we go back to creating a world where every life feels worth living and how do we invest in social cohesion and a social net and freedom from the stressors that make us feel really scared and worried. And I think a lot about gender and race and how we, like the cultural scripts of how we act. So how do we encourage white middle-aged men in rural communities to get care? How do we make sure that people from indigenous communities have clean water and freedom from trauma and have ways to tell their stories in ways that matter? And I think that's what suicide prevention looks like to me.

Chase:
Thank you so much Juveria for joining us today. We really appreciate having you on the podcast. Your answers were incredibly insightful and always helpful in guiding how we think about suicide as trainees and helping us move forward beyond risk assessments. So thank you so much. Did you have any final comments or any words of advice for our listeners?

Dr. Juveria Zaheer:
I think what I would say is that we're you guys are really good at this, like you're good at talking to people about suicide. The more you do it, the better that you get and don't ever think that the checklist is more important than your humanity. You need to learn the checklist; you need to make sure that you're thorough and you create a plan that works for people but the thing that people are going to remember about you is your humanity and your kindness and your openness.

Chase:
Thanks for listening. We hope you found our conversation informative and enjoyable. PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and recorded by myself, Chase Thompson and our theme song is Working Solutions by Olive Musique. You can contact us at Psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thanks again for listening. Bye.

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Episode 47: Understanding the DSM-V-TR with Dr. Michael First

PsychEd+episode+47+-+Understanding+the+DSM+V+TR+with+Dr.+Michael+First.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Alex:
Welcome to PsychED, the Psychiatry Podcast for Medical Learners by Medical Learners. This episode covers all you need to know about the new DSM five TR. I'm Alex Raben. I'm a staff psychiatrist at the Centre for Addiction and Mental Health in Toronto, and I'm also a lecturer at the University of Toronto. I'm joined today by my co-host Saja Jabri. She is a international medical graduate and a psychiatry enthusiast and this is her first episode. So welcome, Saja.

Saja:
Thank you. I'm very happy to be here.

Alex:
This was also such as brainchild. I should say so. Thank you, Saja, for picking a wonderful topic. We're also very pleased to be joined by our esteemed expert, Dr. Michael B first, and he is a professor of clinical psychiatry at Columbia University. Dr. First is also a internationally recognised expert on psychiatric diagnosis and assessment issues as a private practice in New York City and also conducts expert forensic psychiatric evaluations in both civil and criminal matters, including the 2026 trial of Zacharias Moussaoui.

Dr. First:
Sorry. Moussaoui.

Alex:
Moussaoui. Thanks, Doctor. First. And then especially important to this episode, Dr. First is the editor and co-chair of the DSM five Text Revision Project, the editorial and coding consultant for DSM five, the chief technical and editorial consultant of the World Health Organization ICD 11 Revision Project and was an external consultant to the NIMH Research Domain Criteria Project or RDOC. Dr. First is also the lead author of the Structural Structured Clinical Interview for DSM five, known as the SCID. More broadly, and this is a widely used or the most widely used structural diagnostic instrument for DSM five diagnoses and in research and in the clinical setting. He has also authored and co-edited a number of books, including a research agenda for DSM five, the DSM four TR Guidebook, the DSM five Handbook for Differential Diagnosis and Learning, DSM five by Case Example. So we could not be more pleased to have you here, Dr. First on the show to talk about this topic, which you are clearly a leading expert on. Welcome to the show.

Dr. First:
Thank you. A pleasure to be here.

Alex:
Now I'm going to just quickly talk about our learning objectives today, and then I'm going to hand it over to Saja, ask the first question. So by the end of the episode, the listener will be able to, number one, understand the rationale for undertaking a DSM five TR revision, as well as how that revision process looks. Number two, become familiar with disorders, the text and the symptom code additions and modifications to the DSM five TR. And number three, understand the purpose and function of the DSM generally and be able to contemplate what future directions are going to look like in this area. All right, Saja, I'm going to hand it over to you to take it away.

Saja:
Okay. So without further do, I'll jump into things to start with, Dr. First. Could you briefly describe to our listeners in simple words, what is the DSM and where did it come from and how did we get to the present edition?

Dr. First:
Okay, so the DSM that stands for the Diagnostic and Statistical Manual of Mental Disorders and the version that the subject of today's presentation is the DSM five. Tr So that means it's the fifth edition of the DSM, and the TR is the latest version, which is a version that focuses primarily on revising the text. So the DSM is basically a dictionary, so to speak, of all of the psychiatric diagnoses which are accepted as valid by the American Psychiatric Association. The fifth edition when the first edition came out in 1958 and the second 62 and DSM three, which is the one that is it's the first one to have diagnostic criteria for every disorder. That was the 1980, and then DSM four was in 1994, and now we're up to DSM five, which is in 2013. So we're now 11, eight years past the release of DSM five. So we felt that a revision was needed and that's what the DSM five text revision is.

Alex:
That's terrific. Thanks so much, Dr. First. No, we live in Canada. You live in America, but we have listeners from all over the world, certainly in North America. We turn to the DSM quite frequently in our clinical practice, as you said, as a dictionary for diagnosing. But our international listeners, I'm guessing they might use some other sources. So there's the ICD. So how do we differentiate the ICD from the DSM five? And could you take us through that?

Dr. First:
Sure. So the it's a little complicated. So the the version, the DSM, the ICD 11, which is the 11th revision, just got finished a couple of years ago, but no country is yet implemented yet. Eventually, every country in the world will have to use ICD 11 codes in the same way. Right now, the United States, Canada and all the countries of the world are using ICD ten codes. The DSM uses the ICD code. So when you open up the DSM and make a diagnosis and write down the code, you're actually fulfilling the obligation to use the ICD codes. But the definitions in ICD and DSM are very, very similar, but they're different. There's been attempts over the years to harmonies them, and I've been involved in that process. So they're pretty close. But there are still differences that have to do with some different historical traditions between the United States and other parts of the world and different levels of detail, different types of disorders. So they're pretty much the same, but not identical. It really depends upon where you live. Even though the DSM is produced by the American Psychiatric Association, there are a number of countries around the world which also use the DSM. It's been translated into different languages, and that got started basically after DSM three came out in 1980. DSM three had introduced diagnostic criteria for every disorder. The basically the rules you need what needs to be present in the patient duration and symptom wise in order to make the diagnosis at the time. The system which is affected in the rest of the world was ICD nine, which did not have those kinds of definitions. So a lot of countries decided to use the DSM three as their main system, mainly because of the sense that the diagnostic criteria were so useful. It was they preferred using the DSM. Since then, ICD has caught up. The ICD 11 does have something called clinical descriptions of diagnostic requirements, which are like criteria. So both systems now have criteria. So I think the usage of the ICD 11 has greatly increased over the years, and in many countries that's the only system that's used.

Alex:
Interesting. I didn't realise there was that sort of practical difference between the manuals historically and caused a lot of uptake of the DSM three. For that reason. It's quite interesting.

Saja:
Okay. So, Dr. First, thank you so much for that. Could you tell could you briefly describe to our listeners and tell us more about why was the DSM five are needed? What was the rationale behind it?

Dr. First:
Okay. So the as you can imagine, the DSMB is an amalgam of what we currently know about the mental disorders. And we luckily live in a world where what we know keeps changing as we learn more things. So know, like any textbook, you would not use a textbook of medicine from ten years ago. You would assume that a lot of things there would be out of date. So the same thing is kind of true too. There are two components to the DSM. There's the criteria which defined the disorders, but actually 95% of the words in the DSM are the text. That's the information about the disorders. It includes things like prevalence, sex ratio, familial pattern, all those aspects about the disorder, which are very important. And in more recent years we include things like risk factors and diagnostic markers. So this information, it's really become an authoritative source of information so that information could get out of date. As we know things happen. So the the version, the DSM five from 2013, all the texts there was based upon what we knew about mental disorders in 2012. So in the intervening eight or nine or ten years, a lot of the information in the DSM is really no longer up to date. So this is an attempt, since we don't know when the next big DSM six will be. We wanted to take the opportunity to revise the text to make it up to date. Now, one thing that's a little new this time around is in the previous DSM's, in between DSM editions, there were no changes, so you had to wait till the next big DSM to make changes.

Dr. First:
We finally got rid of that way of doing it, which is kind of bad to have to wait for some artificial period of time and changes can be made on a rolling basis. There's a process by which people could submit proposals for changes to the DSM five website, and then there's a whole process by which the proposals are evaluated. They have to be empirically based. You can't just write in and say, I think it would be a good idea to have this kind of disorder. You would say, I think we'll give you an example. A disorder that is becoming more and more popular around the world is Internet gaming disorder. People who have basically kind of like a gaming addiction. ICD 11, when they came out, has actually a disorder called gaming disorder, and DSM five doesn't yet. It's in the appendix. But it's very possible that in maybe the next ten years there's more and more data is collected. They'll feel that there's enough data to justify going into the DSM five. So new disorders could be added when there's enough data. There was one new disorder since DSM five came out that has been added, and that's prolonged grief disorder, which that's been much discussed already also in ICD 11. But the DSM group finally felt that there was enough data to justify being added to the DSM. So it is now in the text revision.

Alex:
I see. So a lot of years have passed. There's progress in science taking place all the time. And so there was this need to update the the DSM clearly, but it needs to be data driven. You can't just make an arbitrary change, as you were saying. You mentioned one of those changes, prolonged grief disorder. We are going to get into the meat of what these changes are very shortly. But I did want to talk about the process because you've been directly involved in that. So I was hoping with your personal perspective on that, what does that look like? How do these changes get approved? Who's sitting on these committees, how many committees, that kind of thing.

Dr. First:
So when the DSM five came out, that was the preparation for the DSM five was about seven or eight years. So that was a big process with different work groups working over that period of time to make all of the proposals. And once we've changed over to DSM five, post DSM five, this new ongoing revision model, we now have a different process. Now, for the first time, we have a website open up for proposals, and when a proposal comes in to the website, the website is very specific about what a proposal has to include. So for example, if you want to add a new disorder, which is probably the hardest thing to do, you have to show a lot of data about things like its validity and different kinds of validity. It's clinical utility, it's reliability, all the kinds of things you would want to know about before you make the decision to add a disorder. So a lot of data has to be collected, and it's pretty clear on the website what kind of data it needs to be. So this website has been open since 2013 and proposals have come in and some of the proposals are for tiny changes, but there have been a number of proposals that have been evaluated and have gotten through the process and that prolonged grief disorder is one of them.

Dr. First:
So now for that process, there's a steering committee that is the first line of when when a proposal comes in, they evaluate and see whether it looks like there's enough data in the proposal to even spend time considering it. If somebody just writes it, this should be this and. My data is I did a study of five people or whatever that would clearly not not immediately get sent back and say we need a lot more data. But so you would outline the proposal, kind of say what kind of data they're planning to give in. And then the committee would decide, okay, if they're in the ballpark of getting in, they would actually send it to a special committee that had expertise in whatever area it is that somebody had a proposal for a new mood disorder, the Mood disorder group would look at it and they would review a proposal and decide whether the data was sufficient, and if not, they would send it back to the submitter and say, you know, this is really good, but we still need more about this kind of validity, and then would go back to them and then it would be up to the person who submitted the proposal to provide that data.

Dr. First:
Then it would go back to the committee again. And if the committee feels like there's sufficient data, then the next step gets posted on the website for public comment for 45 days and then know notices are sent out to organisations saying there's a new proposal for such and such on the website. And then after 45 days we look at what comes in and then they get analysed and then that goes back to the steering committee to see whether or not any of the concerns that were raised by the public comments need to be addressed. And if everything's sort of taken care of and everybody's satisfied with how it looks, then it goes through the APA approval process. The APA has a board of trustees and an assembly. They also get to look at it and give a thumbs up or thumbs down on it. So by the time it's in there, it's got going through many, many layers of approval and the not so easy gets up at the end basically.

Alex:
Doesn't sound like it. So just to summarise that for our listeners, because it's harder to do visually, this would be, I think, a little bit easier, but it sounds like it goes to the steering committee first. If it passes a threshold, then it goes on to the individual committees that are experts in those areas or review committee. And then from there there's a public appraisal.

Dr. First:
Let's say it goes back to the steering committee first, because the steering committee has to approve. So the review committee would say, we think it's good. Then the steering committee debates whether to put it in. And when they're satisfied, like, okay, we really think it's solid and then it goes for public review and then then we'll see what the public has to say. And and hopefully it happened. It's been you know, the big one was the prolonged grief disorder. We got lots of very helpful comments. And the criteria that were proposed actually were changed after the public comments came in to address some of the problems that they pointed out.

Alex:
Interesting. And I think that's something. Yeah, Really? No, because I don't think a lot of people, myself included, realised there's this public component to it and and then after that back to the steering committee and then ultimately kind of APA for the final signoff. Okay.

Dr. First:
And that's what this is the first time we ever did that. There was never such an all the previous DSM's while people would write things into the APA and whenever there was never a formal process by which the public could make a proposal, that's that's new since DSM five.

Alex:
Gotcha. Okay. Very cool.

Saja:
Wonderful. Dr. First. Can I submit a proposal, let's say? Or who can submit these proposal for changes to the DSM? Is it open to the public?

Dr. First:
Well, the the hard part is fulfilling the requirements for the data. I mean, a regular person, a psychiatrist in practice might think there's a good idea for new disorder, but to get it in, a lot of data would be collected. And that's what that's what's laid out on the website, what that data is needed. So generally most of the people are either organizations or researchers or groups of researchers who can present all the data that is required to at least submit the proposal. But you're right. Theoretically, if an enterprising clinician collateral that data available, then then sure, you know that absolutely would be appropriate.

Alex:
Great. So I wonder if maybe we should go to the case now as a entryway into some of the changes in the DSM five, if you want to read that out.

Saja:
So for today's episode, we have a case presentation. Mariyam, she's a 56 year old female, married her daughter, completed suicide more than two years ago. She often feels depressed but does not think that she feels depressed most of the time, and she's unsure whether she feels depressed most of the day. Her appetite is normal. She sleeps very well. She often experiences fatigue and anhedonia. She experiences recurrent involuntary dreams and memories associated with her daughter's suicide. She used to avoid places and things that reminded her of her daughter outside the home rather than inside the home. But this is no longer the case. Her beliefs about the world have become negative and very pessimistic, and she struggles with substantial guilt associated with her daughter's suicide. She has invested. A great deal of time and effort to investigate and try to find answers and reasons for her daughter's suicide. She's not particularly angry, or hypervigilant, and she does not engage in reckless, self-destructive behaviours. She thinks about her daughter very frequently and longs for her daily. Since her daughter's death, she feels as though a part of herself has died. She has struggled to engage with friends or interest and experiences life as meaningless and feels intensely lonely and emotionally numb. So I don't know. Should we take a minute to think about the possible diagnoses?

Dr. First:
Yeah, I mean, you want me to comment on it.

Alex:
That'd be Great.

Dr. First:
So if you if her mother, Miriam, if you saw her mother one month after her daughter's suicide and she gave that story, you would say to her, you're going through a normal grieving process. It's painful, but there's then maybe counselling to help you get through the grief. But you would not consider her having a disorder because, you know, that's normal for people to grieve the loss of especially a child. The fact that it's two years later is what suggests that might be pathological. Another thing that's in the differential there. So normally when when there's a death like that, the two most common besides this, a grieving and abnormal grieving process could be depression. Major depression can be triggered by grief reaction, like any life stressor. But certainly if you're predisposed, have a family history of depression, you have a past history of depression that could trigger a depressive episode. But as was described in the case, she doesn't have the symptoms that would justify a diagnosis of major depression. The depression wasn't every day didn't include many of the required symptoms. So that was sort of ruled out. The only other diagnosis that sounds possible could be PTSD, avoiding things, you know, feeling nightmares that that's a symptom. So one of the questions which wasn't in the case was what was the nature of the suicide that the mother let's say the the she found her daughter had killed herself with a shotgun and the mother finds the body in the bedroom.

Dr. First:
That exposure to that traumatic experience could actually be enough to go for PTSD. But it doesn't sound like from the description that the typical symptoms of PTSD were, they're like things like re-experiencing the trauma. The only one that was a little bit like that were the dreams. But the doesn't sound like a picture of PTSD, but that would be in the differential. So and all three of these could happen together. So the three diagnoses I've mentioned in the differential would be major depression, PTSD, And then this new diagnosis, which has recently been added, which is called prolonged grief disorder. And the concept is simple. There's certain a certain amount of grieving. And some people, when they're grieving, become non-functional for a month or two after the death of a loved one. They really can't do anything but the normal grieving process. People at different paces slowly get over it. At a certain point in time, most people will have gotten pretty much back to normal, at least somewhat, and for that reason. So this the idea here, this is a diagnosis reserved for that subgroup of people who experience a loss, who never get over it. Now, that's a tricky state. When I use phrases like get over, a lot of people would say, Nobody, you never get over the death of your child, which is true.

Dr. First:
That's why getting over it is not the right word. But there's the way you get. If your grief is stuck at such a high level two years later, where it's preoccupying your life and it's interfering with your functioning, then we could say that that's not a normal grief reaction. When this diagnosis was put on the website for comment, there was a contingent of people who are very upset about the idea of labelling grief of any kind as disorder. And we're very we're very sensitive to that. We want to make it very clear that there's a normal grief and then there's abnormal prolonged grief disorder. And what made it even more compelling to add this diagnosis to the DSM is there's a treatment that has been shown to work. It's a cognitive therapy type treatment. There's no medication for this condition. It's a therapeutic therapeutic edition. And theoretically, you're supposed to wait a year until the death has occurred to be able to say you have prolonged grief disorder. So, I mean, I'm sure you could start the therapy earlier if you wanted. But as far as getting the label, you really need to wait a full year before you can conclude that the reaction to the grief and the person's life change is beyond what we would consider normal.

Alex:
That's really interesting to me that the way the public commentary kind of played into thinking about this as a disorder. And thank you for outlining your differential in the case. I couldn't agree more. And then you also let us nicely into this prolonged grief disorder discussion. You kind of outlined a bit of it for us, including even treatment. But I'm wondering, can we get a bit more specific? Like what are these criteria that clinicians will be looking out for? What's the sort of DSM version of this?

Dr. First:
As with the many DSM diagnoses, is symptoms which are core that are required for all cases. So for a manic episode, you must have elevated or expansive mood the rest of the symptoms, whether or not you don't need sleep, that's optional, that's variable. But you must have the elevated or irritable mood to have mania in the same way. Prolonged Grief disorder has two symptoms in particular, one of which must be present in all cases. The two cardinal symptoms. Either of them have to be present, usually both, or it's a yearning for the person and preoccupation with thoughts or memories of the person you can't get, Everything you think about has to do with the death of the person. So you have to have those. And as with many DSM definitions, you have to have it's not just every once in a while. It's got to be nearly every day for 12 months, very long period of time. That's the first part of it. So if you don't have either of those, you're not even in the ballpark. But once you have either the yearning or the preoccupation, then there's a bunch of other symptoms that you need. At least I believe it's three. There's a list of eight symptoms and three out of the eight are required. And let me tell you what the first is called identity disruption, which means that you feel like as though a part of yourself has died.

Dr. First:
A lot of people in right after the death of a level. And they feel that. But again, months later and again, that's why that itself would not be enough to make the diagnosis. That's why it's you need a whole cluster. It's a combination of the symptoms together. So that's one of them. Some one another one is a more sense of disbelief about the death. You really can't believe the person has died. Avoidance of reminders that the person is dead. Intense emotional pain, which includes anger or bitterness, difficulty reintegrating into one's relationship. So it's very common to kind of withdraw into yourself when you're grieving. But the part of the normal grieving process, you get back to your old life, you reconnect with your friends. In this condition, you really have a real hard time integrating with the way your life used to be. Some people are emotionally numb. They feel like they don't have any emotions at all. People will feel life is meaningless and there's an intense loneliness as a result of the death. So any one of these on their own may not be pathological. It's the three together, plus the yearning or preoccupation. All of that together is required. And like most DSM diagnoses, there's a requirement that that all of these symptoms together have to be severe enough to cause distress or impairment in occupational or social functioning. All that together is what makes it a disorder.

Alex:
Thank you so much for taking us through that doctor. First and looking at the list. I'm also kind of struck by, as you were mentioning before, like the overlap with PTSD, for instance, or some other conditions. Right. Identity disruption. You can think of that in other conditions, emotional numbness, avoidance. But to me, it seems like it's very oriented around the person you're grieving. That seems to be a very distinct difference here. And then the timing, as you were saying as well.

Dr. First:
That all of the symptoms, the identity disruption is as a result of the death. So, you know, people can have these symptoms chronically before the death happened. So you couldn't count that as part of prolonged grief disorder unless you could attribute it to as a result of the death of the loved one.

Alex:
It makes sense. Makes sense. Great. Thank you for taking us through that. I think now we'd like to turn to the other changes because prolonged grief disorder, that's the only new disorder added to DSM five TR. But there have been a number of other changes. Could we maybe go through?

Dr. First:
Well, actually, there are a couple of other new new in quotes. They're not completely I mean, this is the major one. There's no question. This is the one of the most clinical interest. It's three other disorders or conditions which have been added. One is something called unspecified mood disorder, which sounds it's a technical thing of sorts, but it's for real. When DSM five got rid of, you know, all of the categories in the DSM have an unspecified sort of a wastebasket for individuals who have presentations that don't meet the criteria for any of the disorders. And that actually is fairly common. A decent percentage of people who come for treatment don't actually meet the full criteria. So you really can't give them a diagnosis of one of the disorders in there because you don't meet the criteria. So you have to use one of these unspecified categories. So for someone who has like a subthreshold depression or subthreshold bipolar disorder, they would get a in the DSM five, bipolar, unspecified bipolar disorder or unspecified depressive disorder. But what is the mood category like something like irritability? Is that a depressive thing or is that a bipolar thing or agitation? Those certain mood symptoms aren't specific to either depression or mania. So one of the questions was what if somebody comes in and their main problem is irritability and agitation, but they don't meet the criteria for any of the disorders? What do you call that in the DSM five, you'd have to pick between decide whether is it really depressive or is it really bipolar.

Dr. First:
But the arbitrator, if you don't know anything, you have to pick like flipping a coin. The problem with that is then the person ends up having that wrong diagnosis stuck on their chart. So the solution is to take a step back and and reintroduce something which used to be in the DSM, which is an unspecified mood disorder. So we're now allowing the clinician to just say, hey, this is a mood problem. I'm not going to commit myself to whether it's bipolar or unipolar as of yet. So it's mood. So as you know, with all of these unspecified, there's more information comes in. You hope to be able to rewrite the diagnosis based upon new information. So you have to start somewhere. So this is sort of like a place to start for some unspecified general mood problem without committing yourself to bipolar versus unipolar. So that was one. There's a category called No Diagnosis. Believe it or not. So what? You know, when you work in a hospital, you have to write down a diagnosis or your practice. So sometimes you're going to get somebody who comes in, says, you know, I need to have a doctor's note saying I'm ready to go back to work.

Dr. First:
I've been on disability, everything's gotten better. So what would the diagnosis be for that person? There was really nothing in it. So we reintroduced another category that used to be in the DSM called No Diagnosis or Condition. So for somebody getting a wellness exam or sort of a duty to work thing that's been reintroduced for that reason. So these two are a little bit administrative, but they have real world implications. Another new thing was in the in the neurocognitive section, substance induced neurocognitive disorder. So that's a section of conditions that could cause dementia. Mostly dementia Drugs like alcohol, inhalants and sedatives can lead to a dementia that is very, very severe. The DSM five got rid of dementia, interestingly, and replaced it with a category called neurocognitive disorder. That comes in two levels of severity major, which is really the same as dementia. And this new thing that was added to DSM five, which is mild neurocognitive disorder. So it turns out the three drugs which cause dementia, which is inhalants, sedatives and alcohol, also cause mild neurocognitive to, I mean, the severity of the symptoms. If it's going to cause dementia, it should also cause less severe cognition.

Dr. First:
But it turns out there's one substance which only causes milder neurocognitive care, but not severe, and that's amphetamines. So amphetamines can present with a prolonged cognitive impairment that's not severe enough to call it a major neurocognitive disorder that was by accident, left out of the DSM five. So that's been now a new diagnosis, which is basically stimulant induced mild neurocognitive disorder. And the other new addition, which is a new thing for the DSM, which is to have codes for symptoms that are not disorders. And you can now add and the two that were added to DSM five was a code for suicidal behavior and non suicidal self injury. If suicidal behavior can occur in a wide variety of conditions that it's clearly very, very often it's going to be a focus of attention. It's something you really want to know. It's present and be able when you're referring the person to another clinician, know that that's on the table. So there was no way to indicate that suicide was part of the picture before. Now there's a special code that you can now write down the chart, which basically is for either current suicidal behaviour or past history of suicidal behaviour, and the same thing for non suicidal self injury, current and history. So those are all, those are new to.

Alex:
So is that diagnostically sort of agnostic in terms of the suicide behaviour and non suicidal self-harm behaviour, You could apply that to anything.

Dr. First:
You can apply to any diagnosis. You can also apply with no diagnosis. I mean there are people who make suicide attempts and you can't find any diagnosis at all. So you could write, you could use the code for that. But so there's so basically this categories for two uses. One, when those behaviours occur in the absence of a condition, but we expect that most cases of suicide or non suicidal self-injury will have a co-mental disorder diagnosis like depression, schizophrenia substitutes or whatever, they're usually going to use the codes that are code with an actual diagnosis.

Alex:
Right, Right. Makes sense.

Dr. First:
So that's those are the big changes with respect to new things. Some of that we've corrected some definitional problems or things that were unclear. Probably the biggest one is persistent depressive disorder. So persistent depressive disorder, which used to be known as Dysthymia in DSM five, is now any depression which lasts more days than not for at least two years, is now called persistent depressive disorder. So that includes the old dysthymia, which was. But if you have a major depressive episode every day for two years, that's also a persistent depressive disorder. If you have what used to be called double depression, there are chronic mild depression with occasional intermittent, serious depressive episodes. That's also if it's last at least two years. That's also called persistent depressive disorder. So you can indicate what waiver it is by using one of the subtypes. But the question was, do you also write down a diagnosis of major depressive disorder and persistent depressive disorder? So somebody, the double depression, get two diagnoses or just the the persistent depressive disorder. And the problem was that depending the two different spots of the DSM, which had the exact opposite thing, so it was really unclear what to do.

Dr. First:
It turns out that the actual it was supposed to be that you're supposed to use both diagnoses. You're supposed to use major depressive disorder and persistent depressive disorder. And the reason that's important, it's a little bit of a technical thing. It's a coding. So, for example, the coding for major depressive disorder allows you to see if the person's psychotic or mild, moderate, severe and psychotic are available in the diagnostic code. So if you write if that shows up in the chart, you could see immediately this person had a psychotic depression. The persistent depressive disorder, the code is is has nothing, nothing of severity, no anything. So if we only use the persistent depressive disorder code, you would have lost the information of the person had a psychotic depression. You need to use a code for major depression to get the psychosis in there, not plus the severity, which could also be relevant. So kind of technical reasons. We really want both codes there. And in a sense, the persistent depressive code really is used to say this is a chronic type of depression. And then the major depressive disorder codes indicate what the episode looks like.

Alex:
Makes sense.

Saja:
Okay. Shall we move on to the next question? So, Dr. first, as everybody knows, there are changes in regards to the terminology as well that's used in the manual. Could you briefly highlight the most important ones our listeners should be aware of?

Dr. First:
Sure. Some of them are extremely technical, which I won't even go into. It has to do with the most has to do with the people may have noticed that some of the diagnoses have parentheses next to them, which gets their alternate name. We kind of change some of the alternate names. The two most important ones are the use of the word neuroleptic. So Neuroleptic is a word from the fifties. I believe that's how the antipsychotics were referred to, and that word is still around. Neuroleptic malignant syndrome is still there. But through the DSM it appears in a number of different places that were term is really going out of disfavour and neuroleptic. If you look at the history of the word, basically focusing on the side effects of antipsychotics, that's what a neuroleptic is. So we decided to change it and get rid of it. Accepted in one spot. Neuroleptic malignant syndrome has been entrenched so much we sort of allow it there. But whenever we refer to the class of drugs, we call them antipsychotics and other dopamine blocking agents. Now, if in the text we refer to it as this is a drug for schizophrenia, we would call antipsychotic. The problem is that class of drugs is sometimes used for other medical uses, like nausea. You know, some of the dopamine blocking agents neuroleptic could be used to treat nausea. So we don't want to call them antipsychotic when they're not being used for that purpose. So we basically made the terminology throughout the whole book consistent. And we also got rid of the word neuroleptic wherever we could. The other area where there's significant changes of terminology was, perhaps not surprisingly in the gender dysphoria section, terminology about gender.

Dr. First:
If there's one area of the terminology, it's changing very, very rapidly. That's one of the a lot of terms become both. I don't say old fashion exactly, but they're just I guess they're let's let me tell you. So the key ones in in the gender dysphoria section, we used to say that the person you had your gender and the desired gender was the terminology that was original use. That's been changed now to the experienced gender, which is much more accurate. It's not just that you want it, you experience yourself as being that gender. Another the word phrase cross-sex as in the terms of a cross-sex medical procedure. That's another term, which is you can understand why the term was there. But that term is also going out of favour and it's been replaced by gender affirming medical procedure. And the other big one is the issue of being assigned Natal. So if you're considered a natal male, that means you were born male. That's, that's, that's also replaced because it's been replaced by assigned male at birth. It's really emphasizing the gender is what you were assigned with the doctor and the family thought you look like at birth. That's what gets you started. It's not that you're actually a male at birth, so it's really kind of highlighting the fact that gender is a social construct. And so the words have been changed to reflect that gender is not just a biological phenomenon. So they're basically basically bringing the text in line with current usage of these concepts.

Saja:
That's great. So just to summarise it, we've changed. Instead of saying desired gender to experienced gender and instead of saying cross-sex medical procedures, we use gender affirming medical procedures. And the third one would be instead of saying natal at birth, natal male at birth or natal female at birth, we say an individual assigned male at birth, and the fourth one us retiring the term neuroleptic and using antipsychotic. Amazing. Should we move on to the next question?

Alex:
I'm really curious to get your thoughts on this one Dr. First, for the DSM, as we've been talking about, used very widely, very highly regarded, and especially in North America. But I guess we're also wondering from your opinion, what does it do well, clinically and where where there's still some blind spots or weaknesses in your opinion, either from your own experience clinically or from what you've heard from other clinicians? And also you could speak to the research world if you feel there are pros and cons there to.

Dr. First:
Well, absolutely. The DSM has gotten an immense amount of criticism over the last 30, 40 years. There are very high hopes when the DSM in 1980, when DSM three came out, that these conditions actually were like diseases and that they were closer to medicine than they turned out to be. So it's turned out, for example, that it would have been nice if all if you had a diagnosis of depression, that drug that antidepressants would be the drugs to use and only they would work. But it's turned out that the relationship between a diagnosis and treatment is many to many. So many treatments work for the same diagnoses like SSRIs, work for like anxiety disorders, a compulsive disorder, and given a disorder that's many, many different treatments. So we were hoping it would be a better fit between making the diagnosis and knowing what the treatment is. And that didn't quite work out. So that in that sense the utility has been a problem. So when some people say, well, why use, you know, what's the point of using the DSM if it's not going to help me practice? Certainly one use of the DSM that I think everybody would agree on as a as a getting back to the dictionary term, that's the way we communicate with everyone, coalitions, family members, newspapers, everybody uses this terminology. And if you use the word major depression, the person hearing you, if they know how depression is defined, well, understand that I'm giving you I'm going to refer you a patient with major depression. If the person is using it correctly, you can expect when that person walks into your office what that person you'd expect to look like.

Dr. First:
You'd expect them not to have manic episodes, because if they had manic episodes, you would have said they were bipolar. So the terms both indicate what they have and what they don't have. So the terms are powerful as a communication. Beyond that, that's where it gets more controversy. The fact is that all of the treatments that have been developed in the past 50 years have been geared to some DSM diagnosis, like all of the medications on the market. To get approved for use in patients, you have to pick a drug indication to say this drug is indicated for depression. All that means is the studies have been done on patients with that diagnosis and it's been demonstrated that the medicine works better than placebo for that diagnosis. So as a clinician, if you're looking if your patient that you're seeing has a presentation that meets the criteria for social anxiety disorder, then if a drug is indicated for social anxiety disorder, you would expect it to work for that patient because that's where they date. So that all the treatment data and all the studies have been geared to the DSM system. So that's another. So it does tell you something, if we didn't have it, any system at all, you really be hard to get to get started about how how to think about how to plan the treatment. So it's been the framework for psychiatry for the past 50 years.

Dr. First:
It's far from perfect and people point that out all the time. You have this lack of specificity. The the other hope was, I think when DSM three came out that once we defined when we really didn't know the causes of any disorders and I'm I was in practice back then and I and I the belief was that now that we have a system of criteria that makes it clear what the patient's conditions look like and we do the work and the studies will find out what the causes are now that we at least have a language we all agree on. You know, here we are 50 years later, we still don't know what the cause of virtually any of the mental disorders are. That's been a really big disappointment. In fact, some researchers have blamed the DSM for our not being able to find the cause. I think that's a little over, but I could see they make some points. It's the DSM drives research funding and drives drug development, and the system itself is has no validity. Then you're really in a hole. I think there's some problems with validity, but I still think it does. Have a considerable amount of validity, enough validity to make it useful, but it's far from what we would have liked it to be. So I think that I'm I'm the first to admit that it's an imperfect system. But when people start harping on I said, Well, what should we replace it with? And then nobody has an answer.

Alex:
All right. An imperfect system is better than no system. As you were saying. Okay. So I think that that leads us in nicely, though, to Saja's, I think our last question for today. And so I'll hand it over to Sasha.

Saja:
Yeah. So when thinking about the DSM and this whole system, if we are to replace it, what can we replace it with? And there has been increasing, increasing evidence about the Rdoc framework that the APA is working on. Could you tell us if it's going to replace the DSM and what are the differences between those two systems?

Dr. First:
If Rdoc is not really a replacement. I mean, the ICD ICD is the only system in existence which is trying to do the same thing the DSM does. So, I mean, you know, you could argue maybe they really should only be one system, but I think it's safe to say that the ICD and the DSM will continue to co-exist indefinitely. But the other newer hopes, like Rdoc is basically a framework for doing research. That was an attempt. It kind of got started with the idea you should you shouldn't be doing a study looking recruiting patients for major depression because there's no doubt and schizophrenia is the same way that the people who have major depression probably have many different things going on biologically. It's a huge amount of heterogeneity. That's the big problem you have to people who meet the criteria for major depression, they're completely different, nothing in common other. Then you even have depressed mood in common necessarily because either depressed mood or loss of interest. So there's a huge variability for all of these diagnostic categories, which is a real problem. So Rdoc partly said, you know, if we're going to try to find the cause, the underlying biological cause of mental disorder, we should be recruiting patients based on whether they meet the criteria for a DSM disorder. We should be recruiting patients because they have some biological factor or pathway in common.

Dr. First:
And that's what Rdoc. Rdoc has broken things down into domains of functioning. And so and they they break them down into they're based on known neurocircuitry. For example, there's a whole group of domains which are called negative valence systems, and they correspond to symptoms that people have that are negative like fear, anxiety, loss. These correspond to actual brain circuitry. So the idea is if we recruit somebody, a group of patients that all share in common the same domain, which is linked to the biology, we're much more likely to be able to have a homogeneous group of patients to be studied. So that's another one called Positive Valence, which is where mania and stuff comes in and substance use disorders as a cognitive one. And so so these are broken down, not diagnostic. And that's the whole idea that Rdoc it's cross diagnostic. It kind of ignores the entire DSM system and recruits patients based upon these common symptom factors which are connected to the neurobiology. It's a sensible approach. So it's almost like, say, the the DSM, we know we're not going to find the cause of mental disorders if we just use the DSM. I think everybody would agree very strongly. The question is what would help us find the cause? And Ladakh was a proposal by the NIMH for a completely different approach, much more tied to the biology.

Dr. First:
And since a lot of the treatments they were looking for a biological and since we all know there is a biological basis for most mental disorders, that was very promising and continues to be a very promising approach. It's you can see it's not ready to replace anything. I mean, I think the reality is it will help us improve the DSM and the ICD as information comes in, we maybe will be grouping the categories differently. For example, once we determine that OCD and anxiety disorders have the same neuro circuitry. So we would reorganise maybe the disorders by the neuro circuitry, That approach is very appealing, but we're still far from getting there. So I don't think we see the Rdoc as a very, very useful replacement for basing science on a system, but it's also completely not practical for clinicians. That's the other thing. I mean, the DSM having a system which is symptom base that corresponds to the symptoms you see, that's very valuable. And also the Rdoc approach doesn't do well with things like delusions. What, what neurobiological is a delusion. I mean, the circuits, it's way too complicated. So it really works really well for anxiety, depression, addiction, not so well for a lot of the psychotic disorders.

Alex:
That's super interesting. And I know I said that was our last question, but that discussion that just now raised one more for me, if that's okay with you Dr. First, which is that you said and I think nice line why Rdoc is not a DSM replacement. I know you don't have a crystal ball, but where do you see the future of the DSM going, like in DSM six, for instance, and beyond?

Dr. First:
That's I think there's been a push on the DSM five. When they started work on DSM five, there was this hope for a paradigm shift, partly because of the frustration with the DSM. And that was not very I think it was very clear during the DSM process that we weren't ready to get rid of the current approach. One thing that another criticism of the DSM is the fact that it's a categorical system. You either have a diagnosis or you don't know which is not the world. Everything is not. Yes, no, it's like the shades of things. So everything's dementia, like blood pressure. One of the best examples of hypertension is a category. You either have hypertension or you don't. But in fact is it's a continuous measure of blood pressure. So any place you cut it, that's where you could call hypertension. So the same idea could work for mental disorders where you could have different possible cut points across the spectrum. And then and there's some reflection of that in the DSM five itself. So, substance, in fact, what I mentioned earlier, they got rid of dementia that was replaced by this neurocognitive impairment spectrum and autism. They got rid of Asperger's and autistic disorder, and that's now been replaced by an autistic spectrum disorder. And they did that with substance use and dependence. Now it's substance use disorder. So they're trying to move towards having some broader dimensions with cut points within them to define. So that's certainly a very, very important direction and that's already been started. And I think it will continue as we move forward. I'm not sure if this what the next big paradigm shift is, because if I knew that, I would have to know what's going on. I mean, I have a really amazing crystal ball to know that.

Alex:
Or what proposals might come through that. The new website.

Dr. First:
Yeah, right.

Alex:
Well, thank you so much, Dr. First, for joining us today. We really appreciate it. I know I learned a lot. And so thanks for being here. And Saja, thanks so much for the great first episode and this idea. And I hope you come back for another. Take care, everyone, and we'll see you next time.

Dr. First:
Okay. Thank you.

Saja:
Thank you.

Alex:
Psyched is a resident driven initiative led by residents at the University of Toronto, where affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Saja Jabari and myself, Alex Rabin. The audio editing was done by Alex Raben. Our theme song is Working Solutions by all live music. Special thanks to our incredible guest, Dr. Michael B, first for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at PsychED Podcas.org Thank you so much for listening.

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Episode 46: Antisocial Personality Disorder and Psychopathy with Dr. Donald Lynam

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PsychEd+Episode+46+-+Antisocial+Personality+Disorder+and+Psychopathy+with+Dr.+Donald+Lynam.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Dr. Chase Thompson:
Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. This episode covers the development of antisocial or psychopathic personalities and features our guest expert, Dr. Donald Lynam. Dr. Lynam is a clinical psychologist by training and professor at Purdue University, where he heads the Purdue's Developmental Psychopathology, Psychopathy and Personality Lab. He has written extensively on the topic of antisocial and psychopathic personalities. The learning objectives for this episode are as follows one Develop a basic understanding of what is meant by antisocial or psychopathic personalities two be aware of some of the core characteristics and traits of these personalities. Three Describe the theoretical basis for the development of these personalities, as well as their clinical trajectory over time. I just want to make a note to our listeners that we will be referring to the DSM five criteria for antisocial personality, as well as a psychopathy checklist or PCL. Dr. Lynam, is there anything you would add to that or anything you want to clarify?

