The Chronicle of Neurology & Psychiatry Feb. 2015 by The Chronicle of Neurology & Psychiatry

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Canada’s National Newspaper of the CNS Sciences n February 2015

N ow pr in te d o n 50% po st -con s u m er re cycl ed pape r THE CHRONICLE is committed to environmentally sustainable policies, and to encouraging “green aware” practices in healthcare. We are now proud to provide this journal on the highest percentage of recycled paper stock currently commercially available.

Editorial: LGBTQ psychiatry comes out of the closet ..................3 Clinical trends: Monitor new, existing patient populations ..........7 Film review: ‘Finding Vivian Maier’ ..................................16

Genetic testing for epilepsy becoming quicker, cheaper Epilepsy

A position paper

Improving mental health care for

LGBTQ communities

n Thousands of genetic fragments viewed at once

by John Evans,

Assistant Editor, The Chronicle

ECHNOLOGICAL improvements in gene sequencing have made and will continue to make genetic testing for epilepsy faster and less expensive, but empirical risk estimates are necessary for patient counselling, two presenters concluded during the 2014 Canadian League Against Epilepsy Biennial Meeting in London, Ont. Studies of family histories and monozygotic twins have shown that for many types of epilepsy there is a strong genetic component, says neu-

rologist Dr. Patrick Cossette, head of the epilepsy program at the Montreal University Health Centre. Genetic testing for epilepsy has until recently been performed using Sanger sequencing, which tests a long string of DNA one reaction at a time, says Dr. Cossette. But new, next generation testing can look at hundreds or thousands of genetic fragments simultaneously, making sequencing faster and cheaper. “Using this technique we can do whole exome sequencing or whole genome sequencing,” he says. Because —please turn to page 15

Monitoring bariatric surgery patients With the growing popularity of bariatric surgery, and a high proporClinical trends

please turn to page 12

New Tx for MDD improves cognition

tion of patients who undergo bariatric surgery presenting with an underlying psychiatric condition, many of these patients will likely require vigilant monitoring and possible adjustment of their pharmacological therapy, says Dr. Sanjeev Sockalingam. —See page 7

Depression

n Vortioxetine hydrobromide approved by Health Canada for adults by Emily Innes, Assistant Editor, The Chronicle

depressive disorder (MDD) in adults has been approved by Health Canada. Vortioxetine hydrobromide is the first and only antidepressant to have been independently shown to improve measures of cognition, according to a Toronto-based psychiatrist involved in the clinical trials of the medication. Dr. Roger McIntyre, professor in the Departments of Psychiatry and Pharmacology at the University of Toronto and —please turn to page 8 NEW THERAPY FOR THE TREATMENT OF MAJOR

This issue’s Chronicle Vitae profiles Dr. David Goldbloom, the senior medical advisor at the Centre for Addiction and Mental Health in Toronto, on his recent appointment as an Officer of the Order of Canada. See page 18

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“In these days when science is clearly in the saddle and when

our knowledge of disease is advancing at a breathless pace, we are apt to forget that not all can ride and that he also serves who waits and who applies what the horseman discovers.” —Dr. Harvey Cushing, American neurologist (1869-1939).

Guest editorial: LGBTQ psychiatry comes out of closet

November in the Canadian Journal of the Canadian Psychiatric Association (CPA) has affirmed the need for high quality, accessible and culturally competent psychiatric care for members of the lesbian, gay, bisexual, transgender and queer (LGBTQ) communities suffering from mental illness. This position paper is incredibly important, because the field of psychiatry has in the past been downright antagonistic to the LGBTQ communities, which leads many community members to be distrusting and skeptical of psychiatrists, compromising therapeutic relationships. While in the past the higher prevalence of mental health problems in this population was wrongly thought to be due to inherent psychopathology, today we know that this discrepancy is due to minority stress. Minority stress is psychosocial stress that minorities of all kinds endure due to discrimination and marginalization.2,3 Dr. McIntosh Examples of the LGBTQ experience of minority stress range from violent assault (“gay bashing”) to more subtle forms such as heterosexism, as when LGBTQ people are presumed by individuals or the larger culture to be heterosexual (or are expected to act that way). While minority stress is also experienced by ethnoracial minorities, they typically have family, cultural, and religious community support to provide a buffer for these stresses. A member of the LGBTQ communities, on the other hand, cannot necessarily count on this. Such individuals often experience highly negative reactions from family when they “come out,” that is, disclose their non-normative sexual orientation or gender identity to their family. The loss of family support can sometimes precipitate a crisis, especially for LGBTQ young people, who may be depending on family financial support to survive. LGBTQ individuals are disproportionately represented among homeless youth as a consequence of family rejection.4 LGBTQ people from ethnoracial minorities who lose family support are doubly wounded, as they also lose the family buffer against ethnoracial minority stress and may experience N A POSITION PAPER PUBLISHED LAST

Psychiatry,1

ABOUT THE AUTHOR Dr. Christopher McIntosh is a staff psychiatrist at Toronto East General Hospital, clinic head of the Adult Gender Identity Clinic at the Centre for Addiction and Mental Health, membership chair of the Association of Gay and Lesbian Psychiatrists and co-editor-inchief of the Association’s journal The Journal of Gay and Lesbian Mental Health.

communities.5

racism from the LGBTQ LGBTQ people from religious communities may find themselves welcomed when they come out, as some communities like the United Church of Canada and the Metropolitan Community Church are welcoming of LGBTQ people. However, all too often coming out leads to rejection or worse from religious groups.6

CPA OPPOSES PRACTICE OF CONVERSION THERAPY Some individuals may be pressured by their family or religious community to attempt to change their sexual orientation or gender identity through so-called “conversion therapy” (also known as reparative therapy or more broadly, sexual orientation change efforts).7,8 The CPA, in its position paper, has made very clear in their eighth recommendation that it opposes such discredited practices, which risk psychological harm to the patient when they inevitably fail. The CPA position statement pays particular attention to transgender and gender nonconforming individuals in their fourth and sixth recommendations, affirming the importance of respectful support for transgender people in all settings (including using the patient’s chosen name and preferred pronouns) and advocating for coverage of medical transition therapies by provincial health insurance plans. Transgender people have often had their health care subject to capricious politics or ignored altogether, and experience an incredible amount of minority stress. Rates of suicidal ideation, particularly among trans youth, are far higher than in the general population and are often inversely related to the degree of family support.9,10 Given these stressors it is crucial for LGBTQ individuals seeking help and support for a mental health issue to be treated with respect and competence and that their concerns are taken seriously. I encourage all psychiatrists to read over the position statement paper, which comes with a helpful glossary for those unfamiliar with the terms used.

IMPORTANT TO ACKNOWLEDGE LGBTQ PSYCHIATRISTS While the CPA’s position statement makes no explicit mention of LGBTQ psychiatrists, it is important to acknowledge that sometimes members of our own profession may be subjected to the stressors described here. It was not that long ago that to be an openly gay or lesbian psychiatrist was anathema and likely to lead to dismissal from one’s position. Today transgender and gender non-conforming psychiatrists and trainees may fear similar opprobrium. Groups such as the Association of Gay and Lesbian Psychiatrists11 can be an important source of support for individuals experiencing discrimination and stress within their profession. —See references on page 12

The Chronicle of Neurology & Psychiatry is published six times annually by the proprietor, Chronicle Information Resources Ltd., with offices at 555 Burnhamthorpe Rd., Ste. 306, Toronto, Ont. M9C 2Y3 Canada. Telephone: 416.916.2476; Fax. 416.352.6199. E-mail: health@chronicle.org. Contents © Chronicle Information Resources Ltd., 2015, except where noted. All rights reserved worldwide. The Publisher prohibits reproduction in any form, including print, broadcast, and electronic, without written permissions. Printed in Canada. Mail subscriptions: $72 per year in Canada, $125 per year in all other countries. Single copies: $12 per issue (plus 13% HST) Canada Post Canadian Publications Mail Sales Product Agreement Number 40016917 The Publisher certifies that advertising placed in this publication meets Revenue Canada requirements for tax deductibility. Volume 18, Number 1, published February 2015 ISSN 1209-0565

Research

n Problem adaptation therapy (PATH) was

found to be more effective than supportive therapy for cognitively impaired patients (ST-CI) in elderly adults ages 65 years and older with depression and cognitive impairment at reducing depression and disability, according to a study published in JAMA Psychiatry (Jan. 2015; 72(1):22-30). —Find more info at http://ow.ly/Idnea

n Insomnia associated with physiological

hyperarousal is associated with a significant risk of hypertension. Insomnia combined with physiological hyperarousal, measured by Multiple Sleep Latency Test (MSLT) >17 minutes (75th percentile of mean MSLT value), increased the odds of hypertension by 400% (odds ratio=4.33; 95% confidence interval=1.48–12.68), according to a study published in the American Heart Association’s journal Hypertension (Jan. 26, 2015). —Find more info at http://ow.ly/IdwhO

n Deliberate self-harm patients who

receive psychosocial therapy with short-term and long-term follow-up have a reduced risk of repeated selfharm, general mortality, and has a protective effect for suicide, compared to individuals who do not receive this therapy, according to findings published in The Lancet Psychiatry (Jan. 2015; 2(1):49-58). —Find more info at http://ow.ly/IdAHv

n Migraine has been found to be associ-

ated with Bell Palsy, which was previously an unidentified risk factor. The association between the two conditions suggests a linked mechanism that is worthy of further exploration, concluded the authors of a study published in Neurology (Jan. 13, 2015; 84(2):116-124). —Find more info at http://ow.ly/IdCuw

n Recovery-based cognitive behavioural

therapy has shown promise in regards to feasibility and potential clinical effectiveness for bipolar patients, according to the results of a pilot trial published in The British Journal of Psychiatry (Jan. 2015; 206(1):58-66). —Find more info at http://ow.ly/IdGGL February 2015 n 3

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The woman who created this image came to art therapy to gain insight into her feelings of low self-esteem and general unhappiness. She created this image following a guided visualization exercise, in which she imagined herself approaching a wise woman who asks, “What is your question?”. The house appears to be complete, warm, and inviting, yet it is has no solid foundation—it’s floating on water. In describing the house, the client explained that she has remained in a job that is overseen by a severely critical boss. She is worried about being fired, and consequently feels anxious about her ability to afford her home. She described the looming rain cloud as an accumulation of strong emotions evoked by the following selfstatements: “I am never good enough”, and “I do not do things right”. The question she imagined during the visualization exercise was, “Who am I without that cloud?” Her associations with the images provided a starting point for a discussion about the ways in which her life choices are affecting the quality of her life. —Andrea Charendoff, professional art therapist, Toronto —More information on Andrea Charendoff and her work is available at www.speakingthroughart.com Founding Editor

Richard Gladstone,

4 n February 2015

n Clinical trends: Certain patient populations need more monitoring in 2015 (p. 7) n Depression: rTMS safe and promising Tx of depression, pain, and suicidality (p. 9) n Neurology: Lower BMI in patients with essential tremor suggests condition is neurodegenerative (p. 11) n LGBTQ mental health: CPA pushes for better mental health care for individuals who identify as LGBTQ (p. 12) n Epilepsy: New technology to be utilized to gain better understanding of epilepsy networks (p. 14) n Film review: ‘Finding Vivian Maier’ (p. 16) n Chronicle Vitae: CAMH’s Dr. David Goldbloom appointed Officer of the Order of Canada (p. 18) primary progressive aphasia, and six (20%) with Huntington disease. Common criminal behaviours in the bvFTD group, which had the highest percentage of patients with documented criminal behaviours, were theft, traffic violations, sexual advances, trespassing and public urination. Traffic violations were commonly committed by AD patients, often related to memory loss. All the patients who urinated in public were men. Men were also more likely than women to make sexual advances (15.2% vs. 5.1%). “The findings from this study suggest that individuals who care for middle-aged and elderly patients need to be vigilant in the diagnosis of degenerative conditions when behaviour begins to deviate from the patient’s norm and work hard to protect these individuals when they end up in legal settings,” the authors concluded. —Read more information at http://ow.ly/I5PdT

