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

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

So I was just reading an interesting piece called “Protecting Teens in Crisis: Constructive Oversight of Programs”, in which a number of significant concerns were raised about what is called the “struggling teen industry”.  Put bluntly, it seems that there are a number of institutions (mostly in the USA as far as I can tell) that may be or may have been involved in a number of non-therapeutic or perhaps even abusive practices,  all in the name of “therapy” or “treatment”.  Indeed one of the phrases used in the piece was “stories of mistreatment, abuse and even death…”

Wow.  Shocking.

An American professor is quoted as saying that these concerns need to be addressed using state regulations and licensing.  This makes sense for sure.  I am personally astonished that such a regulatory framework is not apparently in place. How could “treatment” settings operate without oversight and standards of care?

However, this is not enough.  Not by a long shot.  Reading about some of what passed as “treatment” makes me shudder.  It sounds brutal and harmful, not therapeutic and helpful.  So, where do people who offer these “treatments” (whatever they are) dream them up?  Who has studied these so called “treatments” and what have they found?  Are these interventions helpful?  Are they useful?  Do they work? Are they safe?

In short, what is the scientific evidence for the so called treatments being used?  And here, let me be very clear.  We need strong, hard scientific evidence.  This not the same thing as “best” evidence.  “Best” evidence can be what someone thinks is a good idea shared with some other people who think it’s a good idea.  It may even be a well-intentioned idea.  But, the road to hell is paved with good intentions (as the saying goes).

So – bottom line.  Show me the evidence.

–Stan

The Province of Nova Scotia spends about 3.8 percent of its health care budget on mental health services. Well below the minimum recommended by the World Health Organization.  A small proportion of this goes to child and youth mental health.  As the week long series in the Chronicle Herald (March 8 to March 12) pointed out – the entire provincial mental health system is very broken.  In my opinion, we have to tear it down and start again.  If we had a blank slate there is no way that we would build a mental health system in the way we currently have it.

So, where do we start.  Tearing and building will take a bit of creative thought and a bit of time, not to mention some very difficult slogging to move out of current rigidities and the control of vested interests.  What should we do now?

Well, I wrote about three ideas on this http://thechronicleherald.ca/Letters/1172666.html and the first was focusing on child and youth mental health.

Most mental disorders begin before age 25 years.  Most of these are life-long.  Most of these respond quite well to the evidence based treatments that we have.  Early intervention with effective care has the potential to decrease short term morbidity and improve long term outcomes.  The most effective way to decrease suicide rates is to identify and treat mental disorders.  And the list goes on and on.

Yet we persist in back end investment.  Lets stop this foolishness now.  Of course we need to provide better care and services for post-youth and vulnerable populations (such as refugees, first nations, the economically and socially disadvantaged, etc), but we need to really ramp up our investment at the front end.  So while we work on transforming the entire system we should immediately increase our investment in providing the best evidence based care with the best human resources we can allocate to children, youth and their families.  And we should do it now!

–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

It’s hardly a day goes by that we don’t read about depression and its impact on people and the economy and the toll it takes with suicide. We also read about how wonderful treatments are and how it is important to get help as soon as possible. All the above is true and for sure if I, or one of my loved ones, or one of my friends, was depressed I would certainly opt for immediate treatment with an antidepressant medication and an evidence based psychotherapy, delivered by competent health care providers.

But, and this is a big but – the evidence shows that good as our treatments are, they are not as good as they should be. The medications really help a lot but they do not help everyone. The psychotherapies help a lot but they do not help everyone. Combining the treatments helps more people but even this does not help everyone. So what do we need to do?

Well, it’s all well and good to make our systems of care more accessible and to train more health care providers to be able to treat depression but wait a minute. Shouldn’t we be spending a whole lot of time and effort on making our treatments better? Shouldn’t we be making sure that when we offer a treatment to someone the chances of it working the first time are as close to 100 percent as we can get? What would you prefer – a one day wait time for a treatment that works 50 percent of the time or a one week wait time for treatment that works 90 percent of the time? And while we are at it – why not a one day wait time for a treatment that works 100 percent of the time.

So we need to invest in treatment research. We can have all the health care providers and all the clinics and all the nice posters on the walls of schools and neat anti-stigma ads on the television and radio and on and on and on – but, if we do not get better at treatment, how much further are we really ahead? Do you know how many high powered (meaning really good scientific studies) have been done in Canada in the last five years on the treatment of some of the most common mental disorders that begin in adolescence. One? Five? Nine? Maybe none? Do you have any idea how much money is being spent on finding out how to better treat young people that have psychosis or depression or obsessive compulsive disorder compared to treatments for other medical illnesses or even compared how much is spent on posters that tell youth about problems? Don’t you think you should have some idea?

