A look at how mental health treatment and research have evolved over the last 10 years and about future possibilities for more effective, personalized treatment approaches. with Dr. Zul Merali, President and CEO, The Royal's Institute of Mental Health Research

1. Understanding &
treating mental illness:
The changing tides
Zul Merali
President & CEO
Royal’s Institute of Mental Health Research

2. Current realities &
challenges

3. Focus on Major Depression
• Is the most common of all psychiatric disorders
• It ranks among the top causes of worldwide disease
burden
• 500,000 people did not go to work today due to
depression
• Co-occurs with many physical and mental disorders,
impacting outcomes

4. Patient 2
 Depressed mood
 Hypersomnia (sleeping a lot)
 Increased appetite/weight gain
 Psychomotor retardation
 Lack of energy
 Suicidal ideation
Patient 1
 Marked loss of interest/pleasure
 Insomnia - difficulty falling asleep
 Decreased appetite/weight loss
 Psychomotor agitation
 Impaired concentration/decision
 Inappropriate guilt
The many faces of major depression
DSM-V current diagnostic instrument
(Symptom based– agnostic of biology)
+
Depression is likely a disease impacting several
brain systems – not one region or one transmitter

5. 75
50
25
Suicide
Stroke
AIDS
Heart Disease
All (Leukemia)
PercentofPeak
Mortality from Medical Causes
Peak
1965-1995
Current
2009-2012

6. 33%
33%
33%
Full Remission
Partial Response
No response
Kennedy et al, Human Psychopharmacology 2001
Only 1 in 3 patients recover fully
Antidepressant Effects at first intervention (6-8 Weeks)
40-70% relapse within 1 year
Trivedi et al. Am. J. Psych. 2006

7. How do you fix an
organ you cant see or
touch?
Can technology help?

9. Royal’s Brain Imaging Centre (BIC)

11. [11C]OMAR volume of distribution (VT) values in Posttraumatic stress disorder
(PTSD) and trauma-exposed control (TC) groups relative to healthy control (HC)
group.
Diagnostics:
Elevated brain cannabinoid CB1 receptor availability in post-traumatic
stress disorder: a positron emission tomography (PET) study

12. Imaging-based treatment selection

13. Can technology
provide alternate
interventions?

14. rTMS (repeated transcranial magnetic
stimulation)

15. rTMS (repeated transcranial
magnetic stimulation)

16. What could
depression care look
like in 2020?
Zul Merali
President & CEO
Royal’s Institute of Mental Health Research

17. Change through courage
and imagination……
what care in 2020 could look
like

18. Measurement-based assessment and care
Screening &
Monitoring Package
EMR
Research
Portal
Patient
Portal
Clinician
Portal
De-identified
registry
Data
Analytics
Primary Care
Interface

19. Deconstructing Depression subtypes using
biomarkers
Depression(DSMIVcriteria)
Depressionphenotypes
Biomarkers

20. Biomarker
platforms
Assessment/
assignment
Patient
referral &
recruitment
Clinical/Research
triage
Comprehensive
research screening
Biochemistry/stress
endocrine
Genotyping/
pharmacogenetics
Sleep, chronobiology
Neuropsychology & EEG
Brain imaging
Gender/psychosocial
Clinical ratings (SCID,
PHQ-9, DIGS)
Inpatient
Outpatient clinic
Consult & Refer back
with treatment suggestions
IMPACTS

21. Benefits
Longer-term
impacts
Immediate
impacts
Better system
efficiency
-readmission
-occupancy
National standards of
diagnostics & care
Drug cost savings
Reduced social burden
Improved confidence in
system of care
Increased employee
productivity
Reduction in long-term
disability costs
Support &
empowerment for
clinicians
Capacity building
Improved access to care
Faster & sustained
relief for
-Patients
-Caregivers
-families

22. THANK YOU

23. DRC initiatives
• Ist episode depression care and research
• Ketamine – suicide and depressions target
– Replacement for ECT?
– Imaging for suicide ideation
• rTMS
• Research informed and measurement-based
care

