Host: Dr. Paul Kurtak is a psychiatrist and scientist at the Center for Addiction and Mental Health in Toronto and a senior scientist and lead of the mental health and addictions research program at ICE and he joins us in studio. How are you sir?

Dr. Paul Kurtak: Great. Thanks for having me.

Host: All right. Your study measured the incidence of psychotic disorders across different groups in Ontario. When you stepped back and looked at the findings, what surprised you the most?

Dr. Paul Kurtak: Well, I think the the first thing that surprised me uh and I should say at the beginning that I was a co-author on this study. Um it was led by a colleague of mine at University of Ottawa, Dr. Daniel Myin did a great job on this project. When we looked at the findings, the there are a couple things that struck out. one is that um that that the incidence which means the the rate of new newly diagnosed individuals is increasing over time.

Host: Uh it is happening in younger individuals over time. And then the third piece is the the the way that the diagnosis are breaking out. Uh, so there are different types of diagnoses that that are part of of what we call psychotic disorders and and that's a bit of a nuanced aspect of the study, but that was a third piece that was kind of interesting to us.

Host: All right. Well, let's let's pick up on that. When you say psychotic disorders, what do we mean? We have schizophrenia in one room, an umbrella term perhaps, and then we have schizophrenia and we have psychosis. Help us understand uh sort of the terms there.

Dr. Paul Kurtak: Yeah. So, so there's schizophrenia and schizopeeffective disorders and for people to be diagnosed with those uh conditions they they need to meet certain criteria and and that uh the the incident rate for those diagnoses did have increased a little bit but not that much. The the one that's increased more so is called psychosis not otherwise specified. And this is a diagnosis that clinicians like myself use when somebody is clearly presenting with prominent psychotic symptoms like a deviation from reality.

Host: Sorry, hallucinations,

Dr. Paul Kurtak: delusions. Exactly. And uh but but they but there are other issues that prevent us from saying it is clearly schizophrenia and schizoeffective disorder. So, we know that the person's psychotic, but there could be other factors that that may ultimately be contributing to it. Um, like it could be related to substance use, it could be related to medical conditions, etc., etc. So, so it's kind of like a hedge diagnosis. It is definitely a psychotic disorder

Dr. Paul Kurtak: and most individuals with this diagnosis do over time evolve to developing a diagnosis schizophrenia. just bel it it suggests a level of uncertainty that is truly schizophrenia at the time of first diagnosis. I don't want to simplify it but fair to say like you like you mentioned the specific set of symptoms one of them is it's chronic with schizophrenia that is longterm that's about usually six months or more

Host: correct

Host: okay all right I want to look at a graph uh from this study this graph shows the incidence rate ratios for schizophrenia spectrum disorder which is in the dark blue color

Host: psychosis not otherwise specified in green and psychotic disorders which include both schizophrenia and psychosis in black. Now for each cohort studied, this is comparing to the 1975 1979 cohort. For psychotic disorders, the black line, there is a gradual increase in the rate of diagnosis starting with those born in the 198589 cohort. When researchers separated the data, it showed that the rate of schizophrenia goes up slightly but then starts to go down, but the rate of psychosis increases kind of like a ski hill. What is this telling us?

Dr. Paul Kurtak: Yes. So, so if we return to the difference between psychosis not otherwise specified and and uh the something that is like truly a schizophrenia spectrum disorder. Uh it is the the the market increase in in the sort of the slightly uncertain category. the psychosis not otherwise specified which means that

Host: uh at the time of first diagnosis there is is less certainty that this is truly schizophrenia which means that there are there's complexities in in in the diagnosis over time that is increasing the most

Dr. Paul Kurtak: yeah so I think the the The first important point is that this study was very well designed to characterize changes in rates over time. There's nothing about this particular study that helps us understand why we're observing what we're observing. So when I think about the links, it's really like extrapolating to evidence beyond this study. Um but I would say uh what we are observing generally amongst young people and these are 16 to 35 year old individuals typically uh what we're observing amongst young people is they are far less stigmatized than previous generations and much more inclined to seek help. So that may partly explain why we're seeing more and younger. Um the other factor is that uh over time there has been more robust um implementation of early psychosis intervention programs proincially.

Host: Okay.

Dr. Paul Kurtak: So anytime you put more services into a province it that there's a tendency to pull in more more cases. And then the third piece that that actually is the cause for concern is is the um is the fact that the rise in the less certain diagnosis the not otherwise specified is is occurring dramatically at a time of uh cannabis legalization. And and what comes with cannabis legalization is the young people are exposed with high potency uh cannabis which uh evidence outside of this study suggests does pose a serious risk for the onset of psychosis.

Host: What does cannabis high high potency or not? Uh these are young brains that we're talking about. We're talking um you know when they're still developing up until about the age of 25. But what what does it do to the brain?

