Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners.
This episode covers Schizophrenia, with guest speakers Dr. Jason Joannou and Dr. Andy Lustig from the CAMH inpatient psychiatry unit.
In this episode we discuss schizophrenia, with the following objectives:
The DSM V diagnostic criteria of schizophrenia
The impact of the disease and its trajectory
The differential diagnosis of schizophrenia
Clinical approach to patients with schizophrenia
The Mental Health Act and involuntary admission
By the end of this episode, the listener will be able to…
Know the DSM V diagnostic criteria of schizophrenia and specific manifestations of the disease
Know some of the epidemiology, triggers and impact of the disease
Know the differential diagnosis of schizophrenia and its subtypes
Know how to elicit a good history and how to approach patients with schizophrenia
Know the Mental Health Act and the legalities around forming a patient with schizophrenia.
The perspectives we have elicited in this episode are from inpatient psychiatrists who generally tend to see more severe cases of schizophrenia.
CPA Note: The content of this podcast are created for medical Learners by medical learners. The views expressed in this podcast do not necessarily reflect those of the Canadian Psychiatric Association.
For more PsychEd, follow us on Twitter @psychedpodcast, and subscribe to us at our website: psychedpodcast.org.
Episode+5+Treatment+of+Schizophrenia+with+Dr.+Andrew+Lustig+and+Dr.+Jason+Joannou.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.
Speaker1:
Great. Okay. Let's get started.
Lucy Chen:
Hey there, psychEd podcast listeners. I'm Lucy Chen.
Carrol Zhou:
And I'm Carrol Joe.
Lucy Chen:
Today we're going to explore the complexities of recognising and diagnosing schizophrenia and hopefully simplify the content to enhance our understanding of the disorder.
Carrol Zhou:
So we have a few objectives for this episode.
Lucy Chen:
So first objective is knowing the diagnostic criteria of schizophrenia and specific manifestations of the disease.
Carrol Zhou:
We also want to know the epidemiology, the triggers for the disease, the impact of the disease and its trajectory.
Lucy Chen:
We want to know the differential diagnosis with schizophrenia and its subtypes.
Carrol Zhou:
We also want to know the Mental Health Act and the legalities around forming someone with schizophrenia.
Lucy Chen:
We want to know how to elicit a good history and how to approach patients with schizophrenia as well. So to help us achieve this understanding, I'm joined by two inpatient psychiatrists, Dr. Andrew Lustig and Dr. Jason Joannou, based at Chem H in Toronto. Thanks so much for taking the time to help us delve into the world of schizophrenia.
Dr. Andrew Lustig:
You're welcome. Thank you for having us. All right.
Lucy Chen:
So perhaps you guys can tell us a bit about yourselves and how you found yourself in the kind of work that frequently involves caring for people with schizophrenia.
Dr. Andrew Lustig:
Okay. Yeah. So when I went to medical school, I did not envision a future for myself in psychiatry. I was like, really into, like the physical sciences and kind of like, I guess what they're calling a positive epistemology now. And so I, I undertook training in other specialities before psychiatry. I did some time in internal medicine and in radiology. And while those are, you know, really exciting specialities, I found the narrative to be a little thin in both of them. And no disrespect to my colleagues, of course. And the thing I found really fascinating about psychiatry is that it gives you a chance to really get to know people and to hear about their stories in like an infinite amount of detail and to talk to them about it. So I found that really exciting and that really drew me to psychiatry.
Lucy Chen:
Great. Thanks.
Dr. Jason Joannou:
Somewhat similar to Dr. Lustig, I was into Psych Keener. I think when you go into residency, there's the divide between the people who are born to be psychiatrists who have been working at it since they were in diapers to people who just kind of stumble across it. And definitely one of those people stumbled across it. Definitely wanted to do internal medicine. And I like the kind of reading about it, the science of learning about it. But the actual practice, I found a little mundane. And then I met a girl that's most good stories go yada, yada, yada. We're married with two kids now and she's a psychiatrist as well. But she really kind of introduced me to psychiatry, and I've been doing that since.
Lucy Chen:
That's great. It's nice to get a picture of how people do this kind of work. Yeah. So let's jump into this. Diagnosing schizophrenia.
Carrol Zhou:
So schizophrenia affects about one in 100 or 1% of the population. Different sources will vary, but that's something that you can quote to a patient that's easy to remember. First of all, how do we diagnose schizophrenia? Well, in order to. You need to know the five big categories of symptoms.
