Medications and Mental Disorders in Young People

The recent Globe and Mail piece on mental health concerns pertaining to children and youth strikes many correct notes, but unfortunately also incorrectly hits a few important “major chords”, particularly pertaining to the use of medications to treat mental disorders in young people.

Contrary to much popular opinion, there is a rich and scientifically sound data set pertaining to the effective use of medications to treat specific mental disorders and also specific symptoms that are found in some mental disorders. Indeed, there has arguably been much more rigorous first order clinical trials research conducted in medications use than in any other treatment modality in this population.

For many mental disorders, the use of medications is an essential (albeit not sufficient intervention) that helps control symptoms and promotes recovery. Unfortunately, public understanding of the medication use issue in the treatment of mental disorders in young people falls far short of the scientific evidence that supports this intervention. It is not uncommon to read reports about the increase in medication prescriptions to treat mental disorders over the last few years, and usually this data is negatively portrayed. Frequently the media issue focuses on the presumed “over-use” of medications.

Now, we know that diagnosis and treatment of mental disorders in young people has been a concern for decades. Fundamental to this concern has been the finding that these disorders have been under-recognized and under treated. This sorry state of affairs has been slowly changing. Today more young people are being appropriately diagnosed and treated for their mental disorder. However, now when we find the statistics increasing for both diagnosis and effective treatment, there is criticism that this increase is somehow alarming and to be feared.

Did you know that the use of medications in young people to treat asthma and diabetes has increased more than the use of medications to treat depression over the last few years? Do we read sensationalized reports of “over-medication” for diabetes? No we do not – quite the opposite. Publicly we are concerned about the increasing rates of diabetes and we want to address this problem effectively and comprehensively. So we advocate for better diet, more exercise and earlier diagnosis and treatment with medicines that help control blood sugar.This is different than what happens when we publicly address the issue of treatment for mental illnesses. In their case we seem to criticize the use of treatments known to be effective. This is quite the difference in approach, so we need to begin to wonder why.

I am not saying that medications are always properly prescribed and properly used in the treatment of children and youths living with mental illnesses. That is clearly not the case.And the proper use of these medicines needs to be improved. There is a great need to provide better education to doctors and all other health providers about how to best and most properly use medications to treat mental disorders in young people. We also need more research to help address some of the issues that we have not yet fully understood and we need to develop more sophisticated research studies that compare and contrast the use of medications with other forms of treatment so that we can get the complexity of care needs better understood.

So, I wonder why. Could it be that we as a society still somehow hold the fantasy that mental disorders really do not affect young people and thus they do not need medical treatments?Could it be that we hold invalidated beliefs about what works in the treatment of mental disorders in young people – a sort of herbs and spices model that we abandoned for such childhood diseases as cancer and diabetes long ago? Could it be that we do not really know the correct information about appropriate or inappropriate medication use and instead of trying to find out are just happy being intellectually lazy? Could it be that our understanding of brain function and brain development is so uninformed that we assume that any kind of medication that affects brain function will have more negative than positive effects but that for some unknown reasons other interventions, which also affect brain function, are somehow uniquely spared such concerns? Or could it be that we still hold a very very very strong stigma against children and young people that are mentally ill – and as a result would deny them access to properly researched and properly provided treatments?

These are serious issues. I will address a number of the important issues around medication use in young people in the next few blogs – starting with this: what does it mean for a medication to be used “off label”? Keep your eye on this space! If you want more info check out our evidence-based medicine guide for patients.

~ Dr. Stan Kutcher

Broadening the Spectrum of Stories about Mental Illness

This week the Globe and Mail is revisiting the issue of Canada's mental health crisis in a week long expose. Saturday's article addressed child and youth mental health. Kudos to Anderssen and Picard for bringing attention to an issue that is often underreported and often misunderstood by mainstream media outlets. The piece has some important points to make - most notably about the absurd double-standard we have about mental health care in this country:

"If only one in six adults who needed a hip got one, there would be a revolt," says Simon Davidson, a psychiatrist at the Children's Hospital of Eastern Ontario. "So how can we tolerate a situation where one in six sick children get care?"

The article also successfully highlights the many ways that mental illness affects all aspects of a child's life, especially relationships with parents and teachers. The complexity of understanding mental disorders in children and youth, as well as the complex health systems in place for youth to get help are indeed barriers that need to be addressed.

"Most young people with mental illness suffer in silence ... Sometimes their parents are oblivious, or put it all down to a phase. But often their families suffer with them, unsure of where to turn in a system bogged down by turf wars, waiting lists and funding shortages."

