Protection of privacy or impediment to care?

Earlier this week a friend of mine told me his nineteen year old daughter had been admitted to a psychiatric inpatient service. His relationship with his daughter is close, supportive and positive. Her illness had taken a turn for the worse and the difficult decision to hospitalize had been made collaboratively by the young girl, her parents and her outpatient treatment team. The next day he called the inpatient service to find out how she was doing. She was involved in a scheduled activity and was unavailable to chat with him. So he asked the staff member a simple question: “how is my daughter doing”? The response – “I can’t talk to you because that would be breaking her confidentiality”.

As expected, he was shocked. Not only was he one of her major supports, he had been involved in her care, her successes and her sorrows for the entire time she was unwell. He had worked with her and her previous health providers to address the challenges of her illness. And now, suddenly, he was told that he could not even be told how is daughter is doing because of “confidentiality”?

What kind of care is this? Does “confidentiality” mean that a concerned, involved and supportive parent cannot receive the simplest information about how their child is doing from a care provider? Is this barricading of children from their parents common across all types of health care, or is this unique to brain disorders? Is this what are trying to achieve when we work together to help people recover from their mental illness?

Certainly, young people need to be able to share their concerns, questions and problems in confidence with their health care provider. Is this the same thing as denying parents access to basic information about their child? Parents have important and essential roles to play in the lives of their children. This obligation does not end when puberty begins. Indeed, it amplifies: and becomes more complicated. Health care providers need to understand how important the relationship between parents and their children is. They need to understand that “independence” is a relative term, one that continues to evolve over the entire duration of the relationship between parent and child. We have to do better.

--Stan

Data clarifies 'sexting' panic

Almost every week I hear stories in the media about “sexting”. For those who have been vacationing on mars for the last five years “sexting” is a word describing sexual images that people (often the finger is pointed to teenagers) send to their friends – often these images are of themselves. Given the media coverage it is not a wonder that many parents have been asking me about the “sexting epidemic” (note: their words – not mine.)

So now a study has been reported on the USA prevalence of this behavior, click here.

It turns out that “sexting” is not an epidemic after all. A nationally representative sample found that less than 1.5% of teens reported that they had sent or created an image of themselves that showed breasts, genitals or someone's bottom. Now some would say that is quite a high number, but others would wonder what happened before electronic tools enabled such material to be widely distributed. What was the proportion of teens a couple of decades ago who took photographs of themselves and gave them to a boyfriend or girlfriend? Or before that, who drew a picture of themselves and gave that to a boyfriend or girlfriend? We have no idea. Maybe it was the same number, maybe more, maybe fewer. 

In any case, this is likely not a new behavior. This is likely not a behavior that has been created by newly available technology. It is also not a signal that is showing that our youth are falling apart under the pressures of modern adolescence. 

However, “sexting” can lead to problems. Once an image is available electronically, it can be made available to everyone. This is something that our young people need to understand.  In addition, unlike a traditional photography, it can be passed quickly and widely to many --  that is the issue. We need to help young people understand the consequences of their behaviors in the electronic world. 

New technologies may not only create new human behaviors but they can make longstanding human behaviors more apparent. So, while the sky may not be falling, in terms of “sexting”, we need to make sure that we help young people understand that in the age of instant electronic communication that sometimes a private act can become a public spectacle.

--Stan

Does anonymity breed cruelty?

I just saw the very powerful You tube video posted a few days ago by a Jonah Mowry (already over 6 million people have watched it).

I don’t want to comment on the video – it speaks for itself. What I want to address are some of the comments that the video has received. 

It is difficult for me (and I am a psychiatrist and am supposed to understand these things) to read so many cruel comments (I will not dignify them by repeating them here). Why are so many people posting such cruel and vicious comments? Are so many people by nature so cruel and so vicious? Is this a phenomenon that is encouraged by the medium of electronic communication? Is this a reflection of levels of homophobia so deeply rooted in our society? Is this the result of anxiety aroused by seeing a young person in distress? Why the anger?

I have no answers to these questions. But I do know that such cruel and vicious comments are wrong. There is no place for such cruelty towards others in our society. Trying to understand why however does not excuse us from taking action to stop such cruelty. This is an obligation from all of us. From those who control the electronic world – there should be no e-space for such attack. From those who are teachers and coaches and parents – we have to stand firm and make it clear that there is no social space for such attack. For peer and friends and all young people – you have to stand up and make it clear that there is no teen space for such attack.