Dr. Lynam:
No, that sounds about right. I mean, I also work on sort of just personality disorders more generally and personality more generally, but that's a pretty good description.

Dr. Chase Thompson:
Dr. Lyneham Since is kind of an interesting area, we don't always ask our expert this, but I'm just curious how you how did you get interested in this area of personality and psychopathy more in general?

Dr. Lynam:
Sure. Well, I started my graduate training with Terrie Moffitt at University of Wisconsin, and her her main interest was kind of the longitudinal study of antisocial behaviour and folks who would become kind of severely antisocial later in adult. I mean, that's a huge issue kind of in that sort of research is that all adults who were antisocial were antisocial as kids, but not all antisocial kids grew up to be antisocial adults. So a lot of her work was about how can you identify kids who are at greatest risk for continuing kind of their delinquent or their antisocial behaviour into adulthood. So I kind of started there looking at early risk factors like IQ and neuropsychological deficits and problems. And while there, her husband, Aslam Caspi, also worked some with him, and he was more interested kind of in personality. So I added this kind of personality layer. And then I took several classes with Joe Newman, who's a psychopathy researcher. So I became very interested in psychopathy at that point. And so those those kind of interests began to merge. And my earlier work was sort of on trying to identify can you identify in early adolescence kids who look psychopathic and who might go on to become to be psychopathic in adulthood? So that was kind of my my earliest work. But then I was at University of Kentucky, and I began working or hanging out more with Tom Whitaker, who was a big five factor model of personality fan. And it's sort of at that point that I began thinking of psychopathy the way I do now as sort of this collection of personality traits that that if you're extreme enough and you have enough of these, you're going to be psychopathic. And so that's kind of the history of how I got involved in this. And ever since about whatever late nineties, I've been pursuing that line of research.

Dr. Chase Thompson:
I see. And I think we'll get into some of those points that you brought up a little bit later on. But I think maybe a good place for us to start would be sort of some definitions of the terminologies, because I think that's a source of confusion for myself at least. And I know some other learners in the areas of psychiatry and psychology. So maybe I'll just put it out to you. Like how would you sort of define the terms an antisocial personality, or how is that different or similar to a psychopathic personality?

Dr. Lynam:
Well, I think ultimately that they are referring to the same things. I mean, there's been a distinction. So there are three terms that get used. Psychopath, sociopath and antisocial personality disorder. And I think ultimately they're all referring to the same people, which typically is sort of folks who are seriously, consistently chronically antisocial. It's sort of what it's meant to capture. The distinction between APD and psychopathy was really about how they were operationalized. So so in DSM three, this distinction really began to emerge. DSM three adopted these very behavioural criteria that came out of Leigh Robins work. And so it was really just a series. It was like a behavioural checklist, right? And you just sum those up and check the things they had done and that was how the diagnosis of of APD or antisocial personality disorder was arrived at. Psychopathy was about was a bit different. It kind of grew out of work. It was more closely aligned with kind of beckley's clinical description. And it had a direct line through Bob Hare who was trying to take collect these description. He had this in-depth, in-depth descriptions of 16 folks that he thought were psychopathic, and he had a set of criteria. And Bob Hare was interested in using those criteria in prison settings, maybe to identify this this kind of very chronically and consistent antisocial group of folks.

Dr. Lynam:
And so he built the psychopathy checklist in that kind of forensic setting or that prison setting. And it was a bit more focused on sort of traits. Right. So callousness, lack of remorse, lack of guilt, irresponsibility. So it wasn't just this behavioural checklist. And so that was the initial big distinction between antisocial personality disorder and psychopathy across time, like DSM four DSM, four TR, the criteria for APD have moved much more much closer to psychopathy criteria, where now they're really just traits that are being assessed and rather than the close. So so APD and DSM three are used very close criteria. Right. Did they do this act? Did they do that act? Did they do this other act? The criteria now in the current DSM are much more open, like, does he does things? Do they do things that look like they lack remorse? So it's not just this like checklist of things that you had to check. And so those diagnoses are becoming much more closely aligned. And I think a big deal was made about how different they were early on, I think in part Bob Hare and colleagues, to try to highlight how good the psychopathy diagnosis was and why you might want to use that. Their big line was like virtually 90% of people in prisons will receive antisocial personality disorder diagnoses.

Dr. Lynam:
But but only a subset of those 20% will get diagnoses of psychopathy. So but but all psychopaths, also all individuals with psychopathy, will get diagnoses of APD. And that, I think, was mostly about threshold. I mean, so on the psychopathy checklist, to get a diagnosis of psychopathy, you need 30 out of a possible 40 points. And that's a pretty strict cut-off. But for APD, you needed three out of nine criteria. So so there's a huge difference in the threshold that led to that sort of subset finding or that sort of subgroup finding. And the other thing that gets used is a sociopath, and it's often contrasted with psychopath. And the idea there is that sort of there's a difference between why people got the way they did. And so there was an assumption that if you were for people who were psychopathic, they were sort of born that way or as innate or something internal to them. But the sociopath was created by his or her environment. They they grew up in a really poor environment which pushed them down that path. So they're still meant to refer to the same type of people. But there's a difference in the assumption about where it came from.

Dr. Chase Thompson:
And correct me if I'm misconstrued misconstruing what you're saying a little bit, but it sounds a little bit like the DSM version of antisocial personality is sort of a an outward checklist that tries to capture the person's outwardly manifesting behaviours. Sorry for listeners who don't have the DSM criteria in front of them, but basically they're mostly outward behaviours, except for, I believe, one which is lack of remorse for, for such behaviours. But I guess there's been concerns raised by some people that one could enact those certain antisocial behaviours. Say you're, you're experiencing poverty and you need to commit a certain amount of crimes to feed yourself and or you have a substance use disorder and you're sort of caught in this horrible cycle of trying to, to obtain substances for yourself that basically an individual without sort of a core of psychopathy could, could still end up meeting criteria for an antisocial personality disorder, but may have a different underlying subjective experiences. Is that a concern in terms of differences between those two constructs or.

Dr. Lynam:
I mean, it's possible. I mean, I think I think the DSM criteria have more kind of trait like things. So I'm staring at them now. So I can tell you, I mean, one is very behavioural failure to conform to social norms and so indicated by repeatedly performing acts that are grounds for arrest. Lots of reasons for for committing crimes, as you just outlined. I mean, deprivation need sort of know growing up in a culture where that's in a place where that's the only available way to get, get the things you want. But there are some others deceitfulness, impulsivity or failure to plan ahead, irritability and aggressiveness, reckless disregard for the safety of others, consistent irresponsibility, lack of remorse. So, I mean, those are a little more less behaviorally tied or less less specifically tied to the antisocial stuff. But but it is still a concern. But but it's also a concern for psychopathy. I mean, if you look at how the psychopathy checklist is scored, it's based on a semi-structured interview and a file review. Right. And there's a lot of emphasis placed on crimes committed. So so in fact, a lot of what they call factor two psychopathy is based kind of on criminal history. How much have you done? When did you start? Do you show remorse about those crimes? I mean, so so so those crimes sort of suffuse the psychopathy checklist as well. So so I do think that's a possible concern. I mean, I think it would be very hard to hit the tops of these scales just on the basis of having come from a really rough and deprived environment or disadvantaged environment. But but certainly sort of low to mid-level elevations would certainly be possible, I think, for reasons that didn't have to do with sort of the underlying personality that this person possesses.

Dr. Chase Thompson:
Got you. You know, in terms of when we think about, say, psychopathic individuals, maybe I'll draw a similarity to, say, borderline personality disorder, where we think of affective dysregulation. Is this core one of the core defining features of the disorder and some of the other aspects of the disorder kind of flow out from that core. Is there a sort of core characteristic or defining features of psychopathic individuals?

Dr. Lynam:
Sure. I mean, I think I think there's one big one and then sort of a fairly large secondary one. And the first is sort of this this interpersonal dimension that that if you want to talk about the negative pole, you call it antagonism. If you want to talk about the positive poll, you call it agreeableness. But this is sort of a basic measure of personality shows up in everybody's personality model. It shows up in these models of disordered personality and it's an interpersonal dimension and it's really about how you feel about other people. So it's separate from extroversion, which is like, how much do you like them, how warm you are, This is your orientation to them and you kind of at a very basic level, it's a nice versus mean dimension. Antagonistic folks are egocentric, they're lying and manipulative. They're callous. I mean, they really just don't care much about other people. And I think that accounts for almost all of the most of the symptoms that we that we use to define psychopathy. And in fact, if you take these sort of self-report measures of psychopathic personality. It's the glue that holds them together, both within an inventory and across inventory. So this is a feature that that is really shared across all various ways of assessing psychopathy.

Dr. Lynam:
There's another important part which which is sort of this low conscientiousness or lack of constraint or disinhibition that also seems to be in there. And so this is that poor impulse control, this lack of self discipline, this lack of this irresponsibility bit that sort of has. And when you put those two things together, I mean, you just have a person, I think, who is free to do whatever pops into their head because they're not constrained by by what the effect their actions have on others or what other people expect. So boom, they can do whatever they want there. And and they're probably not constrained by consideration of future consequences either. And so. Yeah, they just they lack these internal constraints that most of the rest of us have. If an antisocial impulse pops into our head, we think, well, I could get in trouble. That might hurt that other person. They might be really hurt. What would that do to my social? I mean, there are all these things that we think about that kind of keep us in line. But if you start peeling those off, you get a person who's pretty much capable of doing almost whatever they please.

Dr. Chase Thompson:
And along those lines, like lack of remorse is sort of one of the criteria as well. And I think, you know, when you you hear about psychopaths talked about in the media or or among just in general conversation, it commonly comes up that they don't they lack empathy. I mean, part of the reason I bring this up is because lack of empathy is a feature that occurs across numerous different disorders in psychology and psychiatry, including it's like a schizoid personality or pathological narcissism or. So on, but you don't necessarily see these like very antisocial acts among in these other sort of diagnostic entities. So are you sort of suggesting that it's this antagonism and lack of restraint that is sort of the the thing that separates them and sort of drives the antisocial behaviours?

Dr. Lynam:
Or in part, I mean, I think I think I mean, narcissism and psychopathy are pretty closely related. I mean, we we do research on narcissist, I do research on narcissism as well with my collaborators. And the core feature to lots of narcissism is this very similar antagonism dimension. I mean, that seems to be what's what, why these two things are so highly correlated with each other. If you look at kind of relations between psychopathy and narcissism is they both share this sort of antagonistic core of I'm better than others. And I'm I don't really care what my what what effect my actions have on you because frankly, you're not important. Right. And so so that is a common theme there. I mean, I think what you get for psychopathy is maybe it's a little more broad. You add that deceptive Ms.. And that willingness to manipulate other people and and use them, there may be a little bit absent in narcissism. But the other big part is narcissism is not associated with this control or disinhibition. Right? I mean, it doesn't have that sort of poor impulse control piece to it. So I do think that's important for separating out psychopathy from narcissism.

Dr. Lynam:
The other role it serves, too, is you'll hear people sort of talk about successful psychopaths often. And what I think people mean when they say that is they mean people who are antagonistic but can still hold it all together. Right. So they've got impulse control. I think they have enough impulse control to contain to to get advanced degrees. They have enough impulse control not to punch somebody when they feel like it. Right. And so but but that kind of callousness and that coldness and that lack of concern for other people lets them do lots of stuff that is not very nice. Right? Cheating, manipulating, using. I mean, this is where all the financial or some of the financial crimes come from, right? They don't care about the people whose money they're taking. Right. It's all about sort of them. And so those folks get called successful because they haven't been arrested. They don't have a long rap sheet. But but but they're really just sort of these incomplete manifestations of psychopathy because they've got some of the some of the traits, but not the others.

Dr. Chase Thompson:
This is sort of touch on what you talking about is psychopathy being sort of a cluster of specific traits. I'll just put it to you. Like, what are the traits? Is it you mentioned antagonism and impulsivity.

Dr. Lynam:
Right. So I work from this this big five model, A personality, which is sort of the current coin of the realm. And it suggests there are these five broad traits that you can use to describe everybody that are relatively universal and extroversion. So one's orientation to others, whether you really like being around others or you prefer to be alone neuroticism, which should be very familiar to anybody working with psychopathology, right. Sort of high levels of negative affect that are experienced easily, often, and take longer to subside versus kind of an emotional stability. There's this openness to experience idea that people are open or close to new experiences. And then you've got the two that I'm most interested in, which is the one is that antagonism dimension or that agreeableness dimension, which is really that other interpersonal dimension about how you are oriented to others or whether you care about them or you don't, whether you're nice or whether you're a jerk. And then the last one is this conscientiousness domain, which has a couple of pieces to it, but it's like organisation and impulse control and that's sort of what it gets at. And so I work with them. I work with a slightly bigger model because the specific five factor model that I work with has six subscales for each one of those. And you can get this very kind of well articulated profile of psychopathy across them. One of the things that comes out is they are low on every aspect of agreeableness. So they are they are distrustful, They are lying and manipulative, They are selfish, they are noncompliant, they are immodest and they are callous.

Dr. Lynam:
And so across the board, that's true. And so that's a huge feature. And the other bit is you get within conscientiousness like it order doesn't matter, right? So one of the aspects of order is like, how neat is your room? That doesn't seem to be very psychopathy, but the things that are like dude awfulness like I do, what I'm supposed to do is self discipline. I finish stuff, I start and then sort of deliberation, I think things through. So those are the big pieces. And then there's this little mix of stuff on extroversion and neuroticism, the kind of up and down. So within neuroticism, they have a lot of hostility, but they don't have much self-consciousness, they're not depressed, they're not anxious. And then in extroversion, they are not warm, but they are sort of gregarious and assertive. So it's kind of this little mix profile. And that extroversion neuroticism piece gets clumped together in some inventories and it gets called boldness or fearless dominance. So those are the big three pieces of psychopathy. And I know there's debate about how important that boldness piece is. I mean, I think it's window dressing, right? I don't think it does anything really for for the kinds of stuff we care about in psychopathy. But but those are, I would say, the big three pieces. And so the more of those pieces you have, the more psychopathic you are kind of in my model because it's nothing more than just this collection of extreme traits.

Dr. Chase Thompson:
Yeah. And I think going back to the impulsivity thing and talking about the high functioning psychopath versus the lower functioning or someone we might imagine is in a lower socioeconomic status group and maybe more involved with the criminal justice system. It almost seems that the the ones who do have some restraints on their impulsivity and who are of more ability to carry out their goals is maybe as aligned as they are, almost seem to be more harmful in some sense. Like, I don't know, I guess I'm thinking of people like Bernie Madoff. I think he was assessed and not actually found to have psychopathic personality by whoever assessed him because he didn't meet sort of the other external behaviours. But I guess it seems like there's like this problem of maybe overdiagnosis in people who are more, more actively involved in in criminal acts versus those who are sort of high functioning and sitting in, in a high up office downtown somewhere.

Dr. Lynam:
I mean, I think that's definitely a risk. I mean, but, you know, that's an issue with white color crime anyway, right? I mean, people regarded differently than kind of non white color crime, right? It gets overlooked a lot or that's not real crime or I don't know how people feel about it, but but that's just my kind of my general sense is that people don't think of white color. Crime quite in the same way they think of other types of crime. And so, I mean, but I mean, Bernie Madoff defrauded. Tons of people out of lots of money. But I mean. But but, but, but he but he wasn't violent, right? And he didn't have a huge, you know, a long, long rap sheet, which will elevate your psychopathy checklist scores because that's a huge focus of of of what they're assessing in prison settings. So, yeah, I mean, but the other thing that happens to I mean is that people want to call Bernie Madoff psychopathic. Right? And they want to call the person who's called psychopathic because it's like a curse word, you know? You know, and it's like we don't like that person. That person's not good. But but you have to be a little careful about how you throw the label around, because it is more than just that callousness. It does include these other pieces. And sometimes people will shrink the entire idea down to just one trait, coldness or lack of empathy or fearlessness or whatever it is. But these are all just kind of sub manifestations of the much bigger construct.

Dr. Chase Thompson:
Right. As in people who are not necessarily psychopaths can still do some pretty bad things.

Dr. Lynam:
Right. Exactly. I mean, you know, the the the individuals of psychopathy don't have sort of the corner on the market of antisocial behaviour. Right.

Dr. Chase Thompson:
Maybe just changing gears a bit. Can we talk a bit a little bit about how common is the problem of psychopathy? How how many people in broader society or kind of experiencing what we're talking about here?

Dr. Lynam:
It's funny, I've had a back and forth for three weeks now with one individual wanting me to try to tie me down to, well, exactly how many are there. And I think that's I think that's hard to do, because I really do think this is something that is continuously distributed in lots of ways. So my response to this person was, well, how many tall people are there in the world? Right. And that's the problem you run into. At what point do we decide to call somebody tall? And at what point do you decide to call somebody psychopathic or give them a diagnosis of psychopathy? I mean, the psychopathy checklist has a pretty explicit criteria. It's 30 out of 40 on their scale. That'll probably identify less than 1% of the population is my guess. If you could assess everybody on the psychopathy checklist, which you probably can't because you need to file a review and it takes forever. But but they have a pretty strict criteria. So kind of if you use that criteria, it's about 1%. If you do something like I think APD criteria is 3 to 5%, something like that. But again, if you change the threshold, how many do you need? How many? What's the score on the psychopathy checklist? Well, instead of 30, let's make it 25, because those guys are pretty bad, too. Then all of a sudden your prevalence rate increases. And with APD, we'll just require a set of three of three of them or four of them require five or six, and then your prevalence will decrease dramatically.

Dr. Lynam:
Mine is always about sort of I think this is this is you can you can see this as not relatively normally distributed in the population. You have some people who are basically anti psychopathic, right. They are they have great impulse control and they're really agreeable. So they're like negative, psychopathic. And then you've got most of us who are somewhere in the middle and then you've got a bunch of folks out on the far end. And how far out do you want to draw that? I mean, two standard deviations above the mean prevalence rate of two and a half percent. So something along those lines. So that's how I think about it. I mean, the really, really extreme folks are relatively rare, but it depends on what criteria and what what threshold you're going to use. So it's sort of hard to put a number on that. But if you went with the psychopathy checklist, you're going to tell you about less than 1% at the very, very, very extreme end. And that's comforting unless you think that, you know, the person with a 29 is basically as bad as the person with a 30, and so is the person with 28, that it is continuous, that there's no point at which this seems to become qualitatively different. And so that's the issue you face anytime you're dealing with something that's continuously distributed like that is prevalence depends on where you want to draw your cut point.

Dr. Chase Thompson:
Right. Right.

Dr. Lynam:
That may not be what you wanted, but that's all I got.

Dr. Chase Thompson:
Sorry. No, fair enough. I don't know if this is known, but is it is it expected that the prevalence is sort of the same across different populations?

Dr. Lynam:
I think there's been some research suggesting well, some research suggesting that say the items on the PCLR don't function the same in certain groups. And so so that's a bit problematic. And that gets back to your idea about are these scores going to be elevated for people from disadvantaged backgrounds? And so there's some evidence that at least on some of the symptoms that are used in the psychopathy checklist, that that is problematic. And I think it's probably around most of the antisocial items because there are a lot there are multiple pushes to making people antisocial. And so if you grow up in an environment where you're experiencing a lot of those, you're you're going to elevate a little bit on the antisocial related facets. But but in terms of I mean, mostly men score higher than women, as you might imagine. And that's actually you can actually predict that just from the basis of what we know about the traits that are involved and the gender differences there. So that's one thing that you could certainly say with, I think, some authority, although there are some folks who disagree a bit saying, well, we should change the criteria. If you change the criteria and had different criteria, they would be more equal. That's that's possibly true. But but but in general, actually, it's interesting. Among all the personality disorders so kind of attend DSM, PDS and psychopathy if you sort of calculate gender differences on the basis of gender differences in the traits that they contribute to them, psychopathy by far has the largest sort of male to female ratio, but it should be the most male disorder of them all.

Dr. Chase Thompson:
What do we know about the development of psychopathic personalities in terms of like, is it genetic, environmental and.

Dr. Lynam:
Well, I think like most things, I mean, it's, you know, what is it, 40 to 40 and 50% of the variance seems to be heritable, you know, or 40 or 50% of the variation in the population seems to be due to genetic variation. And that's that's true for for lots of lots of these sorts of things. What we do know is, is that that that this adult manifestation has kind of adolescent and childhood precursors. I mean, if you look at if you look at kind of conduct disorder diagnosis in the DSM, there's a specify that is called callous unemotional traits. And that's basically Paul Frick's version of psychopathy in a lot of ways. And I had a version, too. We called it the childhood psychopathy scale, but it was much the same as kind of what what Paul's done, which is that sort of you can identify early on folks who are callous and impulsive and don't seem to care about other people and and all these traits. And there is some stability across time. And so it's not surprising that the kind of the child who's going to grow up to receive a diagnosis of psychopathy, of psychopathy, or who's going to look psychopathic in adulthood is also looking psychopathic in childhood and adolescence.

Dr. Lynam:
Do we know how that comes about? Not really. Really? Well, I mean, I think Paul has done some work sort of on on on on parenting. And there seem to be some parenting styles that are associated with with those sorts of traits in kids in adolescence. But the problem with those studies, it's awfully hard to know. I mean, parents are also reactive to kids, and that's been shown again and again, right? Difficult kids who are difficult end up with parents who have certain parenting styles. And it may not be the parenting styles that come first. So it's really kind of a thorny thing to try to figure out about how does this develop. We do know there's a genetic component. We also know that 50% of the at least 50% of the variation is not genetic. And that's the hardest piece to get on. And, you know, and again, we didn't know what the genes what the what the genetics of it are at all. Anyway, These are global estimates, and our ability to identify any specific genes is really lousy. So I'm not sure that those numbers ever help us a whole lot.

Dr. Chase Thompson:
Sometimes you commonly hear that, for example, an individual who has severe a personality disorder, that there tends to be some sort of contribution of early life trauma. Is that something that's relevant in psychopathic personality disorders?

Dr. Lynam:
I'm not I'm not sure. I'm not sure about that. I'm not sure that's been as strongly demonstrated for psychopathy as, say it has been for some some other sort of disorders. So I would I'm not going to go out on a limb and say anything about that. Sorry, I just I just don't know.

Dr. Chase Thompson:
Yeah, no worries. And you mentioned something about children showing some there being some stability of psychopathic traits over time, even from early childhood. What are some of the early signs that you tend to see in children?

Dr. Lynam:
A lot of them are just sort of just the similar manifestations as what you find in in adults. So my earliest work was taking the psychopathy checklist and trying to operationalise it in a group of 13 year old boys using sort of archive data. And so so you could find things like they lie a lot, right? They're aggressive, they're in trouble a lot, but they don't seem to feel bad after misbehaving. They've got impulse control problems, you know, they steal. So it's a lot of the same sorts of traits. I mean, they're not stealing cars, right? But they are stealing food or things like that that are a little more developmentally normative. But sort of those same traits seem to be present earlier on as well, that they look slightly different, but they seem to mean the same thing. Yeah. So, you know, they seem to be they seem to be callous, they seem to be selfish. And one of the concerns was some of that stuff is, well, aren't all kids callous and selfish and and things like that. But but it's really a matter of degree, you know, like these folks are these these kind of kids who will grow up to show more psychopathic features are even more callous and even more self-centred and lie even more.

Dr. Lynam:
And so it's about sort of elevations across all of those things that seems to predict higher levels of psychopathy. I mean, we did one study where we had those 13 year old boys that we had that we had assessed using this kind of childhood psychopathy scale, and we followed them up 11 years later in the young adulthood and gave them the the PCLSB, which is a psychopathy checklist screening version. And across those 11 years, I mean, the stability wasn't high, but it was a correlation of about 0.35, which is not awful when you consider it's 11 years. And these are different instruments being used. And there's mother ratings at time one and it was interviewer ratings at time, too. So there's definitely some degree of stability in all of that. And again, it's sort of like predicting like it's, it's the same sorts of behaviours, early predicting the same sorts of behaviours later on.

Dr. Chase Thompson:
So what about in the DSM for antisocial personality? One of the criteria is that there's some evidence of conduct disorder behaviour in the past, and at the beginning we were talking about the concept of a sociopath or someone who might be like a it's an acquired antisocial personality. I guess I'm wondering how do you reconcile those things or is acquired sort of antisocial personality, not really a thing or or what's going on there?

Dr. Lynam:
I mean, are you thinking that sort of those who acquire this antisocial personality won't show that sort of early evidence of conduct disorder? I'm not sure quite what you're.

Dr. Chase Thompson:
Yeah. I mean, I guess I'm wondering, like if you have an adult who has what seems to be really antisocial behaviours, but as far as you can tell, there isn't clear evidence from, from the parents or on review of their development that there was clear conduct disorder behaviour.

Dr. Lynam:
There have been a couple attempts to look at that. I mean there have been a couple this was years ago that I read on it, but there have been some people arguing that you can have kind of antisocial personality disorder in the absence of evidence of of earlier conduct disorder that you can sort of meet these other criteria and that it's still sort of meaningful and important. So I do think that's possible. I mean, I think there's a whole issue of sort of a lot of times like psychopathy checklist is used to predict future violence or it's used to predict recidivism, things along those lines. But there is an issue about the assessment being saturated with the behaviour you want to predict later on. So one of the reasons that the psychopathy checklist might serve so well as a predictor of future antisocial behaviour is because, boy, it's certainly built on past antisocial behaviour in a lot of ways because that file review just just bleeds into lots of those criteria. And so if you have lots of anti sociality in your background, in your file, you're going to elevate that psychopathy checklist purely on the basis of the past behaviour. So of course that's going to predict future behaviour very well.

Dr. Lynam:
One of the ways we've tried to move away from that is trying to move to a much more pure personality assessment. And there have been some other folks too in the adult military who are working around the psychopathy checklist saying we should try to exclude antisocial behaviour so we eliminate that kind of contamination and we're getting more at sort of pure personality. There's something that's a little bit separate from the behaviour that we're interested in and care about, and that's almost what you'd be doing with the APD if you eliminated childhood conduct problems because that's the most antisocial or the most, frankly, anti-social criteria in that set. But I mean, I think it's I think it's meaningful to to have these characteristics in the absence of I mean, I think they I think a lot of times antisocial behaviour will follow from having this collection of traits because again, I think it's about the removal of of internal controls that let you do almost anything. And so I think anti-social behaviour is a pretty probable outcome if you have these traits. But, but again, doing away with previous childhood conduct problems is probably might not be a bad idea for for the APD criteria. Mm hmm.

Dr. Chase Thompson:
What can we say about the prognosis or long term clinical trajectory of individuals with psychopathic personalities?

Dr. Lynam:
Years ago, they thought they would talk about them being untreatable, right? You couldn't do anything with psychopathy, with individuals, with psychopathy. And they pointed to a couple treatment studies that looked just like things went terribly. There was no help at all. But but more recent scholars have looked at those and said those were crazy treatments you were trying. And sort of more recent stuff suggests that they're about as treatable as anybody with a personality disorder, which is so you can treat some, but it's not great, right? I mean, I think psychopathy may be a particularly difficult disorder to treat because there's not a lot of distress. I mean, like borderline right, individuals, borderline PD. I mean, they are remarkably distressed, right? I mean, they are not happy with how stuff's going. Right. But I think I think for folks with who are high in psychopathy or anybody who's high in antagonism generally, like they don't feel a lot of distress. They're like they're not anxious and worried and really, really sad. I mean, the pissed off and it's not their fault either. Right. I mean, it's your fault for for being so soft or it's it's the cop's fault for coming along at an inopportune time or it's the victim's fault for falling and hitting your head more severely.

Dr. Lynam:
I never intended for her to get hurt that bad, You know, this sort of things like that. And so I think it may be harder to get a lever. What do you grab to try to convince somebody to change? And Reed Molloy years ago was talking about kind of what he tried to do and was try to make them understand that you are not happy now. Jail sucks. Jail is not fucking right. What can we do to keep you out of ending up here again? And so it kind of it's an appeal to a certain amount of selfishness that sort of you might be happier if you could avoid prison or if you could sustain a relationship or. And so I think I think that's an issue for for psychopathy is sort of where do you grab on to? What kind of handle can you get? Because that big handle of subjective distress and you feel terrible, let's figure our way out of this just is not as available as it is in other places.

Dr. Chase Thompson:
Right. Right. I think there's also been some areas I've read around kind of like a burnout effect of antisocial behaviour as as individuals hit their midlife. Is that a phenomenon that that you recognize?

Dr. Lynam:
Well, one of the things that seems to happen a lot I mean, is this sort of crime decreases, our crime changes at least. So if you chart sort of the changes in levels of the psychopathy checklist factors, they break them into two factors. One, they I think erroneously call personality and the other they call antisocial behaviour. And it's more about for me, it's more about pure antagonism and then a mix of antagonism and conscientiousness. But what you see is that that factor one stuff changes a little bit, maybe decreases a little bit, but it's really the factor two stuff that drops off. And that's probably due to the kind of the way in which it's assessed and the reliance on crime. I mean, at 50, you just can't fight as much. You can't you can't break stuff and climbing windows anymore. I mean, it's sort of I think the burnout is more about the sort of crimes that are being committed. And so so those are definitely dropping off because I think they're hard to sustain as you get older. So I do I do think that that part's definitely a real thing. We're about to start looking at, at least in an older age cohort, just sort of psychopathy assess purely on the basis of personality. So not including the really antisocial stuff to look and see what does happen across 15 year old, 15 year span from, say, 60 to 75. Are the traits themselves changing very much at that point, or is it reasonable to believe that all the change people are reporting on is really this this drop off in antisocial stuff?

Dr. Chase Thompson:
So if I can try and paraphrase you it's it's it's that the outward behaviours decline, but maybe the inner subjective world remains the same.

Dr. Lynam:
Yeah, I think that's fair.

Dr. Chase Thompson:
Okay. Psychiatry and psychology. We always see a lot of comorbidity. And what are the common comorbid issues that people with psychopathic personalities run into?

Dr. Lynam:
I mean, you know, one is, is it really a kind of a close cousin personality disorder, which is narcissism. So you end up with narcissism is highly correlated with psychopathy. Substance abuse and substance use problems are highly correlated with psychopathy as well. I mean, there are diagnoses, but but aggression is a problem. Relationships are a problem. But but again, because they tend to lack this subjective distress, it's not as comorbid with other forms of psychopathology as, say, borderline personality disorder is right, which is co morbid with almost everything, because they all have this big piece of of emotional reactivity and subjective distress. And you don't really find that in psychopathy, but it is co morbid with all the externalising behaviours. So various sorts of substance use alcohol problems, I mean all, all that sort of what gets called externalising stuff, psychopathy sits right in the middle of that.

Dr. Chase Thompson:
So is it kind of protective against the internalising depressive depressive anxiety disorders?

Dr. Lynam:
It is, especially if you allow that boldness component in. I mean, in fact, if you allow boldness in psychopaths, psychologically speaking, you really want to be psychopathic because you are relatively immune to those sorts of those sorts of problems. If you don't have that in there, then you can get some of the kind of depressive sorts of stuff going on. But but if you allow boldness as a piece of psychopathy, it definitely protects against against kind of internalising disorders because frankly, it's it's virtually the opposite of internalising disorders.

Dr. Chase Thompson:
Right, Right. So I think we're getting closer to the end of our time together. One maybe question I have is sort of more theoretical, broader question, but sometimes thinking about personality, I wonder why is psychopathy a something that's developed in people as opposed to any other disorder? And does it we've talked about it being sort of on the spectrum.

Dr. Lynam:
I see.

Dr. Chase Thompson:
Is there some sort of benefit that antagonism maybe has a in a more milder sense or what is is there any sort of function of psychopathic orientation?

Dr. Lynam:
Sure. So I'd say a couple of things. One, one thing I would say I think is that I'm not sure psychopathy is a natural category in the sense that sort of I think what it is, is it's a it's a presentation that is really kind of bothersome and people notice it. Right. And so you can't help but see it. These folks are like this. But but I'm not sure that it coheres like a syndrome does. So I'm not sure it's a natural category. But but the question is interesting, like, why does high antagonism exist at all? But why are we not all just kind of flat, bare and all nice to each other and stuff? And, and I do think there's some advantage to being a bit of a jerk. I mean, quite quite frankly, I think I think this is a way of pushing and getting what you want. It's a way of stepping ahead of others while stepping on others, which can be to kind of your individual advantage. I mean, these are sometimes I think of these if you think of these in evolutionary terms, different reproductive strategies, these are the cheaters. These are the folks who aren't following kind of our rules as long as there are too many of them.

Dr. Lynam:
It's a very successful strategy. And so I think that sort of these folks are probably I mean, if you want to talk purely evolutionarily, these folks are having more babies, right? At least at least the men are right. If you're if you're sort of can't have committed relationships, then any relation you have is sort of uncommitted. And so you have lots of them. And and just that'll propagate your genes just quite simply. And I do think just from a subjective feeling, I mean, some of these folks are decently successful because they're the first in line and they will find their way up front if they're not there already. And so this is a manipulative they don't care what they do to you. They don't think you're particularly important. And this this this allows them to get some of what they need at the expense of others. And so so that's why I think probably, you know, there is high antagonism out in the world. But not everybody could be like that. Right. Because living in community becomes really very difficult, is my thought on it. I mean, I'm not an evolutionary psychologist, but that's me pretending to be one.

Dr. Chase Thompson:
Fair enough. I know you spoke a little bit about treatment, just in the sense that there's not a lot a ton of intersubjective distress that drives someone towards treatment. But say you did have someone who is, for some reason, very motivated to get treatment. Is there any sort of modality that's been shown to help at all? Or.

Dr. Lynam:
Not really

Dr. Lynam:
I mean, I don't think I mean, I don't think people have studied treatment for psychopathy in the same way they have, say, for for borderline or for depression. I mean, not what works best. I mean, so you certainly don't have these sort of cross treatments and people trying to figure out what will work. I think people have thought for a while that these folks are probably relatively untreatable. So and frankly, they don't come in a lot. I mean, you know, in your clinical practice, let's say, how many grandiose narcissists do you see rolling in of their own accord? I think the answer is very few. They get there because the spouse brings them in or court orders them there. I mean, this is what kind of brings them in. So there's not a huge population to work with. And I think a lot of a lot of clinicians find that group a difficult group to work with. And I think individuals with psychopathy are much the same because they've got that same core of I don't know why I'm here, I don't have a problem. You guys have a problem. This kind of shifting of blame. And again, what do you do? I mean, I think Reed Molloy was probably right. If I find a lover in there, that's a selfish leaver. Look, you don't like coming in to see me. You don't like being in trouble with everybody? What's something we could maybe figure out that you could do differently that would keep you from ending up in jail or would allow you to resume a decent marriage with with your spouse. Right. I mean, that's kind of the only thing I can think of. I mean, I do think I mean, I'd love to see somebody develop. There's a unified protocol for negative affects in the world today. I mean, boy, if you could come up with something like that for antagonism, that'd be great. You know, maybe it starts with this kind of motivational interviewing approach about sort of just getting them to think about change because the way they're doing stuff now is is less than optimal for them.

Dr. Chase Thompson:
Hmm. Mm hmm.

Dr. Lynam:
But but I mean, appeals to look at. Look at how you hurt this person are probably not going to work very well. Wow. Yeah.

Dr. Chase Thompson:
Hmm. Well, is there anything that you think that we haven't touched on in terms of psychopathy that you think is important to say at this point?

Dr. Lynam:
No, I think I think I've got to say pretty much everything I wanted to say. I appreciate your questions and I hope I was somewhat clear, at least.

Dr. Chase Thompson:
Yeah, I think you're. Yeah, absolutely. Well, thank you very much for being on our podcast. We really appreciate it.

Dr. Lynam:
Thanks for the invitation.

Dr. Chase Thompson:
Okay.

Dr. Chase Thompson:
PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by myself, Chase Thompson. Theme song is Working Solutions by all Live music, especially thanks to our incredible guest, Dr. Donald Lynam, for serving as our expert for this episode. If you want to get in touch with us, you can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.Org. Thank you for listening bye.

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Episode 45: Reproductive Psychiatry with Dr. Tuong Vi Nguyen

PsychEd_Ep_45_-_Reproductive_Psychiatry_with_Dr._Tuong_Vi_Nguyen.mp3: Audio automatically transcribed by Sonix

PsychEd_Ep_45_-_Reproductive_Psychiatry_with_Dr._Tuong_Vi_Nguyen.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Nima Nahiddi:
Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. In this episode, we'll be exploring the psychiatric aspects of reproductive mental health. I'm Dr. Nima Nahiddi, a fourth year resident at McGill University. And I'm joined by Arielle Geist, a second year resident at the University of Toronto, and Audrey Le, a first year resident at McGill University.

Arielle Geist:
Hi, everyone.

Audrey Le:
Hi, everyone.

Nima Nahiddi:
We're really grateful to have our guests, Dr. Nguyen, this week to share her expertise. Dr. Nguyen, if you could, please introduce yourself.

Dr. Nguyen:
Sure. So I'm a reproductive psychiatrist at McGill University Health Centre.

Nima Nahiddi:
For this episode. Our learning objectives are the following to define the field of reproductive psychiatry to discuss the possible neurobiological pathways impacting mood and cognition during the reproductive cycle of women, to discuss the influence of sociocultural gender roles on psychopathology, to list the DSM five diagnostic criteria of Premenstrual Dysphoric Disorder. To recall the Epidemiology of Premenstrual Dysphoric Disorder. To describe the steps in the diagnostic evaluation of Premenstrual Dysphoric Disorder. To list lifestyle and psycho pharmacological interventions for Premenstrual Dysphoric disorder and to discuss common mental health concerns during the perimenopausal period.

Arielle Geist:
So I'll start with the first question today. So before diving in today's discussion, could you briefly explain the clinical scope of reproductive psychiatry and what your work entails? Exactly.

Dr. Nguyen:
So reproductive psychiatry is really about all of the mental health changes that occur in a woman's lifetime during reproductive periods, typically around puberty. You start to see changes related to hormones and you can see a significant proportion of women who start to have premenstrual syndrome, 70 to 80% with a smaller proportion that go on to the premenstrual dysphoric disorder. Another stage of life when you have these hormonal fluctuations is, of course, the pregnancy and postpartum period. And then finally you have the perimenopausal period. And there has been talk amongst us, reproductive psychiatrist that psychiatry should also include hormonal changes for men. But we'll see maybe in in ten years. For now, it's pretty focused on women's mental health.

Arielle Geist:
Mm hmm. Since you mentioned hormones, my next question was, how do these hormones, especially in the field of reproductive psychiatry, where the focus is on mostly estrogen and progesterone, how do those hormones modulate mood and the neurobiological pathways that are involved in regulating mood?

Dr. Nguyen:
There's no simple answer for that. I think that when you think about hormones and women hormones, you have to think about the fact that there are classes rather than just thinking about estradiol and progesterone. It's really all of the steroid hormones are linked together. And you can have up to 54 metabolites, maybe more, maybe more metabolites could be discovered. And then you have these three or even four classes. I don't know if you're aware, but it all starts with cholesterol. And then you have one branch that go on to be corticosteroids. You have one branch that go on to be the estrogens, but then you have tons of different types of estrogens, including 17 beta estradiol, the most famous one. And then you have the progesterone progestogen basically progesterone alone and all of these related hormones. And then you also have the androgens like DHEA and testosterone. So all of these hormones change cyclically throughout the menstrual cycle and then very drastically during pregnancy and the postpartum period and of course the perimenopausal period in terms of how they affect neurotransmitters, I would say again, no easy answer, but just in a very broad way, in simplified way, the estrogens tend to regulate serotonin. Well, all of the all of the neurotransmitters, it's really like they're really almost like dirty medications. So they will affect serotonin and norepinephrine, dopamine in different ways. Progestogen also and estrogen suppression tend to have opposite effects. So for example, estrogen tends to be more stimulating to, for example, up the serotonin, serotonin tone and also androgenetic tone. And then progestogen tend to act again, not all of them, but most of them act through the GABA receptor and then they will lead to inhibition or kind of downregulation of the HPA axis, for example. So the kind so more a bit more like benzos androgens, there's a lot of research that remains to be done on androgens, which are really not well studied. But the typical effect is really in terms of activity, mood, lability, competitiveness, things like that.

