My name is Faydra Aldridge. Welcome to Look Again. Mental Illness Re-examined, a podcast brought to you by the BC Schizophrenia Society, otherwise known as BCSS, as well as our partner organizations.
Well, I've been tried on eight different medications,
... a lot of the "hundred yard stare" drugs and "hurt your heart" drugs, and finally, a doctor tried the Paliperidone, and that has really worked well for us, so...
Risperidone, with some dosage adjustment, but that worked well for her.
...on Abilify, and a number of other medications. But he takes that one on a monthly injection,
...countless combinations and dosages, and you just end up with this casserole of medications.
Some people with serious mental illness don't like the idea of taking medication for a variety of reasons, and some families of people with mental illness often struggle against the need to take medication because they see it as hindering a person's quality of life. On today's episode of Look Again, we're asking what's at the root of the hesitation around using meds to treat serious mental illness? And how do the medications used to treat disorders such as schizophrenia actually
work on the brain? Why is it so important to start treatment early? These are just a few of the questions we're going to be tackling. Also, we're going to be exploring the public perception of what it looks like when people are "on" or "off" their meds. Our collective literacy with these signs and symptoms is critical to preventing negative interactions, both systemic and personal, with people who suffer from mental illness. Today, I'm joined by Dr. Fidel Vila-Rodriguez from
the Department of Psychiatry at UBC. As a clinician-scientist, Fidel does research looking at the neurobiology of psychiatric illnesses and considers the clinical applications of this knowledge. So in other words, he looks at the biology of mental illness and how we can actually use that information in a clinical setting
to actually help people. So, Dr. Rodriguez, we are so happy you're here today to not only talk about medication, but also about other treatments that work in conjunction with medications that can potentially help people who are affected by serious mental illness. Fidel, I'm intrigued. I'm excited. Welcome to the show.
Thank you so much, Faydra. It's a great opportunity. And I really appreciate being here this afternoon to have this conversation about this very important topic.
So a minute ago, we heard the voices of some people with schizophrenia and their families listing off names of some of the drugs that they need to take for their symptoms. Now, there is a lot of complicated names, and it can be really difficult to figure out what a drug does. So tell us, what are some of the most common medications prescribed for people with schizophrenia?
Absolutely. And I'd like to take just one minute to back up and perhaps make emphasis on why do we give medications to treat schizophrenia? And I think it's important to emphasize that schizophrenia is an illness that affects the brain. And what we know is that the illness affects the brain in a way that makes symptoms like voices, hallucinations or delusions or these very nagging negative symptoms, which means things like a person does not have the strength and
does not have that drive to do things. So that's because the brain is affected by the illness and it's not working. Well, one of the key medications that has been around now since the 1950s when they were first described is called antipsychotics or before they were called neuroleptics. They described generically the same class of medications. These are medications that when we take them, they go to the brain and their mechanism of action is on something called
dopamine receptors. One of the mechanisms and one of the things that happens when someone is suffering schizophrenia and having delusions or hallucinations is that there is a state of, so to speak, too much dopamine acting in the brain. And so what these medications do is work on the dopamine receptors to allow this "too much dopamine" in the brain to go down, and treating the symptoms. So antipsychotics are one of these medications.
When do you decide that a person does, in fact, require this antipsychotic medication?
That's an excellent question. And while there are times when it might not be entirely clear that medications are needed or not, the majority of the times when someone gets to a point that they need to seek help and they need to see a physician, a mental health professional, it means that what drives that need is some sort of impact on their lives. So I think that's very important to emphasize as well. This illness, schizophrenia, this illness of the brain affects people in such a profound way
that it gets in the way in life. And that can look different ways. It can look, a person does not do well at school (when they were doing fine) and struggles a lot. A person starts not seeing their friends, not socializing when they before were doing that, they might not be able to perform at work, or all of the above. So there's an "impact on functioning" that we call it. So the symptoms, the delusions, the hallucinations, the negative symptoms
get in the way in life. And that's what we assess when I see a person who's struggling and the person shares with me that they are having these symptoms, and I ask them whether they are getting in the way. If it becomes obvious that they are getting in the way in a big way, they're interfering a lot with their functioning, it becomes clear that we need to do something to treat the symptoms.
So what is the response that you typically get when you have to tell an individual or a family that they do require medication?