The sooner we get our sh*t together on this, the better for all of us.

-Stan

Is it boys or is it ADHD?

In recent years it has become fashionable in some circles for people to equate ADHD with being a boy. The lack of understanding about what ADHD is, or what is different about being a boy with ADHD from a boy without ADHD does not seem to give pause to certainty of their opinions.  Just last week, I was subjected to one of these passionate diatribes by a Professor teaching in a division of health human resources about the “medicalization of childhood” (his words, not mine).  When I gently reminded him about the brain imaging research on ADHD, his response was not with interest in what had been found, but in denying its importance completely.  “Everyone knows boys are driven by their emotions,” was his reply.  Strange, the last time I checked emotional regulation was a brain function.

 A recent study reported in the June 2011 edition of the Journal of the American Academy of Child and Adolescent Psychiatry (Neuroanatomical and neurophsyological correlates of the cerebellum in children with attention-deficit/hyperactivity disorder – combined type) has added new and more detailed information about brain structures in children who have ADHD.  In this study, the researchers found that a particular brain structure, called the posterior inferior vermis was significantly smaller in children with ADHD than in controls. A  finding that is consistent with a fairly large number of studies demonstrating cerebellar differences in young people with ADHD.  As the cerebellum is important for impulse control, shifting of attention and motor coordination, these finding are very important for they may explain in part many of the symptoms found in ADHD.  A collateral finding, that medications which are effective in treating ADHD impact this part of the brain, lends further support for this consideration.

So what does all this mean for the opinionated Professor and his dogmatic but uniformed certainty?  Perhaps it is time to start teaching neurodevelopment in all human services training programs.   If you are studying to be a social worker, a teacher, a psychologist, a child and youth worker, a nurse, a doctor, etc., you need to know neurodevelopment and understand how brain function underlies human experience, emotions and behavior.   While it may be too late for us to change the Professor’s stigma, the worse since it is cloaked in profundity and ignorance while concurrently enjoying the status of his position, we may be able to encourage reason and curiosity in the next generation of teachers, health providers and professors.

--Stan

A Global Opportunity to Advance Mental Health: Can we grasp it?

September 2011 will be an important month for many different reasons. One reason will be especially important for improving mental health across the globe. The United Nations will be holding a special session on Non-Communicable Diseases in New York that month. The purpose of that meeting is to encourage a global response to these diseases, and mental disorders are at the top of the list of diseases causing the greatest burden of illness worldwide. Unfortunately, mental disorders are not at the top of the list of the conveners of this special session. As we are all too familiar, mental disorders are too often not on the list when it comes to health care investment – not only here in Canada but around the world.

We know how important mental health is – in wealthy and in poor countries. It is well documented that mental disorders can lead to poverty, decreased educational attainment, job difficulties, incarceration and a poorer quality of life. They increase the risk for substance abuse (including alcohol and tobacco), a variety of physical illnesses and poor adherence to treatment for a number of different illnesses – including HIV-Aids. Mental disorders are very costly, in both direct (for example, hospital beds) and indirect (for example, decreased work productivity) ways. Effective and cost efficient treatments are available and have recently been catalogued and widely distributed to health providers across the globe by the World Health Organization (if you are interested, google mhGAP). What is now needed is to get mental health on the global health agenda.

And we need your help to do this.

Write your Provincial Minister of Health and the Federal Minister of Health and your local member of Provincial and Federal Parliament. Tell them that you would like them to bring this issue forward at this very important meeting. Ask your friends and neighbors to do the same. Not only may this have an impact at the global level, but it may help in your Province and in Canada as well!

Helping Early May Help in Unexpected Ways

Our team has been doing some interesting work in school mental health for a few years now. Much of it has been focused on enhancing mental health literacy for teens (through a secondary school curriculum) and teachers (through a variety of different mental health for educators training programs) as well as facilitating early identification and effective treatment for young people who have a mental disorder – such as depression, panic disorder; etc. While the potential mental health benefits of early identification and effective treatment are relatively easy to understand, there are other benefits that may be less evident but also very important. One area of such benefit is found in relation to a number of physical illnesses: diabetes; heart disease and maybe even some forms of cancer!

