S10 – Managing Complex Patients: What Happens When Standard of Care Fails?

S10 – Managing Complex Patients: What Happens When Standard of Care Fails?

Le vendredi 20 octobre
10:45 – 11:45 (1 hr)
Salle de réunion : Port Alberni (4th floor – North Tower)
Martin Katzman*, BSc, MD, FRCPC; Martin Katzman, BSc, MD, FRCPC; Irvin Epstein, BSc, MD, FRCPC; Tia Sternat, MS, MPsy, PhD (cand)

Rôles CanMEDS :

  1. Professionnel
  2. Expert médical
  3. Promoteur de la santé

À la conclusion de cette activité, les participants seront en mesure de : 1) Critically evaluate the appropriateness of nootropics, cannabis, ketamine, and psychedelics as part of a comprehensive treatment regimen; 2) Conceptualize comorbid cases by understanding the shared etiology across disorders; and 3) Consider the incorporation of mindfulness approaches in their practice.

Despite advances in research and pharmacology, most treatment outcomes in psychiatry remain unsatisfactory. The severity of psychiatric illness is often associated with comorbid psychiatric and medical conditions. Up to 34% of people with difficult-to-treat depression may also have undetected attention-deficit hyperactivity disorder (ADHD). Treating severe and highly comorbid cases requires an understanding of underlying neurobiological mechanisms that contribute to shared presentations, including poor sleep, concentration difficulties, or anhedonia. By identifying these mechanisms, targeted approaches may be employed with the aim of improving outcomes in difficult-to-treat cases.
This presentation will review the relevant biology of common and overlapping symptoms and how novel therapeutic options might improve psychiatric outcomes. Presenters will consider the potential of nootropics based on the current evidence in psychiatric disorders. The next area of focus will be recent studies of the neurobiology of cannabis, ketamine, and psychedelics in difficult-to-treat cases, highlighting multiple systems of interest, and therapeutic potential based on the self-medication hypothesis. Comprehensive and multimodal care includes the use of mindfulness meditation, which has shown benefits in reducing ruminations, increasing levels of self-compassion and episodes of emotional reactivity. This presentation will additionally address the evidence supporting the structural application and functional benefits of mindfulness. Finally, the speakers will invite the audience for a discussion regarding their conceptualization of complex cases and future directions of novel therapeutics in the context of improving personalized and precision medicine.

S10a – The Use of Cannabis and Ketamine in Psychiatric Care
Martin Katzman, BSc, MD, FRCPC

À la conclusion de cette activité, les participants seront en mesure de : 1) Review our current understanding of the mechanisms of action of agents such as cannabis and ketamine in relation to their potential in treating psychiatric illnesses; 2) Consider the ability of cannabis and ketamine to target issues of treatment resistance; and 3) Discuss the appropriateness and risk of using cannabis and ketamine within clinical practice.

Issues of poor outcomes in psychiatry have precipitated an increased focus on the role of novel pharmacological agents in difficult-to-treat cases. Complex cases often present with symptoms that stem from an overlap in neurobiological deficits. As such, identifying these deficits and targeting them pharmacologically may improve outcomes. Cannabis in particular is highly used for both recreational and therapeutic purposes. Appropriate cannabis use can improve sleep and anxiety. Yet, misuse of cannabis can cause substance dependence, increased anxiety, and impaired memory. Therefore, it is imperative that clinicians consider the impact of cannabis use within their practice and how the endocannabinoid system is implicated in psychiatric illness.
Ketamine and esketamine have also recently been employed in the treatment of difficult-to-treat depression and suicidality. Although the mechanism of action for these agents remains unknown, the interplay between opiate agonism, NMDA antagonism, and AMPA agonism may offer therapeutic benefits when SOC produces insufficient results. One major benefit of ketamine treatment is improved prefrontal activity, which may supplement deficits seen across diagnoses such as depression, anxiety, and attention-deficit hyperactivity disorder, thereby targeting issues of treatment resistance.
The use of cannabis and ketamine lies in their potential to impact distinct and unique systems when standard treatments fail. By incorporating a diverse set of tools, clinicians may be able to improve targeted treatment outcomes. Simultaneously, clinicians must be cautious of the limitations of novel therapeutics and determine the appropriateness of each approach for each patient.

Références :

  1. Sharma P, Murthy P, Bharath MMS. Chemistry, metabolism, and toxicology of cannabis: clinical implications. Iran J Psychiatry 2012;7(4):149–156.
  2. Andrade C. Ketamine for depression, 1: clinical summary of issues related to efficacy, adverse effects, and mechanism of action. J Clin Psychiatr 2017;78(4):e415–e419.