Arielle Geist:
Thank you. I think you really were able to simplify something that that seems very complicated to. I think many trainees. Next, because of the way that we formulate things in psychiatry, going with the biopsychosocial model, I wanted.

Arielle Geist:
To step away.

Arielle Geist:
From the biological aspects of reproductive mental health for a second and take some time to explore its social aspect. So my next question was about how do you feel that social and cultural type of gender norms affect clinical presentations of this field? For example, how the way that it might affect the experience that mothers who have postpartum depression have?

Dr. Nguyen:
I think there are still many unanswered questions regarding that. And one of the key aspects of the literature is that we still don't know enough about the social determinants of health for perinatal depression. I hope that beyond post-partum depression, we'll start to talk about perinatal mental health disorders. I think PPD has become very famous. Postpartum depression has been recognized by and large by the mainstream media. But then oftentimes we miss the anxiety disorders that present during the period of period the post-traumatic stress disorders, OCD, which is its own different beast as well. And so I think that, yes, there's a lot of advantages to to have more recognition and awareness, awareness of depression. But we must I think it would be more helpful for women if we use a broader term, perinatal mental health disorders. And I think that in the past decade or so, more and more women are delaying fertility or delaying reproduction to further career or other interests that they may have. And so more and more women will have unfortunately, more and more couples will have infertility and fertility problems. And then that kind of opens the door to a whole other area of mental challenges, which is all of the mood fluctuations related to hormonal treatments, IVF IUI, and in addition to the psychological issues of repeated miscarriages and pregnancy complications. So I think in terms of in terms of that social aspects of mainstream recognition and awareness, we've done a lot, but there's still there's still a lot of work to do because some women will still come to me and say, well, I have suffered for two years because I had no idea.

Dr. Nguyen:
I thought they were suffering from postpartum anxiety, let's say, and then not want to present to not want to discuss it with their doctor because it's they felt they were obviously not depressed. So I think that's that's one aspect. I think the other aspect socially that is that is important to mention is that unfortunately, we're still, despite the fact that Hillary Clinton said several years ago that women's rights are human rights or human rights or women's rights, something like that. I don't know if I'm quoting her properly, but I still think that we are struggling to we are struggling to kind of have the political recognition that we that we need. And this is at all levels. Just to give you an example, all of the reproductive psychiatrists currently working in Quebec have really struggled to implement to have even a prenatal clinic. This in the in face of the fact that we know now that maybe one in three women around the period may have a significant period of mental health disorder with all of the uncertainties surrounding COVID, with the fact that most of the child care burden and house chore burden still falls on the woman at home, and that several of them have out of work because of that. Even so, we're still really struggling to establish these these clinics. And there's actually just one, I would say, clinic in the Quebec province that offers psychological help, an experienced nurse and a psychiatrist. Then the rest of us are basically perinatal and reproductive psychiatrists that are working with little support.

Arielle Geist:
Mm hmm. Thank you for all of that wise insight. I have one last question about the social aspect that I think you kind of touched on to. So when I was reading on the literature leading up to doing this episode, some of it suggested that premenstrual syndrome and postpartum depression and such are quite seem to be a bit more culture bound because there is some literature out there that suggests that it's less prevalent outside of Western countries. So I was just wondering if you had any comments to make in terms of how those differences might be explained by cultural norms or whether that even is true, whether or not we do see it pretty prevalent in in all cultures?

Dr. Nguyen:
Yeah, No, no, absolutely. I wanted to mention that too. So it's again, an example of of perhaps some of the biases that are in some of the controversy that always surround women's mental health in terms of of how long it took for the premenstrual dysphoric disorder to make it into the official category of the diagnosis instead of being relegated to the culture bound syndromes. I would say all of the evidence up to now point towards the fact that there are similar percentages, proportions of women suffering from PMDD across all across all cultures, across all ethnicities. And so I would say if you have a multiple choice question, I would say that PMDD is not the culturally bound syndrome. And it it really does seem that there is an overlap between the women who suffer from PMDD and the women who may have bad reactions like disinhibition and aggression with alcohol. So there seems to be something surrounding maybe men alone and the GABA receptor, but there's several biological and particular genetic contributions to this to this illness.

Audrey Le:
Thank you for answering all of those questions. We're going to move a little bit now into premenstrual dysphoric disorder. So this is a depressive disorder that's linked to the menstrual cycle with symptoms presenting in the week before the onset of menses. Before we dive into this further, it might be helpful for our listeners to briefly talk about the DSM criteria for premenstrual dysphoric disorder to get a better understanding of what this looks like. So before asking further questions, I'm just going to run through the DSM criteria for premenstrual dysphoric disorder. So A, in the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses start to improve within a few days after the onset of menses and become minimal or absent in the week post menses, criteria B one or more of the following symptoms must be present, and these include effective lability, irritability or anger or increased interpersonal conflicts, depressed mood, feelings of hopelessness or self deprecating thoughts and anxiety, tension and or feelings of being keyed up or on edge. Criteria C, one or more of the following symptoms must additionally be present to reach a total of five symptoms when combined with the symptoms and criteria B above.

Audrey Le:
These include decreased interest and interest in usual activities, subjective difficulty in concentration, lethargy, easy fatiguability or marked lack of energy, marked change in appetite, overeating or specific food cravings, hypersomnia or insomnia, a sense of being overwhelmed or out of control. And lastly, physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of being bloated or weight gain. Of note, the symptoms I mentioned must have been met for most menstrual cycles that occurred in the preceding years. And the rest of the criteria after this include D causes significant distress or interference with daily activities or relationships. E The disturbance is not an exacerbation of the symptoms of another disorder such as MDD, panic disorder, PDD, or personality disorder. F Criterion A should be confirmed by prospective daily readings during at least two symptomatic cycles, which we'll talk about more detail later in the episode and G. The symptoms are not attributable to a substance medication or another medical condition. So now that I've gone through the diagnostic criteria of premenstrual dysphoric disorder, let's talk about the epidemiology. How prevalent is this disorder and how does it evolve across the lifespan?

Dr. Nguyen:
So in terms of the last estimates, they go between two, it's 2 to 8%. I think if you define it very rigorously with a two month perspective ratings, which not all women are willing or able to complete, then it maybe is 2 to 5% and that is compared to the 70 to 80% of women who have premenstrual syndrome.

Audrey Le:
Thank you. And and how does this tend to evolve across the lifespan?

Dr. Nguyen:
So typically, PMDD, unfortunately, tends to get worse with the years, particularly after having had children, that we we still don't know what exactly in terms of hormonal mechanisms that's due to. But that has definitely been documented in terms of it's getting worse over time.

Arielle Geist:
And again, thinking about premenstrual dysphoric disorder, what's the differential diagnosis that you think about when you're seeing a patient?

Dr. Nguyen:
Oh, you have to think about all of the gynaecological endometriosis, for example, PID (pelvic inflammatory disease), ovarian cysts or ovarian torsions. There's a lot of different gynaecological conditions that you have to think about. I am actually of the school of thought that I don't. I think that disorders can be co-morbid. And so even though I know that in the DSM, it says it cannot be the exacerbation of another condition. We know from family studies that, for example, MDD and PMDD coexist in these families. And so you will have several women who suffer from both. And so then it's really difficult to disentangle. Is it just an exacerbation of MDD or PMDD and MD together? So for me, it's not kind of hard exclusion criteria per se.

Nima Nahiddi:
I was just wondering how realistic or easy do you find it is for people to do the prospective charts for the two months? Is that something that if you will have resources or with your smartphone, that is very doable.

Dr. Nguyen:
It is doable. I just find that this is this goes back to the social determinants of health, I guess, but it's just very special to me that it's the only disorder which you require. Two months perspective ratings for all of the other disorders are not it's not that hard to to meet the criteria, basically. And I think that for some of our some of our population it is quite difficult. You know, like you have three children, you're trying to get diagnosed with PMDD, you just don't have the time. So it can be challenging for some people. So at least we have the option of being of giving a PMDD provisional diagnosis until the person kind of hands in the two months perspective readings. But typically I really try to encourage them to do it either like you said, on the smartphone or some people just like hard paper copy. So it's it's doable. But I think maybe in ten years there may be changes again to that specific criteria.

Audrey Le:
And thinking of those rating scales. What are some rating scales that are typically used in diagnosing premenstrual dysphoric disorder that you use?

Dr. Nguyen:
They're quite widely available now, particularly given that a lot of women are trying to track their fertility. So you just there are several apps like Overview and several other new apps as well. It's called Fertility. I don't remember, but there are several for both iPhones and Google Samsung phones now. And even if you just do, you don't even have to download an app. You can just do a Google search and you'll see like all of these paper forms, you just have to make sure that the big categories, like the effect of symptoms, cognitive symptoms, physical symptoms are all properly listed, but they're widely available and free.

Nima Nahiddi:
Now that we've reviewed the diagnosis of premenstrual dysphoric disorder, what is your approach to the treatment once you've diagnosed someone?

Dr. Nguyen:
It really depends on the patient. I think most of I think most of reproductive psychiatry is. There's a lot of joint decision because it's such a it's such a personal decision. For example, for PMDD, it depends whether the woman is willing to consider contraception, in which case you could try something like Yasmin for three cycles with four days off. It's important to mention, though, because I see this very commonly, is that you cannot just throw any oral contraceptive pill at PMDD and hope that it works. Several pills, particularly the ones that have more androgen potency, actually can make PMDD worse. One common culprit is alesse, for example, which is quite commonly prescribed. So even though if alesse has very low levels of hormones and so some GP's or some other health care practitioners may think that this is going to be helpful for someone who's suffering from PMDD. It actually is not about the levels of hormones but about the potency and which direction, which of the different classes of the steroid hormones that I mentioned earlier, which the oral contraceptive is offering. And the other thing that people often forget is that you have to prescribe it really three cycles and four days off, which is not the typical regimen for oral contraceptive pills. Usually it's like three weeks on and then you have like a week of sugar pills or placebo pills. But you need to do this to disrupt the cycle and to help in terms of the PMDD symptoms. Another aspect I would say is some women actually come to me already on SSRI, And then I think in that case, it's easy to consider, okay, why don't you try to increase your SSRI during your luteal period? And so the week before menses, this is depending on their perspective tracking this.

Dr. Nguyen:
This can be useful in terms of knowing. Does the woman start to have symptoms right after ovulation, which some women do, unfortunately. So they have like a full two weeks of symptoms that then only start to improve slightly when menses start. Some women only have like three days of symptoms before their period occurs. And so depending on the timing that you can tell them to increase, bump it up a little bit. For example, if the person is on escitalopram, they could go up to 25 or 30 just for that period. What's important to remember is that the mechanism through which the SSRI work for PMDD is not the same as how it works for depression, for depression and anxiety. You have all of these changes at the synapse or occurring the changes in auto receptors 5HT1A But for PMDD, it's really thought to occur through a disruption in the way that the hormones are being metabolized. So again, because there's this communication between the serotonin and just overall neurotransmitter systems and the hormones, basically the if you administer SSRIs or an increased dose of SSRI during this period of time, perhaps it's changing how fast the hormones are being self-rated or converted to different metabolites in a way that then helps women. So there's still a lot of research, kind of more fundamental research that needs to be done in terms of how that occurs. Exactly. But there are now several studies showing that the SSRI are quite effective for PMDD when administered in this fashion.

Nima Nahiddi:
So to clarify for pharmacological treatments, there's oral contraceptive pill and SSRI. And so can you explain in which situation would you choose one or the other or would you recommend one or the other?

Dr. Nguyen:
I think I've touched a bit on that in terms of, you know, depending on the on the patient perspective and what they what they want to priorities. Some women may be in the midst of trying to conceive and so the Yasmin wouldn't be the right choice for them. Some women might have a family or personal history of stroke, pulmonary embolism, deep vein thrombosis and other and have other risk factors such as being over 35 years old and smoking, etc. And in that case, Yasmin and Yaz, that whole category of oral contraceptives actually are associated with an increased risk of stroke and deep vein thrombosis, etc. So there are some exclusions in some cases where I tend to shy away from the Yasmin or Yaz, oftentimes. Also, it may be easier for women who are already on SSRI to just continue on and just change their dosages that way. And then it's less stressful for them in terms of changing medications. I just want to mention also that if SSRI and oral contraceptives don't work, then you can help. GNRH agonist or antagonists are kind of like basically surgical or medical menopause. So this is really a last resort, though. And I would say 70 to 90% of women actually respond to Yasmin or SSRI. And in terms of the study. It does seem that the contraceptives have a slightly higher rate of success. It may be 80 to 90% versus the SSRIs, which are more like 70 to 80%. So like a highly treatable condition.

Nima Nahiddi:
You had mentioned that we should avoid certain contraceptives like Alesse, What is the specific reason why you would avoid that? Just to clarify.

Dr. Nguyen:
So some contraceptives have more androgen activity like you remember, Like the difference, like there's androgen activity, progestogen activity and estrogen activity. So each pill actually has different balances or mixes of of that similar to, I guess, the antidepressants in the different neurotransmitters. So if you have one that acts more on androgen and not so much on the drospirenone or basically it's the metabolite that is in the progesterone category that is part of Yasmin and Yaz, then it's not going to be effective. So some some contraceptives will just be neutral. It will neither help nor worsen the PMDD and then some others will make it worse if they have the wrong mix, if they have too much androgen activity, for example. And then that's why we think that it's Yasmin or Yaz, that has that is efficacious because of that drospirenone metabolite specific to those medications.

Nima Nahiddi:
Thank you so much for clarifying that. Are there any lifestyle interventions that can help with the treatment of PMDD?

Dr. Nguyen:
Unfortunately, there's very weak evidence to support that. Some women will say, I've tried calcium, I've tried B vitamins, I've tried exercise. And I'm not saying like in lots of cases, add on CBT, add on light therapy even could help. There's a lot of different conditions, but it's just that the the evidence behind those complementary therapies is still quite weak.

Nima Nahiddi:
So I'd like to finish our discussion by going to another topic. Mental health concerns during the perimenopausal period. Can you clarify? First, the definition of perimenopausal?

Dr. Nguyen:
Perimenopausal is again, difficult to define because you have so you have menopause, which is one year after the cessation of the complete cessation of menses. So you can basically only define menopause retrospectively because you never know if you're going to have another period at perimenopause. In most of the studies are is thought to represent the whole period of when the ovaries or the follicles are starting to decline up until menopause, which is one year after the last period. And then you have early perimenopause and you have late perimenopause. I feel like for your learning, you don't need to know all the details of that, but just know that the changes of hormones are different in early versus late perimenopause. Menopause in early perimenopause, you can see a lot of erratic changes in estradiol and other hormones, too. I don't want to get too much into the complexities of that. And in the late period menopause, that's when you start to see a profile that is more similar to menopause. So a lot of ups and downs and fluctuations throughout that whole period. And just to mention that some women can start to enter the early menopause around age 40, 45 years old. So it can be quite much earlier than than some of us would expect.

Nima Nahiddi:
And what are some mental health concerns that arise during this time period?

Dr. Nguyen:
It's typically anxiety and depression, but you will also see exacerbations of schizophrenia and exacerbations of bipolar disorder, for example. So again, if you have a patient with bipolar disorder or schizophrenia and suddenly you have treatment resistance, you have to think about asking those questions about the menstrual, the menstrual history and reproductive history in terms of the more common disorders like anxiety and depression. And so what we see is that these perimenopausal mental disorders tend to be more persistent and more comorbid. So instead of just seeing a classical picture of depression, you will see a lot of anxiety, kind of depression with anxious features, difficult to treat, a lot of insomnia. And sometimes the women will describe it as the worst, the worst mental breakdown that she's had during her entire life and accompanied accompanying these mental symptoms. You have, of course, the physical symptoms also. So the hot flashes, the vaginal dryness, there's a lot of discomfort physically that occurred during this time as well.

Nima Nahiddi:
Can you speak about the incidence of depression specifically in the perimenopausal period and perhaps what effect estrogen has in the treatment of depression?

Dr. Nguyen:
I think other than the fact that the depression is often comorbid with anxiety in terms of presentation, I don't see any remarkable features of the depressive symptoms that are different from an MDD at another period of life. It's possible, though, that in terms of psychological and social contexts it's even harder because it's like a woman ageing, her children leaving. There's a lot of life changes also that are different from other periods of life in terms of the hormonal treatment. So I mean, we do consider transdermal estradiol as one of the useful add ons to antidepressant treatment. I don't tend because I'm not a gynaecologist, I don't tend to start with the transdermal estradiol, Some gynaecologists will, and I guess it's for them to comment on how the how they think, how they consider it first line versus second line. For me, I consider it more second line because there are several antidepressants. All of the antidepressant categories have been shown to be effective for perimenopausal depression and anxiety. Maybe with the SNRIs being a little bit more effective, we think because of all of the hypothalamic changes and dysfunction in the noradrenergic nucleus in the hypothalamus that happened with hot flashes. And that may also be may also cause some of the mood fluctuations that occurred during this period. So perhaps a SNRI a little bit more effective, but SSRI is also effective. Mirtazapine is also effective. I wouldn't go so much with bupropion though, because it's too activating and it can increase the anxiety that is often comorbid with perimenopausal depression.

Dr. Nguyen:
And then if that doesn't work, then you can consider something like transdermal estradiol. I think Raloxifene at some point was also discussed. It tends not to be very effective, maybe mildly effective sometimes a bit like how we use Pregabalin for for GAD like it can be effective, but oftentimes more like an ad as an add on. It actually has been studied in schizophrenia. I don't know if you're aware, but in terms of schizophrenia for cognitive and effective symptoms of schizophrenia and Raloxifene, which is a selective receptor modulator, seems to be effective for those symptoms in schizophrenia. And so that's why sometimes we also use it for perimenopausal depression. If someone, for example, has contraindications to transdermal estradiol, I always make sure to have a family doctor or a gynaecologist who is my partner in prescribing these medications. Typically, I've had no issues with people kind of collaborating and getting back to me quickly. And usually it's like at least it takes six weeks of transdermal estradiol and sometimes a bit more six weeks to six months. I would say after that I would be reluctant to continue to prescribe unless I have like an ultrasound or a really good follow up by the the other either family doctor or gynaecologist to make sure that endometrial thickness is not has not change, etc..

Nima Nahiddi:
And these other side effects that you've spoken about, like hot flashes that occur during menopause, do you find that these contribute to having increased mental health concerns?

Dr. Nguyen:
So just like the co-morbidity between PMDD and MDD, sometimes it's hard to disentangle. However, all of the prospective studies have shown that even when you control for hot flashes and all of the physical symptoms of menopause, you still have a peak. So the mental health symptoms do seem to be independent, although of course, the worse, the more anxious you are, the more you can suffer from hot flashes also. So so so there's a bidirectional kind of exacerbation that can occur. But even in a woman who would have very little physical symptoms of perimenopause, you can still have an increased risk of perimenopausal depression, anxiety, as well as exacerbations of bipolar disorder and schizophrenia.

Nima Nahiddi:
Thank you so much for that overview of reproductive mental health. Before we leave, do you have any specific clinical pearls you'd like to leave our listeners with?

Dr. Nguyen:
Oh, I would say I mean, I hope that everyone who listens to this podcast will remember to ask about menstrual history, because that's what I kept repeating throughout the podcast and then strong sexual history. I think these are really key and this is something that we often as psychiatrists feel uncomfortable to talk about and at any life stage, as you can see. So even a woman who comes to you 55 years old. So I have to ask about reproductive history, sexual history as well.

Nima Nahiddi:
Thank you so much, Dr. Nguyen.

Dr. Nguyen:
You're welcome.

Arielle Geist:
Site is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode is produced by Dr. Nima Nahiddi, Dr. Arielle Geist, Dr. Audrey Le and Dr. Rebecca Marsh. The episode was hosted by Dr. Nima Nahiddi, Dr. Arielle Geist and Dr. Audrey Le. The audio editing was done by Dr. Audrey Le and the show notes were done by Dr. Arielle Geist. Our theme song is Working Solutions by All Live Music, and a special thanks to the incredible guests we had today, Dr. Nguyen, for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

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Episode 43: Psychedelic-Assisted Psychotherapy with Dr. Emma Hapke and Dr. Daniel Rosenbaum

• Episode 43: Psychedelic-Assisted Psychotherapy with Dr. Emma Hapke and Dr. Daniel Rosenbaum

  Nikhita Singhal: [00:00:14] Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners. This episode covers an introduction to psychedelic assisted psychotherapy, an exciting and rapidly developing area in the field of psychiatry, which has been receiving growing attention in the scientific community and among the general public lately. I'm Nikhita, a third year psychiatry resident at the University of Toronto, and I'll be co-hosting this episode alongside a few of my colleagues who I'll pass it along to so that they can introduce themselves.

  Chase Thompson: [00:00:43] Hi, I'm Chase. I'm a fourth-year resident at the University of Toronto and I'll be hosting along with Nikita.

  Annie Yu: [00:00:49] Hi, I'm Annie. I'm a fourth-year medical student at the University of Toronto, and I'm really excited to join in on this conversation.

  Jake Johnston: [00:00:56] And I'm Jake Johnston, a fourth year medical student at UBC. Also very happy to be here.

  Nikhita Singhal: [00:01:02] Thanks. We also have two experts among us. Our guests for this episode are Drs. Emma Hapke and Daniel Rosenbaum. Dr. Hapke is a psychiatrist, psychotherapist and psychedelic researcher at the University Health Network in Toronto and is co-founder and associate director of the Nikean Psychedelic Psychotherapy Research Centre at UN. She's also a lecturer at the University of Toronto. Her specialty is Women's Mental Health and the treatment of developmental trauma, sexual trauma and complex PTSD. She has extensive training in multiple modalities in psychotherapy, as worked clinically with ketamine assisted psychotherapy. She also has a growing interest in psychosocial oncology. Dr. Hapke works with MAPS as the principal investigator for the Montreal site of the Phase three trial of MDMA assisted psychotherapy for PTSD, and is MAPs trained to deliver MDMA assisted psychotherapy. Dr. Rosenbaum is an attending psychiatrist at UHN, as well as the Inner City Health Associates (ICHA) in Toronto. He's also a clinical lecturer in the Department of Psychiatry at the University of Toronto. He works on an assertive community treatment team serving people with severe and persistent mental illness, as well as a palliative education and care for the homeless team through ICHA. Dr. Rosenbaum is interested in psychosocial oncology and palliative care, especially end of life issues for marginalized populations.

  Nikhita Singhal: [00:02:20] He's a certified CALM therapist managing cancer and living meaningfully and has received training in ketamine, assisted psychotherapy and completed the MAPS MDMA therapy training program. He's also co-founder of the Canadian Climate Psychiatry Alliance. Dr. Rosenbaum has published articles in peer reviewed journals on psychedelic assisted therapy and palliative and cancer care and on psychedelic microdosing. He's also a co-founder and faculty member of Nikean Psychedelic Psychotherapy Research Centre. Now the learning objectives for this episode are as follows. By the end of the episode, the listener will be able to briefly describe the history of psychedelics and psychiatry. List the four classes of psychedelic drugs and their mechanisms of action. Summarize the evidence regarding psychedelic assisted psychotherapy for various psychiatric disorders. Discuss patient selection considerations for psychedelic assisted psychotherapy. Describe the safety, tolerability, and possible side effects of psychedelic assisted psychotherapy, and understand how psychedelic assisted psychotherapy session is practically carried out. I'll hand it over to Annie to get us started and it's great.

  Annie Yu: [00:03:25] Thanks, Nikhita. So just to start off with some basic definitions - Dr. Hapke and Dr. Rosenbaum, can you tell us what the definition of psychedelic is and how these psychedelic drugs differ from other classes of medications that are already used in psychiatry?

  Dr. Emma Hapke: [00:03:42] First of all, I just want to say thank you guys so much for having us. It's a real pleasure to be with you today.

  Dr. Daniel Rosenbaum: [00:03:48] In some ways, I think it might be most helpful to start by categorising the various medicines that might be discussed at a psychedelics conference. And then I think from there, we'll be able to effectively answer the question of in what ways they're different from conventional pharmacotherapies that are used in clinical psychiatry. So I know one of the learning objectives for the episode is about the different categories of medicines, and I'll start by talking about the so called classic psychedelics, and I think that will take us towards a definition as well. Pharmacologically, the classic psychedelics are so called or defined by their action at the serotonin 2A receptor. And so some examples of the classic psychedelics include psilocybin, which is the psychoactive component found naturally derived in about 100 species of mushrooms, which can be found all over the world. In fact, there's also lysergic acid diethylamide or LSD along with mescaline, as well as dimethyltryptamine or DMT. And then there's also 5-methoxy-DMT (or 5-MeO-DMT). And together these comprise the category of classic psychedelics, the five HT2A receptor. Maybe we'll talk about this more a little bit later, but it's really key to understanding the subjective effects of the classic psychedelics. And there's plenty of evidence that points to the specificity of that receptor in particular, and serotonin 2A receptor mediated signaling in governing the profound and at times quite unusual subjective effects of psychedelics. So one piece of evidence is that the receptor occupancy after someone is administered a psychedelic at the 2A receptor has been shown to correlate with the subjective effects and then also serotonin 2A antagonists, including a medicine called ketanserin blunt or basically abort the psychedelic experience. I'll turn it over to Emma to talk about a different category of medicine.

  Dr. Emma Hapke: [00:06:00] Sure. Maybe I'll just add a little bit about some of the subjective effects that you can experience with the classic psychedelics. In general, psychedelics induce a non ordinary state of consciousness. And so with higher doses of psilocybin and LSD, for example, you'll hear about this phenomenon called ego dissolution. So that typical sense of self starts to melt away, and parts of the brain that don't normally communicate start to communicate. So we'll probably go into the mechanism of action in more detail later on. But there's a part of the brain called the default mode network (DMN). And we think that that that's sort of the conductor of the brain. So it kind of controls which parts of the brain are communicating, and it's active when you're just at rest and letting your mind wander. And some people have wondered, is that equivalent to our sense of self or ego? I think that's an open question. But what we do know is that with these classic psychedelics, the default mode network is quieted and therefore you get these pretty profound changes in perception and emotion and thinking as a result of that and other things that are going on. Those are the classic psychedelics. I think the second big category is empathogens, of which the most well known one is MDMA, 3,4-methyl​enedioxy​methamphetamine. And this class is different in the sense that with your classic psychedelics, chemically they resemble serotonin, so they bind those serotonin receptors, whereas with MDMA, it actually causes a massive release of your own stores of serotonin.

  Dr. Emma Hapke: [00:07:44] So it's a serotonin release, but it also releases dopamine and cortisol as well as norepinephrine in the brain and oxytocin. So it really does a number of different things in the brain. And one of the effects of it is this sort of heart opening effect, this increased sense of empathy, both for yourself and for others. It's also been called an entactogen, which means "to touch within." And part of that's getting at its ability to allow the person to become really self reflective and gain a better understanding of their own inner state in addition to sort of the empathic effects of it. One of the things that I think is interesting to note about MDMA is it's quite anxiolytic, meaning it reduces anxiety and it reduces activity in your limbic system. And the amygdala, for example, which is sort of the smoke detector of the brain and a lot of other medications in psychiatry that reduce anxiety also cloud the sensorium, so they lead to this state of greater confusion. But because MDMA also increases cortisol and dopamine, it's both anxiolytic but increases alertness. And I think that's part of what facilitates trauma processing and makes it a good catalyst for psychotherapeutic work. Dan, do you want to take it away with some of the other categories?

  Dr. Daniel Rosenbaum: [00:09:12] Yeah, pleased to. I also wanted to come to a definition of psychedelic. It's different from the pharmacologic action of the various medicines that Emma talking about, empathogens and relating that to the nature of the effects or the experience among people who take them. The word psychedelic etymologically derives from Greek words psyche and delos, psyche, meaning "mind" and delos, meaning "to manifest." So putting them together, we get mind manifesting. And that's really what the word psychedelic means. And it comes from an exchange of letters between two quite famous figures in the world of psychedelic science and history, one of whom is Aldous Huxley, the English philosopher and writer, and the other of whom is a psychiatrist named Humphry Osmond, who was working in Weyburn, Saskatchewan and was interested in LSD and doing trials for people with alcohol use disorder, what was called alcoholism, I suppose, at the time. And Osmond was very influential as he gave Aldous Huxley mescaline for the first time. And mescaline can be found in the peyote cactus as well as the San Pedro cactus. And Huxley's experience with mescaline turned into his famous book, The Doors of Perception. And after that, these two men struck up a lifelong dialogue. But I do also want to say that before this word was created, these medicines were called and classified or understood quite differently.

  Dr. Daniel Rosenbaum: [00:10:55] So when LSD was initially synthesised, it was distributed mostly to psychiatrists, actually. And psychiatrists were encouraged to take LSD so that they could better understand the psychotic experiences of their disturbed patients. This is quite interesting. And as a result of this understanding of what LSD was and how it might be useful, it was classified as a psychomimetic. In other words, that it mimed or brought about psychotic experiences. And it's probably not the most useful term. I think probably a lot of people are also familiar with the term hallucinogen, which is still sometimes offered as the classification of these medicines, which is to say that they bring about hallucinations. That's probably also not quite accurate. It's sort of rare for people to have frank hallucinations with these experiences. The nature of the subjective, psychedelic state or experience I think we should get into a little bit more later, but Emma's done a good job already introducing that. And then the one last term I'd offer as a potential substitute for psychedelic is this term entheogen, and entheogen refers to or means revealing the God within.

  Dr. Daniel Rosenbaum: [00:12:11] And so entheogen is often used when referring to the use of these same medicines in their plant medicine form by indigenous cultures. And so I think maybe we'll get into some of the history of Indigenous use of psychedelics as well, but shifting to a different category of broad psychedelics or again the things you might hear discussed at the psychedelics conference, we come to ketamine and I'm aware that the podcast has covered ketamine in a different episode, but I'll just say briefly that ketamine, which acts at NMDA receptors as an antagonist, is a rapid acting antidepressant medication which can be administered either intravenously, intramuscularly, sublingually, or also orally and at high enough doses, still sub anaesthetic doses, but at high enough doses, people can have experiences on ketamine that resemble in terms of the subjective experience, a psychedelic state. And for that reason, sometimes ketamine can be paired with psychotherapy, so called ketamine assisted psychotherapy, in a similar way that the classic psychedelics or MDMA are used in conjunction with psychotherapy. But I think that's all I'd like to say about ketamine for today is I think we should leave the focus of our conversation to the classic psychedelics and MDMA.

  Dr. Emma Hapke: [00:13:28] One other category of psychedelic that has its own complex pharmacology that we'll just mention very briefly is iboga. And iboga is this root bark that comes from Gabon in Africa, and it's one of the most potent psychedelics on earth. And it seems to have this possible effect around the treatment of specifically opioid use disorder. It's a molecule that can induce a rapid detoxification from opiates, which is really interesting. And then it also induces these profound mystical states, which may be linked to how it's plays a role in the healing of addiction. It's used typically in a ceremonial context. It's the tradition from Gabon that uses iboga. And I think that it's an interesting area of study. There's a higher death rate with iboga than other forms of psychedelics. So it may have some form of cardiotoxicity that we need to research. And I know there's a number of companies that are looking at extracting parts of the molecule to see what elements of it are healing.

  Chase Thompson: [00:14:43] Thanks so much for that overview. Dan and Emma, I just had a question about a points that each of you raised. Emma, you talked about the psychedelics being causing the effect of ego dissolution. And Dan, you kind of went through the etymology of the word and how it means to manifest the mind. So I'm kind of wondering, like these might seem maybe contradictory sort of effects where you dissolve the ego or maybe the self, but also revealing the mind. I'm just wondering if you guys have any thoughts about whether that's a contradiction or how that occurs?

  Dr. Emma Hapke: [00:15:21] When I think about psychedelics, I really think of them in some ways as like non-specific amplifiers of the psyche. And sometimes it's our ego structures and our defences that actually keep stuff from our past down. Sometimes Carl Jung would talk about the shadow - when I think of the shadow, I think it's the part of our psyche that we're not typically conscious of in our normal waking consciousness. And often things get pushed into the basement of our mind that were difficult in the past or that we were unable to process. We're still carrying them around and they're still affecting us. And so as the normal sense of self starts to dissolve away, you will often see some of that other psychic content come up for processing. And it's not always that the person's actually trying to consciously process it in the psychedelic state. It's more about experiencing it in the psychedelic state. And then after, in the integration phase, when they're no longer in the non ordinary state of consciousness, that's when we try to make meaning and interpret what came up. And I think the other piece that happens to as the ego dissolves, in addition to sort of the mind itself manifesting and coming up, is there's also these connection to these expanded states of consciousness. So people will talk about having these mystical experiences where they feel connected to everything or connected to something greater than themselves. And that also seems to be profoundly healing. Do you want to add anything, Dan?

  Dr. Daniel Rosenbaum: [00:16:57] You've got a great answer. It's a great question too Chase. I've never really noticed actually that potential contradiction in terms. So I mentioned that the term psychedelic was coined or emerged out of this exchange between Huxley and Osmond before they arrived at Psychedelic. Huxley suggestion was a term called phanerothyme. I'm not quite sure about the etymology with phanerothyme, but it means soul revealing. So before they arrived at mind manifesting, Huxley, who was a deep mystic, thought that this word soul revealing best captured the nature of the experience, that that the mescaline or LSD was a kind of medium through which the soul was revealed to itself.

  Jake Johnston: [00:17:52] Dr. Rosenbaum, you've sort of beautifully set us up to go into the history by talking about Huxley. You also mentioned psychedelic youth and indigenous cultures in the past. I'm wondering if you could sort of - I know it's a massive topic to go through in a short podcast - but an overarching overview of the history of psychedelics as medicines.

  Dr. Daniel Rosenbaum: [00:18:12] Yeah, thank you for that. I'm glad you prefaced it that way because it is an enormous question that I will not be able to do justice to, nor am I an expert on this particular topic. But I do find it interesting. And I would also say - I mean, to your point, Jake, there are hundreds of ways to tell the story of psychedelics even before we come to the biomedical story in the West in the fifties and sixties. But we can say a few general things about what we know regarding indigenous use of psychedelics. And again, I'll use the term psychedelics. But in different cultures these would be understood and referred to as very different things, perhaps plant medicines, and perhaps we could apply a different term like entheogens, as I mentioned earlier. But one thing that's interesting to note is that indigenous cultures in various regions of the world for centuries or probably even millennia, have been using these plant medicines with psychoactive properties in healing and spiritual rituals and ceremonies. And I have a wonderful quote here from the Canadian ethnobotanist and anthropologist Wade Davis. And just to give a sense of the different frame or context or the kind of setting and the purpose that these medicines or plant medicines would have been used. And so he's referring here to ayahuasca and just to provide a brief orientation. Ayahuasca is an Amazonian brew, which contains a number of different psychoactive plants. One is Psychotria viridis, which is a shrub from the coffee family that contains dimethyltryptamine. Dimethyltriptamine is orally inactive, which means that it has to be combined with a different medicine, a monoamine oxidase inhibitor to inhibit the enzyme that would otherwise break down DMT.

  Dr. Daniel Rosenbaum: [00:20:12] And somehow this occurred in a variety of different settings, in fact, which is remarkable in and of itself. People learned which combinations of plants to include in this brew to bring about these transcendent experiences. And so Davis, in describing the use of ayahuasca, says that these preparations, the ayahuasca preparations allow people to invoke some technique of ecstasy to soar away into the realms of trance, a higher state of consciousness, if you will, that allow them to achieve their medical, mystical acts of healing, but also, in the case of communities, a kind of annual or monthly reaffirmation of the connection between human beings and the natural world, a balancing of the energetic flows of the universe. And in that sense, the substances and the rituals become a prayer for the well-being of the entire Earth and the cultural continuity of the society itself. So there's obviously a lot to that quote, and I offer it only as I think a quite radical juxtaposition to some of the ways in which psychedelics are being studied and offered in a more narrow biomedical way, which I think will be the focus of our conversation. But just to kind of frame the history, I think I find that resonates so deeply. I mean, it's so powerful, right? So coming into the popularisation of psychedelics in the West, one version of the story goes that a Western banker named Gordon Wasson, who was working at J.P.

  Dr. Daniel Rosenbaum: [00:21:46] Morgan, visited the Oaxaca region of Mexico, where a quite famous medicine woman, or Curandera named Maria Sabina, who worked with psilocybin mushrooms, welcomed Wasson and his wife and allowed them to participate in a mushroom ceremony. And upon returning to the States, Wasson wrote an article for Life magazine called, "Seeking the Magic Mushroom." And this became the most widely read edition of the magazine in its history. In parallel, a Swiss chemist named Albert Hofmann was working on the ergot fungus, which is a fungus of the rye plant, and he serendipitously discovered lysergic acid diethylamide or LSD. I say serendipitously, because he was not seeking to create or discover a psychedelic medicine, but he did, and he took some of it as a kind of test on himself. And without knowing exactly what would happen, he took a very, very low dose on the order of a couple of hundred micrograms, thinking that it might not do a lot. He didn't know that LSD is tremendously potent. And so after taking a very what he thought was a very low dose, he then bicycled home. And this was April 19, 1943, which is an infamous date now in this world, which has since become referred to as Bicycle Day, because what occurred on that bike ride home was a rather peculiar and probably disturbing experience for him. I mean, he tripped and discovered that there was something significant going on with this medication. And so the pharmaceutical company that he was working with at the time, Sandoz, began synthesising lysergic acid diethylamide.

  Dr. Daniel Rosenbaum: [00:23:30] It was fully legal at the time, as I mentioned earlier, it was then distributed to psychiatrists, which was initially thought to be its value, helping the psychiatrist understand the experiences of their patients. And from there it it was recognised that it had potential therapeutic value. So it began to be used in some cases in conjunction with psychotherapy and in other cases more in isolation for the treatment, principally of alcoholism, as well as to help people prepare for death and dying, or to help treat anxiety and depression associated with serious illnesses like cancer or the terror associated with death and dying. And so in the fifties and sixties, there were tens of thousands of patients treated with LSD, another couple of thousand patients treated with psilocybin. Many thousand articles written. A lot of the studies did not have the same methodological rigour or ethical standards that the clinical research today does. But the results were intriguing and for the most part, research participants that the treatments were safe. Unfortunately, there was a large political backlash that occurred, which led to the scheduling of these medicines and the almost total banning of research involving psychedelics by the 1970s. And the political backlash followed basically from the associations between psychedelics and the counterculture movement of the sixties. So that infamous figures like Timothy Leary, who then President Richard Nixon called the most dangerous man in America because of his psychedelic evangelism, the famous phrase "Turn on, tune in, drop out." The use of these medicines outside the lab and I guess even inside the lab was thought to be too terrifying for the establishment, essentially.

  Dr. Daniel Rosenbaum: [00:25:27] And so all research was halted. I'll just mention briefly, there is a dark side, if you will, to the psychedelic history that I think it's important that we don't gloss over and people may be familiar with or have heard at least something about the CIA's use of an investigation into LSD. And this was part of the MK-ULTRA program. Canada also has a dark history to play here. There was a psychiatrist at McGill, in fact, named Ewen Cameron, who was part of the LSD experiments involving LSD. And in general, in a number of different places, people were frankly tortured in conjunction with the use of LSD. So people were put together in groups forced to take very high doses of LSD repeatedly. They were naked. They were fed through straws from a hole in the wall. I mean, really, really horrific kind of stuff. And for people who are interested, there's a great CBC podcast series called Brainwashed, which covers this history. And skipping ahead a few decades, there was the beginning of the so-called psychedelic renaissance, or the resurgent interest in psychedelic research, at least in the States, began in the nineties and into the early 2000s. And some of that work was done in California with Charlie Grob, a psychiatrist at UCLA, but also at Johns Hopkins, Roland Griffiths and his group. And maybe I'll leave it there because I feel like I've been talking for a while.

