May 1, 2023 • 23 mins
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.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
We know with most mentalillnesses, the longer that they
stay in the brain, the harderthey become to treat. So if we
can treat it in a few weeksrather than a few months, we're
going to get better outcomes.
Hello, I'm Annie DeMelt, andwelcome to this Code Life
interview brought to you by theMontreal General Hospital
Foundation. Our guest today isDr. Karine Igartúa,
(00:20):
psychiatrist-in-chief of theMUHC's Mental Health Mission.
And that mission is to providethe best patient care through
innovative programs, but alsothrough research.
Researching new ways to maketreatment more personalized,
more precise. So, Dr.
Igartua, thank you so much forbeing with us.
Thank you for having me.
Let's start by how incrediblybusy you are right now in the
(00:42):
departments of psychiatry andpsychology. We've gone through
a difficult phase for a lot ofpeople's mental health.
What are you seeing right nowin terms of demand and access
to your services?
We're in a really toughsituation because the demand is
increasing or has beenincreasing for many, many years
(01:04):
and the resources have beenshrinking. 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 gradualover time, less beds.
With COVID, there's been a lotof people who've decided to
(01:27):
retire or leave the health caresystem. So in terms of
personnel, we've got adifficulty, too.
But also we have a society thatis moving in ways that I want
to say is toxic to our brain.
Whether it's the higher dosesof THC in our now legal
cannabis. Whether it's thecomplete bombardment of our
(01:47):
brain, of always being on ourphones 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 becausepeople tend to have their
phones in their bedrooms and,you know, they binge Netflix
(02:08):
late at night and they don'tsleep.
Or the lack of exercise, becausewe know that the more time you
spend in front of a screen, theless you move around, the less
you move around, the lessexercise you're getting.
And finally, the lack ofcommunity and socialization.
Even when people...
I see it, the kids, when they'retogether, they're all together
sitting on the couch, buteverybody is on their own
(02:29):
different phone. So they'retogether but not really
together. So that leads toisolation and lack of feeling
of connectedness. So there'sall of these kind of...
this cocktail, these trendsthat are happening in society
that are bad for our mentalhealth. Put that together with
difficulty getting first linecare. Difficulty accessing a GP
(02:53):
if you actually have one, or apsychologist if you're lucky to
have insurance. People come tothe emergency room because they
have nowhere else to go.
And some people come for bonafide mental illness.
So psychotic disorders or mooddisorders. But a lot of people
also come with emotionaldistress, social crises.
(03:15):
And the reality is this week inthe emergency room, I see a
patient who's been there forten 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 bedupstairs is absolutely not
unusual because we just don'thave the capacity.
(03:37):
So increased demand, lowercapacity or capacity that's not
keeping up, which is forcingyou to be a lot more efficient
with your programs.
And you do have a number ofspecialized programs that are
part of the Mental HealthMission. One of them that we're
going to talk about is thisTransitional Day Program.
So who's this for?
(03:57):
What population is this?
Is this for people in crisisand how is it unique and
innovative?
So the Transitional Day Program.
It's funny to say that it'sinnovative now because we've
had it for 20 years.
But it was innovative 20 yearsago, and to my knowledge, it's
still the only program in theprovince like this. So
(04:20):
essentially we took all of thetherapeutic ingredients of a
hospitalization. So whetherit's seeing an OT to help with
goal-setting and organization.
Whether it's psychoeducationaround illness and illness
management. Whether it'sidentifying emotions and
emotional regulation.
(04:40):
Coaching about nutrition andexercise. We even have a choir
that's part of that. So musictherapy. All of the therapeutic
ingredients of ahospitalization, but in a day
program format.
So patients arrive early in themorning, they have a couple of
workshops during the morning,they have lunch at the hospital
(05:03):
cafeteria. So a bit morenormalizing than a tray in your
room kind of thing. It createsa socialization and a sort of a
group belonging kind of effect.
They have a few more workshopsin the afternoon, than they
might have an individualmeeting or two.
And then they go home.
And the going home is greatbecause it means we're
(05:26):
promoting recovery and notregression. So you go home, you
still get to walk your dog, youstill get to check your emails,
you still get to hug yoursister. So the going home.
.. The messaging is you're nottaking a break from your life.
