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

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

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

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.

…“Off Label” Medication Use: What does this mean? (Part I)

Medication regulatory agencies (such as Health Canada, the FDA, etc.) have no authority in deciding on how medicine is practiced. That is the role of professional and licensing bodies. Thus, while a medication may be “off label” as far as the medication regulatory agency is concerned, that medication may be a useful part of accepted medical practice as far as professional and licensing bodies are concerned. Therefore, medicines may be frequently used in a medically appropriate manner, even if they are “off label”.

Fundamentally, the lack of a “label” for use does not mean that the medicine is not appropriate for use in any particular medical condition (that is a professional and licensing oversight decision). What this means is that the medication has not received medicine regulator approval for treatment of the condition in which the physician is using the medication, frequently because the company making the medication has not submitted for regulatory approval.

There are many useful criticisms that can be made of this state of affairs, not the least of which is the confusion that the concept of “labeling” has created in the minds of the public and health providers alike. Another criticism is the concern that the standard of proof for safety and efficacy required by medicine regulatory agencies prior to the awarding of a “label” for use may be less for those uses not labeled. Other criticisms may relate to concerns that the public may be less protected from “off label” use than it is from “on label” use. Some commentators point out however that all “over the counter” medications and “health supplements” (including herbal remedies) and all psychological treatments never receive regulatory approval – despite their widespread use.

So what is the patient or the family to do in such a confusing situation?

Just because a treatment is “off-label” does not mean that it is not appropriate. If that were the case then many of our medication treatments would be deemed inappropriate and all of our psychological treatments would be deemed inappropriate.

First, is to understand what the tem “off label” use means, and what it does not mean. Hopefully, the information in part one of this post helps with that. Unlike what the mass media suggests, “off label” use does NOT mean dangerous, ineffective or inappropriate use. So gaining clarity and understanding is a good start.

Second, is to understand what questions you should ask your health provider about ANY treatments that you are receiving. All treatments should be based on best available evidence of effectiveness and safety. This is called “evidence-based medicine”.

All treatments should be subjected to the same degree of rigorous scientific scrutiny and judged by the same high standards. All patients and their families have the right to know the evidence upon which any treatment is based and it is the ethical duty of their health provider to provide them with that information.

So, here are the questions to ask:

• Why are you recommending this treatment?
• What is the evidence (effectiveness and safety) supporting the use of this treatment for people who are like me and who have the same diagnosis (or problem) that I have?
• What regulatory or professional bodies support the use of this treatment?
• What are other treatments that could be used?
• What is the evidence for those treatments? Is it stronger or weaker than the evidence for the treatment you have recommended?

There are many other questions you should ask about your treatments. Reading the evidence-based medicine information guide for patients and seeking more information about medications at www.teenmentalhealth.org should help with that.

~ Dr. Stan Kutcher

Recently, there has been a plethora of media reports about the “off label” use of medicines for the treatment of child and adolescent mental illnesses. Invariably these reports note that such use is inappropriate if not downright dangerous and often counsel parents, patients and others to refrain from using medications prescribed “off label”.

Overall the impression is that such use is not part of usual medical practice and that for some reason it is being preferentially applied with psychotropic medications. The latent argument is that physicians may be acting irresponsibly or recklessly and putting the lives of their patients at risk. But, what actually is “off-label” use? Does it only apply to medications used to treat young people who have mental disorders? Is it an aberration in medical practice? Is it an attempt by physicians to control patients rather than treat them?

The answer is complicated and goes back to understanding the historical development of systems designed to regulate the sale and distribution of medications.

Over time, regulation of prescription medications has moved from providing a degree of certainty that these compounds were relatively safe, to providing a degree of certainty that these compounds were also likely to be effective. And, believe it or not, these developments are relatively recent and continue to be refined by all national regulators (such as: Health Canada - Canada; Food and Drug Administration – USA).

As part of this process, companies that make products that they wish to be submitted for regulatory approval gear their drug discovery and development programs to meet the standards demanded by regulators. Once a compound has met these standards it receives regulatory approval, which is accompanied by detailed information about the medication issued under the direction of the regulator. This is what is meant by the medicine being “on label”.

Following introduction into the marketplace, the regulator conducts or oversees post-marketing surveillance that is designed to identify possible safety or effectiveness concerns that initial development research was not able to address. Regulators do not dictate how medications may be used by physicians for conditions outside those identified in the regulation approval process, however, companies that make or distribute medications are not allowed to advertise their use in areas outside those already approved by regulators.

What does this mean in real life? Once a medication has received regulatory approval it is said to be “on label” for use in a particular disorder or condition. For example, medication “A” has been approved for the treatment of medical condition “Z”. However, physicians and researchers may discover that medication “A” is also effective and safe in the treatment of conditions “X” and “Y”. However, for many different reasons (such as cost, business development plans, market issues, etc.) the company holding the patent on that medication (or the generic company making that medication) decides not to conduct the studies required for registration of that medication for conditions “X” and “Y”. This means that the medication does not receive regulatory approval for the treatment of conditions “X” and “Y”, even if it has been found by independent researchers and clinicians to be effective and safe in those conditions. Thus the medicine does not receive a “label” for use in conditions “X” and “Y”.

But, the studies on the use of the medicine have been published in medical journals and experts in the treatment of those conditions have decided that in their experience the medication is a useful addition to the treatment options for that condition. Therefore, many physicians begin using that medication in those conditions – even if it has not received a “label” for use in those conditions. They are using the medication “off label”.

