1. Discuss the Mental Health and Addiction System in Canada and identify the strengths and limitations of such systems.

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1 Course Outline and Syllabus for Students Names: Jamie Kellar, Beth Sproule Course Number: PHM386 Course Title: Mental Health and Addictions Elective Course Description: This course is designed to provide students with a specific interest in mental health and addictions a broader knowledge base in the field. It will introduce students to the mental health and addiction system in Canada, the role of stigma in accessing and providing care, the role of psychotherapy and the evidence base for specific modalities, including cognitive behaviour therapy (CBT), interpersonal psychotherapy (IPT), mindfulness therapy, and motivational interviewing. The course will also address issues such as medication adherence and mental health first aid. Students will also be taught how to use validated scales to assess for psychotropic-induced movement disorders. The course will introduce additional mental health disorders/issues, not covered in PHM 302 including refractory schizophrenia, personality disorders, and psychotropic medication use in pregnancy and lactation, and child and adolescent psychiatry. It will also cover key substance use disorders/issues in more depth than was possible in PHM 302, including the management of comorbid mental health and substance use disorders. The course will be taught using a variety of techniques including didactic lectures, observed patient interviews, case-based learning and interactive group learning. Required: No Elective: Yes 1. Course Learning Objectives: Upon completion of this course, students will have achieved the following level of learning objectives: Introductory = knowledge and comprehension of concepts, definitions, Intermediate = application of concepts to simple situations Advanced = application of concepts to more complex situations with ability to synthesize and evaluate Knowledge Mental Health 1. Discuss the Mental Health and Addiction System in Canada and identify the strengths and limitations of such systems. 2. Recognize the intersection of the health and legal systems as they relate to mental illness in Ontario. 3. For the following selected mental health disorders, summarize the etiology, neuroscience concepts, epidemiology, clinical presentation, risk factors and progression: refractory schizophrenia, personality disorders, eating disorders, attention deficit and hyperactivity disorders. 1

2 4. Identify the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders IV and 5, used in the diagnosis and ongoing monitoring of the selected disorders. 5. Recognize different movement disorders in patients with mental illness and be able to apply the following rating scales (Abnormal Involuntary Movement Scale [AIMS], Barnes Akathisia Rating Scale [BARS], Symptom Angus Scale [SAS]) to a patient for the purpose of assessing side effect severity at the time of diagnosis and throughout treatment. 6. Compare and contrast the available classes of medications used for the selected disorders based on the following criteria: indications, efficacy, mechanism of action, pharmacokinetics, pharmacodynamics, pharmacogenomics, adverse effects, warnings/precautions, contraindications, drug interactions (drug-drug, drug-food, drug-laboratory), convenience, cost, formulations and stability. 7. Discuss the evidence of non-drug measures used to treat different mental health disorders (e.g., Electroconvulsive Therapy (ECT), Repetitive Transmagnetic Stimulation (rtms), Cognitive Behavioural Therapy (CBT), Interpersonal Psychotherapy (IPT), Mindfulness therapy and Motivational Interviewing. [INTRODUCTORY] 8. Describe the role of Mental Health First Aid programs in Canada and the utility for practicing pharmacists. [INTRODUCTORY] 9. Recognize the role of the pharmacist in medication adherence and identify evidence based strategies to facilitate this process in patients with mental illness. 10. Identify the role for psychotropic medications in pregnancy and lactation. 11. Explain stigma and how it impacts patient care. Knowledge Substance Use Disorders 12. Compare and contrast the available classes of medications used for the selected disorders based on the following criteria: indications, efficacy, mechanism of action, pharmacokinetics, pharmacodynamics, pharmacogenomics, adverse effects, warnings/precautions, contraindications, drug interactions (drug-drug, drug-food, drug-laboratory), convenience, cost, formulations and stability. 13. Describe the following rating scales and their place in therapy: COWS and CIWA-Ar. 14. Discuss the evidence of non-drug measures used to treat different substance use disorders (e.g., Cognitive Behavioural Therapy (CBT), Interpersonal Psychotherapy (IPT), Mindfulness therapy, Motivational Interviewing, and group versus individual therapy. [INTRODUCTORY] 2

