March 2022

This month's brainbuzz™ features CAMH research updates on a clinical trial with promising results in people with schizophrenia who have cannabis use disorder;  a smoking-cessation study comparing the efficacy of drugs when prescribed virtually versus in a clinician’s office; and a moving story of a CAMH patient with schizoaffective disorder. Please reach out if you have any questions or feedback.

Aristotle Voineskos
VP Research, CAMH
 

Brain stimulation shows promise as treatment for cannabis use disorder in people with schizophrenia

Repetitive transcranial magnetic stimulation (rTMS) associated with up to 60 per cent reduction in cannabis use in CAMH-led clinical trial

Repetitive transcranial magnetic stimulation (rTMS) was associated with a reduction in self-reported cannabis use by up to 60 per cent among people with schizophrenia who have cannabis use disorder (CUD), according to a CAMH-led study just published in the journal Schizophrenia.

The double-blind study is the first of its kind to investigate the effectiveness of rTMS in treating CUD in people with schizophrenia, and was supported by the U.S. National Institute on Drug Abuse (NIDA) and the CAMH Foundation.

“People with schizophrenia have very high rates of cannabis use disorder compared to the general population, and there is strong evidence that cannabis use worsens psychiatric symptoms and quality of life in these people,” said senior author CAMH clinician scientist Dr. Tony George. “Despite the known harmful effects, there is currently no approved treatment for CUD with or without schizophrenia.  These results indicate rTMS may be a safe and effective way to reduce cannabis use among people with schizophrenia.”

Until relatively recently, brain stimulation technologies like rTMS were used primarily for treatment-resistant depression. However, studies have now found rTMS to be effective in reducing drug use and cravings for several substance use disorders in the general population. 

Study participants were given rTMS treatment at the Temerty Centre for Therapeutic Brain Intervention at CAMH five times a week for four weeks targeting the brain’s dorsolateral prefrontal cortex (DLPFC), which is associated with the brain’s reward system and executive function.

Those who were given rTMS reported a reduction in cannabis use by up to 60 per cent after 28 days as well as reduced cravings, compared to controls receiving sham rTMS.
 

of the largest schizophrenia outpatient clinics in North America as well as state-of-the-art addiction treatment programs,” said Dr. George. “All those factors make CAMH one of the few places in the world that can lead a study like this.”

"It was a difficult study to recruit for given the intensity of time commitment required by patients,” said study lead author Dr. Karolina Kozak Bidzinski. “However, the awareness patients had of the negative effects cannabis was having on their lives, the expected benefits of reducing their use and noticing the various positive outcomes that would surface throughout the duration of the trial, enabled such a high number of patients to complete the study. Hopefully this work paves the way for more research into investigating the effects of rTMS as a treatment for cannabis use disorder in people with schizophrenia."
 

Smoking cessation drugs prescribed over the internet are as safe and effective
as in-person treatment

Up to a third of participants smoke-free after 12-week program

Smoking-cessation drugs prescribed exclusively over the internet in a clinical trial were as safe and effective as when prescribed in a clinician’s office, according to a newly published CAMH study in the journal Drug and Alcohol Dependence.

The study, the first internet-based trial for smoking cessation using prescription medication, found that 30.3 per cent of study participants given the drug varenicline were smoke-free after 12 weeks and 19.6 per cent given the drug bupropion were no longer smoking at the end of the trial. Notably, the quit rate was substantially lower for an unassisted attempt (without aids or intervention) and hovered between 3-5 per cent. 

“This study demonstrates that internet-based smoking cessation intervention using prescription pharmacotherapy is feasible and effective—as effective as what was found in in-person clinical trials,” said lead author Dr. Laurie Zawertailo, Senior Scientist, Campbell Family Mental Health Research Institute and Addictions Division at CAMH. “The study findings can be used to inform the design of future web-based randomized controlled medication trials as well as virtual treatment delivery methods for tobacco dependence.”

Currently in Ontario, patients typically see a prescriber in person for smoking cessation drugs like varenicline which is the most effective quit-smoking medication available. The authors state that expanding the use of internet-based smoking cessation treatment programs is particularly important because the rate of smoking is disproportionately higher among marginalized populations, and those in rural areas, who may have more difficulty accessing in-person clinical trials and treatment programs.

Study co-author Dr. Peter Selby, Clinician Scientist at Campbell Family Mental Health Research Institute at CAMH, says the finding that these drugs are just as effective when used in an internet-only clinical trial is significant because it is common for smoking-cessation drugs to have better success rates in a clinical trial than in a real world setting. People in clinical trials are often situated close to the academic hospital and are also more motivated. This study is more real world and was available across Ontario. 

Although this study was conducted before the COVID-19 pandemic began, its validation of internet-based smoking cessation interventions is timely, according to Drs. Zawertailo and Selby. This is because many smokers have had a harder time trying to quit during the pandemic due to a combination of increased stress, the absence of workplace-related no-smoking restrictions for people not going to the office, and reduced access to clinical services. In fact, the number of patients attending CAMH’s Nicotine Dependence Clinic has dropped by nearly half during the pandemic.

