I am sitting in the comfort of a rustling train as it bumpingly floats its way through the winter-white Nova Scotia countryside,  heading back home after four days of work in a rural part of a neighbouring province.

I am reading yesterday’s Globe and Mail.  The lead editorial headlines: “Those who read well at 15 succeed”.  And, the story is about a Canadian study reported by the OECD that young people who can read well at age 15 tend to do well in life and that young people who can not, do not.  It also reports the truly amazing finding (here I am being fascitious) that those youth who study do better than those who do not!

What insights! What revelations! What a surprise!  Teenagers who read well and study hard do well?  This is news?

Well, the news here is that reading ability is a good proxy measure for many problems.  We have known for a long time that the inability to read at grade level in grade three is predicitive of poor educational, social and vocational outcomes.  Seems that is also the case at age 15.  Reading is a complex skill.  Reading difficulties can be the result of psychosocial adversity, mental disorder, learning disability, or combinations of many factors.  Whatever the reason, reading ability is a “marker” that can be used to identify young people who may need help in sorting out what the problem is and then they can be given  personal assistance in addressing the problem so that they can become successsful.

So why are we not doing this?  Why are we not assessing reading levels in grade three and at age 15 in every single school in this country and using that assessment to identify young people and develop personal interventions that can help them be as good as they can be?  Why are we wasting large amounts of money on building self-esteem and other similar programs when the issue is not self-esteem?  Why are so hesitant to put our money and our efforts into those areas that are likely to bring the best results, particulary for those who need it?

From what I have seen, one reason may be that it is difficult and costly to provide the assessment and intervention services that young people who are having difficulty need.  So it is easier and perhaps cheaper to provide programs for the many that do very little, than interventions for the minority that may do a lot.

There is also a highly discriminatory ideology at play – not manifest but latent.  We do not want to “label” those who need help so we do not identify them and we do not provide them with what they need for success.  You see, “labelling” would hurt their self-esteem and would thus be unfair.  Instead we shunt them aside in favour of “helping” everyone (including mostly those who do not need any extra help).  This of course is more “fair” to those who need help as it denies them what they really need and sets them solidly on the road to poor outcomes. “Oh well, at least they were not labeled and their self-esteem did not suffer as a result”.

Is this fair?   Is this the right thing to do?  Not in my book.

–Stan

Today I was teaching in a primary health care workshop.  Helping a variety of health care providers become comfortable with mental health competencies that could be used by family doctors, nurse practitioners, nurses, social workers and other to provide mental health care to those that need it.

During the discussion about anxiety, we chatted about the way that anxiety makes us feel.  Many of the examples that people gave included the phenomenon of withdrawal, that is, avoidance of the situations in which we feel anxious.  That is surely true, and is one way that anxiety causes great difficulty for people.  This is one way in which anxiety leads to what we call functional impairment: the inability to do what you want or need to do because of the mental disorder.
But, there is another way that anxiety shows itself.  That is through a

ggression.  Yes, sometimes anxiety can lead to lashing out at others.  Have you ever been worried about someone who is late for dinner or late in meeting you at a movie?  What about the parent who is worried about where their child is late at night when it is an hour past the time that they were supposed to be home?  What often happens when your friend shows up or the child slinks into the house?

Right.  You got it.  Instead of being hugging and warm it is often the opposite that occurs.  You get angry and act annoyed.  The parent yells at their child.  Yelling is verbal aggression.  The anxiety has resulted not in avoidance but in attack!

That this happens should not be a surprise.  Remember that anxiety leads to the fight or flight response.  Avoidance is part of the flight and anger is part of the flight.  Yet another way that anxiety can make lives more difficult for people.

Anxiety: Fight or Flight

We often forget how much of a problem overwhelming anxiety can be.  Panic attacks, social anxiety, generalized anxiety and obsessive compulsive disorder all have the potential to be quite disabling.  They can also all be treated and both avoidant behavior and attacking behaviors can be controlled.  In the next couple of months we will be posting a lot of new information on this website, much of it about anxiety.  Stay tuned!

–Stan

FINALLY, the Lancet (one of the world’s top medical journals) has retracted their publication of one of the most misleading articles in the history of modern medical  science – the now totally discredited piece on the relationship between autism and the MMR vaccine http://www.cbc.ca/health/story/2010/02/02/autism-mmr-lancet-wakefield.htmlt.

What took them so long?  It seems that the Lancet editors where the last in the world to know that the article was basic bunkum.  And why did they even print it?

If you can find me another article that uses the same low level of scientific evidence and flawed thinking that the Lancet has published in the last decade as this one used I will buy you a chocolate cookie. (Only one cookie per customer, just in case).  I for one have no idea about what the answer to either of those questions is.  But the fallout has been substantial.  It seems that large numbers of children died because they were not vaccinated.  And to what end?  Because a researcher (who it seems was in the employ of lawyers making lots of money suing vaccine manufacturers) published such poor science and because a learned journal did the publishing?