We have known for some time now that mental disorders are risk factors for a number of other illnesses. That means that the presence of a mental disorder (such as depression) can increase the probability that a person will develop another illness (such as diabetes). There is also some evidence that suggests that having a mental disorder following the onset of another illness, such as heart disease, increases risk for early death from that disease. Although there are many hypotheses about why this may happen, we do not yet really know how this happens and research into understanding how this may happen is currently under-way. Did you know that the same brain chemical that is involved in controlling mood (serotonin) may also be involved in controlling how platelets clump together in the blood? Could it be that problems with serotonin function in the brain can result in depression and at the same time may make blood clotting (which could lead to strokes or heart attacks) more of a problem? Ongoing research may help us better understand this issue.

So, it may also be that if we can better identify, diagnose and effectively treat young people when they first develop a mental disorder, we may also be able to decrease the risk of them developing another illness – such as heart disease, diabetes and perhaps even some forms of cancer. Or, if not that, maybe early and effective treatment of mental disorders might delay the onset of another illness or maybe improve treatment outcomes. Right now we do not really know the answers to these questions but being aware of this possibility is really important for us – both personally and for public health reasons.

Secondary prevention, meaning the prevention of another illness by effective treatment of a pre-existing disorder, of some physical illnesses might be achieved by early effective treatment of a mental disorder during the teenage years. This is an exciting possibility! Will this pan out? We don’t know yet. But, to my way of thinking, there is enough evidence on this possibility already available to further underscore the need to better identify, diagnose and treat mental disorders in young people. We know what needs to be done – now we only have got to get our act together and do it!

The Academy in Mental Health for Educators: A new opportunity

We have been working in the area of school mental health for some years now and have created a variety of programs and educational resources for educators, health providers, youth and parents. Over and over again we have heard from teachers, social workers, psychologists, nurses, principals, school superintendents and others about the need to provide more training for educators in the area of youth mental health and a better understanding of youth mental disorders. Over and over again we have heard that a summer program would be a good venue in which this could be done. So guess what – we listened and decided to do exactly that. Our first Academy in Mental Health for Educators will start next week – in Halifax, Nova Scotia. As far as we know, this is the first event of its kind ever in the Atlantic Provinces.

So what will happen at this Academy. First, it will take place over a two day period – actually two such two day periods. The first will be on a Monday/Tuesday and the second, on a Thursday/Friday will be a repeat of the first session.   There are a variety of different topics to be covered. These range from detailed information about common mental disorders in youth to advice on how to talk to teens and parents to understanding medications and their role in treatment to specific “classroom pearls” for helping young people who are living with a mental disorder be more successful in the school setting. Participants will also be exposed to a variety of useful and effective educational materials and programs.

We are really excited about the program and our presenters. In addition to key members of our Sun Life Financial Chair in Adolescent Mental Health Team, presenters will include psychiatrists; psychologists; teachers and others who work with youth, families and educators. We hope that the program will be fun and informative for all who attend. One of the fun components will be a “Halifax dine around” evening where participants can sign up to join one of the presenters for dinner at one of the many excellent restaurants in the city. Not only may people discover a great new place to eat, but they will have the chance to chat to an expert in the field – and hopefully that will be both fun and informative!

As always, we will be evaluating how the Academy turns out. Not only in terms of participant satisfaction and improvement suggestions but also in terms of learning that has happened during the sessions. And, as always, we will be posting the results of this learning on our website. Frankly, I am both a bit excited and a bit nervous about this. What if our learning evaluation does not show a significant positive impact of the session on participants’ mental health knowledge? Or horrors of horrors, what if it shows a negative impact on participants’ mental health knowledge? At best that would be so embarrassing.

--Stan

Helping Students with ADHD Achieve Success: Tips for Teachers

ADHD impacts approximately 5-10% of children, which means as a teacher, 1 in 10 students may present with ADHD symptoms. It can seem like a handful with students squirming, drifting off in space, and disturbing others around them. But it doesn’t have to be.

As a teacher you are in a unique position to help the student learn habits at school that will help them be successful in their home and with them as they move through the education system.  Assisting young people with ADHD to learn how to feel and think better about themselves, and to identify and build on their strengths can be an important step in helping them control their symptoms of ADHD. Students with ADHD need to learn how to cope with daily problems and control their attention as well as their impulsivity, teachers and parents need to work together to help students achieve this success.