The need to address mental health problems early in is also clear. Dr. Waddell's metaphor is apt: "If we wait until adulthood to treat these problems, it's like using a teacup to bail out the boat". However, for all the positive points addressed in the article, the authors somewhat undermine their own message by using language that only seeks to enhance the stigma associated with mental illness. By telling the stories of youth who have "violent rages", and by using phrases like "locked in their rooms, cutting themselves, crying and plotting suicide", and suffering from some kind of "Dr. Jekyll and Mr. Hyde" syndrome, the authors are not providing a very balanced viewpoint about youth with mental disorders. The challenge is to give mental illness a "face", without giving it a face that paints a very extreme picture of what people with mental disorders experience. So much of the public understanding of mental illness is informed by these extreme pictures - people who are violent, out of control, hallucinating, etc. - when in reality people who experience those episodes comprise a very small percentage of the population. if we are truly going to normalize and destigmatize the issue of mental illness we need to start telling stories from different perspectives that reflect the wide spectrum of experiences that youth and families dealing with mental illness have.

 ~ D. Venn

Depression is not just being Blue

Depression is not just being blue.

Everyone feels low or sad sometimes. Often those feelings are in response to a negative event or life problem. Those feelings are perfectly normal. Indeed the ability to experience these emotions may be an essential part of what it means to be human.

These feelings will frequently lead to changes in our behaviour. That is, they help us adapt to our environment – often by enhancing our use of social supports. That is why we feel better when a friend, parent or family member gives us a hug or spends quality time with us. These feelings can also be helped by us seeking out and participating in activities that we usually enjoy.

Sometimes we feel low or sad for no reason. This is also normal. Our moods fluctuate over the course of a day, monthly and yearly. Spontaneous mood changes may be more pronounced over the teen years but everyone has them. These changes are short-lived, do not lead to pronounced social, interpersonal or job problems and usually go away as mysteriously as they came. When these feelings are there you can help them leave by hanging around with people you care about, exercising, listening to music or doing things you like to do.

Unfortunately, we often refer to these normal feelings as depression. This is a shorthand for a whole host of different emotions, including the following: despondent, distressed, despairing, demoralized, disturbed, frustrated, blue, sad, low, etc. Not only does the use of the shorthand “depression” to mean all of the above detract from our ability to communicate the rich nuances of our feelings, but the word depression used as a substitute for these normal feelings can be confused with the concept of clinical depression – which the word depression could be reserved for.

A clinical depression represents a failure of brain adaptation. Unlike feelings of sadness, distress, despondency, etc. which signal brain adaptation, a clinical depression describes a state of being in which a person’s functioning is impaired – that is, they cannot do what they usually do because of how they are feeling. Fundamental to understanding a clinical depression is the decline in functioning that it causes; such as, poor performance at school or at work, problems in interpersonal interactions, social withdrawal, etc.

Unlike the usual and common feelings of sadness, despondency, distress, etc. which are often alleviated by increased positive social interaction or usual enjoyable activities, a clinical depression will usually require a more specific and sustained intervention – usually a psychological or biological treatment. That does not mean that doing things that usually make you feel better (for example: talking with friends, exercising, etc) are not helpful – on the contrary, they may well be. What this means is that for clinical depression these interventions are unlikely to be helpful by themselves. If someone is living with a clinical depression they usually require professional help – from a therapist or physician. These professional helpers will provide additional specific treatments that have undergone rigorous empirical scientific evaluation and have been generally shown to be effective in promoting recovery from the clinical depression.

In addition to the functional impairment, a clinical depression differs from usual low moods in many ways. The low feelings must be persistent and sustained; there is a marked loss of interest or pleasure; there are substantive and persistent feelings of worthlessness or hopelessness; there is often fatigue, lack of appetite and sleep difficulty and there frequently are persistent ideas about suicide or even suicide attempts. Clearly, this state is not a brief response to environmental adversity or a temporary blip in mood.

So, depression is not the blues. Personally, I would really like to see us get away from using the word depression as a shorthand term. So instead of saying “I feel depressed because my boyfriend broke up with me” say instead “I feel distressed (or unhappy, or pissed off, or hurt, or despondent, or whatever) that my boyfriend broke up with me”.

Let's start using the rich lexicon of our language to identify the varied and nuanced expressions of our moods.