Dr. Paul Kurtak: Yeah. So, so there's lot So, it's not entirely clear, but that does seem to uh like there's a there's a aggregation of evidence that suggests that there's something about uh the THC chemical in cannabis that binds with certain receptors in the brain that causes a biological inclination to become psychotic. So the way I think about it and there are there are people who are more better experts than me on this is I think like if you are vulnerable to developing a psychotic disorder, exposure to high potency cannabis may increase your likelihood to develop a psychotic disorder.

Host: Okay. Um is there a difference between uh men and women?

Dr. Paul Kurtak: There's there's been a a baseline difference in men and women in the onset of of schizophrenia. So men develop it uh psychosis at a younger age. They tend to be more disabled as a result of the condition. Uh the ratio of men to women is a little higher in men. And of course uh as it relates to the cannabis risk factor uh and actually to the service utilization. Men, young men are notoriously difficult to engage in healthcare. Uh and they are much more likely to consume substances than women.

Host: uh we talked about legalization of course 2018 um looking at this data and of course this is just just the beginning here was that the right call

Host: yeah so so uh it's it's an important question um the policy is inherently a compromise and I think that the the legalization issue in 2018 responded to a couple of important issues one is that that I mean, if you walk around Toronto, there's clearly a a public interest in having ready access to marijuana recreationally. I mean, that that is just what what people want and so policy follows what what people want typically. I also think, and this is a really important piece, is that um when cannabis was illegal, uh the the consequences of it being illegal, incarceration for possession did not happen equitably. and that we know we knew and that more marginalized individuals were more likely to be incarcerated and have all the negative consequences of having a criminal record etc.

Dr. Paul Kurtak: uh as a result of that. So, so that was a very good legitimate reason to enact the policy. But now as more evidence emerges like this is what we want to be able to do, right? Monitor unintended consequences of policy. So now what do we do? and and and to me like uh tobacco is probably a better example than alcohol.

Host: Tobacco is a legal substance, but it's pretty highly regulated and highly taxed. So, you know, I think there are policy solutions to to find that compromise or balance between, you know, maintaining the benefits for which the policy was first enacted at the same time address some of the risks that we're learning about.

Host: All right. receiving this kind of diagnosis uh can be frightening for many. Um, could you explain how this diagnosis is challenging for the indivi dual or for those who are in their lives as well?

Dr. Paul Kurtak: Oh, this is you know my my clinical work is in the CAMH emergency department and this is this is one of those ones where you uh you really feel for the individual. Uh so how it manifests um it typically it is a it often a slowly evolving sort of uh deviation from reality and also often uh a slowly evolving uh social withdrawal that that uh so a young man uh in high school like totally social engaged in everything starts to withdraw from stuff

Host: then starts like like avoiding school, reluctant to avoid school, family starts noticing that that he might be sort of talking to himself, laughing inappropriately at times. Um, so that's kind of how it it it manifests. Um, and and it's incredibly important that individuals uh have access to care early because we know that the longer an individual goes untreated, the worse the prognosis uh is. like like if we can get people into care early the we can really change the trajectory of a young person's life.

Host: I think I know the answer to this but are there enough supports uh in place for those seeking treatment?

Dr. Paul Kurtak: So uh I would say that um throughout our province we know that we don't have enough services uh for individuals struggling with mental illnesses generally. In this case, we do have a in comparison [clears throat] to other areas of our mental health system, we do have a robust system of early psychosis intervention programs that currently exist. Um, but evidence that has come out of uh my research team suggests that even though this provincial network exists, um not not everybody with the disorder can can can or does access them. And and some of of that has to do with inadequacy of resources. Some of it has to do with awareness. And so, for example, if you're diagnosed by a psychiatrist or diagnosed in a hospital setting, you're much more likely to be referred to one of these programs, excuse [clears throat] me, than if you were managed in primary care. And that's probably just an awareness situation. Um [clears throat] and and the the that's a big problem because uh what we know about the consequences in addition to like you know longer periods of no treatment uh this is a deadly illness that that um you know people who are diagnosed in a hospital these are 16 to 35 year olds uh one in 25 die within 5 years. If you're diagnosed in outpatient setting one in 40 nobody should be dying between the ages of 16 and 35. And

Host: how do they how do they die? The most common cause is suicide.

Dr. Paul Kurtak: Okay. Yeah. The the suicide rate is is incredibly high and and it just makes sense because these are young people who have a sense of who they are and what they're going to be doing in their life and their whole identity gets rocked by this diagnosis.

Host: All right. Uh doctor, we're going to have to leave it there, but really appreciate your insights. Uh thank you for this and of course um with this there will be more things to come out of this in terms of uh research and studies and policy. So, we look forward to that and uh thank you so much.

Dr. Paul Kurtak: Thanks very much for having me.