Tips for teachers:

·         Encourage youth to ‘stop and think’. This could take the form of counting to 3 before asking a                 question, or writing the question down and asking it at the proper time.

·         Create a token reward system – where emphasis is placed on the positive outcomes of behaving           appropriately.

·         Help your students have a regular routine. Posting the routine, reminding them of homework at               the end of the day, use organizers to help them keep their days straight.

·         Post rules in the classroom where they are easy to see and adhere to. Out of sight, is out of                   mind.

·         Helping kids who distract easily involves physical placement, increased movement, and breaking             long work into shorter chunks.

·         Post the day’s schedule each day at the front of the room, and cross of items as they are done.             Young people with impulse problems may gain a sense of control and feel calmer when they know           what to expect.

·         Be brief when giving instructions. Breaking them into bite sized chunks by asking the student to               do one step, and then tell them the next step once the first is completed, will help all students, but           especially those with ADHD

·         Incorporate physicality into learning by giving students opportunities to act out stories, or sing                 songs. Providing them with outlets for their physical energy.

Students with ADHD are often easily distracted and can become that way even in mid-sentence. If you do not know what they are talking about, ask them to help you understand. When speaking with a student, it’s best to not assume you know what a young person is going through (unless you yourself have struggled with ADHD) and instead ask them to tell you what it’s like, and what they need from you to help them be successful.

Meet with parents and talk about their son/daughter’s treatment as well as tactics and techniques they use at home. If you can reinforce successful tactics at home and school, you create an increasingly familiar routine for the student. Rewards programs can extend beyond the classroom and into the home life if a parent and teacher can work closely.

Each student will be different, so developing a toolkit of strategies that you can use with each child will help you find the best fit for them. Make sure to talk to other teachers and parents, to share great ideas and success stories.

--Stan Kutcher, MD, FRCPC and Christina Carew, ABC

How do I talk to my teenager about suicide?

One of the issues that arise in discussions with parents about youth mental health is: “how do I talk to my teenager about suicide?" This is most often in the context of a media report about a youth suicide or a community or school experience of youth suicide. There is no “right” way to discuss this issue but there are some useful guideposts.

Be prepared to chat if your teen brings it up but do not be surprised if that does not happen. If you have concerns that your teen may want to discuss this you can address the issue in a gentle and “just putting it out there” manner. Saying something such as: “I was reading in the paper about the young person who recently died. Sounds like a tragic situation” can be an ice-breaker. Then if your teen is interested, they have an opportunity to discuss it with you. Sometimes they will be interested and sometimes they will not be interested. Or, they may bring it up at a later time, when they are ready.

If, however, you or your teen knows the person who had died, then this discussion should be explicit. This is now not an issue of “talking” to your teen, but an issue of grieving while at the same time acknowledging that death was by suicide. There can be a tendency to both avoid the issue of suicide or to over-focus on the issue of suicide. Try not to do either. 

Sometimes both you and your teen may need more support than usual (such as family and friends or religious communities). If this is the case, you can seek out services that are available through your local community health center or mental health care providers. A useful resource is the booklet “Have you lost someone to suicide?” which is available on this website here.

If you are concerned that your teen is having a mental health problem or may be depressed, it is a good idea when you are discussing this to bring the issue closer to home. There is nothing wrong with acknowledging that depression or a mental health problem increases risk for suicide and making that knowledge part of what you monitor when your teen is not feeling well. If you have diabetes you monitor your blood sugar and your diet. If you have depression you monitor your mood and thoughts about suicide.

-Stan

Parents Can Make A Difference

As a psychiatrist (and a parent of a child with ADHD), I want to reassure parents of children with (or exhibiting signs of) ADHD, it gets better when they receive the right intervention.

The best thing a parent can do is to be informed. The more you know about ADHD, the better you will be able to help your son or daughter with the challenges they face. There is no biological test that can confirm a diagnosis, so it is often a discussion between parents, teachers and health care professionals that determines the diagnosis of the child involved.