~ Dr. Stan Kutcher

Studying the Brain from the Inside Out

Ever find one of those websites you just can't stop going to? A few months ago a friend sent me a link to TED - an annual conference devoted to technology, education and design. Now I'm hooked. Their site contains hundreds of archived talks from some of the world's premiere thinkers and doers. One of the most inspiring talks on the site is by Jill Bolte Taylor, a brain scientist who had a massive stroke and was able to watch and experience as her brain functions shut down one by one. It's a pretty amazing story and gives insight into just how complicated the brain is. Often it's not until something goes wrong that we think about brain health, and how it's just as important to keep our brains healthy as it is to keep our bodies healthy.

When the brain is not working properly or is working in the wrong way, a person may experience difficulty thinking or focusing attention, extreme emotional highs and lows, or sleep problems. When these symptoms significantly disrupt a person’s life, we say that the person has a mental disorder or a mental illness.

While we know that mental disorders are brain disorders, Jill Bolte Taylor's story is an example that brain problems do not always indicate mental illness.

~ D. Venn

Enhancing Successful School Learning by Understanding How the Brain Works

There is no health without brain health. A healthy functioning brain is the foundation for all successful learning, social, civic and economic development. The school environment is an important component of healthy brain development. Just as schools are locations in which physical health can be encouraged and improved, so are they locations in which brain health can be encouraged and improved.

How and when a young person's brain develops affects how they learn. An understanding of how a young person’s brain functions may help us better create brain-healthy environments and educational approaches that can enhance learning outcomes.

The human brain is the most complex entity in the universe. It has more connections than there are stars in the Milky Way. It is the organ of adaptation and of civilization. What we are, what we think and what we do, as individuals and as a human species are the outcomes of how our brains work. That in turn is influenced by a variety of other factors including our genetic endowment, the way our brains naturally develop over time, and the impact of the environment on the way our brains develop and on how they work.

The adolescent years (puberty to about age 25) are characterized by a second major period of brain development (the first is during the early years of development). New brain connections are developed, old connections are pruned, and complex systems that guide emotional integration, motivation, craving-induced behaviors and the capacity for good executive functioning (impulse control; problem solving; empathic/cognitive integration; etc.) come online.

These neurodevelopmental changes continue to be guided by both genetically-determined neurodevelopment and by environmental influences. As this development occurs a number of challenges are presented to the school setting. Some of these include the following: how to structure the school environment to improve learning potential; how to best motivate for learning; how to present materials to enhance uptake and retention; how to address brain dysfunction or brain disorder to best support the students with those disabilities.

The adolescent years are also characterized by the onset of the severe and persistent mental disorders, such as major depression; schizophrenia; bipolar disorder; panic disorder; social phobia and others.

Schools can provide curriculum on brain health and brain disorder to help decrease the stigma associated with these conditions and to help students identify these problems early when interventions can make the greatest positive impact. Teachers should be well versed in knowledge about and understanding of these issues and training institutions and ongoing continuing educational programs should be in place to enable teachers to acquire the knowledge and competencies needed.

The recently developed Secondary School Mental Health Curriculum and its accompanying teacher training module is a good example of this application. Schools could provide linkages to appropriate health care services and can become community resource centers that provide information on a variety of health related matters – including brain health and mental disorders.

In summary, neurodevelopment is directed by a genetic blueprint and modified by the environment. Schools are uniquely placed in a situation in which they can shape the developing brain by applying brain-healthy environments. Additionally, neurodevelopmental factors can be better understood and this better understanding could result in the creation and application of various educational strategies that can be applied in such a manner as to enhance learning outcomes.

Further information: Dana Foundation, Brain Explorer, BrainBlogger

~ Dr. Stan Kutcher

What is Health 2.0?

Web 2.0 has been exploding over the past few years. Simply put Web 2.0 is a an innovative, creative and collaborative way to share information on the web using tools such as social-networking sites, video sharing sites, wikis, and blogs.

Because of the constant changing nature of the internet, Web 2.0 is also constantly changing to meet user demand. It's application is expanding to sectors beyond marketing and business. One of these expansions it into the health care sector.

Health 2.0 is an emerging concept of health care that uses web 2.0 technologies to promote collaboration between patients, physicians, health care professionals, and other members of the health community. It's application is ever-changing, and the evidence for its effectiveness is still raw, but there's a lot of potential for this type of new technology to improve mental health education and mental health care.

For more info check out Chris Paton's blog, Health 2.0 Conference and Medicine 2.0 Conference.

~ D. Venn