Dr. Willam Honer was the honoured guest and presenter at the last fall’s BCSS Foundation Donor Appreciation Event held online in December, 2021. Dr. Honer trained in medicine at Queen’s University and in psychiatry at Columbia University. He is the Jack Bell Chair in Schizophrenia, Professor, and former Head of the Department of Psychiatry at the University of British Columbia. Dr. Honer is also an honorary professor in the Department of Psychiatry at University of Hong Kong and a lecturer in the Department of Psychiatry at Columbia University. He serves as a consultant psychiatrist to the BC Psychosis Program based at UBC Hospital, and he is also on the BCSS Medical Advisory Committee.
During his presentation, Dr. Honer described his own career trajectory that drew him to the study and treatment of schizophrenia and his current role as Jack Bell Research Chair. The Chair serves the important function of supporting education and research in schizophrenia and then linking that research to clinical care. After his presentation, Dr. Honer took the time to generously answer questions from attendees.
However, we followed up with him with a few more questions inspired by his presentation.
How would you describe the importance of the Jack Bell Research Chair in Schizophrenia?
Universities have a number of different kinds of chairs in either research disciplines or within medicine in illness-focused areas. Jack Bell was one of the first in Canada to identify schizophrenia as an illness that really needed attention and focus. The role of a Chair is to keep that alive in the academic and the university environments and serve as a hub in some ways for bringing together people who are interested in schizophrenia and encourage younger faculty members and trainees to connect. I think that what we’re doing provides some source of hope for those family members and for patients who may have this often very disabling illness.
The Chair position helped me support building a team of faculty members to connect the research to the BC Psychosis Program. If we didn’t have the Jack Bell Chair, I’m sure this work would be much more challenging.
Facilitating international connections has been very important in the game. With these relatively small niche areas, we really do have to look widely for colleagues and for shared interests and successes derived from working together. I’ve always valued that a lot and really enjoy working with colleagues that are similarly committed to schizophrenia research.
How do you go about attracting researchers to this area?
There is an increase number of incoming young researchers specializing in schizophrenia and related psychotic disorders. It is different than when I was a student as, overall, I think public awareness of schizophrenia has increased. But it still is considerably challenging, relative to some other disorders. I don’t think it’s helpful for illnesses to be pitted against one another for funding. But still, I would be remiss in not saying that, relative to the burden of illness, I think we are underfunded. So, it’s a bit of a of a challenge when you’re advising young people in their careers.
To address this, I think broadening some of the concepts in terms of thinking about psychotic disorders and thinking about the more serious forms of mental illness leaves a few more options for people. It is also important for us, who are dedicated to schizophrenia, to not be too narrow in our focus and to learn from other types of disorders, other illnesses in neurology, or other physical illnesses to inform where we’re going forward. There’s been much more progress in cancer treatments, HIV, heart disease, and mental illnesses in general. We are just at the stage of bringing more attention to schizophrenia. I don’t think we’ve yet seen the outcomes of that attention in terms of resources we might have and the outcomes of doing more research to benefit patients.
Can you elaborate on how researchers are expanding their focus and learning from other disorders?
Even in the area of dementia, there’s more understanding of its complexities by looking at community-based studies. These brain disorders can’t be reduced to single genes, or to single molecules, or to single causes. There won’t be “magic bullets” for these things. We have to think in a more integrative, physiological way about factors that come together, and mechanisms that that interact together. Perhaps for different parts of the illness, for different symptoms, for relapse, it may be different than the first episode. Maintenance treatments may need to be different from treatment of the acute phase of the illness. These are both things we need to think about more carefully.
Overall, how would you describe the state of research in schizophrenia?
I’m optimistic about the near future, actually. But there was a period of time where most of the innovation was in changing the side effect profiles, increasing the efficacy of medications. The effect of the medications is, in the short-term, large and easy to measure. The parts of the illness that are more demanding in terms of the negative symptoms are a lot more difficult to treat. We don’t have medications yet that are very effective with the loss of initiative, drive, or the feelings of emotional poverty. And they don’t respond as quickly to things that that we do, so that’s been part of the challenge.
I think integrating our understanding of cognitive impairments is important, such as problems of memory of planning, initiating actions, and making decisions. It’s been less than 10 or 15 years since we’ve become more aware of these, but we really don’t have any good levers to prove non-pharmacological approaches such as cognitive remediation. And medications themselves don’t yet seem to have much benefit on the cognitive problems and can sometimes exacerbate them.
A Recap of the Questions from the BCSS Foundation Donor Appreciation Event
Is there any research into successfully discontinuing anti-psychotic medication when a person with schizophrenia is stable?