  Jake Johnston: [00:27:09] That was a terrific answer. And you've really sort of synthesised a complex, broad history down into a very nice narrative for us.

  Nikhita Singhal: [00:27:18] Yeah, it's certainly had a very turbulent course, both in medicine and in politics. And it seems like we're arriving now at an era where things may be showing promise and improvements in terms of a lot of the errors and things that happened in the past. You mentioned there's many exciting ongoing trials within the field of psychedelics. Now, what do we kind of know about psychedelics so far in terms of their efficacy and clinical potential for various psychiatric disorders?

  Dr. Emma Hapke: [00:27:51] So I think in terms of psychedelics moving through the drug development process, mostly in the United States, the one that's furthest along is MDMA assisted psychotherapy for the indication of post-traumatic stress disorder. And so that's in the second half of the phase three trial. So that trial has 16 sites, 12 in North America, there's two in Canada and one in Israel. And so they've published the first half of that in Nature Medicine, and the second half is recruiting and underway right now. Psilocybin is the next furthest along. So there's sort of two main groups that are moving it through the drug development process. So we have Compass Pathways, which is a for profit company that's moving psilocybin assisted psychotherapy through the drug development process for the indication of treatment resistant depression. And they've recently published their Phase two data. And I believe they'll be moving on to conversations with the FDA to start phase three trials next and then Usona Institute, which is a non-profit player, is also moving their formulation of psilocybin through the drug development process for the indication of major depression. And they have yet to publish their phase two results, but those should be coming soon. So that's sort of those two are the furthest along. And there's an emerging and fairly strong evidence base for psilocybin assisted psychotherapy at the end of life, which maybe I'll let Dan talk about in a moment, I'll tackle MDMA first, because that's sort of the literature that I'm most familiar with. So I think what we're seeing with MDMA assisted psychotherapy is at least for a significant portion of patients that take this treatment, that it is both a safe and effective treatment.

  Annie Yu: [00:29:43] So if you look at our phase three results, 88% had a clinically meaningful response to the treatment and 67% lost their diagnosis of PTSD by the end of the trial, and 33% went into complete remission, which means they lost their diagnosis of PTSD and they had something called a Caps five score under ten, which means very, very low symptomology for PTSD. And so that's at the end of an 18 week protocol, which includes three MDMA sessions. And what I think is important to note that these are people with severe and treatment resistant PTSD. So the average number of years that they had suffered in the trial was 15 years. They had high degrees of comorbidity, so comorbid childhood trauma, dissociation, history of substance use disorder. So this is a difficult to treat population that had failed other treatments. So failed pharmacotherapy that has been unable to gain benefit from some of the other evidence based psychotherapies for PTSD. So that's one thing. And what's also interesting is that we saw good results as well in people with those comorbidities. So they're also responding to the treatment. And in addition to the reduction of PTSD symptomology, we also saw reduced incidence of depression in the MDMA group and improvements on something called the Sheehan Disability Scale, which looks at sort of people's functional abilities and sort of domains of work in general life.

  Dr. Emma Hapke: [00:31:19] So it's interesting it seems to work in a significant proportion of patients that take the treatment. There's definitely still a group that don't respond that I think we need to study better and understand. And then the next question is, do these results last is are they durable? We don't have the long term follow up data yet from the Phase three study. But what we do know from Phase two is it does seem that the results are durable. So the phase two data, if you look at it a year later, again, 67 or 68% of people are showing that response. So it seems that with MDMA anyways for PTSD that what we're seeing is the results seem to be durable for the vast majority of patients. So it seems that it catalyses this process of healing and resilience that then allows people this ability to perhaps have greater resilience in the face of future stress or continue to their own self healing journey that's catalysed by the MDMA therapy. Things are less clear with the treatment of psilocybin assisted psychotherapy for depression, especially treatment resistant depression. So the Compass Phase two results were recently published, and what we're seeing is about 25% response at the 12 week mark, which is not insignificant for a population with treatment resistant depression. But there's still a significant subset that are not responding at 12 weeks. Now, in that trial, they just did one high dose session in one low dose session.

  Dr. Emma Hapke: [00:33:03] So I think one of the unanswered questions is, is do people actually need more sessions with psilocybin assisted therapy to get a more prolonged and endurable response? Also, I think what's important to note in the Compass trial is there was a higher incidence of serious adverse events around suicidality in the group that got the high dose psilocybin. Not statistically significant, but more than in the group that got the low dose. And so I think that's important to note because it brings up a lot of questions around the safety of this, especially since in most cases people have to be taken off their SSRI to participate in these trials. And that's another unanswered question is can people stay on their SSRIs and take psilocybin? And I think the jury's still out on that one. So we're taking people off of their treatments in order to participate. And is there a risk involved there? And I think that, again, getting into that sort of hype disappointment cycle in the Compass results, it's the people that had those adverse effects were typically the non responders to this treatment and so going off of their typical treatments to participate in this and then not getting a response I think has a potential to be harmful for people or at least there's some risk involved that people really need to consent to and to understand before they participate.

  Dr. Daniel Rosenbaum: [00:34:29] I wanted to make a comment or, you know, a plea for restraint is maybe one way to put it, just to call attention to the tremendous amount of hype that exists around psychedelics, a lot of which is driven from the commercial, corporate, for profit sector. And we've come to a place where it could be fairly argued, I think, that the hype has outpaced the state of the clinical research. So in terms of what we know for sure, what I feel most comfortable hanging my hat on is that results from the preliminary research in the contemporary clinical trials are promising enough clearly to warrant greater study. Again, well designed, methodologically rigorous study with a greater number of patients proceeding into phase three trials and so on and so forth. But I think we want to be careful not to say at this point, psychedelics are going to be the next breakthrough, revolutionary treatment, silver bullet, panacea that's going to fix mental illness.

  Dr. Emma Hapke: [00:35:46] Just add to that. I think that the hype is actually a really big challenge for researchers because there's so much coverage in the lay press about psychedelics and it's often not factual and the effects can be exaggerated. So people come in with these very high expectations that this treatment is going to work. And these people often feel very desperate because they've failed many other treatments. So they can be really set up for significant disappointment if it doesn't work. And that can actually present a number of really challenging ethical dilemmas for the field. And the other big challenge is - gets into some of the challenges in the field - is I think we clearly have enough of a signal that this is worth continuing investigating, but it's also a treatment that's very hard to study with our traditional methods of double blind RCTs because of this big problem in psychedelic research of blinding. So it's usually pretty obvious to the patient for the most part, whether they've received a psychedelic or not. And so that creates a whole host of methodological issues that the field is grappling with. And I think some people are even questioning, like, can we even conclude that this works when with some of these methodological challenges? So we need to be very cautious as we proceed. And I think we need to really educate our patients that this remains an experimental treatment, that it's not for everybody.

  Dr. Emma Hapke: [00:37:18] And the other thing that I say is that know what I was when I'm coaching people who are considering being in a clinical trial for PTSD with MDMA, it's a piece of work. I think it's harmful when people think that they're going to go into this trial and aim for a complete cure. I really think of the MDMA as a catalyst for your own psychotherapeutic process, and it's for people who are ready to go in and go deeper because we're starting to see the medicine and the container can start to strip away some of your defensive mechanisms like dissociation and numbing, for example. And if you're not ready to start facing what's coming up and you don't have adequate support internally and externally, that can be really challenging. And especially in a clinical trial which is not flexible, you can only have three treatments and then it's illegal. So you can't actually access it legally. So what if you find that you're starting, but then there's more work to do. That can be a real challenge for people. And we've noticed that at the termination phase of the study that some people feel there's more work to do. So these are things that I think we're all grappling with and there's no easy answers to them.

  Nikhita Singhal: [00:38:31] Thank you so much for mentioning those really important considerations. I think being cautious and aware of some of the risks is really key. And you've mentioned that another of the indications is end of life care. Could you tell us more about that?

  Dr. Daniel Rosenbaum: [00:38:47] The greatest area of clinical interest for me personally in this field is the application of psychedelic assisted psychotherapy in palliative and cancer care to help people prepare for death and dying, to help mitigate some of the distress associated with life threatening illness. And there's an interesting history to these research programs, again, at least as far as the US based research is concerned. At Spring Grove, the Maryland Psychiatric Research Institute in Maryland, of course, there was a program of LSD assisted therapy research for the treatment of alcoholism in the sixties, and one of the nurses involved with that was diagnosed with cancer. And I believe the story goes that she asked her fellow researchers to receive LSD to help her manage the distress associated with her condition. And from that emerged a series of research trials and a whole research program, including luminary psychiatrist Stanislav Grof, who initially did a lot of his work and Czech Republic before coming to the states, but also people like Bill Richards. And there's a wonderful book about this research program for people who are especially interested called The Human Encounter with Death, which Stan Grof wrote with his then wife, Joan Halifax. But what I can say is that between the mid sixties and up to about 1980, there were six open label trials of psychedelic assisted psychotherapy for end of life distress, existential distress, that sort of thing. Most of the participants had advanced cancer or terminal cancer. More recently in terms of the contemporary clinical trials, there have been four randomised controlled trials done since 2011, one of which included LSD and three of which used psilocybin. All of the psilocybin randomised controlled trials were done in the States and they were all based on the Spring Grove program developed by Grof and colleagues.

  Dr. Daniel Rosenbaum: [00:40:57] In all of the contemporary clinical trials, what we see is rapid, robust and sustained improvements in cancer related psychological and existential distress. Then in terms of the robustness, the effect sizes, these are relatively small studies, so the biggest of which was done at Johns Hopkins. A landmark paper published in 2016 by Roland Griffiths and colleagues had 51 patients, so not huge. But in terms of psychedelic clinical trials, this is quite a large study and the effect size in terms of reductions in cancer associated depression and anxiety are massive like really blows something like an SSRI or more conventional pharmacologic treatment for depression among cancer patients really out of the water. Again just highlight as a point of caution. This was not a head to head trial. It was not comparing a psychedelic to an SSRI, but just to highlight the really robust effect sizes associated with this intervention in these patients. Importantly, the intervention has been shown to be safe for people even with serious illness, which is very important because we're talking about people with potentially significant medical issues approaching end of life and so forth. So the two most important studies that have been done in this area thus far, both published in 2016, in the Journal, the same edition of the Journal of Psychopharmacology, one was the Johns Hopkins study that I mentioned. The other was conducted at New York University. The lead author is Stephen Ross. They're quite similar in terms of the study design, the patient population, the results, the NYU study.

  Dr. Daniel Rosenbaum: [00:42:41] It was really useful because it came along with a couple of qualitative research papers, one of which I always recommend to people who are interested in this area. It's called Cancer at the Dinner Table. It's a 2017 paper published in the Journal of Humanistic Psychology and the lead author there is Thomas Swift. And so in this paper, transcripts of participant interviews, which were done with the researchers using a semi-structured interview kind of questionnaire, were coded and distilled into themes. So this was a kind of interpretive, phenomenological analysis, and I'll just say, just will highlight the ten themes that emerged from participant reports about their experiences in the trial. Because this is I find always I find so moving and the language is so evocative. So first of all, participants experience the psilocybin session as very distressing. This is an immersive experience. It's not always ecstatic or it's not the same kind of use that you might that people might use recreationally for fun. I mean, Emma's already spoken about the fact that high dose psychedelic therapy is work and it can be really, really distressing. And so this emerged from the participant reports in this trial. Participants also reported that the psilocybin helped them reconcile with death. It helped them acknowledge the place of cancer in life. Uncouple emotionally from the cancer and to reconnect to life or to reclaim presence in the face of cancer or possible cancer recurrence. And one last thing I'll mention about this is that there is a lot of the participants had a spiritual or religious interpretation of the experience, and I think that opens a whole other door of conversation potentially.

  Dr. Emma Hapke: [00:44:34] I would just add that what we're seeing in the psilocybin literature, especially for the treatment of end of life distress, but also for depression, is that having a mystical experience which is measured on something called the MEQ, the mystical experience questionnaire, seems to mediate positive therapeutic benefit in the psilocybin literature. And so I believe it's approximately 70% are having a complete mystical experience in those end of life population using psilocybin. What's interesting in MDMA, it's closer to 40% are having a mystical experience. So it's lower and it doesn't seem to connect to positive therapeutic outcomes. So we think that the MDMA may facilitate more an ability to process trauma as opposed to connect to the mystical, although that element and the transpersonal element is very much still present with MDMA.

  Nikhita Singhal: [00:45:29] Thank you both so much for that. I think we've kind of covered some of the what the evidence has shown so far. Maybe to give our listeners a better idea, maybe hand it over to Annie for our next question, what this actually looks like for sure.

  Annie Yu: [00:45:45] So in our discussion around some of the evidence and literature around psychedelics, the term that popped up was psychedelic assisted psychotherapy. So it sounds like aside from just the psychedelic treatment itself, it's generally paired in both clinical and research settings with more guidance using psychotherapy. So can you maybe walk listeners through what the components of psychedelic assisted psychotherapy looks like and what a typical session session looks like in your respective practices?

  Dr. Emma Hapke: [00:46:21] Sure. So when I think about psychedelic assisted psychotherapy, I like to think of a triangle. So at the top we have the therapeutic modality and there's research going on into like what is the best type of therapies to pair with different psychedelics for different indications, but you have the actual therapy itself. Another point on the triangle would be the therapeutic relationship, which we know for any psychotherapeutic process, that is a really important mediator of a successful outcome. And then on the third point of that triangle, we have the drug effects, which I really see as a catalyst, catalysing the psychotherapeutic process, and then inside the triangle, I imagine the patient's own inner healer. So in some of the models that I've been trained in that come from Stan Grof and other sort of pioneers in the field, they talk about this idea of the inner healing intelligence. And you think about it just as the body moves towards healing. For example, let's say you cut your arm, you go to the emerg. The Emerg doc might clean it out, even suture it. But it's your body that heals that from the inside out. And similarly, your psyche wants to move towards wholeness. And sometimes what we're doing in the psychedelic state is we're removing some of those blockages to allow your own natural inner healing intelligence to work. And so really in this model, we're really trusting the patient's inner healer and the patient to allow up the thoughts, feelings, memories, sensations that are most in service of their healing. And especially in the integration phase. It's the patient's inner healer that's the has the ultimate authority on interpretation and meaning making, and we're really following that.

  Dr. Emma Hapke: [00:48:10] So as a therapist, you're following the patient's lead. A typical course of psychedelic psychotherapy would typically have two therapists and involves three main phases. There's a preparatory phase, there's the dosing or the medicines administered, and then there's an integration phase, and you'll hear these terms set and setting. And I think they're really important to be aware of when we're understanding psychedelics. So the setting is the physical environment in which the person takes a psychedelic, but it also includes the psychotherapeutic environment that's created by the therapeutic relationship and the entire container in which the experience is going to unfold. And we pay a lot of attention to that. In psychedelic therapy, we want people to feel at ease so that they can trust the process, trust the therapist, trust themselves. And so you'll often see psychedelic therapy rooms look less clinical. There's dim lights, there's art, there's plants, and there's a bed. The patient in the dosing session will lie down. They'll typically have eye shades on. There's music played throughout, which also supports that setting for the person. And part of why the setting is so important is because psychedelics induce a greater state of neuroplasticity. So we're really seeing this especially in the psilocybin literature, but also for MDMA. So it's inducing these states of neuroplasticity, which is why the setting in which you take it is so important. And that's happening both while you're being dosed with the medicine, but also in the time that follows. And that's when the integration phase is also really important because the brain is more changeable.

  Dr. Emma Hapke: [00:49:54] And so what you do in that time after really matters in terms of set. What that refers to is sort of the mindset of the person going into the experience. And so it includes things like their intention, how they're feeling that day and what work they've done to prepare. And so the preparation phase, it varies, but typically would be at least three sessions that are 60 to 60 minutes to 2 hours long, where the therapists are really getting to know this patient, they're getting to understand their life history to connect with them. You're beginning that process of trust building and you're providing a lot of psychoeducation on the effects and what they might what they might experience in the psychedelic state. And one of the things that we really encourage people in the preparation phase is to trust and surrender to the experience as much as possible. So the more that you're able to surrender and open up in the psychedelic state, they're more able to access these expanded states of consciousness that can be really healing. And so we also encourage people to move towards things that are difficult and to adopt the stance of curiosity towards the darker elements that might come up. And there's something very transformational that comes from moving towards something that's difficult and working through that and coming through the other side of it. And that's one of the mechanisms that we're learning seems to be facilitated by psychedelic therapy, is overcoming experiential avoidance, which can often maintain a lot of psychiatric disorders. The integration phase then is a, I think, there's two main things that are happening in integration.

  Dr. Emma Hapke: [00:51:38] One is meaning making. So the person is continuing to process what came up and connect the dots and understand how might this apply to my life. And often some lessons will emerge that then they want to then try to implement to make change in their life. And then the second part of integration I think of as practices to maintain that sense of connection that they felt in the psychedelic state. So really encouraging people, especially in the days and weeks that follow, to take time to go inward, be it journaling or art or time in nature, meditation, whatever works for them to reconnect to themselves and to try to continue to maintain that sense of connection. And I think the sense of connection is, again, one of these what we're learning is sort of one of the mechanisms of action when I think about trauma in particular, but really a lot of psychiatric illness, a state of disconnection from yourself, from others, and then from something bigger than yourself are really, I think, predominant themes that we see in a lot of psychiatric illness. And I think the psychedelic state has the potential to help people feel more connected. But then in the integration phase, it's like, how do you maintain that? I think communities of practice and communities of patients who have received this kind of treatment that can connect to each other in an ongoing fashion after is going to be part of what really increases the chance that people can maintain the gains that they're seeing in the immediate post session phase.

  Dr. Daniel Rosenbaum: [00:53:08] Emma mentioned set and setting. Set as having to do with someone's degree of preparedness heading into the experience, the intention they bring to it and so forth, and setting being for the most part synonymous with environment or the surrounding influence of the environment. So you can imagine if someone takes a handful of mushrooms at a music festival and they're surrounded by thousands of screaming people, and there's lots of stimulation in the form of loud noises and flashing lights and so forth that they might be more likely to have a challenging experience, to have a bad trip, so to speak, even if their intention is to have a good time with others. On the other hand, if someone takes the same dose of mushrooms with a loved one who they trust very much and who will be taking care of them in an idyllic setting like a meadow, and their intention is to connect with nature and have a peaceful experience then the kind of experience they have will likely be quite different even though it's the same medicine at the same dose that they're taking. So I think that's a helpful illustration of the importance of setting in terms of set, the mindset, the preparation. Think about the same meadow, the same couple, let's say, and someone comes across some mushrooms in the meadow and they decide to take the mushrooms because they figure they're edible mushrooms. If they don't know that they're psychedelic mushrooms and within an hour they start to trip out, they're liable to go to the emergency department because they're not prepared, they're not expecting, they don't have the intention to take a powerful psychedelic, to have an experience of connection with nature or whatever. And so I think that's been a helpful way for me regarding the importance of those factors.

  Dr. Daniel Rosenbaum: [00:54:54] And why that's important is that the quality of the acute drug experience has been shown across human studies in various indications to predict, be correlated with or mediating the long term outcomes. So the acute drug experience is key. And one of my favourite findings in the field of psychedelic science comes from regarding the nature of the acute drug experience and how it leaves people afterwards is a healthy volunteer study from Johns Hopkins. So this was one of the early studies that constituted the psychedelic renaissance and really, I think, kindled people's interest in this. So researchers at Johns Hopkins offered people synthetic psilocybin under blinded conditions. So they told people that they might get a variety of drugs. And under blinded conditions in a hospital room with guides and in the same kind of setting that I described with eyeshades and the headphones, and in a comfortable living room like environment, people who took a high dose of psilocybin reliably reported that it was either the most or among the top five most personally meaningful experiences of their lives. If you stop and consider that for a moment, I think you'll find that it's remarkable. It's incredible. The same is true that the researchers always used readings of spiritual significance, and people also reported these experiences were among the most spiritually significant of their lives. And so both in terms of personal meaning, meaningfulness and spiritual significance, people talked about them as being akin to the birth of a child or the death of a parent. So clearly something profoundly moving is happening for people in relation to these experiences of taking a high dose psychedelic under the appropriate set and setting.

  Dr. Daniel Rosenbaum: [00:56:45] The only other thing I'd add to that is, you know, in a clinical context, it's still common for parts of the experience to be quite distressing or challenging. And it's just that I think one of the differences in a clinical setting is that the person has support and feel safe to actually work through those challenging experiences, which can then lead to this feeling of resolution, which can then often lead into these transcendent and ecstatic states. And so people will also describe them as some of the most challenging experiences of their lives. But it's the resolution of that that also seems to be healing.

  Chase Thompson: [00:57:25] I think that leads to an important question that I have, which is, you know, in that study that you mentioned, and it sounds like people are describing some of their experiences with psychedelic psychotherapy experiences, some of the most important in their lives. I think some people might hear that and think about ethics. Whether that's something that should be happening in a medicalized setting with patients, doctors versus friends and colleagues. And I think from the psychedelic community, there's been some pushback that psychedelics should not be administered in a medical setting and should be kind of more available in the community for people to just do given that they're very physiologically safe and that there's a low risk of harm from medical causes. I'm just wondering if you have any thoughts on kind of the movement of psychedelics into a more clinical setting? And what are the ethical implications of having this really significant or profound experience with your doctor, say, versus your friend or partner?

  Dr. Emma Hapke: [00:58:36] Yeah, I mean, I think one thing that comes to mind there is that for people with psychiatric distress and psychiatric illness, such as trauma, having somebody who's trained in trauma informed psychotherapy, who's bound by a regulatory college, who has training in psychedelic assisted psychotherapy, I think can increase the chance that this is a healing experience and it can increase the safety of the experience. So for people that are really suffering with these treatment resistant conditions, I think there are certain risks when taking them outside of a clinical setting. So I think that's one thing. I think that you bring up an interesting question, which is sort of what is the role of spirituality in modern medicine? It's been largely divorced from and when we're taught to formulate us in psychiatry, we're taught the biopsychosocial model. But I've also wondered what about the biopsychosocial spiritual model? Because it's often those things that are greater than ourselves and doesn't necessarily need to be a specific religion, but it could be meaning and purpose or a sense of connection to nature. Or just connecting to something that's bigger than you is fundamentally really healing. And I think thinking about that in the context of healing as psychiatrists is actually important, but it brings up a question of training and exposure. And I think that there's a real role in psychedelic medicine for interdisciplinary teams. Like on one of our teams, we're bringing on spiritual care providers, for example, who can really help us in the preparation integration phase with patients who've had these complete mystical experiences, which can be paradigm shifting for people who have previously had no sense of that kind of connection. So I think training and interdisciplinary teams in our ways to address some of these ethical issues and I think it's also a really important area of study. So those would be some of my initial thoughts. Dan, do you want to add anything?

  Dr. Daniel Rosenbaum: [01:00:47] Yeah, I'll add a couple of things and I'll just say it. It's a great question and it brings to mind quite a lot of considerations, a few of which Emma's already touched on the study that I was referring to with the healthy volunteers at Hopkins and the personal meaning and spiritual significance that people derive from the psychedelic state. I think there's a way to take those results and come away with the view that the psychedelic experience is itself intrinsically healing. And I think that's a partial misread because again, talking about the critical importance of context, the people in the study were offered a high dose psychedelic in the presence of trained guides and therapists. They had been prepared for the experience extensively, and in the end, following the experience, they had opportunities to process challenging material and to. There was a clear and explicit invitation of frame to make meaning from the experience. So I think it's probably more helpful to think of the psychedelic experience. I mean, setting aside for a moment the awesome, literally awesome and profound kinds of subjective things that might go on for someone but the experience opens a window of change. And this is the sort of recently proposed terminology about psychedelics as psychoplastic, meaning that you're opening up a critical window for change and that that window itself is outcome agnostic and that we can expect a greater potential for healing.

  Dr. Daniel Rosenbaum: [01:02:40] And I'm not saying that that has to be done in a hospital with a psychiatrist per se, but with people who are trained to work with the medicines, who are trained psychotherapist, as Emma was alluding to, that that's where a greater potential for healing can come and where harm can be reduced, I think to a greater extent. I don't know that bio psychiatry has yet to come to a good, doesn't know exactly where to place this treatment paradigm. It's a complex intervention and clearly it kind of straddles a number of perspectives. It's not a pure pharmacology. It's not pure psychotherapy. It seems to invite this this marriage of the two: the psychological, the biological. It invokes the spiritual. I mean, words like mystical experience appear in the German Journal of Psychopharmacology, and it rests on a great deal of indigenous traditions and wisdom. So there's really a lot of paradigm and perspective straddling going on that it's just key that we recognise all these perspectives being brought to bear and that we're thoughtful about offering these treatments to people. And that sets aside altogether the question of decriminalisation, legalisation, recreational use and so on, which I hesitate to get into too much at the moment.

  Chase Thompson: [01:04:04] I think one of the things that you've also mentioned is having a challenging experience and and that's the so called "bad trip" can sometimes arise and whether that occurs can be influenced by the setting that one uses psychedelics in. And so I'm wondering, in a more clinical setting, how common is it for people to have challenging or bad trips and and does that lead to a poor outcome for people? I think many in the general population may have a notion that's having a bad trip, for example, could produce lasting psychological damage or even trauma.

  Dr. Emma Hapke: [01:04:45] So I think that in some of the trials, they see something called anxious ego dissolution, which is when as the psilocybin is coming on and the sense of self is starting to soften, that can be really terrifying for some people and can induce this these states of terror and panic. And I've seen rates around 30% in some of the trials. So it's not insignificant, but that doesn't necessarily mean that it's going to negatively impact the outcome. And it's very often that as people work through those really intense, challenging moments of a trip, that that in of itself is actually healing. And so, one, I could draw your attention to the Zendo Project because they have these principles of harm reduction that they use at festivals for people. And this idea that there's no bad trip, that no matter what happens, this is data that's coming up. And if the person is able to work through it in the integration process, though, it can be challenging. It still has the potential to be healing. And so I think that's something that's really important for people to keep in mind, especially if they've had their own difficult psychedelic experience and they're not knowing what to do with it. Finding an integration coach or somebody that's experienced with psychedelic integration can be really helpful because even if you're still feeling like something's opened and it hasn't closed or I have so many questions or I'm feeling really unstable, there's work that can be done and integration can go on for months or even years after a psychedelic experience for people.

  Dr. Daniel Rosenbaum: [01:06:14] The qualitative study that I mentioned out of NYU, in their cancer psilocybin trial, they said almost everyone referred to the immersive and distressing nature of the psilocybin experience. There are a few quotes from that cancer at the dinner table paper about people being being brought right to the brink of what they can tolerate. And what I think what that experience is like is, as I mentioned, sometimes terror, anxiety. People can even have transient experiences of paranoia during the psychedelic session. This again speaks to the trust and presence of trained guides so that during the experience the participant can seek support if needed, whether that's gentle touch in the form of hand-holding or to say, I'm really scared, I'm having a hard time. And the response that they would typically be met with is, You're safe, we're here with you. Everything's unfolding the way it should be. And people are encouraged to go into that experience and to be curious about it. There's a story which I hope I won't misrepresent too much in Buddhist psychology about encountering one's demon and one's demons and inviting them, welcoming them. And to the extent that you can tolerate it, being curious about it. And I think that's where, as Emma was alluding to, a lot of the healing can happen, going through the challenging material and going all the way back to one of the initial questions about the ways in which psychedelics may be different from conventional pharmacotherapy is a lot. In a lot of ways, pharmacotherapy is like SSRIs for the treatment of, say, depression or anxiety disorders can be understood as suppressive, which means that they suppress some of the distressing symptoms of those illnesses. And there's a great paper from Robin Carhart-harris and David Nutt about it's called A Tale of Two Receptors, and it examines the differences between SSRI mediated serotonin 1A receptor signalling which governs this sort of suppressive response compared with the psychedelic mediated, serotonin 2A receptor signalling, which has to do with working through. That distinction, is maybe helpful.

  Chase Thompson: [01:08:40] Yeah. Just to note, I would direct our listeners just to our previous episode with Dr. Carhart-harris. We actually talked about some of those differences with him for overview. If you're interested on the differences between the more suppressive effects of SSRIs and the activating effects of psychedelics, and it's episode 27, just for reference.

  Dr. Emma Hapke: [01:09:02] I think the other thing that this brings up is the question of how to train therapists to hold space for people in psychedelic states. So I think an unanswered empirical question is whether having your own psychedelic experience as the therapist gives you a greater competence or confidence or ability to hold space for people. And that's a question we hope to maybe start to address empirically at the Nikean Centre that we're developing. And, you know, as as I said, it's an unknown question. But what I will say is that things can look really rough from the outside of when you're watching somebody on a psychedelic, it can look terrifying. It can look like they are in so, so much distress. And there can be a very strong urge to want to help and try to get them through that and try to stop what's going on. Or a guide who's not experienced with, you know, not necessarily psychedelics themselves, but just psychedelics in general could really think there's a problem here when actually everything is unfolding just as it's meant to. And when the guide trusts the psychedelic state and the person and the medicine and the container and doesn't get too worked up about what they're witnessing, I think that really creates a greater state of trust in the patient. And so that's one possible reason why having your own experience may allow you to better hold space. But like I said, we need more research on that.

  Nikhita Singhal: [01:10:33] Thank you both so much for for walking us through that. And I think we've touched on a lot of the challenges, the risks and and you mentioned some of the upcoming work. So I guess I'm curious to hear what what do you see as kind of the future of this field moving forward? What are you most excited about investigating and what are what are you working on now?

  Annie Yu: [01:10:52] So I think, you know, one of the things that I'm really curious about is how is this how are these treatments going to be integrated into the public health care system in Canada and down in the States, of course, into their more complex health care system with all the different insurers? The last I heard, MDMA could be regulated by the FDA in Q4 of 2023. So this treatment is coming down the pipeline very soon. And in Canada, we recently had the government open up something called the Special Access Program, which potentially creates a route for a physician to prescribe MDMA for a patient with severe and life threatening PTSD. And I think we're going to see in Canada a lot of for profit clinics potentially trying to provide these treatments. And I think one of the things that really concerns me is how are we going to create equitable access? I would hate to see this treatment only be available to the elites and those who can afford it. And I think in Canada we really need to watch this creep of privatisation in our health care system where we have a universal health care system. So I think some of the work that we hope to do at the Nikean Centre over time is collect data both on patient safety and quality improvement, but also to create a cost benefit analysis for OHIP, which is our provincial insurer here in Ontario, really create the business case of why the government insurer should cover these treatments. That's a stage once we really are confident that the treatment works. So that's one piece that I've been thinking about.

  Dr. Daniel Rosenbaum: [01:12:41] As I said earlier, the area of interest that most excites me in this field is the potential application of psychedelic therapy and palliative and cancer care. And in that regard, actually, maybe first I'll mention that a great paper that was published in 2021 by Yvonne, a palliative care physician in the States, who, with his colleagues and after convening a conference of experts and soliciting opinions and so forth, set out a research agenda for psychedelic assisted therapy among patients with serious illness. And they highlighted it as actually four areas of opportunity. And I think our research group here at UHN, which has developed a psychotherapy intervention called Pearl, which stands for Psilocybin, Assisted Existential Attachment and Relational Therapy. Which I can say more about in a moment. But we're trying to operationalise these four opportunities in terms of advancing research in this area. So one of which is clarifying indications. Is it important, for example, that someone carries a diagnosis of major depressive disorder in addition to their advanced cancer in order to qualify for or benefit from a course of psilocybin assisted therapy, these researchers identified the development of clear therapeutic protocols as important. So in response to that, that's part of how we and why we developed Pearl therapy. Investigating the impact of set and setting.

  Dr. Daniel Rosenbaum: [01:14:23] This is key. One major element of set and setting, which we haven't talked about and which I think again is a big open door that we can spend a long, long time on is the role of music in psychedelic therapy. And so we have a wonderful PhD music therapist on our team, and we might begin to pose some questions about the role of music and psychedelic therapy for people at end of life. And then finally continuing to further the understanding about mechanisms of action. So thinking about at the biological level, the psychological level, so what kinds of psychotherapeutic processes are at play over the course of psychotherapy, not just in the psychedelic session? And then of course however you might characterise or whatever language you might bring to bear on the psychedelic experience itself, which often leads into the terrain of the spiritual. And so in this regard, we're also planning collaborations with spiritual care providers and chaplains, both to help in the spirit of training and making sure that our therapists are most well equipped to work with people who are experiencing these profound states. Also thinking about in terms of the mechanism of action, what is going on? How can we best understand this so that we can best help people in the future?

  Dr. Emma Hapke: [01:15:34] I think a lot of those questions also apply just more broadly in the field. So figuring out what indications are best treated with which psychedelics in combination with which types of psychotherapy. So for example, people have combined access ACT, which is Acceptance and Commitment Therapy with psilocybin for depression. There are studies that are going to be happening in Toronto that combine cognitive processing therapy with MDMA for the treatment of PTSD. So what existing psychotherapy is best combined with which molecules for which indications I think is going to be really interesting work. And then, as Dan said, a greater understanding of the mechanism of action and biomarkers both biologically, also psychologically and also spiritually, and really trying to understand how this treatment works. And I think moving eventually to personalised medicine, which I think the entire field is going to hopefully move in that direction. So can we actually scan somebody and interview them and figure out where what type of psychedelic is best? Where do we start? I think down the line you may actually see like a menu of psychedelics. Maybe you start someone, for example, with PTSD, with some ketamine, which can allow them to feel good in their body again, which can help them get used to being in a non ordinary state of consciousness. Then they might move on to processing with MDMA or psilocybin. So I think really understanding the person's unique makeup, both genetically and psychologically, will help us better figure out which psychedelic in which treatment is going to help them the most. So just a couple other things that I think we're really interested in at the Nikean Centre. One is this question that I mentioned earlier of how do we train therapists and studying experiential training through things such as whole entropic breathwork, which is a form of breathing that can induce a non ordinary state of consciousness and may provide a way for therapists to have some experience of both holding space and being in a non ordinary state without having to take a psychedelic.

  Dr. Emma Hapke: [01:17:42] And then also potentially what is the role of having an actual psychedelic as part of your training? And that's being used in the ketamine model of training pretty commonly is therapists will receive their own dose of ketamine when they're training for that, but hasn't been studied. So that's, I think, something that's really interesting to us. I think another question that the field is grappling with that I think is really important to keep on the forefront, is remembering that using substances to induce a non ordinary state of consciousness comes from indigenous cultures around the world. And this question of how do we incorporate indigenous worldviews into the training of therapists without appropriating their cultural practices and with making it suitable to our own setting and culture while also honouring what they've learned, including their their knowledge and working in the unseen and working with spirit. So these are really important questions to grapple with in this. You have indigenous reciprocity that we're not just taking something and potentially capitalising on it in a for profit model, but actually giving back and working with Indigenous healers and indigenous teachers. When we think about the design of curriculum and also when we think about the actual treatments and especially when we're treating patients from an indigenous background. So that's just something I wanted to mention as well.

  Nikhita Singhal: [01:19:07] Thank you both so much. It's been an incredible episode and I think our listeners have learned so much and we have as well, I guess, tying things up. Do you have any recommendations for people in terms of learning more like a favourite book, podcast movie in this field? And are there any last thoughts that you want to leave our listeners with?

  Annie Yu: [01:19:29] I'll do a little plug for our research centre. So we've co-founded the Nikean Psychedelic Psychotherapy Research Centre at the University Health Network in Toronto, and so we're Canada's first non-profit academic research centre, and we're really hoping to develop an academic and innovation hub for psychedelic assisted psychotherapy in Canada and abroad. So you can check out our website. Nikean is spelled "N I K E A N," and you'll find us and you can learn more about the work that we're doing and we're always accepting donations as well. So if you're looking to donate to psychedelic research in Canada, we of course would welcome that. In terms of training, we are going to be developing a training program through the Nikean Centre that will launch in the fall. I think you're going to see a number of trainings popping up all over. So I think it's really important that you do research on the training program that you're considering, too. If you're really keen on being a psychedelic therapist and you're already part of a regulated health profession or in training to do so to programs that have a really good reputation would be the certificate in Psychedelic Therapy and research at the California Institute of Integral Studies. So I'd recommend checking them out. And then MAPS is also doing a lot of training, specifically around MDMA assisted psychotherapy. And both Dan and I have done their training program and it's really good. So those are a couple really reputable ones. There's going to be a lot popping up, so make sure you do your due diligence and ask questions about what they're offering and who's teaching.

  Dr. Daniel Rosenbaum: [01:21:11] Yeah, and I'd just like to add, I'd like to start by expressing my gratitude for the invitation to be here and to participate in this podcast series. I think it's wonderful that you're covering this area, of course, being a researcher and someone interested in the field. Nikhita, you talked about a favourite podcast. I mean, if I'm right, this is one of what will become a series around psychedelics, and I look forward to listening to future episodes of this podcast around psychedelics. And I would also direct listeners, as has been done already today, to the episode with Dr. Robin Carhart-harris. But thank you so much for being here and directing the conversation.

  Annie Yu: [01:21:51] Yeah, thank you guys so much for your interest in this area. You know, it's exciting in mental health to have a new treatment and really a new treatment paradigm on the horizon. And so I think we all owe it to ourselves and our patients to learn more about this area. So thank you so much.

  Nikhita Singhal: [01:22:10] This concludes our episode on Psychedelic Assisted Psychotherapy with Dr. Mahaffey and Dr. Dan Rosenbaum. And we hope it may be the first, as mentioned, of a series of episodes that focus on this topic. Psyched is a resident driven initiative led by residents at the University of Toronto. We're affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Chase Thompson, Jake Johnston and you and Nikhita Singhal. The audio editing was done by Nikita Singhal. Our theme song is "Working Solutions" by All of These Things. Special thanks to our incredible guests, Dr. Emma Hapke and Dr. Daniel Rosenbaum, for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com Or visit us at psychedpodcast.org. Thank you so much for listening!

Episode 42: Interpersonal Psychotherapy (IPT) with Dr. Paula Ravitz

PsychEd+episode+42+-+IPT+with+Paula+Ravitz.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Jake Johnston:
Welcome to PsychED, the Psychiatry podcast for medical learners by medical learners. This episode covers Interpersonal Psychotherapy or IPT for short. I'm Jake Johnston, a fourth-year medical student at UBC, and I'll be hosting this episode. I'm joined by my colleague Sena, who will be co-hosting. Sena why don't you introduce yourself?

Sena Gok:
Hi. I'm Sena Gok, a doctor with international training and huge passion for pscyhiatry. I'm really excited to be here!

Jake Johnston:
Awesome! Thanks. And last but not least, we have the privilege of hosting Dr. Paula Ravitz as our guest expert for this episode. Dr. Ravitz is an associate professor of psychiatry at the University of Toronto and senior clinician scientist at the Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital. She was the director of Psychotherapy, Humanities and Education Scholarship Division, the University of Toronto Department of Psychiatry. Dr. Ravitz is also one of three authors on the latest Canadian Psychiatric Association position Statement on Psychotherapy in Psychiatry, just published in November 2021. The last position statement was published in 2003. Dr. Ravitz, would you like to introduce yourself?

Dr. Paula Ravitz:
Sure. First of all, thank you so much, Jake and Sena, for inviting me to participate in this. And it's my pleasure to be able to share some ideas about Interpersonal Psychotherapy. IPT I have been involved in teaching and practising and also researching IPT for the last 20 years or so, and I'm delighted to be able to share some of the ideas about the core principles of IPT in this episode for interested learners.

Jake Johnston:
Thank you so much for coming on to this episode, Dr. Ravitz. We are truly lucky to have you. Without further ado, I will launch into our learning objectives. By the end of this episode, you should be able to one define Interpersonal Psychotherapy to describe the core principles and phases of IPT. Three become familiarized with some psychological theories underpinning IPT. Four, List some patient selection considerations for IPT. Five, describe the efficacy and evidence base for IPT. Six, understand how IPT is practically carried out. Seven, briefly compare and contrast IPT to other common psychotherapies. Now the learning objectives are out of the way, Dr. Ravitz will take us away. We'll start off with the question; what is IPT?

