Head injury: Dealing with an important mental health concern in youth

Recently, the Globe and Mail reported that the Province of Ontario had decided to introduce legislation that would require schools to instate head injury prevention and management programs across the province. Read the article here.

In my opinion, this is a welcome and innovative direction for Ontario’s education system. Laurel Broten, Ontario’s Minister of Education, deserves high praise for this step forward.

Head injuries (or concussions) are a significant mental health problem in young people. While most are sports related, concussions can be the result of a car accident, a fall, foul play or other recreational activity. The fact is they can happen almost anywhere.

Concussions can range from mild to severe, depending on the strength of the impact and where the hit occurred. A little known fact is that with today’s technology and research, helmets do a good job preventing brain injuries. Although, just because your wearing a helmet, doesn’t mean your invincible.

There are some other facts that we should all become more aware of.  First off, teenagers who suffer a concussion may take longer to recover than adults do. Second, many teenagers who suffer a concussion return to play before they’re actually ready, which can increase the chances of worsening the damage to the brain. Third, depression can be the result of a concussion. Fourth, because the teenage brain is in a rapid and important phase of growth, damage at this time can cause long term problems. Lastly, treatment is very helpful, but teens need to understand it takes time. Be sure you’re cleared by a medical professional before returning to play.

The first step to effectively addressing this problem is awareness.  Our team at the Sun Life Financial Chair in Adolescent Mental Health will soon be launching two brain injury guides across Canada. Brain Injury Guide for Youth is written with the assistance of the Chair’s Youth Advisory Committee. This guide provides teens with the best available information about concussions, how to try and prevent them, what to do if they occur and how they can be helped if they receive one. Understanding Brain Injury in Adolescence is written for parents, coaches, teachers or any other adult working with youth. This guide helps the reader understand what a concussion is, what its signs and symptoms are, what needs to be done to help prevent concussions, what must be done if a concussion is suspected and what should be done if a young person sustains a traumatic brain injury. Together these guides will help create awareness, while educating youth and the people who care about them.

Keep an eye on our website TeenMentalHealth.org for future information.

- Stan

What causes or prevents mental disorders?

There is so much confusion about what the causes of mental disorders are and what prevents mental disorders.  There is so much confusion about what the concept of “risk factors” means and  what the concept of “protective factors” means.  And for many years, some of the research in these areas has been contributing to this confusion.

One of the most commonly held confusions is that about what causes or prevents depression.  In my opinion, there is probably more nonsense written about those issues than about almost anything else pertaining to mental health and mental illness – except maybe for medications used to treat mental illness. 

Much of this confusion comes from or is related to our very simplistic models of causality – that is, our thinking about what causes what.  We often think of causality as linear – so that something that comes before the event (or diagnosis) is considered to cause that event (or diagnosis).  As we know in our frontal lobes, this kind of linear model is rare.  Mostly causality is multi-factoral and sometimes the most substantive “causal” factors are not readily apparent.  So people get lazy in their thinking and go into brain default mode – choosing to assume that what comes first causes what happens after.  This of course is using our limbic systems as explanation.  Not a good way to be less wrong most of the time.

Depression does not arise in one day.  It takes a long time between when the illness begins and a diagnosis is made.  If you (as most researchers to date have done) look at events preceding the diagnosis of depression you will get a very skewed and biased idea of what may have “caused” the depression.  As a person is getting depressed, they may create events that are due to the depression and not the other way around.  Lazy thinkers then make a completely incorrect causal inference.  They could not be more wrong!

Enter some hard thinking researchers.  They decided to investigate the link between religion and depression.  Many who did earlier cross-section studies found that depressed people went to church less often than those who were not depressed.  So what did they conclude: that being religious prevented depression!  Ouch – and this idea has been around for so long that many people thought it was true!

So here is the new lens.  It’s a prospective study (so not a cross-sectional analysis) that followed people over time led by Dr. Joanna Maselko of Duke University and published in the American Journal of Epidemiology in February 2012: http://bit.ly/AmDqcl. 

And what did they find?  They found that contrary to current mythology, religion does not prevent depression!  What they found is that as people became depressed, they stopped going to church!  Social withdrawal was a result of the depression, not the other way around. 

So, is addressing spirituality for people a waste of time?  Likely not.  Will that prevent depression – no. 

What should we learn from this information?  We need to stop thinking about causality in linear fashion and we need to start doing research that can give us answers to questions in a best evidence way – not jumping to conclusions that reinforce our biases.  Isn’t science grand?  It’s the only system that we have that is independent of our ideologies.  We need to use it more – for everything.   

-Stan

Informing Canadians about mental health: The media has a lot to answer for

Trying to understand how the Canadian media addresses mental health has been a concern of mine for many years now.  Many of my concerns have been about the negative perspectives of that those who live with mental illness that to me seemed over-represented in the pages and airwaves across Canada.   Another huge concern is how treatment for those with mental disorders is portrayed – particularly the use of medications. 

In most media reports addressing the use of medications, what is portrayed is the need to ensure that those who have various illnesses have access to the best care possible – including medicines.  The opposite seems to be true for mental disorders.  Here, highly effective medications for mental disorders are mostly painted by a negative brush.  If you have cancer and you don’t have access to a medicine that may have a minor positive impact of marginally increasing your life-span you are seen as a victim.  If you get terrible side effects, that is seen as an inconvenience. 

Comparatively, if you happen to have ADHD and medications may have a huge positive impact  on all aspects of your life, you are criticized for taking it and minor side effects are portrayed as horrific and terrifying.

There is some good Canadian data demonstrating that media in this country depict mental illness in a very negative light.  The National Post actually reported on this information – good for them.  You can find the information here.

