The elephant in the room: Mental disorder or mental health problem?

Let’s be honest about it.  Sometimes it is difficult to determine where the boundary between a mental health problem and a mental disorder can be.  A mental health problem is a signal that a person is having substantial difficulties coping and is suffering a number of difficulties in their feelings, their thinking and even in their behavior.  Usually the person is also having some problems functioning in their daily lives – at work or at school for instance.  A person with a mental health problem will often sort things out with help from friends or confidants or when the stressors that are overwhelming them pass.  Sometimes, help from a counselor or another health provider is helpful.  A disorder is more substantive and usually signals that the person needs professional help – treatment to recover.

In the absence of independent biological markers (such as blood sugar levels for diabetes or the electrocardiogram tracings for heart attacks), psychiatric medicine has to rely on signs and symptoms and statistical methods to define disorders.  This can leave some grey areas – perhaps more than we would like. 

How to deal with these grey areas?  One school of thought – exemplified perhaps by Dr. John Oldham, President of the American Psychiatric Association (APA) chooses to extend the boundaries of the diagnosis of disease, to include people with mental health problems – the so called false positives.  In order to ensure that those people who need treatment can receive it.  Others, me included, think that a more narrow definition of disease is warranted, so that we do not make normal life equal pathology.  And, we argue that people with mental health problems are deserving of intervention but perhaps they don’t need treatment from doctors.

One area in which this debate is very heated is in the upcoming plans of the APA to consider normal bereavement as a mental disorder.  To me this is just plain nonsense.  Any idiot can understand that the loss of a close and intimate relationship leads to depressive like symptoms and that this is not the same thing as depression.  There is no need to make usual life a psychiatric diagnosis.  There is no need for medical doctors to “treat” normal bereavement.  Unless of course there is insurance money involved!  I wonder, is that the elephant in the room?

-Stan

The right care when you need it!

Yesterday, there was a story on CTV News a story of a young man who has been battling substance misuse, ADHD and depression for some time.  According to the news story, he had recently decided to try and turn his life around and with the support of his mother had been admitted to the Children’s Hospital for an inpatient treatment stay.  According to the story, he did well in hospital and was discharged with recommendations to continue treatments in the community, including substance abuse care.  Guess what?  You guessed it!  Not available!

So here we have yet another potential tragedy unfolding.  On the face of it (and I am aware that I do not have all the details or facts of the story), here is a young man who has realized that he needs care, first steps that care have been provided, but now when he needs a period of long-term assistance that assistance is not available.  So what is the likely outcome?

Well, maybe the best will be a revolving door scenario.  In this, he will be in and out of hospitals and emergency rooms, dealing with crisis situations and not getting the continuous best care he needs.  The worst case scenario may be premature death by suicide.  Look at the risk factors that were identified in the news story – a young male with a mental disorder (inadequately treated), substance abuse and a history of involvement in the juvenile justice system.  I for one, hope that this worst case scenario will never occur..

And what is the solution?  Part of the solution is to make sure that the mental health care services that young people need are available to them when they need them.  If this young man had fragile diabetes or a heart condition that required continuous care would there be no room in the health care inn?  I doubt it.  This young man however has a mental disorder – and for people with a mental illness it is ok not to have room in the inn.

Let’s call it what it is.  Not stigma but discrimination.

--Stan

If we don't build it, it can't work

A recent study reported in a British Psychiatric Journal found that the barrier erected on the Bloor Street Viaduct in Toronto eliminated death by suicide from jumping off that bridge, but total suicide deaths by jumping did not significantly decrease after the barrier was built. 

So here we have a quandary. The bridge barrier was 100 percent effective in stopping suicide deaths by jumping from the bridge. But the total number of suicide deaths by jumping did not decrease. The bridge effect was off-set by jumping elsewhere.

What does this tell us? Does it mean we should not erect suicide barriers on bridges? Not at all. Barriers are 100 percent effective! What this means is that we need to erect barriers on all bridges. So here is what we need to do. We have to ensure that whenever a bridge is built from now on, it is designed in such as way as to prevent people from jumping off. Will that cost a bit more – maybe. Will it be worth it in the long run – probably. Should we do that – for sure.

This also tells us that there is no simple quick fix in suicide prevention. We need to apply many different approaches, and we need to ensure that the approaches that we apply actually work. So this article is good in that respect. Bridge barriers work at the site where they are erected. They do not work if they are not built. So lets get with the plan and build bridges that include barriers. And lets get on with doing some other things that we know work – such as training doctors and nurses to identify and treat people who are suicidal. And lets start evaluating things that might work but we do not know for sure if they do!

Will we be able to prevent all suicides? Maybe not. Will we be able to prevent more than we are now – most likely. Lets get on with it.

--Stan

Stigmas role on perpetuating the cycle

I remember once seeing one of my patients who had a psychotic illness. He was doing very well and was very engaged in his recovery process. Unfortunately, a “friend” of his was providing him with free and easy access to illegal drugs – mostly marijuana. This was having a negative impact on his well-being and about a week before our visit his employer had let him know that if he appeared to be “stoned” once more at work, that he would be let go. In our discussion, I raised the opportunity for him to attend a drug discontinuation group that we had been working with. It provided young people with a support system and framework to help them get off and stay off illicit drugs. Mike (not his real name) became annoyed when I suggested that. “I have a psychotic illness” he said, “I am not a drug addict”.