Lucy Chen:
One.
Carrol Zhou:
Delusions or fixed false beliefs about something. Two hallucinations, which are things like you're seeing or hearing or smelling that are actually not there. Three disorganised speech where, you know, basically your words are jumbled up and they don't make sense. And at the, at its worst, like kind of right now it can be called a word salad where essentially you say words that don't usually connect together and don't make any sense, four disorganised or catatonic behaviour, which includes a variety of different bizarre behaviours. Five negative symptoms, which essentially is regular human experiences that individuals with schizophrenia lack, like lack of motivation, lack of enjoyment and activities which you'll hear us talking about in a little bit. In order to diagnose someone with schizophrenia, you would need at least two of these five symptoms, and at least one of them must be either hallucinations, delusions or disorganised speech. In terms of the timeline, you need to have symptoms for at least six months. Of course, in psychiatry we always say it has to affect you socially in work, play relationships, that kind of thing, for a significant amount of time, for it to meet diagnostic criteria for a disorder, and it can't be attributable to another condition. And there are many conditions that can mimic this, as we'll talk about in a bit.
Lucy Chen:
It's a severe mental illness and it affects the way patients think, process emotions, maintain relationships and make decisions. When people think of schizophrenia, they might picture Russell Crowe in A Beautiful Mind or maybe Edward Norton and Brad Pitt in Fight Club with bizarre, twisted delusions, or maybe the imagery of homeless women at Dundas Square whispering to herself and pacing in the corner. These manifestations what we call the positive symptoms of schizophrenia. So basically hallucinations and delusions. There's also a constellation of negative symptoms and cognitive symptoms that we don't typically think about. What is like someone with severe schizophrenia? Negative symptoms like what? What does that typically look like?
Dr. Andrew Lustig:
Well, I guess in terms of like what they call the negative symptoms, they talk about things like alogia, which means, you know, speaking less than usual and energy of having less energy than usual and affective flattening. So essentially, for people who have negative symptoms of schizophrenia, they find it, I think, more difficult or are less likely to engage in the kind of social interaction activity that people without schizophrenia do. So, for example, they would find it more difficult to like get up at a certain time, kind of get showered, get clean, get ready for the day, prepare breakfast, pack your bags, make lunch and get out the door to get to, like, say, a job or school on time. And then if they were, say, in school, they might find it more difficult to engage with other students, to kind of actively listen and take notes and take the required complex steps to kind of succeed at the tasks that they're engaged in.
Lucy Chen:
I have a question for you guys. In the context of you working in the inpatient with inpatient population and kind of seeing more extreme sort of manifestations of psychosis and schizophrenia and kind of what that looks like or maybe even like what catatonia could look like.
Dr. Andrew Lustig:
Catatonia is is rare in schizophrenia now, and I've really only seen like a handful of times having seen in schizophrenia, although I understand it was pretty common like a hundred years ago. And I understand it's something of a conundrum as to why its its commonality has decreased so much. But, you know, when people are catatonic, they'll they'll either like not move at all for extended periods of time or engage in what we would regard as like purposeless movements, like holding kind of like a strange posture for hours on end or just engaging in some repetitive movement that doesn't really have an obvious function for a long period of time.
Lucy Chen:
I'm thinking about also students who kind of might manifest like symptoms of poor concentration, poor memory, and I'm kind of wondering about more of the cognitive symptoms associated with schizophrenia.
Dr. Jason Joannou:
So definitely, I think some of the cognitive symptoms get overlooked when we're teaching schizophrenia to medical students or even residents or even when you're doing your assessment. But they can be really impactful for the actual patients and families who have to deal with them. So some things that we do know are, you know, processing speeds, things that fancy words like Bradyphrenia just means your brain is working slower than usual. So you can actually do the task. It just requires a lot more energy and attention and it doesn't allow you to kind of like multitask as well because you're just focusing so hard on something that other people might otherwise be able to do with a lot less intent. Other things are kind of like facial recognition. So, you know, people who have suffered from schizophrenia are known to have more difficulty discerning between emotions on people's faces. So you can see how that could even play into like things like paranoia, right? If you can't read somebody's face. Right. You think they're there, have some sort of malintent or you're just not quite sure what's going on. And then your brain's already in a paranoid fashion, perhaps from your kind of positive symptoms of schizophrenia, and they kind of interplay that way. So definitely it's important to kind of think about these cognitive symptoms as well.