You are in recovery of whatevercrisis you're in.
(05:47):
And we want to get you back toyour life as soon as possible.
So TDP was innovative when westarted it, and we want to
innovate further. So two of thethings that we're going to be
... We're going to be looking atTDP in terms of adapting some
of the therapies so that thepatient with the first episode
mania might not need exactlythe same thing as the patient
(06:10):
who is in a suicidal crisis,for instance. So we might be
mapping out the trajectories alittle bit differently.
For that, we need the help of apsychologist. And that's
actually great because that'sone of the things that the
foundation is helping us with.
The other project that we wantto bring in is Les Impatients.
Les Impatients is a communityorganization. They're well
(06:32):
established. It's artists thatrun workshops for people with
mental illness, and they'realso recovery-oriented.
So we want to bring in LesImpatients so that people in the
Transitional Day Program andpeople in our Brief
Intervention Unit have accessto this art expression.
(06:55):
You talked about mapping outpeople'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 thebigger picture?
One of the other things we'vedone to try and and palliate
(07:15):
the lack of beds, but also interms of being more efficient
in treatment is we opened theBrief Intervention Unit.
The Brief Intervention Unit isfor people who we think a 3 to
5 day hospitalization will bebeneficial. So we've mapped out
6 or 7 clinical situations inwhich patients might present
(07:37):
that might be useful. Sowhether it's a first episode
psychosis, whether it's anintoxication that's altering
mental status or whether it's apatient with a personality
disorder that's in crisis or apatient in a suicidal crisis.
So these are the type oftrajectories of patients that
might come to the BIU.
(07:58):
And what we've done istrajectory mapping so that
everybody knows with thisparticular clientele in the
first 0 to 12 hours, this iswhat 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 apsychologist sort of running
(08:19):
the show. The doctors know.
So everybody knows what theirrole is and what their role is
on day one, two and three.
So that there's less waitingaround for treatments to happen.
In addition to managing this andso much more, you're one of the
co-founders of the McGillSexual Identity Centre.
I want to talk to you a littlebit about what kind of
specialized care you'reproviding to to patients there
(08:41):
right now.
We're the first and, as far as Iknow, still the only
psychiatric clinic that catersto sexual minorities.
Initially, the clinic was meantto be a safe space for
lesbians, gays, bisexuals,particularly because psychiatry
had stigmatized them for many,many years. It was a pathology
(09:02):
in our DSM.
Over time, society has evolved.
People have evolved.
So internalized homophobia andjust straight discrimination
for homosexuality is much lessso we see much less of that
population. However, that'skind of been in parallel with
this explosion of peoplequestioning their gender
identity. I would say ourpopulation that we cater to now
(09:28):
is about 75 or 80% peoplequestioning their gender
identity.
The range is obviously greaterthan what we would have had a
few years ago. Acceptabilityyou talked about, acceptability
being greater. So what are youworking towards in your
treatment and what you offerthose patients?
It used to be that when wetalked about the trans
population, we were talkingabout a very specific minority
(09:51):
of people who were hell-bent onchanging the body and the
gender that they had beenassigned at birth.
And so these were people whowere willing to go to terrible
lengths because I have to sayit, our treatments were
archaic. We asked people tocross-dress for a year before
giving them access to hormones,which is really just asking for
(10:14):
discrimination. It's reallyquite sad. But so that
population, that transpopulation, we actually have
good data on the lack of regretor the happiness with their
outcomes. So these were peoplethat were uber motivated to
transition from one box to theother. Now what we're seeing is
(10:35):
an explosion of boxes.
Not everybody feels thatmasculine and feminine cater to
everything and that some peoplefeel in between or a mixture of
both, or they feel moremasculine on one day, more
feminine on the other day.
And we're getting a lot ofteenagers that are questioning
this. So our understanding ofgender identity has shifted
(11:00):
over the years and society'sunderstanding of gender
identity has shifted.
We're more open and at the sametime we're not. So on the one
hand, we now tell people youcan choose the gender that you
want. You want to be masculine,you go ahead and be masculine.
But there's still this sort ofsubconscious underlying message
that you can be masculine, butyou better make sure your body
(11:24):
corresponds to the genderyou've chosen. And so what
we're trying to work towards isundoing that sort of body
determinism for gender.