Dr. Paula Ravitz:
Well, first of all, I think IPT is predicated on the centrality of relationships in our lives. Relationships matter in health and disease and resilience, in coping with stress and in recovery from illness. So this is the rationale for IPT, which is a time limited psychotherapy model that focuses on relational aspects of experience and mental health. And there's a strong evidentiary base. I know we're going to get into that a little bit later, but there are both phase and focus specific tasks of IPT. So there's a beginning, middle and end phase. Generally it is anywhere from 4 to 16 sessions. In my clinical practice and teaching, I use a 12 session model of IPT and in many low and middle income countries we use a briefer version of IPT. So for example in an implementation project we did a number of years ago in Ethiopia, we used a 4 to 8 session model of IPT. Generally. I know there are a number of questions, but the beginning phase of IPT is similar to what we do in psychiatry and an assessment. So we begin to establish an alliance with the patient. We learn about what they're struggling with. So that's what we do in the diagnostic assessment and in the history of presenting illness. So we learn both about symptoms about, but as well in the story of the context of what's going on in their lives right now.

Dr. Paula Ravitz:
And IPT focuses on these universal life events of loss of change and of conflict and relationships that are often associated with the onset or worsening of symptoms. And so there are therapeutic guidelines for the middle phase, for grief, for what we call role transitions, which has to do with large life changes. And that happened to us all. We all have multiple social roles which kind of determine what we expect from one another, depending on kind of the social roles. And social roles change inevitably in a lifetime, and sometimes the changes are planned and wished for and sometimes they're unplanned and I've wished for. And these can be associated with distress or symptom onset or worsening. And then of course there are conflicts or non-shared expectations that can unfold in relationships and that are often kind of the salt in the wound and IPT is predicated on this idea that what happens in our relationships and what might unfold in terms of symptoms or distress are bi-directionally linked. So it's when people are in a state of depression, it's often more difficult to engage or utilize social supports. And similarly, when there are difficulties in relationships or people are more disengaged or in conflict or they've experienced losses in their social network, that can also exacerbate or contribute to symptoms.

Jake Johnston:
Thank you so much for that eloquent overview of IPT. It sounds like it's somewhat of a feedback loop where relationships feed into mood and mood feeds into relationships. With that, I'll pass the mic over to Sena for our next learning objective.

Sena Gok:
Thank you, Jake. So, Dr. Ravitz, could you please tell us further about the core elements of IPT?

Dr. Paula Ravitz:
So in terms of the core elements, first of all, I want to emphasize common factors in psychotherapy that I think apply to every therapeutic engagement session, whether we're providing follow-up psychiatric care, doing a psychiatric assessment or delivering any of these evidence supported psychotherapy models. So these are included in the core elements. So first and foremost, it's really important to establish a therapeutic alliance in which there is a trusting bond. And we need to earn our patient's trust and we need to actively listen, use empathy, engage with our patients with positive regard, seeing them for their strengths, for their healthy wishes to recover and to find their way to feeling and doing better and for receiving care and help in a time of need. The core elements as I mentioned, there are three phases of IPT. So in the beginning phase of IPT, in addition to conducting an assessment of symptoms, getting agreement on the patient's goals and at a very high level, the goals of IPT are the same as we have for all medical care to help our patients feel and do better. And the way we do that is by helping them to connect with support of others. We try to identify one of four interpersonal problem areas or focal areas of IPT. The four focal areas have to do with what I've already alluded to. Grief is one of them related to loss of a significant other.

Dr. Paula Ravitz:
Role transitions, which has to do with life changes, for example, becoming coupled or becoming separated, becoming a new parent, moving, migrating, whether it's chosen migration or forced migration, graduating from a training program and starting your new role as a practising professional. So starting a new job. Losing a job. So life changes, as I say, are kind of very common. There's lots of literature of IPT in perinatal depression for people who are becoming new parents and a very strong evidentiary base as well. There's lots of evidence for IPT, for different age groups. So in adolescence there's lots of life changes as as young people begin to affiliate more with peers and get a sense of their identity separate from their families of origin. And in adjusting to a medical illness that might be disabling or life shortening or disfiguring and in in late life, right. Adjusting to retirement or the loss of some of a functioning or certain social roles. There's also role disputes where there's non shared expectations and then there's a default focus that in earlier manuals of IPT was called interpersonal deficits. I think many of us see that term is somewhat pejorative. And so what I tend to use is the more 21st-century term of interpersonal sensitivities, and that's for individuals where there doesn't seem to be any clear life event associated with onset or worsening. But oftentimes as we dive into the work, we will learn of smaller life events.

Dr. Paula Ravitz:
But it's for individuals who have difficulties with forming or sustaining relationships and as I said, in the middle phase, we are guided by those focal areas which each have a set of therapeutic guidelines. For example, with social world transitions, we will explore the change. What do people miss and what are they grappling with? There's a sense of grieving, if you will, over positive aspects of what was and struggling with some of the challenges or negative aspects of the new role. And I like to divide the middle phase into two parts. Early middle is about deepening understanding. In the late middle phase, patients often become more emboldened, regain a sense of agency, begin to connect with support of others as they problem, solve and find ways to manage the new role. We focus very much on what happens in communication. So communication analysis is something that we do a lot of in the middle phase where we understand I like to think of it as way more than fact finding. We understand problems with understanding, with empathy, with non-reciprocity. We might brainstorm and do role plays or marginal role plays in order to help our patients clarify what their expectations are, how they might express them. And in the process of doing communication analysis, we often use principles of mental sizing, right? This idea of that, we all have thoughts and feelings and expectations of one another. These thoughts and feelings are not necessarily known. They're sometimes opaque. And sometimes what we assume in terms of what's happening in others may or may not be true. Right? So this is where I might intersect with some of the principles of cognitive therapy. Excuse me, in the early phase, I forgot to mention we really focus on what we call the interpersonal inventory. Getting a sense of who are supportive, others and which relationships and which focal area we want to work on. We try to limit the focus to two areas. Even though all there might be salience in all four areas because it is brief and it is structured so we mark time. I like to use validated measures such as the PHQ-9 and the GAD-7 and of course in research studies we'll monitor those symptoms week to week. But in usual clinical care you want to have repeat measures, so you want to do it at least three times beginning, middle and end. Or if you're doing a 12 session model, you might want to do it at least monthly or every few sessions. Remembering that there's a whole literature on self-report versus clinician rated symptoms, there's going to be a subset of patients who continue to endorse high. And you might notice as the clinician that they seem to be getting better, in which case you might want to do a HAM-D on them, a clinician rated, and see if there is a mismatch. There's also a subset of patients that seem to under-report, but you get a sense that they're suffering in functional.

Dr. Paula Ravitz:
Their struggles with functioning are more profound. So, we use measurement-based care, but we also want to use our clinical judgement. And then in the final phase of IPT, again similar to the beginning phase, which I think can be used in any therapeutic episode of care, right? It's about kind of doing an assessment, getting a sense of what's going on, where the problems are, where we might help our patients to find resolution to those problems. In the ending phase. I find that the termination phase tasks of IPT are very much generalizable to any episode of care, such as discharging someone from an inpatient stay or from a course of treatment in a day hospital program and in the termination phase we try to consolidate gains. So we look back and we'll ask patients thinking back to when we first started and now what are you taking away and what's your sense of kind of how you're feeling or doing differently or how things have changed? And so if I was a fly on the wall and I was doing competence ratings with my IPT hat, I could tell whether you were in a beginning, middle or ending phase. The ending phase is we need to be very deliberate in our practice in order to consolidate gains. There's going to be a subset of patients who struggle more chronically. Treatment works for 100% of patients, but there's still value in marking efforts and gains that might not result in full recovery or significant reduction in symptoms. So the other thing that we do in the end is we think about what next, what more, what else might make sense. In terms of sequencing care episodes it's very important to be able to have a good goodbye. So Winnicott wrote about how we have to navigate a gazillion separations in a lifetime and how you don't want to leave things unsaid. Right? The ending phase can be evocative of the termination phase of of any treatment. When we say goodbye, we might feel some emotions, some sadness in parting. And again, we it's helpful to differentiate what is normative sadness from full on clinical depression. So sometimes people might feel alarmed that they're feeling depressed again or feelings of sadness and IPT is focussed. And it's not that we want to make sadness go away. Sadness is an important, useful marker in the face of loss, right? That's the core emotion. So we want to help our patients for those who have recovered to be able to differentiate, tease apart normative sadness, who they might talk to, who else they might connect with and get support from, and when to recognize if depression is returning and have a contingency plan, for example, of connecting with their family physician or seeking reassessment.

Jake Johnston:
Thanks Dr. Ravitz, for walking us through the core principles and phases of IPT. We're curious to learn more about some of the psychological theories that underpin IPT. Our preliminary reading indicated that attachment theory is one of them.

Dr. Paula Ravitz:
Yeah. I mentioned earlier that at the time of Bowlby's work on attachment theory was very much kind of in academic discourse. And I think it has remained very central a relationships. This is based on Bowlby's work are critically important for survival and for thriving and that we need to have a secure base in order to explore, in order to manage now. Early relationships might shape these attachment patterns of relating because it's about survival. So for example, in individuals where attachment figures are generally unavailable, it's adaptive for individuals to become more self sufficient. Right? Remember that attachment patterns are only evident in times of stress. Otherwise, they might not be so evident when patients come in with symptoms of mental illnesses. They're in a state of distress, I mean this is true of medical illnesses. Right? And so that's when we might see these attachment patterns of relating, whether it's someone being somewhat kind of avoidant or dismissive of care or the other insecure attachment pattern is anxious, preoccupied. And again, if you think back, it might have been adaptive for someone to be signalling their attachment needs very loud and frequently in the face of others being inconsistently available. So the other theory that I draw from is contemporary interpersonal theory by the late Don Kiesler and Timothy Leary that talks about these universal needs that we have for affiliation or connection in our relationships, along with a sense of agency or power or influence in our interactions. They have developed what they call the interpersonal complex, where individuals can be mapped based on kind of our patterns of expectations of others.

Dr. Paula Ravitz:
And again, this intersects with attachment theory, right? Bowlby talked about these internal working models based on early life experiences of what we tend to expect from others. And contemporary interpersonal theory is interesting because there are some predictions about the polls that we have that might be distancing or might be silencing of others and lead to individuals being kind of inadvertently authoring distance or perpetuating this sense of being disconnected or disempowered in their relationships. And we did some process research at a number of years ago. I'm happy to share the article where we looked at both attachment, self reported attachment and mapping on the interpersonal complex and looking at changes with treatment. And we found that in IPT patients with depression and this is patients with depression tend to be disempowered and with chronic forms of depression tend to be disconnected. And so one way of conceptualising recovery and IPT is that we help patients regain their sense of agency and to become less disconnected in their relationships. And we found that patients who recovered fully from depression in a course of IPT, whether or not they were on medication or not, tended to regain their sense of agency and become less disconnected as well. They moved away from dimensions of attachment insecurity towards security. So we did find some validity to these models. However, in terms of movement towards attachment security, we only found that in patients who fully recovered from depression. So you might wonder about how the state of depression also might interact with these self reported experiences of attachment in relationships.

Jake Johnston:
Thanks, Dr. Ravitz, for touching on and contextualising some of the psychological theories that are important in IPT. One thing you had mentioned was that no treatment works in 100% of patients, which is something we all know is true in medicine. With that in mind, are there any characteristics that make people better or worse candidates for IPT? Specifically, we're curious if there are any indications or contraindications for IPT and some patient selection considerations.

Dr. Paula Ravitz:
So based on this idea that IPT has these therapeutic guidelines for grief, for social transitions and parole disputes, it makes sense that especially for depression, where there's the strongest evidentiary base and the most IPT studies, that if an individual is presenting with depression and in the timeline in the history of present illness, it's clear that the depression, the onset of worsening depression seems very much linked to the death of a loved one, to disagreements in important close relationships, or to big life changes. Then for sure, IPT is likely to be a good model. Right? And then I started doing clinical research where the inclusion criteria was depression in not acutely suicidal because of course, then we need to move to kind of acute crisis care or higher level in order to ensure safety. It might require admission for patients who are not psychotic. So there really haven't been a lot of studies showing that. There's only one study that I know of that shows that IPT can be helpful for patients with affective psychosis. This was done at CAMH years ago and there was a poster presentation with Janice Harris who used to work at the Effect of Psychosis Clinic at CAMH. So depression, not acutely substance abusing or functionally impairing substance abusing, I should say. Not acutely psychotic and not acutely suicidal. So I started in the context of doing research studies with inclusion and exclusion criteria, found that patients who intuitively I wasn't so sure that IPT was going to help, that I started discovering that the IPT model actually helped patients who even in this fourth category of interpersonal sensitivities or whether there was no clear precipitating or triggering life events.

Dr. Paula Ravitz:
So I would say for your first training cases to try IPT because the middle phase therapeutic guidelines are so useful and can be applied. However, I think that IPT is really a good depression treatment. It's very powerful and it has sustained effects, sustained improvements. For a depression treatment, Ellen Frank and Holly Swartz. Ellen is a professor emeritus from University of Pittsburgh, has done a lot of the landmark IPT studies, including for patients with more chronic and recurrent forms of depression, and has adapted IPT for individuals with bipolar disorder. Holly Swartz is doing an NIH study looking at comparing IPT and Quetiapine IPT as a monotherapy for patients with bipolar disorder. It includes kind of a behavioural element with what they call "using a social rhythm tracking" where they find that if they can stabilize social rhythms, it actually significantly extends the period of wellness. Like not only does it aid recovery, but it delays relapse. Originally, it was in combination with mood stabilizing medications for Bipolar 1 Disorder for sure. As well, IPT has been researched for eating disorders, particularly for Bulimia in a group format.

Dr. Paula Ravitz:
Earlier studies were done by Chris Fairburn and Denise Wolf showing that compared to IPT, compared to CBT. That. Actually, it's interesting. It's kind of the turtle and the hare, the horse race that if you look long-term that IPT actually surpassed CBT. But in the short-term there were CBT seemed to work better in the kind of short-term follow up, but they're both powerful models. IPT has been extensively researched in adolescence for adolescent depression. This has been led by Laura Mufson and Jami Young has looked at group IPT as a preventative treatment and is doing work in high schools in the US. Using her model, a family-based IPT model has also been shown to be helpful by Laura Dietz. And again, for people who are interested in learning more about these models, there are many publications. We did a 40-plus year scoping review of IPT, looking at trends and themes over time and looking at all the different clinical populations including in low and middle-income countries. IPT for PTSD, I suspect, will be in future guidelines. As you know, in these guideline panels you have to have a minimum of two randomised controlled trials conducted by different groups of researchers in order to control for kind of allegiance or bias of the research group and the original gold standard study conducted by John Markowitz compared to the prior gold standard which is exposure based CBT and shown this was the first non-exposure based structured treatment to be as effective as exposure based CBT. Since that time, others are kind of have done studies in other settings, including in Brazil. What's interesting about the adaptations of IPT is that the model is generally the same in contrast to some other models of therapy that have been adapted for specific patient populations that differ quite a bit like exposure-based or exposure and response prevention for PTSD or OCD in CBT. Whereas with IPT, the model is essentially kind of preserved. So there's a bit less variation in the adaptations of IPT. As I mentioned, there's very strong evidentiary base of IPT for postpartum and perinatal depression, and many of us have been numerous studies, including one that was led by Cindy-Lee Dennis and Sophie Grigoriadis and myself were the clinical leads where we supported nurse therapists in the delivery of telephone IPT. This was published back in 2020 and found that 85% of our patients who started out meeting full criteria based on skid with 12 sessions of telephone IPT remitted. Again, there were no differences in patients who were on medication versus not on medication and with sustained improvements over time.

Jake Johnston:
Thank you very much for that thorough answer. Dr. Ravitz. So just to sort of summarise and reiterate, you're saying that IPT has the best evidence for major depressive disorder. According to the CANMED guidelines, IPT is a first line treatment for acute depression, second-line maintenance treatment for depression. And as you were saying, according to the can guidelines is a first-line treatment for depression in several special populations, including children and youth, mild to moderate, major depressive disorder in pregnancy and mild to moderate postpartum depression during breastfeeding. It's such a strong treatment that it is recommended before medications even in these populations. Dr. Everts, you had also mentioned that there's evidence for use in some other disorders, including Bipolar Disorder, Bulimia Nervosa and PTSD. One clarifying question I wanted to ask was if you could comment on IPT's use in anxiety disorders.

Dr. Paula Ravitz:
Yeah. John Markowitz and the late Joshua Lipsitz did a review looking at the evidentiary base for IPT and anxiety disorder. At present we don't really have sufficient evidence for it to make it into guidelines. But what I can tell you is that depression and anxiety are often comorbid. As mentioned in all of the depression studies that I've participated in, we monitor both GAD- and PHQ-9 and in our perinatal in our postpartum IPT telephone IPT study, we found that the patients who had comorbid levels of depression and anxiety seemed to benefit even more. In all the clinical trials that I've participated in, including a current clinical trial that I'm a clinical lead on using behavioural activation for women with perinatal depression the SUMMIT Trial. Interestingly, in the back channels I'm noticing that the anxiety scores are also going down significantly. So I think for patients who have comorbid depression and anxiety, both symptoms often decrease significantly. And perhaps surprisingly, because we're not directly targeting anxiety. But IPT is not only interpersonally focussed, it's affect focussed.

Jake Johnston:
Okay. Thank you for the information on the indications for IPT. Are there any contraindications?

Dr. Paula Ravitz:
I think if patients are kind of acutely suicidal, we need to provide kind of crisis support and we need to assess safety. So I think that clinically you need to just shift your focus and not necessarily proceed regardless of what their therapeutic model you might have in mind to be rendering. There really isn't evidence for a patients with psychosis. There's been some really important and helpful modifications of CBT for psychosis, and there is some evidence of the adaptations of that model. That work hasn't been done in IPT. It might be eventually over time, but in our thus far, over these last 40 years, there haven't really. There really isn't evidence for it. So I don't think it's indicated. And for patients who are struggling with functionally impairing substance misuse, it's really important to address the Concurrent Disorders and see if we can kind of help our patients with that. It doesn't mean that you can't still integrate some of the principles of these other useful evidence supported therapeutic models such as CBT or MI or IPT. I think they can still be integrated, but there really isn't research showing that it's helpful.

Jake Johnston:
Thanks, Dr. Ravitz, for walking us through some of the patient selection considerations for IPT. You've already touched on the some of the evidence base behind IPT. I'm wondering if you would be able to take us and our listeners through a brief history of sort of how IPT was developed and maybe a deeper dive into the evidence base behind IPT.

Dr. Paula Ravitz:
The first controlled study for depression was published over 40 years ago and originally there was a study conducted by Gerald Klerman and Myrna Weissman and others that compared IPT to medication. So this was, as I said, over 40 years ago, and what they tried to do was operationalize what effective, well-respected community-based therapists were doing. So in a way, it was a descriptive study of kind of good psychotherapy where they discovered that patients were coming in with these universal relational life events. So it was kind of a life events based model. At the time of IPT's genesis, Bowlby seminal work on Attachment Theory was kind of in in academic discourse as well. Brown and Harris studies on the associations between bereavement and depression were being published, and the etiological links between biological and psychosocial factors were becoming influential in discourse on illness and recovery. Since that time, the importance of relationships for health, coping and resilience has been well established. And in the very first study, to Gerald Klerman surprise and he was a pragmatist, he found that patients who received this structured psychotherapy and at that point in time it was a 16 session model. And partly the reason for the dose was because they also wanted to compare it to pharmacotherapy over time, they found that IPT worked as well as medication as pharmacotherapy. Now remember back then it was the tricyclic antidepressants, but that led to IPT being included in what still stands as a landmark study, the TDCRP study with Irene Elkin that was published long ago in which IPT-CBT pharmacotherapy and a kind of comparative, just supportive response to when patients requested it was conducted.

Dr. Paula Ravitz:
It was the first multi-site RCT that compared IPT and CBT. And in that study Lester Luborsky wrote a paper that quoted the Dodo bird from Alice in Wonderland that said "all must have prizes and all have won". So in the initial analysis, they found that everyone seemed to improve even the low-contact patients. There have since been multiple analyses of that study looking at process factors, looking at moderating factors, and they looked at baseline patient severity and when they examined that, the patients and pharmacotherapy did best, followed by IPT, then CBT and then the kind of low contact model. And subsequent to that study, there have been many studies of both IPT and CBT in particular showing that both models are highly effective, thus included in many international consensus guidelines as a depression treatment, especially including the World Health Organization here in Canada, the Canadian Association of Mood and Anxiety Treatments. It's amongst a very short list of three first-line treatments for depression based on many effectiveness and efficacy studies. And for people who are interested, there's Pim Cuijpers in the Netherlands has done many well conducted meta-analyses and the most recent one published in 2016 was a transdiagnostic meta-analysis of IPT showing that IPT is is helpful in the horse races. Comparing IPT and CBT in particular, they're both shown to be highly effective treatments, thus both recommended in consensus treatment guidelines here in Canada, in the US and in other parts of the world, including the World Health Organisation. So it's long been included in the mental health gap and guidelines of the World Health Organisation.

Jake Johnston:
Thank you, Dr. Ravitz for that comprehensive answer. You mentioned the IPT being cited as one of the three most effective psychotherapies in the CANMED guidelines. And I'd just like to point out that I noticed your name on the author list for that paper and just for our listeners, all of the papers that Dr. Ravitz has mentioned, we'll make sure to include in the show notes. So Dr. Ravitz, you've sort of gone through and given us a really good idea of what IPT is. The principles behind it are some of the patient selection considerations and some of the evidence behind it. And I'm curious, can you go through some of the more practical elements of going through a course of IPT? You know, you mentioned that it's usually sort of 12 ish sessions. There's a beginning, middle and end phase. And I'm curious if you could sort of paint a picture for our listeners what it's like to actually go through and maybe experience each of those phases and what type of things happen in each of those phases.

Dr. Paula Ravitz:
So, first of all I think that the provider needs to be aware of the structure. So a number of sessions. So when I first meet with a patient, if I'm doing IPT, I will orient them to the different phases and explain to them the rationale. I might say, "thank you for coming. Today is our first session of 12" and I explain the phases. So, "in these first few sessions, I am going to learn more about you as a person, about what's been going on in your life that's associated with you feeling worse. I am also going to ask you about important relationships so that we together can decide on which relationships and which focus we want to pursue in the middle phase of our work together. I'm going to be monitoring your symptoms as we go along using these two questionnaires, the the physician health questionnaire, which is nine items, which asks you about the last two weeks, how you have been feeling and to what extent it's affecting you, along with another short questionnaire about anxiety symptoms. The reason I do this is because the goal of our work together is to help you feel and do better. So this is one way I can track how you're feeling and doing in order to lessen the symptoms of depression and anxiety. And in the middle phase of our work together, once we decide which relationships in which focus I, we will go through a process of, first of all, deepening our understanding of what's been going on with respect to changes or losses or conflicts in your relationships that are linked to the moments when you're feeling worse or better. Then in the final 1 to 2 sessions, we'll try to consolidate our gains and what you've taken away if necessary. Think about next steps. Again, as I mentioned, I'm going to be tracking your symptoms over time so that if you're feeling worse or not feeling better, we're not going to wait for 12 sessions to think about what next. I might, depending on your symptoms, make recommendations".

Dr. Paula Ravitz:
In my mind, I'm also monitoring for the need for medication and safety monitoring. So then I proceed similar to what we do in psychiatric assessments to getting their identifying data. Chief Complaint History of present illness and a symptom review along with family, psychiatric and medical history, their past psychiatric history, medications, they are on. And then in the psychosocial history, the interpersonal inventory is kind of it happens in the beginning session and I usually begin with a genogram, but I ask them using the interpersonal inventory to tell me more about the important relationships where I learn about kind of maybe 6 to 10 closest relationships. I like to use questions from the adult attachment inventory, some of them. So I'll ask "Who raised you?". I love that question because it doesn't assume that it was biological parents. Sometimes people will say, "I raised myself or it was my big sibling or my neighbour or a teacher or a religious leader". It gives me, again, similar to doing communication analysis, data about their back story about whether there might be unresolved developmental trauma. I also watch and listen very carefully. If there are lapses in narrative coherence and I watch for affect, when do they become flushed with emotion or when do they tear up? Because again, this is data for me to revisit most important relationships in the middle phase. That's how I might introduce IPT. I track time. And at three points at the beginning when I'm kind of contracting and this is again, there might be times when you are post call or a crisis comes up and you have to reschedule or it could be just a word conflict or a personal conflict, and the same might be true for them. So you want to kind of set some ground rules. "I will let you know ahead of time but I understand that emergencies come up and you can let me know". I try to reschedule in the same week, where possible. And again, "I don't think we have time today, but there's going to be a subset of patients that it's it's hard for them to come within a period of time". Or they keep cancelling that they there's this might signal problems in the alliance of a tendency to kind of withdraw or be reluctant to trust or to engage. And that's a topic for another conversation. But I then in the middle so it's session six, say "we're halfway through".

Dr. Paula Ravitz:
People are often surprised, but do you want to mark time and you also want to get a sense I will sometimes work it as a middle session, but I'll also ask like what more else? Like thinking back to kind of where we are right now and that we have six more sessions including today. "What more else do you think would be helpful and important for us to focus on that seems to be linked to your distress?" and as I mentioned, the homework that I assigned in IPT has to do with paying attention to their emotions, to their affect both times when they feel more upset or distressed or annoyed or disconnected or sad or angry or scared. So any negative emotions but also positive emotions are really important for us to mark and track the times when they feel better, because hopefully it's linked to times when they feel more connected or understood or a sense of belonging or a sense of having begun to master some of the interpersonal problems that brought them in. Then in the last 10 minutes of the third from last session, so if I'm doing 12 sessions last 10 minutes of the 10th session, I'll say something like, "We have two more sessions after today". Again, that's a very different homework assignment. I'll say "Between now and when we meet, I'd like you to give some thought, and I will as well give some thought to this thinking back to when we first started and now what are you taking away? And also thinking back and this is again of a bit of a pre-post, what's changed? How you feeling different or what's changed in terms of your life or your relationships?" So one has to do with kind of of all the things that we've done and talked about.

Dr. Paula Ravitz:
This is such great data for learners and for therapists because sometimes the things that we think are the most salient or most important in terms of kind of supporting change and recovery are not necessarily what our patients report. So I think it's iterative discovery, joint discovery, and you want to also give some thought to that such that if I was a fly on the wall or I was doing a competency rating in the final two sessions, the first, maybe third of the session, 15, 20 minutes, you want to unpack whatever they bring again? I often I ask from session two onwards, How have you been since we last met? If they report events, I'll ask. And how did that affect your mood or symptoms? If they affect if they report motor symptoms? I want to ask and how did that and what's been going on? So again, we begin to socialise our patients to making those bidirectional links. Over time, patients just spontaneously report both right and so. You want to give some thoughts to those same questions that we ask our patients? And when you begin to ask those questions to say, okay, this is our second from last session, as I mentioned last week, we want to take some time today.

Dr. Paula Ravitz:
So it's similar to agenda setting that we might do in more highly structured therapy like CBT. "Thinking back to when we first started what are you taking away or thinking back to when you first started? What's changed?" You want to use therapeutic communication 101. So open-ended questions, empathic, paraphrasing or summarising what your patient tells you and not parroting, but paraphrasing. So this is part of the skill set that I think in all therapies our clinicians can improve over time and that will help them in all their clinical interactions, regardless of what kind of medicine you're going to practice. Actually, sometimes questions pop up in your mind that are like, yes, no questions that I often invite trainees. It's a good question. So how can you rephrase that to be more open-ended questions such as or prompts such as "Can you say more about that?" or to paraphrase. So, "You had an argument with your partner last week and it was really upsetting to you". Full stop. Don't even ask the question. Just paraphrase. Nine times out of ten, when our patients feel like we're really with them in that moment, they'll just elaborate spontaneously. There will be a subset of patients where it's like pulling teeth. And you actually have to ask, "Can you say more?" or "I'm not sure I quite understand."

Dr. Paula Ravitz:
And I want to just go back to communication analysis, because oftentimes when patients come in, they'll just give us the tip of the iceberg, the most heated moment of the argument or the way that they were feeling or the resentment that they experience from feeling kind of misunderstood or mis misinterpreted or responded to in ways that felt just kind of really empathic or miss a tune. And you want to roll the tape back. You get "Hang on, so this is what happened at the end and how you were feeling." So. "Where were you" and "What time of day" and "What day of the week" and "How did this start", "What was going on just before the interaction started?" And you want to get what words did you use or what did you say and how did they respond and how will you feel and what do you think they were thinking and what do you think they were feeling or what do you think they thought you thought. So you begin to draw kind of this figure eight linking of kind of two people in an interaction. And again, that gives us data about misunderstandings, about difficulties with empathy or with mental sizing and whether expectations or wishes are both reasonable and realistic. Sometimes we need to lower expectations, considering limitations of others. Sometimes we need to be more clear in our communication, right? In being in the way we give voice to things.

Jake Johnston:
Thanks. I'm sure of it. So that communication analysis sounds a lot like chain analysis, DBT for Borderline Personality Disorder which is actually a good segue way into our last learning objective. But all parking lot that for now, that was a beautiful way you took us through sort of how IPT is practically carried out in the focus of the various phases. A couple of more pointed questions. You mentioned it's about usually about 12 sessions in total. How long does each session last?

Dr. Paula Ravitz:
There's variability. Generally, I think the shortest sessions are 30 minutes and depending on kind of whether what practice setting you're in and also patients, they may or may not have time ideally, I think 45 to 60 minutes. So psychologists tend to do 60 minute sessions and psychiatrists do, like 45, 46 minute sessions. I think this is partly been driven by funding plans, but that's been my practice and that seems to be a good amount of time to really kind of cover a good amount of material using the IPT model, both phase and focus specific guidelines. Generally, it's once weekly, but for example, 12 sessions can take as long as four months because of holidays or interruptions. But you want to probably complete it. You want to complete it with them, 4 to 5 months or 4 to 6 months, I would say if it's 16 sessions within six months.

Jake Johnston:
And could you comment on maintenance IPT? Is that something that you practice?

Sena Gok:
Yeah, so I do. I was very much influenced by Dr. Alan Franks studies, I've showed that what gets you well, keeps you well. IPT alone can be very helpful. So if our patients, we have a more a history of chronic depression have gotten well with IPT rather than just kind of concluding with no follow up at the end of 12 or 16 sessions, what I do instead is the last few sessions I increase the time frame between. So it's a tapering, right? So let's say they've recovered by session ten or 12. I might then schedule sessions every other week for the next few sessions, then every third week and then offer monthly follow up for because they're at higher risk of relapse as well in the event that they become ill or severely symptomatic. We have a good alliance, so they're more likely to accept medication if I think it's indicated based on severity, functional impairment. So, they may have said no to pharmacotherapy in the past, but agreed to it in the future. And I find that there's a subset of patients who actually recover and then they just naturally taper off because they enter into their lives and no longer feel the need for mental health care and support. I usually keep my door open in the event that they're in crisis or feeling unwell that they can call. And I'm happy to reassess or sometimes I'll do some booster sessions with them. And again, having already had a relationship and know a little bit about their back story and their relationships, we can move into kind of therapeutic action pretty quickly. Right? In just a few sessions I can help to stabilise them. So that's in my clinical practice how I tend to work and with the residents that I provide supervision to the guidance that we give for patients who recover but who have a history of more longstanding struggles with depression. I suggest you kind of extend those 12 to 16 sessions over a longer time period, especially.

Jake Johnston:
Towards the end. I love that you call them booster sessions. It's like extending our immunity on the assaults on our mental health.

Sena Gok:
Yeah, that's a that's a beautiful metaphor.

Jake Johnston:
Yeah, absolutely. Thank you, Dr. Ravitzt. So that was a really helpful overview of the practical aspects of IPT. Just wrapping up now with our last learning objective, I'll pass the mic over to Sena.

Sena Gok:
Thank you, Jake. So Dr. Ravitzs, you mentioned earlier that IPT might have some advantages when compared to CBT. Could you explain these further, and are there also other advantages to other common psychotherapy methods?

Dr. Paula Ravitz:
So I think that we as clinicians need to have a repertoire of approaches because no one treatment works for everyone. I think as well that clinicians have models that just feel like a better fit, right? And so I think that just like is as medical students, you will kind of have preferences or things, areas, clinical populations or therapeutic tasks that are more appealing and feel like a better fit in terms of your motivation to gain expertise. The same is true in these different psychotherapy models, but what is also true about these psychotherapy models is that there are factors that are common to them. All right. And that are included right in the teaching of them and I think if you only learn one, you might not know that. Right? You might think this is IPT or this is CBT, when in fact it is an important common element for people who are interested in that. John Norcross and Bruce Wampold have done some wonderful work and looking at common factors and in fact in the most recent can that guidelines, we include a list of the common factors. We got permission from John Norcross who vetted it to include that run across such as the therapeutic alliance, use of empathy, positive regard, presence. These are very important having agreement on the goals and the tasks of whatever treatment you're doing.

Dr. Paula Ravitz:
So being explicit, being collaborative, being authentic and being non-judgmental, using open-ended questions and empathy and using paraphrasing and summative comments really go a long ways. No matter what you're doing, no matter which brand or guilt of practice you identify with, CBT is highly effective. And I think CBT has been shown to be effective diagnostically more. So there's been more studies but IPT the evidence is that the jury is out. It's the effect size is like compared to a cholinesterase inhibitor that has an effect size of over 30. The effect size of in terms of number needed to treat in IPT is over 30 for cholinesterase inhibitors and it's three for IPT and something like seven or eight for for CBT. But again, it depends on the practitioner, your preference, your style. As I mentioned, I think IPT is particularly helpful in the context of existential life events, right, in which one's appraisal might have, you know, a degree of accuracy. S,o I also think that it's helpful to actually have more than one model in your therapeutic repertoire. You don't want to be to have kind of a one size does not fit all. Procrustes was a famous innkeeper in Greek mythology that used to the idea of a one size fits all, because he used to cut the legs of long-legged people or stretch the legs of short-legged people in order to fit the one-size bed.

Dr. Paula Ravitz:
So one size does not fit all. And so that's why I really encourage people interested in having kind of these powerful psychotherapeutic approaches. And again, we've used we've trained nurses, we've trained family medicine residents and family physicians and into professional providers of social workers. It's not just for mental health specialists, because we know from the work of Martin Prince and Vikram Patel and those landmark articles that were published in the Lancet that there is no health without mental health, and it's incumbent on us all to be alive to struggles with mental health, which can help our patients in their recovery and in their functioning. So IPT focuses on clinician, on thoughts, CBT focuses on relationships, they are both affect focused, they're both structured, they're both time limited, they're both evidence supported. Jake, you mentioned comparing communication analysis to chain analysis in DBT. DBT has strong evidence base for our patients with Borderline Personality dDisorder. A handful of studies of IPT would be PD, but I think that right now, mentalising based therapy and DBT have the strongest evidentiary base for our patients with Borderline Personality Disorder. But communication analysis and chain analysis are not dissimilar and in behavioural activation, we look at helping our patients in a more kind of concise and simple way with communication of feelings or asking for help or being assertive, you know, by kind of starting with facts, feelings, a request or expression, but also thinking about impact which is important in thinking about sometimes we say things that aren't understood or aren't clear or don't land well with others for all kinds of reasons.

Dr. Paula Ravitz:
And so I think that there's lots of intersection and some of the things that we describe in these different models. It's a matter of semantics. And if you train and I have trained and taught and edited books on kind of multiple models of therapy, including through one series that learners might be interested, it might be in the library collections of the different schools where you go called Psychotherapy Essentials to Go that have both videotapes, and they're kind of learner's guides for some of the key principles of IPT for depression, CBT for depression, CBT for anxiety, affect regulation, skills from DBT and Motivational Interviewing along with a book on Common Factors and Improving Alliances and Outcomes. So I encourage learners to peruse these different models and make sense of them. You know that sometimes it's a matter of semantics and there's lots of similarities. But I also think that these different models of therapy give us different frameworks that are really useful to make sense of patients experiences and to give us kind of a roadmap for fostering reflection and exploration that will then lead to patients kind of finding their way in problem solving and adjusting to new roles or resolving disputes or processing grief through bereavement.

Jake Johnston:
That was a beautiful comparison, Dr. Ravitz, and a great way to sort of wrap up the learning objective part of this episode. I think we better let our listeners off the hook here pretty soon. It's been a ton of information and you've shared a lot of your expertise with us. Do you have any closing thoughts before we wrap up?

Dr. Paula Ravitz:
First of all, I think that psychotherapy has a role in the armamentarium of especially mental health specialists in both the training and provision of care. A group of us, Gary ChaimoWitz, Weerasekera and myself, recently published a position paper on psychotherapy in psychiatry with the Canadian Psychiatric Association, reaffirming the role. And I think that as mental health specialists, we are the ones who see patients who are at higher risk, who have higher levels of severity, chronicity, comorbidity, functional impairment. So it's really important that we have a full armamentarium of therapeutics, both to establish alliances, to understand, to monitor and to provide care and treatment to people who maybe have failed treatment from multiple first trials of either therapeutics or self-help or pharmacotherapy. I think the good news is our Mental Health Commission of Canada has done a really wonderful job of decreasing stigma and raising awareness of how common struggles are and with mental health and how we really need to scale access and treatment to mental health care. And there are apps and online treatments and lower intensity treatments that are being studied and offered. But when those aren't sufficient, I think that we as for those of you who want to become mental health specialists, I really encourage you to get training in a number of these evidence supported psychotherapies. They're powerful treatments. And for those of you who are going to become other kinds of specialists, I think it will really serve you and your patients and the teams that you work on well to. It's easily accessible to get more training and learning, including through these terrific podcasts that your group is hosting on these evidence-supported psychotherapy models.

Jake Johnston:
Thanks, Dr. Ravitz. Those are some beautiful closing thoughts and I really like the way how you framed it within the broader context of psychotherapy and within the broader context of our healthcare system. Before we wrap up the episode, Dr. Ravitz, you had mentioned a website that you're currently developing that could be useful for learning more about IPT.

Sena Gok:
Thank you Jake, for reminding me of that. So with IPt experts and instructional designers and learning management system programmers, we've developed what I think is a really exciting learning resource for people interested in kind of taking a deeper dive into learning about IPT. It's called www.learnipt.com. At present we're just at the tail end of completing an educational research study and we're in conversations about extending access to medical learners at different levels across the educational lifespan. So for people who are interested in doing the course, where we have all kinds of videotaped demonstrations that are captioned and transcribed so it can be translated into different languages, interactive case based learning exercises and brief segments of different experts talking about therapeutic aspects of IPT, including a welcome message from Myrna Weissman, who is the founder of IPT and John Markowitz, who has done more IPT studies than anyone I know. They're both at Columbia University. A brief segment from Holly Swartz, from Ellen Frank. So I've mentioned some of these and from Wanda McGinn along with psychologist Giorgio Tasca, talking about kind of colonic common elements and the therapeutic alliance. So I know I'm biased, but I think it's terrific learning resource. We've gotten wonderful feedback from learners and people can email me directly. So it's not open access at this point, but we hope there will be. We will find ways to open access over time. So I'm at Paula Ravitz at Sinai Healthcare and you can probably kind of put that in the resources for people who want to contact me or who want for the readings as well.

Jake Johnston:
Sounds great. We'll do. Well, Dr. Ravitz, on behalf of the entire team, we thank you very much for coming to speak about IPT on this episode. And we would also like to thank our listeners for your continued support and dedication to our podcast. Until next time!

Dr. Paula Ravitz:
Thank you so much, Jake and Sena for your interest and for this really enjoyable conversation about IPT.