Carrol Zhou:
When people are in an acute episode of psychosis and schizophrenia, they actually score lower on cognitive testing during the acute phase and then somehow recover after. Or after treatment?
Dr. Andrew Lustig:
Yeah, definitely. Like cognitive structured cognitive testing while most often employed to detect, you know, cognitive impairment from like dementia, you know, requires, you know, focusing on a task and engaging in kind of various cognitive operations. And if somebody is, you know, either if they're disorganised or if they're distracted by by internal stimuli or if they're, say, very frightened or very distrustful, then you would expect them to score lower on a structured cognitive test for sure. Now it's recorded.
Lucy Chen:
So we're only on the cusp of understanding what's going on at a neurophysiological level in schizophrenia. At this point, what we do know is that there's evidence that it is a neural developmental illness, meaning there's numerous brain anomalies and abnormalities that explain some of the manifestations of schizophrenia. By the time a patient presents with the first episode of psychosis, they already have bigger ventricles and decreased grey matter. And like Dr. Lustig was saying, they may score lower on cognitive testing because of these structural abnormalities. And in keeping with the thought that this is a neurodevelopmental disorder, children that later develop schizophrenia frequently have more social and cognitive deficits in childhood. It's also important to note that schizophrenia also tends to be associated with something called a prodromal period. So this is characterized by brief psychotic experiences and a bit of social withdrawal, and it can actually kind of appear like a depression for a few months or even years prior to the manifestation of the first episode of psychosis. So we're really getting a sense of like the heterogeneous kind of manifestations of schizophrenia and that it is quite a spectrum of presentations. And, you know, there's a clear genetic predisposition to schizophrenia and there are really triggers and neural insults that can tip a person over and and and trigger the disorder. We're commonly seeing a lot of psychosis emerging and youth with cannabis use. And we're curious about your understanding or what you can speak to about the influence of marijuana use and the risk of schizophrenia.
Dr. Andrew Lustig:
Yeah, well, I mean, I think it's a somewhat controversial topic and I think the jury is still out. But as I understand it, cannabis is not thought exactly to have a causative role in the onset of schizophrenia, but that in people who have kind of a predisposition, it has a tendency to hasten the onset of the illness. And then there are these people that we see who appear to develop psychotic symptoms when they smoke cannabis for a period of time, and then they kind of like they'll come into hospital and they'll say they won't smoke cannabis, maybe they'll get some anti-psychotic medication and the psychotic symptoms will resolve and then typically they'll go back, go and go back to smoking cannabis and get the psychotic symptoms again. And oftentimes that then will kind of evolve to the point where then they have psychotic symptoms even when they're not smoking cannabis. So it seems as though that cannabis induced psychotic symptoms seem to indicate like a strong vulnerability or predisposition towards developing psychosis.
Dr. Jason Joannou:
You know? Yeah. Andy's right. Like there hasn't been a formal causal link, but there never will be because you're not going to be able there's a very strong association. And this is kind of one thing, I think, with the public health policy around the legalisation of pot and, you know, various statements including the organisation that we work at, work work at, we don't work out here, there's no gym, there's no gym and they'll never be randomised controlled trial, right? So you can't say, well expose all these young people with pristine brains to pot and all these other ones without and see how many develop schizophrenia in these two groups. You're not going to get that past an ethics board or nor should you. But we have these large conscript studies from, you know, Scandinavian countries. You know, I think the ends like 18000 to 20000, and you have an odds ratio in different publications between like one and four, and it kind of converges around two of that. And there are certain risk factors whether you start smoking pot very early like before age 13, whether you're defined as a heavy user, i.e. more than 50 times in your life. And that has a very strong association with developing a primary psychotic disorder and whether those people would have had it or not, I agree with you, we will never be able to do it, but I don't think the evidence will get any stronger than it is now. And based on the fact that we can't kind of study it any closer, we're going to we can't do a randomised controlled trial in the setting.
Carrol Zhou:
Yeah, there's definitely limitations to what and how you can do research around. Substance use.
Dr. Jason Joannou:
And when you and when you talk to people with anything, they try to find evidence to confirm their findings versus disconfirming. And that's kind of I think is kind of human nature. Like, you know, they'll go on the Internet and they'll find things that kind of confirm what they want to believe. So what I what I tend to tell people is like there's many people, most people, in fact, who can smoke marijuana and, you know, won't become psychotic or have a psychotic experience and relatively safe in that regard. But if you're seeing me, that ain't you. And you're kind of playing with fire. And, you know, just like anyone else with any kind of substance issue or health issue, you know, if you had diabetes, you have to be careful about your sugar intake. I'm warning this is, you know, unfortunately, your brain's vulnerable for psychosis and really you should be staying away from this stuff.
