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

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

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

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

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

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

--Stan

Stigmas role on perpetuating the cycle

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

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

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

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

-Stan

What's next?

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

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

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

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

--Stan

It's time to focus on triumphs

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

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

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

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

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

-Stan

Preventing youth suicide: Doing the right thing or not?

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

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

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

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

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

--Stan

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