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

Getting the message

One of my friends who has done some thoughtful analysis of media reports on mental health pointed out the Globe and Mail of January 14, 2012 had a piece tucked away at the top of page F4 called “From Evil to Mentally Ill in the Media”. I found the reading of it interesting, particularly in light of my last blog on the role of media in addressing mental health problems and stigmatization that media reports can create.

The reporter, Erin Anderssen, comments on a study conducted in Montreal in which around nine thousand Canadian media stories pertaining to mental illness and found that only 12 percent took an optimistic or positive tone. About one-third use derogatory language in referring to people with a mental illness and about 40 percent related mental illness to violence and criminality. Wow! 

Although I am disappointed to read that data, I am not surprised by it. Why should the media harbor less stigma than the population in general? Should we expect reporters to know more about mental illness and write about it from a base of some expertise? The Carter Center in the United States of America has some very interesting programs in mental health literacy designed to better inform and educate reporters, with the expressed hope that once this happens their reporting will be more accurate and less stigmatizing,  this includes the Rosalynn CarterFellowships for Mental Health Journalism. Perhaps we need a similar program here in Canada.

That same page in the Globe carried a thoughtful and constructively critical story written by Erin Anderssen about a young man named Michael Kimber who has taken his story public, and how that story is making a difference. 

In my opinion, we need more Michael Kimbers and we need more journalists like Erin Anderssen.

--Stan

Reading between the lines

So it’s another new year. And of course, as traditionally expected, I have made some new year’s resolutions. One which I considered was to resolve to make no resolution but that seems a bit peevish. I did make a couple related to this blog. One was to try and be more consistent with writing and another was to try and point out how careful we need to be when we read or hear things about mental health and young people. Careful so that we do not confuse fact with fiction and careful so that we can critically consider what others write or say.

Take for example one of my favorite news stories of 2011 on adolescent depression. You can find it here. It made the CBC – so that is a pretty reputable news source. What does the headline say: Music Linked to Adolescent Depression. And the story is that there was a study of depressed youth conducted in Pittsburgh that showed teens who listened to the most music where about 8 times more likely to be depressed than those who listened to the least amount of music. Wow! 

What does that tell us? Does it mean that music causes depression? Does it mean that teens who are depressed use music to treat their depression (remember the Biblical story of David playing music to treat the depression of King Saul)? Does it mean that teens who are depressed are too despondent or tired to engage in study, group or social activities or challenging physical pursuits? Is there some other factor at play? Did the researchers just ask a million questions and in their statistical analysis they found this relationship by chance (this is called data dredging)? Who knows?

Well, nobody knows. So why is this news story? You got me.

So what are the implications of this story? Could it be fodder for idle cocktail chatter? Will parents whose teenagers listen to music start wondering if their child is depressed? Will teens who read this scoff and dismiss the story and the idea of depression as “bulls**t”?

I do not know how news editors select news stories about adolescent mental health. Perhaps they use common sense. Perhaps they try to identify stories that have the potential to inform and educate. Perhaps they choose on the basis of emotions or sensationalism. Perhaps there are other reasons (I would think so).

Could there be negative consequences to stories chosen, or how those stories are portrayed?  One huge area of concern regarding this issue is the well known contagion effect of media stories about teen suicide. Let’s keep a critical eye on how stories about youth mental health are reported in the media this year. Perhaps we will all learn something.

Happy New Year

-Stan

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