Rebecca Marino: Courageous Young Woman, Confusing CBC Story

Yesterday, CBC National carried an interview with Rebecca Marino, a young woman who has recently announced that she will be stepping away from a promising tennis career because of the toll that living with a Depression has taken on her. Click here to see the interview.

Kudos to her for being open and honest about the challenges she has faced.  As she put it, “I don’t have the passion I used to have”.  Depression is tough - it takes a toll on energy, on concentration, on experiencing pleasure and on many parts of life.  For some people who are caught in the jaws of Depression, just getting up every day and getting a small task accomplished is a success. 

And, let’s not underestimate the incredible toll that training to become an elite athlete can take on young people.  It’s tough!  The commitment has to be total, the stakes are high and the price of failure is also high.  It takes dedication and determination of a quantity and quality that most of us could not summon.  Elite athletes are amazing people and to be successful they need to be mentally and physically healthy.

So what did the CBC news story say?  On the website the story byline is: “Canadian admits social media comments took a toll.”  And what did the interviewer ask about – cyber bullying!  And what did Rebecca Marion say: “there were a lot of negative tweets along with a lot of positive tweets”…”this has not impacted my choice”.

Indeed, she was very clear.  She said that “depression has impacted my life and my career.”  That is the story – Depression, a mental illness has made it difficult for her to continue her career – to the point that she has decided to step away from that choice.  What if she had suffered a severe tear to her rotator cuff and could no longer swing her racket?  Likely the same outcome!  What if she had suffered a complex, multiple fracture of her tibia and fibula, so that she could no longer move rapidly across the tennis court?  Likely the same outcome!  But she suffered a perturbation of brain functioning called Depression and the CBC wants to make the reason cyber-bullying?

Am I missing something here?  Or is the media missing something here?  Is the point of the story supporting a promising young athlete dealing with a potentially career ending injury or is the point of the story to sensationalize cyber-bullying?  If Marino had suffered a shoulder or leg injury would the story be about cyber-bullying?  I doubt it.  Why is then a story that should be about Depression has become one about cyber-bullying? 

This story makes me wonder about a couple of things.  Are we seeing stigma against mental illness at play here?  Are we seeing a substantial lack of mental health literacy in media personnel here?  Are we seeing an attempt to “sell the news” instead of “reporting the news” here?  I don’t know.

But let’s not throw out the baby with the bathwater.  The Toronto Star also did a story on this.   Here the story is more balanced, more nuanced, yet even here the headlines focus on “cyber-bullying”.

Did Marino experience negative social media comments?  For sure she did.  Is that different than other elite athlete’s experiences? Maybe not.  Did they take a toll on her?  Likely.  Would she have been able to roll with the punches if she did not also have Depression?  Maybe – Depression takes a huge toll on a person’s ability to deal with negative events and negative experiences.  It makes you more vulnerable and may interfere with your usual ability to adapt to the “slings and arrows of outrageous fortune.” 

So now we have a better insight of the complexities of the issue.  Its really not about cyber-bullying – it’s about Depression and how it interferes with a person’s ability to adapt.  This does not mean that we can condone such negative electronic interactions.  As a society we need to learn to deal with the huge negativities that Twitter and Facebook and other social networking tools can create – especially to vulnerable people.  But let’s not forget Depression.  As far as I can tell, Marino’s career ending injury was a Depression, not Twitter.

- Dr. Stan Kutcher

My Wish for the New Year: More understanding less sanctimonious self – interest when it comes to talking about mental health in the public domain

So my New Year’s wish is that for 2013, the public discourse addressing mental health and mental disorders are civil, based on best available evidence, welcoming of all and not driven by sanctimonious self-interest.

The year that was 2012 saw lots of the opposite, to the above wish.  Two issues that stand out for me were: the reporting of youth suicide in the mainstream media & the NRA statements on school shootings following the Sandy Hook tragedy.

First, the mainstream media and youth suicide perturbations: The Amanda Todd suicide became a lightning rod for concerns about the responsibilities of media reporting related to youth suicide.  The relationship between suicide contagion in young people and sensational media reporting is well recognized and although good & useful guidelines for reporting on youth suicide in the media are well known, many of Canada’s mainstream media ignored these in their rush to titillate disguised as reporting.  Even the Globe and Mail, usually a vehicle of some considerate reflection jumped on the bandwagon in an editorial crying that the push to sell the story (in their argument, their need to keep the public informed about each emotionally driving tragic details of what happened) trumped the evidence to help keep vulnerable youth safer. 