3 Skills 1. Select relevant data from patient demographics, review of systems (ROS), laboratory tests, medical imaging, and, drug therapy in order to identify drug therapy problems. 2. Analyze relevant information from subjective and objective sources, (e.g., review of systems, medical imaging, diagnostic tests, biochemical markers), to identify drug therapy problems, urgency, and priority for a given clinical situation. 3. Justify the selection of a preferred alternative for a given therapeutic scenario based on the assessment of relevant therapeutic alternatives and specific patient population. 4. Demonstrate the skills required to initiate varencline and bupropion for smoking cessation, and to adapt and renew medications for the selected disorders. 5. Develop a care plan for a given clinical situation. 6. Locate reliable sources of information in the area of psychiatric therapeutics. 7. Demonstrate the ability to critique and interpret results from observational studies, randomized controlled trials and meta-analyses in mental health and addictions 8. Assess patients for movement related disorders using the Abnormal Involuntary Movement Scale [AIMS], Barnes Akathisia Rating Scale [BARS], Symptom Angus Scale [SAS]. Attitudes / Values 1. The student will undertake assessment and care plan development activities in a manner that illustrates their understanding of the importance of respecting patient autonomy and individual therapeutic goals. 2. The student will use interprofessional patient-centered care principles to reach decisions for therapeutic alternatives with members of their peer groups. 3. The student will articulate the importance of demonstrating a non-judgmental, empathetic, and professional attitude towards patients who have psychiatric and substance use disorders, which continue to be associated with significant stigma. 2. Rationale for Inclusion in the Curriculum: Mental Health Disorders account for significant morbidity and mortality worldwide. The World Health Organization lists several mental health disorders on their list of the top 10 leading causes of disability worldwide. In Canada, 1 in 5 Canadians will personally experience a mental illness during their lifetime. (Health Canada. A Report on Mental Illness in Canada, 2002). In Ontario, the Select Committee on 3

4 Mental Health and Addiction reviewed the mental health system in Ontario and in their final report (2010), recommended that primary care providers should be given the proper tools and support to enable them to develop a greater sensitivity for the mental health and addictions needs of their patients, and that all interdisciplinary primary care models should include a mental health and addictions treatment component. A key recommendation in the College of Physicians and Surgeons of Ontario report entitled, Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis (2010) is that enhanced training and ongoing education of health care providers in the safe use of opioids is needed. For students with a particular interest in the field of Mental Health and Addictions, this course provides learning and experiences beyond the core disorders and pharmacotherapy taught in Phm 302: Neuropsychiatry. It introduces students to the mental health system in Canada, the social issues faced by patients with mental illness, the role of non-drug measures in the treatment of mental illness and provides enhanced learning opportunities for pharmacy students who wish to learn how to manage patients with complex mental health disorders. 3. Pre-requisites: Phm Statement of agreement from course coordinators of courses for which this course is a prerequisite: N/A 5. Co-requisites: (for the current and subsequent year) (Link to relevant course outlines) Specify relevant knowledge or skills that are co-requisite areas of emphasis 6. Statement of agreement from coordinators of courses for which this course is a co-requisite: Coordinator's Name and course name and/or number: 4

5 7. Course Contact Hours and Teaching Methodologies: Didactic (lecture) Large group problem-based or case-based learning Large Group Size (eg 30, 60, 120, 240) Laboratory or Simulation Tutorial/Seminar/Workshop/Small Group Small Group Size (eg 5, 10, 15, 20, 25) Experiential On-line Other (please specify)* * Other specific information: Total course contact hours 26 hours hours persons hours hours persons hours hours hours 26 hours 8. Estimate and description of student's weekly out-of-class preparation time excluding exam preparation: Review learning objectives, required readings, assignments, case reviews, patient assessments, care plan documents prepared for each disease state (3 7 hrs/ week), higher during weeks of case discussions and exam preparation. 9. Course Coordinators and Contact Information: Jamie Kellar, BScHk, BScPhm, PharmD Beth Sproule, BScPhm, PharmD PB 739 PB 704 (416) x (416) x 6501 jamie.kellar@utoronto.ca beth.sproule@utoronto.ca 10. Course Instructors and Contact Information: TBD 11. Required Resources/Textbooks/Readings: a) Pharmacotherapy: A Pathophysiologic Approach, 8 th edition, J DiPiro, RL Talbert, G Yee, G Matzke, B Wells, LM Posey (eds), McGraw Hill Medical, b) Assigned articles related to clinical discussions for critical appraisal. c) Other readings as assigned. 12. Recommended Resources/Textbooks/Readings: Primary literature and reviews, determined based on current literature related to each therapeutic topic. 5

