Programme

To leverage collective expertise, perspective and skills, Health Quality Ontario brings together experts, health care providers, administrators, patients, and the public to collaborate on emerging issues. Acting as an objective facilitator, these issues are analyzed and evidence-informed solutions and recommendations are developed to inform changes in policy and practice.

In his presentation, Dr. Joshua Tepper, President and CEO of Health Quality Ontario, will focus on the following areas: the role of HQO as the provincial advisor on quality issues; HQO Quality Standards, their creation, legislative basis and role in better care; HQO quality standards in psychiatry, including depression, schizophrenia, dementia, with a special focus on the recommendations related to psychotherapy.

Learning Objectives

• Understand the role of HQO as the provincial advisor on quality issues
• Understand HQO Quality Standards, their creation, legislative basis and role in better care 
• Learn about the HQO quality standards in psychiatry including depression, schizophrenia, dementia 

About the Speaker

Before coming to Health Quality Ontario, Joshua was the Vice President of Education at Sunnybrook Health Sciences Centre, in charge of educational strategy and programming for learners, physicians and staff, patients and their families, and the community. Prior to Sunnybrook, he served as the Assistant Deputy Minister at the Ministry of Health and Long-Term Care, where he led the HealthForceOntario health human resources strategy to ensure Ontarians had access to the right number and mix of qualified health care providers. Joshua has also been active on a national scale as the Senior Medical Officer for Health Canada, an Adjunct Scientist at the Institute for Clinical Evaluative Sciences, and a Research Consultant for the Canadian Institute of Health Information. He has received several provincial and national awards for his leadership in these positions, including the Ontario College of Family Physicians, Jan Kasperski Leadership Award (2011-12) and Canada’s Outstanding Young Leadership Award from the Canadian College of Health Services Executives (2009).

Joshua received his Doctor of Medicine from McMaster University. He has a Masters of Public Health in Quantitative Methods from Harvard University and an MBA from the Richard Ivey School of Business. He holds a Bachelor of Arts in Public Policy from Duke University.

Genetics is rapidly becoming a key component of psychiatric theory and practice. Researchers are zeroing in on genetic factors that contribute to mental illness in children and adults. Many new lessons have been learned from this research. For example, 1) psychiatric disorders often share specific genetic risks, 2) that common and rare, inherited and de novo variants can influence mental health, and 3) genetics can influence treatment choice and response. Consequently, practitioners are faced with a series of new challenges including when to considered and test for genetic risk factors and understanding how to take genetic risks into account when providing feedback and care to patients. This workshop will explain different types of genetic variants (e.g., common and rare variants) and how they could affect behaviour and mental health, review evidence for genetics of common mental illnesses (ADHD and OCD in childhood; SCZ, MDD and ID as examples), describe some of the evidence for shared genetic risks across disorders, present strategies for discussing genetic testing and results of testing with one’s patients, and illustrate how genetic findings might influence practice (using examples from various clinical populations--dual diagnosis, ADHD). 

Learning Objectives

• At the end of this session, the participants will be able to describe genetic variation and its potential impact on mental health
• At the end of this session, the participants will be able to understand current research strategies for discovering genetic risk factors and some of the key findings pertaining to mental illness in children and adults

• At the end of this session, the participants will be able assess and evaluate genetic influences on mental health and incorporate these results into clinical practice

The Royal College Competence by Design (CBD) initiative is being implemented across all specialties, including psychiatry. Many postgraduate programs in Canada have already begun to initiate principles of Competency Based Medical Education (CBME) in residency programs. The need for faculty development regarding this major shift in educational paradigm is substantial. Within the CBD framework, valid assessment methods are key to the acquisition of defined competencies required by a psychiatrist. There is a close relationship between effective learning and valid assessment methods, as observation and feedback are powerful tools to change learner behaviours. Faculty engagement and training are critical in ensuring that assessment methods are effective in measuring learner competence in real life. When competence is not achieved, remediation is implemented to address deficits in performance, often requiring more resources. With the advent of CBD, psychiatry postgraduate programs will need to ensure that faculty are informed, engaged and prepared to utilize the assessment methods and tools. This will require a shift in approach to supervision and assessment, with a focus on early identification and intervention of performance deficits. The CBD framework is intended to address many of the aforementioned challenges. This workshop will provide an introduction to the general principles and terminology used in describing CBME-based models of training. We will also review principles of assessment within a CBME-based model, with particular application to psychiatry training. Queen’s University has developed and implemented competency-based training across all postgraduate programs, including psychiatry and its subspecialties. Examples and insights from Queen’s experience in developing and implementing a CBME-based training program will be discussed, to illustrate how a competency-based program can meet the challenges inherent in assessment for trainees in psychiatry at all postgraduate levels. 