Morguefile

Psychiatry Editor

Publication Index

Dementia patients at risk of exhibiting criminal behaviours

CRIMINAL BEHAVIOUR CAN OCCUR in patients with some neurodegenerative diseases, J. J. Warsh, MD, FRCPC although patients with Alzheimer disease Editor, Innovation in the Mind (AD) were among the least likely to comSciences mit crimes, according to a study published Roger S. McIntyre, online by JAMA Neurology (Jan. 5, 2015). MD, FRCPC Neurodegenerative diseases can cause dysfunction of the neural structures Editorial Director involved with judgment, executive function, R. Allan Ryan emotional processing, sexual behaviour, vioSenior Associate Editor lence and self-awareness. This dysfunction Lynn Bradshaw can lead to antisocial and criminal behavAssistant Editors iour, according to the study background. John Evans Dr. Madeleine Liljegren, with Lund University in Sweden, Dr. Georges Emily Innes Naasan, of the University of California, in Publisher San Francisco, and co-authors examined Mitchell Shannon the type and frequency of criminal behavProduction and Circulation iours among patients with a dementing disorder by reviewing medical records of Cathy Dusome Sales & Marketing 2,397 patients seen at the University of California, Memory and Aging Center Sandi Leckie, RN Comptroller between 1999 and 2012. The patients MD, FRCPC

s Quick-start guide to The Chronicle, February 2015:

included 545 with AD, 171 patients with behavioral variant of frontotemporal dementia (bvFTD), 89 patients with semantic variant of primary progressive aphasia and 30 patients with Huntington disease.

BEHAVIOURS: THEFT, TRAFFIC VIOLATIONS, SEXUAL ADVANCES The medical review showed 204 of the patients (8.5%) had a history of criminal behaviour that emerged during their illness. Among the different diagnoses, those patients who exhibited criminal behaviour were 42 of the patients (7.7%) with AD, 64 of the patients (37.4%) with bvFTD, 24 with (27%) semantic variant of

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“If you do not have a proven treatment

for certain illnesses, bid [sic] your time, do what you can, but do not harm your patients.”

—Jean-Martin Charcot, French neurologist (1825-1893).

Exploring attitudes ALS Ice Bucket Challenge funds study to about mental health explore potential of pimozide, biomarkers in the workplace

CONDUCTED BY the Centre for Addiction and Mental Health (CAMH) in Toronto found that nearly four in 10 workers would not tell their manager if they had a mental health problem, yet half said that if they knew about a coworker’s illness, they would desire to help. The study, published in The International Journal of Occupational and Environmental Medicine (Oct. 2014; 5(4)), reveals that workers have both negative and supportive attitudes about mental health in the workplace. “A significant number of working people have mental health problems, or have taken a disability leave related to mental health,” stated Dr. Carolyn Dewa, CAMH’s senior scientist who headed the project, in a Jan. 2015 press release. “Stigma is a barrier to people seeking help. Yet by getting treatment, it would benefit the worker and the workplace, and minimize productivity loss.” Working adults in Ontario (2,219) were asked if they would inform their manager if they had a mental health problem and if a colleague had a mental health problem would they be concerned about how work would be affected. STUDY

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begin studying the potential of a drug approved by Health Canada for psychoses to slow the progression of ALS (amyotrophic lateral sclerosis). The research is as a result of a grant made possible by the funds raised during last summer’s social media phenomenon— the ALS Ice Bucket Challenge. A team led by Dr. Lawrence Korngut, at the University of Calgary, that includes Dr. Lorne Zinman, from Sunnybrook Health Sciences Centre and University of Toronto, will initiate a randomized controlled trial of pimozide in subjects with ALS. The phase II study will Dr. Taylor involve 100 participants across eight ALS clinics across Canada. This trial, led by the principal investigator of the Canadian Neuromuscular Disease Registry (CNDR) and the Chair of the Canadian ALS Research Network (CALS) will also explore a potential new biomarker that will help validate the effectiveness of the treatment.

ANADIAN RESEARCHERS WILL

EXPLORE POTENTIAL BIOMARKER Since pimozide strengthens or restores the neuromuscular junction (NMJ), Dr. Korngut’s team will measure whether this decremental response can be a biomarker to recruit individuals likely to benefit from pimozide, but also to monitor whether pimozide is acting as hypothesized so a positive or negative

result on ALS can be properly interpreted. If pimozide does slow ALS progression, the researchers will undestand whether or not it is a result of NMJ connectivity. “What is most exciting about this portion of the project is that Dr. Korngut will examine the effectiveness of this biomarker in a small pimozide human trial that is already underway at the University of Calgary,” said Dr. David Taylor, director of research for ALS Canada. “Should it work, the biomarker can also be used to recruit individuals with the highest likelihood to respond to pimozide.” Testing pimozide in the clinic is the next step in a series of projects that have taken several years to develop. Pimozide was first discovered as a potential treatment for ALS in the Canadian labs of Drs. Pierre Drapeau, Alex Parker and Richard Robitaille at Université de Montréal working with zebrafish, worm and mouse genetic models.

INTERNATIONAL PEER REVIEW PANEL The ALS Society of Canada, in partnership with Brain Canada and the Government of Canada, announced the recipient of The Arthur J. Hudson Translational Team Grant in Jan. 2015. For the first time ever, ALS Canada, in partnership with Brain Canada, have utilized an International Peer Review Panel consisting of seven European and American ALS experts, spanning the basic to clinical spectrum, who convened in Toronto in November to determine the top project amongst strong competition.

Anthony Quintano via Wikimedia Commons

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FEAR PREVENTS OPENNESS Among the 38% who would not tell their manager, more than half were afraid that it would affect their careers. Other reasons for not disclosing were the bad experiences of others who came forward, fear of losing friends, or a combination of these reasons. Three in 10 people said they would not tell because it would not affect their work. A positive relationship with their manager was the key reason given by those who would reveal that they had a mental health problem. Supportive organizational policies was another factor, which was cited by half of those who would disclose. “One surprising thing we found was that 50 per cent said they were concerned because they would want to help their co-worker,” said Dr. Dewa. About one in five also worried about making the mental health problem worse. —Read more information at http://ow.ly/I2vGn

n International peer panel selects Canadian ALS research project

In the news . . . n As a result of the largest-ever

autism genome study that looked at 340 genomes from 85 families, researchers discovered that 70% of siblings had little or no overlap in gene variations that contribute to their autism, according to a study published in the journal Nature. These findings indicate that there is not one autism but possibly hundreds of autisms, reports CBS News (Jan. 27, 2015). —Read this article at http://ow.ly/I3cnc

n An Ottawa-based researcher

demonstrated that adults 65 years and older, who are hospitalized for a severe bout of pneumonia are at an increased risk of a stroke, heart attack, or dying of heart failure, for at least a decade after the event, according to a study published in the Journal of American Medical Association, reports The Globe & Mail (Jan. 20, 2015). —Read this article at http://ow.ly/I5yHS

n In a study, looking at the brains of

Romanian children who were either abandoned or institutionalized, put into foster care, or who were raised by their biological family, researchers found that the children who were abandoned had noticeably altered white matter. These findings demonstrate a harmful impact of childhood neglect, reports Time (Jan. 27, 2015). —Read this article at http://ow.ly/I5F1z

n MRI imaging of 12 violent crimi-

nals with psychopathy, compared to controls, depicted that criminal psychopaths have a reduction in grey matter. The investigators from London, Montreal, and Bethesda, Md. found a different organization of their reinforcement learning system that shapes behaviours, reports CBC News (Jan. 28, 2015). —Read this article at http://ow.ly/Iatwa February 2015 n 5

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Upcoming guidelines in neuro reflect research advancements n The American Headache Association developing new Tx guidelines; recent stroke guidelines

by Louise Gagnon,

Correspondent, The Chronicle

EUROLOGISTS WHO TREAT MIGRAINEURS can look forward to therapies in the pipeline that are targeted at preventing migraine and neurologists also have new Canadian clinical practice guidelines at their disposal to manage migraine. “The drugs under study reduce the number of migraines and severity of migraines and produce very few side effects,” said Dr. Christine Lay, the director of the Centre for Headache at Women’s College Hospital and an associate professor, University of Toronto. The emerging agents, which are entering Phase III clinical trials, address the neuropeptide calcitonin gene-related peptide (CGRP), which has long been regarded as playing a key role in the pathophysiology of migraine, according to Dr. Lay. One of the better treatments now available for acute migraine attacks with or without aura is diclofenac potassium powder, a non-steroidal, anti-inflammatory drug that dissolves in water, noted Dr. Lay. In studies, the powder formulation was more effective than diclofenac potassium tablets in providing pain relief within two hours.

NEW GUIDELINES IN THE WORKS FOR TREATING MIGRAINE In addition to the Canadian Headache Society issued guidelines for acute drug therapy for migraine headache (Can J Neurol Sci Sept. 2013; 40(5 Suppl 3):S1-S80), The American Headache Society is also developing new treatment guidelines for migraine. Narcotics should be avoided for managing headache because the strong painkillers do not ultimately improve pain for patients, said Dr. Lay. “They only compound the problem and patients can get a whole lot worse,” said Dr. Lay. Clinicians should pay greater attention to the childhood experiences of their adult patients who report daily chronic headache, noted Dr. Lay, pointing to evidence that childhood adversity or trauma is a risk factor for the presence of chronic headache in adulthood. (Headache June 2012; 52(6):920–929). “If [patients with chronic headache] have experienced abuse in their homes [growing up], that is a piece of their history,” said Dr. Lay, suggesting an opportunity to discuss their childhood experience in therapy might help to resolve the headaches. “If they have not had counselling, it might help in terms of controlling their headaches.”

6 n February 2015

offered thrombolytic therapy, there is a large unmet medical need for therapy for patients who experience hemorrhagic stroke, said Dr. Hill. Mortality related to hemorrhagic stroke is significantly greater than mortality related to ischemic stroke, he added. Stroke can also be a substantial issue in patients with dementia, explained Dr. Hill. “The dementia substrate is pre-existing, and a small stroke can be what puts patients over the edge,” said Dr. Hill, noting most dementias are not purely vascular or purely Lewy Body dementia. “The majority of dementias are mixed.” Managing hypertension and controlling other vascular risk factors will decrease the chances of individuals developing Dr. Hill dementia.

