Just was reading an interesting article on police and mental health.  Not the mental health of police, although that would be a very important issue to know more about.  Can you imagine the stresses of that occupation?  But about how police respond to individuals who are exhibiting mental health problems, or individuals with mental disorders who are in distress or acting in such as way as to be causing distress to others.  So here is the piece: http://www.guardian.co.uk/commentisfree/cifamerica/2010/jul/14/police-mental-health-training. As you can see the title is: US Police need proper training in mental health.  And the sub-title is: “People suffering mental health crises are too often subjected to brutality by poorly trained and frightened police officers”  According to the writer (in a UK paper by the way): “Every day in various American communities, people enter mental health crises and their friends and family members pick up the phone to call for help. Often, the first responders on the scene are police officers, and the resulting interaction does not go well. Poorly trained and frightened police officers may resort to excessive force, and sometimes this ends in death for a person who is guilty only of being in urgent need of psychiatric care.”

Although the piece is long on hyperbole and heart wrenching descriptions of police attacking individuals suffering from mental disorders, and short on any substantive data and overall balanced reporting regarding what police forces are actually doing, the writer does bring attention to an important issue.  Certainly police officers should have more training in dealing with the unique needs of people who have mental illnesses and who are behaving in a way that may put them or others at risk of harm.  Certainly we need more and better community based mental health care services.  These needs are real and we have to get working on doing more.

But it is also important to recognize that much has been done in the last decade or so.  Here in Halifax, there is a mobile crisis service that I am proud to have been part of its launch.  It pairs police officers with mental health professionals.  It goes to where people need them and it works – not perfectly mind you, but it works.  One of my colleagues, Dr. Bianca Horner and members of the Department of Psychiatry and the Mental Health Program have developed a national training program for the RCMP, called “Recognition of Emotionally Disturbed Persons” regarding this matter.  Other police forces in Canada are now beginning to address this issue.  I have had the opportunity to be part of the Minister’s task force on TASER in Nova Scotia and the privilege to chair the sub-task force on excited delirium.  As a result of these reports there have been substantive movements towards improving all aspects of first responder approaches to individuals with mental disorders.

While these are a good beginning we certainly have to do more.  It is not appropriate nor is it fair nor is it right that our prisons have become holding bins for people who require mental health care.  The federal government has decided to build more prisons.  I for one would like to see them invest more in mental health care instead.  Don’t you think it’s preferable to treat someone who has a mental disorder in such as way as to assist and support their recovery instead of throwing them in jail?  I do.

–Stan

Recently there was a report of an extraordinary example of political interference in mental health treatment. A political interference based not on knowledge but as far as I can tell, based on stigma or perhaps with a bit of so called “law and order” pandering to the uninformed.

The story unfolds in this way. A person who is in secure treatment for a murder committed when he was psychotic applied to have supervised outdoor walks. The mental health treatment team supported that application and it was permitted by the Criminal Code Review Board who are charged with the responsibility for such decisions. Without these walks (remember that they would be supervised – that is, the person who as far as I know has improved with treatment would be accompanied by two trained mental health staff during short outings) the person would have to languish indoors all summer.

Upon hearing about this decision, the Minister of Justice in Manitoba – Andrew Swan, overturned the board’s decision, ordering that no supervised walks could be allowed! Why? According to Swan it was “contrary to the interests of public safety”.

What hogwash. Since when did Minister Swan get his credentials in mental health? And what possessed him to overturn a duly constituted and credible evaluative process? Could it be stigma against the mentally ill? Could it be the lowest form of political pandering to ignorance and fear? What kind of a message does this send to people living with mental illness? What message does this send to their families? What message does this send to society in general?

Shame on Minister Swan. This is something we could have expected in medieval times, not in 2010 in Canada.

–Stan

Interesting story in the Toronto Star. Seems that some bright inventor decided to apply restaurant technology to hospital clinics and ER waiting rooms. So, (wait for it) here is the amazing way forward! Yes, you guessed it – beepers. http://www.thestar.com/news/sciencetech/article/828089–the-wait-is-over-laval-inventor-tackles-waiting-room-frustration. Mrs. Jones, your table, er… guernsey is waiting. Please slip on this johnny gown with the gap at your backside and wait behind this curtain. Your health provider will be here sometime before H-ll freezes over. Actually, if you happen to be a patient with a mental health crisis it could take much longer than that.