6 13. Topic Outline/Schedule: For each, indicate level of knowledge, skills and attitudes learning objectives. Week Topic Method Duration 1 Introductions/Course Overview/Expectations/Delivery Introduction and Overview of DSM-V Mental Health and Addiction System in Canada 15 min 30 min 1 hr 15 min 2 S is for Stigma 1 hr Refractory Schizophrenia 1 hr 3 The role of non-drug measures in treating mental health and addiction disorders Psychotherapy (CBT, IPT, Mindfulness) Electroconvulsive Therapy (ECT) Repetitive Transcranial Magnetic Stimulation 4 Neuroscience concepts, clinical presentation, diagnosis and treatment of Personality Disorders and Eating Disorders 5 Understanding and Assessing Movement related disorders and Tardive Dyskinesia in patients with Mental Health Disorders Part 1 6 Understanding and Assessing Movement related disorders and Tardive Dyskinesia in patients with Mental Health Disorders Part 2 Interactive Interactive 7 Child and Adolescent Psychiatry (Overview, Approach to Care) 1 hr Neuroscience concepts, clinical presentation, diagnosis and 1 hr treatment of Attention Deficit Hyperactivity Disorder 8 The use of psychotropic medications in pregnancy and lactation 9 Medication Adherence in Mental Health; A review of the 1 hr evidence and the role of the pharmacist Mental Health First Aid 1 hr 10 Smoking Cessation including initiating varenicline and bupropion., large group discussion 11 Pharmacotherapy Management of Alcohol Use Disorders, large group discussion 12 Management of Chronic Pain and Opioid Addiction, including, large assessment and pharmacological management. group discussion 13 Comorbid Mental Health and Substance Use Disorders, including epidemiology, relationships between the disorders, evidence for treatment., large group discussion 6

7 Sample Learning Outcomes: Treatment Refractory Schizophrenia 1. Explain the goals of therapy in the management of treatment refractory schizophrenia and indicate what medications are used to achieve these goals. 2. Develop a care plan for a patient with treatment resistant schizophrenia 3. Design a monitoring plan for a patient with treatment refractory schizophrenia being treated with the following: clozapine; clozapine plus risperidone; clozapine plus valproic acid 4. Explain the utility of therapeutic drug monitoring as it relates to clozapine Sample Weekly Learning Objectives: Pharmacotherapy of Treatment Refractory Schizophrenia 1. Apply the diagnostic criteria for treatment resistant schizophrenia from the DSM-IV TR and DSM-V. 2. Describe the treatment approach for the management of acute agitation in a patient with treatment refractory schizophrenia. 3. Rationalize the role for therapeutic drug monitoring in patients taking clozapine for treatment refractory schizophrenia 4. Evaluate the CATIE trial to determine the relative efficacy of different antipsychotic medications. 5. Discuss the role of the following adjunctive agents in the management of treatment refractory schizophrenia: a. anticonvulsants b. lithium c. benzodiazepines d. antipsychotics (oral or depot) 6. Describe benign ethnic neutropenia and the clinical implications 7

8 14. Assessment Methodologies Used: Assignments: Movement Disorder Assessment Examinations: Midterm and Final (multiple choice / short answer questions) Learning Objectives Addressed Assessment 1: Relevant knowledge, skills, attitudes/values for topics in weeks 1-6 as per Topic Outline/Schedule above. Assessment 2: Skills used to identify and assess patients for movement related side effects Assessment 3: Relevant knowledge, skills, attitudes/values for topics in weeks 7-13 as per Topic Outline/Schedule above. Assessment Method Used Assessment 1: Midterm Test (multiple choice / short answer questions) Assessment 2: Assessment of Movement Related Disorders Using validated scale Assessment 3: Final Exam (multiple choice / short answer questions) When Administered Assessment 1: Midterm Test period (but not prior to week 7 of fall term) Assessment 2: Week 9 Assessment 3: Final Examination period Percentage of Course Grade Assessment 1: 40% Assessment 2: 20% Assessment 3: 40% For Group Work (maximum 10% of course grade) indicate how marks within groups are allocated: Individualized or Same for all Group Members Assessment 1: Assessment 2 Assessment 3: Remediation Opportunities? Assessment 1: Students who do not achieve a passing grade are invited to review their test responses with a course coordinator. Assessment 2: Students who do not achieve a passing grade are invited to review their assignment with a course coordinator. Assessment 3: One or more sessions with course coordinator prior to the supplemental exam to enhance student understanding of course materials may be scheduled. Expectation for pass grades for all Pharmacy courses is 60%. 15. Policy and procedure regarding make-up assignments/examinations/laboratories: 8