And saying people can adoptwhatever gender they want and
they can be in their body,however they feel most
comfortable. And we don't haveto have just these two boxes.
(11:46):
And so that implies that noteverybody is going to have the
same transition journey.
Where it used to be firstsocial transition, then
hormonal, then surgical.
That's sort of the archaic wayof doing it. Now, some people
will have a social transitionwithout anything else.
You know, I'm no longerPatricia. I'm Patrick.
Call me Patrick. I'm cutting myhair short. I want to be known
(12:07):
as Patrick. Some people that'llbe sufficient for them.
For other people.
I want my voice to deepen.
So I'm going to take hormonesjust until my voice deepens.
And then that's it. I don'twant the other hormonal
effects. So all that to say isthat there's a whole range of
(12:27):
gender presentations.
And what we work towards in theclinic is helping people to
figure out how to embody theirgender in a way that's most
comfortable for them.
How important is it to have thatpathway to be able to predict
outcomes? And what's theconnection with one of your
(12:49):
flagship research projects atthe MGH.
One of the questions we get themost 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 thatwe don't have data,
particularly on teens who arefirst 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
(13:23):
questioning their gender.
We don't have very much outcomedata to know, am I better off
transitioning or am I going tobe just as miserable but with a
different body? So any kind ofresearch that would allow us to
track this population
prospectively and see (13:41):
When I transition, does that improve
my mental health outcomes ornot?
Would be great. And that'sexactly what we can do with the
Centre for PrecisionPsychiatry, which is our big
research project in thedepartment, because that's what
it does. It gets patients whenthey first come into the clinic.
(14:01):
And patients can be followedfor ten years witt twice yearly
psychological assessments, awhole bunch of baseline
psychological data to try andfigure out what the predictive
factors are going to be, butthen also biomarkers and
imaging. So patients who agreeto will get their brain
scanned. So we're reallylooking at all different kinds
(14:24):
of data to try and then, in tenyears we'll be able to
retrospectively look back andgo, oh, when patient had A, B
and C, they were more likely tobe happy post-transition than
not.
And this is for all kinds ofdifferent conditions. So it
could help you predict anepisode of psychosis or someone
who comes in with a depressionreally young. What are some of
(14:45):
the other potential scenarios?
There's a lot of trial and errorin in psychiatry because, you
know, we can't, when a patientcomes in, crack their skull,
open their brain, take a sliceand have a look at it to figure
out what we need to give them.
So there's a lot of trial anderror. So whether it's about
antidepressants. Am I betteroff with Wellbutrin or Effexor
(15:05):
or Pristiq or Remeron.
Or, for a bipolar patient.
Is this a bipolar patient who'sgoing to respond to lithium or
is this going to be a lithiumnon-responder who would be
better off with Epival, forinstance. Or for the first
episode psychosis.
Is this someone who I can getaway with treating a very tiny
dose of an antipsychotic, or isthis someone who's going to
(15:25):
need a bigger dose?
And so right now we kind of dothat with trial and error and
sort of gestalty kind offeelings about things.
So we have to readjust ourtreatments, which is, okay.
We do that. But, if we're ableto target the exact dose
somebody needs quickly, then weget to remission faster.
(15:49):
And we know with most mentalillnesses, the longer that they
stay in the brain, the harderthey become to treat. So if we
can treat it in a few weeksrather than a few months, we're
going to get better outcomes.
As a psychiatrist-in-chief andalso as a clinician, where
would you hope we would be in,you know, 10, 20, 15 years?
What would your dream be ifyou were allowed to dream big a
(16:12):
little bit.
In terms of treatment, it wouldbe great to be able to identify
which treatment would be goodfor any specific person.
Right? Because you can have 5or 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'mruminating.
For somebody that's going to bea depression and they're going
to respond to an antidepressant. For somebody else that's going
to be a hyper adrenergic statethat's going to respond to
something else. You know, alldifferent kinds of ways of
(16:48):
looking at it. But if I candream even bigger than that, I
would hope that our societywould have enough of an
awareness of what our mentalhealth needs are, that we start
to make some some societal andsystemic changes to the way we
live so that we are not puttingour brains in these toxic
(17:10):
environments. You know, I wasmentioning things before about
social media and lack of sleepand, lack of feeling of
community, lack of exercise.