Carrol Zhou:
So aside from marijuana, there are several other notable risk factors for schizophrenia. For example, there's a clear genetic predisposition to developing the illness. If one pair of a monozygotic twin has schizophrenia, the other twin has a 48% chance of also developing the disease.
Lucy Chen:
Interestingly, males are overrepresented in schizophrenia with a risk ratio of about 1.4 relative to females. Additionally, males tend to present earlier have poor pre morbid adjustment and have more cognitive impairments and may have a worse prognosis. Many have hypothesised that oestrogen may have a protective effect on the development of psychosis. This is further supported by the fact that women do seem to have an increased risk for psychosis after menopause. And in the Perry pardon period.
Carrol Zhou:
Other risk factors for schizophrenia include immigration, urban city or growing up in a city older paternal age and having a medical problem during pregnancy.
Lucy Chen:
Another reliable risk factor for schizophrenia is urban city. So living in a larger, more busier city and also older paternal age. So having a father that's older during the time of birth, having a medical problem during pregnancy or delivery is also associated with a 2 to 7 increased risk of developing schizophrenia. There are multiple things that come into play with regards to this risk, such as foetal growth retardation, intrauterine infections such as influenza, Coxsackie, B rubella, toxoplasmosis and nutritional deficiency, such as low vitamin D, placental abnormalities, RH factor incompatibility, pre-eclampsia, foetal distress and low APGAR scores. Also, if the neonate had experienced hypoxia or birth asphyxia. So these are all types of risk factors around the birth period that can play into this increased risk of schizophrenia in the context of pregnancy or delivery. I'd like to go back to this idea of like psychosis not always being schizophrenia, and that it could be the result of a mood disorder like bipolar or substance induced sort of state or a medical illness. And I'm wondering whether you guys see a lot of like medically induced episodes like psychosis that's confused the schizophrenia or other kind of manifestations of sort of psychosis that are typically seen. Yeah.
Dr. Andrew Lustig:
Well, I think, again, because of the way like my practice, our practices are structured, we don't we don't see a lot of medically induced psychosis like secondary to general medical illnesses because we work at a standalone psychiatric hospital and we partner with a general medical hospital down the street where they see everyone who has medical illnesses. So that that kind of gets filtered out before people get to us. Generally in terms of, yeah, we see tons of substance induced psychosis, probably as much or more than schizophrenia. And you know, we see lots of cannabis induced psychosis because cannabis is so popular and also a lot of crystal meth induced psychosis and to some degree like like some cocaine slash kind of crack cocaine psychosis, that's pretty common as well. And then, yeah, we see psychosis secondary to mood disorders. A lot of people can't get sight either develop psychotic symptoms in the context of depression or in the context of mania. And we see a ton of that. And sometimes that can be difficult to distinguish. And then also there's this phenomenon of what they sometimes call micro psychosis, which is kind of interesting. It's when people with severe personality disorders develop some psychotic symptoms, but they don't appear to be kind of a prominent part of the clinical picture. They'll be things like visual disturbances in the like the visual periphery sometimes like like a vague kind of murmuring or someone like saying your name over and over again and things of that nature. And so that's something that we sort of like take care to try and differentiate from like a primary psychotic illness. And sometimes it's very obvious and sometimes it's like next to impossible to tease them apart.
Carrol Zhou:
So another clinical pearl here, a really common differential diagnosis, a substance induced psychosis. Common substances that can cause psychosis include stimulants and hallucinogens such as MDMA, cocaine, ketamine, marijuana and mushrooms. Alcohol and benzodiazepine also cause psychosis, but it's less frequent.