Learning Objectives

• To examine the role of faculty in the relationship between learning, assessment and the acquisition of competence in psychiatry residency training
• To review new terminology required in implementing the Royal College CBD framework in residency training
• To examine how a competency-based framework within psychiatry may potentially address inherent challenges of assessment in psychiatry training

Dialectical Behavior Therapy (DBT) is an adaptation of cognitive behavior therapy which was developed to reduce suicidal and self-harm behaviors in people with borderline personality. Over time, its applications have broadened to address a variety of emotion dysregulation and impulse control problems. In this workshop, two addictions psychiatrists will present their understanding of how the fundamental principles of DBT can be applied build engagement and target complicated problems in substance use treatment. Using a true-to-practice case example, and plain, irreverent language, we will explain dialectics, Marsha Linehan’s Biosocial Theory and some of the unique tools available within DBT. There will be a hands on components, where participants will learn how to do a behaviour chain analysis and a missing links analysis. This is a core skill that can help patients avoid repeating dangerous behaviours. 

Learning Objectives

• At the end of the session, participants will be able to describe a dialectic and think of examples.
• At the end of the session, participants will be able to explain Linehan’s biosocial model of emotional dysregulation in plain language.
• At the end of the session, participants will be able to perform a behavior chain analysis.

Community treatment orders CTOs are employed worldwide. They are being employed in increasing numbers. Yet much of the international literature consistently concludes that CTOs are ineffective or at best, of questionable effectiveness. We will address the major factors contributing to this paradoxical situation. Local data will be provided. This data will demonstrate the potential benefit of CTOs in Ontario, particularly the lessening of time in hospital for many of the patients who are subject to CTOs. Several cases will be presented that describe typical scenarios for the use of CTOs in Ontario. 

Learning Objectives

• Understand the causes of the conflicting conclusions about the effectiveness of community treatment orders

• Appreciate the clinical factors that limit the benefit of community treatment orders

There are many medications that help when people use substances. These include naltrexone, accamprosate, baclofen and topiramate for alcohol use disorder and buprenorphine for opioid use disorder. These medications were not a part of standard psychiatric or primary care training in the past, but the evidence is quite strong for their use. In this interactive workshop, people will get an overview of the various pharmacotherapies for substance use disorders, engage in small group discussions around cases with the aid of a facilitator and a free booklet that covers the basics. Those that attend will have the opportunity to join a community of practice and be connected to mentor as they try to integrate these skills into their practice. 

Learning Objectives

• At the end of the session, the participants will be able to describes the various pharmacotherapies for alcohol and opiate use disorders.
• At the end of the session, the participants will engage in small group discussions around various cases and determine collectively which specific medication would work best for which patient.
• At the end of the session, the participant will have an opportunity to reflect on their practice and develop a strategy to integrate these skills into their outpatient practice.

On March 1st, 2016, the Ministry of Health and Long-term Care changed regulations governing pre-approval of sex-reassignment surgery (SRS) in Ontario, partly in response to the increasing numbers of transgender people seeking these services. This workshop will review the place of mental health assessment in this new landscape and describe the components of a mental health assessment as currently performed at the CAMH Adult Gender Identity Clinic. Included in this will be a discussion of diagnosis of Gender Dysphoria, eligibility criteria for surgery as promulgated by the World Professional Association for Transgender Health (WPATH) as well as individual surgical readiness issues and barriers to informed consent. Efforts will be made to emphasize similarities to the kind of mental health assessments participants may already be doing (e.g. general psychiatric assessments, capacity assessments) to increase clinician comfort with providing these assessments, given increasing need for services. Participants are encouraged to bring their own clinical questions for an extended Q&A session. 