If I had a dollar for every hour that a patient with a mental health crisis had to wait to be seen by the emergency physician in many of the hospitals that I have known, I could have retired a wealthy man. Why is it that people who have a mental disorder end up at the back of the line? Surely it can not be because of stigma in health providers? Surely it can not be because of inefficient care pathways? Surely it can not be because of inadequate numbers of mental health providers?

Maybe it is all of the above. In that case, you can hand out as many beepers as you want and nothing will happen. Mrs. Jones, your bed is ready for you. Sorry it took seventeen hours to get you there. If only you had a broken leg instead of a depressive psychosis accompanied by severe suicidal ideation we could have done a bit better. And your beeper? Please put it in that box over there. Mr. Watson will be needing it next. We only have one available for psychiatric patients and he has already been here six hours.

–Stan

Just had a chance to read a report put out by well meaning people on the topic of suicide prevention in youth. In that report the author kept repeating about the many community and school-based programs that have been proven to prevent youth suicide. While I wish that this was true, it is simply not the case. So I am going to write a few blogs about how we know if a program actually prevents youth suicide or not. The first issue is what does the program measure as an outcome?

If a program intends to prevent suicide it must measure suicide. No other measure can be substituted. To my knowledge, there is no data available on this key outcome variable in reports about these community and school-based programs. Instead, we read that some programs increase knowledge about suicide or even decrease the incidence of self-harm behaviors over a short period of time. These are what we call proxy measures and these do not predict changes in suicide rates. We have many examples of interventions that change proxy measures and yet have no impact on the key outcome measure. You can not determine the depth of a well by measuring the length of the pump handle!

Unfortunately, too many people use these proxy measures as “proof” of suicide prevention and go about putting these programs into place. This is a big problem. Not only do we not know if these programs decrease suicide or not, but we do not know if they do any harm! Some early research showed that well intended school interventions actually increased suicide rates! And, guess what, the decrease in suicide rates begin well before suicide prevention programs were put into place and occurred in locations where these programs never existed!

“Fools rush in where angels fear to tread”. “It is not enough to do something. It is imperative that we do the right thing”. “The road to hell is paved with good intentions. Remember all these cautions?” Could be that they apply to so called suicide prevention programs also?

–Stan

The G(irls) 20 Summit delegates, Globe and Mail article, resonates with me. There is no doubt that the equality of women should be a joyous and wonderful thing celebrated by all women everywhere! But what is this meeting of delegates missing? Focusing entirely on women fails to address women’s equality and health. What? That’s crazy! Women and girls are facing inequality resulting in health disparities—shouldn’t we then focus on women? No, actually we shouldn’t.

Focusing exclusively on women is bad for the health of men and women. It fails to provide the necessary variety of perspectives about how gender interactions are contributing to inequality and how this could be addressed in a comprehensive manner.

There are negative consequences of societal gender expectations on all members of society. This includes the people, too often forgotten (at least in North America) who don’t fall into this fabricated gender binary. What about people who are not male or female? What does that mean? You know, people who identify as something other than male or female, including (but not limited to) gender queer people, transmales, transfemales, and intersex people. These groups of people are often ignored completely and face oppression to an exponential degree in comparison to women.

Imagine this. You’re suffering with mental illness and searching for your identity in a society that doesn’t represent you on the washroom label. You’re unsure of your gender identity because examples of others like you are lacking and your existence is denied in innumerable ways. How do you then go about treating your mental health issues (in a society poorly structured to deal with mental illness in the first place) or for that matter any of your other health issues that largely fly under the radar of most mainstream doctors?

Many trans people face a complex web of health issues (mental, sexual and physical health). This is further complicated by the lack of research pertaining to trans people and plausible solutions to the issues they face. A potential starting point for society to tackle this challenge is by backing trans-supportive organizations to take the lead on an international initiative with money and resources. Taking trans initiatives international has potential to provide insights about how other cultures treat trans people and how to improve our society.

But most importantly, we should be tackling the problematic gender expectations and we should be doing it in an all-encompassing/collaborative manner. That is, if we want to address inequalities and related health disparities successfully. Or we could continue attempting to separate inseparable social issues (gender inequality vis à vis males) and members of society (female, male, or gender queer) to create an illusionary solution for the illusionary “separate” issue.

–Holly Huntley

When I read the piece in the Globe and Mail about the G(irls) 20 Summit delegates, I was impressed. Kudos to Belinda Stronach and her Foundation for this innovative and necessary initiative.

