Jennifer Farber felt like she was on a health-care merry-go-round, searching for an answer to the dizziness, anxiety and fatigue that plagued her for months.
“I could barely be out of bed for more than a few hours; I was so dizzy I could barely stand and I had extreme anxiety,” says the 42-year-old Toronto school teacher.
Over the course of a year, Jennifer saw a long list of specialists, including a neurologist, rheumatologist, gynecologist, psychiatrist and ophthalmologist. But none of them were able to determine the root cause of her symptoms.
It was a frustrating and challenging time, Jennifer says. Unable to work, she battled with her insurer to claim disability, because doctors couldn’t come up with a cause. “I didn’t know what was wrong with me,” she says.
Then Jennifer saw Dr. Matthew Burke, a cognitive neurologist and member of Sunnybrook’s Hurvitz Brain Sciences Program.
“Within 30 minutes of telling him everything, he said, ‘I know what’s wrong,’” Jennifer recalls.
Dr. Burke diagnosed her with persistent postural perceptual dizziness (PPPD), a complex disorder of brain network dysfunction that is treatable.
That quick, breakthrough assessment of Jennifer’s condition is a testament to Dr. Burke’s skill as a physician. It’s also an example of the creative thinking happening at one of the world’s leading hubs of interdisciplinary research and clinical care for complex brain disorders and disease.
Soon, this innovative research program will have a new home. Sunnybrook’s Garry Hurvitz Brain Sciences Centre will bring together some of the greatest minds across diverse areas of expertise in brain health, including psychiatry, neurology and neurosurgery, to encourage collaboration. The highly integrated team will develop the next generation of treatments for mental illness, dementia, stroke, neurological disorders and more.
Tearing down silos
The Hurvitz Brain Sciences Program “involves any kind of specialty in medicine that involves anything to do with the brain and central nervous system,” says the program’s chief, psychiatrist, Dr. Anthony Levitt.
Created five years ago with Dr. Levitt at the helm, the program’s mission was to encourage collaboration between psychiatry, neurology, neurosurgery, ophthalmology and otology (ear, nose and throat medicine), as well as neuropharmacology, neuroradiology and neuropsychology.
“The major brain afflictions of our time – mood disorder, stroke and dementia – are all interrelated,” Dr. Levitt explains. “So it makes sense for us to understand and treat them with meaningful collaboration between specialties that have previously functioned separately and in silos.”
An ongoing challenge, however, has been that these specialties are spread across Sunnybrook’s sprawling Toronto campuses, which can sometimes impede collaboration. The new Garry Hurvitz Brain Sciences Centre will bring Sunnybrook’s top clinical and research minds together.
Thanks to generous donations from the public and corporations, Sunnybrook raised more than $60-million for the 121,000-square-foot, three-storey facility. A matching $60-million contributed by the provincial government will help increase the capacity for adult and youth inpatient mental health care, making Sunnybrook one of the largest adolescent mental health services in the Greater Toronto Area. The building, which will house a number of Sunnybrook’s Hurvitz Brain Sciences Program treatment programs for youth, adults and the elderly (see sidebar), is specifically designed to be able to expand and accommodate additional floors in the future.
In the past, and even today, experts in mental health and neurological disease have tended to work independently, notes Dr. Levitt. But there’s a growing realization that previous distinctions between all brain-related disciplines like psychiatry, neurology and neurosurgery are increasingly blurred.
“In the last five years, for example, we’ve recognized many psychiatric disorders are not only caused by a chemical imbalance, but might also reflect circuitry issues, too,” says Dr. Levitt. “The brain is an electrical organ, and there may be specific circuits that are malfunctioning in disorders such as depression and obsessive-compulsive disorder (OCD).”
Jennifer is an example of someone with a challenging health problem that doesn’t fit neatly into one medical discipline. PPPD is a disorder that involves the vestibular system, a sensory system located in the inner ear that is crucial to maintain normal balance and equilibrium. In PPPD, there is a problem with the signals sent back and forth by the vestibular system and the brain, causing a sensation of dizziness in the body.
Patients like Jennifer with functional neurological disorders – complex conditions where patients experience physical symptoms without a clear structural problem in the nervous system – are at risk of falling through the cracks, because their disorders straddle neurology and psychiatry, Dr. Burke says.
“What often happens is, they’re assessed by a neurologist, who finds no evidence of disease,” says Dr. Burke, who recently authored a groundbreaking article on the subject in JAMA Neurology entitled, “It’s All in Your Head – Medicine’s Silent Epidemic.” Says Dr. Burke: “You’ve essentially ruled out a structural – or a hardware – problem.”
But patients are left with very real symptoms, he adds, “and the message they often take from that is, ‘It’s all in your head.’”
Jennifer’s condition and similarly challenging functional brain disorders are “software” problems, Dr. Burke explains. “This means the connections between brain regions – the networks and circuits – become disrupted and dysfunctional, which doesn’t show up on structural MRI and CT scans.”
Dr. Burke notes the Garry Hurvitz Brain Sciences Centre represents a significant leap forward for standard of care for this emerging area of brain disease.
“Generally, [functional] disorders require collaboration across the brain sciences, and patients may suffer when that doesn’t happen,” he says.
Expertise and education
In addition to helping researchers collaborate and improving patient care, the centre will also be a venue for unique educational opportunities, including a new Brain Medicine Fellowship supported by the Hurvitz Brain Sciences Program.
Fellowship director Dr. Sara Mitchell, a neurologist cross-appointed within the Department of Psychiatry, says traditional fellowships often focus on one area of expertise. For instance, a psychiatry trainee might be involved in treating bipolar disorder through therapy and medication, and pay less attention to the underlying neuroanatomical basis of the disease.
“But the goal of the Brain Medicine Fellowship is to develop cross-disciplinary competencies,” she adds. “It tries to broaden perspectives and show physicians how when different brain-focused specialties collaborate, patients ultimately receive better care.”
Dr. Sarah Levitt (no relation to Dr. Anthony Levitt) was the first fellow to embark on the new training program beginning last year. Her focus is on improving care for individuals with severe mental illness who are also diagnosed with life-threatening medical conditions.
“We know people with severe, persistent mental illness – like schizophrenia – tend to die 20 to 30 years younger of cardiovascular disease, cancer and diabetes,” she says.
Dr. Sarah Levitt further notes that these patients are often best served by a multidisciplinary approach that synchronizes the efforts of many professionals toward one goal. The new centre will foster better collaboration not just through the fellowship, but also by creating a physical space for multidisciplinary clinics where patients will see a few specialists at once.
“It helps patients for them to have access to different expertise at the same time,” she says.
In short, the new centre is designed to help patients get the care they need, when they need it, in a co-ordinated space, says Dr. Anthony Levitt.
“Our goal is to have several related specialists seeing patients in the same clinic space, providing integrated care. This reduces the burden of patients and caregivers trying to navigate a complex process of specialist referrals and separate departments – in a population that is often challenged in managing these tasks as a result of the underlying illness”
Now on the mend, Jennifer says she is grateful for the treatment she received at Sunnybrook and believes the Garry Hurvitz Brain Sciences Centre will only improve care for others like her going forward.
“My hope is this new centre leads to more research, so future patients are diagnosed more quickly and get the care they so desperately need.”