It varies. And there's obviously a range of responses. Sometimes there's a reaction of disbelief. It could be in both families and the person in trying to come to terms with the diagnosis. It's a normal, understandable reaction from families,
from the person suffering the symptoms. And the task at hand is to really go over the impact that those symptoms are having and together work through, really realizing, look, this goes beyond really what you would expect from this breakup, from this stress at work, and it's really interfering in your life. We need to treat. Now for people suffering from this schizophrenia, there is a particular symptom that is very challenging. We call it "lack of insight." It can
be understood as lack of awareness. We take for granted a lot of the things that our brains do for us from walking from paying attention to things, from speaking. One of the things that our brain does is it allows us to be aware of our environment, of how we are doing, where we are thirsty, whether we are hungry. It also makes us aware whether we are struggling with pain or with any other symptoms. In schizophrenia, it's difficult to realize that they are struggling with a medical illness.
That's the lack of insight. So what follows is if a person has difficulty to realize that they are suffering an illness, why would they need treatment? And so that is a very challenging situation.
What you said there is that it's something inherent in the illness itself. And that's what would make it so difficult, because, as you said, how could somebody say and put up their hand and say, I need help, I need treatment, if they don't realize that they're even ill? They don't, if they no longer have the ability to recognize that they have an illness.
And the other aspect is the symptoms that the illness causes generate an experience in the person that is suffering them. And their experience is real. It's what they are experiencing. It's like pain. You can't explain to someone else what you are feeling. You feel the pain all the people might understand, but they don't really feel it.
So now let's talk about other treatments. And I know that some of your research focuses on non-invasive neurostimulation therapies. That's quite a mouthful. So can you tell us a little bit about this type of treatment?
Absolutely. So the mouthful -- what it means -- is that there are ways of treating medical illnesses, illnesses of the brain, that do not involve using a chemical like a medication. The brain is similar to the heart in that it's an electrical organ. When we generate thoughts, when we walk, when we do anything that our brain is involved in, it generates tiny little current. And what these non-invasive neurostimulation therapies do, is leverage that principle of electricity and use currents to
stimulate the brain. And they can do this in different ways. One of the treatments that's been around for a long time and that, still to this date, unfortunately, is still controversial, is called electroconvulsive therapy or ECT. And it's still to this date, the most effective treatment we've got for depression. And it's also very effective to treat schizophrenia. This treatment leverage s a very counterintuitive mechanism. What we do is, when a person is under general anaesthesia, we trigger a
seizure in the brain with external current. When that happens, when we trigger a controlled seizure, there are a lot of good things that happen in the brain. One of them, for example, is there's a release and regulation of those dopamine levels that we talked about earlier with medication. So what ECT accomplishes in the context of treating schizophrenia is it helps regulating, as well, the dopamine levels in the brain.
Tell us about CBT.
So now we are transitioning from these treatments that leverage currents to treatments that rely on talk therapy and traditional CBT or cognitive behavioral therapy. The way that CBT usually is structured is, the person suffering schizophrenia works with their therapist, and they work together to identify these "cognitive biases," meaning
jumping to conclusions, for example. And so by looking at these patterns of thinking and trying to work with the person, then identifying how to modify them not only during the session, but after the session and in between sessions, doing homework and identifying these patterns, eventually it helps the person to leverage these tools and catch whenever they go into this thinking pattern.
Now, with CBT, as well as those non-invasive neurostimulation therapies that we were just talking about, are they used in conjunction with medication then, or are they used instead of medication?
All the current treatment guidelines for schizophrenia clearly identify that the backbone treatment starts with medications, with antipsychotics. In addition, we can add CBT, we can add ECT as an approved treatment for schizophrenia, and there are other interventions that can be used, in addition. But the backbone, when someone is suffering from schizophrenia and actively having positive symptoms, delusions and hallucinations: medications need to be in place.
You're listening to LookAgain, Mental Illness Re-examined, a podcast brought to you by the BC Schizophrenia Society and BC partner organizations. I'm your host, Faydra Aldridge . This podcast would not be possible without the support of the entire community. From the bottom of our hearts, we want to thank you for caring about mental illness together. We truly can make a difference. // So we're back with Dr. Fidel Vila-Rodriguez talking about mental illness, medications and treatment.
My son had anosognosia, which means he did not know he was ill. He was very sick but did not know it, and "he doesn't need medicine." So "what are you talking about?" So he was that for sure, all the way to his death. And so he had to be on forced injections.
Well, firstly, they don't make him feel very well. And so the drugs themselves are hard on them. He doesn't sleep well when he's on the drugs. You know, he-he doesn't feel well. They can create different health issues, weight gain. And that's part of it. Part of it is an acceptance and belief that you have to take them to be healthy too...
... other side effects, of course, is, you know, when he gets his shot that it makes him very slowed down. He doesn't like to be slowed down.
...a lot of problems with him staying on it. He kept going off and back on and off and back on.