Unlike the ongoing boondoggle involving fake lakes and public toilets well out of the reach of the public and denial of reproductive rights enjoyed by Canadian women to women in other countries, the Stronach initiative strikes the right notes.

Domestic violence, rape, the need for gender equality, the need for high quality easily accessible education, maternal health and well-being (including family planning) where all issues identified by the young delegates profiled in the Globe article.  Of course these are all issues that are too familiar with here in Canada as well – not to the same degree as in low and middle income countries but certainly in kind.  Guess what.  These are mental health issues as well.

Empowering girls and women and ensuring gender equality in all social, civil and economic undertakings are interventions that will spill over into mental health promotion and prevention of negative social and health outcomes.  This is an excellent way to address the social determinants of mental health – everywhere.

We have to do a much better job in this area globally and at home!  The mental health of nations must be built in part on national policies that promote and ensure the well-being of girls and women.  This is a task that we all must participate in.  I for one would like to see very piece of federal, provincial and territorial legislation reviewed to ensure that it promotes this agenda.  Sure we need mental health policies, programs and plans.  But we need a pro-gender equality framework that informs everything we do.

–Stan

Stan questioned the methodology of the data, and as a youth, I question both the results and the hypothesized causes. True, maybe “callous reality television” is making us youth more ‘detached’, but maybe not. Ok, so we may not develop empathy watching the girls on The Hills shop for purses (except maybe for the poor cameramen who have to film Spencer and Heidi’s nauseating displays of affection), but what about reality shows that highlight very real issues like drug addiction, health problems and poverty? Is there a difference between letting someone cut in front of you in line and crying into your Ben and Jerry’s for the contestant on American Idol who has had a difficult life struggle?

The other day I heard a story on CBC radio’s Mainstreet about a school in Halifax that implemented a problem solving strategy based on restorative justice, which focuses on the needs of both the victim and the perpetrator. The students at this elementary school regularly engage in ‘circles’, where everyone involved in the conflict answers five simple questions about the incident and their feelings about what happened. This approach has been effective in helping kids mend relationships and put themselves in someone elses shoes. Through this process, the kids are strengthening their ability to empathize, and in fact now regularly ask to engage in this dialogue! The effectiveness of this technique was highlighted in a teacher’s comment that recently she returned to her classroom after running across the hall to find that her grade two students had self-organized and were taking turns sharing compliments about one another!

Maybe these students displayed empathy since they are too young to be corrupted by the ills of social networking. Because of course, no conversation about the self-centeredness of today’s youth would be complete without a discussion of the hazards of Facebook, Twitter, and other tools of social media. Do these tools merely make it easier for us to “ignore others pain”, as the article suggests?  How about Facebook groups formed in support of political prisoners, ill friends and relatives, or victims of natural disaster? Avaaz.org, the largest global web movement in history, has had 20,000,000 actions taken since 2007, many of those by youth who are concerned about injustices faced by friends and strangers worldwide. Youth may now be less likely to look after a friend’s plant (keep in mind Stan’s point about the reliability of this data), but how about youth from across the globe who participated in an online photo campaign that was instrumental in pressuring coffee giant Starbucks to create more equitable policies for Ethiopian coffee growers? Social media allows us to empathize with both our local and global neighbours.

Is taking the time to sign an online petition in support of others more or less empathetic than returning incorrect change? Does watching reality television chip away at our sense of concern for others? Are parents actively failing kids today, by teaching them success first, sympathy second? Or are we as youth merely finding other ways to express our empathy and connection with others? The article neglected to mention that youth volunteerism has been steadily increasing over the past decade, as has service-learning. So let’s stop stereotyping youth and start celebrating them. What a show of empathy that would be!

What do you think? Are youth more or less empathetic than in previous generations?
–Jess

Recently the Globe and Mail published a story about a study that purported to show that college students in the USA were 40 percent less emphatic than those of a few decades ago.  Whether this is indeed correct cannot really be determined by the methodology used in the study quoted but that does not seem to stop enthusiastic speculation about what has “caused” this so called drop in empathy.  As expected, the usual boogy-men have been trotted out.  None of these have been demonstrated to be causal in this change but that does not seem to stop pontification, particularly if it leads to sales of programs or newspapers.