RESEARCHERS EXPLORE HOW TO BETTER TREAT ARSACS There has been some progress in identifying the etiology of autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS), a neurodegenerative disorder linked to mutations in the SACS gene, first observed in the Charlevoix-Saguenay region of Quebec, and now recognized as a universal disease. “It is now the second most common recessive ataxia in the world,” said Dr. Bernard Brais, a University of McGill neurologist who is the co-director of the Rare Neurological Diseases Group at the Montreal Neurological Institute in Montreal and coordinates the CIHR and Fondation de l’Ataxie de CharlevoixSaguenay new emerging team on ARSACS. “The [SACS] gene is now being sequenced all over the world.” Dr. Brais and fellow investigators are investigating how the SACS gene functions to develop treatments that target the pathogenesis of the condition. Using SACS knockout mice, Dr. Brais and colleagues demonstrated defects in mitochondrial dynamics, which are key in the pathophysiology of ARSACS (Hum Mol Genet Feb. 2015; 24(3):727-739). Treatments that are currently administered to patients with ARSACS address symptoms of the condition such as bladder urgency Dr. Brais and muscle stiffness, explained Dr. Brais. Treatments being developed are looking at improving cerebellar function, slowing neurodegeneration and improving mitochondrial function.

STROKE: STILL A MAJOR CAUSE OF DEATH AND MORTALITY Dr. Michael Hill, professor of clinical neuroscience, community health sciences, radiology, and medicine at the University of Non-proprietary and brand name of therapy: diclofenac potassium Calgary and the director of the Stroke Unit in the Calgary Stroke powder (Cambia,Tribute Pharmaceuticals Canada Inc.) Program at Alberta Health Services, was one of the authors of the 2014 update of the Canadian Secondary Prevention of Stroke guideline. He said data PRACTICE IN ONTARIO? Participants needed for a demonstrates that delays of even 10 minutes Sunnybrook Driving and Dementia research study produce clinically relevant decreases in better If you are a neurologist, psychiatrist, geriatrician or family physician in Ontario who outcomes for stroke patients. sees up to 12 new patients with mild dementia/mild cognitive impairment per year, “The impact [of delays] is measurable,” you can help us test an innovative online decision tool that provides a recommensaid Dr. Hill. “Speed is critical. It is an issue dation on whether or not to report your patient with mild dementia to the Ontario of a need for continual improvement. Some Ministry of Transportation. The tool can be easily institutions try to identify where they are accessed online from your office. For more inforslow and where things can be improved.” mation, email Mark.Rapoport@sunnybrook.ca Unfortunately, there are institutions in with the subject line “Decision Tool Study”. Canada where patients can wait “an inordinately long time” to be treated, said Dr. Hill. While patients who experience ischemic stroke can be

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Certain psychiatric patient populations need more monitoring in 2015

n Increasing popularity of bariatric surgery is creating a new population of psychiatric patients who require vigilant monitoring

by Louise Gagnon,

Correspondent, The Chronicle

who undergo bariatric surgery present with an underlying psychiatric condition, and many of these patients will likely require vigilant monitoring and possible adjustment of their pharmacological therapy, says the deputy psychiatrist-in-chief at University Health Network in Toronto. “We want to minimize complications [following bariatric surgery], especially serious ones like suicide,” said Dr. Sanjeev Sockalingam, who is also the director of the Bariatric Surgery Psychosocial Program at Toronto Western Hospital and an associate professor in the Department of Psychiatry at the University of Toronto. “It is important that clinicians be educated about careful monitoring because complications have been reported after bariatric surgery.” One of the impacts following Roux-en-Y gastric bypass, the gold Dr. Sockalingam standard in bariatric surgery, is altered absorption of medications, a phenomenon that has to be taken into account in psychiatric patients taking pharmacotherapy, noted Dr. Sockalingam. “It is important to know that some medications are not as well absorbed after surgery,” said Dr. Sockalingam. “We do not preemptively change medications unless they are [already on] extendedrelease medications. Those medications will need to be switched [prior to Roux-en-Y gastric bypass].” Another post-surgical consideration is the threat of discontinuation syndrome from antidepressants, such as selective serotonin reuptake inhibitors, because of poor absorption of medications, explained Dr. Sockalingam. In some instances, where patients present with complex psychiatric illness, other bariatric surgery modalities, such as sleeve gastrectomy, may be contemplated because sleeve gastrectomy does not present the same impact of decreasing absorption of medications post-operatively. “[Sleeve gastrectomy] may not be as good as Roux-en-Y in terms of overall efficacy, but the data are evolving,” said Dr. Sockalingam. In all instances, it is imperative to ensure that stability of patients is attained before bariatric surgery, said Dr. Sockalingam. “It may require optimization of psychiatric medication or engagement in psychotherapy to achieve a period of stability before bariatric surgery,” he said in an interview with THE CHRONICLE OF NEUROLOGY + PSYCHIATRY. HIGH PROPORTION OF PATIENTS

TREATING PREGNANT WOMEN WITH DEPRESSION To medicate or not medicate patients with depression during pregnancy is a controversial issue, particularly with more data emerging regarding antidepressant use by pregnant mothers linked to potential adverse effects on babies, according to Dr. Sophie Grigoriadis, the head of the

Women’s Mood and Anxiety Clinic at Sunnybrook Health Sciences Centre in Toronto and associate professor in the Department of Psychiatry at the University of Toronto. Randomized, double-blinded, placebocontrolled trials cannot be conducted during pregnancy. In the absence of such studies, no cause and effect relationship between antidepressant use and the health of newborns that can be confirmed, with Dr. Grigoriadis existing evidence coming from observational investigations, explained Dr. Grigoriadis. Still, some research has shown that a relationship between antidepressant use in pregnant mothers and adverse outcomes exists, such as persistent pulmonary hypertension (PPH) in newborns. Specifically, a statistically significant association between SSRI exposure in late pregnancy and PPH was concluded in a systematic review and meta-analysis. Even though the link was significant, the clinically absolute risk of PPH in newborns remains low (Br Med J Jan. 2014; 14(348):f6932). “It is an individual decision [to take antidepressants] that is different for every case, and the decision has to be best for both [mother and baby],” said Dr. Grigoriadis, who is the co-academic leader of the Reproductive Life Stages Program of the Women’s Mental Health Program at Women’s College Hospital in Toronto. “For mild-to-moderate depression, we should first think of psychosocial interventions.” When pregnant patients have moderate-to-severe depression, Dr. Grigoriadis said there is a “stronger role” for antidepressants and noted that factors such as previous episodes of depression in women and previous positive responses to antidepressants might favour the decision to prescribe antidepressant medication. Frequent follow-up of pregnant patients with depression is warranted, added Dr. Grigoriadis. Dr. Grigoriadis and colleagues have created and piloted a physician reference guide in Ontario to assist clinicians including family physicians, obstetricians, and psychiatrists, in their care of pregnant patients, with the guide serving as an aid in forming recommendations to patients on the use of pharmacotherapy during pregnancy. “We are at the stage where we are incorporating feedback from the pilot experience,” said Dr. Grigoriadis. “We are revising the guide, plan to publish it in the near future, and start disseminating it. It will be something handy for clinicians to use in collaborative discussions with their patients in order to ultimately inform decisions.” Researchers at Women’s College Hospital and Mount Sinai Hospital are studying the use of transcranial direct current stimulation in pregnant women with depression, assessing the safety and efficacy of the

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non-pharmacological therapy for moderate-to-severe depression in pregnant women. Dr. Lily Hechtman, a professor of psychiatry and pediatrics, the director of research in the Division of Child Psychiatry at McGill University in Montreal, noted that her current research is examining the impact of rigorous follow-up by specialists of children with attention deficit hyperactivity disorder (ADHD) who are taking prescribed medication, which is typically a stimulant.

ADHD RESEARCHERS EXPLORE EFFECTIVENESS OF RIGOROUSLY MONITORING PATIENTS ON MEDICATION “The premise of our study is that ADHD is a chronic condition,” said Dr. Hechtman. “Our hypothesis is that maintaining treatment gains is much better [with specialist followup] than [with] usual follow-up in the community.” All children participating in the two year, randomized trial are given carefully titrated medication and other treatments they require Dr. Hechtman during the first three months. After this phase, participants are assigned to have follow-up by community care or by physician care. The community care group receives booster sessions, if needed, of the treatment previously received during the first three months of comprehensive treatment. In the tailored case management group, the family is telephoned once a month, and an intervention follows, which can include parent training, child social skill training, anger management, medication adjustment, or contact with the child’s teacher to see if any intervention can take place at school to improve the child’s performance. Another phone call is placed to families to see if any other interventions are needed. Every three months, there is a visit with parents and the child’s teacher to get feedback about any need for medication adjustment. Both groups of children undergo comprehensive evaluations every six months up to two years. February 2015 n 7

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Vortioxetine approved to treat adult depression in Canada

—Continued from page 1

interesting that they are reporting that.” Vortioxetine was demonstrated to be safe in the adult population. The most common adverse emergent effect was mild nausea lasting one to two weeks. Some patients experienced gastrointestinal issues such as diarrhea. Objectively measured—using the Arizona Sexual Experience Scale—sexual dysfunction compared to placebo was only lower by a few percentage points. “Physicians should routinely inquire about possible sexual side effects during treatment with [vortioxetine],” the product monograph states. Dr. McIntyre says this is an important criterion because 50% to 60% of patients on serotonin-specific reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SSNIs) experience sexual dysfunction.

Head of the Mood Disorders Psychopharmacology Unit at the University Health Network, said the approval is positive primarily because it provides a new therapeutic option for the many Canadian MDD patients who do not fully recover when taking medication. “The first point, which is more kind of a state of the union, is that most people in Canada with MDD who require medication treatment are simply not getting where they should be,” Dr. McIntyre told THE CHRONICLE OF NEUROLOGY + PSYCHIATRY. “That really provides the impetus for us to have available to our patients a new treatment . . . That in itself is a very important point: it is a new alternative for a common and VORTIOXETINE NOT ASSOCIATED WITH WEIGHT GAIN often disabling disorder.” Another commonly reported side effect with SSRIs and The secSSNIs is weight gain, but for patients ond point of taking vortioxetine there was no statisDr. McIntyre i n t e r e s t , tically significant change in weight or I think there are going according to Dr. McIntyre, is that body mass index. vortioxetine has shown to improve Dr. McIntyre said another intriguto be a number of cognitive symptoms. It has recenting point about vortioxetine is that it has stakeholders that are ly been repeatedly observed that a unique mechanism of action as it is a patients who have remitted sympmulti-modal antidepressant. The medgoing to take interest toms of depression still do not ication is an inhibitor of serotonin (5in the clinical profile, i.e., have complete recovery because of HT) reuptake and also an agonist at 5the cognitive impact of MDD. cognition and its functional HT1A receptors, a partial agonist at 5“People still continue to flounHT1B receptors, and an antagonist at 5der in the workplace,” said Dr. improvement with HT3, 5-HT1D, and 5-HT7 receptors. McIntyre. “They are often absent It also modulates glutamate, vortioxetine. from work and they are often missacetylcholine, and histamine which, ing work. This has taken us down a —Dr. Roger McIntyre, professor in the according to Dr. McIntyre, each on very interesting path and we have Departments of Psychiatry and Pharmacology their own and collectively can benefit learned that among people with at the University of Toronto measures of cognition. depression one of the principal From a scientific and health perreasons that they are not able to spective, he believes that vortioxetine have full functioning recovery or have full quality of life will be a first line and first choice antidepressant for patients. return is that they have ongoing cognitive problems.” “I think clinicians continue to desire, not just alternatives, but alternatives that are without a risk of weight gain and sexual IMRROVED COGNITION MEANS IMPROVED FUNCTIONALITY problems,” he said. “And the fact that this medication has this The benefits of the cognitive improvements from vortioxereplicated and clinically significant benefit in the dimension of tine were highly correlated with improvements in functional cognition with associated functional improvement, I think that measures, noted Dr. McIntyre. is going to be very interesting, not just for patients, but also for “I think from a larger societal and medical perspective healthcare providers. I think it is also going to be interesting for this is really exciting because that is what we all want. We want providers [of health insurance] . . . and employers.” the burden of depression to be lifted and the burden of Dr. McIntyre added, “I think there are going to be a depression is largely a statement about the impairment of number of stakeholders that are going to take interest in the function,” he said. clinical profile, i.e., cognition and its associated functional The improvement was demonstrated not to be a pseuimprovement with vortioxetine.” dospecific effect by observing the subgroup of the patients The efficacy of vortioxetine in providing symptomatic relief who did not show improvements in depression scores when was demonstrated in a double-blind, placebo-controlled clinical taking vortioxetine. The researchers found that these patients, trial. Vortioxetine is indicated for use for patients 18 to 65 years despite not remitting, exhibited an improvement in their cogof age. The minimum recommended dose is 10 mg daily, adminnitive measures. istered orally. Its efficacy and safety has not been tested in pediFurthermore, Dr. McIntyre said he heard many anecdotal atric patients (<18), geriatric patients (>65), and pregnant women. reports from patients about the cognitive improvements even Dr. McIntyre disclosed relevant relationships with without being primed about the benefit. numerous pharmaceutical companies including speaker fees “They use different language [such as] ‘my mind is more and research grants from Lundbeck Canada Inc. clear,’ ‘I am more sharp,’ ‘I can really focus better,’ and I had a patient say once ‘my mental dexterity has improved.’ But this Non-proprietary and brand name of therapy: vortioxetine hydrois something that was not coached or came from us, so that is bromide (Trintellix, Lundbeck Canada Inc.)