Our society is going in adirection that's not good for
our mental health and ourwell-being. And I would hope
that by 15 years from now we'vefigured that out. And we've
(17:30):
dialed it back a bit and thatwe've actually equipped our
younger generation to be ableto be more mindful of their
mental health and to give themthe tools to not deteriote.
We can do that now.
It can start now. You're a bigadvocate for education and
(17:53):
awareness to protect yourmental health so it doesn't
become mental illness,basically. Right? So,
concretely, what would it looklike?
For me, and any time I get themic to say this, I will, so
thank you for giving me the micfor this again. I think that we
... Not I think, I know that weneed mental health education in
(18:14):
schools and it needs to startin kindergarten and it needs to
go all the way to the end ofhigh school. And obviously what
we teach in kindergarten and atthe end of high school will be
different. But we need to startby teaching social emotional
awareness. So how am I feeling?
Am I happy, sad, angry orscared? And why am I feeling
that way? What can I do to, youknow, if I'm over emotional,
(18:38):
what can I do to tone it down?
Or if I'm under activated, whatcan I do to bring my energy
level up to meet the situationthat I'm in? Then once I'm able
to self regulate, then I'm alsoable to ask for what I need and
what I want, and I'm able tothen learn to negotiate my
relationships better.
So we start with selfregulation, then we go to
(19:01):
relationship negotiation kindof 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 havemeaningful parts of my life and
I have enough awareness of whatI need as a human and what my
(19:23):
brain needs as an organ sothat 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 impacton that?
To me, this is so crucialbecause, you know, we keep
hearing there's this many moremillions for mental health and
(19:43):
this many more millions for...
The reality is if we don't dosomething to equip our youth
and our society to bettermanage our mental health, we
can keep throwing more and moreresources. Although, we're
still very underfunded.
I'll just put that caveat outthere, But we're never going to
catch up. And so we're alwaysgoing to have these stories of
(20:06):
people who are waiting for daysand days and days in the
emergency room because there'sno beds available upstairs.
Or who have, you know, called 80places and can't find a
psychologist that can helpthem. So unless we start to
equip our youth and theirparents. Right, let's let's be
honest. Part of the reason thekids don't know this is because
(20:28):
their parents don't know iteither. If we don't equip
ourselves as a society tounderstand what our brains and
our minds need in order tofunction well, then we're
hitting a wall.
You're also doing this already.
You know, through theseprograms, through the
Transitional Day Program,there's more of an educational
(20:48):
component as well, right?
There's a shift towards that aswell. 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 ofpermeating through psychiatry
and through public health,really.
Two things I want to say. One isthat a lot of treatment for
(21:14):
mental distress, I'm not goingto say mental illness, but
mental distress can be done bythe person themselves if they
know what to do.
So that's yes, part of thepsychoeducation point.
And the other point I wanted tosay is that we also know and
this is derived from firstepisode psychosis programs.
(21:34):
We also know that if youintervene quickly.
.. You know, the quicker youtreat a psychosis, the easier
it is to treat and the lesssequelae you're going to have.
And so if you can treat a firstepisode psychosis and go to
rehabilitation and reconnectingsomeone with their meaningful
relationships and functioningin life, you're going to get a
(21:57):
better outcome than if youcatch someone two, three, five
years down the road, andthey've been psychotic for all
this time. And meanwhilethey've destroyed all their
relationships and they nolonger have a job and oops, you
know, they forgot to renewtheir welfare. And so now they
don't even have a place tostay. So that sort of downward
drift, we know that thathappens in psychosis.
It probably also happens inmood and anxiety and sort of
(22:22):
mood dysregulation kind ofdisorders like personality
disorders. So one of theexciting things - I've got a
new staff coming on after hisfellowship at Stanford in Young
Adult Health - will be to startup a mood and anxiety first
episode type program as well.
So yeah, we're trying to catchthings quickly so that they
(22:43):
don't deteriorate.
Thank you so much Dr. Igartúaand thank you for tuning in to
this Code Life interviewbrought to you by the Montreal
General Hospital Foundation.
Don't forget to subscribe formore interviews and follow us
on social media to get all ofthe latest updates.