Lucy Chen:
Other differential diagnoses of schizophrenia include the following bipolar disorder, depression, schizotypal personality disorder, and schizoaffective disorder. These are all things that could look like psychosis or and, well, basically have psychotic components to them that look like schizophrenia. The timing and predominant symptoms of these conditions differ from schizophrenia. So that's one way you can differentiate these disorders from schizophrenia. Bipolar and depression will predominantly have a mood component rather than psychosis. And a personality disorder would reflect a pattern of behavioural abnormalities throughout their life instead of a discrete single episode of psychosis. Schizoaffective disorder is the trickiest. It describes a disorder where there's a mood episode present concurrently for the majority of the total duration of the action of the active and residual proportions of the psychotic illness, but also have a period of at least two weeks where there are just positive psychotic symptoms and no mood changes. This diagnosis can only be made after serial clinical assessments and observation of the patients, sometimes for years. So it's always on the differential. When we first meet a patient and bipolar disorder and depression, you'll predominantly have a mood component rather than psychosis and a personality disorder like a schizotypal of personality. You'll essentially have an odd pattern of behaviour throughout your entire life rather than a discrete episode of psychosis. In schizoaffective disorder, you'll essentially have mood symptoms like mania or depression, and you'll also have psychotic symptoms. But there's going to be a period of at least two weeks where there's just psychotic symptoms and no mood symptoms at all.
Dr. Jason Joannou:
Yeah, I think it's the nice thing about being a general psychiatrist is that we see all things. So not every you know, if all you have is a hammer, everything is a nail, right? So sometimes that's sometimes what you risk when you go to subject. Again, not our colleagues in subspecialties who only like see first episode psychosis, who or who only see 22 Q 11 deletion syndromes. You know the very good what they do and they're great clinically. But one of the advantages of being a general psychiatrist is that you see so much of everything that when something doesn't fit the bill, it makes you question and then you kind of look into it. And, you know, there's been many times that somebody has come to me with a diagnosis of schizophrenia, and then something just wasn't right about it. Either, you know, the onsets or the or the actual, like nature of the symptoms or there was something else going on and turned out they didn't have schizophrenia. Yeah. Yeah. So it's always it's always important to revisit the diagnosis, even if it's been established before they come to you. Although I would say for schizophrenia in general, it's a pretty it's not one of those diagnoses that there's, it's pretty consistent amongst providers, unlike things like bipolar or bipolar two.
Dr. Andrew Lustig:
Although, you know, I have seen people that were just like, you know, say like very odd and they had a diagnosis of schizophrenia and they were kind of like passed around and it gets written in your chart and then it gets copied every single time you get readmitted. And every discharge summary has schizophrenia written on it, then it's in your chart like 30 times. And so as a clinician, you're reading through somebody's chart and you see schizophrenia all over the place and you walk into the interview thinking, Yeah, this person has schizophrenia, but then sometimes it's helpful to, to kind of just like revisit like what are the psychotic symptoms here? Are there positive psychotic symptoms and is the diagnosis warranted or is it some something like, you know, sometimes like autism can be confused or like kind of a schizotypal of personality or something along those lines? Yeah.
Carrol Zhou:
Speaking of weird and unexpected cases, what were some of the most unexpected? Sorry, What were some of the most unexpected causes of psychosis you have ever seen in your career? Thinking back.
Dr. Jason Joannou:
I mean, there's a couple there's always like the weird, the weird and wacky stuff you kind of remember. So like, like when you do, like, consult liaison psychiatry, which is like when you're going to the medical wards, there's a lot of medical causes of psychiatry. So, you know, I saw some interesting, weird and wacky things like press syndrome, where people kind of whole brains like light up on MRIs and they go cortical blind and then it resolves and and stuff. So, you know, nobody thought they had acute onset schizophrenia when they were in the ICU, but they were psychotic and needed our help or what have you. But the most interesting one I had was a man, again, just revisiting who was labelled as schizophrenia treatment resistant. You know, multiple courses failed clozapine and but his symptoms just weren't proper. Like he had a he kept having visual hallucinations, which is not in not typically seen in schizophrenia more of an organic illness or kind of drug intoxication and withdrawal symptom and very articulate man. But he was profoundly suicidal because he it was tormenting him, these visual hallucinations he was having. And they weren't improving treatment. He had failed clozapine. And I just he was on a sub therapeutic dose of epival that someone added just for fun. And he had a previous history of seizures. So I was just like, Oh, well, let me just up your epival and we'll see. Maybe that will help because there were some, you know, on probing there might have been maybe this was like a partial seizure of some sort like temporal lobe epilepsy or what have you. So we just upped his up epival, didn't even, like, do anything fancy, like an EEG or whatever, and they went away and he was so thankful. Then we consulted our neurology friends. It's like, again, this is like the asystole comment. They were like, Well, the only way we'll know for sure is we take them off, see if they come back, do an EEG and.Then do it.So I proposed that to him and he said, No, thank you. I'll leave with my epival script.