To my mind, the mainstream media has a responsibility to keep the public informed.  It also has a responsibility to keep the public informed responsibly.  Young people contemplating taking their own lives are ambivalent during the period of intense emotional crisis that accompanies this consideration.  While in this vulnerable position, they can be pushed to choose life or they can be pushed to choose death.  We have noticed a substantive co-relation between the recent rise in suicide rates (after a decline for over 20 years) and the amount of sensationalized print and electronic media reporting of this issue.  I wonder if this is causally related.  Selling newspapers or advertisements for the newest blender, skin care product or automobile is, to my mind, not a reason for increasing the risk for choosing death by suicide for young people.

Second, the NRA pronouncements following the Sandy Hook tragedy:  Not only did their initial suggestions (turning America’s schools into armed camps) defy logic and any semblance of civil social organization, but their idiotic (and there is no nicer word for that) statement that there should not be a registry of guns but a registry of those who live with a mental illness is so absurd and so stupid and so dangerous that it gives me cold chills.  Just what other kinds of registries should there be?  Immigrants, people of color, people whose shoe size is between 6 and 7.5, and so on? Lets just register all those who live with a mental illness (that would be about 70 million Americans) so we can watch them like a good Big Brother.   Lets just register everyone and give guns to those whom we like and call them the “good guys” (those are the words the NRA used) and lets just allow them to shoot all the “bad guys” (those that we do not like).  What a solution!  So, why stop at guns?  Why not give all the “good guys” personal nuclear bombs and turn schools into chemical war factories.  Then the “good guys” will really be much better able to defend themselves.  After all, why use a semi-automatic/automatic weapon that can only kill 30 people at a time when you can use a nuclear bomb and get rid of millions.  Responsible gun ownership is one thing, killing humans is quite another.

So, that is my New Year’s wish.  Wonder if it will come true?

-Stan

Connecticut Tragedy: A reasonable vehicle for addressing mental health needs in young people?

Recent media coverage, sensationalistic and omnipresent as it is (and, by the way – has anyone noticed the correlation between frequency of school shootings and this type of media coverage?) has raised numerous issues about the relationship between the tragic story in Connecticut and youth mental health.  Largely the story line has gone something like this: oh my gosh, this young man had a psychiatric diagnosis; his mental illness likely made him act this way; why can’t our society do a better job of identifying youth who are likely to have this kind of negative impact; we need to fix our mental health services.

Have we ever wondered where that kind of story line takes us?  Does it take us to a rational and evidence based understanding of mental health and mental disorders?  Does it take us to a place where we can logically develop mental health care that meets the needs of young people and their families?  Does it provide reliable information about what a mental illness is and how a mental illness may or may not lead to specific behaviors and outcomes? OR – does this kind of knee-jerk reporting maybe increase the stigma associated with mental illness, lead to inaccurate understanding of what a mental disorder is and how that relates to specific kinds of behaviors and in both the long and short run, do a disservice to all those who are living with a mental disorder, their families and those who work to help them get well and stay well?

We know that easily accessible, responsive and best quality mental health care is not readily available for most young people who need it. We know that most young people with mild to moderate or non-complex mental disorders can be appropriately and effectively treated in primary care (click here to check out the child and youth mental health components.) We also know that it is the tiny minority of young people with a mental disorder who require intensive and high acuity mental health care.  And, we know that is only a tiny minority of those who may have a mental disorder of the type that leads to the tragedy recently played out in Sandy Hook.  So why is this event even considered to be the poster child for mental health reform?

I think we need to have many adult conversations that this tragic incident forces us to consider.  The most obvious one is that of: how to best deal with the killing capacity of the final common pathway – automatic/semi-automatic weapons and handguns.  The Dunblane school shootings in Scotland led to popular protest that led to changes in gun related legislation that has been associated with a substantial decrease in deaths of young people from shootings.  This is a no-brainer – or maybe this is the problem.

We also need to fix the mess that is mental health services for young people – everywhere.  Just because we live in Canada does not mean that we are doing what needs to be done – on the contrary.  But we don’t need to have a tragedy to address this reality, we need commitment from all of us and political will.

-Stan

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