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rTMS is safe and promising for treatment of depression, pain, suicidality

n Prefrontal repetitive transcranial magnetic stimulation can be used to stimulate targeted areas of the brain for treatment

by Lynn Bradshaw,

Senior Associate Editor, The Chronicle

magnetic stimulation (rTMS) is a safe and promising option for the treatment of depression, postoperative pain, and suicidality, according to Dr. Mark George. “rTMS is an interesting form of technology that utilizes an electrical magnetic field,” said Dr. George, who reviewed various rTMS studies during a presentation at the 2014 Campbell Family Mental Health Research Symposium in Toronto. “When the device is held over the scalp it can stimulate targeted areas of the brain,” noted Dr. George, professor of psychiatry, radiology and neuroscience and director of the brain stimulation laboratory at Medical University of South Carolina in Columbia, S.C. He used a video titled Rewiring the Brain’s Circuits with Transcranial Magnetic Stimulation, released by the Medical University of South Dr. George Carolina (http://ow.ly/GZIci), to illustrate that researchers are starting to get a better understanding of what different parts of the brain do. In the video, Dr. George added that “we now know that the brain is made up of various circuits and when these circuits are faulty it can result in problems that we see in neurological conditions like Parkinson’s, and tremors.” “We are starting to apply that same concept to understand psychiatric illnesses and it is actually a similar concept,” he explained. In the case of depression and other psychiatric conditions, Dr. George finds that the common circuit area of the brain at fault seems to be the prefrontal cortex. He added that the prefrontal cortex regulates REFRONTAL REPETITIVE TRANSCRANIAL

the limbic system. One of the common concerns of rTMS treatment is the fact that the procedure is somewhat painful during the first few administered treatments. However, eventually rTMS procedural pain decreases over time, which is apparently independent of other emotional changes, said Dr. George, who referenced a study published in the journal Brain Stimulation (Apr. 2009; 2(2):88–92).

DEPRESSION rTMS TREATMENT EFFECTIVE, SAFE Another study reviewed by Dr. George was a prospective, multisite, randomized, active sham-controlled study designed to assess whether daily left prefrontal rTMS safely and effectively treats major depressive disorder (Arch Gen Psychiatry May 2010; 67(5):507–516). “During this study we assessed 200 anti-depressant drug-free patients with unipolar nonpsychotic major depressive disorder,” said Dr. George. “Interestingly, we came up with a new way of doing sham stimulation that allowed for the patients, treaters and raters to be effectively masked.” Dr. George and his colleagues reported in their study that sham rTMS used a similar coil with a metal insert blocking the magnetic field and scalp electrodes that delivered matched somatosensory sensations. The investigation delivered rTMS to the left prefrontal cortex at 120% motor threshold (10 Hertz (HZ), 4-second train duration, and 26-second intertrain interval) for 37.5 minutes (3,000 pulses per session) using a figure-eight solid-core coil. Findings revealed that minimal adverse effects did not differ by treatment arm, with an 88% retention rate (90% sham and 86% active). Primary efficacy analysis revealed a significant effect of treatment on the proportion of remitters (14.1% active rTMS and 5.1% sham) (p=0.02). In addition, the data revealed that the odds of attaining remission were 4.2 times greater with active

rTMS than with sham (95% confidence interval, 1.32– 13.24). Also, the number needed to treat was 12. Most remitters had low antidepressant treatment resistance. Almost 30% of patients remitted in the open-label follow-up (30.2% originally active and 29.6% sham). “I think the result of this study demonstrates that rTMS has a role in the treatment of depression,” he said. Dr. George also referenced research conducted by an associate professor from Medical University of South Carolina, Jeff Borckardt, PhD, and other colleagues. This trial involved 20 patients who received rTMS immediately after gastric bypass surgery (Brain Stimul Apr. 2008; 1(2):122–127).

rTMS AND ITS IMPACT ON POSTOPERATIVE PAIN According to the authors, after surgery the participants were randomly assigned to receive 20 minutes of real or sham rTMS (10 Hz, 10 seconds-ON, 20 seconds-OFF for a total of 4,000 pulses). Patient-controlled morphine pump usage was tracked throughout each participant’s postoperative hospital stay. In addition, pain and mood ratings were collected via visual analogue scales twice per day. Findings revealed that participants who received real TMS used 36% less morphine and had significantly lower ratings of postoperative pain-on-average, and pain-at-its-worst than participants receiving sham. In addition, participants who received real TMS rated their mood-at-its-worst as significantly better than participants receiving sham. “It is really remarkable how a single 20 minute session of TMS can result in a remarkable reduction in the use of morphine,” said Dr. George.

rTMS POTENTIALLY REDUCES SUICIDAL THOUGHTS Another study referenced by Dr. George was an investigation that sought to determine whether a high dose of rTMS was safe —please turn to page 13

Re-conceptualizing major depressive disorder as an infectious disease

MAJOR DEPRESSIVE DISORDER (MDD) SHOULD BE RE-CONceptualized as an infectious disease, according to Turhan Canli, PhD, associate professor of Psychology and Radiology at Stony Brook University (SBU) in Stony Brook, N.Y., and the director of the university’s Social, Cognitive, and Neuroscience Centre. In a paper published in Biology of Mood & Anxiety Disorders (Oct. 2014; 4(10)), Dr. Canli suggests that major depression may result from parasitic, bacterial, or viral infection. He presents examples that illustrate possible pathways by which these microorganisms could contribute to the etiology of MDD.

FUTURE RESEARCH SHOULD SEARCH FOR PARASITES, BACTERIA, VIRUSES “Given this track record of MDD, I propose reconceptualizing the condition as some form of infectious disease,” stated Dr. Canli in a press release. “Future research should conduct a concerted effort search of parasites, bacteria, or viruses that may play a causal role in the etiology of MDD.” In the paper, Dr. Canli presents three arguments why reconceptualizing MDD as

an infectious disease may be a fruitful endeavor. First, he points out that patients with MDD exhibit illness behaviour, and that inflammatory biomarkers in MDD also suggest an illness-related origin. Second, he describes evidence that parasites, bacteria, and viruses infect humans in a way that alters their emotional behaviour. Thirdly, Dr. Canli brings the notion of the human body as an ecosystem for microorganisms and the role of genetics. “Patients who are depressed act as if they are sick— they are lethargic, they lose appetite, they lose interest, they may have a tough time even getting out of bed,” said Dr. Canli during a TED talk at SBU in Oct. 2014. “It turns out that depression is indeed associated with biomarkers of inflammation, a signal of some kind of illness.” Dr. Canli suggests a major research step would be to conduct large-scale studies with depressed patients, controls, and infectious-disease related protocols to determine the association or causal nature of infectious disease and depression. More information at http://ow.ly/I3653 and http://ow.ly/I36e

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Canadian Geriatrics Society

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The CGS has been a leading advocate for high standards in the medical care of the elderly in Canada since 1981. Our membership includes Physicians interested in the care of older patients (Family physicians, Care of the Elderly physicians, Long Term Care physicians, and specialists in Geriatric Medicine), Allied Health Professionals and Medical Residents and Students.

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REGISTRATION T NOW OPEN !!! The Canadian Academy of Geriatric Psychiatry (CAGP) is happy to be holding the annual Geriatric Psychiatry Online Course for Psychiatrics and other Physicians. The course commences November 2014 and runs through to August 2015. Visit www.cagp.ca to register now and find out more information on this highly interactive and educational course.

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Surveying the current

Neurology literature Re-evaluating frequency of deep brain stimulation for PD patients

Lower BMI in patients with essential tremor suggests condition is neurodegenerative

Ineffective Tx of episodic migraine increases risk of progression to chronic migraine

Recently come across something from the peer-review literature that you consider to be interesting or impactful? Share it with your colleagues. E-mail your clippings, along with your comments, to: health@chronicle.org

ow frequency 60-Hertz (Hz) stimulation in patients with Parkinson disease (PD) who undergo bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) demonstrated improved swallowing function, freezing of gait (FOG), and axial and parkinsonian symptoms compared to patients who received routine 130-Hz, according to a study published in the journal Neurology (Jan. 27, 2015; 84(4):415-420).

Researchers studied seven patients with PD who experienced FOG that persisted despite routine 130-Hz stimulation and dopaminergic medication. Each patient received three modified barium swallow (MBS) studies in a single day under three DBS conditions in the medication-on state: 130-Hz, 60-Hz, or DBS off, in a randomized double-blind manner. The laryngeal penetration and aspiration events were cautiously assessed, and a swallowing questionnaire was completed. The Unified Parkinson’s Disease Rating Scale, Part III motor score, axial subscore, tremor subscore, and FOG by a questionnaire and stand-walk-sit test were also assessed. The best DBS condition, in this case the 60-Hz producing the least FOG was maintained for three to eight weeks, and patients were assessed again. The investigators found that compared with the routine 130 Hz, 60-Hz stimulation significantly reduced aspiration frequency by 57% on MBS study and perceived swallowing difficulty by 80% on questionnaire. It also significantly reduced FOG, and axial and parkinsonian symptoms. The benefits at 60-Hz stimulation persisted over the average sixweek assessment. —Find more information at http://ow.ly/IaTAt

atients with an essential tremor (ET) were found to have reduced body mass index (BMI), according to a study published in the European Journal of Neurology (Feb. 2015; 22(2):384-388). This finding adds to the growing evidence that essential tremor is a neurodegenerative disease.

