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?

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

Official press release

A new report will better position government and its partners to help Nova Scotians at risk of attempting suicide.

The report, Suicide and Attempted Suicide in Nova Scotia, was released today, July 15. Its purpose is to help those who work in the areas of suicide prevention, intervention and support.

“Suicide is a very complex and sensitive public health issue,” said Dr. Robert Strang, Nova Scotia’s chief public health officer. “We need to talk about it more and better understand it to ensure the right programs and supports are in place to help Nova Scotians.”

The report describes the conditions surrounding suicide and attempted suicide in Nova Scotia. The data is based on hospital and vital statistics records of suicides and suicide attempts from 1995 to 2004. It examines demographic factors, how people attempt suicide and complete suicide, and the types of health-care services used by Nova Scotians at risk.

“This report is a baseline we can use to evaluate future efforts on this important issue, and we’ve made good progress since 2004,” said Dr. Strang. “We’ve developed a suicide prevention framework to reduce suicides and attempted suicides, we’re doing additional research with the medical examiner’s office, and we fund our community partners who work with Nova Scotians.”

Dr. Stan Kutcher, Sun Life Financial Chair in Adolescent Mental Health, a partnership with the IWK Health Centre and Dalhousie University, said that even though suicide and suicide attempt rates are decreasing, and Nova Scotia is experiencing lower suicide rates than most Canadian provinces, there is more to be done.

“Improving care for people with mental disorders, enhancing the capability of health care and education professionals to identify people at risk, promoting overall good health and resiliency, and improving access to good mental health care, can all help further reduce Nova Scotia’s suicide rates.”

Highlights of the report include:

• The rate of hospitalizations for suicide attempts declined by 30 per cent over the 10-year period
• 55 per cent of those hospitalized were female
• Lower income was associated with higher rates of both hospitalizations for suicide attempts and suicide deaths
• The rate of suicide death declined from 11 to nine individuals per 100,000
• Nova Scotia’s suicide rate was lower than the national average, nine out of 100,000 individuals compared to 11 out of 100,000
• 84 per cent of suicide deaths were male
• 55 per cent of suicide deaths were previously diagnosed with a mental disorder

The report is available online at www.gov.ns.ca/hpp.

Carol Marquis has written a touching and highly personal story about her brother Donnie and his tragic suicide at age 27 years. While Carol’s personal journey led her to feel life more deeply, my professional journey is more focused on what we can do to prevent others, who like Donnie are living with a mental disorder (in his case bipolar illness), from death by suicide.

We know that unfortunately suicide is a mode of death for people who suffer from and live with mental illnesses, much like a heart attack is a mode of death for those who suffer from and live with heart disease. Thus, it is no surprise that in Canada, the highest rates of suicide are found in people who live with a major mental illness – in particular: major depression; bipolar disorder; schizophrenia. Study after study has demonstrated that these mental disorders are the greatest risk factors for suicide. Study after study has demonstrated that there are effective interventions for individuals living with mental illness that can decrease this risk for suicide.

Some of these interventions are: the continued application of effective treatments (medications and psychological interventions); easy access to emergency/crisis mental health care; unique programs that address a variety of factors that can lead to or trigger a suicide act. We know that the majority of individuals who die by suicide visit a health provider prior to the event.

The difficult questions we need to ask are as follows. Why is it that with so much knowledge about what can be helpful that so many people living with mental illness still die by suicide? Why is it that with so much knowledge about what we can do we still invest in programs and activities for which there is little or no evidence of effectiveness? Why is it that we do not widely distribute and ensure that evidence based standards of care for suicide prevention are available in every location where health care is provided? Why is it that we spend little or no time in educating the large legion of health providers to identify and intervene when their patients are or could be suicidal?

Are there many other areas in medicine where we know what to do to make things better and we still persist in doing things that we either know do not work or do not know if they work? If not, what is it about the field of mental health that encourages us to act this way?

~ Dr. Stan Kutcher

Recently, The Chronicle Herald published a story titled “Young people need more access to mental health services – volunteer.” While I agree with this message, we must also begin to think about how we can better provide mental health care, and not just keep applying a model of mental health services that does not appropriately meet the needs of young people and their families.

Just doing more of the same will not result in substantial improvements in the mental health of our youth, nor will it ensure that those who develop and are living with mental illness receive the best possible scientifically validated care in the most timely and respectful manner. We have to begin to think differently and act innovatively.

First, we must use the best available scientific evidence to create, deliver and evaluate all programs and interventions that are provided to young people and their families. Fortunately, there is increasing recognition of this necessity among policy makers, care providers and the public.