It’s important to remember that all children are not the same, and therefore can’t be treated the same. If you have a child that has ADHD, and one that doesn't, it’s challenging to remember that you can’t expect the same behaviors from both. When your child is fidgety, when it seems like they aren't listening, or they've forgotten something again -- if you know are aware these are their struggles, your response will be different to the situation. It’s often difficult to remember that this child isn’t bad (in relation to their brother or sister or other children), but that their ADHD causes them to be impulsive, inattentive or both.

As a parent, it’s important to help your child to be successful and to reach their maximum potential. Young people with ADHD responds better in well structure environments, you can help them with homework and chores, by creating a routine. As many children with ADHD have trouble sustaining attention, breaking items into small tasks with an immediate reward at the end has proved to be quite effective. Instead of suggesting your son clean his room, ask him to fold his clothes. The way to reward your child varies with age.  Charts have a better impact in smaller children, for older children or teens you can offer them pick out what’s for dinner, let them watch their favorite television show or spend extra time with favorite video game.

Increase your child’s self-esteem, this point is very important as many young person with ADHD has a low self-esteem. Focus on their strengths and things they do well.  For instance, individual sports and activities such as track and field, or swimming, are generally more fulfilling and successful then groups sports.

Help make the things they find most challenging easier. One of the best ways to do this is to help your child be organized. It can be helpful to tape lists to mirrors, doors and lunches. Calendars, timelines, agendas, alarm clocks can all be tools that can be helpful. And helping your teen get on a regular schedule can do wonders for their organization.

Make sure you spend quality time with your teen. Going for a walk with them is a great way to be able to connect with them and get some exercise. Sharing feelings, connecting with someone they trust, and getting regular exercise are great ways for your youth to have positive interactions and shed some pent up energy.

As a parent you can also help to make sure your youth is good to their body. Eating a healthy breakfast can decrease stress and improve performance at school and work. Caffeine and sugar rich drinks can increase anxiety and agitation. Ensuring your teen has a balance diet, and stays away from alcohol and drugs can help improve life balance.

Depending on the severity of your child’s ADHD, treatments will include therapy and sometimes medication. In combination with the above, you can get your child on the road to recovery and a successful life ahead.

-- Stan Kutcher, MD, FRCPC; Iliana Ortega-Garcia, MD, and Chrisina Carew, ABC

Youth have Say in Mental Health Research

A recent Australian media report describes an “innovative approach to mental health research”

This is a website where young people who have received mental health care can rate what they think was helpful to them. Good idea, but hardly new.

Our group in Toronto published an academic study on this question in the 1990’s in the Canadian Journal of Psychiatry. And, last year, the Institute for Families published its report of a national consultation involving youth, parents and researchers from across Canada in which the issue of what should be mental health research priorities in our country. This report was the outcome of shared consultations that may help identify national child and youth mental health research priorities for our national and provincial health granting councils.

Regardless of pride of place with the idea – it’s essential that young people and their families be involved in the identification of what should be researched. Those who provide clinical care and those who do research can only do what they do best when they are informed by those they work with – patients. I can still remember when one of my patients, a young girl with a manic episode told me that the mood rating scale I had given her to fill out made no sense – because it did not have a place to mark down depressed or low mood. When I changed the scale with her help we made the discovery that manic episodes in young people fluctuated widely in their mood levels. And when we applied this new measurement technique to scores of other young people we were able to describe for the first time, the now understood to be “classic” description of mania in teenagers: mixed rapid cyclic manic episodes. And that is only one example.

So what does this tell us? What good health providers have known for centuries. listen to your patients. Involve them respectfully as full partners in their care. Learn from them.

--Stan

Substance Use and Mental Health Care, Can They Co-Exist?

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:http://www.huffingtonpost.com/dr-harold-koplewicz/is-drug-addiction-mental-illness_b_858815.html 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

Reaching Out Can Make the Difference

Youth that are suffering from mental illness more often than not find it difficult to get through school. For some people, all they can think about is how they’re going to get through the day and keep it together. Sometimes things such as anxiety and depression can get in the way of success. The gravity of the anxiety and the depression can take a toll and negatively affect academic performance or social interactions.

For most of my life, I was an overachiever and always excelled in school. However, in years past, I dealt with anxiety and depression and found myself going in a downward spiral. It started in junior high and at first, it wasn't a big deal. A few missed assignments and my grades fell a bit. I knew I could do better but then I stopped caring. My grades dropped from excellent to mediocre. For a time period due to a loophole in the school system, I got away with skipping class without my parents finding out. I never thought I would ever skip class, but things happened and I started doing it more and more. I felt terrible whenever I was at school, so I thought “why should I have to go?” I had a minor intervention and things were fixed, at least for the time being.

