BC-CfE and Vancouver Coastal Health Collaborate on new Treatment Optimization of Psychosis (TOP) Collaborative

The Treatment Optimization of Psychosis (TOP) Collaborative officially launched on Wednesday, June 23rd. TOP is a quality improvement initiative led by the BC Centre for Excellence in HIV/AIDS (BC-CfE) in partnership with Vancouver Coastal Health’s (VCH) Mental Health and Substance Use Services.

TOP aims to systematically share, measure and implement best practices in the treatment of psychosis in community settings rather than in hospitals. Teams from across the VCH region will come together to achieve similar goals over the course of 12 months – connecting people living with psychosis with the best possible treatment, care and monitoring in their own communities, while raising awareness of effective clozapine treatment.

Clozapine is the only treatment approved by Health Canada for people who live with treatment-resistant psychosis (TRS). Compared with other medications, clozapine is about twice as likely to succeed in reducing their symptoms. However, a small percentage of people may have side effects and require extra supports. TOP is designed to help teams develop the expertise to offer this treatment to all clients who could benefit from it. The TOP team noticed how this medication was severely underutilized in BC compared to other jurisdictions and seeks to change this. For example, in Australia and New Zealand clozapine usage is estimated to be about 30% in TRS, but only 17% in BC.

Bob Chapman, Interim Vice President of Vancouver Community for VCH said, “We know that many people living with mental health challenges often receive other treatments before the ideal treatment option. This quality improvement initiative will bring greater awareness of the efficacy and safety of medication and help to ensure that health-care practitioners can best support their clients who may benefit from optimized treatment options.”

With nearly 80% of adults in BC having at least one dose of COVID-19 vaccine, and more than one million people in BC fully vaccinated, the COVID-19 pandemic in BC is hopefully nearing its end. However, those living with mental health challenges suffered disproportionately negative impacts throughout the pandemic as physical distancing, isolation, and instability in work and relationships took their tolls. The new ambitious goal thus became known as the UN 90-90-90 Target. By the end of 2020, B.C. and a few other jurisdictions around the world had met or surpassed the target, with consequent significant favourable impact on their respective rates of AIDS related morbidity/mortality as well as HIV transmission. The original plan called for the UN 90-90-90 Target to become the UN 95-95-95 Target as of the end of 2020.

In the VCH region, psychosis is the number one cause of readmission to acute psychiatry within 30 days of discharge. TOP has the potential to improve the health of individuals and decrease the use of acute care as research indicates that for appropriately selected patients, clozapine is associated with 18.6 fewer inpatient days per year per client treated.

Hon. Sheila Malcolmson, BC Minister of Mental Health and Addictions said, “For too long, it’s been hard for people experiencing psychosis to access care. This new training program will improve care and treatment, and might reduce the need for hospital care. I am grateful for Vancouver Coastal Health and the BC Centre for Excellence in HIV/AIDS, supporting families and people living with psychosis.”

TOP’s origins are rooted in the experiences and accomplishments of the Treatment as Prevention (TasP) strategy pioneered by the BC-CfE. TasP created a legacy of health-system improvement in B.C. through programs such as the Seek and Treat for Optimal Prevention HIV/AIDS Program and the BOOST Collaborative (Best-Practices in Oral Opioid agoniSt Therapy).

The TOP Collaborative will follow the same approach in its implementation to shift initiation of psychiatric care from hospital to community settings; build capacity at each participating community mental health and substance use team in the VCH region; and improve the quality of care for clients living with psychosis.

The scope of TOP is large, as all VCH community adult mental health and substance use teams, Assertive Community Treatment, and Early Psychosis Intervention teams will be included in the collaborative. This means Strathcona, West End, Kitsilano, South, North East, Grandview-Woodlands, Ravensong, Early Psychosis Intervention, Vancouver Coastal Assertive Community Treatment teams, and Sechelt Mental Health and Addiction Services will each send several delegates for learning events and have these delegates disseminate the knowledge they gain.

TOP participants will take part in eight continuing medical education events for physicians, clinical staff, and administrative support staff; TOP learning sessions, focused on how to create and sustain clinical changes; action periods where information learned is implemented; and four one-hour webinars focused on topics covered in the learning sessions.

Hardeep Thind, Coastal Regional Manager, British Columbia Schizophrenia Society said, “it’s really important for families to have good, accurate information – I believe providing this training will assist frontline staff and help them be more confident in sharing information on clozapine.”