So for him, that's his big negative, is that he thinks that he can function well enough, independently, enough without them, that he doesn't need them, that he would be OK.
Slowly, the wheels started turning and they started actually noticing that he can survive. He can go to work full time when he's taking his medication.
He doesn't, he hasn't come to the point where he says, "my life, my quality of life is not good when I when I'm not being medicated."
But he's much, much better. But I was all for it. I'm like, oh, Jesus, just please take your medication. I want my son back.
That was pretty powerful. The last line, I just want my son back, I'm sure you hear that a lot, Fidel, with your patients and the families that you work with. But we also heard families talk about their fear of the side effects and the potential resistance to take medications when they are told that they are necessary to their treatment.
What do you say to families or to the individuals with schizophrenia and serious mental illness that you work with around the need to take medication despite the potential side effects?
I think the clip that we just heard is a very powerful reminder of the testimony of of this suffering and the challenges that people who suffer with schizophrenia and their families go through. And sometimes the very difficult decisions that come on the table, like someone not recognizing they need help and professionals need to resort to involuntary treatment.
Hearing these testimonies from families brought me back to the day-to-day work with families and the realization that there are times when the illness is so severe that gets in the way of the person being able to ask for help. And that's a situation where families, professionals, we don't want to be in that spot. But when we are, we recognize the suffering. Unfortunately, when those situations come to play out that way, involuntary treatment might be the last resort.
But it's the only thing that we can do. That leads me to, to your question about side effects. Any treatment, no matter what medical condition, has the potential of coming with side effects. And the conversation, like in any other field in medicine, boils down to carefully gauge how much benefit and how much risk we are dealing with here. It's very important to carefully describe what are those side effects, what are the chances of experiencing them, and very importantly, what can we
do to minimize the risk of those happening. That last point is a very important one, because it is true that any medication, any treatment has a potential for side effects. But it's also true that we can do things to minimize to make that risk as low as possible. It doesn't go to zero, but we can do things to minimize it.
So, Fidel, at the beginning we talked about when somebody is "on" their meds or "off" their meds, is this something that you hear a lot? Do people go on and off their medications?
People with schizophrenia, they sometimes forget a dose. Sometimes there are situations when there is a need to increase dose. That dose that we were giving stopped being enough and that can lead to symptoms coming back. If someone is not taking all the medication that they need, or they don't, they don't have enough dose that can lead to symptoms coming back. And the way this looks varies a lot from person to person. Families are really good at picking up the cues.
So if a person is on medications, should they be worried about getting the covid vaccination?
We know -- and there's research that has recently come out about this -- that unfortunately, people who suffer from schizophrenia are at higher risk of having Covid and complications from Covid. So we know that. So the risk is even higher. So the need for getting immunized is even more pressing. The vaccine is safe in the general population, as it is
for people with schizophrenia. The only situation that there's been a few case reports and that it's important to pay a little bit more attention, is for people who are taking one particular antipsychotic called Clozapine. Clozapine is the most effective antipsychotic that we have for schizophrenia. But unfortunately, it comes with some side effects and sometimes has been can
be associated with fever... high temperature. Vaccines in anyone can cause a transient, very temporary reaction where we have a little bit of fever. And what this means is they want to make sure to convey, is very clearly, being on Clozapine is not a contraindication for a vaccine. The vaccine is safe. The benefits of getting the vaccine for people with schizophrenia in general far outweigh the potential risk. So it is very important to get vaccinated.
I cannot thank you enough for joining me today, Dr. Rodriguez. It has been absolutely fascinating.
Thank you so much, Faydra.
So just a reminder to everyone who is listening. Thank you for being a part of our show today. We will, of course, be posting all of the relevant links for this conversation in our show notes and of course, on our website www.BCSS.org . I hope you learned as much as I did. And coming up on the next episode, we're going to be looking at concurrent disorders and perceptions around how common serious mental illness is. And trust me. Spoiler alert here. It's way more common than what you think.
Bye for now.
This podcast is brought to you by the BC Schizophrenia Society and the B.C. Partners for Mental Health and Substance Use Information, where a group of non-profit agencies providing good quality information to help individuals and families maintain or improve their mental well-being. The B.C. Partners Members are Anxiety Canada, BC Schizophrenia Society, Canadian Institute for Substance Use Research. Canadian
Mental Health Associations, B.C. Division, Family Smart, Jessie's Legacy, a North Shore Family Services Program, and Mood Disorders Association of B.C., a branch of Lookout Housing and Health Society. The B.C. Partners are funded and stewarded by B.C. Mental Health and Substance Use Services, an agency of the Provincial Health Services Authority. For more information, visit heretohelp.bc.ca