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