Dr. Andrew Lustig:
Yeah. And I you know, I actually have not seen a confirmed case, but recently read this book Brain on Fire about anti NMDA receptor encephalitis, which is I guess a weird and wonderful not wonderful if you have it cause of psychosis that can be confused with schizophrenia.
Carrol Zhou:
Other medical causes of psychosis can include neurological conditions such as Lewy body dementia or dementia, with Parkinsonian features, brain tumours, seizure disorders, endocrine disorders like hypothyroidism or adrenal insufficiency, electrolytes or metabolic changes, and even lupus. Steroids, antivirals, anti-Parkinsonian drugs, digoxin antimalarials, and even carbon monoxide and heavy metals can all cause psychosis.
Lucy Chen:
If you strongly suspect a medical cause of psychosis and want to do some blood work, a good place to start would be CBC. Electrolytes, including extended electrolytes, blood glucose, liver and kidney function, TSH, B 12, and imaging studies or other serum markers as indicated.
Carrol Zhou:
Also always ask for collateral information from the patient's family and friends in order to find out the onset of the illness and whether there was a prodromal period of social withdrawal, bizarre beliefs or behaviour and functional deterioration. You'll find that with this patient population, the collateral information is often more reliable and very useful to your diagnosis. You probably work with some patients who have really poor insight onto their illness. They come onto your unit. They don't believe they should be there. How do you engage with someone like that?
Dr. Jason Joannou:
I think the the kind of the crux of the matter is. He they don't see a reason for being on the unit and they might be distrustful anyways. And it's very important to try not to disempower them. It's a very disempowering thing to have your perhaps your civil liberties limited, to have the kind of authority of the state looming over you saying that you're ill and you need medication when you don't believe that to be true. So I think, you know, one of the most important things about doctoring is aligning with your patients. So I'll often, especially with like younger patients, I'll do things like we're all on Team Joe, we all want you to do well. And this is kind of what I've heard. This is, you know, some of the concerns that that have come up when I see this, this might imply this. So I don't I tell them what I think and why I think it and at the same time tell them that my only goal here is that I'm your doctor and I just want you to have the best health possible. And right now there might be some concerns that you don't share in terms of your safety or other people's safety while you're in the hospital, but we'll work through that together.
Dr. Andrew Lustig:
Yeah, I agree. And, you know, like forming an alliance is really one of the most important things because ultimately, if you if a person really does not believe or really does not want to get treated, even despite legal measures to try and make people get treatment, it's very, very hard, verging on impossible, to get someone to have a good outcome and really kind of go with the treatment plan. So I find one thing that's helpful is to try to find I think this is what you're talking about, Jason, some kind of a common ground where even if you don't agree about the diagnosis or you don't agree about the symptoms, is there anything that you can find as common ground like you want to get back to school? This might help with that or you want to get out of the hospital or you just want to you want to get outside to have a cigarette and maybe we can work together towards that.
Lucy Chen:
Other pearls specifically for interviewing a very paranoid patient, include keeping personal distance in having a respectful, curious, non judgemental attitude for really paranoid patients. We may choose not to give direct eye contact and allow as much physical space as possible for them to feel safer.
Carrol Zhou:
If a thought expressed by the patient seems illogical or affectively charged in an inappropriate way, then just delve into it with curiosity. Gently guide the patient into further discussion by showing interest and asking clarifying questions so that way their defences can go down and delusional material may be more readily shared with you.
Lucy Chen:
Working with this sort of population that's very, very ill. And we kind of alluded to this at the beginning, but this idea of involuntary detention and forming a patient and that process of it, how what does that process look like to put someone on a form and kind of that process of telling a patient and informing them that they're involuntarily detained?
Dr. Andrew Lustig:
Yeah. So, I mean, I think it's a really tightly regulated process because, you know, as physicians in Ontario, we have a tremendous power to basically to to detain somebody who's not committed a crime, not been convicted of anything, often hasn't really done anything wrong based on something that we think might happen in the future. And so basically the way it works here is that if we think that somebody meets the threshold, you know, which is typically that they're likely to cause serious bodily harm to themselves or somebody else or suffer serious physical impairment, then essentially we have to fill out a form and then we have to give the patient a formal notice that they're being detained against their will. And typically when we give them the formal notice, which is a legal document, we also explain what's happening and answer any questions that they might have. And as you can well imagine, people are usually really, really unhappy about being detained in the hospital. The hospital's generally not a pleasant place to be. The food's not very good. People aren't that nice. There's not very much to do. And oftentimes people who are detained don't even think they need to be in the hospital in the first place.