Learning Objectives

• At the end of this workshop, participants will understand the components of a mental health assessment for individuals seeking gender transition surgeries.
• At the end of this workshop, participants will understand eligibility criteria for gender transition related surgeries as promulgated by the World Professional Association for Transgender Health.
• At the end of this workshop, participants will have greater comfort providing assessments and support to individuals seeking gender transition surgeries

It is now well recognized that bipolar disorder among adults is associated with greatly increased vascular risk, including heart attack and stroke, and that this risk is evident prematurely in life. The excessive vascular risk associated with bipolar disorder is compounded by, but is not fully explained by, such factors as psychotropic medications, substance use, and suboptimal lifestyle. Indeed, the elevated risk of cardiovascular disease in bipolar disorder exceeds what can be explained by even traditional cardiovascular risk factors such hypertension and obesity. Vascular risk has psychiatric as well as physical relevance, as numerous studies have found that cardiovascular risk factors are associated with a more pernicious symptomatic course of bipolar disorder. Dr. Goldstein will begin by providing a high-level review of the above-noted literature, and summarizing the recommendations from a recent American Heart Association scientific statement in relation to adolescent bipolar disorder. He will then focus on recent evidence of excessive vascular risk among adolescents with bipolar disorder, including peripheral and cerebral imaging data that informs our understanding of the genesis of the vascular-bipolar link.  Finally, clinical, scientific, and stigma-related implications will be discussed.

Learning Objectives

• Recognize the increased cardiovascular risk associated with bipolar disorder
• Identify different factors that may explain this association
• Consider how the heart-bipolar link may inform monitoring, treatment, and stigma-reduction in bipolar disorder

About the Speaker

Dr. Goldstein is a child-adolescent psychiatrist and Professor of Psychiatry and Pharmacology  at the University of Toronto Faculty of Medicine, as well as Adjunct Professor of Psychiatry at the University of Pittsburgh.  He is director of the Centre for Youth Bipolar Disorder and director of research in the Department of Psychiatry at Sunnybrook Health Sciences Centre, and a Senior Scientist at Sunnybrook Research Institute. Dr. Goldstein’s efforts focus on teenagers with, or at familial risk for, bipolar disorder. His team’s integration of heart health with mental health is intended to identify clinically relevant biomarkers and innovative prevention and treatment strategies, and reduce stigma. Dr. Goldstein has authored over 130 scientific articles, and has received national and international awards for his research. His research is currently funded by grants from Brain Canada, CIHR, the Heart and Stroke Foundation, and the Ontario Ministry of Research, Innovation and Science. An active educator, Dr. Goldstein serves as Director of the Clinician Scientist Program in the University of Toronto’s Department of Psychiatry.

 With family physicians playing increasingly central roles in delivering mental health care in most jurisdictions, the need to improve the relationship with mental health services and to build collaborative partnerships becomes even more pressing. This presentation presents a model for collaboration that aims to build upon and complement those services that primary care are already delivering (primary mental health care). Using a variety of frameworks including the collaborative care model, the work of the WHO and MHGAP, and the principles of quality improvement it defines primary mental health care and the services that can be delivered in any primary care setting, outlines the principles to guide collaboration and shows how effective collaborative partnerships can build upon and enhance primary mental health care. It outlines specific responsibilities of and opportunities for the psychiatrist working in such partnerships using the experiences of the Hamilton Family Health Team which has successfully integrated mental health counsellors and psychiatrists into the offices of what is now 180 physicians over the last 20 years. It presents strategies and practical approaches for adapting and implementing these concepts in any community and changes that can be made by any mental health service to improve collaboration and will emphasise practical tips, tools and suggestions that can be introduced in attendees own practice

Learning Objectives

• To understand the role that primary care plays in delivering mental health care
• To become familiar with the principles that should guide collaborative partnerships
• To learn the key steps when implementing a collaborative project

About the Speaker

Nick Kates is a Professor and Department Chair, with a cross appointment in the Department of Family Medicine and also works with the Hamilton FHT.  For 4 years he was the Ontario lead for  quality improvement in primary care through QIIP. Other roles have included Director of ERMHS, McMaster Psychiatry Residency Program Director, Director of the Hamilton Region Psychiatry Program and Director of the Hamilton HSO (now FHT) Mental Health and Nutrition Program. Since 1997 he has been the co-chair of the CPA / CFPC Collaborative working group on shared mental health care in Canada 

He has participated in many provincial and national planning initiatives for mental health and primary care and has consulted to over 100 Canadian and International governments, organizations and programs. He has published over 60 articles and authored 2 books.

He is a Distinguished Fellow of the Canadian Psychiatric Association and the American Psychiatric Association and an honorary member of the College of Family Physicians of Canada. In 2000 he received the Canadian Psychiatric Association Paul Patterson Award for Leadership in Education; in 2001 the CPA C.A. Roberts Award for Leadership in Clinical Services and in 2005 the CPA / Canadian Academy of Psychiatric Epidemiology Alex Leighton Award for Psychiatric Epidemiology.