Jake Johnston:
PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Jake Johnston. The episode was hosted by Jake Johnston and Sena Gok. The audio editing was done by Jake Johnston. Our theme song is Working Solutions by All Live Music. A special thanks to the incredible guest, Dr. Paula Ravitz for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

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Episode 41: MAiD and Mental Illness with Dr. Sonu Gaind

• Episode 41: MAiD and Mental Illness with Dr. Sonu Gaind

  Dr. Alex Raben: [00:00:10] Welcome to PsychEd, the psychiatry podcast for medical learners by medical Learners. This episode covers medical assistance in dying and mental health or MAID and mental health. We're going to be covering this topic mostly from a Canadian perspective, although we hope our international listeners will gather some important general points that can apply to their jurisdictions as well. I'm Alex Raben. I'm a lecturer at the University of Toronto and a staff psychiatrist at the Centre for Addiction and Mental Health. I'll be the host for today's episode. This episode will be using a slightly different format than our general episodes, because today's episode is not just a podcast, it's also a grand rounds. It's Dr. Urvashi Prasad's Grand Rounds to be specific. For those who are not familiar with what Grand Rounds are, this is a time honoured tradition in medicine, not just in psychiatry, where a physician, a learner and allied health member will deliver a presentation to a live audience in a hospital on a medical topic. However, now, with the pandemic and with technology what it is, we're really happy that the PsychEd podcast is able to act as a platform for grand rounds. We'd also like to thank the University of Toronto for allowing this to be possible and to fulfil Dr. Prasad's Grand Rounds requirements. So let me introduce Dr. Urvashi Prasad, who is a PGY3 at the University of Toronto to the show. Hi, Urvashi. Welcome.

  Dr. Urvashi Prasad: [00:01:46] Hi, Alex. Thank you for that introduction. As Alex mentioned, my name is Urvashi Prasad. I'm a third year psychiatry resident here at the University of Toronto. I am very excited to be here today and also super eager to share with you today's topic of discussion, which was one that piqued my interest not too long ago. Some months back, as a member of the American Psychiatric Association, Ontario branch, I remember sitting in on a brief discussion on Maid and Mental Health, which was led by Dr. Sonu Gaind. At the time, it was the first time I became formally aware of this topic. Fast forward a couple months from there, I was introduced to a patient during my SPMI block or Severe Persistent Mental Illness who had been requesting for made for primarily their psychiatric disorder. My appointments with her always left me with several questions on this topic, some practical as to what would be the eligibility criteria for MAiD for mental health. Is it legal to some of the more challenging questions around some of the ethical dilemmas around this topic? And so putting all of that together, this has brought me to here today where I decided to do my grand rounds topic on this on on made for mental health with the hopes of both educating myself and also perhaps educating others within the field. So to our listeners, whatever your reason might be for tuning in to our podcast today. Thanks for being here and we hope that we can make your time here with us worthwhile.

  Dr. Alex Raben: [00:03:36] Well, thank you Urvashi for being here and for leading this episode today. We're really excited to learn more. You mentioned Dr. Sonu Gaind and he is actually our topic expert today who will be joining you in educating us on this important subject. And I'd like to just briefly introduce him as well. So Dr. Gaind is a professor at the University of Toronto, as well as the chief of psychiatry at Humber River Hospital and works clinically as a psycho-oncology consultant. He's been a past president of the Ontario Psychiatric Association, the Canadian Psychiatric Association and PARO. His experience in this topic is quite big. And I won't be able to, I think, list all of these things he's been involved with. And he can certainly add to this, but I'll mention just a few. He has testified, for instance, at the Federal External Panel on the options for a legislative response to legislation around this issue. He's also chaired the Time Limited Canadian Psychiatric Association Task Force on MAiD, and he has given talks both within Canada and internationally on the subject, as well as written papers on the subject. So, Dr. Gaind, we want to welcome you to the show as well. Thanks for joining us.

  Dr. Sonu Gaind: [00:05:06] My pleasure to be here, and thank you for inviting me.

  Dr. Alex Raben: [00:05:09] And then last but not least, we are also joined by David Eapen-John, who is a third year medical student at the University of Toronto who is eager to learn more and want to be part of the show as well in order to give the medical student perspective. So thank you, David, for being with us as well.

  David Eapen-John: [00:05:30] Thank you so much, Dr. Raben. Very excited to be here.

  Dr. Alex Raben: [00:05:34] Great. So I will briefly go through our learning objectives for this episode and then I will hand it over to Urvashi to take us through a background on the topic and to go through the topic with our expert guest. So by the end of this episode, you, the listener, should be able to, number one, briefly summarise the history of MAID in Canada. Number two, define the present policies of medical assistance in dying and mental health in this country and how that might apply in your jurisdiction. Number three, evaluate the arguments in support of and against the implementation of MAID in the mental health context. And number four, discuss the possible impacts of MAID both on the profession of psychiatry and on our patients. So without further ado, Urvashi, please take it away.

  Dr. Urvashi Prasad: [00:06:36] Awesome. Thanks, Alex. Before we jump into the topic at hand and hearing from our expert guest speaker today, I'd like to take a few minutes to provide our listeners with some definitions and a bit of background on the history of MAID in Canada. This will hopefully help orient ourselves and help put things into a bit of context as we later focus our discussion on Maid and mental health specifically. So let's get started and maybe we can begin by some definitions. David, do you want to take this one on?

  David Eapen-John: [00:07:11] Thanks so much, Dr. Prasad. So first to according to the government of Canada MAID itself describes the administering by a physician or nurse practitioner of a substance to a person at their request that causes their death or describes the prescribing or providing by a physician or nurse practitioner of a substance to a person at their request, so that they may self administer the substance and in doing so cause their own death.

  Dr. Urvashi Prasad: [00:07:43] With that definition in mind, let's dive a little into the history of MAID in Canada, and this will hopefully also cover our first learning objective for today. So assisted suicide was illegal in Canada from 1892 to 2016 under section 241 B of the Criminal Code. During this time, anyone found guilty of counselling someone to take their own life or aiding someone to take their own life was guilty of culpable homicide and subject to imprisonment of up to 14 years. However, starting in the early 1900s, there were a series of court cases and legal proceedings which challenged the prohibition of assisted suicide as contrary to the Canadian Charter of Rights and Freedoms. Particularly, these cases argued that the law against assisted suicide violated Section seven and 15 of the Canadian Charter of Rights and Freedoms, which guarantees the right to life, liberty and security of person and equality. Some of you may be familiar with a few of these landmark cases, which include the Sue Rodrigues case in 1993, which was a case about a woman with ALS or amyotrophic lateral sclerosis requesting for physician assisted suicide. The Robert Latimer case in 1994, which was a case about a father ending the life of his severely disabled daughter. And the Carter versus Canada case in 2014, where Lee Carter assisted her 89 year old mother with degenerative spinal stenosis to assist her in planning her death in Switzerland.

  Dr. Urvashi Prasad: [00:09:19] Subsequently, in the year 2015, after decades of legal battles, the Supreme Court of Canada ruled unanimously to allow physician assisted suicide, which became legal in June 2016. According to the second Annual Report on Medical Assistance and Dying in Canada, published in the year 2020, the total number of medically assisted deaths reported in Canada since the enactment of federal legislation in mid 2016 to late 2020 was about 21,589 individuals. The average age at time of MAID being provided in 2020 was 75 years and cancer was the most commonly cited underlying medical condition, making up about 69.1% of the individuals who received MAID, followed by cardiovascular conditions, chronic respiratory conditions and neurological conditions. And these were similar trends that they saw in 2019 as well. So of course, all of that was in regards to Maid so far in Canada and some statistics to help sort of orient ourselves before we jump into MAID, specifically focusing on MAID for mental illness. Before we focus in on some of the questions with our expert guest speaker, what might be helpful is perhaps as a segue into our discussion is to introduce the patient case. And this is loosely based on the patient that I had alluded to a little bit earlier in my introduction as a means of perhaps anchoring some of our discussions around a topic around this topic.

  Dr. Urvashi Prasad: [00:11:13] I should also mention importantly that all of this information here has been de-identified to ensure that we can preserve patient confidentiality. So let's talk about Anna. Anna is a 50 year old single female who lives in a supportive housing and is financially supported on government disability supports. She has around a ten year history of schizophrenia, during most of which unfortunately she had been untreated and I was previously a high functioning individual with a husband and two children. She had her her own house and a stable job after completing four years of an undergraduate degree since the onset of her illness, likely about ten years ago now, she gradually lost her family, her employment, her housing, and was only brought to medical attention when bystanders called 911 after seeing a homeless woman engaging in bizarre behaviour at the time. Anna spent three months in hospital on a psychiatric unit where she was started on Paliperidone, an antipsychotic medication, which is which she has shown fortunately some response to. She no longer hears voices, is able to organise her thoughts and is much less paranoid of others. Since discharged from hospital, she's able to maintain her supportive housing and has never failed to miss an outpatient psychiatric appointment.

  Dr. Urvashi Prasad: [00:12:38] However, Anna still struggles with persistent delusions about being controlled by aliens, such that these aliens seem to dictate what food she eats. She also presents with prominent negative symptoms of schizophrenia, of being asocial, demonstrating a poverty of speech and a lack of motivation to do most things. She spends most of her time sleeping, waking intermittently for lunch and dinner, going on short walks and watching television. She has no interest in reconnecting with her family and has no desire to seek employment. From her perspective, Anna feels no change in medications would allow her to go back to her previous level of functioning prior to the onset of her illness. She does not feel that she is capable of leading a fulfilling life with her current illness and feels that the only answer to end her suffering is through Medical Assistance and Dying on the grounds of a mental illness. All right. Thank you all for patiently hearing me speak. I know it's a lot of talking on my end, but we are very excited and eager to hear Dr. Gaind's input on this discussion as well. So now that we've established the background of MAID as a whole in Canada, we can shift our focus on the topic of mental health. Maybe David can take this one on.

  David Eapen-John: [00:14:04] For sure. So why don't we start with the probably the most important question in the forefront of our listeners minds: Is MAID for individuals with primarily mental illness legal in Canada right now?

  Dr. Sonu Gaind: [00:14:19] So it's actually surprisingly complex answer because you would expect an answer to that question would either be a straightforward yes or no. But the history has been a bit more convoluted than that. Back in 2016, when MAID originally came about in Canada, there was no prohibition against MAID for sole mental illness conditions. However, there was a requirement. One of the safeguards that was in place in 2016 original legislation was that natural death needed to be reasonably foreseeable. And what that meant, for all intents and purposes, was that in the vast majority of cases, sole mental illness conditions wouldn't qualify because sole mental illness rarely, if ever, leads to natural death being reasonably foreseeable. And suicide was not considered a natural death that was reasonably foreseeable. Now, what's happened recently in 2021 with the new legislative changes is that initial safeguard of natural death being reasonably foreseeable is no longer there. That was removed. And in lieu of that, the government has put in what now is a temporary prohibition against made for sole mental illness, but they've attached a so called sunset clause to that, which means that within two years of that legislation being enacted, which was March 2021, that by March 2023 MAID for sole mental illness conditions is supposed to be permitted in Canada. So a somewhat convoluted answer to a fairly simple question.

  Dr. Urvashi Prasad: [00:16:12] Thank you for that, Dr. Gaind. So to sort of put that into context with Anna, the patient that we talked about, it seems like at the moment made for mental health is currently not available for individuals with so mental illness. So she would not at present be eligible to apply. But it sounds like by March of 2023, as you mentioned, that starting from that time, there may be eligible for applying for MAID in individuals with primarily mental illness. Would that be correct?

  Dr. Sonu Gaind: [00:17:05] That's correct. And part of what makes the area quite murky is that there are multiple eligibility criteria or safeguards that are in place, and you need to fulfil all of them in order to qualify for MAID in Canada. And so the question becomes that even once made for mental illness and I should clarify, by the way, that it does not mean that if you have a mental illness, you cannot apply for MAID, you can apply for MAID if you have a mental illness. However, some other condition needs to be the condition that's leading to reasonably foreseeable death or that is the basis of your application for it. So you're not precluded just by virtue of having a mental illness from getting MAID. Now, in 2023, what will change is that, as I mentioned, that sunset clause kicks in and so that temporary prohibition is removed. I should point out that when the original legislation that was passed in March 2021, Bill C-7, when that was drafted the previous year in 2020, the government had actually put in an exclusion of made for mental illness without a sunset clause. And so for that entire year from the draft legislation 2020 March to 2021 March or actually was February, the government had maintained that MAID for sole mental illness conditions would not actually be permitted pending further work and study. And then in a relatively short time, all of that changed in March where they put in this sunset clause to allow MAID for mental illness by March 2023. The question then shifts to are the other criteria able to be met for some mental illness conditions. And I'm sure that the discussion will lead into some of this. But the overarching criteria for any applicability for MAID is that somebody suffers from a grievous and irremediable medical condition. And then there are various ways that that's outlined in the legislation.

  Dr. Urvashi Prasad: [00:19:31] Yeah. Thanks for bringing that up, Doctor Gaind, we'll certainly dive a little bit deeper into the criteria in just a little bit, hearing you share some of your thoughts around that has also got me thinking about one other one other aspect of this, which is upon the some of the history that we that we heard around how MAID in Canada was established at the time in 2016, it seemed to have been driven by real people stories that resulted in landmark Supreme Court cases when it comes to MAID for primarily mental illness. Has there been any such movement from patient experiences in terms of legal proceedings?

  Dr. Sonu Gaind: [00:20:24] So for sole mental illness conditions, actually, this reflects one of the challenges we're facing that the legislation that's been drafted in response to court cases has all been drafted in response to court cases involving various degenerative or neurodegenerative medical conditions that are eminently predictable. And what has happened is that the policies have expanded to all sorts of other conditions, including now with the sunset clause, eventually mental illness conditions that were not examined by the courts. And that raises certain problems and questions, of course. There was one case back in 2016 prior to the original legislation being implemented, and this was at a time after the Carter ruling. The Carter ruling took place in 2015, and the country was given one year to come up with legislation to allow MAID in some circumstances. And during that time, prior to legislation being enacted in 2016, there were individual kind of applications to the courts that were allowed to be made. So there was one known case of a patient called EF in Alberta who did receive MAID at that time for sole mental illness conditions or a mental illness condition, I should say. And what that involved was a woman who was she was in her mid-fifties with conversion disorder and she suffered from intractable spasms, impaired mobility. And her family actually supported her application for MAID and she did receive MAID. Now, that case raised some concerns because it showed the potential problems or challenges when we don't have standards for what we're doing. In that case, the psychiatrist who opined on the case and on capacity based their entire assessment on chart review. They never saw the patient nor spoke with the patient. And they actually testified not just that they felt that the situation was irremediable, but also that the patient had capacity for the made request despite never speaking with the patient. And so it did raise eyebrows and concerns in some quarters about kind of the need for standards and what may happen when those don't exist.

  Dr. Urvashi Prasad: [00:23:05] Wow. Yes, that sounds very controversial and potentially highly problematic. And also gets me wondering whether from now until March 2023, when MAID might be available for individuals with sole primary mental illness. What can we expect in terms of some of the the legislative changes and such from now until then?

  Dr. Sonu Gaind: [00:23:34] So at this point, what's happened from the last legislative changes in March 2021 is that two pathways are now there in you could consider in a way in parallel for made one remains the pathway if death from some other medical condition is reasonably foreseeable. And in that pathway there's no longer a waiting period to receive MAID. There used to be a ten day waiting period that was required prior to getting MAID. But if death is deemed to be reasonably foreseeable under the current legislative changes, that waiting period is no longer there. But if death is not reasonably foreseeable. And so this was the big change in in March 2021 that Bill C-7 expanded MAID to eligibility for people who were not dying. And so if you have any disability. Other than a sole mental illness. But if you have any disability and you're not dying and you apply for MAID, you may qualify for it. If it can be shown that your illness is or you're suffering and condition is irremediable and you meet the other criteria and then you have a 90 day, three month waiting period. So looking forward to when to March 2023 once MAID for sole mental illness is supposed to be permitted. We don't know what the full legislative framework will be, but presumably there will be some pathway that has differences from some of the other pathways in terms of potentially waiting periods and other things like that. At this time, there is an expert panel that is deliberating on how to implement the processes for made for mental illness by 2023. I should point out that it's been made very clear that the expert panel is not deliberating about whether to provide MAID for mental illness or whether it is safe to or whether you can determine irremediably. They've been charged with essentially providing an instruction manual for how MAID for mental illness will be provided by 2023.

  Dr. Urvashi Prasad: [00:25:42] Okay. Thank you for for clarifying some of that. I'm also wondering, at the time of legislation of Made in Canada in 2016, there were a few other countries at the time being Switzerland, the Netherlands, Belgium, Luxembourg and some US states, including Vermont, Oregon and Washington, which had already legalised assisted suicide in certain circumstances prior to Canada. When it comes to MAID for primarily mental illness reasons. Do we know if there are other countries that we could perhaps look to that may have already legalised assisted suicide and mental illness?

  Dr. Sonu Gaind: [00:26:22] Yes, there are some of the European countries. So the jurisdictions that you mentioned in the states, they had and still have laws allowing assisted dying, but not for mental illness. So the ones in North America till now have all required in some way that death is either reasonably foreseeable as it had been previously in Canada or there's some element of terminality, etc. They don't allow MAID for sole mental illness conditions. The only jurisdictions that do allow that are in Europe and the Benelux countries. So the data we have is mostly from Belgium or Netherlands. We don't really have a lot of good data about the Swiss experience with this. And what we find from the data in Europe does, again, in many of us raised concerns because what it shows is that it's a different population that applies for MAID when it is sought for mental illness reasons. The data in North America till now when death needed to either be reasonably foreseeable or it was for some terminal condition, what that actually showed is that the people who would receive made here in North America under those circumstances tended to be better off. It was more affluent people who are better educated, higher socioeconomic status. And they actually had essentially, you could consider it, they had greater opportunity to live lives of autonomy. And the reason they're seeking MAID in those circumstances was to die with autonomy as well. And the dying with dignity, peace. In the European countries that allow MAID for mental illness, you actually lose that association. What you find is that when people apply for MAID outside of those conditions and for mental illness, they do have unresolved psychosocial suffering. They are not from the better off socioeconomic classes.

  Dr. Sonu Gaind: [00:28:30] In fact, they have unresolved, as I was saying, psychosocial suffering and loneliness. One of the early works that showed the kind of all of the consecutive MAID requests in the Netherlands over a period of about two or three, I think it was about three years. What it also found and looked at all of the MAID requests in the Netherlands for mental illness and it found a 2 to 1 disproportionate gender gap or ratio of 70% women versus 30% men getting MAID for mental illness. And that contrasts to a 50-50 equal balance of MAID when it's for terminal conditions in North America. So that raises some concerns as well, because even in terms of demographics that then, as you know, parallels the 2 to 1 ratio of suicide attempts that we find women to men have. In terms of mental illness driven suicide attempts. And what it also found that data that the most common condition, as you would expect that people sought made for mental illness for Netherlands was depression. And that's paralleled in Belgium as well. And you also had some conditions, including psychosis, PTSD, somatoform disorders, but also prolonged grief and autism. It found that in over 10%, I think it was 11 or 12% of cases, there was no independent psychiatric input despite these being primary conditions of mental illness leading to MAID requests. And then fully one quarter in one quarter of the situations that people got MAID for mental illness, there was disagreement amongst consultants about whether the person should get it. But eventually some or sufficient consultants felt that the person should that they did end up receiving MAID. And all of these are differences from the other patient populations that we see seeking made.

  Dr. Urvashi Prasad: [00:30:34] And just to clarify, Dr. Gaind, you mentioned that in these individuals with primarily psychiatric disorders, such as depression, that there was no psychiatric input. Just to clarify that for ourselves and our listeners, do you mean that there weren't any psychiatrists or mental health professionals that were involved in the MAID assessments and in the proceedings?

  Dr. Sonu Gaind: [00:30:58] Yes. And about 11% of them, there wasn't any psychiatric input. The other point, bearing making here is that when you look at the demographics, they're not just of who gets made, but who does the made assessments. That also changes when MAID for mental illnesses provided versus other conditions. So in Netherlands, they have what are called end of life clinics, where people can go and get MAID assessment and get MAID provision. And those are clinics where the person hasn't received their ongoing medical or psychiatric care. And what we find is that at least 75% or more of the psychiatric MAID applications go through those clinics. So more than the vast majority, more than three quarters go through those clinics. And that contrasts to less than one in ten of the general medical assessments going through those clinics. So even the and what that seems to reflect is that in many of those cases, the mental health providers who had been involved in the person's care did not want to participate in the assessments or didn't agree with.

  Dr. Urvashi Prasad: [00:32:12] Okay. That is certainly an interesting point. I'm also wondering, do these countries have specific regulations around MAID for primarily mental illness that perhaps would be helpful for our discussion?

  Dr. Sonu Gaind: [00:32:25] It's a very good question. Whatever we're doing, we want to do as safely as we can and with as much evidence and evidence bases as we can. And what they tend to have and I'm actually going to rewind for a second to point out some of the differences from their regulations and Canada's because I think that people often don't realise that, in fact, with the Canadian law as it is and where it's heading, it's actually much more expansive than what the Benelux countries allow. People often think that because the Benelux countries were providing MAID earlier and because they allow it for mental illness, that other countries that follow will have more restrictive policies. In fact, Canada will have a much more open policy because in both Belgium and Netherlands, actually anywhere else in the world, that MAID is allowed. There is also a requirement that essentially means there is an assessment from the medical team that all reasonable options at treatment have been tried and exhausted and that there is no reasonable prospect of improvement. Canada is the only jurisdiction in the world that does not have that requirement. And the reason for that is that one of the pieces in legislation says that any treatment that may relieve suffering must be acceptable to the patient. And it's interesting because, of course, we don't want to be forcing treatments on people. People have autonomy and the right to make decisions when they have capacity. But what that does in the context of MAID legislation is it says that even if you haven't had treatments, you may qualify from it.

  Dr. Sonu Gaind: [00:34:13] Now, think about what that means for someone with depression who has internalised a sense of hopelessness as part of the symptoms of depression. And I'm sure we've all had patients like this. I have one lady who, despite having been on low to moderate doses of citalopram, that each time she gets depressed actually help her relatively quickly. Every time she gets depressed, she is convinced nothing will ever help her and she doesn't want any help. And so the Canadian legislation, when you're asking about do those other jurisdictions have some frameworks that might help us, they do have some frameworks that might help us, but we don't have those in our legislation. Our legislation explicitly allows for people to get MAID despite not having received treatment. And when you have only one in three Canadians who need treatment for mental health having access to it, you can see that becomes an additional problem. And the one other piece that I think will hopefully have a chance to talk about is in terms of the safeguards and criterion, what it means to provide MAID for what purpose, meaning that if it's being provided for an irremediable medical condition, we need to be able to predict that a condition is irremediable. If it's being provided for other reasons, because we think someone has enough suffering in their lives, then that's a different criteria. But in Canada, it's supposed to be for irremediable medical conditions. And the whole question of whether you can actually predict that in mental illness, hopefully we have a chance to discuss.

  Dr. Urvashi Prasad: [00:35:53] Why don't we take a look at the current eligibility criteria for MAID in Canada? I know we've been alluding to this for quite some time now, so let's take a moment here and we will go through the eligibility criteria. And then perhaps after we go through that, we can take a look at each one and discuss how this might if and if it might have to change and how that might look like when discussing the eligibility criteria for MAID in mental illness. So the current eligibility criteria for MAID, as defined in the Medical Assistance and Dying Act at present includes that an individual must be one eligible for publicly funded health care services in Canada to be 18 years of age or older. Three Be capable of making health care decisions. Four have a grievous and irremediable medical condition, which means A, the patient has a serious and incurable illness, disease or disability. And B, the patient is in an advanced state of irreversible decline and capabilities. And C, the patient is enduring physical or psychological suffering caused by the medical condition or the state of decline that is intolerable to the person and cannot be relieved under conditions that they consider acceptable.

  Dr. Urvashi Prasad: [00:37:33] Five, Be making a voluntary request. Six, Provide informed consent to medical assistance in dying, which means one of two things; 1. For a person or a patient whose natural death is reasonably foreseeable, the patient provides consent after having been informed of the means that are available to relieve their suffering, including palliative care. And for a patient who's not or for a patient whose natural death is not reasonably foreseeable. The patient provides consent after having been informed of other means available to them, including counselling, mental health supports, disability supports, community services and palliative care. And after having been offered consultation with relevant professionals as available and applicable, and after having discussed these means with the medical or nurse practitioner and given serious consideration to these means. So maybe what we can do now is take a look at this criteria and perhaps discuss if and how some of these criteria might change or that we speculate might need to be changed or modified in order to fit the framework for MAID for individuals with primary mental illness.

  Dr. Sonu Gaind: [00:39:03] So thank you for that background and a comprehensive overview of what the current criteria are and in terms of how those may be modified. There are many different criteria there. I actually tend to consider many of those as safeguards in terms of we call them criteria. But the purpose of them also is to ensure that when people apply for made, they get it for the reasons that society thinks makes sense essentially and whatever normative and evidence based judgements we're making on that, that's the ostensible reason for the criteria. So I'm not going to comment on all of them because many of them I think are translatable. We my background is in psych-oncology and CL psychiatry and in any field in psychiatry and especially in CL, we make challenging decisions all the time, having to do with capacity, having to do with people wanting or not wanting treatment. And keep in mind that the vast majority of time our patients with mental illness has retained capacity. So it's not that they're formally incapable. They pass the criteria of capacity. But what I will do is point out a couple of challenges that that poses. And I'll end with the biggest one. But one is in terms of capacity. The vast majority of our patients can, should and do pass the capacity test when it comes to decisions about living and dying. Think about what or how mental illness can affect the person's wish to live while they still retain capacity. So the point I'm making is that capacity as a safeguard alone is a challenging one because you don't want people to not to be deemed incapable when they're capable. But we also do know that, again, for depression, the typical cognitive triad of what we get when we get clinical depression affects our view of the world, ourselves and the future in a way where we still retain capacity, but it might well influence our decision making nonetheless. And so that's one of the challenges. And how you sort that out in legal terms is really difficult because you're not going to say someone lacks capacity, but we need to be aware of those impacts. Another area is in terms and we tend not to weigh in to the motivation. Funds that people have for decisions because that's their autonomy about why they're making decisions. But when we're talking about life and death, the issue of suicidality also needs to be considered. And unlike any other medical conditions, suicidality is a symptom of some mental illnesses. It's not a diagnostic. We can have suicidality in the context of many things in life, but it's not a potential diagnostic criteria of any other medical conditions other than psychiatric ones. And so how we tease that apart also is challenging. And I don't have an answer for you for how we actually do that with criteria. And in fact, when you look at the data, you find that when people apply for MAID for medical conditions, you can see a difference between the populations that are traditionally suicidal versus those seeking made for other medical conditions. But when people are applying for a mate for mental illness, you see overlapping characteristics between the populations and shared characteristics of people with traditional suicidality for mental illness, including ambivalence, including despair about the future and other things. So those are two challenges that it's unclear to me how existing criteria would potentially address, but we'd be need to be mindful of those. But the biggest one that I said I would kind of lead to is the fundamental what I call the foot in the door safeguard, which is the need to have a grievous and irremediable medical condition. There's no doubt that mental illnesses can be grievous. They cause terrible suffering in people, and that suffering can be as bad or worse as any other suffering or medical condition. But the question of whether we can predict irremediably in mental illnesses is different. And there I would say that the evidence shows or suggests that we cannot. And people often, I think, mistakenly think that. Well. Does that mean that things that when someone has mental illness, it can never be irremediable? Remember that for assessments. That's not the question. The question is, can we predict that in this person the situation is irremediable.

  Dr. Sonu Gaind: [00:43:51] And all the groups that have looked at this have concluded that you cannot make that prediction. And I'm just going to read the quote from Camh specifically on this point. And this is in their consultation advice, policy advice on MAID. And they conclude CAMH concludes that at any point in time it may appear that an individual is not responding to any interventions, that their illness is currently irremediable, but it is not possible to determine with any certainty the course of this individual's illness. There is simply not enough evidence available in the mental health field at this time for clinicians to ascertain whether a particular individual has an irremediable mental illness. And to me, this leads to the crux of the dilemma we're currently in. And I should preface my comments by saying I'm not a conscientious objector to MAID. You know, I'm not sure if I'd mentioned previously, but I actually am physician chair of our hospital MAID team. I certainly wouldn't do that if I was a conscientious objector to MAID and I see the value MAID can provide in certain circumstances. It's also sensitised me to the potential dangers if we proceed on safely. And the fundamental lack of ability to predict irremediable and mental illness, to me, that shows that the very first safeguard cannot be met. And so now we're in a dilemma where legislation is saying you have to allow it by March 2023.

  Dr. Sonu Gaind: [00:45:26] All the science and evidence is saying we can't make predictions if irremediability. So it raises the question that if people end up getting MAID for mental illness but we can't predict irremediability; what are they actually getting it for? And so it does challenge our fundamental notion of what MAID might be provided for. And this is not to make a normative judgement even of whether it should or should not be provided. But I personally do think it is dangerous to provide MAID or death for one reason, when in fact we can't say that's the reason we're providing it for. And then it opens the door to all of the other reasons that people may be seeking death. And in fact, we've seen this. There are as we speak, there are people in Canada who have actually said with the MAID expansion that they will seek made when they run out of money. In other words, the worst case scenario that well, now what I want MAID when I have some other psychosocial suffering that society doesn't help me relieve. But if I can currently also have a mental illness, that might be my quote unquote foot in the door to apply. But if people can't even determine, my mental illness is truly irremediable, but I get MAID, what have I gotten MAID for? So a lot of things to consider and ponder.

  Dr. Urvashi Prasad: [00:46:44] Certainly a lot there for us to consider and ponder. And I think it raises a whole bunch of questions in regards to the practicality of what the criteria, what and if the criteria may need to change, but also a whole slew of ethical and moral questions that also arise from that in terms of whether MAID would disproportionately affect a certain subset of our population versus others. Moving on to address our third objective for today is a discussion around some of the support for and against MAID for primarily mental illness. Perhaps prior to jumping into this, I believe there was a recent survey from conducted by the Ontario Medical Association. And Dr. Gaind, feel free to correct me if I'm wrong, which gathered the opinion of psychiatrists across Ontario on the topic of MAID. I'm aware that you were involved in this project and I'm hoping you could share with us some of the key results from the survey to help us get a sense of the opinion of our profession on this very highly controversial topic.

  Dr. Sonu Gaind: [00:48:01] Thank you. And you're correct. It was conducted by the Ontario Medical Association section on psychiatry. So it was done just for or administered to psychiatrists in the province, and it was developed by the OMA section on psychiatry. I sit on the OMA section as an executive member, but it was developed by the entire executive, not just by one or two individuals. It was vetted by all of us. What the survey found, this was done in the fall of last year and the goal of the survey was both to ask questions, to solicit opinions of Ontario psychiatrists, but also to provide context of the expansion to mental illness, peace, and to get those specific questions of things that currently aren't in place but are predicted to be. And there were about 300 or so I think there were about 270 validated responses. So the OMA staff has a process of ensuring responses are validated, etc. and that's about how many ended up being validated. And what we found is that the overwhelming majority of psychiatrists support made about 86%. So actually let me give you the actual number. 86% said that they supported MAID in some medical situations, 11% did not support it and 3% preferred not to say. So that showed that the vast majority support MAID and are not conscientious objectors. When the question was shifted to "Do you believe MAID should be permitted for sole mental illness conditions", then it changed and there 56% did not support MAID for sole mental illness and 28% did.

  Dr. Sonu Gaind: [00:49:46] When you looked at the end of range, strongest responses, in other words, comparing the people who strongly support to those who strongly don't support, then it was an even greater margin of 3 to 1, strongly disagreeing with MAID for sole mental illness to those who strongly agreed for it. And so that was the overall result. And we did have other nuanced questions that asked about things related to irremediability, whether stances should be based on evidence which most psychiatrists did agree with, did ask question on mature minors and advanced directives. I can go into any of those if you want more details, but the one that I do want to focus on, because this again points out a difference in Canadian law. Familiar to anyone, anywhere else in the world is whether psychiatrists thought a patient should be eligible for MAID for mental illness if standard best practice treatments have not been tried. Because again, as I mentioned, in Benelux countries and everywhere else, standard best practice treatment is a fundamental safeguard before applying for MAID, not in Canada. And here, as you'd probably expect, the overwhelming majority of psychiatrists thought that if standard best practice treatments have not been tried, then MAID should not be offered. And it was about over 90% felt that with.

  Dr. Urvashi Prasad: [00:51:16] So if I were to apply that to or in other words, perhaps it sounds like the overwhelming majority of psychiatrists greater than 90%, as you point out, would likely not be in favour of MAID for mental illness as the legislation is currently laid out at present. Would that be a reasonable understanding of the statistics?

  Dr. Sonu Gaind: [00:51:49] You know, I think it's a reasonable kind of conclusion from that, but with a caveat, because we don't know what additional potential safeguards might be coming into play. And so right now, based on the absence of that safeguard, I think that's a reasonable understanding because if it was simply MAID is allowed for mental illness, even if you haven't had standard, best practice standard, best practice treatment attempts or access. Right. It goes both ways then, yes, 90% of psychiatrists would think MAID should not be allowed in those circumstances.

  Dr. Urvashi Prasad: [00:52:35] Okay. I'm also wondering what might we foresee as a field some of the challenges in supporting MAID for mental illness.

  Dr. Sonu Gaind: [00:52:48] You know, it's something where there are different approaches to suicide prevention. But one of the commonalities is that in many of the approaches, we have tried to keep patients alive and think about our certification laws so somebody comes in to emerge. And if they're suffering from a mental illness and they say that they want to end their lives, in many cases they may end up being certified and hospitalised with MAID for mental illness on the horizon. How all of that plays out is unclear because then you may have somebody who comes in who is saying that and they end up being certified and they're beside someone in a stretcher who is saying something slightly different, who ends up then going down a MAID pathway. And so it does raise questions about what our role is, what will be our response to how we carry out other parts of our mandate as well. Is legislation aligned in a way that actually makes sense across the spectrum, not just MAID, but all of the other legislation do?

  Dr. Urvashi Prasad: [00:53:57] And certainly, Dr. Gaind, you point a very vivid picture in my mind in terms of what as a resident where we frequently do work overnight on call, interfaced with some of these decisions around suicidality being in a scenario in the near future, perhaps of varying a suicide assessment based on whether a patient may be eligible for MAID or not does certainly seem to pose its challenges. I'm also wondering, for the sake of and for the sake of rounding out our conversation and also I think perhaps this might be important for us to touch up upon, is that what might be some of the reasons for supporting MAID for mental illness?

  Dr. Sonu Gaind: [00:54:48] So, you know, I think that is not just an excellent question. I think that is the fundamental underlying issue we need to think about in terms of both how have we gotten to where we are and where do we think we should be going? Again, I'll present some that I think have led us to here and also provide some counterpoints, because I think some of them are based in a little bit of a myth, actually. But one of the fundamental ones in terms of mental illness is, look, we are the people who have advocated for those with mental illness. People with mental illness have been discriminated and stigmatised for decades, centuries. And so how can we now say that mental illness is treated, quote unquote, differently? So one of the fundamental arguments has been that it would be discrimination to treat mental illness differently. Now, my view on that is that mental illnesses are absolutely valid, as valid as any other illnesses, but it does not mean they're the same as everything else. No two illnesses are exactly the same. If they were, they'd be the same illness. And that applies whether it's mental illness or medical illnesses. And we just need to look at things like the issues of suicidality or how decision making is potentially affected, even while capacity is retained, to give some hints at that. And so I think we have to move away personally from the idea that, well, everything has to be treated the same or it's discrimination. We need to treat things for what they are. Equity is not the principle of everything being the same, but being treated properly for what it is.

  Dr. Sonu Gaind: [00:56:35] The other is that it's autonomy, right? That it's an issue of autonomy. And the push for expansion has largely been about that. And there are some valid points to that, that what you do see is that in many of the situations where people seek MAID and these are probably the ones that you and I can picture. If I picture ahead about various life circumstances that might unfold, I want to have some autonomy over my life and death decisions. And so that's a valid point. However, we have to keep in mind that things need to be reasonable public policies, not just for me or for you, but for everyone that they're going to apply to. And so the autonomy, I actually think it's the autonomy myth that's largely fuelled this because people can easily see that argument that, well, I want autonomy to have a dignified death. But when we see the differences that data and evidence point out to how these issues play out differently for different populations, especially for marginalised populations and ones that suffer from mental illness that tend to be marginalised. So again, I'll take a segway here to the Aboriginal suicide rates. Nobody would say that Aboriginal suicide rates and it's not just Canada. First nations everywhere suffer this. Nobody would say that those suicide rates are because they just have a higher predisposition to mental illness. It's not that it's a social disenfranchisement that literally leads to that, and it may at times combine with mental illness. So the point I'm making there is that the drivers that lead people to wish to end their lives differ for different populations.

  Dr. Sonu Gaind: [00:58:23] And so the autonomy myth that's fuelled the wide expansion suggests that MAID is safe. And what I would say is that MAID actually may be safe for many people. It's a little ironic to use the word safe in me, but I think you know what I mean, that it could be provided in an appropriate way that society thinks is being done for the right reasons. However, the broader we expand the criteria and eligibility, the more and more people potentially fall under it. And we're now at a point of expanding it so far that it's not just the people who've lived a life of dignity, who want to lie, who want to die with dignity. It's people who've never had a chance to live a life with dignity, who seek an escape from life suffering. And so there is a group that may get more autonomy as these things expand. And again, that gets back to your gets back to your question. What's one of the fundamental reasons for this expansion? I think that's one of the fundamental ones. But the problem is that when you expand that autonomy for me, you are also expanding the risk to a marginalised population. So it's actually not true autonomy, it's a privileged autonomy. It's more autonomy for the privileged at the expense of the marginalised. And that's where my concerns come into play. And they're fuelled by the fact that in my opinion, if. We are making determinations of irremediability that science and evidence tells us that we're not able to make and we're abandoning our role as medical experts as well.

  Dr. Urvashi Prasad: [00:59:57] Doctor, again, I think your answer tugs at some of the fundamental principles of that most of us perhaps have thought about in the field of medicine. And the topic of MAID and mental health perhaps is posing a challenge, which is the conversation around autonomy versus doing no harm. And I certainly do think that this conversation, it speaks to that largely. I know I'm just keeping an eye on the amount of time that we have together. And I do want to thank you for your time here today and in assisting with my grand rounds, helping facilitate it. I do really appreciate you being here as the other individuals on today's episode as well. I will pass it back to Alex to facilitate the Q&A period.

  Dr. Alex Raben: [01:01:03] Thanks, Urvashi. And I echo your thanks to Dr. Gaind as well. Of course. So now we'll move to the Q&A period for you, Urvashi and Dr. Gaind, as mentioned before, you should feel free to add to this. But this is kind of a tradition of grand rounds, is that we do get a chance to ask some spontaneous questions towards the end. And so one thing I'm wondering, hearing this discussion and being a physician who doesn't come up against the MAID legislation very often in my practice, although that may be changing as we're hearing today. One kind of question that didn't quite get answered for me is we've talked about these criteria, but how is it implemented practically in the real world? Who is doing this assessment? Is it only would it be only psychiatrists? Would it be any physician you talked to? We heard about these clinics in Europe that are doing assessments. So how will this play out Dr. Prasad in Canada or what's the legislation currently?

  Dr. Urvashi Prasad: [01:02:10] So based on my understanding, the legislative currently is not limited to just psychiatrists and it is open to other medical professionals or doctors specifically who are participating in doing these specific MAID assessments. And I believe it's more than one doctor, so it would be at least two doctors opinions in order to perform these assessments. And for somebody to be eligible to go ahead with MAID. I will certainly open up the space here for Dr. Gaind and as well to add his input on this.

  Dr. Sonu Gaind: [01:02:58] Thanks, Urvashi. And you're correct, the current legislation requires two medical practitioners, but they don't have to be just physicians. It does allow for nurses, nurse practitioners or physicians. And one of the things that's changed so the original legislation, it's easy because they're the kind of, I guess one is half the other. So that's how you can remember the numbers. The original legislation was C-14 back in 2016, and that one is the one that required two medical practitioners but didn't have to be physicians, could be nurses, nurse practitioners, and it didn't define who you needed to be. With the change in C-7 in March 2021, as I mentioned, there are now the two pathways, one for if death is reasonably foreseeable and the other if it's not. So the non-dying disabled pathway you could say. And for that second pathway it is something where the requirement is supposed to be that at least one of the medical practitioners is expert in that particular area that the person is applying MAID for. And so presumably if that held true down the road, it would mean that a psychiatrist would need to be one of the people if the person's applying for MAID for mental illness. But again, that's all pending what happens in 2023 in terms of the specifics of the legislation.

