Presents for Christmas

Since it is Christmas and since gift giving is “top of mind” (regardless of your religion – this is a time of year that gift giving is celebrated – OK, not the retail kind, the REAL kind), I thought about what gift I as a mental health professional would like to receive. And guess what – a number came to mind.

First, I would like to see a Canada and the global society be a place in which people living with mental illness had exactly the same rights, equalities and access to care as people with illnesses that are not disorders of the brain have. When we can speak of diabetes and colitis and arthritis and schizophrenia all in the same breath and with the same considered and supportive perspective then we will have gone a long way to decreasing stigma and barriers to mental health care.

Second, I would like to see us beginning to talk about finding a cure for various mental illnesses, much as we speak about finding a cure for breast cancer or finding a cure for prostate cancer. We have finally developed and are rapidly developing our understanding of the brain and its functions – in health and in disease. And we are getting closer to understanding the social and environmental impacts that effect brain function and how those may contribute to the development or perpetuation of mental disorders. So its time we set our sights on a cure for schizophrenia, a cure for major depressive disorder, a cure for bipolar disorder and so on. We may not find a cure in the next five or ten years, but by gosh the search will take us a long way forward.

Third, I would like to see our mental health community supported and enhanced by coming together of various components instead of those components pulling us apart. Sometimes I think that if we spent one half of the time and effort that we seem to put into supporting pet ideologies or convincing others of our “truths” in common purpose, we would be so much further ahead. One foundation that we really need to build our community on is scientific literacy. We need to use science to advance our cause. We need to use the best scientific methods and the knowledge that they bring to us to inform our directions. We need to embrace the science and not rail against it. Building on this foundation we can work together to ensure that all the interests and different voices of individuals and groups are expressed, heard and included. A house has many rooms, but if its foundation is not strong it will collapse, regardless of how pretty it may look.

So those are my three Christmas gift wishes. The best of this gift reminding season to you and yours. Regardless of your religious beliefs or other defining features. Be well.

--Stan

Doing better with Depression

It's hardly a day goes by that we don’t read about depression and its impact on people and the economy and the toll it takes with suicide. We also read about how wonderful treatments are and how it is important to get help as soon as possible. All the above is true and for sure if I, or one of my loved ones, or one of my friends, was depressed I would certainly opt for immediate treatment with an antidepressant medication and an evidence based psychotherapy, delivered by competent health care providers.

But, and this is a big but – the evidence shows that good as our treatments are, they are not as good as they should be. The medications really help a lot but they do not help everyone. The psychotherapies help a lot but they do not help everyone. Combining the treatments helps more people but even this does not help everyone. So what do we need to do?

Well, it's all well and good to make our systems of care more accessible and to train more health care providers to be able to treat depression but wait a minute. Shouldn’t we be spending a whole lot of time and effort on making our treatments better? Shouldn’t we be making sure that when we offer a treatment to someone the chances of it working the first time are as close to 100 percent as we can get? What would you prefer – a one day wait time for a treatment that works 50 percent of the time or a one week wait time for treatment that works 90 percent of the time? And while we are at it – why not a one day wait time for a treatment that works 100 percent of the time.

So we need to invest in treatment research. We can have all the health care providers and all the clinics and all the nice posters on the walls of schools and neat anti-stigma ads on the television and radio and on and on and on – but, if we do not get better at treatment, how much further are we really ahead? Do you know how many high powered (meaning really good scientific studies) have been done in Canada in the last five years on the treatment of some of the most common mental disorders that begin in adolescence. One? Five? Nine? Maybe none? Do you have any idea how much money is being spent on finding out how to better treat young people that have psychosis or depression or obsessive compulsive disorder compared to treatments for other medical illnesses or even compared how much is spent on posters that tell youth about problems? Don’t you think you should have some idea?

We need to invest in a major way in learning better ways to treat mental disorders in this country. We are not doing that in Canada. It is time we started to. Improving access to care is a good idea. Improving access to care that actually works is an even better idea.

