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

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

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

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

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

Some of us think we have a problem in our suicide research and in our suicide prevention approaches.  Actually there may be many problems with those (stay tuned for future blogs) but one of the concerns is the meaning of the statistics when it comes to the definition of “suicide attempt”.

A suicide attempt can be defined as a purposeful self-injury with the intent to die.  A self-harm attempt on the other hand can be defined as a purposeful self-injury without the intent to die.  Self-harm can be the result of many different factors, including but not limited to: difficulties with problem solving, difficulties with impulse control, copycat phenomenon,  social or situational control, etc.  Increasingly, research is showing that young people who self-injure may be substantially different from those who attempt suicide.  So what does this mean?

Hospitals that use the ICD system (and that is all of them) tend to code self-injury as a suicide attempt.  Even DSM at the time of this writing, does not allow for differentiation of self-injury from suicide attempt.  Could it be that many of our statistics about suicide attempts are incorrect?  Could it be that “truths” that we think we know – such as more females attempt suicide than males – may not be accurate but may be an artifact of not separating out self-harm attempts from suicide attempts?

And what about suicide prevention programs?  Does a decrease in reported incidents of self-harm equal a decrease in real suicidal behaviour – that is suicide attempts?  That does not mean that we should not try to bring down self-harm attempts, but it may mean that the methods useful for one outcome may not be useful at all for another outcome.

Actually, I think its time that we started to think more critically about what we mean when we use the words “suicide attempt”.  Is it really a suicide attempt or is it a self-harm event?  It is an important distinction.  Both are important targets for interventions – public health type and clinical type.  We need to separate them out in our statistics and we need to separate them out in our programs.  Then we can get a better handle on what is actually happening and what we can do about it.

-Stan

How do you let people know about your cause?

For big corporations and organizations this problem isn’t so difficult. They throw money at national advertising campaigns, they hire creative PR firms, they design complex websites, etc. But as non-profits our capacity to engage in these expensive promotional techniques is often limited.

Here are some useful, more cost-effective ways to share your message

Collaborate instead of communicate - when we work in a silo we don’t accomplish as much as we could if we worked in partnership. Find other organizations either at home or around the world who have the same cause and vision as you and ask them to partner. Don’t help yourself first. Bring something to the table that is of value to them, especially if you are the smaller organization. What do you have that they don’t? Find a way to make the partnership mutually beneficial. (See our project with ViewFinders as an example)

Listen to what others are doing - yours is not the only voice in the room. Instead of trying to communicate your message, listen to how others are communicating theirs. Set up RSS feeds to track what other people are doing, read blogs (Beth Kanter’s blog on how non-profits can use social media is excellent), follow people on Twitter and Facebook. Listening to others will give you great ideas about how to spread your cause.

Know your audience - a group of a few who care is often better than an army of many who don’t. Communication is not always a numbers game. Find a core group of people who really care about what you are doing and ask them to help you spread your message. (Chris Guillibeau talks about this idea in his Brief Guide to World Domination). A few people in power positions and really connected to what you are doing may have a much greater impact on your cause than many people with minimal influence.

Use multiple mediums - diversify the mediums you use to communicate your message. The best approach encompases multiple streams of communication. Email and e-newsletters may be great for reaching some people, but blogs and social media may be useful for reaching others. Cross-link your communications for a comprehensive approach. To Write Love On Her Arms is doing this really well.

A Child and Youth Mental Health Case Study

On July 1st we are opening up a survey as part of the Evergreen project to ask Canadians to share thier values and ideas about child and youth mental health. We have been implementing the principles above to spread the word about this initiative. Here’s how we are using these principles:

Collaboration - we don’t have many connections with parent groups so we found a publication that did and partnered with them. Today’s Parent has been supportive of our project from day one and have even helped us by asking their audience to take a survey about mental health and take part in this cool online flower garden for children’s mental health.

Listen - we have been using google RSS feeds and a del.icio.us account to track news and blogs about mental health. It’s been a great way to listen to what others are doing and to join the conversation.

Know your Audience - our key audiences, in addition to youth and parents, are health professionals and educators. By using promotional networks specific to these audiences (ie: HPClearinghouse) we can target our communications efforts.

Multiple Mediums - our blog and website are strong tools for reaching our audience. Recently we have expanded to Facebook and are using e-newsletters (sign up on left hand side) to engage people who are interested in what we are doing. Another great tool is interactive media like Slideshare.

Have you found a particular technique helpful or useful? What other ways are you are promoting your cause and voicing your message? Share your ideas in the comments section!

~ David Venn

(image credit: omacaco)

New government figures out this week in the UK claim that public attitudes towards people with mental illness have reached a tipping point.

The Department of Health survey shows improvements including:

• 77% agree mental illness is an illness like any other an improvement of 3% on last year and up 6% since 1994
• 73% think that people with mental health problems have the same right to a job as everyone else, up 7% on last year
• 78% judge the best therapy for people with mental illness is to be part of a normal community, up 8% on last year
• 61% agree that people with mental illness are far less of a danger than most people suppose, an improvement of 4% on 2008

However, it also includes some more alarming figures:

• 11% would not want to live next door to someone with a mental health problem, an increase from 8% since 1994
• Almost a third of young people (16-34yrs) think there is something about people with mental illness that makes it easy to tell them from ‘normal people’
• 52% of young people agree people with mental illness are far less of a danger than most people suppose, 17% less than people over 55yrs
• 22% feel anyone with a history of mental health problems should be excluded from taking public office
• When the issue is brought closer to home - only 23% feel that women who were once patients in a mental hospital can be trusted as babysitters.
• 65% underestimated the actual prevalence of mental illness and only 13% were aware that 1 in 4 people will experience at mental health problem.

Stigma is essentially the polite word for discrimination. It has no place in our caring society. While some public attitudes toward people with mental illness are improving, the numbers above suggest we still have a long way to go.

It is all too easy to look at these numbers with rose-coloured glasses and proclaim that we have reached a tipping point. However I believe the Canadian Medical Association’s assessment of a similar study conducted last year to be more accurate when they called Canadian stigma and attitudes a “national embarrassment“.

Findings from that report (pdf) indicate:

• One in 10 thinks that people with mental illness could “just snap out of it if they wanted”
• One in four Canadians is afraid of being around someone who suffers from serious mental illness.
• Only half of those surveyed would tell friends or co-workers that a family member was suffering from mental illness.
• Only 16 per cent said they would marry someone who suffered from mental illness, and 42 per cent said they would no longer socialize with a friend diagnosed with a mental illness. By contrast, 72 per cent would openly discuss cancer and 68 per cent would talk about diabetes in the family.
• Half of Canadians think alcoholism and drug addiction are not mental illnesses.
• One in nine people think depression is not a mental illness, and one in two think it is not a serious condition.
• Almost half of Canadians (46%) think the term “mental illness” is used as an excuse for bad behaviour;
• A solid majority of Canadians would not have a family doctor (61%) or hire a lawyer (58%) who has a mental illness;

Stigma against the mentally ill is recognized as one of the greatest barriers to social justice, appropriate health care and development of civic society. We are not at a tipping point yet, but hopefully sometime soon.

~ David Venn & Dr. Stan Kutcher

(image credit: nite fate)