Researchers enrolled 382 ET cases and 392 controls in a study of the environmental epidemiology of ET at Columbia University Medical Center and measured the weight and height of each participant using a standard protocol. Daily calorie count (kcal) was also calculated using the Willett Semi-Quantitative Food Frequency Questionnaire. Finally, tremor severity was assessed with a clinical rating scale (total tremor score, range 0–36). BMI was lower in ET cases than controls [26.7 ± 5.0 (median=26.2) vs. 27.7 ± 5.6 (median=26.7), p=0.03] despite the fact that the daily caloric intake was marginally higher in ET cases than controls (p=0.09). In ET cases, BMI was not associated with tremor severity (Spearman’s r=-0.02, p=0.66) but, among younger onset ET cases, longer tremor duration was associated with lower BMI (Spearman’s r=-0.14, p=0.049). The authors concluded that the observed lower BMI in ET is consistent with the neurodegenerative hypothesis of ET. Furthermore, that the data suggests that some mechanism other than decreased daily caloric intake or an involuntary movement-related increased burning of calories is likely to account for this case-control difference. —Find more information at http://ow.ly/I7fxR

neffective acute treatment of episodic migraine (EM) is associated with an increased risk of newonset chronic migraine (CM) over the course of one year, according to the findings published online in the journal Neurology (Jan. 21, 2015).

Researchers tested the hypothesis that inadequate treatment of EM could result in CM by looking at data from the EM respondents from the 2006 American Migraine Prevalence and Prevention Study who completed the Migraine Treatment Optimization Questionnaire and who provided outcome data in 2007. Among the 5,681 eligible study respondents with EM, 31% progressed to CM. Only 1.9% of the group with maximum treatment efficacy developed CM. Rates of new-onset CM increased in the moderate treatment efficacy (2.7%), poor treatment efficacy (4.4%), and very poor treatment efficacy (6.8%) groups. In the fully adjusted model, the very poor treatment efficacy group had a more than two-fold increased risk of new-onset CM (odds ratio=2.55, 95% confidence interval 1.42–4.61) compared to the maximum treatment efficacy group. The authors concluded that improving acute treament outcomes might prevent new-onset CM. They noted that reverse causality cannot be excluded. —Read more at http://ow.ly/I7fZt February 2015 n 11

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CPA advocates for improved mental health care for

LGBTQ communities By Emily Innes,

Assistant Editor, The Chronicle

CANADIAN PSYCHIATRIC Association (CPA) is receiving praise for the position paper it released concerning mental health care for people who identify as lesbian, gay, bisexual, transgender, and (or) queer (LGBTQ) (The Canadian Journal of Psychiatry Nov. 2014; 59(11):Insert 1–7). The CPA’s paper that advocates for decreased stigma and discrimination for this population, as well as a better understanding of their mental health needs, has been recognized as being an important reminder of the special challenges these communities face. Some psychiatrists, though, have noted its brevity and certain omitted topics. “The CPA position paper seems well intentioned and is a step toward improving mental health care for LGBTQ people in Canada,” said Margaret Robinson, PhD, an affiliate research scientist at the Centre for Addiction & Mental Health’s Re:searching for LGBTQ Health team in Toronto. “The CPA’s recommendations about better education, rejecting conversion therapy, and the importance of supportive housing, health, and educational facilities are timely and necessary.” Dr. Robinson continued, “The real question is, what is the CPA Dr. Robinson willing to do if a member rejects these recommendations? Are they able to sanction a psychiatrist who offers conversion therapy? Are they working with funders to stop research that damages the lives of LGBTQ people? I would like to see the position paper have more teeth.” Dr. Allan Peterkin, a professor of psychiatry and family medicine at the University of Toronto and the co-author of the book Caring For Lesbian and Gay People: A Clinical Guide, said the guidelines are an important reminder of the obstacles most of this population has experienced within the health care system and the ongoing discrimination faced within their families, schools, places of worship, workplaces, and communities. “The document asks us to pay Dr. Peterkin attention to the language we use and to challenge assumptions we make about gender and human sexuality,” Dr. Peterkin told THE CHRONICLE OF NEUROLOGY + PYSCHIATRY in an e-mail. The co-authors—Dr. Albina Veltman, an associate professor in the Department of Psychiatry & Behavioural Neurosciences and the diversity and

February 2015

Flickr: William Murphy (Infomatique)

position paper and that they feel the topic is extremely important,” said Dr. Veltman, a member of the Board of Directors of the Canadian Professional Association for Transgender Health. Dr. Veltman said she believes all the recommendations are important though she recognizes number eight as being of great significance. In number eight, the CPA condemns the use of conversion therapy as its use assumes that those who identify as LGBTQ have a mental disorder and that the person could and should change their sexual orientation or their gender identity. “[Conversion therapy] is a practice that is less and less common but still practiced in Canada. I think it is important that the CPA took a stand and said ‘we consider it something that needs to stop’,” said Dr. Richard Montoro, a professor in the Department of Psychiatry at McGill University in Montreal. “The rest of the recommendations are important as they support what most Canadians already endorse, such as discrimination against a population causes problems and we should be working hard at eradicating discrimination.”

engagement chair of the Undergraduate MD Program at McMaster University in Hamilton, and Dr. Gary Chaimowitz, former president of the CPA, professor of psychiatry at McMaster University, and head of service of forensic psychiatry at St. Joseph’s Healthcare Mountain Site—began the paper by identifying psychiatry’s past strained relationship with the LGBTQ community. “Psychiatry has a history of conflating LGBTQ identities with mental illness and has, therefore, historically contributed to the stigma and discrimination faced by people who identify as LBGTQ, affecting not only their mental health but also their access to appropriate mental health care,” the authors wrote. “Many of my colleagues have commented that they are appreciative of the guidance offered by the

STATEMENT NEEDED MORE FOCUS ON YOUTH Dr. Montoro said he would have liked to see a greater focus on youth and LGBTQ families in the position paper. While recommendation number five supports fostering “care environments and juvenile justice programs that promote an understanding and acceptance of all youth, regardless of their sexual orientation, gender identity or gender expression,” he would have liked the paper to touch on the need for positive community spaces for chil—please turn to page 17

—Continued from page 3

REFERENCES

1. Veltman A, Chaimowitz G: Mental health care for people who identify as lesbian, gay, bisexual, transgender, and (or) queer. Can J Psychiatry 2014; 59(11):S1-S7. 2. McIntosh C, Bialer, P: Diversity, our strength. J Gay Lesbian Ment Health 2014; 18(3):245–246. 3. Meyer IH: Prejudice, social stress and mental health in lesbian, gay and bisexual populations: Conceptual issues and research evidence. Psychol Bull 2003; 129:674–697. 4. Kruks G: Gay and lesbian homeless/street youth: special issues and concerns. J Adolesc Health 1991; 12(7):515–518. 5. Follins LD, Walker JJ, Lewis MK: Resilience in black lesbian, gay, bisexual, and transgender individuals: A critical review of the literature. J Gay Lesbian Ment Health 2014; 18(2):190–212. 6. Hamblin RJ, Gross AM: Religious faith, homosexuality and psychological well-being: A theoretical and empirical review. J Gay Lesbian Ment Health 2014; 18 (1):67–82. 7. Bialer P, McIntosh C, Barber M: New perspectives on sexual orientation change efforts. J Gay Lesbian Ment Health 2015; 19(1):1-3. 8. Drescher, J: Can sexual orientation be changed? J Gay Lesbian Ment Health 2015; 19(1):84-93. 9. Ryan C, et al: Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs 2010; 23(4):205–213. 10. TransPulse: Impacts of Strong Parental Support for Trans Youth. http://www.transpulseproject.ca, 2012. 11. AGLP: The Association of Gay and Lesbian Psychiatrists. http://www.aglp.org, 2015.

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New suicide checklist could improve accuracy of assessment

n The Osler Suicide Interview Checklist enhances post clinical interview, which is still best practice by Louise Gagnon,

Correspondent, The Chronicle

HE OSLER SUICIDE INTERVIEW CHECKLIST (OSIC) acts as an adjunct to an expert interview for clinicians who are performing a suicide risk assessment, says the chief of psychiatry at William Osler Health System, with hospital sites in Brampton and Etobicoke, Ont. “This is a self-audit tool for the experienced clinician,” said Dr. David Koczerginski, during a symposium on emergency and acute care psychiatry at the annual meeting of the Canadian Psychiatric Association. “It should be used after the expert interview but prior to any decision being made about discharging a patient. He explained the OSIC contains 25 items and groups the items under categories such as the presence of depressive symptoms, the presence of suicidal thoughts, the presence of substance abuse, and any history of suicide or suicide attempts in an individual’s family. One of the main responsibilities of the hospital-based psychiatrist is to perform suicide risk assessments and determine if patients can be discharged or whether they should be admitted to hospital or remain in Dr. hospital, explained Dr. Koczerginski. Koczerginski Given diminishing resources at many acute-care hospitals in Canada, not all patients who undergo a suicide risk assessment can be admitted for overnight stays as a precautionary step, said Dr. Koczerginski. It can certainly happen that some elements of a thorough assessment of suicide risk can be overlooked in a busy clinical practice, said Dr. Koczerginski.

OSIC USEFUL FOR REDUCING ERRORS IN RISK ASSESSMENT “A clinician can be very rushed in a real-world setting,” he explained. “There can be distractions like phones ringing or pagers going off. They may be interrupted by others. Because of time pressures, many clinicians may miss a crucial area of inquiry. That’s not a function of lack of skill or knowledge. That is a function of the work that we do.” The checklist acts a reminder to inquire about important details such as family history, according to Dr. Koczerginski. “Our hope is that it [OSIC] will help ensure adequacy and comprehensiveness of documentation of risk assessment. A single mistake can lead to a catastrophic outcome.”

The OSIC can be used very quickly and ensures that clinicians have done their due diligence in terms of suicide risk assessment, he said.

NEED TO BUILD GOOD PATIENT-PHYSICIAN RAPPORT Clinicians will be able to perform a more accurate assessment of the risk of suicide in a patient if they are able to develop a rapport with the patient. “You will get a better assessment of the level of risk [of suicide] if you have good clinical engagement with the patient,” said Dr. Koczerginski. There may be some resistance to clinicians incorporating the use of a checklist in their workflow, but Dr. Koczerginski noted that the use of a checklist is common in other areas of medicine, such as surgery, and other professional areas, such as aviation. Specifically in 2008, the World Health Organization published a set of guidelines to ensure the safety of surgical patients. In 2009, the checklist was modified with a goal to decrease major surgical complications and proved to be effective. Surgery has a reported mortality rate of 100 per million surgeries, and a field like civil aviation has reported a mortality rate of less than one in a million exposures, but still uses checklists. “It is not a question that surgeons do not know how to do surgery or pilots do not know how to fly planes,” said Dr. Koczerginski. “It is about avoiding catastrophic outcomes.” There are growing external pressures on Canadian hospitals and other healthcare facilities to ensure appropriate accreditation. Accreditation Canada accredits hospitals with a goal to improving the quality and safety of care. Accreditation Canada states that institutions have required organizational practices, and various types of risk assessment fall under these practices. Risk assessment of suicide is one of the types of assessments that is required on the part of hospital clinicians. For the time being, the OSIC is available in paper format but it may be available on digital platforms in the future, said Dr. Koczerginski. Preliminary data suggest that psychiatrists who have used the OSIC have found it to be helpful in capturing relevant items to make certain the suicide risk assessment was thorough, he noted. Canadian acute-care hospitals can consider adopting the OSIC in their suicide risk assessment. Dr. Koczerginski stressed that if a patient is in an emergency room and intoxicated, the expert interview and the OSIC checklist have to be delayed until the patient is lucid and sober. Only then can the interview be conducted and the checklist administered.

rTMS treats the prefrontal cortex to provide control

—Continued from page 9

and effective for the treatment of suicidal inpatients, according to data published in Brain Stimulation (May 2014; 7(3):421–431). This prospective, two-site, randomized, active sham-controlled (1:1 randomization) design study involved 41 inpatients who were admitted to the hospital for suicide ideation. Over the course of the investigation rTMS was delivered to the left prefrontal cortex with a figure-eight solid core coil at 120% motor threshold, 10 Hz, 5 second (s) train duration, 10 s intertrain interval for 30 minutes (6,000 pulses) three times daily for three days (total 9 sessions; 54,000 stimuli). The authors noted that sham rTMS used a similar coil that contained a metal insert blocking the magnetic field and utilized electrodes on the scalp, which delivered a matched somatosensory sensation. “Findings revealed that after just one day of rTMS treatment the patients who received active rTMS rather than sham

rTMS had their Beck Scale of Suicidal Ideation (SSI) remarkably reduced—actually cut in half,” Dr. George said. “After three days of treatment the two groups normalized; however, the visual analog scale in patients who received active rTMS was found to be significantly less.” Dr. George said that the common comment from these suicidal patients regarding their thoughts prior to a suicide attempt was that they thought their life was out of control and they could not see any other option. “The prefrontal cortex designed for flexibility and problem solving was not working well in these suicidal patients, resulting in their feeling of loss of control,” said Dr. George. “These patients were not psychotic. They were just not seeing the world as others see it. Their prefrontal cortex was just not working properly and rTMS treatment helped them feel more in control and less suicidal.”