24. Strategic Priorities
Depression: getting
people better
faster through
tailored treatments
Research
Capacity
Practice
Changing
Research
Collaborations
& Partnerships
Innovation
Pipeline
Increase
Research
Revenues To
$10M
Increase # Of
Research
Informed
Interventions
Increase
National /
International
Leadership
Understand
Brain Map /
Brain Circuits
Double # Of
Scientists
Strategic
Alignment
Establish
Clinical
Research
Structure
Electronic
Patient
Assessments
& Care
Expand
Translational
Collaborations
Increase
Collaborations
with UOHI &
uOtttawa
Develop
Personalized
Medicine
Biomarkers
Develop New
Modalities of
Treatment
Increase
Media Hits &
High Impact
Publications
Double # Of
Clinical
Research
Projects
Establish
WHO
Collaborative
Centre

25. Sleep and depression
understanding through brain imaging
“Sleep is of the brain, by the brain and for the brain.”
- J. Allan Hobson

26. Practice Changing Research
Depression: getting
people better
faster through
tailored treatments
Research
Capacity
Practice
Changing
Research
Collaborations
& Partnerships
Increase
Research
Revenues To
$10M
Increase # Of
Research
Informed
Interventions
ble # Of
entists
Strategic
Alignment
Establish
Clinical
Research
Structure
Electronic
Patient
Assessments
& Care
xpand
Increase
Media Hits &
High Impact
Publications
Double # Of
Clinical
Research
Projects
Establish
WHO

27. Innovation Pipeline
Depression: getting
people better
faster through
tailored treatments
Research
Capacity
Collaborations
Innovation
Pipeline
Understand
Brain Map /
Brain Circuits
Double # Of
Scientists
Develop
Personalized
Medicine
Biomarkers
Develop New
Modalities of
Treatment
In
Med
High
Pub

28. Research Capacity
c Priorities
Research
Capacity
Increase
Research
Revenues To
$10M
nderstand
rain Map /
ain Circuits
Double # Of
Scientists
Strategic
Alignment
Estab
Clini
Resea
Increase
Media Hits &
High Impact
Publications
Double # Of
Clinical
Research
Projects

29. Schizo-
phrenia
Military
Mental
Health
Chair
Youth
Mental
Health
Addiction
&
Depression
BRAIN
IMAGING
CENTRE
Neuro-
modu-
laton
rTMS
Mood
Disorders
Chair
(CRC)
Brain
Imaging
Chair
(CRC)
Forensic
Mental
Health
Sleep
Labs
Sleep &
Mental
Health
DEPRESSION
RESEARCH
CENTRE
Pre-
clinical
Neurosci
ence
Brain &
Heart
Suicide
Preventio
n
Chair
Work-
place
EEG Lab
WHO Centre of
Excellence
Networks:
CDRIN, MHCC,
CCSA
Universities
Aging/De
mentia
E-Mental
Health

30. Schizo-
phrenia
Military
Mental
Health
Chair
Youth
Mental
Health
Addiction
&
Depression
BRAIN
IMAGING
CENTRE
Neuro-
modu-
laton
rTMS
Mood
Disorders
Chair
(CRC)
Brain
Imaging
Chair
(CRC)
Forensic
Mental
Health
Sleep
Labs
Sleep &
Mental
Health
Pre-
clinical
Neurosci
ence
Brain &
Heart
Suicide
Preventio
n
Chair
Work-
place
EEG Lab
WHO Centre of
Excellence
Networks:
CDRIN, MHCC,
CCSA
Universities
Aging/De
mentia
E-Mental
Health
Depression
Research
Centre

31. Collaboration & Partnerships
Depression: getting
people better
faster through
tailored treatments
Practice
Changing
Research
Collaborations
& Partnerships
Innovation
Pipeline
Increase
National /
International
Leadership
Electroni
Patient
Assessmen
& Care
Expand
Translational
Collaborations
Increase
Collaborations
with UOHI &
uOtttawa
elop New
dalities of
eatment
Establish
WHO
Collaborative
Centre