“As devastating as COVID-19 has been for Canadians, the hidden issue is that smoking continues to cause twice as many deaths each year, and we can do something about it,” said Dr. Selby. “Not only does quitting smoking cut your risk of heart disease by half within the first year, if you continue to smoke you are more likely to become hospitalized or get very sick from COVID-19. Now that this study is published, we are looking at ways to make internet-based treatment programs like our own STOP on the Net more available to the public.”

CAMH smoking-cessation tools include:

Nicotine Dependence Clinic: Offers virtual and in-person services from a specialized treatment team that includes a nurse, therapists and physicians, for people who want to change their tobacco or e-cigarette use. Offering access to individual and group counselling and medications.

STOP on the Net: Offers eligible participants a free kit containing an eight-week supply of nicotine replacement therapy (patches and choice of gum/lozenges) mailed directly to their address, with no healthcare provider intervention or in-person travel required. In order to join STOP on the Net, individuals must be 18 years or older, reside in Ontario, be willing to a quit attempt within 30 days of enrollment and meet other specific eligibility criteria. STOP on the Net is available in both English and French.

My Change Plan App: A free mobile app developed by CAMH’s Nicotine Dependence Service that helps users track their tobacco use, develop a plan to quit, and chart their progress towards quitting or reducing smoking or vaping.
Download from the Apple store
Download from Google play

Youth psychosis won’t destroy our future.
Not Today.

Alex Stewart on finding hope after years of suffering. Watch Alex and Susan's story here.

In many ways, the life and near death of Alex Stewart is what CAMH's Today campaign is all about. A gifted computer science student, he had been accepted into a highly competitive program at Waterloo University and was just getting ready to make his own way in the world when mental illness took over his young life.

"It’s all very jumbled,” says Alex, 24, about his memory of that time. “I have memories of saying things to people in high school and people reacting strangely, saying ‘that didn’t happen’. I remember locking myself in my room for about a year after high school. I didn’t have the will to get up and go downstairs for breakfast or dinner. I just couldn’t. Although my family has been incredibly supportive, in the beginning my behavior definitely caused some conflict. Because no one, including myself, understood what was going on. Objectively I guess I was depressed because I was sleeping a lot, but I don’t remember my suffering, which is probably a good thing that I’ve forgotten.”

“One of the things people don’t understand about having a loved one with a serious mental illness is that when it starts it is incredibly frightening,” says his mother Susan. “We don’t have the knowledge we have of other illnesses. It’s not easily diagnosed, so it can be going on for a long time before you really know what’s going on. I had people tell me that this was normal teenage angst. I just had a bad feeling it was lot more than that.”

She was right. Alex was just a few months away from his first episode of psychosis.

Because of the seriousness of the disease and the time of life it typically emerges–in the late teens or early twenties–untreated first episode psychosis is a grave threat to human health and early intervention can truly be a matter of life and death. Compounding the danger is the hard truth that currently there is no way to detect psychosis before it emerges and no way to predict who may be at risk.

Even at CAMH, home to some of the best experts in youth mental health in the world, an accurate diagnosis for Alex proved elusive. After his psychosis emerged and he was diagnosed with schizoaffective disorder, it would take a few more torturous years of trial and error before an effective treatment could be found.

The hope is that some day soon, with the aid of state-of-the-art brain imaging at CAMH using PET tracers invented by CAMH scientists, a genetic risk for psychosis in young people like Alex can be identified in the brain before it emerges. In combination with other CAMH innovations like pharmacogenetics and neuroinformatics, diagnosis and treatment plans could be customized to the needs of each patient, giving them exactly what they need when they need it.
 

After finally finding a treatment that allowed him to manage his mental illness, Alex recently moved out on his own to complete the last term of his computer programming degree, daring to feel hopeful for the first time since his psychosis first emerged with renewed optimism about his ability to lead a rewarding and productive life. 

“There are people who don’t even make it to first episode clinics because what has happened has caused them to take their lives. I look at my son who comes from a background with mental illness in the family, and think there is probably a genetic component we can find there. If I could have said to my children when they were 14 years old that if they smoke pot it may be a trigger for psychosis, it would have given them more information in which to navigate their lives in a safe way.”

Now he wants to pay it forward.

“I’ve been in a lot of psych wards over the years.  I’ve seen the suffering first hand. So just to mitigate that suffering is a pretty simple answer to why I am doing this. I remember one patient one time I was in emerg.  She was just screaming and screaming. She seemed in such distress.  I went up to her and tried to say something, but she seemed scared by me. It was just terrifying. So if I could help someone like that in any way, that would be great.”

“This is not a hopeless diagnosis,” says Susan. “I didn’t always know that. This is an unprecedented time of hope. The beauty of the scientific research going on at CAMH is that it translates into patient care. It’s helping people in real time. There is a real connection with research and clinical care right now and not just in the future. Because people are suffering right now.”

Alex's story is part of the featured content within the powerful Today campaign which conveys the momentum that CAMH is creating to prevent suicide and invites people to accelerate it.  Visit the campaign website to see other featured content and to learn more. 
 

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• Anxiety, feelings of depression and loneliness among Canadians spikes to highest levels since spring 2020: CAMH-Delvinia survey on mental health and substance use
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