We need to invest in a major way in learning better ways to treat mental disorders in this country. We are not doing that in Canada. It is time we started to. Improving access to care is a good idea. Improving access to care that actually works is an even better idea.

-Stan

Recently I wrote a post on mental health in the palm of your hand - exploring how technology and iPhone applications were being used to share medical and mental health information.

Following that post I contacted Dr. Harvey Castro at Deep Pocket Series to ask him about Sad Scale - a self screening Depression test and iPhone application tool.

Understanding the need for a Depression scale for children, Dr. Castro worked with our team to adapt the Kutcher Adolescent Depression Scale (KADS) for use on the Sad Scale application.

The KADS, along with the Center for Epidemiological Studies Depression Scale for Children (CES-DC), are now available on the Sad Scale. These applications will give you a graph on your progress and will also allow you to email your health care provider the results of the test.

The iPhone application is available now and can be downloaded for $0.99 from iTunes.

We are now adapting the Kutcher Generalized Social Anxiety Disorder Scale for Adolescents (K-GSADS-A) … stay tuned! (literally)

~ David Venn

Great video on youth mental health produced by YoungMinds in the UK. But good advice for any country and its leadership.

“YoungMinds Very Important Kids (VIK), our national panel of young people with mental health problems, have launched a manifesto  and accompanying film to highlight to politicians the changes that need to be made to improve young people’s mental health.”

You can download the YoungMinds children and young people’s manifesto here

“Written in their words and including their own stories it covers 11 areas where they believe things must change so that all young people with mental health problems get the support they often so desperately need.”

Manifesto main points

1. Stigma still affects us; its about time we were able to talk about how we feel.
2. Dealing with problems when we are young; train primary school staff
3. Growing up is difficult; support us when changes happen in our lives
4. Getting what we need at secondary school; train everyone to understand teenagers problems.
5. Waiting lists and assessments just make it harder; make them shorter and provide us with one worker for all our care.
6. Some doctors don’t listen to us; they need to understand and support us
7. Going to Accident and Emergency can be traumatic; treat us with respect, see beyond our labels
8. Some psychiatric units feel like prisons; learn from the best ones
9. Someone to speak up for us; we all need advocates
10. Lost in the system; don’t forget about us when we are 16 plus
11. We’re the experts; start  listening to us

In the past few weeks I’ve come across several advertising campaigns aimed at raising awareness about mental health problems. Two in particular focusing on Autism and Eating Disorders caught my attention (you can see why below).

Advertisers know what “sticks” when it comes to marketing: sex, shock and emotion. These approaches can be effective ways to sell products or promote a brand identity - but how well do they transfer into the world social awareness? Or for that matter mental health?

SEXY

The people at Sociological Images alerted me to this Rethinking Autism ad campaign. The RA site maintains that:

“All too often in the world of autism, celebrity and sex appeal are used to promote pseudo-science that exploits autistic people, their family members and the public.  We decided to put those very same factors to work in service of the truth.”

This is a clever ad. It’s information is scientifically-based and it captures your attention.

But is it effective?

While I get the tongue-in-cheek reference that Autism has become a “sexy” topic of discussion, I question whether the core message gets buried beneath a sea of lingerie.

The Rethinking Autism website claims to want to “change the conversation one video at a time”, but are we changing the conversation towards Autism and debunking pseudo-science or does the ad instead meander towards a debate about the objectification of women as sex objects. If the latter then the message is lost.

EDGY

Next up is a series of ads from the Looking Glass Foundation for Eating Disorders based in Vancouver BC.

The ads are edgy alright - but their message is misleading. The tagline in the ads is “Not every note is a suicide note” - which falsely implies that eating disorders are a method of suicide. We know this is not true.

So while the ads are effective in shocking us, they do little to advance discourse because of their false message - in fact they may even perpetuate the myth that eating disorders are motivated by suicidal intent.

EMOTIONAL

Finally an anti-stigma ad campaign from the Mental Health Foundation of Nova Scotia (see video on their homepage).

The ad uses personal narratives, emotional music and dream-like backgrounds to tell a story. In under a minute the video captures the pervasive stigma that accompanies mental illnesses, touches on the scientific basis of mental disorders as brain disorders, points to the need to improved resources to meet the needs of those living with mental illnesses and challenges the viewer to talk more openly about mental illness and mental health.

Effective doesn’t have to be flashy and this ad is a great example of the power of emotion and story to communicate an important message.

~ David Venn