There’s quite a lot of research in terms of what happens when you do that. The biggest consequence of discontinuing medication is having a relapse. There are maybe five or 10 percent of patients where it might be successful with no relapse over a period of five or 10 years. Just how well they would continue to function is not clear because it might not be a relapse, but they might have other symptoms – the negative symptoms or other things going on. There’s quite a wealth of information about what the consequences are. Unfortunately, we don’t have good predictors of whether discontinuation will succeed and the patient will relapse. The real risk is how many patients are going to be harmed by increasing or stopping medications to find those very few who might not relapse. I think that it’s really important that we try to talk with patients and understand what their concerns are with medications and try and see if we can improve the side effects they may be having.
Can improvements in the hippocampus and the plasticity of the brain also be seen with other things such as reduction in stress or improvements to the social determinants of health like housing and food security. Similarly, can doing aerobic exercises, artwork, reading books, and other activities help, and have they have been studied separately or in conjunction with exercise?
I think it’s entirely likely that these other kinds of interventions probably do improve the connectivity or the plasticity of other areas of the brain. Music therapy actually does have a pretty good effect in terms of helping patients with schizophrenia. One of the most famous examples of plasticity is having people who were not trained in juggling learn to juggle. Exercise results in change in the structure of the brain, the hippocampus. I’m just not so certain that the hippocampus per se is a target that is sensitive to all of these kinds of interventions. That doesn’t mean we shouldn’t be doing these studies – they’re all potentially quite helpful. But we haven’t done enough studies, and of course, they’re much more complicated to do in terms of some of the psychosocial interventions mentioned. It’s hard to do a controlled study of those sorts of things to understand how they might be working and what has improved in the structure of the brain. Does that direct outcome, and can we generalize to other things in the patient’s life? Or is it just that one skill you’ve developed? Which locks are being opened by those different keys?
In those with stimulants issues, how do you know if psychotic episodes are only due to the drug effects or because they have schizophrenia?
This really requires time to work with the patient. We need to learn about the sequence of things to help understand the role of the stimulant drugs and the role the psychotic disorder itself might be playing. We ask questions like: “Did the psychosis start before any use of stimulant drugs? If stimulant drugs are used, and there is psychosis with the stimulant drugs, and the stimulant drugs are stopped when you’re in an inpatient unit, how long does it take for the psychosis disappear?” You also look at the expected effects of the drugs. People who take hallucinogenic drugs like LSD, or stimulants like cocaine, or methamphetamines, may often see things and they may have hallucinatory experiences. But you need to look more closely at just what happened. How long did it last? How severe was it? How unusual was it? Did they do something as a consequence? Were they very paranoid or just worried? We have to talk to the patient to really understand what their experience was, when they were using the drug, and how that changed after the acute effects of the drug were wearing off. Separating these things in terms of the time course is the best strategy we really have.
Is the medication supposed to quiet the voices, and does it feel like a weight or pressure in the head?
Some patients experience the voices in their heads, some experience the voices coming from outside, and some can have a physical sensation and a sound that accompanies. That would be less common, but it’s certainly possible that if there’s a connection between a physical feeling related to hearing a voice, that could be part of a psychotic experience as well.
Could some patients have a co-diagnosis of depression, and can an antidepressant be added to a person’s anti-psychotic medication to help with drive and motivation?
Depression is as likely in a person who has schizophrenia as it is in a person who doesn’t have schizophrenia. It is a separate independent illness, and they’re at the same risk, as many of us are – maybe a little bit higher, because illnesses tend to go together. It’s important to distinguish the symptoms of depression from the negative symptoms of loss of drive and motivation. That could come from depression, but it could be the negative symptoms of schizophrenia. If those symptoms are from a depressive illness, it’s more likely that they’ll respond to an antidepressant. Sometimes we use antidepressant drugs to try and improve the negative symptoms themselves. They are not usually particularly successful, but sometimes we give it a try.
Is there research into how slowly tapering off anti-psychotic medication must happen to successfully discontinue the medication?
Yes. There are some recent studies that have pulled together many years of information about that and have come up with some strategies. They really suggest that it takes many months to taper down anti-psychotic drugs. We’re talking about six months to a year.
How can we access overdue reassessment and treatment opportunities for someone who has had very few are opportunities for rehabilitation programs in Victoria, BC. How can the BC psychosis program assist me – a parent and caregiver?
Each health authority has a referral mechanism to the BC Psychosis Program. So, the treating physician would need to work with the referral group in the health authority to see if they want to make a referral to the program. That’s how the system works. Access to psychiatry and to specialty care is a huge problem.
