Innovative Mental Health Care: Dr. Karine Igartúa

Dr. Karine Igartúa, psychiatrist-in-chief at the MUHC and co-founder of the McGill University Sexual Identity Centre, speaks with Annie DeMelt. In just 23 minutes, they cover topics ranging from the research that will shed light on gender identity questions and improve the treatment of mental illnesses; innovative programs that reduce hospital stays and promote faster crisis recovery; and the vital importance of lifelong mental health education. 

Learn more about the Montreal General Hospital’s Transitional Day Program, art workshops by Les Impatients, the Brief Intervention Unit, the Centre for Precision Psychiatry, the McGill University Sexual Identity Centre and more, with the co-Lead of the MUHC Mental Health Mission. 

Chapters

• 3:37 Transitional Day Program
• 6:25 Les Impatients art workshops
• 6:55 Brief Intervention Unit
• 8:28 Sexual Identity
• 17:46 Mental health education

Transcript

0:00

We know with most mental illnesses, the longer that they stay in the brain, the harder they become to treat. So if we can treat it in a few weeks rather than a few months, we're going to get better outcomes. Hello, I'm Annie DeMelt, and welcome to this Code Life interview brought to you by the Montreal General Hospital Foundation. Our guest today is Dr. Karine Igartúa, psychiatrist-in-chief of the MUHC's Mental Health Mission. And that mission is to provide the best patient care through innovative programs, but also through research. Researching new ways to make treatment more personalized, more precise. So, Dr. Igartua, thank you so much for being with us. Thank you for having me. Let's start by how incredibly busy you are right now in the departments of psychiatry and psychology. We've gone through a difficult phase for a lot of people's mental health. What are you seeing right now in terms of demand and access to your services? We're in a really tough situation because the demand is increasing or has been increasing for many, many years and the resources have been shrinking. So, you know, when I started my residency, we had-between the old Royal Vic and the old Montreal General- probably about 120 beds in psychiatry. We now have 42. So that's sort of been gradual over time, less beds. With COVID, there's been a lot of people who've decided to retire or leave the health care system. So in terms of personnel, we've got a difficulty, too. But also we have a society that is moving in ways that I want to say is toxic to our brain. Whether it's the higher doses of THC in our now legal cannabis. Whether it's the complete bombardment of our brain, of always being on our phones and on our Zooms and our Teams and in front of a screen, which means that our brain never really has time to relax, cool down. Whether it's also the lack of sleep because people tend to have their phones in their bedrooms and, you know, they binge Netflix late at night and they don't sleep. Or the lack of exercise, because we know that the more time you spend in front of a screen, the less you move around, the less you move around, the less exercise you're getting. And finally, the lack of community and socialization. Even when people... I see it, the kids, when they're together, they're all together sitting on the couch, but everybody is on their own different phone. So they're together but not really together. So that leads to isolation and lack of feeling of connectedness. So there's all of these kind of... this cocktail, these trends that are happening in society that are bad for our mental health. Put that together with difficulty getting first line care. Difficulty accessing a GP if you actually have one, or a psychologist if you're lucky to have insurance. People come to the emergency room because they have nowhere else to go. And some people come for bona fide mental illness. So psychotic disorders or mood disorders. But a lot of people also come with emotional distress, social crises. And the reality is this week in the emergency room, I see a patient who's been there for ten days down in our unit, waiting for a bed upstairs. It's not always that bad, but, a couple of days down in"emerg", waiting for a bed upstairs is absolutely not unusual because we just don't have the capacity. So increased demand, lower capacity or capacity that's not keeping up, which is forcing you to be a lot more efficient with your programs. And you do have a number of specialized programs that are part of the Mental Health Mission. One of them that we're going to talk about is this Transitional Day Program. So who's this for? What population is this? Is this for people in crisis and how is it unique and innovative? So the Transitional Day Program. It's funny to say that it's innovative now because we've had it for 20 years. But it was innovative 20 years ago, and to my knowledge, it's still the only program in the province like this. So essentially we took all of the therapeutic ingredients of a hospitalization. So whether it's seeing an OT to help with goal-setting and organization. Whether it's psychoeducation around illness and illness management. Whether it's identifying emotions and emotional regulation. Coaching about nutrition and exercise. We even have a choir that's part of that. So music therapy. All of the therapeutic ingredients of a hospitalization, but in a day program format. So patients arrive early in the morning, they have a couple of workshops during the morning, they have lunch at the hospital cafeteria. So a bit more normalizing than a tray in your room kind of thing. It creates a socialization and a sort of a group belonging kind of effect. They have a few more workshops in the afternoon, than they might have an individual meeting or two. And then they go home. And the going home is great because it means we're promoting recovery and not regression. So you go home, you still get to walk your dog, you still get to check your emails, you still get to hug your sister. So the going home... The messaging is you're not taking a break from your life. You are in recovery of whatever crisis you're in. And we want to get you back to your life as soon as possible. So TDP was innovative when we started it, and we want