Part II of this post here …

~ Dr. Stan Kutcher

Evidence-based medicine (EBM) is a term that has become widely used in health care settings. But, what exactly is EBM and what does it mean for you?

EBM is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”. The “best evidence” comes from the more than 20,000 scientific research studies that are published every year, and “patient care” involves everything from diagnosis to treatment.

EBM is not just a recipe for treatment (e.g. every 15 year-old male with depression is not automatically prescribed the same medication). It is a methodical approach to patient care that is comprised of three components: the scientific evidence, the expertise of your health provider(s), and you.

EBM “integrates the best external evidence with individual clinical expertise and patients’ choice” to ensure that patients receive the treatment that best meets their needs. Evidence-based medicine goes beyond treatments. It also applies to how patients are assessed, diagnosed, monitored, and followed over time.

When we are unwell, it is often difficult to tell what has caused the problem and what can best help. Imagine that you are ill for a few days with a sore throat and cough. When your condition improves, you might wonder what made you feel better. Was it the bedrest, the cold medication, the chicken soup, or was it simply giving your body enough time to fight off the illness? And what if your friend gave you a “secret remedy” made from milk, cognac and grass? Is that why you feel better?

Before you spend time and money on a treatment, you might have a lot of questions. You might want the best information about whether the treatment works, how well it works compared to other treatments and what possible problems can result from the treatment. You should be aware of possible problems (such as the types of side effects that might
happen, the cost of the treatment and the difficulties in taking the treatment) that may occur when you and your health care provider are deciding which treatment you should have.

The ultimate goal of EBM is to help patients receive the treatment that is most appropriate for them. This means finding a balance between the scientific evidence, the patient’s values and the experience of their health provider(s).

Remember, people can respond differently to any given treatment, so it is impossible to know exactly how you may respond. However, at least you can know what the chances are that you might be helped or harmed by a given treatment. This can help you, your doctor and other health providers come to a better decision about what treatment is right for you.

To help understand evidence-based medicine the Chair has developed a guide for patients. Feel free to download it from our website and use it to help you make the best decisions about your health care.

A teen version of this guide will be available sometime soon!

~ Dr. Stan Kutcher

The recent Globe and Mail piece on mental health concerns pertaining to children and youth strikes many correct notes, but unfortunately also incorrectly hits a few important “major chords”, particularly pertaining to the use of medications to treat mental disorders in young people.

Contrary to much popular opinion, there is a rich and scientifically sound data set pertaining to the effective use of medications to treat specific mental disorders and also specific symptoms that are found in some mental disorders. Indeed, there has arguably been much more rigorous first order clinical trials research conducted in medications use than in any other treatment modality in this population.

For many mental disorders, the use of medications is an essential (albeit not sufficient intervention) that helps control symptoms and promotes recovery. Unfortunately, public understanding of the medication use issue in the treatment of mental disorders in young people falls far short of the scientific evidence that supports this intervention. It is not uncommon to read reports about the increase in medication prescriptions to treat mental disorders over the last few years, and usually this data is negatively portrayed. Frequently the media issue focuses on the presumed “over-use” of medications.

Now, we know that diagnosis and treatment of mental disorders in young people has been a concern for decades. Fundamental to this concern has been the finding that these disorders have been under-recognized and under treated. This sorry state of affairs has been slowly changing. Today more young people are being appropriately diagnosed and treated for their mental disorder. However, now when we find the statistics increasing for both diagnosis and effective treatment, there is criticism that this increase is somehow alarming and to be feared.

Did you know that the use of medications in young people to treat asthma and diabetes has increased more than the use of medications to treat depression over the last few years? Do we read sensationalized reports of “over-medication” for diabetes? No we do not – quite the opposite. Publicly we are concerned about the increasing rates of diabetes and we want to address this problem effectively and comprehensively. So we advocate for better diet, more exercise and earlier diagnosis and treatment with medicines that help control blood sugar. This is different than what happens when we publicly address the issue of treatment for mental illnesses. In their case we seem to criticize the use of treatments known to be effective. This is quite the difference in approach, so we need to begin to wonder why.

I am not saying that medications are always properly prescribed and properly used in the treatment of children and youths living with mental illnesses. That is clearly not the case. And the proper use of these medicines needs to be improved. There is a great need to provide better education to doctors and all other health providers about how to best and most properly use medications to treat mental disorders in young people. We also need more research to help address some of the issues that we have not yet fully understood and we need to develop more sophisticated research studies that compare and contrast the use of medications with other forms of treatment so that we can get the complexity of care needs better understood.

So, I wonder why. Could it be that we as a society still somehow hold the fantasy that mental disorders really do not affect young people and thus they do not need medical treatments? Could it be that we hold invalidated beliefs about what works in the treatment of mental disorders in young people – a sort of herbs and spices model that we abandoned for such childhood diseases as cancer and diabetes long ago? Could it be that we do not really know the correct information about appropriate or inappropriate medication use and instead of trying to find out are just happy being intellectually lazy? Could it be that our understanding of brain function and brain development is so uninformed that we assume that any kind of medication that affects brain function will have more negative than positive effects but that for some unknown reasons other interventions, which also affect brain function, are somehow uniquely spared such concerns? Or could it be that we still hold a very very very strong stigma against children and young people that are mentally ill – and as a result would deny them access to properly researched and properly provided treatments?

These are serious issues. I will address a number of the important issues around medication use in young people in the next few blogs – starting with this: what does it mean for a medication to be used “off label”? Keep your eye on this space! If you want more info check out our evidence-based medicine guide for patients.

~ Dr. Stan Kutcher