Thank you so much and see younext time.
We know with most mentalillnesses, the longer that they
stay in the brain, the harderthey become to treat. So if we
can treat it in a few weeksrather than a few months, we're
going to get better outcomes.
Hello, I'm Annie DeMelt, andwelcome to this Code Life
interview brought to you by theMontreal General Hospital
Foundation. Our guest today isDr. Karine Igartúa,
(00:20):
psychiatrist-in-chief of theMUHC's Mental Health Mission.
And that mission is to providethe best patient care through
innovative programs, but alsothrough research.
Researching new ways to maketreatment more personalized,
more precise. So, Dr.
Igartua, thank you so much forbeing with us.
Thank you for having me.
Let's start by how incrediblybusy you are right now in the
(00:42):
departments of psychiatry andpsychology. We've gone through
a difficult phase for a lot ofpeople's mental health.
What are you seeing right nowin terms of demand and access
to your services?
We're in a really toughsituation because the demand is
increasing or has beenincreasing for many, many years
(01:04):
and the resources have beenshrinking. 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 gradualover time, less beds.
With COVID, there's been a lotof people who've decided to
(01:27):
retire or leave the health caresystem. So in terms of
personnel, we've got adifficulty, too.
But also we have a society thatis moving in ways that I want
to say is toxic to our brain.
Whether it's the higher dosesof THC in our now legal
cannabis. Whether it's thecomplete bombardment of our
(01:47):
brain, of always being on ourphones 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 becausepeople tend to have their
phones in their bedrooms and,you know, they binge Netflix
(02:08):
late at night and they don'tsleep.
Or the lack of exercise, becausewe know that the more time you
spend in front of a screen, theless you move around, the less
you move around, the lessexercise you're getting.
And finally, the lack ofcommunity and socialization.
Even when people...
I see it, the kids, when they'retogether, they're all together
sitting on the couch, buteverybody is on their own
(02:29):
different phone. So they'retogether but not really
together. So that leads toisolation and lack of feeling
of connectedness. So there'sall of these kind of...
this cocktail, these trendsthat are happening in society
that are bad for our mentalhealth. Put that together with
difficulty getting first linecare. Difficulty accessing a GP
(02:53):
if you actually have one, or apsychologist if you're lucky to
have insurance. People come tothe emergency room because they
have nowhere else to go.
And some people come for bonafide mental illness.
So psychotic disorders or mooddisorders. But a lot of people
also come with emotionaldistress, social crises.
(03:15):
And the reality is this week inthe emergency room, I see a
patient who's been there forten 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 bedupstairs is absolutely not
unusual because we just don'thave the capacity.
(03:37):
So increased demand, lowercapacity or capacity that's not
keeping up, which is forcingyou to be a lot more efficient
with your programs.
And you do have a number ofspecialized programs that are
part of the Mental HealthMission. One of them that we're
going to talk about is thisTransitional Day Program.
So who's this for?
(03:57):
What population is this?
Is this for people in crisisand how is it unique and
innovative?
So the Transitional Day Program.
It's funny to say that it'sinnovative now because we've
had it for 20 years.
But it was innovative 20 yearsago, and to my knowledge, it's
still the only program in theprovince like this. So
(04:20):
essentially we took all of thetherapeutic ingredients of a
hospitalization. So whetherit's seeing an OT to help with
goal-setting and organization.
Whether it's psychoeducationaround illness and illness
management. Whether it'sidentifying emotions and
emotional regulation.
(04:40):
Coaching about nutrition andexercise. We even have a choir
that's part of that. So musictherapy. All of the therapeutic
ingredients of ahospitalization, but in a day
program format.
So patients arrive early in themorning, they have a couple of
workshops during the morning,they have lunch at the hospital
(05:03):
cafeteria. So a bit morenormalizing than a tray in your
room kind of thing. It createsa socialization and a sort of a
group belonging kind of effect.
They have a few more workshopsin the afternoon, than they
might have an individualmeeting or two.
And then they go home.
And the going home is greatbecause it means we're
(05:26):
promoting recovery and notregression. So you go home, you
still get to walk your dog, youstill get to check your emails,
you still get to hug yoursister. So the going home.
.. The messaging is you're nottaking a break from your life.
You are in recovery of whatevercrisis you're in.