This workshop will review a few peer assessment programs in psychiatry as a frame to present the newly redesigned Peer Assessment Program (PAP) of the College of Physicians and Surgeons of Ontario (CPSO). PAP will be discussed with participants with ample opportunity for discussion and feedback; the PAP is a commitment to Quality Improvement as its focus is to identify opportunities for improvement while reassuring ongoing good practices. The role of the PAP in physician regulation and ongoing quality improvement will be reviewed. The CPSO operates a PAP for Ontario physicians focused around a chart review and physician interview with the overall purpose of validating appropriate care and highlighting opportunities for practice improvement. This workshop will provide an overview of the PAP with a specific focus on a recent redesign of the assessment for psychiatrists. Historically, the template used in the PAP in psychiatry was a common resource shared with other specialties; psychiatry has recently redesigned a new template for the assessment. The rationale for the CPSO peer assessment redesign and the process undertaken will be reviewed. The new handbook prepared to assist assessors and psychiatrists involved in the PAP will be presented. Participants will learn how psychiatrists are selected for the PAP and how the assessors are assigned. We will review initial contact with the CPSO, with the assessor, chart selection and review, the content of the assessment interview, and the possible outcomes. We will highlight the elements of quality that are part of the peer assessment process. Tips for optimizing the peer assessment process will be reviewed. Psychiatric assessors will share their experiences and answer questions related to the PAP. The potential role of the handbook in self-assessment and continuing medical education activities will be discussed. Feedback related to the peer redesign and handbook will be encouraged. 

Learning Objectives

• At the end of the session, the participant will be familiar with role of the CPSO Peer Assessment Program.
• At the end of the session, the participant will be familiar with the revised peer assessment process.

• At the end of the session, the participant will be comfortable preparing for a peer assessment.

Obsessive-compulsive disorder (OCD) is a common psychiatric condition for which efficacious treatments have been developed. However, first-line pharmacotherapy is often less effective in typical outpatient practice than the evidence suggests or clinicians would hope. Cognitive-behavioural therapy (CBT) is a recognized first-line treatment, but many clinicians have relatively limited knowledge regarding this treatment modality in general, and its application in OCD, restricting the frequency with which it is offered. Outcomes with either modality are often limited by lack of specific knowledge regarding disorder-specific differences in treatment for OCD as compared to other mood and anxiety disorders. The focus of this workshop will be on providing clinicians with OCD-specific tips to optimize outcomes using both medication and CBT. Pharmacotherapy will be reviewed with emphasis on practical strategies to enhance treatment success. The application of CBT for OCD traditionally requires significant training, however excellent self-help treatment manuals now exist; thus this workshop will provide clinicians with key knowledge to effectively facilitate bibliotherapy-guided CBT. Last, there are unfortunately a significant number of individuals with OCD who fail to respond to these evidence-based treatments. A number of alternative therapies showing promise for treatment-resistant OCD will therefore be reviewed, along with rationale for a stepped-care approach. These include: neuromodulation approaches such as repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS), and psychosurgery, as well as high-intensity CBT which is newly available in Canada. Key points will be illustrated by presentation of selected cases, with opportunity for attendees to discuss application of these principles to their own cases. 

Learning Objectives

• Optimize pharmacotherapy for OCD to enhance outcome.
• Understand principles of CBT for OCD, and effectively utilize and facilitate bibliotherapy-based treatment.
• Discuss treatment alternatives for treatment-refractory patients.

The Ontario Psychiatric Association has created a new program to facilitate the challenge of navigating the transition from residency to independent practice.  The morning session will provide a brief orientation to planning for key milestones and will offer an interactive panel featuring psychiatrists practicing in a variety of settings to help residents consider the breadth of available models.  The afternoon session will feature presentations focusing on additional practice management topics such as understanding billings and accounting considerations.

Learning Objectives:

• To plan for ways to optimize the final year of residency in preparation for independent practice.
• To consider a range of practice models that are available in both academic and community settings post-residency.
• To learn about billings and other financial considerations when engaging in independent practice.

There are multiple complex issues currently at play, which directly affect Ontario's 2000 psychiatrists in their day to day clinical work. These include the province's mental health and addictions strategies, the services agreement negotiations, pressures related to access to and distribution of psychiatrists, and issues related to psychiatric health human resources.