Meetings

Mar. 18-22, 2015 The 12th International Conference on Alzheimer’s and Parkinson’s Diseases Nice, France Contact: Registration Phone: 41-22-908-0488 E-mail: adpd@kenes.com Website: http://ow.ly/wkMK8 Mar. 20-22, 2015 International Medicine in Addiction 2015 Melbourne, Australia Contact: Registration Phone: +61 (3) 8699 0300 E-mail: nfsi@racgp.org.au

Mar. 21-25, 2015 6th World Conference of Sleep Medicine Seoul, South Korea Contact: Registration Phone: +1.507.316.0084 E-mail: info@wasmonline.org Mar. 22-25, 2015 6th World Congress on Women’s Mental Health Tokyo Contact: Congress Secretariat Phone:81-3-5216-5318 E-mail: iawmh2015@congre.co.jp Website: http://www.congre.co.jp/iawmh2015

May 16-17, 2015 The Society of Biological Psychiatry 70th Annual Scientific Meeting Toronto Contact: Registration Phone: 1-904-953-2842 E-mail: maggie@sobp.org May 16-20, 2015 American Psychiatric Association 168th Annual Meeting Toronto Contact: Registration Phone: 1-703-907-7300 E-mail: registration@psych.org June 3-6, 2015 The 17th Annual Conference of the International Society for Bipolar Disorders Toronto Contact: Registration Phone: +41 22 908 0488 Fax:+41 22 906 9140

June 9-12, 2015 Canadian Neurological Sciences Federation 50th Congress Toronto Contact: Registration E-mail: cnsf@intertaskconferences.com Website: http://congress.cnsfederation.org/

February 2015 n 13

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New technology available to better explore seizure networks n Need to harness advanced technology to find treatment for non-lesional epilepsy patients

by Emily Innes,

Assistant Editor, The Chronicle

N ASSISTANT PROFESSOR IN neurology at the University of Michigan, who utilizes his expertise in biomedical engineering to help determine new ways to treat seizures in patients with uncontrolled seizures, believes this is the “golden age of technology” that will lead to a better understanding of the brain’s seizure networks. During his presentation at the Canadian League Against Epilepsy’s biennial meeting in October 2014 in London, Ont., Dr. William Stacey said technology that is routinely used to diagnose patients with epilepsy (i.e., magnetic resonance imaging (MRI) and electroencephalography (EEG)) were once considered state of the art but it is clear they are insufficient to characterize epilepsy completely. “We have not really applied much of our technological advances into modern medicine,” he said, but noted at the same Dr. Stacey time that this is changing. “Overall we have been unsuccessful in one-third of our [seizure] patients,” he said. “I think one of the biggest problems and reasons for this is that our technology has not had the resolution necessary to understand epileptic networks, but that barrier is basically gone now.” Dr. Stacey explained that the technology for monitoring cells is available, mathematical tools have been developed to understand the networks, and it is now possible to build small devices to monitor animals and humans with very high precision through improved engineering. “People are latching on to [this] and we will be able to understand more of what is going on,” he said.

NON-LESIONAL EPILEPSY PATIENTS DIFFICULT TO TREAT The patients that are the most difficult to treat have a form of epilepsy known as non-lesional. During his talk titled Understanding seizures: new theories, technologies and techniques, Dr. Stacey presented numerous examples of clinical data looking at non-lesional epilepsy as a model of trying to understand what type of biomarker can be found in these patients to better understand seizure networks. Dr. Stacey explained that if the seizure is coming from the temporal lobe—lesional or non-lesional—then those patients are good candidates for surgery. However, if the seizures are extra-temporal there is only a 40% chance of seizure freedom with surgery (J Neurrosurg 2006; 104:513). “It turns out that the non-lesional cases may not be so non-lesional,” said Dr. Stacey, highlighting one of the challenges of understanding these complex seizures. “We use that term based on MRI [results].” Dr. Stacey referenced a study conducted at the Cleveland Clinic Epilepsy Center that looked at 95 “non-lesional” patients. On examination of their pathology after resection it turned out only 7% were actually non-lesional. The only pathology that correlated with outcome in the remaining 93% was a high rate of hippocampal sclerosis (Mod Pathol 2013; 26:1051–1058). EXAMINING THE FOCAL ICTAL BETA One biomarker has been found in neocortical epilepsy called

14 n February 2015

the focal ictal beta. (Dr. Stacey said other names for the biomarker include focal icta gamma, low voltage fast activity, beta buzz, and gamma buzz.) If this can be removed then the patient has a high probability of a good outcome (JAMA Neurol 2013; 70:1003). “If we could understand this low voltage fast [LVF] activity perhaps we could understand the seizure network better,” said Dr. Stacey.

USING MICRONETWORKS TO RESEARCH EPILEPSY During his presentation, Dr. Stacey presented different ways of researching epilepsy and understanding LVF, such as the work of researchers with micronetworks. LVF, according to Dr. Stacey, can be seen as a microcosm of epilepsy and the amount of tissue producing the LVF activity is a number of cells that can actually be recorded. Using a Utah microelectrode array (marketed as NeuroPort Array)— smaller than a coin with 100 microelectrodes—Dr. Sydney S. Cash, et al, with the Department of Neurology at Massachusetts General Hospital, found that many pyramidal cells paradoxically stop firing during seizures (Nat Neurosci 2011 14:635). That study also corroborated previous animal research showing that the beginnings of seizures are desynchronized contrary to previous beliefs about seizures patterns (J Physiol 013 591:787). Instead, cells do not become synchronized until later, when the seizure enters the clonic phase. Dr. Stacey referenced a study conduced by Dr. Catherine A. Schevon, with the Department of Neurology at Columbia University in New York, who “got lucky” and placed the Utah microelectrode array directly into the focus of the seizure. She found another form of fast activity never seen with normal electrodes, which was different from the LVF activity. This study suggested that when a researcher is looking at the LVF activity, perhaps they are actually only seeing the reaction to the seizure (Nat Commun 2012, 3:1060). “We show that there is a sharp delineation between areas showing intense, hypersynchronous firing indicative of recruitment to the seizure, and adjacent territories where there is only low-level, unstructured firing,” stated Dr. Schevon, et al. Dr. Stacey said that Dr. Schevon’s findings raise the question about whether the region with LVF activity may actually be the wong target for resection. “I’m not sure if that is true or not but it is very intriguing.” Using even greater resolution with the thin-film microelecrode arrays, researcher Johnathon Viventi at Duke University’s Pratt School of Engineering observed that rather than seizures being just a burst they may manifest as a spiral wave in the neocortex with a final burst at the end. “The developments reported here herald a new generation of diagnostic and therapeutic brain-machine interface devices,” stated the authors of the study called “Flexible, foldable, actively multiplexed, high-density electrode array for mapping brain activity in vivo” (Nat Neurosci Nov 2011; 14(12):1599–1605).

ALGORITHMS NEEDED TO MAKE SENSE OF THE DATA Many groups are now using fast calcium imaging and cameras to monitor thousands of cells at a time. The dilemma with the large amount of data, noted Dr. Stacey, is finding a way to process the information. —please turn to page 15

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Genetic testing will aid empirical measures for epilepsy risk

—Continued from page 1

mutations in many different genes, and mutations in different locations in those genes, are implicated in epilepsy, most diagnostic labs now offer gene panels that look at about 30 different genes at the same time, he says. “That leads to various experimental strategies that we could not afford before,” says Dr. Cossette. “What we are doing with this approach [whole genome or exome sequencing] is to sequence two or more affected individuals within the same family. Then you look for a genetic variant that will be shared by those individuals, and after that you can test the other members of the family. The advantage of doing that is sometimes you have a phenocopy [a similar presentation of epilepsy with a different cause]. You know epilepsy is quite common in the population, so if you do linkage analysis and you have a phenocopy in your family, it might be very difficult to map the gene. By doing that, it can allow a certain level of error.” This technique also allows researchers to compare two populations, says Dr. Cossette. That could include comparing the epileptic population to the general population, or comparing cases of epilepsy that are pharmaco-resistant to cases that are doing well on anti-seizure medications, he says.

GENETIC TESTING STILL OFTEN DOES NOT FIND MUTATIONS While genetic screening tools have improved, they are not the whole solution, says Dr. Ruth Ottman, a professor of epidemiology in neurology at the Columbia University Mailman School of Public Health and deputy director for Research at the G. H. Sergievsky Center in New York City. “Even though we have made a lot of progress with gene identification and will continue to make a lot of progress, it is still the case that few patients have mutations in any of the genes we have found so far,” says Dr. Ottman. Genetic Dr. Ottman testing will not reveal mutations in most patients, and even if it did most forms of epilepsy do not follow Mendelian inheritance, so empirical risk estimates are needed, she says. Dr. Cossette divided epilepsy with a genetic cause into

several categories, including monogenic epilepsy or transmitted genes, de novo mutation, and somatic mutation. He says the same gene mutation presents different inheritance risks depending on how it was acquired. Monogenic epilepsy— inheriting a mutated gene from a carrier parent—presents the highest risk that a parent or sibling might also have epilepsy. De novo mutation primarily increases the risk of inheritance to the patient’s offspring, and a somatic mutation—one which appeared after the formation of the patient’s zygote—presents almost no risk of inheritance. The typical approach to genetic evaluation in epilepsy has been to do a complete clinical evaluation followed by a complete family history evaluation, then determining if the history is consistent with a known syndrome with identified genes that can be tested for, says Dr. Ottman. If not consistent with a known syndrome, the physician then provides an empirical risk assessment.

LESS NEED TO MATCH SYNDROME WITH SPECIFIC GENE What has changed is that genetic testing is done much more often and there is less need to match a syndrome with a specific gene, Dr. Ottman says. Gene panels help overcome the challenge of keeping up with the known relationships between genotypes and phenotypes, she says. “So we still need empirical risk estimates. And the data for these estimates have to come from well-designed epidemiologic studies,” says Dr. Ottman. These studies should be populationbased and restricted to incidence cases, she says. They need to be broken down by the proportion of specific classes of relatives—parents, siblings, and offspring—affected in a given group of patients, taking into account the age of the relatives to account for change in risk through their lifetime, she says. There are a number of potential sources of bias in these population studies, Dr. Ottman acknowledges, including relatives of people with epilepsy being more likely to attend a specific clinic, patients with certain types of epilepsy being more likely to present at a given clinic, or severity of epilepsy increasing patient likelihood to present at a clinic, for example. To rule out these sources of bias, population-based studies that include all cases of epilepsy regardless of family history or type of epilepsy are needed.