Dr. Jason Joannou:
Yeah. And then they get formal they get formal notification of their rights from somebody called a rights advisor. And they can choose to have the doctor's decision reviewed by a expert tribunal. The consent capacity board in Ontario. And that's meant to be a timely process where that occurs within a week. And then, you know, it's very difficult for patients who come into the hospital. We detain them. We say, here, here you're being detained, but here you can exercise your rights. And then all these kind of formal people are coming around and they sometimes have a hard time differentiating between the rights adviser and not being part of the hospital process or one of our colleagues. So we try our very best to kind of inform them of the rights and such. But it's, as you can imagine, not always a pleasant experience.
Lucy Chen:
So just to recap, the process of involuntary admission to a hospital for a mental health reason may differ depending on the province or jurisdiction that you live in. Here in Ontario, the Ontario Mental Health Act is the law that helps lay out how it's done. The Mental Health Act outlines the criteria under which a patient is admitted voluntarily or involuntarily to certain psychiatric facilities. The hospitals with designated psychiatric facilities that can admit involuntary patients are called Schedule one facilities.
Carrol Zhou:
So essentially the form one criteria require the patient you examined to have demonstrated a danger to themselves or others, and that if they continue, they will be a likely danger to themselves or others, and that this danger is likely the result of a mental disorder. So threefol. One, they have been unsafe in the past. Two, they're likely to be unsafe in the future. And three, the reason that they're being unsafe is because they suffer from a mental illness. The purpose of this form is to send this person to a schedule one facility for a psychiatric assessment.
Lucy Chen:
Once the form one is completed, there's a form that you provide the patient, which is called a Form 42, which basically just lets them know that they've been put on a form one. You can actually obtain these forms. So the form one and the form 42 online by simply Googling form one, form 42, and you can actually fill them out electronically.
Dr. Andrew Lustig:
I was talking to a senior colleague of mine today who's a full professor of psychiatry who told me he doesn't think he's ever correctly filled out a form one.
Carrol Zhou:
Yeah. I had tried to fill out a form one, and then I ran into a staff psychiatrist who was like, Did you sign three times on the form? And I was like three times and sort of went back and realised, No, I only signed one time. So that was, that was all the questions we had.
Lucy Chen:
Yeah. Sort of. Any lasting impressions you want to leave with young learners and future psychiatrists of today?
Dr. Andrew Lustig:
You know, I think maybe, you know that the to be perfectly honest with you, the treatments that we have for schizophrenia right now in 2017 are poor and you know, unfortunately, schizophrenia hasn't seen the benefits that you've seen in like, say, cancer care or like cardiovascular care. And our patients, unfortunately, with actual schizophrenia, have poor outcomes. And so I think it's important to be kind of like to know that that the drug you're prescribing is probably not going to be transformative in their life and isn't going to get them back to where they want to be. And so it's important to be kind of like empathic and humane with patients and not get too caught up in, you know, like the details and the dose and the drugs and to realise that it's going to be a lifelong journey for the patient and to try to make it as, as palatable as possible.
Dr. Jason Joannou:
I thought she wanted you to say something inspiring. No, no, no. For sure. And. But again, I think this is partly because we work in a very acute environment and there are many people with psychosis. I mean, we had that shared patient who I've been following for three years. And you're still shocked that he's doing so well.
Speaker1:
Yeah.
Dr. Jason Joannou:
And those occur. And I think those occur much more often, not where we work. So just because you found yourself to me, especially with the kind of earlier on and I think that's also why I am why we do the work we do because we I think I think there can be a lasting impact on what we do. The medications I agree with at 100%, I think they can be effective. There's just a lot of side effects associated with them as well. And especially earlier on in the in the illness, the illness tends to be much more responsive to the medications. And for people who unfortunately develop kind of more of a chronic course. And that's the same for many things like, you know, multiple sclerosis or other things. There's different kind of patterns of disease. When you when you go to read your Kaplan and Sadique and prepare for your Royal College exam, you'll learn about all these other kind of epidemiology of the disorder. They say 20% of people with schizophrenia recover completely.
Dr. Andrew Lustig:
Yeah, they do say that.
Dr. Jason Joannou:
The literature I mean, that's not what we see.
Dr. Andrew Lustig:
Yeah, I understand that.