Workshop participants will have an opportunity to hear updates about key areas of change that have implications for psychiatric practice in Ontario. Dr. Chaimowitz and Dr. Gaind will provide perspective on the challenges that the Ontario Medical Association have experienced in the last year both in terms of negotiations with the Ministry as well as their own membership. Dr. Freeland will provide an overview of implications of introducing mental health quality standards in Ontario. Patrick Nelson will share an update on the government relations work being undertaken by the Coalition. Finally, participants will have an opportunity to share perspectives, ask questions and raise issues for the Coalition to consider.

Learning Objectives

• Appreciate the current tensions between government and organized medicine in Ontario
• Understand the implications of introducing mental health quality standards in Ontario
• Describe recent legislative changes impacting patient care in Ontario

This workshop will use a case based approach to highlight the complexities of the presentation, assessment and treatment of Borderline Personality Disorder. In particular, the impact of co morbid depression will be reviewed. The interaction of psychological trauma and the diagnosis of complex PTSD will be explored. The importance of the therapeutic relationship and the vulnerabilities of the treater will be considered. Finally the importance of collaboration between caregivers and organizations will be examined. A model of comprehensive care will be presented and applied to a case example. 

Learning Objectives

• Understand the co morbid conditions associated with Borderline Personality Disorder including trauma, substance abuse, depression etc.
• Describe a comprehensive approach to patients with complex Borderline Disorders

• Understand the challenges in the therapeutic relationship in treating these clients

The Ontario Psychiatric Association has created a new program to facilitate the challenge of navigating the transition from residency to independent practice.  The morning session will provide a brief orientation to planning for key milestones and will offer an interactive panel featuring psychiatrists practicing in a variety of settings to help residents consider the breadth of available models.  The afternoon session will feature presentations focusing on additional practice management topics such as understanding billings and accounting considerations.

Learning Objectives:

• To plan for ways to optimize the final year of residency in preparation for independent practice.
• To consider a range of practice models that are available in both academic and community settings post-residency.
• To learn about billings and other financial considerations when engaging in independent practice.

Interpersonal Psychotherapy (IPT) is a time-limited, structured and evidence-supported treatment focused on affectively charged experiences of change, loss, or conflict in close relationships that are bi-directionally linked with the onset, perpetuation, or worsening of the symptoms of mental illnesses (Weissman, Markowitz, Klerman 2018).  National and international consensus depression treatment guidelines recommend IPT [e.g. CanMAT, World Health Organization] based on the strength of evidence from numerous randomized controlled trials and meta-analyses (Cuijpers 2016).  IPT’s therapeutic targets resonate with the universal, central role of relationships in health and well-being across the lifespan.  IPT is used in culturally diverse settings for treatment of depression, eating disorders, PTSD, anxiety and in combination with pharmacotherapy to delay bipolar and depression illness relapse.

This presentation reviews IPT outcome research, clinical strategies, and relational theories of attachment (Bowlby) and mentalizing (Fonagy & Bateman). Insecure attachment patterns of relating and unresolved trauma in clinical populations can contribute to difficulties with recruiting or utilizing social support in distressing times of need. Mentalizing is a theory and therapeutic model, originally designed for treatment of Borderline Personality Disorder that can be broadly applied in mental health care. Attachment and mentalizing together provide a conceptual foundation to understand problematic patterns of relating that often flare in times of illness.  Problems in interpersonal interactions can be due to non-shared expectations, misunderstanding, and communication or empathic difficulties. From emotionally dysregulated reactivity to non-responsiveness, a range of maladaptive ways of interacting coupled with a lack of awareness of internal states and interpersonal impacts can converge to author isolation with worsening distress. “IPT 2.0” integrates the use of mentalizing techniques with IPT to foster adaptive changes in relationships and recovery, especially for patients with insecure attachment, unresolved trauma and poor reflective functioning. 

Learning Objectives

• Describe the indications and therapeutic guidelines of IPT
• List 3 types of attachment patterns of relating and 3 types of non-mentalizing states of mind
• Use IPT with mentalizing in the care of depressed patients with insecure attachment

About the Speaker

Paula Ravitz MD FRCPC, Associate Professor of Psychiatry and Director of the Psychotherapy, Humanities and Education Scholarship (PHES) Division for the University of Toronto, Department of Psychiatry, holds the Morgan Firestone Psychotherapy Chair at the Mount Sinai Hospital.  Her research, publications and teaching have focused on Interpersonal Psychotherapy (IPT), attachment theory, mentalizing, and knowledge translation of evidence-supported psychotherapies.  President Elect of the International Society of IPT, she has taught IPT internationally and helped to adapt IPT for varied settings and providers including with Canadian public health nurses and in Ethiopian primary care.