Stimulant medications and automaton kids: Sociobable or substantive concern?

It is fashionable in some domains of public discourse to denigrate psychostimulant medications and their therapeutic impact on young people living with ADHD.  In particular, it is not uncommon to find armchair philosophers, scientologists or even research naïve journalists happily spouting off about the way that psychostimulants turn young people into robots, take away their feelings and generally make them less than human.

These medications are, in the mouths of those espousing such opinions, at best dehumanizing and perhaps worse. 

They are supposed to take away the mind and the soul of those to whom they have been prescribed. They are supposed to make young people less authentic as individuals and are supposed to block their ability to make critical considerations about their ability to function, on or off the medications.  In short, they are a challenge to authenticity and damage moral agency.

An interesting aspect of this pontificating has been the strength by which these opinions are held, interestingly enough not supported by data addressing authenticity or moral agency. This certainly does not mean it is unimportant, only that it needs empirical evidence to either support or refute the opinion. This would therefore classify it as an informed opinion, not simply an opinion.

So, what does the data show us? Click here to view an interesting article recently published by the British Medical Journal. Interestingly, the author asked what young people’s experiences and considerations were. Further interesting, the conclusion states: “drawing on a study involving over 150 families in two countries, I show that children are able to report threats to authenticity related to stimulant drug treatments, but the majority of children are not concerned with such threats. On balance, children report that stimulant drugs improve their capacity for moral agency, and that they associate this capacity with an ability to meet normative expectations.” In other words, children treated with these medications appreciate their therapeutic value while at the same time preferring not to be taking them and not liking the side effects.

Wow. We would expect the same response from young people taking insulin or medications that treat heart problems or cancer. Interesting however, is the observation that armchair philosophers, scientologists, sociobabblers and others do not set their vitriolic sights on those other types of medication treatments. Maybe treatments for traditional “physical” conditions are okay, but treatments for traditional “mental” conditions are not. Maybe there is a gross misunderstanding that mental actually means brain and brains can get sick, just like the pancreas or the heart. We seem to miss out on the data, i.e. the facts that speak to this exact reasoning which can shed some light to the notion that the difference should not exist.

In my opinion, this is either a lack of knowledge writ large or a familiarity with knowledge submerged in prejudice.  It is hard to know which would be worse, but the stigma that this vitriol contributes to is real.

-Stan

Media reporting of youth suicide: What has happened to responsible reporting?

Once again the issue of media reporting of youth suicide has raised its head. Upsetting reports of a B.C. teenager’s suicide have flourished throughout the media. Details regarding the persons actions, method of suicide and other intense details have been revealed and given this teen a prolific profile in the media. The death has certainly taken the country by storm and opened public’s eyes to bullying and teenage suicide. But, some worry that these reports and continuous updates will affect youth in similar situations and could result in copy-cats.

Over the past week, I had the opportunity to touch on this subject where I discussed ways the media can report these tragedies responsibly and provide the public with useful information. Click here to view an article from the Chronicle Herald.

These sensational reports of youth suicide seem to be increasing throughout Canadian media. Evidence shows that this type of reporting is linked to increased rates of suicide, especially in young people. Some research data shows that there is a “dose response curve” with suicide rates increasing proportionally to the amount of media exposure. On the opposite side of the spectrum, data shows responsible reporting of suicide is associated with decreased rates of suicide in young people.  So why are vulnerable young people being exposed to sensational media stories about suicide? 

A study conducted in the USA found that many reporters were not aware of the degree of negative impact that sensationalized reporting of suicide had on young people.  However, it also showed that many of those did know or did not believe that to be the case.  Personal bias (or maybe some other factors) trumped the data.  I frankly, do not know which is worse, not knowing or knowing and not caring.

Responsible reporting includes, but is not limited to:

• Do not explain suicide stories, undue prominence and avoiding sensational headlines
• Do not provide details of the method
• Give a balanced description of the victim (do not create a model for those considering the same act)
• Do not publish photos of the deceased
• Do not romanticize or provide simplistic explanations (such as bullying being the causation of suicide)
• Provide information about depression and substance abuse - as important factors in youth suicide
• Provide information on where to get help and examples of positive outcomes for young people in similar circumstances 

Is following these guidelines too much to ask?