So then high school rolls around and I moved to a different area, with a new school and a new start. At first, I was doing really well. However, I started heading downhill again. I had difficulty with school and my grades began to gradually fall. Due to my anxiety, I was afraid of approaching anyone, not even my teachers. I felt like I had nobody to talk to. My grades declined from the 90s to failing badly and barely even making the 50s. I was lost in a sea of students and I hardly spoke to any of my teachers if at all.

It was hard to spot a teacher who might have cared but one of my teachers who knew me and knew what I was capable of saw what was happening and started talking to me. Confronted by this particular teacher, I couldn't keep it together and she brought me to the guidance counsellor. It was difficult at first to get me talking but eventually I did… and it felt like a huge weight off my shoulders to let all the thoughts and emotions out. It took a while to figure out how to make things better but it was a great leap forward for me. When I couldn't bring myself to speak, a teacher reached out to me.

So what I want to tell teachers is this: sometimes, all it takes is the simple act of reaching out, and you could make a really big difference for that person. When you look at the sea of students, please reach out and make a difference for those who might be lost in the system.

--Karl Yu

Karl Yu is a grade 12 student in Halifax, Nova Scotia and will be attending University this Fall. He has been an active member of the Youth Advisory Council for the Sun  Life Financial Chair in Adolescent Mental Health.  The Chair works directly with youth to provide easy-to-understand materials about mental health and the brain.  The materials are offered free to parents, families, physicians and anyone who wants them. Visit teenmentalhealh.org for more information.

Karl's blog has also been published on: http://www.ourkids.net/blog/the-simple-act-of-reaching-out-makes-a-difference-10108/

Moving the Mental Health Agenda Forward in Canada

There was some large scale news reported in the Globe and Mail recently:http://www.theglobeandmail.com/life/health-and-fitness/bells-10-million-donation-hailed-as-mental-health-game-changer/article579559/. Kudos to Bell Canada for stepping up and making a huge (yes, 10 million dollars is a lot of money) donation to CAMH in Toronto. This is also yet another public statement from corporate Canada as to its awareness of and support for mental health. And this is very much appreciated.

Now comes the next very important part. How to ensure that this interest is not merely a reflection of the “flavor of the moment” and how can this translate into substantive and sustainable improvements in mental health and mental health care for all Canadians?

Some of this responsibility will of course need to be undertaken by CAMH, as they are the recipient of this largess. Some of this responsibility however will need to be undertaken by those who work in other parts of Canada, parts not as fortunate as Toronto, but where innovative and life-altering work is being done and new directions are being forged. 

Perhaps the generosity of Bell will rub off on other corporations. Perhaps the innovation and improvements that this generosity will help develop at CAMH can be used to encourage and support other parts of Canada as well – so that research conducted and lessons learned there can swiftly and effectively be used to improve the lives of all Canadians. Perhaps all provincial/territorial governments will realize that more and more effective investment in mental health is needed. Perhaps mental health will make it to the table in the discussions in the upcoming national Health Accord (I hope that we will have another Health Accord).

Who know? What is clear however is that the generosity of Bell and the innovative changes un

--Stan

Nova Scotia and its mental health plan: how is it going?

Nova Scotia is once again developing a mental health plan. I have been active in mental health in the Province since 1995 and have seen at least half a dozen or more Provincial and Regional planning processes addressing mental health over that time. Some “wag” once said that if the number of mental health plans sitting in the Department of Health where laid end to end then we would have a pathway of good intentions leading from Province House to the Elephant and Castle.

While I cannot vouch for the accuracy of that comment I can certainly resonate with the emotions behind it. And in a recent story on this issue the Chronicle Herald newspaper reported a similar concern by a participant about the current process: “"These are the same issues that have being going on for 25, 30 or 40 years now," one person said. "What’s going to be different?"  

That is an excellent question. 