(05:47):
And we want to get you back toyour life as soon as possible.
So TDP was innovative when westarted it, and we want to
innovate further. So two of thethings that we're going to be
... We're going to be looking atTDP in terms of adapting some
of the therapies so that thepatient with the first episode
mania might not need exactlythe same thing as the patient
(06:10):
who is in a suicidal crisis,for instance. So we might be
mapping out the trajectories alittle bit differently.
For that, we need the help of apsychologist. And that's
actually great because that'sone of the things that the
foundation is helping us with.
The other project that we wantto bring in is Les Impatients.
Les Impatients is a communityorganization. They're well
(06:32):
established. It's artists thatrun workshops for people with
mental illness, and they'realso recovery-oriented.
So we want to bring in LesImpatients so that people in the
Transitional Day Program andpeople in our Brief
Intervention Unit have accessto this art expression.
(06:55):
You talked about mapping outpeople'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 thebigger picture?
One of the other things we'vedone to try and and palliate
(07:15):
the lack of beds, but also interms of being more efficient
in treatment is we opened theBrief Intervention Unit.
The Brief Intervention Unit isfor people who we think a 3 to
5 day hospitalization will bebeneficial. So we've mapped out
6 or 7 clinical situations inwhich patients might present
(07:37):
that might be useful. Sowhether it's a first episode
psychosis, whether it's anintoxication that's altering
mental status or whether it's apatient with a personality
disorder that's in crisis or apatient in a suicidal crisis.
So these are the type oftrajectories of patients that
might come to the BIU.
(07:58):
And what we've done istrajectory mapping so that
everybody knows with thisparticular clientele in the
first 0 to 12 hours, this iswhat 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 apsychologist sort of running
(08:19):
the show. The doctors know.
So everybody knows what theirrole is and what their role is
on day one, two and three.
So that there's less waitingaround for treatments to happen.
In addition to managing this andso much more, you're one of the
co-founders of the McGillSexual Identity Centre.
I want to talk to you a littlebit about what kind of
specialized care you'reproviding to to patients there
(08:41):
right now.
We're the first and, as far as Iknow, still the only
psychiatric clinic that catersto sexual minorities.
Initially, the clinic was meantto be a safe space for
lesbians, gays, bisexuals,particularly because psychiatry
had stigmatized them for many,many years. It was a pathology
(09:02):
in our DSM.
Over time, society has evolved.
People have evolved.
So internalized homophobia andjust straight discrimination
for homosexuality is much lessso we see much less of that
population. However, that'skind of been in parallel with
this explosion of peoplequestioning their gender
identity. I would say ourpopulation that we cater to now
(09:28):
is about 75 or 80% peoplequestioning their gender
identity.
The range is obviously greaterthan what we would have had a
few years ago. Acceptabilityyou talked about, acceptability
being greater. So what are youworking towards in your
treatment and what you offerthose patients?
It used to be that when wetalked about the trans
population, we were talkingabout a very specific minority
(09:51):
of people who were hell-bent onchanging the body and the
gender that they had beenassigned at birth.
And so these were people whowere willing to go to terrible
lengths because I have to sayit, our treatments were
archaic. We asked people tocross-dress for a year before
giving them access to hormones,which is really just asking for
(10:14):
discrimination. It's reallyquite sad. But so that
population, that transpopulation, we actually have
good data on the lack of regretor the happiness with their
outcomes. So these were peoplethat were uber motivated to
transition from one box to theother. Now what we're seeing is
(10:35):
an explosion of boxes.
Not everybody feels thatmasculine and feminine cater to
everything and that some peoplefeel in between or a mixture of
both, or they feel moremasculine on one day, more
feminine on the other day.
And we're getting a lot ofteenagers that are questioning
this. So our understanding ofgender identity has shifted
(11:00):
over the years and society'sunderstanding of gender
identity has shifted.
We're more open and at the sametime we're not. So on the one
hand, we now tell people youcan choose the gender that you
want. You want to be masculine,you go ahead and be masculine.
But there's still this sort ofsubconscious underlying message
that you can be masculine, butyou better make sure your body
(11:24):
corresponds to the genderyou've chosen. And so what
we're trying to work towards isundoing that sort of body
determinism for gender.