Teens are known to be substantially impacted by media. Youth who are struggling with suicide intent may be particularly vulnerable. Most young people who are planning to take their own life are not certain that they want to go through with the act.  So, what can tip the balance towards choosing life or death? There are many causes of suicide. Media influences are one of the tipping points, which could push the young person in one way or another.

I am not saying that the media should never report on suicide, just that the reporting needs to be done responsibly.  Most suicides never get reported, meaning there is a choice the media is exercising regarding on what suicides they will report and how they will report them. 

Can they not exercise this choice in a way that does not cause harm to vulnerable people?  The media does not have to compromise their right to let the public know about important issues and events, but they need to know that the matter, in which they choose, can be part of the solution or part of the problem.

I have heard some argue that the public’s right to know, trumps all.  This may or may not be the case all the time. Frankly, I wonder if those who make this argument have other factors at play. I have noticed how commonly people can wrap themselves in the cloak of public interest to cover up their self-interest. It is important to have this conversation, but can we not have it in a positive and constructive manner? When it comes to reporting on suicide, the media has the power to provide useful information and hope, instead of a recipe for death.

-Stan

Below are some resources and associations who have worked to underscore scientific evidence on the negative impact of sensational reporting of suicide to urge the media to report on these issues responsibly.

• Canadian Psychiatric Association
• World Head Organization
• National Institute of Mental Health
• Media Contagion and Suicide Among Young People 
• Media contagion and Suicide Among the Youth, American Behavioral Scientist, May 2003, vol. 46, no. 9, 1269-1284
• American Association to Suicidology
• American Foundation for Suicide Prevention
• Annenberg Public Policy Center
• Office of Surgeon General of the USA
• Centers for Disease Control
• Substance Abuse and Mental Health Services Administration

ADHD Medications: Real concern or media hysteria?

Recently, sensationalized reports of health problems associated with the use of some medications used to treat ADHD have appeared in the media.  Check out some of the stories here:

The Spec

Digital Journal

Metro News

It can be frightening to read about incidents of severe adverse effects to medication, but it's important to keep a critical perspective when reading about these sensational stories.

Do medical treatments have risks?  Absolutely!  Every treatment does.  What must happen when a treatment is prescribed is that the patient, parent and health provider must agree that the benefit is likely to be greater than the risk.  For some treatments, risks can range from mild to severe, or either common or uncommon.  For example, the risk of a heart attack may be 1/10,000 as a side effect of that medication, while the risk of a stomach ache may be 1/100 or a headache 1/10.  Compare that to the risk of dying by being struck by lightning (1/79,700), dying in a bicycle accident (1/5,000) or dying in a car accident (1/84).Check out the annual risk of death during one's lifetime.

Determining whether the benefit is greater than the risk is the key issue to almost everything we do.  Indeed, this is part of the government’s assessment of regulated treatments, such as medications (through institutions such as Health Canada), whether they be deemed safe and therefore available as self-selection products (such as over-the-counter medications and natural health products) or deemed to require the opinion of a “learned intermediary” (such as a licensed prescriber) to support their necessary and judicious use. It’s the latter group of prescription medications that carry more risk, but are still considered potentially helpful when used by the right person.  

In order for the patient and parent to be properly informed, they need good and valid information to be able to make a decision about accepting the treatment recommendation or not. Many of the adverse effects reported recently in the media may not be caused by ADHD medication. That’s the difference between correlation and proven cause and the only evidence that’s able to tell us if the medication is causing the adverse effect is solid scientific research. This can be a problem. Sometimes the right information is hard to find. The information can be confusing or even contradictory. There tend to be a lot of misinformation or even disinformation out there. Sometimes the health provider does not give you the information needed.  So what is the patient or parent to do?

It’s essential that all legitimate health providers use the best evidence available to suggest treatments to patients. Patients however need to have a high degree of comfort that what is being suggested is driven by credible evidence, not anecdote, conjecture or simple association. And, they need transparent, clear information.  It can be difficult getting that information and it can be hard ensuring that your health provider is giving you what’s needed. You may require additional help in getting all the information you need.

This is why I suggest young people and parents use guides and health related tools to help them in interacting with health providers.  It’s important to know what questions to ask to help ensure that they get the best possible care.  We have created a number of useful aids for youth and parents. They fall under the rather boring heading of “Evidence Based Medicine”. Boring name, but crucial stuff to countering sensational and uncritical assertions and inferences. It may be a good idea to use them in order to ensure that you get the information needed to make better judgments about the potential risks and potential benefits of any treatment! Click here to view an outline on what you should ask health care providers. 

