From the Editor
“When a Cape Breton cousin of mine was hospitalized at the main asylum for Nova Scotia in the 1940s with psychotic symptoms, his sister told me the family received a phone call from the treating physician telling them to give up all hope for their brother’s future.”
In his new book written with Dr. Pier Bryden, Dr. David Goldbloom – past Chair of the Mental Health Commission of Canada and Senior Medical Advisor of the Centre for Addiction and Mental Health – recalls the story.
Psychiatry is so much better today.
But there is room for much improvement. Uneven outcomes. Provider-focused care. Can we do things differently?
This week, we look at a blog published by HealthAffairs.org, considering the use of clozapine for people with schizophrenia. Dr. Adam Rose, drawing on the research, including his own research, wonders why we don’t use more of this effective treatment.
Then, turning to The Globe and Mail, we look at the life and death of Dr. Kate Granger – a physician who has challenged us health care providers to be more compassionate.
Schizophrenia and Better Care
“Patients With Severe Schizophrenia Aren’t Getting The Help They Need”
Dr. Adam Rose
Health Affairs, 25 July 2016 Blog
Even when effectively treated, schizophrenia can be devastating, impairing a person’s social and family life, ability to work, physical health, and quality of life. Those who have schizophrenia often end up alone and impoverished. Yet the effects of this disease are even worse when treatment doesn’t work.
Treatment-resistant schizophrenia (TRS) is formally defined as schizophrenia that is not well controlled despite adequate trials of at least two medications — a definition that applies to between 20 to 30 percent of patients with the condition. An effective treatment exists for TRS: the anti-psychotic clozapine, which was first used to treat schizophrenia in 1971 and approved for use in the United States since 1989. Multiple studies have shown that clozapine is clearly superior to other treatment strategies for TRS, and that it is the only treatment proven to work for TRS.
Despite this evidence, in most settings only 10 percent of patients with TRS are receiving clozapine — and the percentage is often far lower than that. Although clinical guidelines unanimously recommend offering clozapine after two other medications have not worked, patients are usually given 15 to 20 different medications sequentially over the course of a decade or more before clozapine is considered.
A case could be made that nowhere in medicine is current practice more at odds with medical evidence than the persistent underuse of clozapine to treat TRS.
So opens a blog by internist Dr. Adam Rose.
· Clozapine requires careful monitoring.
· “The main reason patients with TRS do not receive clozapine is relatively simple: The health care system is not equipped to provide it to them.”
· He argues that a more expensive monitoring system would be needed – but could be justified by the savings of wider clozapine usage.
The first-year, per patient savings alone would more than pay for the necessary nurses, pharmacists, drivers, and office help needed to make clozapine easier to administer — and more acceptable to doctors and the patients who would greatly benefit from it.
A few thoughts:
First, this blog is short but it deals with a topic that is big and important. In psychiatry, many of our patients struggle to get access to basic services. It’s also true, though, that access to evidence-based treatments – think clozapine – is even more limited.
Dr. Rose makes good points in his blog. His papers are also highly readable and worth looking at.
The first of the two papers is particularly compelling. The authors make a “business case” for clozapine, arguing that despite the high costs of monitoring patients on this medication, the intervention is a big health-care saver because these patients spend on average 18 days fewer in hospital per year. That works out to a savings of $22,000 per patient. (These calculations are for American patients in the American system, but it’s difficult not to assume that 18 days of less hospitalization would be a cost-saver north of the 49th parallel.) In the second paper, Dr. Rose looks at ways of making clozapine more accessible.
I’ll brag a bit about the efforts of my colleagues at The Scarborough Hospital: we are launching a clozapine program that monitors patients’ blood work in a less intrusive way. This point-of-care, finger-prick blood testing will make the clozapine option more attractive to patients who dislike the idea of the standard weekly blood work and the needles required. Bob Barnes (pharmacist), Dr. Hoa Phuc Nguyen (psychiatrist), Faiza Khalid-Khan (patient care director, mental health), Zehra Bana (clinical resource leader), and Petra Sheldrake (patient care director, laboratory services) have led this first-in-Canada effort, with the support and encouragement of the Senior Team, as part of a larger effort to increase the use of clozapine for our patients.
(Dr. Rose’s blog: Copyright ©2016 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.)
Health Care and Better Care
“Remembering Kate Granger, a champion of human connection”
The Globe and Mail, 26 July 2016
In July 2011, Kate Granger fell ill while on holidays in California. Upon returning home to England, the 29-year-old British doctor was pretty certain she had cancer, but awaited test results in hospital.
‘I’m in pain and alone. A junior doctor comes to see me to talk to me about the results of the MRI scan I’d had earlier in the week. I’d never met this doctor before,’ Dr. Granger recounted in an interview with Cancerworld.
‘He came into my room, he sat down in the chair next to me and looked away from me. Without any warning or asking if I wanted anyone with me he just said, ‘Your cancer has spread.’ He then could not leave the room quick enough and I was left in deep psychological distress.’
Dr. Granger had desmoplastic small round cell cancer, a rare form of sarcoma that was untreatable. She probably had only months to live.
So opens an essay by The Globe health reporter André Picard. The piece recounts the remarkable life and death of Dr. Kate Granger – a young British geriatrician.
Picard writes about Dr. Granger’s early experiences when, almost overnight, she went from being a provider to being a patient.
In the world of cancer, stark and empty, Dr. Granger had a moving experience:
But, one day, when she was to be transported from the emergency room to the urology department, something remarkable happened. ‘Hello, my name is Brian,’ a porter said. He asked if Dr. Granger was comfortable, found an extra blanket because she was cold and chatted while pushing the gurney. ‘He had genuine kindness,’ she recalled.
Dr. Granger goes on to become her country’s most famous patient, launching the “Hello my name is” campaign. The hashtag has been tweeted more than a billion times; “More than 400,000 staffers with the National Health Service in England embraced the philosophy, and there are offshoots in Australia, France, Germany, Italy, the United States and Canada.”
Dr. Granger died in July in hospice care, still tweeting, still having influence.
My final thought: what a remarkable life and what an important message.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.