to innovate further. So two of the things that we're going to be... We're going to be looking at TDP in terms of adapting some of the therapies so that the patient with the first episode mania might not need exactly the same thing as the patient who is in a suicidal crisis, for instance. So we might be mapping out the trajectories a little bit differently. For that, we need the help of a psychologist. And that's actually great because that's one of the things that the foundation is helping us with. The other project that we want to bring in is Les Impatients. Les Impatients is a community organization. They're well established. It's artists that run workshops for people with mental illness, and they're also recovery-oriented. So we want to bring in Les Impatients so that people in the Transitional Day Program and people in our Brief Intervention Unit have access to this art expression. You talked about mapping out people's trajectory and the importance of planning too, given this this context. For psychiatric emergency care, how does this Brief Intervention Unit do that? What's its role as part of the bigger picture? One of the other things we've done to try and and palliate the lack of beds, but also in terms of being more efficient in treatment is we opened the Brief Intervention Unit. The Brief Intervention Unit is for people who we think a 3 to 5 day hospitalization will be beneficial. So we've mapped out 6 or 7 clinical situations in which patients might present that might be useful. So whether it's a first episode psychosis, whether it's an intoxication that's altering mental status or whether it's a patient with a personality disorder that's in crisis or a patient in a suicidal crisis. So these are the type of trajectories of patients that might come to the BIU. And what we've done is trajectory mapping so that everybody knows with this particular clientele in the first 0 to 12 hours, this is what we do. The next 12 to 24, this is what we do. On day two, day three, day four. So everybody's on board. The nurses know, there's a psychologist sort of running the show. The doctors know. So everybody knows what their role is and what their role is on day one, two and three. So that there's less waiting around for treatments to happen. In addition to managing this and so much more, you're one of the co-founders of the McGill Sexual Identity Centre. I want to talk to you a little bit about what kind of specialized care you're providing to to patients there right now. We're the first and, as far as I know, still the only psychiatric clinic that caters to sexual minorities. Initially, the clinic was meant to be a safe space for lesbians, gays, bisexuals, particularly because psychiatry had stigmatized them for many, many years. It was a pathology in our DSM. Over time, society has evolved. People have evolved. So internalized homophobia and just straight discrimination for homosexuality is much less so we see much less of that population. However, that's kind of been in parallel with this explosion of people questioning their gender identity. I would say our population that we cater to now is about 75 or 80% people questioning their gender identity. The range is obviously greater than what we would have had a few years ago. Acceptability you talked about, acceptability being greater. So what are you working towards in your treatment and what you offer those patients? It used to be that when we talked about the trans population, we were talking about a very specific minority of people who were hell-bent on changing the body and the gender that they had been assigned at birth. And so these were people who were willing to go to terrible lengths because I have to say it, our treatments were archaic. We asked people to cross-dress for a year before giving them access to hormones, which is really just asking for discrimination. It's really quite sad. But so that population, that trans population, we actually have good data on the lack of regret or the happiness with their outcomes. So these were people that were uber motivated to transition from one box to the other. Now what we're seeing is an explosion of boxes. Not everybody feels that masculine and feminine cater to everything and that some people feel in between or a mixture of both, or they feel more masculine on one day, more feminine on the other day. And we're getting a lot of teenagers that are questioning this. So our understanding of gender identity has shifted over the years and society's understanding of gender identity has shifted. We're more open and at the same time we're not. So on the one hand, we now tell people you can choose the gender that you want. You want to be masculine, you go ahead and be masculine. But there's still this sort of subconscious underlying message that you can be masculine, but you better make sure your body corresponds to the gender you've chosen. And so what we're trying to work towards is undoing that sort of body determinism for gender. And saying people can adopt whatever gender they want and they can be in their body, however they feel most comfortable. And we don't have to have just these two boxes. And so that implies that not everybody is going to have the same transition journey. Where it used to be first social transition, then hormonal, then surgical. That's sort of the archaic way of doing it. Now, some people will have a social transition without anything else. You know, I'm no longer Patricia. I'm Patrick. Call me Patrick. I'm cutting my hair short. I want to be known as Patrick. Some people that'll be sufficient for them. For other people. I want my voice to deepen. So I'm going to take hormones just until my voice deepens. And then that's it. I don't want the other hormonal effects. So all that to say is that there's a whole range of gender presentations. And what we work towards in the clinic is helping people to figure out how to embody their gender in a way that's most comfortable for them. How important is it to have that pathway to be able to predict outcomes? And what's the connection with one of your flagship research projects at the MGH. One of the questions we get the most often when we have teenagers coming in with their