Another good resource is a mental health medications guide and treatment tracking booklet, called Med-Ed. It was specifically developed to support patients, parents and health providers do a better job in choosing and monitoring medication treatments – checking on their risks and benefits carefully and consistently. The tool promotes something very important - open, clear communications about the benefits and risks of medication treatment between the patient and their prescriber. 

Oh yes – one other thing.  The media stories suggest that regulatory agencies are not doing a good enough job to monitor possible adverse outcomes of regulated treatments. I, for one, would agree, and so do many others who’ve examined Canada’s systems and regulations for assuring that only acceptably safe medications are available to Canadians.  I think that we need to have a properly functioning national adverse events surveillance system and we need to have a solid feedback loop to the regulatory mechanism to make sure we have the ability to better determine risks and benefits of treatments in the long term.

The reports in media may not turn out to be scientifically valid in the long term, but perhaps they will generate some positive benefits if patients begin to ask their health provider some hard questions – not just about their ADHD medications, but about all the treatments that they’re getting. This would be in the best interest for the health of all Canadians.

-Stan

Supporting a friend with mental illness

Some of the most common concerns teen patients have when discussing going back to school and reconnecting with their friends are often surrounded around their social relationships. Things such as, what will my friends think? What will my friends say? What will my friends do?

In our clinical service, we spend a lot of time helping young people determine the best way to mention their living with a mental illness to their friends, teachers and other social networks. As much as we try to help, the transition can sometimes not go as smooth as planned. Sometimes friends won’t fully understand.

One thing that we often tend to not pay enough attention to is helping people understand what they can do to be supportive. It now occurs to me that some of the people we complained about not being helpful and supportive may actually have wanted to be, but didn’t know how. 

Maybe it wasn't always the friends avoidance or apprehensive behaviour that was the result of stigma. Maybe some of that could be been due to awkwardness and not knowing what to say or do – something like what happens when you go to a funeral.  You know, what do you say to someone who has just lost a parent?  It’s never easy.

So, maybe it’s the same thing when supporting a friend who has a mental illness.  What do you say? What should you do?  It’s not always easy.

The recent edition of Moods Magazine has an article that can help people who have a friend living with a mental disorder.  It’s called, “Ten ways you can support a friend with a mental illness”.  For example, here’s the list of ten – in the order they appear in the article, not necessarily in order of importance.

1. Get in touch with your friends
2. Understand that its not your fault, in fact it’s no one’s fault
3. Don’t task yourself with changing your friend
4. Listen, listen, listen!
5. Get our of the house
6. Put yourself first
7. Be positive
8. Be a resource
9. Be respectful
10. A list of web resources is provided in the article

So there you have it.  A few practical and helpful hints on how you can help be more supportive to your friend or loved ones.  Give them a try and create some of your own.

-Stan

Mental health and back to school

Over the past week, I've had conversations with people who have this idea that upon a young person’s return to school, it can cause mental health problems – due to the increase in stress. We've seen this scenario discussed in the paper, in the news and on the radio this past month. Friends have told me that some schools are getting ready to deal with a “tsunami” of counseling needs when students return.  

A parent recently raised (to me) the implausible specter of creating a support group for junior high students to help them go back to school successfully. If Chicken Little were around, she would say that going back to school is causing the sky to fall.

Why is it that we’re beginning to think like this? Like there is this need to make normal like, pathological. Why are we beginning to merge positive stress (leads to improved performance and positive adaptation) with negative stress (leads to poor outcomes and leads to non-adaptation)? Why is it that we seem to continue to think that everyday stress leads to mental illness?

Is going back to school a stressor for young people? Of course it is, but so is getting up in the morning!  This does not mean that going back to school is a bad thing or something that will lead to a disaster.  What happened to the view that going back to school was a positive thing? For most young people, school is an exciting step in the journey of life.  Going back to school should cause anticipation, enjoyment and be fun – even in the presence of some “butterflies”.

The reality is that going back to school is a regular and expected part of normal life. The anxieties that most young people feel are appropriate and signaling that adaptation will need to happen.  And most already know exactly how to adapt –buy some new books and pencils, get a new school bag, link up with their friends, ride their bikes to the school yard and have a look.