The issue frankly is not that we do not know what to do. The previous Bland Report had a number of excellent recommendations that have not yet seen the light of day in Nova Scotia. The newly available document from the MHCC provides a useful call to action. The Evergreen Framework provides a set of values and strategic directions that could be easily incorporated by the Province in addressing child and youth mental health now. The World Health Organization has produced realms of useful documents/materials ranging from the MHPP monographs to the mhGAP. Recently released mental health documents from British Columbia and Ontario have excellent components that could easily be modified for use in NS.

And the list goes on.

The issue is doing, and making sure that what is done is based on what we know and supported by strong and independent evaluation of what we are doing so that we can change things that are ineffective or inefficient and replace them with actions that are effective and efficient. 

We also need to ensure that the appropriate funds are in place to permit necessary action to happen. The mental health budget for Nova Scotia is woefully inadequate. No plan will be useful if it is not properly resourced. 

So what will happen? Follow the money!

-Stan

New Brunswick and its new mental health plan: how will it go forward?

Now that the federal election is over I can turn my attention fully (or as fully as I can get it) back to our very important mental health in youth work. And my attention has been caught by the following article: “NB Unveils Mental Health Plan”

The Minister of Health announced the new plan which is supposed to put people at the center of interventions (I assume these include prevention, early identification, treatment and ongoing system improvements) and identified an additional 12.6 million dollars to help do that. 

Now that sounds like a lot of money but apparently it is to be spread out over 7 years. So lets see what that translates into: about 1.8 million per year. If all of that money is put into human resources that can meet mental health needs of people then that will result in a good improvement in service availability. If however, much is put into administration there will be little to show for that investment. Some also must go into training as we know that substantive concerns about diagnostic and treatment capacity, especially in the primary health care system exist: not only in New Brunswick but across Canada. Some must also be spent on evaluation and quality assurance. How else are we going to know if the investment results in improvement at the personal, family and the system level?

So what will happen in New Brunswick to improve mental health care in that province? Follow the money!

-- Stan

Charlie Sheen, the Media Circus and Mental Disorder

I for one am getting sick of the media circus that revolves around Charlie Sheen. It reminds me of a group of sharks circling around a bloodied and dying mammal, waiting for an opportunity to move in for the kill.

It may well be that Charlie Sheen has a mental health problem. He may also have a mental disorder: bipolar illness has been suggested by some. He may be suffering from the emotional, cognitive and behavioral effects of substances. Or it may be all of the above. Or it may be something else.

Armchair diagnostician’s aside, it is simply not possible to come to a substantive conclusion about the presence or absence of a mental illness such as bipolar disorder without careful, comprehensive and detailed analysis of presenting problems and a life history. The same goes for any other psychiatric diagnosis, including substance abuse and personality disorders. Nobody can speak with any authority about Mr. Sheen based on media reports!

Personally, I find it sad that so many do. I also find it sad that we as a society seem to revel in the difficulties and life problems of those who we have made celebrities. This is not fair to them and certainly does not say much about us.

Recently, Dr. Paul Keedwell wrote a thoughtful piece on this issue. Actually, it has been the first thoughtful piece I have read in the media about this: http://www.bbc.co.uk/news/health-12701154. As for me, I think the media circus should stop. Let us leave Mr. Sheen alone so that he can start to address his concerns in private. Send the sharks away.

--Stan

Can Facebook Prevent Suicides?

Today I read about yet another suicide intervention strategy, launched with media fanfare in the UK. According to the BBC News, an NGO in the UK called the Samaritans has now launched a Facebook scan for people who discuss ideas about suicide http://www.bbc.co.uk/news/technology-12667343. If they identify someone at risk they will contact police and ask them to go and intervene.

Apparently this idea was in response to a suicide tragedy in which a young person died by suicide after posting their intent on Facebook. Is this a good idea? I do not know. Will it work? I have no idea. Will it have the opposite effect of maybe encouraging suicide in vulnerable youth? I do not know. Will this become the focus of hoaxes and “crying wolf”? I have no idea.

On the one hand, it could be argued that addressing youth suicide through social media makes sense because that is where youth “live”.  On the other hand, it could be argued that such Facebook vigilance will lead to more harm than good – either through “copy-cat” activities or to hoaxes that lead to police “interventions”. 

Suicide is an emotional issue. Not every good idea turns out to be a good idea. Sometimes good ideas have negative unintended consequences. However, it seems that the cat is out of the bag on this activity. I hope that someone is doing a careful and appropriate evaluation of what is happening. That alone will give us an idea if this idea is worth pursuing or not.