parents is: 12:57

How do I know that they're not going to regret this decision later?

Right. And the answer is: 13:02

we don't know. The reality is that this population is so new that we don't have data, particularly on teens who are first questioning their gender in their adolescence. They didn't do it in childhood. So they arrive at 13, 14, 15, and all of a sudden they're questioning their gender. We don't have very much outcome data to know, am I better off transitioning or am I going to be just as miserable but with a different body? So any kind of research that would allow us to track this population

prospectively and see: 13:41

When I transition, does that improve my mental health outcomes or not? Would be great. And that's exactly what we can do with the Centre for Precision Psychiatry, which is our big research project in the department, because that's what it does. It gets patients when they first come into the clinic. And patients can be followed for ten years witt twice yearly psychological assessments, a whole bunch of baseline psychological data to try and figure out what the predictive factors are going to be, but then also biomarkers and imaging. So patients who agree to will get their brain scanned. So we're really looking at all different kinds of data to try and then, in ten years we'll be able to retrospectively look back and go, oh, when patient had A, B and C, they were more likely to be happy post-transition than not. And this is for all kinds of different conditions. So it could help you predict an episode of psychosis or someone who comes in with a depression really young. What are some of the other potential scenarios? There's a lot of trial and error in in psychiatry because, you know, we can't, when a patient comes in, crack their skull, open their brain, take a slice and have a look at it to figure out what we need to give them. So there's a lot of trial and error. So whether it's about antidepressants. Am I better off with Wellbutrin or Effexor or Pristiq or Remeron. Or, for a bipolar patient. Is this a bipolar patient who's going to respond to lithium or is this going to be a lithium non-responder who would be better off with Epival, for instance. Or for the first episode psychosis. Is this someone who I can get away with treating a very tiny dose of an antipsychotic, or is this someone who's going to need a bigger dose? And so right now we kind of do that with trial and error and sort of gestalty kind of feelings about things. So we have to readjust our treatments, which is, okay. We do that. But, if we're able to target the exact dose somebody needs quickly, then we get to remission faster. And we know with most mental illnesses, the longer that they stay in the brain, the harder they become to treat. So if we can treat it in a few weeks rather than a few months, we're going to get better outcomes. As a psychiatrist-in-chief and also as a clinician, where would you hope we would be in, you know, 10, 20, 15 years? What would your dream be if you were allowed to dream big a little bit. In terms of treatment, it would be great to be able to identify which treatment would be good for any specific person. Right? Because you can have 5 or 6 people come in with the