Dr. Jason Joannou:
But yeah, no, in our particular setting. So it's important to keep that in mind. But I think you have to instil hope yet being real and honest at the same time. And that's why it's important to kind of just the psychoeducation around things like we were talking about the cannabis or kind of lifestyle or the importance of family. I say the other important, like not to minimise our treatments. Yeah, I don't know if I would say they suck. There's definitely room for improvement, but they, you know, the, the who, who's the who. Rob Ford. They did very large international studies and seventies eighties and nineties. The first one in seventies came out they were wanting to show the the promise and how great antipsychotics were and they compared outcomes in North America and UK to developing countries like India and they couldn't find a difference and they said, oh it's methodological issues, whatever, and they repeated it like the study again in the eighties couldn't find a difference and again in the nineties. So what they found was that people who are much more socially connected, more likely to be married, more likely to have a job, more likely to be part of a community when they're in these places.
Carrol Zhou:
When counselling a patient, it can be helpful to conceptualize the course of schizophrenia. In thirds, approximately 20% to one third of patients will have an episode of psychosis, respond well to treatment and are able to achieve remission. About a third improve symptomatically but continue to experience relapses and about a third have a progressive and deteriorating course with residual symptoms and significant impairment.
Lucy Chen:
Having an insidious onset is associated with a poor prognosis compared with presenting with a sudden and acute onset with a clear precipitating trigger.
Carrol Zhou:
Poor treatment response is also associated with the male gender earlier onset of illness, poor premorbid social functioning, low premorbid IQ, negative symptoms and lack of affective symptoms.
Lucy Chen:
So having a longer duration of untreated illness. So this includes the prodromal symptoms. So the time before the overt psychosis happens, having a longer duration of that is associated with a much worse prognosis. Therefore, it is also important to identify individuals as early as possible and direct them to the right resources. Ideally, a first-episode psychosis program if there's one in your area.
Carrol Zhou:
Drug use and poor medication adherence are also associated with worse prognoses. Very often, an aspect of the illness involves a striking lack of insight that one is even unwell, and therefore it can be very difficult to get patients to agree to take medications and remain compliant with them.
Dr. Jason Joannou:
So I think it's very important that we don't just rely on the medications that if you work with families and try to get people integrated, things like getting them into job trades, whatever school, something productive, there are people too. So not just again, not the asystole leave is broken, must fix it. They're psychotic. I must fix the psychosis and not just the psychosis. It profoundly affects the family and the people that it comes on. So, you know, again, if I don't know how to get people to do what they what I what. I Think is best for I'm such a young people, so it's hard. But like, we do what we do and I think we do good work and it doesn't always work out. But for, you know, the ones that do it does. It's very rewarding.
Lucy Chen:
Thanks for being very real with us.
Carrol Zhou:
Thank you so much.
Lucy Chen:
And for your wisdom and pragmatic sort of contribution to our understanding.
Carrol Zhou:
All right.
Lucy Chen:
That's a wrap. If you record it, it's actually great.
Carrol Zhou:
Yeah. Like what? Like how do they splice that in? Like, blooper? Not blooper, but, like, the real deal segments. Yeah. Keep going.
Lucy Chen:
Keep. You guys are magical.
Dr. Jason Joannou:
They're really good. Braised short rib.
Dr. Andrew Lustig:
There. Really? That doesn't sound like Indian food to me.
Dr. Jason Joannou:
You wouldn't think so, but it's actually quite delicious. Okay.
Dr. Andrew Lustig:
Yeah. And that's all right.
Dr. Jason Joannou:
They're also known for their gunpowder shrimp. They're quite good. Yeah. I don't know what that means.
Lucy Chen:
It must be explosive. Thank you for listening to PsychEd. Please contact us on Twitter at Psyched podcast or check us out on PsychEdpodcast.org, We love hearing from you and your feedback and questions are vital to the podcast. This episode of Psyched was written and produced by DR. Lucy Chen, Carol Zhou, Phoebe Bao, Kara Dempster and June LAMB.
Carrol Zhou:
Audio editing was provided by Henry Barron.
Lucy Chen:
Our theme song is Working Solutions by Olive Musique. We would especially like to thank doctors Andrew Lustig and Jason Joannou for taking the time out of their schedules to share with us their expertise. This podcast was made possible by support from the Department of Psychiatry at the University of Toronto and is produced in affiliation with the Canadian Psychiatric Association. The views expressed in this episode do not necessarily reflect those of the Canadian Psychiatric Association or the Department of Psychiatry at the University of Toronto.
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