In the meantime, I would really like to see us all put into place those things that we know actually do work. This includes: limiting access to lethal means (such as controlling access to guns); training all health care providers to better identify and treat those people at risk; providing “gatekeeper” training for teachers and others who spend a good amount of time with young people – so that they can identify those at risk for mental disorder (still the single largest risk factor for suicide) and seamlessly refer them for the care that they need.

It seems pretty simple to me. Let us do what we know works. Not do what we know does not work. And, if we do not know, let us study it properly so that we can find out.

--Stan

Mental Health in Schools Act

I read some really interesting news from the USA today. Mental Health in America reports that new legislation is being introduced by Rep. Grace Napolitano (D – Calif.) who is co-chair of the Congressional Mental Health Caucus: the Mental Health in Schools Act. 

As far as I can tell from the news reports, this Act will provide a means to address the mental health care needs of children and youth by providing funding for a variety of mental health related activities, including safe schools, early identification and referral to treatment. Kudos to Rep. Napolitano!

This is what I would like to see happen in Canada. First, wouldn't it be a neat idea if we had a mental health caucus in Parliament – non-partisan, committed to moving the mental health agenda forward.  When I become the federal MP for Halifax, I will work to establish this kind of structure. Second, this Act sounds like it may do some good. Although I do not know the details, it seems that it will provide funding to support evidence-based school mental health programs and improve case identification and linkages to mental health services. 

This almost sounds like the model that we developed a few years ago and have been piloting in Nova Scotia and elsewhere in Canada. This “Pathways to Care Model” has been described in various publications (including an upcoming entry in the McGill Education Journal) and an overview can be found on our website. If we can only improve the identification and referral to effective care pathway for young people, we would make great strides forward in improving youth mental health and advance economic, social, family, civic and personal success through secondary prevention following from effective treatment and follow-up. And our model adds even more – mental health literacy for students and teachers as well!

This to my mind is a good federal approach to mental health. It is focused on addressing a huge need, is grounded in best evidence and has the potential for amazing positive impact – both primary and secondary. What a difference to what is happening here in Canada!   In the area of mental health at least, we cannot keep having smug “we are so much better than the USA” self-congratulations.   Now that is a scary thought.

--Stan

Mental Health and Universities: the SFU innovation

Simon Frazer University (SFU) has taken an innovative first step in addressing mental health on campus. Launching their multifaceted program in concert with a national eating disorders awareness week SFU is putting into place a variety of mental health activities and infrastructures. These include programs that seem novel, some that we know may work and ofcourse some that may have little if any substantive impact. In one sense, this is an issue that has characterized many types of community-based mental health interventions as well as the development of mental health treatment facilities. Where numerous interventions are put into place together with the hoped for outcome of success but with little certainty in what components are necessary, which are useful and which are neither.

Regardless of this concern however, kudos to SFU for taking this initiative. Its about time. Our Transitions Program (of demonstrated effectiveness) and our staff (residence dons and faculty) mental health training programs can be used by post-secondary schools across Canada to effectively address mental health needs of students (see http://www.teenmentalhealth.org/). These however, need to be seamlessly linked to intervention and treatment programs for them to have the full range of positive effects needed. Improving mental health is an important goal but it must be linked to early identification and easily accessable effective treatments. Without that link, it is energy expanded for outcomes that are insufficent.

It is addressing this continuum that has been the focus of our work for the last three years. How do we go from mental health promotion (primarily through the enhancement of mental health literacy) all the way to support, intervention, treatment and continuity of holistic helping? 

What we have learned is that interventions must cross traditional silos of education and health providers. There are ways that we can do this and be successful. Part of the answer includes the enhancement of diagnostic and treatment competencies in primary care and reserving specialty mental health services for those students who require more intensive assistance. We are pleased that our first national program to address adolescent depression and suicide has now been made available through MD-CME at Memorial University. This web-based educational program provides both MainPro and MainCert credits. 

We are also working with groups in Nova Scotia, Ontario and British Columbia to pilot and evaluate a novel integrative model that spans the continuum from mental health promotion to care in high schools. Time and lots more work with many partners will help us better understand what needs to be there and how to make it available. Until then, many thanks to SFU for taking this important step. Look forward to seeing the results roll in.

--Stan