  Dr. Alex Raben: [01:04:24] All right. Thank you both for those answers. That's quite helpful. And David, I'm wondering if you had any questions. I've got one or two more myself, if there's time. But I wanted to make sure you had an opportunity as well.

  David Eapen-John: [01:04:37] Yeah. Thanks so much, Dr. Raben. One question that I kind of wanted to talk about a bit, I think a really good point was brought up before about how these bioethical discussions can have different implications on different communities. And I really like the idea that MAID in the context of mental illness may mean more autonomy for the privileged and less autonomy for people who are more marginalised. And I think it also relates to kind of the data we have from other countries in Europe which may have a different population structure and makeup of their population compared to a more diverse place like Canada. And I was wondering if there are like ideas or ways that we can protect marginalised communities specifically by adjusting the kind of legislation that we already have in place, or will that involve like a major rewriting or redoing of the legislation altogether?

  Dr. Urvashi Prasad: [01:05:36] I think, David, you bring up an excellent question and an excellent point. And you speak to the probably the biggest challenge that we currently are experiencing in regards to the the biggest sort of shortcoming of the current MAID criteria in regards to the way it is currently laid out and the fact that individuals from more marginalised communities, particularly lower socioeconomic parts of the community, might be disproportionately affected by the way the law is currently laid out. And I think this speaks to something that Dr. Gaind has had alluded to a little bit earlier in regards to safeguards. I think the legislation would certainly need to expand and or rather narrow down its eligibility criteria and perhaps be more specific to have some safeguards in place to protect individuals that might be more vulnerable and more disproportionately affected by the law. In terms of how we could possibly do that, I think we may have to take a closer look into the definition of what irremediable might be in regards to not just looking at it from a biological lens, but also from a psychosocial lens. So are there financial stressors that are contributing? Are there housing stressors that are contributing? Is there loneliness? Is there social isolation and ways in which to address some of these important struggles and challenges that many of our patients do face? Dr. Gaind, if you have anything else to add in here, we'll be great to hear your input on such an important question as well.

  Dr. Sonu Gaind: [01:07:43] Thanks so much. I think you gave a very good answer to that. And David, that's really on point and insightful question because that's precisely part of what we need to be concerned about. And my kind of I liked your answer Urvashi, I'm just concerned that it may not be implementable. And I'll tell you why. I've been in policy discussions with and this was actually a psychiatrist who was saying that, look, when we see somebody who applies for MAID now, if they are applying for poverty and that's how they framed it, if they're applying for poverty, well, we wouldn't provide MAID. And I thought that's not a realistic actual reflection of what happens because suffering is cumulative. We don't compartmentalize our suffering and say that this amount of my suffering is from poverty, this is from my mental illness symptoms, and this is from my separation, from my family. It's all cumulative. And we've known this for many years in palliative care. There's a concept called Total Pain by Dame Cicely Saunders. And it's that idea that all of the suffering that we have kind of that's what we respond to. So in any practical implementation, if somebody is applying for MAID and they happen to also have poverty, how would we possibly rule that out? Because if we say that, oh, we're not going to let you get it because you are of lower socioeconomic status.

  Dr. Sonu Gaind: [01:09:22] Imagine the discrimination charge is there because then you're actually saying we're not going to provide something to you because you have poverty. No one's going to come and say I want it for poverty, although some people are now actually saying that. But in practical terms, I don't know how you could actually separate it out. And this is why even the UN rapporteur on the Rights of Persons with Disabilities and in fact the UN,there were two UN reports that came out quite strongly against what Canada is doing with this expansion, because they essentially are saying that much of the expansion is based on ableism and that disability should never be a ground or justification to end someone's life directly or indirectly. And they add in the idea of the socioeconomic suffering that also fuels disability and the sense of being a burden to society. And so I really liked your answer. I just don't think it's in practical terms doable because when people come with that cumulative distress and apply for MAID, how do you separate it out?

  Dr. Alex Raben: [01:10:41] Thank you both for your answers there. Yeah, it sounds like quite a complex question and the complex answer that will be very difficult to tease out in a legislative, practical way because of these disparities that exist in our society. I'm sorry, Urvashi. I'm going to ask one last question, but it's kind of double-barrelled, but one I think will be a relatively faster answer. And that's just to bring it back to the case of Anna. I'm wondering if you think with the current legislation, if we fast forward to March 2023, do you think she could be eligible for MAID given her situation? And then my sort of final question is we've talked about feelings of hopelessness in the context of depression, possibly leading to someone applying for MAID. But I think just personally speaking, some feelings of hopelessness have come up for me in this discussion tonight that I'm wondering how we see, what we see, the future of this legislation being and if there is some potential for change here, because we've talked a lot about some problematic potential issues here in the future.

  Dr. Urvashi Prasad: [01:11:57] Yeah. Alex, you ask a question that certainly been on my mind, especially with having some of my interactions with the patient that I alluded to a little bit earlier. So bringing this into Anna's case, particularly, I think if we were to fast forward to March 2023 and if I was faced with this question, the one criteria that I feel would be, possibly the most challenging and one that I would struggle with the most would be within the eligibility criteria. I'm just going to read this out loud just to bring everybody on the same page. So this the point being the patient is enduring physical or psychological suffering caused by the medical condition or the state of decline that is intolerable to the person and cannot be relieved under conditions that they consider acceptable. So given the way that that's worded, saying that it relies on the patient's level of acceptability, I do think that Anna would meet criteria for this and would likely meet criteria for being eligible for MAID. However to me if I were to be looking at that criteria and perhaps maybe even looping this back into David's question in terms of ways in which we could take a look at the current criteria and change it, I think one way of one way of perhaps revising this criteria would be to change it to both the physician and the patient, considering what might be acceptable versus what might not be acceptable treatment.

  Dr. Urvashi Prasad: [01:13:54] So in Anna's case, she's only been on one trial of an antipsychotic medication that we know of. And from a physician perspective, I would consider that to be not acceptable in regards to knowing that there are other treatment options that we could pursue. So, from my regard, I would not find that to be acceptable. However, I think from a practical perspective, if we were just going by the criteria, I think she would meet criteria for MAID. And I'll get Dr. Gaind to weigh in on that in just a second. But I'm hoping to also answer the second part of your question, which is the question of hopelessness that some of our patients might be struggling with. And I do certainly think that in the case of Anna, that was something that was also very much evident.

  Dr. Alex Raben: [01:14:54] Well, let me add to that Urvashi, because I was actually talking more about the provider feelings of hopelessness and where you see our role in this legislation or the role of Canadian Society in addressing some of the problematic issues we've talked about today. And I know it's very complicated, but do you see and it doesn't fall on any one of us. So it is a big question, certainly. And I don't expect you to know to have a single answer. Where do you see the hope in this?

  Dr. Urvashi Prasad: [01:15:28] It's a big question. And to me, I think the first step really is raising awareness on this issue in regards to perhaps as health care providers feeling less isolated in our level of distress and hopelessness around such a complicated issue. And this also speaks to the reason why I was hoping to participate in a grand rounds on this and do a podcast, because I think, surprisingly, there isn't as much awareness on this very important issue. And I think a lot of us perhaps are dealing with the hopelessness around it in sort of silos independently. And I think the biggest step would be to increase awareness on this issue so that collectively, as a group, we could perhaps discuss some of our feelings around it and maybe even take that a step further to creating perhaps some expert panel groups or working with individuals that are working on improvising the policies for MAID in mental health so that there can be some movement driven by psychiatrists and mental health professionals to bring to light some of the challenges around the way the law is currently designed and to perhaps make some changes that would revise the eligibility criteria in a manner where we would not feel so disheartened when so many of our patients possibly maybe talking about or inquiring around MAID. Now how that might happen in terms of what sort of changes we would see in regards to the law would be difficult for me to answer to for all the reasons that Dr. Gaind mentioned a little bit earlier. But I think certainly being able to have being able to raise awareness and being able to discuss some of these emotions and then lead that into perhaps even pushing for changing policies might be the first couple of steps around this.

  Dr. Alex Raben: [01:18:03] That's great Urvashi, I already feel more hopeful after hearing that from you. So thank you. Dr. Gaind, do you have any parting thoughts or thoughts on that? Last question there before we wrap up.

  Dr. Sonu Gaind: [01:18:14] I would just echo actually what Urvashi said. I think you are absolutely right in what you're saying, that the answer to despair and hopelessness in this case is actually both us getting engaged. And by us, I mean all of us in the medical field and residents are the future of our medical field. So especially resonance and raising awareness, because what I can let you know is that although, you know, it's leading to a lot of challenges right now, this is something where as more people become aware of it, they're actually very surprised at the way things have proceeded. It is not something, you know, normally we have a sense of trust and confidence that by the time things come around to being said as national policy, they've gone through all the appropriate due diligence. And I can say to you that in this case, that has not happened. And although that's not a good thing, that it hasn't happened, but it also does really highlight, as more people learn about it, is, you know what, maybe we need to take another look at this. And it's not to say ideologically that something is or isn't right, but to understand what we're doing it for and to do it in at least what we can best try as an evidence-based way. And so, I do think that as people learn about this intermingled, I'd say, Alex, with that sense of "Oh, I'm feeling a bit hopeless" is also, you know what, this is actually a significant issue that's going to affect a lot of my patients and people that my patients know when the people were here trying to help, and that can be very motivated. And so I would say don't despair about it, but I think become aware and informed and also help others become aware and informed. And that can actually lead to positive policy changes and pressure.

  Dr. Alex Raben: [01:20:11] What a wonderful note to end on that. There is there is hope here. And that as has been mentioned already, this episode itself serves as a platform for us to start or continue the discussion. And I hope that continues as well. Thank you again, Doctor Gaind for being our guest expert on this episode and to you, Urvashi and David. And of course, thank you to our listeners and we hope you enjoyed and we'll catch you on the next episode. Bye for now.

  Dr. Alex Raben: [01:20:53] Psyched is a resident driven initiative led by residents at the University of Toronto, McGill and UBC. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Dr. Urvashi Prasad and Dr. Alex Raben. The episode was hosted by Alex Raben, Urvashi Prasad and David Eapen-John. The audio editing was done by Alex Raben. Our theme song is Working Solutions by All Live Music. A special thanks to our incredible guest, Dr. Sonu Gaind for serving as our expert on this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening!

Episode 39: Electroconvulsive Therapy with Dr. Wei Yi Song

• Episode 39: Electroconvulsive Therapy with Dr. Wei Yi Song

  Jake Johnston: [00:00:14] Welcome to PsychED, the psychiatry podcast for medical learners by medical learners. This episode covers Electroconvulsive Therapy or ECT for short. I'm Jake Johnston, a fourth year medical student at UBC, and I'll be the host for this episode. I join my wonderful colleagues who will be co-hosting. Why don't you all introduce yourselves?

  Arielle Geist: [00:00:36] Hi, I'm Arielle Geist. I'm a second year psychiatry resident at the University of Toronto.

  Randi Wang: [00:00:42] Hi. I'm Randi Wang. I'm a first-year resident also at the University of Toronto.

  Alex Raben: [00:00:48] And I'm Alex Raben. I'm a staff psychiatrist at Camh and a lecturer at the University of Toronto.

  Jake Johnston: [00:00:55] And last but certainly not least, it's my pleasure to introduce our guest expert for this episode, Dr. Wei Song, a psychiatrist who are several different hats. Dr. Song is the Department Head of Psychiatry, Director of Mood Disorder Services and Director of ECT Services in Victoria, British Columbia. He is also a clinical professor at the University of British Columbia and a past president of the Canadian Psychiatric Association. Thank you, Dr. Song, for joining us for this episode. Do you want to introduce yourself?

  Dr. Wei Song: [00:01:26] Thank you, Jake, for a kind introduction, and I don't really need to introduce myself as you have already introduced. I'm so glad to be here and very privileged to be able to discuss the topic of ECT. As you know, it's a perennial topic. It's been going on for almost a century. So I'm happy to be here to answer your questions.

  Jake Johnston: [00:01:51] Thank you very much, Dr. Song, for joining us. Let's dive into our learning objectives. By the end of this episode, the listener should be able to one briefly describe the history of ECT from inception to the present to debunk common misconceptions about ECT. Three, describe the major proposed mechanisms of action of ECT. Four, describe the efficacy of ECT for common psychiatric illnesses. Five, list the indications, contraindications, side effects and risks of ECT. Six, understand how the procedure of ECT is performed. Now that introductions are made and learning objectives are covered, let's get into electroconvulsive therapy. Randi, do you want to start us off with some questions for Dr. Song?

  Arielle Geist: [00:02:45] Yeah, that sounds good. So I'll focus on the first part, which is for us to briefly describe the history of ECT from inception to the present. So based on our background readings, we read on uptodate some background information. So we know that ECT is a treatment during which small electric currents produce a generalised seizure under anaesthesia. We know that it's mainly used for severe depression, but can also be used for a bipolar disorder, schizophrenia, schizoaffective disorder, catatonia and even NMS. So from a historical standpoint, it started when physicians observed that patients with schizophrenia actually get better after they spontaneously have a seizure. So that led to some physicians actually inducing seizures, using medications to help treat these conditions. And then beginning in 1938, physicians actually began inducing these seizures, using the electric currents that first there were some physical injuries that were associated with treatment. But now that we have much better understanding of anaesthesia and muscle relaxants, that's really gone away. So nowadays almost all psychiatric facilities offer ECT. And based on data that we've collected, we know that patients who are they're more likely to receive ECT are those who are white and of higher socioeconomic status. So Dr. Song, I'll give you the stage to maybe talk about anything that we've missed. And yeah, why don't you describe what you see is to us?

  Alex Raben: [00:04:30] Well, I think you captured very nicely that brief history and remember the treatment way before modern psychopharmacology. So, you know, mental illness has been plaguing, I think. Our human species since written a history. So for thousands of years and and there are a lot of search for a cure and not to sort of a distant past. You know, you're talking about hydrotherapy and essentially having some sort of an induction of fever that may actually cure mental illness. And I remember my professor in McGill and Dr. Heinz Lehmann talking about injecting sort of comfort oil in the peritoneal and then causing sort of a fever and then having seizure as well to cure catatonia. When you talk about EKGs, do you remember the residency time, the picture of this? 1938. That facility, this Italian psychiatrist and holding this switch of this electric current. And there was a five orderlies jumping on the patient. It was pretty gruesome in some ways. But on the other hand some of the patients were dying of catatonia and psychosis. Right. So certainly it provided dramatic improvement. Of course, like you said, Randi, associated with some of the side effects because those days the ECT was unmodified. I think in some parts of the world, as far as I know, sometimes a modifier is still being conducted because the limited resources and so on. But in the developed world the ECT is very refined. I'm sure you have questions about how it is conducted and so on.

  Arielle Geist: [00:06:36] All right. Thank you. So next, moving on to some common misconceptions that we want to help debunk. We have an article here called Ten Myths about ECT from Current Psychiatry. And I guess I will just get started on some of the most common ones. So the first one, I guess you have alluded to it already. The first misconception is that ECT is very barbaric. So this is actually untrue because those of us who've actually seen ECT know that it's conducted in a very controlled medical environment. We have a psychiatrist there, anaesthesiologist, and many nurses present. Patients are given anaesthetics beforehand to not feel pain and muscle relaxant, so they're not jerking around or experience any physical injuries. And of course, we monitor their vitals the entire time and make sure they're medically stable. And another misconception is that it's very dangerous when in reality, death from ECT is extremely rare. The mortality rate is actually only 2.1 in 100,000 treatments, which is lower than that of just anyone going of an average person going through general anaesthesia. And we can even it's so safe that we can even use it on patients who are pregnant and on patients who have a history of epilepsy. Another misconception is that it could cause brain damage and this is untrue. Studies using MRI's have shown no evidence of negative changes before and after ECT. If anything, it can cause an increase in neurotrophic factors which support growth of brain cells. And then finally, a lot of people have this misconception that it creates permanent memory loss and this is also untrue. So ECT may temporarily impair anterograde memory, which are the events that happen right after the treatments for a few days, maybe a few weeks, and very rarely may cause retrograde amnesia, but overall it is not harmful to memory. So, Dr. Song, please correct me if any of these facts were incorrect. And what are some of the misconceptions you often hear from your own patients?

  Alex Raben: [00:09:02] Stigma is number one. So people, even staff who have not been exposed to ECT. You still remember the movie One Flew Cuckoo's Nest and that movie itself had killed ECT treatment for over a decade, so sometimes the media can have pretty strong influence, be it positive or negative. I'm hoping this is a positive influence doing this podcast. So the reality is ECT, safe, ECT is life saving for a lot of our seriously ill patients. And it's done, just like I say, in a very controlled environment and it's been refined over the last number of decades in terms of anaesthetics, paramedics and even the ECT machine. So the side effects, as you know, it can happen with memory. And like you mentioned, the memory loss is mostly transient. Most of studies will say it's transient and once the ECT treatment is discontinued, most of the cognitive problems will restore within the first two months post-ECT. However, there are patients that we have rely on ECT for maintenance and they can go on basically as a sort of a dialysis for kidney failure. So for years and obviously these patients will say they have some permanent memory difficulties. What I would say is because they have ongoing ECT and there is evidence showing that the more you have, then obviously the more likely you're going to have more cognitive difficulties like memory problem. So stigma is number one. I think people just feel like it's something that's barbaric. And then the misconception, obviously, the some of the practice in certain parts of the world may not have contributed to the positive image of the ECT. For example, conversion therapy or ECT for homosexuality, for example, in history. And those were obviously misuse of treatment just like any other treatment. But with the right patient's right condition, it is one of the treatments that I don't think anything else has surpassed.

  Arielle Geist: [00:11:47] Thank you.

  Jake Johnston: [00:11:49] Yeah. Thank you very much for going over all of that Dr. Song. It seems like a detrimental cycle where misconceptions about propagate stigma and stigma propagates these misconceptions. And moving on down a list of learning objectives. I'm wondering if you could discuss the mechanism of action of ECT. So research over the years has eliminated much about the neurobiology behind its therapeutic effects, although its exact mechanisms remain to be elucidated. So without going into too much detail, can you outline some of the major theories of its mechanism of action?

  Alex Raben: [00:12:26] Oh, that's I think that's a very, very large topic. And I think one can say it's still largely unknown, but there are increasing evidence in research showing that [00:12:42] OECD works. [00:12:43] And why it works involves a number of things, including neurobiology and connectivity and neurophysiology. So one of the theories actually is about the seizure itself. And this actually stemmed from what Randi had mentioned, the history of the evolution of ECT. So the seizure has a lot to do with it. And one of the mechanism perhaps relates to the seizure itself. As we know, with the ECT treatment, every treatment does seem to increase the seizure threshold and then the duration of seizure activity actually seem to shorten with every treatment. And there are some studies stating that using PET scan and EEG, looking at the post, ECT as a reduction in the original cerebral blood flow, glucose utilisation and neuronal activities in the cortex. And there are some increase in the blood flow across certain brain regions, particularly in patients with depression. There are studies also looking at the neurotransmission systems, looking at serotonergic, dopaminergic and adrenergic systems and as well as glutamatergic. So, going back to the theory about the myth about ECT damaging brain, there were some studies that have been done, particularly using a sort of animal studies where the primates, sort of shocking the brain and then surprise the primates and slicing the brain. And there's absolutely no evidence showing the brain damage. On the contrary, for some of the animal studies and we show there is perhaps increase in sort of a neuroplasticity and sort of a connectivity in terms of brain regions and synaptic genesis and neurogenesis and biogenesis. So it's actually it's still emerging. And I think in time we probably have a better understanding. As you know, there is a theory about depression and a lot of psychiatric conditions being sort of neuroinflammatory process. A lot of the treatments we do actually is anti-inflammatory in the CNS system. So I wouldn't be surprised there would be some data showing that ECT itself can be sort of an anti-inflammatory in the in the process. So, you know, really, we don't have a one single explanation why it works. I wish I had anyone who as you have a one some theory I think it will be destined for a Nobel Prize.

  Jake Johnston: [00:15:57] So thank you for taking us through that Dr. Song. I realise it's a very large area of research. Just to summarise for our listeners, the mechanism of action of ECT is multimodal involving neurophysiological processes such as changes to the seizure threshold and regional cerebral blood flow. Neurobiochemical processes such as neurotransmitter, neuroendocrine and neurotrophic changes and neoplastic processes such as alterations in synaptic wiring and changes to the volume of certain brain structures. Is that a fair summary?

  Dr. Wei Song: [00:16:36] Yes.

  Jake Johnston: [00:16:39] All right. Fantastic. All right. Do you want to take it away and tackle our next learning objective?

  Arielle Geist: [00:16:46] Yeah. Thanks, Jake. So now that we've spoken about the mechanism of action of ECT, I'm wondering if you can tell us about what the indications for ECT are. So what might we consider? When might we consider recommending ECT?

  Dr. Wei Song: [00:17:02] The number one indication, at least from what I know and also what we do in Victoria is the treatment-resistant depression. So patients who have failed trials of medications, patients who are the index episode of depression that is very severe and obviously patients who need an urgent sort of a symptom reduction, for example, acute suicidality or inability to have nutritional intake due to catatonia or severe depression. So these are the conditions we do ECT and we do ECT on the pregnant women on a regular basis. As you know, it's very important to have a rapid resolution of depressive symptoms during pregnancy. Depression itself, it's probably more teratogenic to the fetus than some of the medications. However we also just have a very limited amount of approved medications for treatment of pregnant women. So that's what depression. The interesting thing about ECT responses, the sicker the patient, the better the response. And also the patients who are more elderly, they tend not to respond to pharmacotherapy and the ECT also shows a lot more robust response and it is lifesaving for some of the suicidal patients. A lot of times you can see the difference within the first two or three sessions, particularly those individuals who are showing catatonic features who can't eat or drink, who have psychotic symptoms in a depressive episode.

  Dr. Wei Song: [00:19:09] So that's the main indications for depression. Of course, there are other indications as well, like bipolar depression, bipolar mania. I just had a patient who was refractory manic episodes, was in hospital for a good two months. And with multiple antipsychotics and mood stabilizing medications after three or four sessions of ECT, she showed dramatic improvement. So that's another indication. And then some other indications when I was the resident is about 30 years ago now and the we have seen some response with patients who have Parkinson's Disease and we treated actually the depression. The Parkinson's symptoms actually got better. And in literature, you see that new Neuroleptic Malignant Syndrome is one of the indications a few years ago there is emerging sort of evidence looking at treatment-resistant psychosis in schizophrenia patients, particularly patients who have partial or no response to Clozapine. And so we've seen some good results in those patients as well. So these are the major indications. And obviously, number one thing also is the patient preference as well. And some of the patients who can tolerate medications and neurostimulation may be one of the options.

  Arielle Geist: [00:20:45] Thank you.

  Dr. Wei Song: [00:20:46] I hope I answer your question.

  Arielle Geist: [00:20:47] You did. That was very helpful. And it's good to get a sense of what the indications are going forward in our training, thinking when we might want to recommend ECT. I'm also wondering what are some of the contraindications to ECT?

  Alex Raben: [00:21:04] I think it's really there's no absolutes, absolute contraindication that if somebody has got a brain tumour, sort of the space occupying lesion in the brain. So one has to be very careful and probably if you have a known aneurysm, you probably won't want to apply ECT because there is a transient increase in terms of intracranial pressure. Right. But, you know, you've got to be careful. What we do is we always have anaesthesia consult and particularly people with a complex medical comorbidities like cardiac and pulmonary and endocrine. So we want to make sure that those parameters are under control. For example, if somebody has uncontrolled hypertension and that's probably one of the things we need to do is really getting that out of control. I will walk you through about what we do in the ECT suite. And this morning for example, I was doing ECT and this patient's blood pressure was 220 over 100. Anaesthesiologist obviously said, well, you know, I'm going to give some asthma. And so we actually, in a very controlled environment, making sure that blood pressure is down to the acceptable level and then we proceed with the treatment. So I would say those are the space-occupying sort of lesions in the brain and aneurysms and some serious cardiac conditions. You know, that may be even a relative contraindication. I've done ECT on post-stroke post in my patients who are very, very ill and didn't respond to medications and very in within the first couple of months. Even with ICD or pacemakers, it's not a contraindication. Some sides will say, "Okay, let's turn off the ICD or pacemaker". And in my experience, actually, we don't even turn off the pacemaker and because it's really focal right in terms of stimulation to the brain.

  Arielle Geist: [00:23:28] Thank you. That's super helpful! And one of the other things we were wondering about, we did briefly touch on before you had talked about memory impairment, but we're wondering if you could go into a little more detail about some of the possible side effects of ECT?

  Dr. Wei Song: [00:23:45] Yeah, the main side effects actually are headaches, which is fairly common. And I think it's because despite the Paralympics, patients are well modified in terms of what we use in the colon or other muscle relaxant. But we when we do the electrode placement, usually straight to the your temple area. So you will induce whether you have paralysed sort of a major muscle groups or you induce your sort of a jaw clenching. And so that perhaps causes some headaches and maybe other reasons that cause headaches too. And a lot of times those can be mitigated as patients to take Tylenol before ECT at times we'll just give a IV pre-ECT and so on to mitigate that. A memory is another major one, but usually the first treatment, especially index treatment we use anywhere between 6 to 12 treatment sessions. And memory is not a major issue at all. As you know, when one is depressed cognition, there are three major sort of symptom domain, right? You have your emotional symptoms, you have your physical symptoms and you have your cognitive symptoms of depression and cognitive symptoms. Depression, usually a very profound and that's probably why when they do the studies for their acute ECT, even though patients may complain about memory problems and when you look at the results, actually there's not much of difference because depressed patients already have cognitive impairment.

  Dr. Wei Song: [00:25:34] Yeah. So I think, there is some truth about short-term memory and anterograde and retrograde memory problems, but it's not a major issue. You know, the times people have we have had patients may have had dental issues. So we have to be very careful and there's a bite block and making sure that you have the partial if it's secured or not. And those are just related to due diligence, really making sure that the patient's oral cavities sort of checks. Right. You know, some patients may have some nausea, but those can be mitigated as well. Anaesthesiology is of great thing doing that also with psychiatrist, we always communicate on an ongoing basis. Right. And some patients may need to take Ondansetron before or after ECT and that can be done as well. So in short, actually, the side effects is minimal. It's not that much.

  Arielle Geist: [00:26:46] Okay. Thank you. That's helpful to learn about. And I think kind of speaks back to some of the the myths that Randi was talking about earlier in the podcast. One of my last questions for you before I hand it back over to Jake is about some of the risks of ECT and if you could tell us what the risks are. When you say risks, you're talking about side effects or death or more. The second one, we're just kind of wondering about maybe what the mortality rate might be or when do you consider that?

  Dr. Wei Song: [00:27:25] I think the number one risk, what I see is that not the right indication. You've got to be very careful. You know, if it's not the right selection, because we actually do turn down when we do ECT consultations, not everybody comes for consultation, we'll get it right. So, you know, if it's not the right indication, primarily, for example, if somebody has a severe personality disorder and you're using ECT and the outcome is not that great. But you know, in terms of potential mortality, I have never seen a case of death and I've spoken with a lot of people across the country. I don't think anybody's seen that, that there is a theoretical risk of death. And I think the anaesthesia risk is about one in 70,000 because this is a general anaesthesia. Right. And I think there are some reports saying that maybe two per 100,000. So, it's more or less in line with the risk of an anaesthesia. If you select the right patients and you do the right medical screening and control the medical comorbidities, I don't think the risk is negligible, really.

  Arielle Geist: [00:28:53] Thank you. I'm going to hand it back over to Jake now to talk about the efficacy of it.

  Jake Johnston: [00:28:59] Yeah. Thanks, Ari. I know that you've already touched on it a little bit earlier in this episode, Dr. Song, but now that we've heard about how ECT works and why we should use it, can you please fill us in on how well it works? Let's start with its efficacy in major depression.

  Dr. Wei Song: [00:29:17] I think it's a very efficacious treatment and it's still the gold standard if any new treatment comes out and they always want to sort of compare it to ECT, right? So if you look at the literature, it's anywhere between 70 to 90%. Some of the older literature even higher, I think in part is because in the seventies there were not a lot of medications but ECT were the pre. One Flew Over the Cuckoo's Nest sort of a time it probably was used a lot more readily. I mean in the fifties actually ECT was the office procedure in New York because it was so popular. And so if one comes in depressed and you sign up for ECT, your chance of response is really high. And I think, more recent studies may not be as high priced because there is a lot of comorbidities. And sometimes you may miss the sort of a therapeutic window, as you know, that the index episode of depression. The longer it goes, longer it goes under treated or untreated, the longer it takes to get well to get into remission. So I suspect if you see the numbers like 70, 80 or 75, that's probably one of the reasons. But still it's probably still the most efficacious treatment compared to any other interventions for major depression.

  Jake Johnston: [00:30:56] Thank you. The fifties in New York sound like a wild time. The efficacy of ECT for major depression is quite impressive. Are there factors that can help predict whether or not a patient will respond to ECT treatment? You've already mentioned one of them that longer lengths of depressive episodes are associated with poorer response to ECT.

  Dr. Wei Song: [00:31:19] Now I mentioned about old age, right? So you see the geriatric psychiatry we use is a lot more is because there is more medical comorbidities and also the geriatric patients tend to have a poor response to medication treatments and so they actually tend to have better if you compare it to other treatments with ECT, the more severe the symptoms, including psychosis catatonia, the better the response to ECT. Nowadays, we call it endogenous depression, which is reactive and so on, but we don't differentiate that anymore. And essentially, if you have endogenous severe depression, catatonic features and psychotic features and the response to ECT usually is very predictable and the remarkable and I do want to mention, I did mention about personality disorder, it's probably more of a negative sort of predictor of a response to ECT if you have a severe personality disorder. That said, if somebody who has episodic depression along with personality disorder, it is still an indication to use ECT.

  Jake Johnston: [00:32:41] Okay. Thank you. That's a pretty remarkable takeaway point that the more severe depressive episode is, the better. It seems to work. We can't say that about many other treatments in medicine. So Dr. Song. Well, ECT is primarily used in the treatment resistant depression. You've mentioned it can also be used for other illnesses such as bipolar disorder or schizophrenia. Can you please comment on its efficacy in these other disorders?

  Dr. Wei Song: [00:33:09] Yes, I think a lot of our patients actually tend to be bipolar depression, as you will learn. Actually, bipolar depression probably is one of the most difficult to treat condition because there is always a worry about switching to mania and it's a very unpredictable in terms of response to treatment. We tend to use mood stabilising medications we tend to use. I mean, we only have, what, two or three medications that have official indication for bipolar depression. And if you look at the guidelines, it's like sort of a soup recipe for all different kind of medications and so on. It's very difficult to predict. So in that sense, I think bipolar depression, using these, it's probably even better choice because it's more predictable. It does have a similar response rate as compared to a unipolar depression. You're looking at about 70 to 80% response and efficacy. And then we touched base on the schizophrenia, right? So, this is probably more in the last ten years, ten, 15 years. And I think. 50, 60, 70 years ago institutionalised patients with catatonia, with psychosis, they tended to use ECT.

  Dr. Wei Song: [00:34:38] But since the the utilization of antipsychotics and also de-institutionalisation, I think it probably was not used as frequently for schizophrenia patients only in the last, I would say, 20 years. There is some literature suggesting, for example, a combination of Clozapine was a plus, ECT has shown some additive benefit and efficacy and this is probably a treatment algorithm for a lot of refractory psychosis program. You're looking at about between 40 to 50% sort of improvement in terms of response in that population. Still a lot of room to improve for sure. And my experience with that also is it tends to have more you going to actually go extra mile, so to speak, because for depression, we don't usually go beyond 12. If somebody is not responding right, but it predictably 80, 90% of the patients will respond after 6 to 9 sessions, some of them human response much earlier on. Whereas for schizophrenia, we tend to go beyond 12 and 24. A lot of times we see patients actually start to show response after 13, 14, 15 treatments. So that's a bit of a caveat there.

  Jake Johnston: [00:36:01] Thanks for that Dr. Song. It's good to know that in cases of severe schizophrenia, it often takes more treatments to see response. But patients and providers shouldn't lose hope because symptoms do often remit or improve after upwards of 15 or 16 treatments. Dr. Song you mentioned earlier this episode that one of your patients with refractory mania underwent ECT with good effect. Can you expand on the use and effectiveness of ECT for bipolar mania?

  Dr. Wei Song: [00:36:32] It's quite high in terms of success rate. The issue with refractory mania is obviously a consenting process, you know, and it's we don't usually do involuntary ECT but in life, if it's life-saving, we will have to get the patient's advocates and family members involved or substitute decision makers involved. But even that I think, we don't take it lightly to impose ECT as involuntary so that probably one of the barriers and also we know that with time with the treatment milieu reduced stimulation in the inpatient environment and that itself it's anti-manic. So we just don't know when that will happen. So this particular individual actually was a psychiatric nurse and she had good insight, but she was really manic but a good insight. So it's quite interesting and psychotic, but a good insight. So and it is I can't go on like this. And then we went on to get consent and after four or five treatments and she's done she actually we only did in total eight and she's out of the hospital. So she was in the hospital for two months before that. In other words, it's very efficacious, but it's not done as frequent as, say, depressed patients. Right.

  Jake Johnston: [00:38:13] Wonderful. Glad to hear that she had a good outcome in the end. So to wrap up this section on the efficacy of ECT for various psychiatric disorders, let's recap. The literature shows that ECT has a response rate of 70 to 90% in unipolar major depression, 70 to 80% in bipolar depression, 80% in bipolar mania, and approximately 50% in people with Clozapine-resistant schizophrenia. I'll pass the mic over to Alex now to go over our next learning objective.

  Alex Raben: [00:38:47] Yeah. Thanks, Jake. So I'm in charge of helping our audience understand how the actual procedure of act is performed or looks like this is a difficult thing for us to do over a podcast. Of course, it'd be nice to invite you guys to an ECT suite to see it in person, and I would encourage our listeners who have opportunities to certainly shadow people who are doing psychiatrists who are doing it. But Dr. Song, if we can put this challenge to you, because we've talked about how bits and pieces of how act is done, right? There's an anaesthesiologist, there's nurses, there's a psychiatrist, there's these electrodes that are placed on the temples. But maybe you could take us through like a chronological order of how this is actually performed, maybe with a patient who's starting to act for the first time.

  Dr. Wei Song: [00:39:42] Thank you, Alex. For those of you who didn't study in UBC, I mean, I've been involved with the undergrad curriculum for many years. ECT is a must see too. So we made sure that we actually developed a module for ECT. Jacob I've gone through that module and even it was an embedded video. And so for those of you listening to this podcast, I can walk you through. So once patients sign a consent or deem that it's life-saving, so basically through the consultation process and anaesthesia has done the consultation.

  Dr. Wei Song: [00:40:33] So we every setting is different. In Victoria the are of hospital. We do ECT in our PACU, the post-anaesthetic recovery room. We have a little ECT suite within the PACU. So the patient, the porter will take the patient in or patients of outpatients will come in and check in with our porter and then they get changed a lot of times. Some patients may not, and in summertime it doesn't really matter that much. But in wintertime, a lot of them just get changed into screw ups and downs, and then they will be comfortably lying on the stretcher and wheeled into the ECT suite. And then the nurse psychiatrist anaesthesiologist will greet the patient and really trying to make patients comfortable. Imagine the first time doing ECT. You have no idea what's going on and we tend to show some of the information, including videos. There are a number of good's sort of videos out there on YouTube, right from Australia, for example, and from the Duke and other universities. So we show the patients to give them a sort of a bit of comfort, this is what's going on. And then I'll explain. I usually make a joke and say, "well, I'm going to prep your scalp", right? Usually it's your foreheads. And so "I'm doing a facial for you this morning" and sort of put patients at ease and using basically wanting to make sure that patients will have a good sort of a conduction.

  Dr. Wei Song: [00:42:18] So the impedance minimize the impedance if you look at the physiology of sort of a physics of it. So by doing the skin prep and chatting with the patients, I will ask patients how they're feeling and so on and so forth to do a quick mental status while I'm doing that. And then we put the leads on and usually we're monitoring the EEG, EMG and EEG. We have a telemetry sort of monitoring and two sides and anaesthesiologists will establish IV while we're doing all the prep and some of the centres will use the paddles putting on the dependence by temporal or by frontal or unilateral in our sensor. Many years ago I thought to eliminate some of the variabilities, we use these thermal pads actually just stickers. And that actually I believe it's more consistency. So it's not really dependent on the practitioner's strength or how they sort of hold the paddles. So once that's done most of the time we do the by frontal as sort of starting point and then we determine the seizure threshold for the first treatment. So what happens is the anaesthesiologist will give anaesthetic. A lot of times we use Propofol. Sometimes patients if they have resistance or not having good seizure and they may use some other induction agents such as accommodate or Methotrexate, which are more difficult to come by because it's a special access drug.

  Dr. Wei Song: [00:44:12] So Propofol is probably standard across the country and then they use the suction and colon to as a muscle relaxant. And then we hyperventilate the patients and within minutes, patients are already anaesthetised and the muscle a minute or two. And then we apply the electric current. Missing is the only two types of machine that's approved by FDA and Health Canada. Right. So it was back to the other ones. So we have the time machine and we started with 10% sort of an energy and help to give it to somebody 50 and over over the younger it started 5%. So basically we're looking at the seizure threshold. Once we determine the seizure threshold and then we apply one and a half or two times of energy above the seizure threshold as a therapeutic sort of intervention. So we induce a seizure that probably takes about looking at 25 to 60 seconds, sometimes a bit longer, sometimes less. And we look at the seizure quality by looking at the tracing, looking at the EEG, the morphology, the symmetry, the cleanliness and the possible suppression. So the few things that we look at. I'm describing the whole seizure, but actually it goes very quickly. So after the patient complete the seizure and within a minute or two the patient wakes up and the anaesthesiologists will assist patients for recover.

  Dr. Wei Song: [00:46:07] The whole process probably takes about the actual treatment. Getting into the suite and getting out of the suite is about 10 minutes. Well, we can do six ECT in an hour or sometimes nine and a half to 2 hours. So sometimes in this morning we've got a little bit longer because one of the patients had a difficult to establish an IV. So that part is more of a sort of an issue in terms of time. It takes a long time, try to like 7 to 8 sort of access to establish IV. That was more of a time consuming. And then patient goes to recovery sites and usually within 20 to 30 minutes they get up and they go to have a we provide a tea and muffins. This is pretty covered, though, but now I don't think we actually can. And then they go home or the wheeled to the ward if they're inpatient. That's the walk, you know. Give you a visual if you can.

  Alex Raben: [00:47:12] That was amazing, Dr. Song. Thank you so much. You really painted a picture there of walking us through that. And yeah, I don't think people realise how fast this procedure is. I mean, even in the time we're talking, we spent talking today, multiple people could have been going through treatments.

  Jake Johnston: [00:47:29] But do the poor anaesthesiologist, they'll have time to do their Sudoku puzzles.

  Dr. Wei Song: [00:47:34] No, you don't have to check the stock markets us to do that. I think one of the things, though, it's very important to have a good relationship with anaesthesiologist because trying to have the optimal seat for the patient. We have to give the input. Because I talk to anaesthesiology on a regular basis as well. You know, we should probably reduce the Propofol or anaesthetic because I know I've seen it even by ten milligram reduction patients, seizure can be so much better. You know, you can just have this kind of discussions and and whether some patients need to have some other intervention to have a seizure and so on. And as a psychiatrist, I think it's important to be able to give the valuable input to anaesthesiology I you mentioned by temporal by frontal unilateral electrode placement.

  Alex Raben: [00:48:46] Could you take us through the differences there and why you would choose one or another? So I think there have been studies looking at these sort of electoral placement, whether looking at the efficacy versus certain side effects, particularly they're looking at cognitive side effects. So you want to minimize the cognitive side effects. There were a couple of studies sort of comparing head to head, so to speak, looking at the high temporal by frontal and and unilateral. I think if you look at unilateral, the the efficacy is more or less the same as compared to by frontal.