Are there new clinical approaches to early screening for schizophrenia and those with a family history?
There’s research in that area, but I don’t think it’s ready for rollout. As schizophrenia is found in one in 100, it’s not as common as screening for cancer or other kinds of illnesses. And, you have to be very cautious in screening programs about false positives, making mistakes, or missing something. Most assessments that are being used in research studies now aren’t nearly as accurate as they would be in cancer screening programs or those kinds of things. So, it’s not really ready for the same level of engagement as a screening programs are for cancer. On the other hand, it’s been really helpful to have greater public awareness of what the signs of psychosis are, whether something is really just not right. This is needed to have an intervention. Family history and genetic risk is only one part of what creates risk for psychosis and schizophrenia. We’re making some progress, but it’s not nearly ready yet for widespread clinical use.
Do you see any connection between the use of cannabis and schizophrenia?
It’s largely agreed upon that cannabis use is a risk factor for psychosis or schizophrenia. Patients with schizophrenia that have never used cannabis might start using substances. But usually, it’s the other way around: the early use of cannabis would increase the risk of developing schizophrenia. Just how much, just how big of an effect, we’re still working on it. It’s not something we recommend. If you are going to use cannabis, don’t use the high THC types of cannabis and don’t use it regularly. Don’t use a lot of it.
There is study out of Denmark that looked at substance induced psychosis. Somebody uses substances, becomes psychotic, then the psychosis goes away. A few years later, they develop schizophrenia. And alcohol related psychosis was definitely a risk factor. Not as strong of a risk factor as stimulant drugs or cannabis. But because alcohol is so widely used, it is on the population basis and that study was linked to more cases. It’s not as severe, but more people are going to get it. Getting intoxicated and having blackouts is very bad, so alcohol is a much larger public health problem than cannabis is.
In the Vancouver area, there are many programs and services and therapies available for those with serious mental illnesses (SMI). But a high number of individuals with SMIs do not have the insight that these would be of any use, or perhaps the drive or energy to attend. Has there been research on how to help those individuals?
I don’t think the research has been focused on that enough. The challenge is finding them. They are not coming for treatment. Have they got a diagnosis? Maybe they do, but for interventions to be successful in healthcare, they have to be effective and you have to have a good delivery system. Our interventions in psychosis are very effective for the acute state. They’re less effective for chronic illness. And our health care delivery system that gets those interventions to the patients who need them needs a lot of improvement. How to do that better could deserve some attention and research.
Is the area of neuron “pruning” during adolescence still being researched, as well as treatments such as cognitive remediation along with newer pharmaceutical advances? In other words, if the teenage brain has been over-pruned, are there treatments – either psychological therapies or pharmaceutical advances – that can help to restore it?
This idea of pruning relates to plasticity and connections. If we think of the gardening analogy, it’s the way we look after things and keep them healthy. The age at which we do things, when things are more plastic, is really important. The greatest change in connections, meaning loss, probably occurs before age two. There’s modification i.e. taking out too much inhibitory and leaving those excitatory. Learning things involves pruning. Modifying is absolutely important during critical phases of adolescence. That’s part of what we’re working on, and perhaps cognitive remediation could be one strategy for that.
Families talk about their family members who have a history of relapses after discontinuing meds who are being allowed by mental health teams. This is done in the name of the Recovery Model and is seen as supporting the person to experience self-determination. What do you think about this? Should these numbers be better tracked within the mental health system?
I think it would be a good idea to track. Unfortunately, other than the public health officer tracking the number of suicides, we don’t track patient outcomes at all. We track interventions and process outcome variables. For example, we count the number of people who show up for a service or the number of teams we have. The problem is, we’re tracking what we are trying to do, not what the outcomes are. We can track how many patients we took off medication, but not adequately. There are opportunities with digital technologies to do this much more effectively. These would give us more data to look at and help us to know what works and how to personalize it for individual patients.
The research and the randomized controlled studies are not showing the benefit of discontinuing meds. It’s unfortunate that the possible beneficial aspects of recovery and learning to cope with illness have been pushed into stopping medications and treatments. I usually refer back to an article that states that looking at capability is as important a perspective as disability. Capabilities may be limited for some people, but we really need to pay attention to them. This is where we talk about rehabilitation and risk if capabilities aren’t there. We have to be careful of thinking there is a simple solution – for example, we need more supportive employment programs. We need to be more supportive and integrative in what we do and not just abandon the value the interventions can provide. Likewise, we shouldn’t fail to incorporate the perspectives of patients’ families in what to do about this chronic disorder.
A full recording of the event is available here:
Thank you again to the Otsuka-Lundbeck Alliance for making this event possible.