So what are the suggested causes?  Of course, the digital media – facebook and myspace.  The argument here is that they are “physically distant online environments”  [that allow] people to “lionize their own lives” and “functionally create a buffer between individuals, which makes it easier to ignore others’ pain, or even at times, inflict pain upon others.”  This hyperbole makes good theatre but is not very good social science.

Of course the usual cause for every generational “issue” is then also brought to the table.  It’s the fault of the parents: “These kids were born around 1980. It could be a change in parenting style. … Kids are getting the implicit message from parents that success is what really matters. It’s hard to spend your life pursuing success and at the same time pursue empathy, because empathy takes work.”    So here we are treated to more unproven hyperbole.  It sounds plausible so therefore it must be true (that at least is the reasoning).  And guess what – there is a program that can be purchased to fix this supposed deficit.

So what is the back story?  First, is there really a significant change in empathy (even in the face of the research limitations of this study)?  Well the first question is:  what does a drop in 40 percent mean?  Is this a relative drop or an absolute drop?  A drop from 0.1 percent to 0.06 percent of the population is a 40 percent drop – but likely means very little.  A drop from 100 percent of the population to 60 percent of the population is also a 40 percent drop but likely means a lot!  Beware any news story that uses percentages!
Stop confusing co-relations with causality.  Sure facebook and myspace are new social realities.   So are globalization and climate change.  Parenting styles are blamed for every social ill.  Darn parents, if only they could learn to do things right!
Well there are some very interesting things on the horizon in terms of understanding empathy and how it develops and how it may change over time.  Research into children with the rare genetic condition called Williams syndrome (one of the features is extreme sociability) is peeling away the complexity of interactions associated with racial stereotyping.  Other research has identified mirror neurons in the human brain that are associated with abstract thinking, planning and ability to empathize. This type of research, linking our understanding of how brains develop in response to their environments will help us sort out these important issues.  The rest provides lots of impetus for speculation and opportunities to spend our money on programs that work about 40 percent of the time.

–Stan

There was a tragic story in the Halifax newspaper, the Chronicle Herald this week: http://thechronicleherald.ca/Front/1185324.html. The story was both new and unfortunately very old at the same time. The gist of the story was that a young man who had killed a woman a number of months ago was found not criminally responsible because, as the story states: “the teen was psychotic when he killed a woman in February”.

Although there are few details of what happened in the paper, it seems as if the young man had been experiencing psychotic symptoms for some time prior to the event. Apparently, “his family had been trying to get him psychiatric help”.

What a shame. How tragic. How sad. How ironic, that Nova Scotia has one of the nation’s best first onset psychosis programs. What happened? What is the back story?

The Province of Nova Scotia spends about 3.5% of its annually recurring health care budget on mental health, and a fraction of that on child and youth mental health services. This is in spite of the knowledge that about 3/4th of all mental disorders arise prior to the age of 25 years and increasing realization that early intervention and effective treatment may prevent substantial long and short term negative outcomes and yes, maybe in this case would have prevented such a tragic outcome.

I for one am getting sick and tired of reading these stories and writing these blogs. I have decided to run for federal office in Halifax in part to make mental health a national health agenda item. This tragic case should not have happened. Why is it taking so long to do so little that can help so many so much?

–Stan

We have known for a long time that the majority of mental disorders begin before age 25. We have also known for a long time that early onset mental disorders are a risk for many poor short and long term outcomes – indeed that is why we recommend early identification and early effective treatment. So that we can try and prevent poor outcomes and enhance good outcomes.

So a recent study, just published has found that for each person (on average) who has an early onset mental disorder it costs her/him over ten thousand dollars per year when they are an adult – that is correct: PER YEAR. This is compared to what their siblings make. ! OUCH!

So, as you know, I am a strong advocate of early identification and early effective treatment for mental disorders. It is simply not right that we do not meet the mental health needs of children and youth at the time that they need the help most – right after they get sick! We know that not providing care early leads to a host of poor outcomes for the person and for our society. Now we have additional information – this is the personal cost – over ten thousand dollars per year! Think of the effect that has on life and wellbeing. Think of what negative spiral effect that could have – poverty, use of food banks, etc. Think of the loss of tax revenue and the impact of lower incomes on the lives of their families and the wellbeing of their children. Not only is this not economically unacceptable, it is simply not fair.

Hey governments. Hey society. Hey banks and wealthy corporations. Hey citizens. It is time we made the investments early on. We can not afford not to do that!

–Stan