  Dr. Wei Song: [00:49:39] The difficulty was unilateral is you got to have a five or six times of a seizure threshold. And the most machines governed in such a way. We started with the point five, the pulse width, and that's the sort of a short pulse and 2.75 of one. So if you use unilateral what they describe as an ultra brief unilateral, so you have 0.25 pulse width. If my machine if patients set a seizure threshold, for example, is determined that this machine is 40% of my the machine that the output, that means I have to go. Hundreds. Worth 200% which is impossible because the machines 100% is 101 joules. And unless I sort of overwrite. So in other words, a lot of our patients we can't do unilateral because of the depending on the seizure threshold, giving our machine the limitation of the machine. And then if you look at the comparison, the probably the most I mean, it's very slight in terms of differences, in terms of side effects, but there are some differences. So the bitemporal tend to have probably more cognitive short-term memory problems as compared to unilateral and conversely bitemporal may have a bit higher efficacy compared to unilateral. So we chose actually by frontal as a sort of default to begin with.

  Dr. Wei Song: [00:51:30] Based on that, it's simple, it's easy. Perhaps it's in the middle in terms of the chance of having cognitive side effects and then they're looking at the established efficacy. But if patients is not improving, it's just like prescribing medication, right? We'll titrate the stimulus in terms of the how much of a current we were delivering. And then when we changed the electoral placement from by frontal to temporal, we may increase the pulse width as well, just like a titrating the dosage of antidepressant or antipsychotic in accordance of the response. So I'm hearing there that there are some maybe modest differences in terms of maybe by temporal being slightly more effective, but also possibly causing more cognitive side effects and sort of vice versa for unilateral by frontal, you mentioned this word called sweat, so maybe we should just briefly define that. What does that mean exactly? Well, I think the modern city machine versus the old the one I described the doctor selected in 1938. And I think those are a sine wave current. Right. That's as you see, it's not like a whole thing. Whereas modern ECT treatment essentially has these sort of abrupt sort of pulses of electricity, sort of more of a resembles the action potentials endogenous in our brain. So instead of a sine wave, you just have a spurt, right? And there is a frequency.

  Dr. Wei Song: [00:53:19] Basically how many pairs of pulses per second and versus the mini seconds. We use point five as a sort of a standard. Some people even even shorter, which becomes more of a ultra brief. 0.5 is a brief one is probably considered in the past, maybe more standard. And then obviously there's a currency of the amp. So all these actually parameters determine the current how much you gave to induce a seizure. I mean, in the end, we want to induce ultimate sort of a good seizure response. And then that can be measured by the EEG monitoring. And obviously, we also have to look at the patient sort of response in terms of a symptomatology.

  Alex Raben: [00:54:22] Thank you so much for taking us through that a concept that is definitely hard also to talk about without a visual. But we will link to a lot of those videos that you were describing and others that we find as well for our audience. One thing, this wasn't really a planned question, but I think it's something we didn't yet talk about. I just wanted to maybe and I think it's a good topic to wrap up on is we've talked about how effective ECT is, but we haven't really talked about the relapse that can happen post-treatment and how we can mitigate that. I mean, you did mention Dr. Song maintenance treatment, but what does that actually look like?

  Dr. Wei Song: [00:55:08] There's not a lot of studies on maintenance. I mean, there have been a couple of good studies. As you know, depression is a chronic illness and that is sort of episodic for a lot of our patients. So patients may respond very nicely to a course of treatment. But for patients who has severe depression or chronic depression, the relapse rate is quite high when you stop Ect. So in other words, you have to have a very good maintenance strategy. When I was in residency in the nineties actually, I remember looking at the American Psychiatric Association guidelines for ECT. They actually want you to stop mitigation when you do ECT, which is not the practice anymore. So we want to initiate if they're not on medication or we want to make sure that we plan to have an adequate medication for maintenance. So when we say adequate medication, we're talking about more standard. I know you guys use a Kellner Charles as a reference of who is an ECT guru. And he had led several sort of studies, including the maintenance study they use, for example, comparing maintenance these see versus. No trips. Plus Lithium or vaccine doses plus Lithium. So these are what we would say, very robust, potent and sort of maintenance strategies.

  Dr. Wei Song: [00:57:00] So maintenance versus medication, the relapse prevention seem fairly similar. But in reality, some of our patients, even with a potent medication, they still have to have a maintenance. What we usually determine that is if patients relapse and come back and do it again, then we would discuss about options. Obviously, you need to have to be on good medication regimen. For me, I would use something plus Lithium, that kind of a regiment or high doses of vaccine and so on, and then we'll taper ECT once they reach remission like once, once a week, times four weeks, and then every other week times four weeks, times four times, and then monthly. Sometimes in this kind of a process, patients know I can actually from every two weeks to one once a month, because by the third week, you know, I started having symptoms. So then we can sort of really titrate according to patients. So there is a sort of a whole range of sort of time frame for our maintenance program patients. Some patients I have patients who had ECT, one of our patients actually had a severe schizoaffective disorder, started having this when she was 14 years old. And she's 34 now and she's still on weekly ECT. Every time I try to space it, her psychosis just became so much worse. So that's extreme right weekly for decades.

  Dr. Wei Song: [00:58:48] Another is will do every four weeks and then after a year or two, some of our patients view stable is every a monthly for two, one or two years. And I try to space it to say five or six weeks. In my experience, once you're done, you can maintain wellness or your remission after five, six weeks space, probably you can stop ECT. I mean, the idea is always trying to wean people off ECT. Right. As I mentioned earlier on the to sort of if you have a permanent sort of a memory problems is because you have repeated ECT on an ongoing basis for years.

  Alex Raben: [00:59:31] Great! Thank you so much for taking us through that. So if I understand correctly, the relapse rates can be high and that's because depression is a chronic mental illness, as we know, and or it can be relapsing and remitting. But you have options in terms of medication as it maintenance usually Nortryptophan plus Lithium or Venlafaxine or maintenance ECT which is sort of this tapering schedule, as you described it. And you try to get to the kind of lowest frequency that keeps people well. But in reality, often those are not maybe not often, but they can be combined for people who benefit from them. So thank you so much for taking us through that. I'll hand back over to Jake.

  Jake Johnston: [01:00:18] Yeah. Thank you very much, Dr. Song, for taking us through. It's a large topic to cover, but you did an excellent job at conveying the salient points. Do you have any closing thoughts before we wrap up the episode?

  Alex Raben: [01:00:33] Well, I think this is a great opportunity. I'm so glad that you provided the opportunity for me to talk about this subjects and particularly for learners. And it's always amazing to see the learners who has never watched the ECT and exposed to ECT for the first time and realize, "Wow, this is what it is". Because a lot of times you have these pre-conceived notions then from media and from what you talked about. So, I think it's very important to demystify to really educate our learners, but hopefully, actually educate the public. Right? So this is actually a very effective treatment. It's not barbaric, it's scientific and it's safe and it should be available to anybody who wants it who is suitable for it.

  Jake Johnston: [01:01:39] Thanks again, Dr. Song, for joining us. That concludes our episode on Electroconvulsive Therapy. PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. They've used endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Jake Johnston, Arielle Geist, Randi Wong and Alex Raben. The audio editing was done by Jake Johnston. Our theme song is Working Solutions by All Live Music and special thanks to the incredible guest, Dr. Wei Song for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening!

Episode 33: Treating Borderline Personality Disorder with Dr. Robert Baskin and Dr. Ronald Fraser

PsychEd+Episode+33+-+Treating+Borderline+Personality+Disorder+with+Dr.+Robert+Biskin+and+Dr.+Ronald+Fraser.mp3: Audio automatically transcribed by Sonix

PsychEd+Episode+33+-+Treating+Borderline+Personality+Disorder+with+Dr.+Robert+Biskin+and+Dr.+Ronald+Fraser.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Dr. Sarah Hanafi (PGY3):
Welcome back to Psyched, the psychiatry podcast for medical Learners By medical learners.In this episode will actually continue exploring a topic that I'm certain remains of interest to many of our listeners. Borderline Personality Disorder. In the first part of this episode, we reviewed the diagnostic considerations of the gist of this disorder, and the second part of this episode will touch on management of borderline personality disorder.

Audrey Le (CC4):
During today's episode, we'll touch on several learning objectives. One understand the frame and principles of care for the treatment of individuals with borderline personality disorder or BPD. Two, to explore the approach to the treatment of individuals with BPD, including the presentation in crisis to the emergency department, the inpatient psychiatric admission, and finally the context of psychiatric outpatient care. Three understand the use of psychotherapy in the treatment of individuals with BPD, and four understand the use of pharmacotherapy in the treatment of individuals with BPD. Now let's get started.

Dr. Nima Nahiddi:
I think it would be a good idea to start off with describing the general principles of care for treatment of individuals with borderline personality disorder.

Dr. Ronald Fraser:
As Dr. Biskin mentioned sort of in the first podcast, there's a lot of different frames, a lot of different theoretical perspectives on the treatment of borderline personality disorder. I think the one thing that most have in common is that they're psychotherapies. So the most robust evidence for treatment of borderline personality disorders is psychotherapeutic rather than pharmacological and. You know, obviously they have other commonalities. But personally, Dr. Baskin may disagree about this. Personally, I think the thing that's most important is just having a frame, like just having a conceptual framework that that you have confidence in as a therapist. And from my perspective, it's always been important to me to be part of a team and that the team share the same basic conceptual framework. I think that provides a grounding which is particularly useful when situations get challenging or if there are clinical situations that are difficult for the team or for the individual or for the patient. I think having that framework to structure the work is very grounding for everybody involved. And for me, I think that's the the essential ingredient. I have no doubt that the various disciplines of various schools of thought would disagree with that, and they would say that, no, no, no, it's super important that you do X, Y, and Z. I'm not so convinced that that's true. Now, I'm biased because when I put together, along with a team, a framework for our program, we consciously decided to go with a trans theoretical approach where we basically stole components of all kinds of different schools of thought that we thought would best serve our patients. And and I think that has served us and served our patient population well.

Dr. Robert Biskin :
I would I would actually completely agree with what what Dr. Fraser said, that the framework and the structure is probably the most important part of treatment for people with BPD. It highlights one of the challenges in terms of treating people with BPD in an outpatient setting versus other settings. There's a lot more variability in teams and structures in both the emergency room and the inpatient units. So having a consistent team with the same theoretical framework, the same approach to treatment is is extremely important. There was an interesting paper actually a number of years ago that looked at many of the different specialised types of psychotherapy for people with BPD, and it highlighted that the use of a team, the use of a consistent theoretical model, consistent frame force for treatment, the use of psychotherapy and particularly obviously looked at psychotherapies and particularly the use of multiple different types of psychotherapies, often with different treaters providing different parts of the therapy are some of the elements that are really essential or consistent across many different many of these different theoretical models, many of these different specialised treatment programs, which again kind of highlights what Dr. Fraser was saying about how no matter what type of psychotherapy that you choose to employ, there's many different tools from different approaches that can kind of be brought in and are probably very useful for treatment of people with BPD so that those structural elements are probably extremely important. So that would be what I would focus on as primary principles.

Dr. Nima Nahiddi:
Can you discuss what you both mean by the idea of the therapeutic frame?

Dr. Robert Biskin :
So the the idea of the therapeutic frame incorporates a few different components, but it's often a very structured approach to the therapy with very clear therapeutic goals, therapeutic steps and therapeutic outcomes or consequences for different sorts of actions. So a lot of the types of treatment will have very specific types of therapy every week. So you'll have a number of different individual sessions or group therapy sessions every week. And oftentimes attendance at these sessions, at these appointments is very, very important. There's often a lot of specific rules that people might have about attendance, about showing up on time, about communicating with the treating team or indoor therapists in between sessions. But in addition to that, there's a more global framework as well in terms of identifying early on specific targets for the treatment. So this is, in my opinion, an area where focusing on functional outcomes actually becomes very important. Having that as an overarching goal, not necessarily the only goal, but one of the goals for for treatment, for example, being able to find a job or look into or be able to develop new friends or relationships as kind of overarching functional goals for therapy is another part of the framework. And finally, another essential component of framework is that therapy must end. And I do believe that having an endpoint that the patient is aware of from the beginning of therapy is one of the important steps for having this consistent approach, not only because it gives patients the chance to recognise when therapy is going to end and they must take those steps to work on their own and learn to trust themselves in the skills that they've developed on their own. But it's also necessary because otherwise we won't be able to continue providing treatment for new people if we're continuing with the same groups of people indefinitely.

Dr. Ronald Fraser:
Yeah, I think all of that is really, really key. I think the only other thing I would add is that there's also a secondary frame for the team itself. And, you know, both the teams that both Dr. Biskin and I belong to meet on a weekly basis that provides our own internal structure. And one of the things that we do is obviously we provide support, peer supervision, guidance. But also, you know, we have a place where we all feel safe enough to ask difficult questions and ask ourselves, what are we doing and why? But also, what are we not doing? And why. And those are really important questions for us to step back and reflect on, because we have to be accountable to the patient. We have to be accountable to the system. We have to be accountable to each other, and we have to be accountable to ourselves. And so there are two frameworks one, the clinical framework for the patient. And then secondarily, but equally important is a clinical team framework that we work with in.

Dr. Sarah Hanafi (PGY3):
So you've both touched on the emergency department as one of these areas where maintaining that frame is perhaps a little more challenging. And I know in the previous episode we talked about how patients can sometimes present in crisis in the emergency department. I'm wondering, can you walk us through an approach to the management of someone who's presenting with BPD in the emergency department and is in crisis.

Dr. Ronald Fraser:
So that can be. Theoretically easy and. Extremely difficult in reality. So one of the advantages that our teams have is team consistency. Emergency rooms sometimes have that where they have consistency of staffing, but most often they don't. So most often there are different psychiatrists on different shifts, different days with different ideas, which is all fine, but different nursing staff and different patient attendants and just different everything. And you can imagine that that doesn't necessarily lend itself to consistent messaging. And that can be problematic because the one thing that these patients do, all patients do well with is consistent messaging and not mixed messaging. So wherever possible. It's important to try to really communicate amongst ourselves within the emergency room of what the plan is. Why that's the plan, What's the rationale? What are the goals with complex patients that may present more often to the emergency room? Often we'll have case conferences with various stakeholders in terms of their outpatient care, their inpatient care, their emergency care, and try to put together treatment plans. So when a patient presents under such circumstances, this is going to be the consistent response. And obviously the patient is involved in that treatment plan so that there's no there's no surprises. And so they understand what the plan is and they understand what the rationale is. The rationale is to do no harm and to hopefully improve the situation. You know, ideally emergency room team sort of come up with consistent approaches of how they're going to manage these patients and how they're not going to manage these patients. So, you know, not using things that are punitive, not we don't have control over what other people do. So we don't have control over what patients do when they're in crisis. But we do have control over how we choose to respond. And that's what we need to focus on is our choices. And our reactions. I think that's really the key starting starting point for any patient that we see in the emergency room in crisis.

Dr. Robert Biskin :
I'll add a few other points as well. It's interesting because for my experience, the way that I work with patients who are in my clinic at the Jewish General Hospital, it's I have the I have the ability to provide care for them in whatever setting they come in. So if they're in active treatment with us, I will be the one who will go down and see them in the emergency room. I will see them when they're admitted on the inpatient unit and I'll follow them as well when they're discharged into the outpatient clinic. So it provides a lot of consistency in that context, but that's not feasible for people who don't have my job. So in general, the approach that I take for for patients the first time that they're coming or one of the first times that they're coming and presenting to the emergency room is I tend to take approach that gives people more time. So the assessments of the work often does end up taking a little bit longer. And I actually have a rather particular approach that I will use with these patients, oftentimes beginning with the interview similar to what Dr. Fraser described before, more emphasis on people's or in the previous podcast, more emphasis on people's personal history, understanding their context or situation. I'll give people a lot more time to talk and share a lot about their story. And during those times, I'll be looking for clues as to what's the stressor, what are the triggers for why they're presenting to the emergency room that particular day? Because sometimes it's very obvious there was a particular stressor problems at work, relationships, school, etc.. But sometimes people will come in and say that they've just been feeling unwell for a very long time and being able to identify what it is that was making today that much more difficult than the day before is is very useful and it's a source that are the ones that I identify that particular topic. I spend a fair bit of time validating and validating that the person is having a lot of difficulty, that they're doing their best to cope with the situation. They might not necessarily have the best coping skills at work over the long term, but again, to come back to that idea that they're trying their best. So a fair bit of time validating and oftentimes patients who are coming in to the emergency room have not had the opportunity to have these sorts of specialised types of therapies that Dr. Fraser and I are both able to provide. So I'll also talk to them about the the hope for change and see how motivated they are for something like a specialised type of psychotherapy that might be different than other treatments they've received before. I don't try to do psychotherapy in the emergency room. I'm not going to be trying to teach them skills because it's not the best time to do that. But emphasising that there is hope and there are things that can be done. I take a model that's similar to a school that you never had the chance to learn this before in the past, so you kind of need to sit down with the books and have a chance to learn it in a structured way to kind of catch up for the things that you've missed. It often, again, destigmatize a bit about the illness and. Helps people feel more comfortable with the idea of going for a therapy if they're not so comfortable with it before. So, yes, that's kind of the approach that I take. Again, it does take a little bit longer, but most of the time patients again, it often ends with disclosing and discussing the diagnosis. Most of the time patients are quite satisfied with that. They feel like they've been heard, they've been understood, and they're interested in treatment when they're eventually able to get it.

Dr. Sarah Hanafi (PGY3):
Thank you for that. So it sounds like in the emergency department, the stance is very supportive. I'm wondering, outside of the emergency department, can you touch more on these different specialised psychotherapies? It sounds like psychotherapy really is the mainstay of of treatment.

Dr. Robert Biskin :
it's worth mentioning at the very beginning that there's not really any evidence of superiority from one to another. So they're all probably equivalent in many ways. And it's possible that certain elements from one or slightly better than another, but it's minimal. As we talked about before, the frame is kind of a central component of these these specialised psychotherapies. But one of the ones that probably are the one that does have the most research behind it is specialised treatment called dialectical behaviour therapy, which is a variant or it developed out of cognitive behavioural therapy, specifically designed for people who have intense or chronic recurrent suicidality and a lot of self harm. So like many of the cognitive behavioural therapies, it emphasises a toolbox approach. So in DBT it's again a combination of individual and group therapy. In DBT, there's many, many different skills that are taught to patients depending on how you might read the book. There's about 30 or so core skills with a few hundred variants of all of those different skills. So it can often be overwhelming for people at the beginning, but emphasising that there's just a few core skills that people need to work on and develop is part of the treatment and the four main areas that the skills come in is mindfulness, which overlaps a lot with mentalization or sorry, mindfulness based CBT. I mean the ability to just be aware of what's going on inside you and ideally do so non-judgmentally. The second main area is emotion regulation, which kind of steals a lot of the ideas from cognitive behavioural therapy, such as thought records. In DBT, we would call it checking the facts. Opposite action often incorporates a lot of elements of exposure therapy from cognitive behavioural therapy, and there's a lot of activity or a lot of emphasis on kind of having pleasurable activities and developing skills and mastery and things in different parts of life. The third component in DBT is interpersonal effectiveness, which is a lot of skills about managing relationships. So both being assertive but also trying to learn how to validate other people when it's appropriate to or to set boundaries and establish or self respect, as well as managing conflicts and building new relationships as well. And the final component of DBT is what we call distress tolerance, which is a lot of crisis management skills. So distraction techniques, breathing exercises. And a huge component of this section is also radical acceptance, which is accepting things that cannot be changed, accepting things the way they are. And that's often a very challenging part for people in therapy. But the very core idea of DBT. So DBT is typically a therapy that's given over about a year and has been shown to be very effective, particularly for suicidality, self harm. And depending on how you read the literature, certain other elements of BPD as well. So that's the most common type of psychotherapy. But there's a number of others. So mentalization based treatment focuses on the capacity that somebody has to recognise the internal states of other people as well as themselves. So be it. Emotions, thoughts, impulses and the work in that sort of therapy is focused on practicing and developing that is built. It's kind of emphasise as a muscle that you continue to develop, to develop with treatment and it also includes individual and group therapy, other types of therapies such as transference, focus therapy, take a more psychoanalytic approach and focus on the relationship between the therapist and the patient and the expectations that the patient might have of the therapist. But this is just a few of the psychotherapies, and there's a good dozen more that I probably can't talk about in much detail because I don't know them enough.

Dr. Ronald Fraser:
I actually wanted to share a clinical point that has absolutely nothing to do with your question, but popped into my head as I was listening to Dr. Biskin, and it's related to actually to diagnosis. So oftentimes one of the reasons I see people who have never been diagnosed with BPD that have BPD is because they lack one of the nine criteria. And if they happen to be an individual that has never had a past suicide attempt, does not engage in self harm. For some people, for some reason, clinicians feel that this is an essential component of BPD, and if you don't have that, then it's like exclusion criteria. But there's up to 20% of patients with BPD actually don't don't have that criteria. So often these patients will not get picked up and not get identified as having borderline personality or even if maybe they have eight, all eight of the other criteria. So I think that's actually an important point for learners and for trainees to realise that just just because of the absence of suicidality and self harm, that doesn't necessarily mean that this individual may not have borderline personality disorder.

Dr. Sarah Hanafi (PGY3):
Thanks for that clinical pearl, Dr. Fraser. So I wanted to go back to the topic of therapy after that. So bouncing off of the discussion that we've just had about psychotherapy. Could you maybe discuss the role of pharmacotherapy in treatment for these patients, for example, in in terms of how different medications can be used to target the different symptoms that we may commonly see them present with?

Dr. Ronald Fraser:
So this is actually. Probably one of the areas of greater controversy. If you look at the treatment guidelines that come out of, say, the U.K. and compare and contrast treatment guidelines that come out of North America with the APA, there's tremendous differences of opinion on the role of medications. There certainly can be a role. I think everybody agrees that there could be a role for medications. There's no medication that has an indication or treatment of any personality disorder. So they're all used off label. Often the approach is symptom focused. So for example, there are certain medications that one might use for impulsivity. Other medications that people or the exact same medications that people might use for mood stabilization or for anxiety or for insomnia. There's another whole set of medications, obviously, that might be indicated for comorbid conditions, and those have much more robust evidence. One of the things that's always sort of of concern and, you know, I've seen hundreds of patients and so I've seen patients on zero medications and I've seen patients on 12 different medications. And there isn't necessarily much in the way of clinical differences in terms of their outcome. And there's other patients know, you give them one medication and they really find that it makes an a profound impact on one domain. So perhaps there's a diminishing of their anxiety, and that really makes a significant difference in their quality of life. But the main concern that we often have as clinicians is that we see polypharmacy where there's one medication added and maybe there's a little bit of benefit, but it's not certain. And so then another one is added maybe targeting a different symptom or trying to augment the first medication. Very seldom medications are taken away and then gradually over time, you get you find a situation where you're on a 10 to 12 different medications, including medications to treat the side effects of the original medications. You're not entirely sure how the heck we got here, and you're certainly not sure how are we going to get out of here? So you don't like today? I had a follow up appointment with patients, which of course was done virtually because we're in the middle of a pandemic. She joined our program in January, and since she arrived in January, we've been gradually trying to clean up her pharmacotherapy. She's been since let's we're September, so that's nine months. So in nine months we've taken away one at a time. And so she's been taken off lithium. Let's see. So when she started, she was on three mood stabilisers. One of which was lithium, two antipsychotics, two antidepressants, two sleep aids. And so we've removed lithium. Epival, Emmavain, regular Seroquel, Seroquel, XR and Zoloft and Wellbutrin. And her clinical condition is no different, except she has a lot less side effects. So it's complicated and every patient is different. Some patients have a significant response. Very rarely is there like symptom remission. So if you're treating anxiety, it's very rare that they're going to describe, you know what, I'm no longer anxious. I don't have any anxiety. But their anxiety might go from 10 to 8 or 8 to 6, and that may be clinically significant. Even though you don't have remission of the particular symptom, you may have taken enough of the edge off that it makes a difference in their quality of life and perhaps allows greater functioning.

Dr. Robert Biskin :
My opinions about pharmacotherapy are probably a little stronger than Dr. Fraser's. I'm not particularly fond of pharmacotherapy for patients with BPD, and there's evidence that the medications themselves are of generally limited value. And when you look at the literature, the research, the better quality of the study is, the less likely it is to show any benefit over placebo. And this has been shown now with a number of different agents, Zyprexa, Lamotrigine or two that come to mind with recent examples. So I'm skeptical of most of the medications because again, these are most of the medications we use in psychiatry do have a substantial side effect burden. And as well, one of the things that I'm always concerned about is toxicity. So I'm highly concerned about people who are, for example, on mood stabilizers and things like that where the risk, if they overdose on it is quite profound. So I'm very reluctant to prescribe these medications and will often do prescribe medications as well. I tend to if in situations where, for example, anxiety or things like that Are Significant, depressive symptoms are really getting in the way. I occasionally do prescribe medications more than occasionally. Sometimes we'll prescribe medications, but often it is ones that are lower risk, less side effect burden as well. And interestingly, there's been one study that showed that when you prescribe medications for depressive symptoms with people who are actually in the program, the people who receive medications actually did worse. Which is fascinating. And it interestingly fits with my clinical opinion perspective as well in that sometimes people wish or hope for the medications to be the solution because it seems easier to take a pill than it does to do therapy because therapy involves a lot of hard work, whereas the pill, the side effects are not immediate. You're not going to feel anything immediately after taking it. So they might prioritise taking medications as solutions as opposed to therapy. So sometimes emphasising medications too much or people focusing on medications too much lessens their focus on actually making the necessary therapeutic changes and committing themselves to the to the process of psychotherapy. So again, I do use medications on occasion, again, lower typically lower risk medications and again, always monotherapy stopping the medications if they're not effective, sometimes medications for sleep as well, but more or less, less frequently.

Dr. Ronald Fraser:
Yeah, I wanted to actually emphasise this point because I think it's really key in Western society. We have a real love affair with medications and we have this sort of belief that we should never feel any physical or psychological discomfort and if we do, there should be a pill for that. And. As Dr. Biskin points out, it can actually prevent people from engaging fully in the therapy because of their never ending quest for just the right medication or just the right combination of medications. People's belief that there's got to be some medication or combination of medications, and we just haven't hit it yet. And that's going to resolve. All my distress can can really be quite remarkable and it can be very difficult, despite providing tremendous psychoeducation, that that's unlikely to happen. We know from the literature that medication is not likely to be that beneficial. And we know from the literature what is likely to be beneficial is psychotherapy, which sadly is a heck of a lot of hard work. And I think that it can't be emphasised enough but dynamic.

Dr. Robert Biskin :
In my opinion, it often comes back to this idea about trying to the self and validation that people have learned that they're not supposed to feel things, so they will seek out whatever it might be, including prescribed medications, if they're feeling sadness, if they're feeling anxiety, to do whatever they can to make those feelings go away. Many of the patients that I've worked with have said that they wish that they could turn off their feelings if possible, but that's not actually possible in psychotherapy. It's a very clear point that you have to live with your feelings. You have to learn how to cope with them and how to be with them instead of trying to make them go away.

Dr. Ronald Fraser:
Which, of course, is what leads so many patients with borderline personality disorder to develop substance use disorders because there's no more effective short term solution to negative affective straights than intoxication. Unfortunately, it's a spectacularly poor long term solution, but it's the same principles.

Dr. Sarah Hanafi (PGY3):
I actually wanted to address something that you had briefly mentioned earlier, Dr. Fraser, in regards to comorbid disorders. How do you approach treating comorbid disorders in this patient population?

Dr. Ronald Fraser:
So my perspective on this has actually changed over the. Decade and a half. And so this is more personal opinion than anything else. So I think we should have that caveat early on in my career. Saw tons and tons and tons of co-morbidities. Now more and more I conceptualise things as really it's part and parcel of the personality disorder and that really is what needs the focus of attention. There are some exceptions to that. So occasionally I have that conceptualization and then I see them, a year into treatment and they're fluidly manic. And I say, okay, we missed that. That's what's pretty clear that they have bipolar disorder, and that happens about once every 75 patients or something like that. I think the most prevalent comorbidity that I see is substance use disorders. And despite being an addiction psychiatrist, we don't do a great job of treating that. We're not even though we recognise it, we see it. I really wish we did a better job of that. I think the next most prevalent thing that I see is probably things in the eating disorder spectrum. A lot, a lot of very clear comorbidities there. Oftentimes patients we struggle with, we'll refer to the eating disorders program, patients that they struggle with, they'll send to us. And sometimes we have success with theirs and they have success with ours. Different interventions and perspectives resonate with different patients. Anxiety and mood disorders are described as very prevalent comorbidities, but I'm less and less convinced of that as as my career goes on, to be perfectly honest, that I don't think I see it. And I may be seeing a bias sample. And then, of course, trauma related disorders are quite common because unfortunately, many of these patients have had very difficult backgrounds, some of which are just literally horrific. And and often it would be shocking if they didn't have a trauma related disorder, given their experiences. So I think those are the sorts of things you see. The good news is, is that many of the treatments for borderline personality disorders, many of the psychotherapies, also have a certain amount of effectiveness for other things. So if you are suffering from a substance use disorder or trauma related disorder, distress tolerance is a super useful skill, right? If you're suffering from different disorders, usually they're impacting on your interpersonal functioning. So improving that is tremendously helpful. So you don't necessarily have to change the interventions regardless of the comorbidities. But I do think you need to be aware of them. You need to be cognisant of them, and that may sometimes inform your pharmacotherapy in particular.

Dr. Robert Biskin :
I would. I definitely agree with what everything that Dr. Fraser has said and I'm also of the mindset and perhaps slightly controversially so that a lot of the mood disorder symptoms, the depressive symptoms, the anxiety symptoms are often manifestations or components of the person of BPD as part of those difficult or dysphoric states. The comorbidities that are the ones that are most concerning and will lead to changes of treatment really are the substance use disorders, particularly if more severe. And it's that point that I'll refer people to Dr. Fraser, but as well the people with the severe eating disorders and I've seen quite a number of cases of people who once, for example, when they have an anorexia and once the anorexia becomes quite impairing and consuming of somebody's life, it's very hard to pull back from that without the structure and specialised support that eating disorder programs are able to provide. Other disorders. I've had patients in my clinics who often younger patients who at a certain point will have psychotic episodes that will persist for time. And at that point, clearly we have to revise the diagnosis to a psychotic disorder or something like schizophrenia, which dramatically changes the treatment approach. But for many of the more garden variety mood or anxiety disorders, I completely agree that treatment for BPD, whatever that treatment might be, is shown to be efficacious. People's symptoms of depression, anxiety with specialised psychotherapies will reduce will improve as well.

Dr. Ronald Fraser:
I just want to add one last point, because I think this is actually Dr. Biskin touched on an important point, that it's important to contextualize for learners about the controversial aspect of these things and that I think you figured out by now that what we say is not necessarily gospel. So you can have the same patients who Dr. Biskin and I might clearly conceptualise as having borderline personality disorder. And you could have one of our very respected and revered colleagues in a mood disorder clinic who would say, Look, Fraser doesn't know what he's talking about. This is clearly bipolar spectrum disorder. And you know, it's not clear that I'm right and they're wrong or vice versa. And I think that's where it's really important for learners to decide for themselves what makes sense for them, what they think is going on, and recognising that everything you hear from me and Dr. Baskin consciously or unconsciously, has a certain bias based on our training, our background, our experience, all of those factors. And if you had two other people here with different background training and experience, you might get very different answers that might be equally or even more valid than what we're sharing.

Dr. Sarah Hanafi (PGY3):
I'm really enjoying this this discussion. I think it's bringing up some really interesting points. I actually wanted to circle back to something you had mentioned, Dr. Biskin, about safety risk. Briefly, I was wondering, can you just talk about how you approach managing safety in this patient population?

Dr. Robert Biskin :
Boy, that's not an easy question. Much like Dr. Fraser is mentioning about different diagnostic approaches and different diagnostic thresholds. I would say the same applies for thresholds, for accepting risk, because you'll get many different answers for many different people. I would most clearly say that I accept a higher threshold of risk, fortunately or unfortunately, than many of my colleagues who don't work with this population. And it's something that is a particularly tricky question to answer. And I guess, as I pointed out before, for learners, it's something that you would be very careful to discuss with whoever it is that you're working with as time goes on, because you'll get very different perspectives. My particular approach or understanding is that people with BPD, they suffer a lot. And the idea of suicide, because I'm assuming that's mostly what we're talking about. The idea of suicide is something that's pretty much constantly present because it's the escape hatch. If there's a lot of pain in their life and they're doing everything they can to control it and it's just not working, it's sometimes reassuring. Your comforting to know that suicide is there as a backup option, which is very both comforting for patients sometimes when they're thinking about that and also terrifying for them as well, because many times that's not the path that they want to take unless it's absolutely necessary. So accepting the risk that there might be, which is a chronic risk, but people working with this population or in general mental health problems, that accepting that suicide might be a risk is part of the treatment. And it's one of the challenges with when you're deciding what to do with somebody who's presenting in the emergency room. It makes it very challenging because what we know that reduces that suicidality is specialised therapies that exist as on the outside. We don't really have evidence that hospitalization and the treatments provided in a general psychiatric inpatient unit are able to reduce suicide in the same way or suicidality in the same way that the outpatient psychotherapies are. So it's a very difficult question to answer.

Dr. Ronald Fraser:
So one of the things I would add is that, you know, if you don't want to have a patient die, you probably shouldn't go into health care because it's unfortunately an occupational hazard. Our job is, wherever possible to minimize the prevalence of that. But certain populations have higher risks than others. At certain populations are more unpredictable than others not. You have to have a certain tolerance of uncertainty and a certain tolerance of risk to work with this particular population. And not everybody has the temperament or disposition for that, which is fine. I don't have the temperament or disposition to work with other patient populations. I think it's super important to try to differentiate between chronic risk and acute risk. So, you know, I have patients that are, you know, are thinking about suicide every single day. And and as Dr. Biscuit points out. That can be perversely comforting because it actually gives them a sense of one thing in their life that they have control over. I can choose to kill myself or I can choose to not kill myself. I have control over that. I may not have to feel like I have control over anything else. And one of the rewarding things is that as people respond to therapy, you know, often with tears in their eyes, they'll say, you know, I haven't thought about end of my life in months. It used to be my daily companion. So that actually does respond to therapy, as he pointed out. But then there can be acute risk on top of the chronic. And that's where you sort of have to be cognisant of picking that up. And so particularly in acute crises, often if there's a loss of a significant relationship because relationships are so important to people in general and this population in particular. So the the loss of a therapist, whether it's through the end of therapy or if they've had the misfortune them, I've had patients with their therapists have died. So that's difficult or they've been kicked out of the therapy for whatever reason, or there's been a loss of a loved one or a relationship or a pet if there's been some other acute stressor. If you see in your patient that there's a profound clinical change, it helps if you know the patient really well. It's like, okay, this is like they're really disorganised or they're really struggling or they're really like severely dissociating or severely regressed. There's something acute going on here that's that is alarming. Then you're concerned that their chronic risk of suicide may have escalated acutely and you may need to make significant differences in your treatment plan in terms of brief containment and a brief intervention unit or a very short admission until that acute situation stabilises itself. And you may still discharge them with suicidality, but it will be back to their chronic state, not the acute state.

Dr. Nima Nahiddi:
And so to finish off and building on our discussion, which we started in the diagnostic episode. Can you both speak on stigma and Treatment of patients with borderline personality disorder?

Dr. Ronald Fraser:
So that's a big thing and it's less of a thing than when I started. So we're making headway. We've got a long way to go. But when I started the idea that there would be groups for loved ones and concerned others, for people suffering from a borderline personality disorder, like there's a whole network in Ontario of these things. We have Quebec here in Montreal, like the fact that there would that these would even exist was like unheard of. So we're still making headway. There's been a lot of education in the media that didn't use to exist. There's still a lot of bad information out there, as Dr. Biskin touched on in the last session. So the Internet transformed the world. But it's not all positive. And there's a lot of really. Misinformation. Know, I think that's sort of a buzz word for 2020 is misinformation. And so it's really important to try to direct our patients to reliable sources of information. For me, the National Education Alliance for Borderline Personality Disorder is a web resource that I often direct patients and families to. There's a lot of Biblio therapy that I direct people to. So you try to explain that there's just like everything else, the world is good and bad information. But the biggest challenge is, I think, still. Is stigmatization within the health care network. So the reception these patients get when they go to the emergency room. Is often far less than ideal. And many of my patients are smart people and they started to figure out I get a much better perception or reception story if I tell them I have schizophrenia or bipolar disorder, or I tell them I'm having auditory hallucinations. They sort of learn because it's aversive. To present with borderline personality disorder. And I've had patients that have engaged in self-injurious behaviour and they need sutures like that's the medically indicated treatment. And and the emergency room physician will say, you know, if you like pain so much, maybe I shouldn't give you any lidocaine or any anaesthetic or The emergency room physician who have a very difficult job, don't get me wrong, but it's very frustrated and says, you know, I should teach you to try sutures so that you can just suture yourself. How you can do one handed sutures, I'm not sure. But anyway, so they get abysmal Treatment Often when when they interact with the health care system, that really wouldn't be acceptable for any other human being, let alone any other diagnosis. So where we need to make the most progress is around reducing stigmatization within our own health care networks. And one of the ways we do that, which has also been quite fruitful, is through conferences and education and podcasts like this. You know, there's probably, I don't know, 86 people other than my father that are going to watch this podcast, but they will learn something from it. And these things make a difference over time. Maybe underestimated the numbers.

Dr. Sarah Hanafi (PGY3):
We we have more listeners than that, but.

Dr. Robert Biskin :
So to add to to what Dr. Fraser was saying. I do agree that the health care system is one of the sources of a lot of stigma. And I do think that one of the things that has changed and has helped improve the amount of stigma, particularly within mental health care, is greater accessibility to these specialised treatments. So the programs that Dr. Fraser have established and that Dr. Paris have established here in Montreal has helped people change their perspective and seeing that the beliefs that they have about these these disorders are not necessarily accurate. And unfortunately, not every region, not every city has access to programs like we do. Obviously, I think they should. And I think that both education information and advocating for increasing services and increasing recognition of the disorder is something that will help. And this is where I get concerned about people who might label BPD as another psychiatric disorder, such as the comment that Dr. Fraser made last time about the overlap between criteria with complex PTSD and borderline personality disorder, that one of the potential outcomes of that is that it might further stigmatise borderline personality disorder that might think of it as the unwanted illness, even though the symptoms are almost exactly the same. So further awareness and access to the disorder and to the treatments for it, I think is something that over time will help improve the perception within the health care system as well.

Dr. Nima Nahiddi:
A huge thank you to both of you, Dr. Biskin and Dr. Fraser. I certainly learned a lot myself. Do you have any closing remarks for our listeners?

Dr. Ronald Fraser:
Well, I think we both are really appreciative that you invited us. Obviously, hopefully it came through that this is a topic that we're both pretty passionate about. We've chosen to devote our careers to this and any opportunity we get to sort of share the gospel, we're really tremendously appreciative to have the opportunity. So thank you for expressing an interest in it and having it as a topic in your podcast series. And thank you for inviting us. We really appreciate it.

Dr. Robert Biskin :
Thank you very much for inviting us. Definitely something that is not just passionate for us, but something that we genuinely enjoy as well. So any chance that we get to talk about it and to kind of share some of that, that enjoyment that we have with working with these sorts of problems and people with these sorts of problems, we're thrilled to do it.

Dr. Nima Nahiddi:
Thank you both once again.

Dr. Sarah Hanafi (PGY3):
Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sarah Hanafi, Dr. Nima Nahiddi and Audrey Le. Audio Editing by Audrey Le. Our theme song is Working Solutions by all live music. A special thanks to the incredible guest, Dr. Robert Biskin and Dr. Ronald Fraser for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at Select Podcast. Org. Thank you so much for listening.

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