Rob Whitley of McGill University provided the information based on his seminal work on addressing media bias in the  portrayal of mental illness.  Over a third of media reports portrayed violence and dangerousness related to mental illness.  Only about a sixth dealt with recovery or rehabilitation. 

It is interesting that the Harper Government is now committed to building more jails and not in addressing some of the obvious antecedents to crime.  As we well know, up to 60 percent or more of those in jails have mental disorders that are known to be associated with their involvement in crime.  Are our national policymakers getting their information from the media about understanding mental disorders?  Is this driving the building of jails agenda?  Does the Harper Government want to jail those with mental disorders instead of providing care?

As for me, I do not know the answers to those questions.  What I do know is that we need to make sure that this changes.  The stigma against those living with mental disorders and the stigma against not providing most effective treatment for mental illnesses has to stop.  The Carter Center in the USA has special programs for journalists.  Should we do the same here in Canada?  Why not?

-Stan

How can some people be so far out of touch?

Psychiatric diagnoses have always been difficult to develop and to implement.  Primarily this is because as of yet (though things may be changing soon) we have not had robust independent biomarkers to help us validate them.  For example: in the diagnosis of chest pain, a doctor can use an EKG and blood tests to help determine if the patient’s symptoms are more likely to be caused by a heart attack or not.   

While psychiatric diagnoses are built on some good validation criteria for the most part, some are less well buttressed with this evidence than others, and for some, opinion, economics or social influences have quite a measure of impact.

 For example, a recent story in the National Post indicated that some physicians in Alberta were still making a psychiatric diagnosis of homosexuality. Not only does this not make any sense (homosexuality is not a psychiatric diagnosis), but it is offensive and simply wrong-headed.

Frankly, I could not follow the article, and did not understand what the reporter was trying to say – was the problem due to a billing code or was a doctor(s) using that as a diagnostic code (which makes no sense as neither the current ICD-10 nor the DSM diagnostic criteria contain that as a diagnosis)?  Or is Alberta simply so far behind that it is using a medical diagnostic system that is over 25 years out of date?

Whatever the real story here, it is time that psychiatric diagnoses were demanded by the profession and public alike to be more based on the best available science than on opinion, insurance payments or public pressure.  My goodness, if one of the current candidates wins the GOP nomination in the USA who knows what silliness will make its way into diagnostic codes.

--Stan

The elephant in the room: Mental disorder or mental health problem?

Let’s be honest about it.  Sometimes it is difficult to determine where the boundary between a mental health problem and a mental disorder can be.  A mental health problem is a signal that a person is having substantial difficulties coping and is suffering a number of difficulties in their feelings, their thinking and even in their behavior.  Usually the person is also having some problems functioning in their daily lives – at work or at school for instance.  A person with a mental health problem will often sort things out with help from friends or confidants or when the stressors that are overwhelming them pass.  Sometimes, help from a counselor or another health provider is helpful.  A disorder is more substantive and usually signals that the person needs professional help – treatment to recover.

In the absence of independent biological markers (such as blood sugar levels for diabetes or the electrocardiogram tracings for heart attacks), psychiatric medicine has to rely on signs and symptoms and statistical methods to define disorders.  This can leave some grey areas – perhaps more than we would like. 

How to deal with these grey areas?  One school of thought – exemplified perhaps by Dr. John Oldham, President of the American Psychiatric Association (APA) chooses to extend the boundaries of the diagnosis of disease, to include people with mental health problems – the so called false positives.  In order to ensure that those people who need treatment can receive it.  Others, me included, think that a more narrow definition of disease is warranted, so that we do not make normal life equal pathology.  And, we argue that people with mental health problems are deserving of intervention but perhaps they don’t need treatment from doctors.

One area in which this debate is very heated is in the upcoming plans of the APA to consider normal bereavement as a mental disorder.  To me this is just plain nonsense.  Any idiot can understand that the loss of a close and intimate relationship leads to depressive like symptoms and that this is not the same thing as depression.  There is no need to make usual life a psychiatric diagnosis.  There is no need for medical doctors to “treat” normal bereavement.  Unless of course there is insurance money involved!  I wonder, is that the elephant in the room?

-Stan

The right care when you need it!

Yesterday, there was a story on CTV News a story of a young man who has been battling substance misuse, ADHD and depression for some time.  According to the news story, he had recently decided to try and turn his life around and with the support of his mother had been admitted to the Children’s Hospital for an inpatient treatment stay.  According to the story, he did well in hospital and was discharged with recommendations to continue treatments in the community, including substance abuse care.  Guess what?  You guessed it!  Not available!

So here we have yet another potential tragedy unfolding.  On the face of it (and I am aware that I do not have all the details or facts of the story), here is a young man who has realized that he needs care, first steps that care have been provided, but now when he needs a period of long-term assistance that assistance is not available.  So what is the likely outcome?

Well, maybe the best will be a revolving door scenario.  In this, he will be in and out of hospitals and emergency rooms, dealing with crisis situations and not getting the continuous best care he needs.  The worst case scenario may be premature death by suicide.  Look at the risk factors that were identified in the news story – a young male with a mental disorder (inadequately treated), substance abuse and a history of involvement in the juvenile justice system.  I for one, hope that this worst case scenario will never occur..

And what is the solution?  Part of the solution is to make sure that the mental health care services that young people need are available to them when they need them.  If this young man had fragile diabetes or a heart condition that required continuous care would there be no room in the health care inn?  I doubt it.  This young man however has a mental disorder – and for people with a mental illness it is ok not to have room in the inn.

Let’s call it what it is.  Not stigma but discrimination.

--Stan

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