9 Missed Exam Students who miss an examination or a test and who have a valid petition filed with the Registrar s office will be eligible to complete a make-up examination or test. The format of this examination or test will be at the discretion of the course coordinator, and may include, for example, an oral examination. 16. Policy and procedure regarding supplemental assignments/examinations: As outlined in the current Leslie Dan Faculty of Pharmacy Calendar. 9

10 AFPC Educational Outcomes Which AFPC Educational Outcomes will be addressed by this course? As Care Providers, pharmacy graduates: 1.2 Elicit and complete an assessment of required information to determine the patient's medication related and other relevant health needs obtain and evaluate relevant history from the patient, his/her chart, caregivers and other health care professionals; order, retrieve and assess relevant lab tests and diagnostic assessments; 1.3 Assess if a patient's medication-related needs are being met; determine whether a patient's medications are achieving the desired goals including consideration of efficacy and adverse effects; where appropriate, identify a patient's medication-related needs as specific medication therapy problems, and: determine if a patient requires additional care or services consistent with established collaborative practice agreements (see glossary). [INTRODUCTORY] 1.4 Determine if a patient has relevant, priority health and wellness needs Recognize signs, symptoms and risk factors that relate to medical or health problems that fall into the scope of practice of other health care professionals.(including, for example, signs and symptoms of diabetes mellitus, hypertension, arthritis, stroke, cardiac disease.) recognize signs and symptoms associated with medical emergencies; [INTRODUCTORY] recognize problems with activities of daily living important to the patient's well-being, and: [INTRODUCTORY] 1.6 Develop a care plan that addresses a patient's medication-therapy problems and priority health and wellness needs prioritize a patient's medication-related needs; establish goals of medication therapy with the patient (desired endpoints, target values and timeframes for medication therapies) assess alternative strategies and negotiate the therapeutic option best suited to the patient; integrate the recommended therapeutic options for a patient's medication-related needs into a co-ordinated plan; 10

11 1.6.5 determine monitoring parameters for desired therapeutic endpoints and potential adverse effect, specifying target values and start, frequency and end time-points for monitoring; As Communicators, pharmacy graduates: 2.1. Communicate non-verbally and verbally with others when speaking, use organized processes and appropriate, precise expressions and vocabulary; 2.2. Communicate in writing write clearly, using organized processes and appropriate vocabulary; correctly apply the rules of syntax, grammar and punctuation, and: As Collaborators, pharmacy graduates: As Managers, pharmacy graduates: As Advocates, pharmacy graduates: As Scholars, pharmacy graduates: 6.1 Demonstrate a thorough understanding of the fundamental knowledge required of pharmacists and apply this knowledge in daily practice rationalize their recommendations and decisions with appropriate, accurate explanations and best evidence; 6.2 Provide drug information and recommendations critically analyze information including primary research articles; determine plausible solutions and select the most appropriate recommendation; As Professionals, pharmacy graduates: 2. Please estimate resource implications associated with teaching methodologies to be used. 3. Please estimate resources implications associated with assessment methodologies to be used. 4. Which of the five curricular themes will be covered in this course? How will integration of these themes be achieved through teaching and assessment methods used? Critical reasoning Critical appraisal Pharmaceutical Care - PC Process Ethics & Professionalism 11

12 Patient Safety Approval from Theme Coordinator (name of theme coordinator): insertion of theme coordinator s name occurs after your course has been reviewed and approved 12

13 5. Which of the following course evaluation measures will you incorporate in your course to facilitate review and iterative refinement? TBD Dixon s Levels (1-4 increasing validity) Quantitative Measures Qualitative Measures 1 Evaluations Forms ( Happiness Index) Focus groups / Interviews 2 Pre-testing versus Post-testing Participant Surveys / Questionnaires 3 Change daily practice or learning habits Structured Interviews 4 Improve Outcomes Receiver Questionnaires 6. Please note any other relevant information for Curriculum Committee review purposes. 13