BC Centre for Excellence in HIV/AIDS and Vancouver Coastal Health Collaborate on Treatment Optimization of Psychosis (TOP)

The TOP Collaborative aims to systematically share, measure and implement best practices in the treatment of psychosis in community settings. 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 community, while raising awareness of effective clozapine treatment.

Across B.C., psychosis affects over 51,000 people, or about one in 100, from all walks of life and socio-economic and cultural backgrounds. 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.

TOP’s origins are rooted in the experiences and accomplishments of the Treatment as Prevention Strategy (TasP®) 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 (STOP) 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 TOP Collaborative will continue for 12 months with ongoing learning sessions for health-care providers. At these sessions, experts will share approaches to system change using a quality improvement framework. These sessions will be followed by action periods where teams will be supported in actively testing and implementing changes in care processes.

Some of the funding for this collaborative was provided by philanthropic support from TELUS and the VGH & UBC Hospital Foundation.

Sheila Malcolmson, 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.”

Bob Chapman, interim Vice President, Vancouver Community, 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.”

Dr. Rolando Barrios, Senior Medical Director, BC-CfE said, “Closing the gap between science and practice is essential to improving the health of populations. The same successful interventions used to control HIV in BC can be modified to manage other conditions such as mental health and substance use. Shifting the focus of health services from a reactive to a proactive system of care that supports clients where they are is essential for this success.”

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.”

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About Vancouver Coastal Health
Vancouver Coastal Health (VCH) is responsible for the delivery of $4.1 billion in community, hospital and long-term care to more than one million people in communities including Richmond, Vancouver, the North Shore, Sunshine Coast, Sea to Sky corridor, Powell River, Bella Bella and Bella Coola. VCH also provides specialized care and services for people throughout B.C., and is the province’s hub of health care education and research.

About the British Columbia Centre for Excellence in HIV/AIDS
The BC Centre for Excellence in HIV/AIDS (BC-CfE) is Canada’s largest HIV/AIDS research, treatment and education facility – nationally and internationally recognized as an innovative world leader in combating HIV/AIDS and related diseases. The made-in- BC Treatment as Prevention® strategy (TasP®) pioneered by BC-CfE, and supported by UNAIDS since 2011, inspired the ambitious global target for HIV treatment - known as the 90-90-90 Target - to end AIDS as a pandemic by 2030. The BC-CfE is applying TasP® to therapeutic areas beyond HIV/AIDS, including viral hepatitis and addiction, to promote Targeted Disease Elimination® as a means to contribute to healthcare sustainability. The BC-CfE works in close collaboration with key stakeholders, including government, health authorities, health care providers, academics, and the community to decrease the health burden of HIV/AIDS, hepatitis C and addictions across Canada and around the world.

For more information, please contact:

Edmond Chu
Communications Coordinator, BC-CfE
Cell: 236-885-4617
Email: echu@bccfe.ca

Frequently asked questions

1. What is the TOP Collaborative?

The TOP Collaborative is a quality improvement project that aims to systematically implement, measure and share best practices in the treatment of psychosis. 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 community. 

2. What is the goal of the TOP Collaborative?

The goal of the TOP Collaborative is to improve outcomes for our clients with schizophrenia/schizoaffective disorder by connecting them with the best treatment options, with follow-up care and monitoring in the community. 

3. Why do we need the TOP Collaborative?

Treatment optimization of psychosis has the potential to improve the health of individuals, improve quality of life, decrease acute health care utilization, risk to self, and encounters with the legal system. Research has shown that clozapine, for instance, is associated with 18.6 fewer inpatient days per year per client treated.

4. What are the benefits of the TOP Collaborative?

In VCH, psychosis is the number one cause of readmission to acute psychiatry within 30 days of discharge. Treatment of psychosis in community settings is primed for a quality improvement project of this type that will introduce new standardized approaches to monitoring adherence and retention in treatment with increased use of compliance aids, long-acting antipsychotic medications and third line antipsychotic clozapine.

5. How will the TOP Collaborative work?

The TOP Collaborative will follow the Breakthrough Series (BTS) Collaborative methodology developed by the Institute of Healthcare Improvement (IHI).

The TOP Collaborative will create a community of learning in which teams collaborate with each other to discuss common issues, share ideas and common challenges, and spread best practices to offer the best possible treatment and care to people living with psychosis. Throughout the Collaborative, team participants will maintain contact with each other and the TOP project team through monthly meetings, quarterly in-person learning sessions, teleconference calls, electronic mailing list, emails, webinars and website access.

6. Is clozapine safe?

The safety profile of clozapine is well known. Serious adverse reactions such as agranulocytosis and cardiomyopathy have led to early recommendations of hospital admission when initiating clozapine. However, such severe adverse reactions are very rare (at 0.3% for agranulocytosis and 1-3% for cardiomyopathy) and early recognition and treatment has improved significantly since they were first recognized. 

Data from the 1990s to today proves clozapine can be safely implemented in the community through careful selection of clients for community start of clozapine with close monitoring and support. In VCH, clozapine is still mostly initiated in acute care settings (e.g., hospital) or subacute care settings (e.g., facilities such as Venture), which creates unnecessary barriers to appropriate treatment of psychosis, as well as being more costly to the health-care system.

Evidence from other jurisdictions in the world including the United Kingdom, Australia, New Zealand and the US suggest that it is often safe and appropriate to initiate treatment with clozapine in community settings. In fact, overall mortality is lower for those on clozapine than in schizophrenia as a whole. 

7. Who is a candidate for clozapine?

Anyone living with schizophrenia whose psychosis has not adequately responded to treatment.

8. How do we know clozapine will work for these clients?

Clozapine is the only treatment approved by Health Canada for people who live with treatment-resistant psychosis. Compared with other medications, clozapine is about twice as likely to succeed in reducing their symptoms and it also protects them from early death. However, some people may have side effects to this medication and require extra supports to succeed with it. TOP is designed to help teams develop the expertise to offer this treatment to all clients who could benefit from it. Compared with other medications, clozapine is about twice as likely to succeed in reducing symptoms and it also protects them from suicidal thoughts and early death from all causes including medical.

100% of clients whose psychosis failed to respond to an adequate trial of >=2 antipsychotics will be offered clozapine. Of the clients who are eligible for a clozapine start in the community and who accept the treatment, the goal is >90% will undergo titration in the community and >70% of those will reach a therapeutic dose.

9. What are the intended goals for treating clients with clozapine?

The goal of the TOP Collaborative is to improve outcomes for our clients with schizophrenia/schizoaffective disorder. By June of 2022, we aim to have at least 45% of clients undergoing clozapine treatment show an improvement in their functioning as assessed by HONOS score and at least 45% of clients undergoing clozapine treatment have a 20% or more improvement in symptoms, as assessed by standardized rating instruments.

10. How will this project improve the way people living with psychosis are receiving care?

TOP will focus on optimizing schizophrenia treatment and on improving management of Treatment Refractory Schizophrenia (TRS) by shifting clozapine initiation from hospital to community settings by building capacity at each community mental health team.

11. What new treatments are introduced to people with psychosis?

While clozapine is not a new medication, it is the only one known to work in Treatment Refractory Psychosis. It is estimated that 25-30% of clients with schizophrenia meet criteria for TRS and of those, 30-60% respond to clozapine, an antipsychotic medication that has shown clinical efficacy for the treatment of schizophrenia, in people for whom two other antipsychotic medications have not been effective. However, this medication is severely underutilized in B.C. For example, in Australia and New Zealand clozapine usage is estimated to be about 30% in TRS, but only 17% in B.C.