Unfortunately, many programs in place or being promoted either have not been appropriately demonstrated to be effective, or their effectiveness is not known. Worse, some programs are known not to be effective, yet continue in place.

Second, we must think of how to provide mental health care, rather than mental health services. Currently, youth and families frequently must attend specialty mental health providers to receive care that could be more appropriately, more efficiently and perhaps even more cost-effectively provided in primary health care settings.

It is essential that effective and evidence-based mental health care be available throughout Nova Scotia in all primary health care settings. This can be achieved by modifying the way in which primary health care is delivered and by enhancing the mental health competencies of all primary care providers.

Third, we must meet young people where they are – that is, in their families and in their institutions.

Young children are profoundly influenced by their family environments and there is substantial scientific evidence that supports the use of specific early life interventions on improving outcomes for youth. These interventions should be widely available.

Concurrently, we know that our young people spend most of their lives in one of two institutions – schools or jails. It is imperative that we keep them in schools and enhance the capacity of schools to meet their mental health needs in conjunction with providing the best learning enabling environments possible.

In Nova Scotia, a number of initiatives, supported by various government departments are beginning to address this need. These innovations need to be further developed so that all our young people can benefit, and those of us who assist them in their growth and development can be better assured that our efforts will be likely to succeed.

~ Dr. Stan Kutcher

Realted:
Facing mental illness: a 10-step plan for Nova Scotia

Ever wonder where funding for mental health research goes? Or how research evidence informs medicine and practice?

The scientific evidence used in medicine comes from a pool of tens of thousands of published research studies. There are many types of studies, and the design of any given study usually depends on the question that the researchers want answered. Studies can differ considerably in the way they are designed and conducted, and can therefore differ considerably in quality.

Often the scientific community behind mental health research, studies and reports don’t get a lot of attention or gratitude, but without them our knowledge of mental health and mental illness would develop pretty slowly.

Evidence-based medicine is extremely important in the treatment of mental illness in general, and is particularly important in the treatment of mental illness in children and adolescents.

Here are some recent examples of research related to adolescents conducted by the National Institute of Mental Health.

(Our group is not affiliated with any of these studies, their results or NIMH)

Anxious and Depressed Teens and Adults: Same Version of Mood Gene, Different Brain Reactions

An NIMH study using brain imaging shows that some anxious and depressed adolescents react differently from adult patients when looking at frightful faces. This difference occurs even though the adolescent and adult patients have the same version of a mood gene. Researchers in the NIMH Mood and Anxiety Disorders Program and colleagues reported these findings online October 31, 2008, in the journal Biological Psychiatry.

Depression Relapse Less Likely Among Teens Who Receive CBT After Medication Therapy

Adolescents with major depression who received cognitive behavioral therapy (CBT) after responding to an antidepressant were less likely to experience a relapse or recurrence of symptoms compared to teens who did not receive CBT, according to a small, NIMH-funded pilot study published in the December 2008 issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Suicidal Thinking May Be Predicted Among Certain Teens with Depression

Certain circumstances may predict suicidal thinking or behavior among teens with treatment-resistant major depression who are undergoing second-step treatment, according to an analysis of data from an NIMH-funded study. The study was published online ahead of print February 17, 2009, in the American Journal of Psychiatry.

Getting Closer to Personalized Treatment for Teens with Treatment-resistant Depression

Some teens with treatment-resistant depression are more likely than others to get well during a second treatment attempt of combination therapy, but various factors can hamper their recovery, according to an NIMH-funded study published online ahead of print February 4, 2009, in the Journal of the American Academy of Child and Adolescent Psychiatry.

Beth J. Harpaz, The Associated Press

NEW YORK — If you’re the parent of a tween or teen, chances are you’ve been asked to leave the room during your child’s visit to the doctor so they can have a private chat.

Now of course I believe that teenagers should have a trusting relationship with their doctors. But while I’m sitting there alone in the waiting room, watching the younger mommies bounce babies on their knees, I can’t help but wonder what my kids are telling the doctor behind that closed door.

See, I’m a nosy mom, and if something’s going on with my children’s health, I want to hear about it. I mean, if your kid was suicidal, or a heroin addict, and somehow you didn’t know it, would the doctor tell you?

Turns out the answer is yes. “If we are concerned that someone is in danger, we are compelled to share that information,” said Dr. Joseph Hagan, who is part of the American Academy of Pediatrics’ Bright Futures initiative to improve children’s health.

But Hagan emphasized that giving kids a chance to speak privately with doctors “is not about secrecy. It’s about autonomy. A 16-year-old should begin to ask his own questions about his health.”

In fact, if your pediatrician doesn’t ask you to leave the room during teen visits, maybe he or she should. (more…)