So what is a possible lesson here?   Although there are many, one most certainly is that one swallow does not a summer make.  That is, scientific knowledge is not built on one study, but on many, conducted by different and independent investigators, using best methods and techniques and scrutinized by peer review.  Is there the possibility that some studies will show one thing and others will show another?  For sure. Science is nasty, brutish and long.  Remember the word attributed to Mark Twain: “be careful reading a medical text book.  You may die of misprint”.

–Stan

So it was late afternoon and I was chatting with some of my young, active and thoughtful research team members.  And guess what came up?  We need a mental health break during the “dog days” of winter.  The more I thought about it, the more I liked it.

We know that the winter blues are very common at northern latitudes – such as all of Canada.  We know that there is a mental disorder, called Seasonal Affective Disorder that is linked to the relative lack of sunlight during our winter months.  We know how long that stretch of going to work when it is dark and going home when it is dark is – especially between Christmas and the first holidays in the spring.  Apparently there is even some anecdotal evidence that work and school problems peak in February.  And, we know how important a good down day – preferably one in which we can go exercise outside in the sunshine- is for our mental health.

So here is my proposal (actually it is the proposal of Jess Wishart and Christina Biluk), but I am putting forward as mine.  Let’s have a national holiday in early February.  Lets call it mental health day.  Why not?  We can just prorogue for a while.  I bet that it will be good for all of us. And the researchers can study to see if the two weeks after the day show less work and school stress than the two weeks before the day.  Or they could do a controlled trial – one part of the country with the day off and the other part without.  Hah.  Maybe we should just take the day off!

Last week, there appears an article in the San Francisco Chronicle about suicide deaths due to jumping from the Golden Gate Bridge http://www.sfgate.com/cgi-bin/blogs/inmarin/detail?&entry_id=55733.  According the Chronicle, last year there were 31 deaths, the year before that there were 34.  Over 1,300 people have died by suicide from jumping from the bridge since it was built.

And what is the essence of the story?  Apparently the Marin County Coroners Office wants to recommend suicide prevention barriers and this is controversial.  And guess what – more studies are apparently recommended.

Now, readers of this blog know how committed I am to research.  You also know that I am committed to action.  Will putting up an appropriate barrier decrease the rate of successful suicides by jumping from the bridge?  Highly likely.  Is this a good thing.  For sure.  So why is it not being done.  Who knows?

I remember the hard work that went into getting barriers erected on the Bloor St. Viaduct in Toronto.  There the effort was lead by a young man with lived experience of mental illness.  I know of the hard work that went into getting a barrier erected on the MacDonald Bridge in Halifax.  There the effort was lead by a mother who had lost her son to suicide from the bridge.

It the courageous activity of people like those Toronto and Halifax citizens that seems to be necessary before authorities can act.  I am so proud to know and support those leaders and I thank them for everything that they have done and continue to do in this regard.  What I don’t get is this.  Why is it so hard to do the right thing when it comes to mental health action?

Arguably, the area of mental health is the newest domain of health in using independent, empirically valid and scientific approaches to determining what works, for whom, at what financial cost and with what potential harm.  Perhaps because of this “newness” we seem to spend a lot of unproductive time arguing or discussing what we should be doing and frequently confusing opinion with evidence and often not understanding that all evidence is not equal.

The Health Development Agency of the National Health Service (United Kingdom), in a 2004 critical review of youth suicide prevention programs provided the following four criteria to be used in the application of all mental health programs:

1 – Apply good and effective interventions
2 – Avoid ineffective interventions
3 – Eliminate harmful interventions
4 – Facilitate public accountability

These seem pretty reasonable to me.

The problem we seem to have is making sure we do each of these things.  This is especially a difficulty when our pet theories or personal perspectives do not stand up to independent, substantive and appropriate scrutiny.  Yet these are the things that we need to do.

So here is a suggestion.  Before implementing any mental health program can those people charged with doing that simply tic off each of these four criteria.  Have you clearly and with the proper and most substantive type of evidence demonstrated that the interventions are good and effective?  Are you using programs or other interventions that have none or inadequate evidence of effectiveness?  Are you sure that your programs or other interventions do not cause harm?  Have you been open with the public about the effectiveness, cost effectiveness and safety of all the programs and other interventions that you have in place?

If not, why not?

Recently, my research team published a scientific commentary in the Canadian Medical Association Journal dealing with an important mental health concern.  We conducted an assessment of the information dealing with psychological debriefing in schools and found that there was no substantive evidence to support the use of that kind of intervention following traumatic events.  We also found that the best available evidence in studies of adults showed that these type of interventions were not helpful, and indeed in some studies turned out to be harmful (see: Psychological debriefing in schools, www.cmaj.ca Online publication, January 4, 2010)…

Yet, these interventions have been very popular and used so frequently that they have become commonplace.  Who has not heard the news on the radio that grief counselors have been dispatched to a school after a traumatic event?

This raises a very important issue.  That is, before we start wide-scale mental health interventions we need to be pretty sure that they work and we need to be really sure that they do not cause harm.  If we put programs into place that do not work we are creating a false sense of security and using scare resources; money and people, to no good end.  Furthermore, because of our investment in such programs we may be less interested in considering other options – options that may actually work.  In other words, what seems like a good idea may not be a good idea and if that gets codified or ingrained in an organization or institution it may have more negative than positive consequences.