And saying people can adoptwhatever gender they want and
they can be in their body,however they feel most
comfortable. And we don't haveto have just these two boxes.
(11:46):
And so that implies that noteverybody is going to have the
same transition journey.
Where it used to be firstsocial transition, then
hormonal, then surgical.
That's sort of the archaic wayof doing it. Now, some people
will have a social transitionwithout anything else.
You know, I'm no longerPatricia. I'm Patrick.
Call me Patrick. I'm cutting myhair short. I want to be known
(12:07):
as Patrick. Some people that'llbe sufficient for them.
For other people.
I want my voice to deepen.
So I'm going to take hormonesjust until my voice deepens.
And then that's it. I don'twant the other hormonal
effects. So all that to say isthat there's a whole range of
(12:27):
gender presentations.
And what we work towards in theclinic is helping people to
figure out how to embody theirgender in a way that's most
comfortable for them.
How important is it to have thatpathway to be able to predict
outcomes? And what's theconnection with one of your
(12:49):
flagship research projects atthe MGH.
One of the questions we get themost 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 thatwe don't have data,
particularly on teens who arefirst 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
(13:23):
questioning their gender.
We don't have very much outcomedata to know, am I better off
transitioning or am I going tobe just as miserable but with a
different body? So any kind ofresearch that would allow us to
track this population
prospectively and see (13:41):
When I transition, does that improve
my mental health outcomes ornot?
Would be great. And that'sexactly what we can do with the
Centre for PrecisionPsychiatry, which is our big
research project in thedepartment, because that's what
it does. It gets patients whenthey first come into the clinic.
(14:01):
And patients can be followedfor ten years witt twice yearly
psychological assessments, awhole bunch of baseline
psychological data to try andfigure out what the predictive
factors are going to be, butthen also biomarkers and
imaging. So patients who agreeto will get their brain
scanned. So we're reallylooking at all different kinds
(14:24):
of data to try and then, in tenyears we'll be able to
retrospectively look back andgo, oh, when patient had A, B
and C, they were more likely tobe happy post-transition than
not.
And this is for all kinds ofdifferent conditions. So it
could help you predict anepisode of psychosis or someone
who comes in with a depressionreally young. What are some of
(14:45):
the other potential scenarios?
There's a lot of trial and errorin in psychiatry because, you
know, we can't, when a patientcomes in, crack their skull,
open their brain, take a sliceand have a look at it to figure
out what we need to give them.
So there's a lot of trial anderror. So whether it's about
antidepressants. Am I betteroff with Wellbutrin or Effexor
(15:05):
or Pristiq or Remeron.
Or, for a bipolar patient.
Is this a bipolar patient who'sgoing to respond to lithium or
is this going to be a lithiumnon-responder who would be
better off with Epival, forinstance. Or for the first
episode psychosis.
Is this someone who I can getaway with treating a very tiny
dose of an antipsychotic, or isthis someone who's going to
(15:25):
need a bigger dose?
And so right now we kind of dothat with trial and error and
sort of gestalty kind offeelings about things.
So we have to readjust ourtreatments, which is, okay.
We do that. But, if we're ableto target the exact dose
somebody needs quickly, then weget to remission faster.
(15:49):
And we know with most mentalillnesses, the longer that they
stay in the brain, the harderthey become to treat. So if we
can treat it in a few weeksrather than a few months, we're
going to get better outcomes.
As a psychiatrist-in-chief andalso as a clinician, where
would you hope we would be in,you know, 10, 20, 15 years?
What would your dream be ifyou were allowed to dream big a
(16:12):
little bit.
In terms of treatment, it wouldbe great to be able to identify
which treatment would be goodfor any specific person.
Right? Because you can have 5or 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'mruminating.
For somebody that's going to bea depression and they're going
to respond to an antidepressant. For somebody else that's going
to be a hyper adrenergic statethat's going to respond to
something else. You know, alldifferent kinds of ways of
(16:48):
looking at it. But if I candream even bigger than that, I
would hope that our societywould have enough of an
awareness of what our mentalhealth needs are, that we start
to make some some societal andsystemic changes to the way we
live so that we are not puttingour brains in these toxic
(17:10):
environments. You know, I wasmentioning things before about
social media and lack of sleepand, lack of feeling of
community, lack of exercise.