S10b – Psychedelics and Nootropics for the Management of Psychiatric Disorders
Irvin Epstein, BSc, MD, FRCPC

À la conclusion de cette activité, les participants seront en mesure de : 1) Understand the pharmacokinetics and pharmacodynamics of psychedelics and nootropics in the context of comprehensive treatment of psychiatric disorders; 2) Review the potential and risks associated with the use of psychedelics and nootropics in treating psychiatric disorders; and 3) Discuss the state of existing literature, real-world examples, and future directions of the use of psychedelics and nootropics in psychiatry.

There have been limitations when using existing standard-of-care treatments of psychiatric conditions, particularly in people with comorbidities and polygenetic similarities. Patients with inadequate response to traditional treatments are vulnerable to self-medicate through the use of illicit substances. The use of agents of abuse such as cannabis and psychedelics remains controversial. Cannabinoids have been found to both improve or exacerbate anxiety symptoms; however, there are indicators suggesting that selected psychedelics and nootropics may be useful as adjunctive treatments for psychiatric disorders. As a result, there has been a recent focus on psychedelics and nootropics to improve outcomes.
Studies have hypothesized that psychedelics may be effective transdiagnostically due to their ability to increase neuronal plasticity and neurogenesis, also in altering neural networks and connectivity, which may encourage capacity for change in individuals. Further, nootropics have been claimed to improve cognitive functioning and mood and anxiety symptoms, which could enhance treatment outcomes.
This symposium will discuss our current understanding regarding the pharmacokinetic and pharmacodynamics of psychedelics and nootropics and how they may affect change in the neurobiology and etiology of psychiatric disorders. This symposium will review advances in the literature, case examples, and real-world experiences concerning the efficacy of psychedelics and nootropics as adjunct treatments. At the end of the symposium, the audience will have a better understanding of the therapeutic potential and pitfalls associated with using these agents in psychiatry. The audience will also be invited to discuss future directions for psychiatric disorder treatments, including treatment-resistant comorbidities.

Références :

  1. Sternat T, Fotinos K, Fine A, et al. Low hedonic tone and attention-deficit hyperactivity disorder: risk factors for treatment resistance in depressed adults. Neuropsychiatr Dis Treat 2018;14:2379–2387.
  2. Kočárová R, Horáček J, Carhart-Harris R. Does psychedelic therapy have a transdiagnostic action and prophylactic potential? Front Psychiatr 2021;12:661233.

S10c – Mindfulness Meditation as an Adjunct Treatment for Mood and Anxiety Disorders
Tia Sternat, MS, MPsy, PhD (cand)

À la conclusion de cette activité, les participants seront en mesure de : 1) Review the potential and existing evidence on the efficacy of mindfulness meditations as an adjunct treatment in treating psychiatric disorders; 2) Understand the effects of mindfulness meditation on brain structure, function, and networks; and 3) Review the appropriateness of mindfulness meditation in clinical practice.

Mindfulness meditation has received a surge of interest in terms of its potential role as an intervention for psychiatric disorders. This interest is further amplified by poor adherence, side effects, and treatment resistance, which affects 20% to 60% of people with psychiatric disorders. (1) Studies have shown that mindfulness meditation is effective in improving symptoms for people with anxiety and depression, bipolar disorder, attention-deficit hyperactivity disorder, and treatment-resistant depression. (2) However, mindfulness might be most efficacious as an adjunct to primary treatments. Mindfulness aims to encourage awareness and acceptance to present experiences, allowing the development of strategies in response to distress. This process, known as meta-awareness, has been shown to reduce rumination, increase self-compassion, and reduce emotional reactivity, which all have been shown to predict treatment outcomes. (2) Additionally, brain imaging studies have shown changes in brain structure related to mindfulness, associated with the reduction of stress, improved emotion regulation, attention, and behavioural performance, which further enhances treatment outcomes. The increasing popularity and promising evidence of mindfulness meditation as an adjunct treatment emphasizes the importance for clinicians to investigate its efficacy in treating psychiatric disorders.
This presentation will review the effects of mindfulness on the structure and function of the brain, as well as brain networks related to its potential in reducing symptoms of psychiatric disorders. The audience will be invited to discuss the suitability of mindfulness meditation as an adjunct intervention for psychiatric disorders. To conclude, the speaker will highlight the techniques of mindfulness and their clinical outcomes.

Références :

  1. Howes OD, Thase ME, Pillinger T. Treatment resistance in psychiatry: state of the art and new directions. Mol Psychiatry 2022;27:58–72.
  2. Shapero BG, Greenberg J, Pedrelli P, et al. Mindfulness-based interventions in psychiatry. Focus (Am Psychiatr Publ);16(1):32–39.