Utilizing technology to find biomarker that predicts seizures

—Continued from page 14

Algorithms are needed to make sense of the findings from thousands of cells being monitored. Dr. Stacy noted an alternative to recording from all the cells is to analyse the dynamics of a large group of cells. This method makes use of generic state variables that describe the system as a whole, and can predict some of the mechanisms of seizures. He spoke about a recent algorithm that he codeveloped with physicist Viktor Jirsa and electrophysiologist Christophe Bernard, both from Marseille, France. “The prediction from Viktor’s model was that any brain can seize,” said Dr. Stacey. “This is interesting for people with epilepsy because it carries a social stigma. But if you think about it everyone of us could be made to have seizures even if we did not have epilepsy with bioelectrical stimulation or drug administration.” Dr. Stacey continued, “In every brain, there is a certain

threshold to having a seizure. If it is big, then you never cross into seizure regime. If it is small, it is easier. Perhaps that is a way of thinking of epilepsy.” One of the reasons it is difficult to be able to predict a seizure before they occur is because there are so many different pathways to reach a seizure, Dr. Stacey said. “We assume that every patient would always approach the seizure in the same way but that mathematically is not necessary.” Dr. Stacey concluded by posing the question: “Is there some biomarker that we could find that if we monitored it, we could test how far a patient was from seizures?” Until now, clinicians have always relied on low-resolution technology to monitor epilepsy, its limitations have been reached, he stated. “Now, however, new technologies, techniques and theories are available that may allow us to treat the patients that previously have been beyond our capabilities.”

Clinical Trials

n Investigators are seeking patients

between the ages of two and 15 years with a clinical diagnosis of new-onset or recent-onset epilepsy for a trial to test the safety of topiramate monotherapy compared with levetiracetam in this patient popluation. The study consists of three parts: screening 28 days before the study commences; one year of treatment, and post-treatment after 30 days. Safety will primarily be evaluated by percentage of participants with kidney stones and change from baseline in bone mineral density at 12 months. Interested participants are requested to visit this link: http://ow.ly/IaWWT —Find more information at http://ow.ly/IaX1P

n Children between the ages of eight

and 14 years with epilepsy confirmed by a pediatrician who has had a seizure within the past year, are being asked by researchers to participate in a study looking at if enhanced physical activity can improve children with epilepsy’s functioning, psychological well-being, and quality of life. To participate contact Sabrina Hamer at 613-7377600 ext 6051 or shamer@cheo.on.ca —More info is available at http://ow.ly/IaY92

n Researchers are looking for

patients between the ages of 18 and 65 years with focal epilepsy to participate in a study that will evaluate the effect of different intravenous doses of lacosamide on continuous EEG. In addition, this study will assess the effect of IV lacosamide on EKG. Patients are randomly assigned to receiving one of three different doses of lacosamide (100 mg IV, 200 mg IV, or 400 mg IV). To participate contact Dr. Richard McLachlan at 519-663-3293, rsmcl@uwo.ca or Suzan Brown at 519-685-8500 ext 32870, suzan.brown@lhsc.on.ca

—More details at http://ow.ly/Ib0Zz

February 2015 n 15

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Film review: ‘Finding Vivian Maier’ captures psychiatrist’s imagination n Reviewer Dr. Katalin Margittai explores Vivian Maier’s possible psychiatric conditions based on the documentary Finding Vivian Maier

What follows is an impressive series of interviews ECENTLY NOMINATED AS AN OSCAR contender with Vivian’s employers and her former charges (now for best documentary film at the 2015 Academy grown up), presented roughly in chronological order. It Awards, Finding Vivian Maier is a well researched begins with reminisdetective story that leaves as cences from those much unsaid as it does uncover. who met her in her The challenge of tracking twenties when she first down the mysterious owner of started her work as a a box of photos and undevelnanny, and ends with oped films purchased at an auccomments by neightion house is chronicled over 84 bours who had brief minutes in this compelling doccontacts with her umentary by first-time filmtoward the end of her maker John Maloof and veterlife when she was in an Charlie Siskel. her eighties. It is here In choosing to focus on the that Maloof ’s lack of process, Maloof engages us in a formal psychological sweeping journey that spans two training hobbles an continents, five years, and innuotherwise riveting merable interviews with those unravelling. The interwho knew Vivian Maier in differviewer does not seem ing capacities. From the beginProduction: to follow any specific ning, we are drawn in by the Ravine Pictures strategy in his quesalmost willful lack of clues—a Finding Vivian Maier, tioning; simply allowslip of paper with her name on it first released 2013, 84 minutes ing whatever comes up that leads to a dead-end on to pass, without any Google; the contents of her further scrutiny or follow-up. Unfortunately for us, the boxes are unorganized and unlabelled; and nobody at the film goes broad, not deep. auction house knows anything about her. What emerges is a Rorschach image of a woman Much like a first encounter in psychotherapy, we born in New York, who often adopts a French accent, see hints and suggestions that will require much calls herself different names, and lives on the fringes of patience and perseverance to properly grasp their significance. Then, several months later, we get a break. society with no real friends, and working as a nanny ForGoogle February 2015 an issue of Chronicle oftaking Neurology &photographs. Psychiatry Another search retrieves obituary and, as while thousands of There are hints Sherlock would say, the game is afoot. of possible childhood trauma, or sexual abuse, mostly

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PSYCHOLOGICAL POST-MORTEM OF VIVIAN MAIER This documentary will undoubtedly spur many a psychological post-mortem on Maier. Did she have chronic post-traumatic stress disorder or a primitive personality organization? Did she have a hoarding disorder as described in The Diagnostic and Statistical Manual of Mental Disorders 5, or —please turn to page 17

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CARIBBEAN PSYCHIATRY AND PRIMARY CARE

driven by her chronic lack of intimate relationships; her recurrent comments to her charges about how men were not to be trusted and only wanted to hurt you; as well as her growing collection of newspapers that sport headlines about violence, rape and murder. We see her hoarding compulsion escalate over time, and hear about her screaming in rage when some of the old newspapers were removed. There are hints of rituals, how things had to be done in certain ways, and at least one anecdote of a germ obsession or cleaning compulsion, i.e., dumping one little girl’s toys into a bucket of ammonia. We hear she was secretive as she insisted on a special lock for her room; reluctantly gave an alias to a shopkeeper; and even told one child in confidence that she was a spy. We also get the impression that her warmth and kindness with children eventually gives way over the years to impatience and even cruelty, with hitting and force-feeding one little girl. Throughout it all is the constant collection of images with her Rolleiflex camera. Obsessively, she goes through the slums and unsavory parts of town, as well as the stockyards where sheep and cattle were sorted and slaughtered. She does not even develop the vast majority of her film; she just keeps taking pictures: compulsively, relentlessly, hundreds of thousands of negatives.

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Psychiatrists need more training on unique needs of members of LGBTQ communities —Continued from page 12

dren of LGBTQ parents. “Sometimes the kids feel like they cannot talk about their home life because they feel that it is not really kosher in the school environment,” said Dr. Montoro. “I think it is kind of the last frontier when it comes to homophobia.” Dr. Robinson also wanted the paper to focus more on children and youth, specifically regarding gender expression. “I would like to see the CPA come out against practices that interfere with a child’s gender expression, or that alter an infant’s body to conform to an assigned sex. Some Canadian psychiatrists are still involved in these kinds of practices, Dr. Montoro and we need to be clear that what they are doing is not science.”

MORE TRAINING ON LGBTQ SPECIFIC NEEDS Another critical recommendation, according to Dr. Veltman, is number seven, which encourages educating psychiatric residents and psychiatrists about the potential special issues that might arise when working with people who identify as LGBTQ. “There is still a tremendous lack of education on the topic of LGBTQ mental health in most psychiatric training programs,” said Dr. Veltman. She highlighted a study that found the median number of hours of education on LGBTQ issues in medical schools in North America was only five hours and over 50% of Canadian medical schools reported zero hours of clinical training in LGBTQ health (JAMA 2011; 306(9):971–977). Dr. Veltman is working to improve education on this topic and provides a “Queer Think for Straight Shrink” training session, which she says is always well attended and well received. In collaboration with Dr. Tara La Rose, an assistant professor in the Department of Social Work at Trent University in Peterborough, Ont., she is developing a digital narrative curriculum regarding LBGTQ health to be used in a variety of healthcare professional educational programs. During his residency, Dr. Montoro said he received no training on the LGBTQ communities. However, as a member of The Association of Gay and Lesbian Psychiatrists, based out of the United States, he became

aware of training centres in the U.S. specializing in teaching about the unique needs of LGBTQ patients. In 1999, he co-founded the McGill University Sexual Identity Centre as a centre for excellence in training as well as care. It remains the only program of its kind in the country. “The next level of education is to be able to integrate the LGBTQ diaspora into every day psychiatric teaching,” said Dr. Montoro. “So you do not, for example, whenever you hear that someone is gay [think] it is only to tell you that they have HIV or if you hear that a youth is gay it is only to say he is suicidal. There is so much more to the LGBTQ experience.” Dr. Montoro said this improved education system will occur when society demands it. “I think medicine is always catching up to society and so we are always about five to 10 years behind. As society becomes more inclusive and more curious about the experiences of everyone including trans people, gay people, and lesbian people then eventually the people who teach medicine will also make it part of the education that they present, as well as part of the research question.” The CPA position statement will hopefully also help push forward education on this topic as the document indicates that there is a lot to be learned and a body of accessible information, said Dr. Montoro.

TRANS PEOPLE STILL OFTEN MISUNDERSTOOD Dr. Veltman said another key recommendation is number six, which addresses the need for support from Provincial Health Insurance Plans to cover gender transition treatments. “[This] will hopefully result in positive change across the country as it could be used by advocacy groups to improve access to gender transition treatments nationally,” said Dr. Veltman. People who identify as transgender, according to Dr. Montoro, are often more misunderstood and more strongly discriminated against than others in the LGBTQ group. Some psychiatrists still deny the existence of transgender people, which Dr. Veltman noted is “transphobic and unfounded.” The authors note that gender dysphoria was controversially included in the latest Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 because a concern is that this diagnosis pathologizes

transgender identities, while others believe it should remain in the DSM because it ensures continued access to appropriate transition-related medical treatment Dr. Veltman said in her “personal opinion” gender dysphoria should not be included in the DSM because The World Professional Association for Transgender Health (WPATH) Standards of Care published in 2011, stated that “Being transsexual, transgender, or gender nonconforming is a matter of diversity, not pathology.” The CPA position paper stated support for gender transition treatments for individuals who are appropriately evaluated. Dr. Veltman said that WPATH Standards of Care contain guidance for assessing hormone and/or surgical readiness for individuals who as transgender indentify (http://ow.ly/GmWKl). Dr. Veltman Dr. Montoro said some psychiatrists are anxious about treating trans people because of the irreversibility of the surgery, in the unlikely event of the patient changing their mind. Psychiatrists do not want to cause harm. He said it is important to recognize that the surgery does not take place immediately when the patient comes in the door. It is a lengthy process involving counselling, hormones, and multiple sessions of reassessment along the way. Another area that can be challenging or mismanaged for psychiatrists, according to Dr. Montoro, are patients who identify as LGBTQ who came from different cultures. Sometimes it is not safe for these patients to openly identify as LGBTQ and this needs to be evaluated before setting disclosure as a goal. If the environment is not safe, he says, a more appropriate goal is to simply help their patients to accept who they are. “People seem to think that there is no more homophobia because Canada has gay marriage and attitudes are more accepting. When patients report concerns about coming out in their environment, doctors have a tendency to downplay the reality of homophobia in our society, when it can still very much exist,” said Dr. Montoro. The key benefit of the document, according to Dr. Robinson, is that LGBTQ people and supporters can use it to help with “lobbying for policy changes or advocating for themselves within mental health systems.”