So, what is to be done?  First, when we do get solid substantive evidence that what we are doing does not really work, is not cost effective, could be done better in a different way or may cause harm – we should stop doing whatever that is that we are doing.  Sounds simple but it is not so easy.  Usually because there has been a big investment in the initial program and there may even be a big industry and local champions pushing for its continuation.  Second, before putting in a program we should demand solid substantive evidence that the program really works and that it causes no harm. Third, if we decide to put programs in without the kind of evidence we need to have, we better make sure that we also provide the kind of independent and unbiased research that is needed to help us determine if the program works or not, if it is cost effective and it does not lead to harm!

We have to do the right thing, not just do something.

–Stan

Today I saw an article about the movie Avatar.  This article tells all who read it that this movie is causing people to become depressed and suicidal.  What a bunch of journalistic hokum. (http://www.news.com.au/entertainment/feature/avatar-perfection-causing-depression/story-e6frfnv0-1225819063598). 

What this likely illustrates is what a topic of a previous blog has been: the inappropriate use of the word “depression”.  People do not become clinically depressed after watching a movie; they may however experience a variety of negative feelings (or sometimes positive feelings).  We do not call the feeling state that a movie such as Chariots of Fire engenders “mania”.  No, on the contrary.  We call it; uplifting, joyous, awesome, elevating, etc.  Why do we call negative feelings “depression”?

There are so many other words to use.  Our language is so rich in words that describe affect.  So let’s use some of them: dispirited; demoralized; dysphoric; distressed; disgruntled; disaffected; pathic; etc. And while we are at it, lets give reporters who may not know how or can not be bothered to write clearly. (or  who are using emotive words to sell copy),  a clear message that these headlines are of no value in furthering our understanding of the human spirit.  Can a movie stir our emotions? Totally!  Does it cause mental disorder?  No!

–Stan

A recently published study about the relationship between sleep time and depression in teens (http://behavioralhealthcentral.com/index.php/20100111172002/Special-Features/teens-who-dont-get-enough-sleep-risk-depression-and-suicide.html) has many people confused.  It was a co-relational study and thus does not confirm causality.  So it is not possible to conclude that going to bed late causes depression in adolescents.  On the other hand, the study does bring the spotlight back on the well known scientifically but less well appreciated complex relationship between sleep and depression in teens.

We have known for a long time that sleep is disturbed in teen depression.  We have also known for a long time that the usual sleep architecture (that is how the different stages of sleep happen during the night) is disturbed in teen depression.  We also know that some teens who get depressed show subtle changes in their sleep architecture before they get depressed. Many years ago my research team reported those findings and we also showed that there were abnormalities in hormone secretion at night in depressed teens. And, we know that forced waking early in the morning may improve symptoms in depression.  So there is clearly something happening in how the brain controls mood and how it controls sleep.

But, it is simplistic and wrong to assume that setting late bedtimes for teen’s causes depression.  This is not the case and it would be foolish to try to tell parents and teens that going to sleep before midnight is protective against depression.  However, there is much for us to learn about sleep and depression in teenagers.  And there is a growing interest amongst researchers in this area.  So stay tuned!

–Stan

Since it is Christmas and since gift giving is “top of mind” (regardless of your religion – this is a time of year that gift giving is celebrated – OK, not the retail kind, the REAL kind), I thought about what gift I as a mental health professional would like to receive.  And guess what – a number came to mind.

First, I would like to see a Canada and the global society be a place in which people living with mental illness had exactly the same rights, equalities and access to care as people with illnesses that are not disorders of the brain have.  When we can speak of diabetes and colitis and arthritis and schizophrenia all in the same breath and with the same considered and supportive perspective then we will have gone a long way to decreasing stigma and barriers to mental health care.

Second, I would like to see us beginning to talk about finding a cure for various mental illnesses, much as we speak about finding a cure for breast cancer or finding a cure for prostate cancer.  We have finally developed and are rapidly developing our understanding of the brain and its functions – in health and in disease.  And we are getting closer to understanding the social and enviromental impacts that effect brain function and how those may contribute to the development or perpetuation of mental disorders.  So its time we set our sights on a cure for schizophrenia, a cure for major depressive disorder, a cure for bipolar disorder and so on.  We may not find a cure in the next five or ten years, but by gosh the search will take us a long way forward.

Third, I would like to see our mental health community supported and enhanced by coming together of various components instead of those components pulling us apart.  Sometimes I think that if we spent one half of the time and effort that we seem to put into supporting pet ideologies or convincing others of our “truths” in common purpose, we would be so much further ahead.  One foundation that we really need to build our community on is scientific literacy.  We need to use science to advance our cause.  We need to use the best scientific methods and the knowledge that they bring to us to inform our directions.  We need to embrace the science and not rail against it.  Building on this foundation we can work together to ensure that all the interests and different voices of individuals and groups are expressed, heard and included.  A house has many rooms, but if its foundation is not strong it will collapse, regardless of how pretty it may look.

So those are my three Christmas gift wishes.  The best of this gift reminding season to you and yours.  Regardless of your religious beliefs or other defining features.  Be well.

-Stan