What Mike was voicing was in some way a stigmatizing perspective about people who struggle with drug misuse and abuse. This is the topic that another friend of mine just recently wrote about. It’s worth a read and you can find it here. His point is well taken. There is a lot of stigma about drug use in young people and this stigma can get in the way of getting help. I agree.

This is why it is so important to make sure that we have both substance abuse and mental health care easily available in the primary health care system. A young person with either one or both of these problems should be able to get help without going into a stigmatizing separate program. We will know we have finally broken the stigma about substance abuse and mental disorders when anyone can go to their primary health care provider (general practitioner, nurse practitioner, psychologist, nurse, etc.), and get the help and the care that they need. Much as they now go for a sore throat, high blood pressure or diabetes treatment. 

That is our goal. It will take lots of work to get there, but it will be worth it.

-Stan

What's next?

Interesting story in the Toronto Star. Seems that some bright inventor decided to apply restaurant technology to hospital clinics and ER waiting rooms. So, (wait for it) here is the amazing way forward! 

Yes, you guessed it – beepers. Mrs. Jones, your table, er… guernsey is waiting. Please slip on this johnny gown with the gap at your backside and wait behind this curtain. Your health provider will be here sometime before H-ll freezes over. Actually, if you happen to be a patient with a mental health crisis it could take much longer than that.

If I had a dollar for every hour that a patient with a mental health crisis had to wait to be seen by the emergency physician in many of the hospitals that I have known, I could have retired a wealthy man. Why is it that people who have a mental disorder end up at the back of the line? Surely it can not be because of stigma in health providers? Surely it can not be because of inefficient care pathways? Surely it can not be because of inadequate numbers of mental health providers?

Maybe it is all of the above. In that case, you can hand out as many beepers as you want and nothing will happen. Mrs. Jones, your bed is ready for you. Sorry it took seventeen hours to get you there. If only you had a broken leg instead of a depressive psychosis accompanied by severe suicidal ideation we could have done a bit better. And your beeper? Please put it in that box over there. Mr. Watson will be needing it next. We only have one available for psychiatric patients and he has already been here six hours.

--Stan

It's time to focus on triumphs

Recent reports from the BBC highlight the complexities of helping people with psychotic illnesses – specifically schizophrenia, live symptom free and positive lives.

The first story “NHS ‘failed’ overcannibal killer” presents an all too common media response to the extremely rare and thus somehow newsworthy bizarre homicide involving a person suffering from a mental disorder and the problems encountered in better understanding and assisting such individuals from people working within the mental health system. While better training and more careful assessment procedures are in and of themselves important, it is hard to see what such news stories accomplish – except to perpetuate the stigma against people living with a mental illness and those who treat them.

The other story “Embracing the darkvoices within” describes the approach (one that is unencumbered by evidence) of a person described as psychologist Rufus May. What I can glean from this story is that the so called treatment involves getting in touch with your psychosis (voices) in the absence of medication. Oh dear – here we go again. This is nothing new and we have seen the chaos and destruction of lives and families that such idiotic ideologies have created in the past. Those of us old enough to remember the psychoanalytic schools of living through the psychosis or the negative impacts of community circles or the strange world views expressed by the popular “philosopher” R.D. Laing in his books: Bird of Paradise and Politics of Experience or the sad “treatment” described in the novel “I Never Promised You A Rose Garden” shudder when we see history repeating itself.

Schizophrenia is a highly complex and disabling brain disorder often striking in the teen years. We have good evidence on how to provide treatment – evidence based on solid science and many years of improvements and the integration of biological, psychological, social, vocational and civic engagement strategies to promote recovery. Regressing into the darkness of the uninformed past is not news – just as the rare and bizarre homicide is not news. Neither serves the better understanding of mental illness and its optimal treatment.

I would really like to see some stories about how young people have coped with and overcome their disability. I would really like to see some stories about how families have struggled with the adversities wrought by the illness – and have come out on top. I would really like to see some stories about the human relationship between care providers and those living with the illness – the relationships that have gone on for years and have provided the basis for recovery and success. Now, who can we find to write those stories for the BBC?

-Stan

Preventing youth suicide: Doing the right thing or not?

Just had a chance to read a report put out by well meaning people on the topic of suicide prevention in youth. In that report the author kept repeating about the many community and school-based programs that have been proven to prevent youth suicide. While I wish that this was true, it is simply not the case. 

So I am going to write a few blogs about how we know if a program actually prevents youth suicide or not. The first issue is what does the program measure as an outcome?

If a program intends to prevent suicide it must measure suicide. No other measure can be substituted. To my knowledge, there is no data available on this key outcome variable in reports about these community and school-based programs. Instead, we read that some programs increase knowledge about suicide or even decrease the incidence of self-harm behaviors over a short period of time. These are what we call proxy measures and these do not predict changes in suicide rates. We have many examples of interventions that change proxy measures and yet have no impact on the key outcome measure. You can not determine the depth of a well by measuring the length of the pump handle!

Unfortunately, too many people use these proxy measures as “proof” of suicide prevention and go about putting these programs into place. This is a big problem. Not only do we not know if these programs decrease suicide or not, but we do not know if they do any harm! Some early research showed that well intended school interventions actually increased suicide rates! And, guess what, the decrease in suicide rates begin well before suicide prevention programs were put into place and occurred in locations where these programs never existed!

“Fools rush in where angels fear to tread”. “It is not enough to do something. It is imperative that we do the right thing”. “The road to hell is paved with good intentions. Remember all these cautions?” Could be that they apply to so called suicide prevention programs also?

--Stan