Film ‘Finding Vivian Maier’ illustrates new subtype of hoarding: moments of time

—Continued from page 16

was it OCD with obsessions and compulsions pertaining to cleanliness and hoarding? Did she suffer from bouts of major depression? We will never really know for sure; however, her story raises an interesting point. It may be useful for clinicians to recognize different categories within hoarding disorders: food, money, animals, newspapers, specific objects, and now— moments in time. Vivian was collecting slices of life, moments in time. That she happened to be very talented at it was simply an

ironic coincidence. She did not need to see those pictures; she knew they were there, forever—just like the mountains of newspapers that she collected, but would never reread. I would suggest this might not be a unique, idiosyncratic phenomenon. Identifying this subtype of hoarding in our patients may lead to a correct, though hitherto unsuspected condition in its sufferers, and allow us to better address their affliction. Maloof ’s insistence on portraying Maier as a romantic, mysterious photographic genius detracts from clearly seeing her tragedy: a supremely talented woman whose undiagnosed and untreated mental illness created suffering for herself and her charges, and almost deprived the world of a major artistic talent. While we may not actually find Maier, it is definitely worth looking for her. ABOUT THE REVIEW AUTHOR

Dr. Katalin Margittai is a psychiatric consultant at North York General Hospital in Toronto, and has a private practice specializing in psychosomatics and women’s mental health. When she is not engaged in working or seeing movies, she enjoys taking lots of photographs. February 2015 n 17

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“I do not believe that I have had an interview

with anybody in twenty-five years in which the person to whom I was talking was not annoyed during the early part of the interview by my asking stupid questions.” —Harry Stack Sullivan, American psychiatrist (1892–1949).

Courtesy Dr. Goldbloom

Dr. David Goldbloom

Advancing mental health care in Canada r. David Goldbloom has been recognized for his community leadership in advancing mental health care in Canada with his appointment as an Officer of the Order of Canada. Dr. Goldbloom is a psychiatrist who serves as the senior medical advisor at the Centre for Addiction and Mental Health (CAMH) in Toronto, where he was the founding physician-inchief and serves on the board of CAMH Foundation. In 2012, he was appointed to the chair of the board of the Mental Health Commission of Canada (MHCC). Dr. Goldbloom was an advisor to the Senate Standing Committee that in 2006 produced a major and comprehensive national report on mental health, Out of the Shadows at Last—Transforming Mental Health, Mental Illness and Addiction Services in Canada, which led to the creation of the MHCC in 2007. He is also a professor in the Department of Psychiatry at the University of Toronto. THE CHRONICLE’S Emily Innes spoke to Dr. Goldbloom about being named to the Order of Canada and about mental health care in Canada.

How did you react in June 2014 when Governor General David Johnson called to inform you that you were being named to the Order of Canada? Very simply I was thrilled. I felt very honoured and very fortunate. You do not expect to get a phone call from the governor general. When I got the message to call his office, my first reaction was ‘Oh, no. What have I done wrong at a national level?’ It is a little bit like being called to the headmaster’s office, but it turned out to be a wonderful call.

When and how did you first become interested in a career in psychiatry? I think the way many of us do throughout medicine, we have role models that we get exposed to and I had some terrific role models. I come from a long line of pediatricians, but pediatricians who were very attuned to the psychosocial aspects of pediatrics. My father-in-law [Dr. Nathan Epstein], who is a very distinguished Canadian psychiatrist, was a big influence on me as well. Most important, I think, was the exposure that I had as a medical student to people with psychiatric illness and feeling very intrigued by the complexity of their problems, by the breadth of models of under18 n February 2015

standing and by the rewards of seeing people get better.

Why do you think it is important to advocate for mental health care and to contribute to public service in your community? I think it is important to advocate for mental health care because it is so underserved, under-funded, and underappreciated in a country like Canada compared to the burden of illness on Canadian individuals and family. There is a health economics argument, there is a social justice argument, and there is a simple health benefits argument to be made as to why we should be doing a better job and part of that better job comes from improved understanding through research. Part of it comes through improved services and part of it comes through improved engagement with individuals and their families in mental health care. The good news if you will is that there are lots of opportunities to make things better that everyone has a role to play and a chance to contribute. As for community involvement, frankly it is selfish on my part, in the sense that I have had the opportunity to be involved in things I love like the Stratford Festival [as past chair of the Board of Governors] and the Glenn Gould Foundation [as a former member of the Board of Directors] that are completely outside my professional line of work, but enrich the quality of my life by a chance to participate as a volunteer.

How did you end up so involved with the arts and music culture in your community? I always had an interest in the arts and in music. I did a lot of music and theater as a student, but never at the level that would sustain an income or meet the threshold for professionalism. I would describe myself as a proud amateur. When you are interested in that area, then as you become an adult and have a job, you have the opportunity to support the arts from the sidelines and contribute in that way. I just stepped down as chair at the Stratford Festival. That has been an involvement for the last eight years that has been a wonderful experience for me.

You mentioned there is not enough attention paid to mental health in Canada. Why do you think this is? It is certainly not on the basis of burden of illness because a study done in 2012 by Public Health Ontario [Opening Eyes, Opening Minds: The Ontario Burden of Mental Illness and Addictions Report] showed that, looking at just a handful of mental illnesses and substance use problems, that the burden of illness—as measured by years lived with disability or years lost due to premature death—was 1.5 times greater than the burden of all cancers combined in Ontario. And Ontario is one-third of the Canadian population that happens to live in one province. That is an extraordinary impact—yet it is not reflected in the distribution of resources. I think stigma is another reason. The tides are shifting with regard to stigma, but it still represents a significant barrier for people and their families, around accessing care, about feeling part of their community, and about being able to talk openly about what are pretty common illnesses. M

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What would be an important step at this point to help improve mental health services in Canada? A significant improvement is not going to happen without the involvement of primary care because there will never be enough mental health specialists to see all the people in Canada who experience mental illness, nor should there be. Part of it is improving the breadths of resources in primary care with multidisciplinary teams and improving the collaboration between specialists and mental health services and primary care. At the same time we desperately need to improve the range of available treatments in term of their quality, as well as in terms of innovation and discovery—the brain being the final frontier and the most complicated organ in the body. We desperately need new treatment tools and techniques that outperform those that currently exist. —Who’s making a difference near you? Tell The Chronicle, so we can tell our readers. Write us at health@chronicle.org

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1949).

Courtesy Dr. Goldbloom

CNSF 50th Congress We will be celebrating the 50th Congress of the Canadian Neurological Sciences Federation June 9 – 12, 2015 at the The Fairmont Royal York Hotel in Toronto Ontario

We hope that you will join us for this special anniversary meeting! A BRIEF HISTORY - The original Canadian Neurological Association was established in 1948. The founding meeting was held in Montreal and was attended by Wilder Penfield, Allan Waters, Walter Hyland, Jean Saucier, Francis McNaughton and Roma Amyot. C

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The first annual general meeting of this Association was held at the Royal York Hotel in Toronto and was attended by 38 prospective members from across the country. The association was established to represent neurology, neurosurgery and neurobiology and Dr. Wilder Penfield was named first president. In 1949, the association was renamed the Canadian Neurological Society.

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The Canadian Neurological Society was dissolved in 1965 and two new societies were formed representing two distinct disciplines – the new Canadian Neurological Society for neurologists and the Canadian Neurosurgical Society for neurosurgeons. Together, their liaison committees planned the first annual joint meeting held in 1965 – the first Canadian Congress of Neurological Sciences. In subsequent years, they were joined by the Canadian EEG Society (later named the Canadian Society of Clinical Neurophysiologists) and the Canadian Association of Child Neurology. The Canadian Congress of Neurological Sciences was formally incorporated in 1990 with a board of directors representing each of the four member societies, and with a permanent secretariat office in Calgary, Alberta. In 2006, we became the Canadian Neurological Sciences Federation. The name was changed to better reflect the fact that the organization had been, for many years, a federation of four professional societies. This also helped to distinguish the organization from its annual meeting, which is the Congress. Now, in 2015, we are very proud to be hosting our 50th Congress and we are so pleased to be back at the Royal York Hotel in Toronto. The Congress has seen many changes over 50 years and we are very proud of where we are today. We strive to provide a solid scientific program each year assisted by your input from the evaluations and the hard work of your colleagues on the Continuing Professional Development committee and the Scientific Program Committee. Just as the CNSF has grown, the city of Toronto has also grown, surrounding the Fairmont Royal York Hotel. The hotel was built in 1929, and became a notable landmark. The magnificent architecture of this hotel continues to grace the city’s skyline, and dominate the city’s social scene. Located in the heart of down-town Toronto, the Fairmont Royal York is just steps away from the best night life, dining, shopping and other attractions that the city has to offer. The hotel features an indoor swimming pool, state-of-the-art exercise equipment, steam bath facilities and exceptional spa treatments. Come for the CNSF 50th anniversary Congress and the Royal York will ensure that your every need will be graciously met.

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Indication and clinical use • PRISTIQ is indicated for the symptomatic relief of major depressive disorder • PRISTIQ is not indicated for use in children under the age of 18 • The short-term eﬃcacy of PRISTIQ has been demonstrated in placebo-controlled trials of up to 8 weeks • The eﬃcacy of PRISTIQ in maintaining an antidepressant response for up to 26 weeks, following response during 20 weeks of acute, open-label treatment, was demonstrated in a placebo-controlled trial Contraindications • Concomitant use with monoamine oxidase inhibitors (MAOIs) or within the preceding 14 days • Hypersensitivity to venlafaxine hydrochloride Most serious warnings and precautions • Behavioural and emotional changes, including self-harm: SSRIs and other newer antidepressants may be associated with: - Behavioural and emotional changes including an increased risk of suicidal ideation and behaviour - Severe agitation-type adverse events coupled with self-harm or harm to others - Suicidal ideation and behaviour; rigorous monitoring advised • Discontinuation symptoms: should not be discontinued abruptly. Gradual dose reduction is recommended Other relevant warnings and precautions • Concomitant use with venlafaxine not recommended • Allergic reactions such as rash, hives or a related allergic phenomenon • Bone fracture risk with SSRI/SNRI • Increases in blood pressure and heart rate (measurement prior to and regularly during treatment)

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• Increases cholesterol and triglycerides (consider measurement during treatment) • Hyponatremia or Syndrome of Inappropriate Antidiuretic Hormone (SIADH) with SSRI/SNRI • Potential for GI obstruction • Abnormal bleeding with SSRI/SNRI • Interstitial lung disease and eosinophilic pneumonia with venlafaxine • Seizures • Narrow angle glaucoma • Mania/hypomania • Serotonin syndrome or neuroleptic malignant syndrome-like reactions For more information Please consult the product monograph at http://www.pﬁzer.ca/en/our_products/ products/monograph/226 for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001. Reference: PRISTIQ Product Monograph, Pfizer Canada Inc., July 3, 2013.

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