Preventing Tragic Outcomes Starts with Us

There was a tragic story in the Halifax newspaper, the Chronicle Herald this week. The story was both new and unfortunately very old at the same time. The gist of the story was that a young man who had killed a woman a number of months ago was found not criminally responsible because, as the story states: “the teen was psychotic when he killed a woman in February”.

Although there are few details of what happened in the paper, it seems as if the young man had been experiencing psychotic symptoms for some time prior to the event. Apparently, “his family had been trying to get him psychiatric help”.

What a shame. How tragic. How sad. How ironic, that Nova Scotia has one of the nation’s best first onset psychosis programs. What happened? What is the back story?

The Province of Nova Scotia spends about 3.5% of its annually recurring health care budget on mental health, and a fraction of that on child and youth mental health services. This is in spite of the knowledge that about 3/4th of all mental disorders arise prior to the age of 25 years and increasing realization that early intervention and effective treatment may prevent substantial long and short term negative outcomes and yes, maybe in this case would have prevented such a tragic outcome.

I for one am getting sick and tired of reading these stories and writing these blogs. I have decided to run for federal office in Halifax in part to make mental health a national health agenda item. This tragic case should not have happened. Why is it taking so long to do so little that can help so many so much?

--Stan

Show Me the Evidence

So I was just reading an interesting piece called “Protecting Teens in Crisis: Constructive Oversight of Programs”, in which a number of significant concerns were raised about what is called the “struggling teen industry”. Put bluntly, it seems that there are a number of institutions (mostly in the USA as far as I can tell) that may be or may have been involved in a number of non-therapeutic or perhaps even abusive practices, all in the name of “therapy” or “treatment”. Indeed one of the phrases used in the piece was “stories of mistreatment, abuse and even death…”

Wow. Shocking.

An American professor is quoted as saying that these concerns need to be addressed using state regulations and licensing. This makes sense for sure. I am personally astonished that such a regulatory framework is not apparently in place. How could “treatment” settings operate without oversight and standards of care?

However, this is not enough. Not by a long shot. Reading about some of what passed as “treatment” makes me shudder. It sounds brutal and harmful, not therapeutic and helpful. So, where do people who offer these “treatments” (whatever they are) dream them up? Who has studied these so called “treatments” and what have they found? Are these interventions helpful? Are they useful? Do they work? Are they safe?

In short, what is the scientific evidence for the so called treatments being used? And here, let me be very clear. We need strong, hard scientific evidence. This not the same thing as “best” evidence. “Best” evidence can be what someone thinks is a good idea shared with some other people who think it’s a good idea. It may even be a well-intentioned idea. But, the road to hell is paved with good intentions (as the saying goes).

So – bottom line. Show me the evidence.

--Stan

Should we fix child and youth mental health first?

The Province of Nova Scotia spends about 3.8 percent of its health care budget on mental health services. Well below the minimum recommended by the World Health Organization. A small proportion of this goes to child and youth mental health. As the week long series in the Chronicle Herald (March 8 to March 12) pointed out – the entire provincial mental health system is very broken. In my opinion, we have to tear it down and start again. If we had a blank slate there is no way that we would build a mental health system in the way we currently have it.

So, where do we start. Tearing and building will take a bit of creative thought and a bit of time, not to mention some very difficult slogging to move out of current rigidities and the control of vested interests. 

What should we do now?

Most mental disorders begin before age 25 years. Most of these are life-long. Most of these respond quite well to the evidence based treatments that we have. Early intervention with effective care has the potential to decrease short term morbidity and improve long term outcomes. The most effective way to decrease suicide rates is to identify and treat mental disorders. And the list goes on and on.

Yet we persist in back end investment. Lets stop this foolishness now. Of course we need to provide better care and services for post-youth and vulnerable populations (such as refugees, first nations, the economically and socially disadvantaged, etc), but we need to really ramp up our investment at the front end. So while we work on transforming the entire system we should immediately increase our investment in providing the best evidence based care with the best human resources we can allocate to children, youth and their families. And we should do it now!

--Stan

Let’s make everyone feel good and ignore those who need help!

I am sitting in the comfort of a rustling train as it bumpingly floats its way through the winter-white Nova Scotia countryside, heading back home after four days of work in a rural part of a neighbouring province.

I am reading yesterday's Globe and Mail. The lead editorial headlines: “Those who read well at 15 succeed”. And, the story is about a Canadian study reported by the OECD that young people who can read well at age 15 tend to do well in life and that young people who can not, do not. It also reports the truly amazing finding (here I am being facetious) that those youth who study do better than those who do not!

What insights! What revelations! What a surprise! Teenagers who read well and study hard do well? This is news?

Well, the news here is that reading ability is a good proxy measure for many problems. We have known for a long time that the inability to read at grade level in grade three is predictive of poor educational, social and vocational outcomes. Seems that is also the case at age 15. Reading is a complex skill. Reading difficulties can be the result of psychosocial adversity, mental disorder, learning disability, or combinations of many factors. Whatever the reason, reading ability is a “marker” that can be used to identify young people who may need help in sorting out what the problem is and then they can be given personal assistance in addressing the problem so that they can become successful.