Our society is going in adirection that's not good for
our mental health and ourwell-being. And I would hope
that by 15 years from now we'vefigured that out. And we've
(17:30):
dialed it back a bit and thatwe've actually equipped our
younger generation to be ableto be more mindful of their
mental health and to give themthe tools to not deteriote.
We can do that now.
It can start now. You're a bigadvocate for education and
(17:53):
awareness to protect yourmental health so it doesn't
become mental illness,basically. Right? So,
concretely, what would it looklike?
For me, and any time I get themic to say this, I will, so
thank you for giving me the micfor this again. I think that we
... Not I think, I know that weneed mental health education in
(18:14):
schools and it needs to startin kindergarten and it needs to
go all the way to the end ofhigh school. And obviously what
we teach in kindergarten and atthe end of high school will be
different. But we need to startby teaching social emotional
awareness. So how am I feeling?
Am I happy, sad, angry orscared? And why am I feeling
that way? What can I do to, youknow, if I'm over emotional,
(18:38):
what can I do to tone it down?
Or if I'm under activated, whatcan I do to bring my energy
level up to meet the situationthat I'm in? Then once I'm able
to self regulate, then I'm alsoable to ask for what I need and
what I want, and I'm able tothen learn to negotiate my
relationships better.
So we start with selfregulation, then we go to
(19:01):
relationship negotiation kindof 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 havemeaningful parts of my life and
I have enough awareness of whatI need as a human and what my
(19:23):
brain needs as an organ sothat 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 impacton that?
To me, this is so crucialbecause, you know, we keep
hearing there's this many moremillions for mental health and
(19:43):
this many more millions for...
The reality is if we don't dosomething to equip our youth
and our society to bettermanage our mental health, we
can keep throwing more and moreresources. Although, we're
still very underfunded.
I'll just put that caveat outthere, But we're never going to
catch up. And so we're alwaysgoing to have these stories of
(20:06):
people who are waiting for daysand days and days in the
emergency room because there'sno beds available upstairs.
Or who have, you know, called 80places and can't find a
psychologist that can helpthem. So unless we start to
equip our youth and theirparents. Right, let's let's be
honest. Part of the reason thekids don't know this is because
(20:28):
their parents don't know iteither. If we don't equip
ourselves as a society tounderstand what our brains and
our minds need in order tofunction well, then we're
hitting a wall.
You're also doing this already.
You know, through theseprograms, through the
Transitional Day Program,there's more of an educational
(20:48):
component as well, right?
There's a shift towards that aswell. 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 ofpermeating through psychiatry
and through public health,really.
Two things I want to say. One isthat a lot of treatment for
(21:14):
mental distress, I'm not goingto say mental illness, but
mental distress can be done bythe person themselves if they
know what to do.
So that's yes, part of thepsychoeducation point.
And the other point I wanted tosay is that we also know and
this is derived from firstepisode psychosis programs.
(21:34):
We also know that if youintervene quickly.
.. You know, the quicker youtreat a psychosis, the easier
it is to treat and the lesssequelae you're going to have.
And so if you can treat a firstepisode psychosis and go to
rehabilitation and reconnectingsomeone with their meaningful
relationships and functioningin life, you're going to get a
(21:57):
better outcome than if youcatch someone two, three, five
years down the road, andthey've been psychotic for all
this time. And meanwhilethey've destroyed all their
relationships and they nolonger have a job and oops, you
know, they forgot to renewtheir welfare. And so now they
don't even have a place tostay. So that sort of downward
drift, we know that thathappens in psychosis.
It probably also happens inmood and anxiety and sort of
(22:22):
mood dysregulation kind ofdisorders like personality
disorders. So one of theexciting things - I've got a
new staff coming on after hisfellowship at Stanford in Young
Adult Health - will be to startup a mood and anxiety first
episode type program as well.
So yeah, we're trying to catchthings quickly so that they
(22:43):
don't deteriorate.
Thank you so much Dr. Igartúaand thank you for tuning in to
this Code Life interviewbrought to you by the Montreal
General Hospital Foundation.
Don't forget to subscribe formore interviews and follow us
on social media to get all ofthe latest updates.
Thank you so much and see younext time.
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