--Stan

Suicide attempt or self-harm: does it matter?

Some of us think we have a problem in our suicide research and in our suicide prevention approaches. Actually there may be many problems with those (stay tuned for future blogs) but one of the concerns is the meaning of the statistics when it comes to the definition of “suicide attempt”.

A suicide attempt can be defined as a purposeful self-injury with the intent to die. A self-harm attempt on the other hand can be defined as a purposeful self-injury without the intent to die. Self-harm can be the result of many different factors, including but not limited to: difficulties with problem solving, difficulties with impulse control, copycat phenomenon, social or situational control, etc. Increasingly, research is showing that young people who self-injure may be substantially different from those who attempt suicide. So what does this mean?

Hospitals that use the ICD system (and that is all of them) tend to code self-injury as a suicide attempt. Even DSM at the time of this writing, does not allow for differentiation of self-injury from suicide attempt. Could it be that many of our statistics about suicide attempts are incorrect? Could it be that “truths” that we think we know – such as more females attempt suicide than males – may not be accurate but may be an artifact of not separating out self-harm attempts from suicide attempts?

And what about suicide prevention programs? Does a decrease in reported incidents of self-harm equal a decrease in real suicidal behaviour – that is suicide attempts? That does not mean that we should not try to bring down self-harm attempts, but it may mean that the methods useful for one outcome may not be useful at all for another outcome.

Actually, I think its time that we started to think more critically about what we mean when we use the words “suicide attempt”. Is it really a suicide attempt or is it a self-harm event? It is an important distinction. Both are important targets for interventions – public health type and clinical type. We need to separate them out in our statistics and we need to separate them out in our programs. Then we can get a better handle on what is actually happening and what we can do about it.

-Stan

Sleep – A Teenagers Best Friend

So what is this with sleep anyway?

Given what we know at this time, sleep is necessary for brain growth and development. It is also fundamentally necessary for academic success. For example, when we sleep, we learn. Important memories from the previous days are consolidated and the capacity to learn for the next day is refreshed. And, during the teen years, with the accelerated brain growth and re-organization that occurs during those years – youth actually need more sleep than when they were children.

During the teenage years the child pattern of getting up early and going to bed early shifts to going to bed later and getting up later. And at the same time, the brain’s need for total sleep time increases – as much as an hour or more per night. When accentuated by the digital and light enhanced evening environment, staying up later and later becomes the norm for many teens. And, because the school day usually starts fairly early, students (as the research has shown us) are frequently sleep deprived, sleepy and not at their optimal learning capacity – especially in the first hour or two of classes. This pattern leads to not enough sleep during the week and this leads to sleep debt – time that needs to be repaid – you guessed it – on the weekend! This results in a pattern of about 2 hours difference between usual sleep/wake patterns between school days and weekend days for many teenagers. This is equivalent to a jet lag of 2 hours. And that happens mostly every week!

One obvious solution to this problem is starting the school day later for high school students. Indeed, some studies have reported that this results in improved academic performance and one study in Kentucky also found fewer automobile accidents during the later school start trial. However, this accomodation to the changing teen brain has not proved to be popular with education officials and across most of Canada and the USA, schools still start early and teenagers still come to class tired and not ready to learn. And guess what? In many places, exams (including those that take an enormous amount of concentration – such as mathematics) are frequently scheduled for early in the morning!

So what can be done about this? Well, changing the school day is not likely to happen, but that would be a really good idea. Just think, setting up a school protocol to meet the needs of the students – what a novel idea! For the individual student, trying to get to sleep a little earlier (even one hour earlier) would pay big dividends. And if that is just as hard as changing the school start time – at least get a good nights sleep before your exam. Staying up all night and cramming is not helpful. Getting your beauty rest is. Isn’t science grand? Did your grandmother tell you this at some time?