So why are we not doing this? Why are we not assessing reading levels in grade three and at age 15 in every single school in this country and using that assessment to identify young people and develop personal interventions that can help them be as good as they can be? Why are we wasting large amounts of money on building self-esteem and other similar programs when the issue is not self-esteem? Why are so hesitant to put our money and our efforts into those areas that are likely to bring the best results, particularly for those who need it?

From what I have seen, one reason may be that it is difficult and costly to provide the assessment and intervention services that young people who are having difficulty need. So it is easier and perhaps cheaper to provide programs for the many that do very little, than interventions for the minority that may do a lot.

There is also a highly discriminatory ideology at play – not manifest but latent. We do not want to “label” those who need help so we do not identify them and we do not provide them with what they need for success. You see, “labeling” would hurt their self-esteem and would thus be unfair. Instead we shunt them aside in favour of “helping” everyone (including mostly those who do not need any extra help). This of course is more “fair” to those who need help as it denies them what they really need and sets them solidly on the road to poor outcomes. “Oh well, at least they were not labeled and their self-esteem did not suffer as a result”.

Is this fair? Is this the right thing to do? Not in my book.

--Stan

Anxiety: Flight or Fight?

Today I was teaching in a primary health care workshop.  Helping a variety of health care providers become comfortable with mental health competencies that could be used by family doctors, nurse practitioners, nurses, social workers and other to provide mental health care to those that need it.

During the discussion about anxiety, we chatted about the way that anxiety makes us feel.  Many of the examples that people gave included the phenomenon of withdrawal, that is, avoidance of the situations in which we feel anxious.  That is surely true, and is one way that anxiety causes great difficulty for people.  This is one way in which anxiety leads to what we call functional impairment: the inability to do what you want or need to do because of the mental disorder.

But, there is another way that anxiety shows itself.  That is through aggression.  Yes, sometimes anxiety can lead to lashing out at others.  Have you ever been worried about someone who is late for dinner or late in meeting you at a movie?  What about the parent who is worried about where their child is late at night when it is an hour past the time that they were supposed to be home?  What often happens when your friend shows up or the child slinks into the house?

Right.  You got it.  Instead of being hugging and warm it is often the opposite that occurs.  You get angry and act annoyed.  The parent yells at their child.  Yelling is verbal aggression.  The anxiety has resulted not in avoidance but in attack!

That this happens should not be a surprise.  Remember that anxiety leads to the fight or flight response.  Avoidance is part of the flight and anger is part of the flight.  Yet another way that anxiety can make lives more difficult for people.

We often forget how much of a problem overwhelming anxiety can be.  Panic attacks, social anxiety, generalized anxiety and obsessive compulsive disorder all have the potential to be quite disabling.  They can also all be treated and both avoidant behavior and attacking behaviors can be controlled.  In the next couple of months we will be posting a lot of new information on this website, much of it about anxiety.  Stay tuned!

Whatever Were They Thinking?

FINALLY, the Lancet (one of the world’s top medical journals) has retracted their publication of one of the most misleading articles in the history of modern medical science – the now totally discredited piece on the relationship between autism and the MMR vaccine. 

What took them so long? It seems that the Lancet editors where the last in the world to know that the article was basic bunkum. And why did they even print it?

If you can find me another article that uses the same low level of scientific evidence and flawed thinking that the Lancet has published in the last decade as this one used I will buy you a chocolate cookie. (Only one cookie per customer, just in case). I for one have no idea about what the answer to either of those questions is. But the fallout has been substantial. It seems that large numbers of children died because they were not vaccinated. And to what end? Because a researcher (who it seems was in the employ of lawyers making lots of money suing vaccine manufacturers) published such poor science and because a learned journal did the publishing?

So what is a possible lesson here? Although there are many, one most certainly is that one swallow does not a summer make. That is, scientific knowledge is not built on one study, but on many, conducted by different and independent investigators, using best methods and techniques and scrutinized by peer review. Is there the possibility that some studies will show one thing and others will show another? For sure. Science is nasty, brutish and long. Remember the word attributed to Mark Twain: “be careful reading a medical text book. You may die of misprint”

--Stan

How about a mental health day!

So it was late afternoon and I was chatting with some of my young, active and thoughtful research team members. And guess what came up? We need a mental health break during the “dog days” of winter. 

The more I thought about it, the more I liked it.

We know that the winter blues are very common at northern latitudes – such as all of Canada. We know that there is a mental disorder, called Seasonal Affective Disorder that is linked to the relative lack of sunlight during our winter months. We know how long that stretch of going to work when it is dark and going home when it is dark is – especially between Christmas and the first holidays in the spring. Apparently there is even some anecdotal evidence that work and school problems peak in February. And, we know how important a good down day – preferably one in which we can go exercise outside in the sunshine- is for our mental health.

So here is my proposal (actually it is the proposal of Jess Wishart and Christina Biluk), but I am putting forward as mine. Let’s have a national holiday in early February. Lets call it mental health day. Why not? We can just prorogue for a while. I bet that it will be good for all of us. And the researchers can study to see if the two weeks after the day show less work and school stress than the two weeks before the day. Or they could do a controlled trial – one part of the country with the day off and the other part without. Hah. Maybe we should just take the day off!