same constellation of: 16:26

I can't sleep, I'm tired all the time, I can't concentrate, and I'm ruminating. For somebody that's going to be a depression and they're going to respond to an antidepressant. For somebody else that's going to be a hyper adrenergic state that's going to respond to something else. You know, all different kinds of ways of looking at it. But if I can dream even bigger than that, I would hope that our society would have enough of an awareness of what our mental health needs are, that we start to make some some societal and systemic changes to the way we live so that we are not putting our brains in these toxic environments. You know, I was mentioning things before about social media and lack of sleep and, lack of feeling of community, lack of exercise. Our society is going in a direction that's not good for our mental health and our well-being. And I would hope that by 15 years from now we've figured that out. And we've dialed it back a bit and that we've actually equipped our younger generation to be able to be more mindful of their mental health and to give them the tools to not deteriote. We can do that now. It can start now. You're a big advocate for education and awareness to protect your mental health so it doesn't become mental illness, basically. Right? So, concretely, what would it look like? For me, and any time I get the mic to say this, I will, so thank you for giving me the mic for this again. I think that we... Not I think, I know that we need mental health education in schools and it needs to start in kindergarten and it needs to go all the way to the end of high school. And obviously what we teach in kindergarten and at the end of high school will be different. But we need to start by teaching social emotional awareness. So how am I feeling? Am I happy, sad, angry or scared? And why am I feeling that way? What can I do to, you know, if I'm over emotional, what can I do to tone it down? Or if I'm under activated, what can I do to bring my energy level up to meet the situation that I'm in? Then once I'm able to self regulate, then I'm also able to ask for what I need and what I want, and I'm able to then learn to negotiate my relationships better. So we start with self regulation, then we go to relationship negotiation kind of stuff and we can move on to bigger things like identity, and what my values are and how I can live a life where I have meaningful parts of my life and I have enough awareness of what I need as a human and what my brain needs as an organ so that I can maintain my mental health. Sort of going full circle, coming back to people turning up at ERs in distress. What what would be the impact on that? To me, this is so crucial because, you know, we keep hearing there's this many more millions for mental health and this many more millions for... The reality is if we don't do something to equip our youth and our society to better manage our mental health, we can keep throwing more and more resources. Although, we're still very underfunded. I'll just put that caveat out there, But we're never going to catch up. And so we're always going to have these stories of people who are waiting for days and days and days in the emergency room because there's no beds available upstairs. Or who have, you know, called 80 places and can't find a psychologist that can help them. So unless we start to equip our youth and their parents. Right, let's let's be honest. Part of the reason the kids don't know this is because their parents don't know it either. If we don't equip ourselves as a society to understand what our brains and our minds need in order to function well, then we're hitting a wall. You're also doing this already. You know, through these programs, through the Transitional Day Program, there's more of an educational component as well, right? There's a shift towards that as well. And you're hoping to have

even more of that: 20:53

catch people or conditions, I should say, earlier, too, right? There is that concept sort of permeating through psychiatry and through public health, really. Two things I want to say. One is that a lot of treatment for mental distress, I'm not going to say mental illness, but mental distress can be done by the person themselves if they know what to do. So that's yes, part of the psychoeducation point. And the other point I wanted to say is that we also know and this is derived from first episode psychosis programs. We also know that if you intervene quickly... You know, the quicker you treat a psychosis, the easier it is to treat and the less sequelae you're going to have. And so if you can treat a first episode psychosis and go to rehabilitation and reconnecting someone with their meaningful relationships and functioning in life, you're going to get a better outcome than if you catch someone two, three, five years down the road, and they've been psychotic for all this time. And meanwhile they've destroyed all their relationships and they no longer have a job and oops, you know, they forgot to renew their welfare. And so now they don't even have a place to stay. So that sort of downward drift, we know that that happens in psychosis. It probably also happens in mood and anxiety and sort of mood dysregulation kind of disorders like personality disorders. So one of the exciting things - I've got a new staff coming on after his fellowship at Stanford in Young Adult Health - will be to start up a mood and anxiety first episode type program as well. So yeah, we're trying to catch things quickly so that they don't deteriorate. Thank you so much Dr. Igartúa and thank you for tuning in to this Code Life interview brought to you by the Montreal General Hospital Foundation. Don't forget to subscribe for more interviews and follow us on social media to get all of the latest updates. Thank you so much and see you next time.