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

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

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

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

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

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?