Sure, there will be some who will have difficulty with that transition. Either because they may have a mental disorder or because the transition is greater than their adaptive capacity, they may struggle. Schools need to prepare for these students, while at the same time – not buy into the hype that the usual positive stress of going back to school can cause mental health problems.

So here we have it – going back to school is something that most look forward to. As parents and educators, we need to take a deep breath and stop focusing on the negative and start focusing on the positive. Don’t put your head in the sand because their will always be some young people who need help - but don’t make a mountain out of a molehill. Let’s stop this tendency to create pathology out of normal, everyday experience.  We help our youth become resilient by facing and successfully adapting to life stresses - not by seeking to protect them from it.

-Stan

Depression in young people can lead to early death

While we have know for many years about the varied negative impacts that clinical Depression can have on the lives of young people (including its negative long term impacts on personal, social and economic outcomes and increased risk for suicide), some new research is showing that it may also shorten life – specifically by increasing the risk of dying earlier from physical illnesses.  In a recent study published in the Annals of Epidemiology (July 26, 2012) both males and females who had experienced an episode of Depression in their youth had much higher rates of early death from physical causes than those who had not.  Death due to heart disease was mostly to blame!

Unfortunately, I could not determine from the study if this included young people who had been successfully treated for their illness or not.  This of course is an important issue, as early and successful treatment of Depression may change the long-term outcomes for those who have experienced it.  It will be good to know if this also applies to early death from heart disease.

In any case, this information is very important to have.  For too long we have thought that the brain and the body are separate.  They are clearly are not!  The brain has a substantial and ongoing impact on all aspects of body function and vice versa.  The old Latin saying “mens sana in corpore sano” holds. Meaning "healthy mind in a healthy body" (or something like that - its been over 45 years since I took Latin in high school and was not so good at it then). Check it out the full meaning here.

So, let’s do whatever we can to help our brains get healthy and stay healthy.  That means eating properly, exercising vigorously and getting enough sleep.  It means moderate and parsimonious use of alcohol and avoiding substances that can cause brain damage.  It means taking the appropriate precautions to help decrease the risk of head injury.

If we do all that, can we be sure that Depression will not darken our doorstep?  Unfortunately not, but if Depression happens we need to make sure we recognize it early and get the best evidence supported help that we can, as soon as we can.  Overall, not dying early from having a heart attack is a good thing, don’t you think?

--Stan

Exercise as a treatment for Depression: Hot idea or hot air?

It is very fashionable to include exercise as a complementary treatment in Depression.  In fact there are many studies that show that exercise has positive impacts on the brain.  And, in such as way as to possibly help improve depressive symptoms.  In addition, there are lots of studies that show a positive effect of exercise on depressive symptoms and even some systematic reviews that suggest exercise is a good addition to the usual treatment of Depression.  So there we have it – or do we?

A recent excellent research study reported in the British Medical Journal (2012: June 6) suggests that some of our enthusiasm may have been a bit over-extended.

This was a randomized controlled trial in over 350 adults with depression treated in primary care in the UK.  Everyone got the usual care but half received additional exercise coaching to encourage exercise in addition to their usual care.  The exercise group did show much more exercise (that is a good thing) than the treatment as usual group.  However there was no difference in any outcome measure of depression or its treatment over a period of one year!  Ouch!

Now, what does this mean?  Well, like any study this one was not perfect and the participants in the exercise group did not all achieve the recommended 150 minutes of vigorous exercise per week (at 30 minute per day aliquots).  So there may be been a dosing problem – not enough of a dose of exercise.  Or it may mean that exercise may be helpful for mild depressive symptoms – for psychological distress, but not for clinical depression.  Or, it may mean that the model used (an exercise coaching model) is not the best one by which to help people with Depression get the exercise that they need to help them get better faster or to a greater extent.  Or it may mean other things, too many to list.

So, does this mean we should not exercise to help us feel better?  Totally not!  Does this support using exercise as an alternative treatment for best evidence based care for Depression?  Totally not!  Should we keep suggesting patients exercise?  Totally yes – there are lots of other health benefits to exercise as we know.  Should we engage in more systematic study of this before we write the final chapter?  For sure we should!.

Oh well.  Enough reading about research and writing a blog.  I am off to walk quickly for 30 minutes followed by a nice relaxing summer drink.  It’s hot outside!

-- Stan