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

Interesting story in the Toronto Star. Seems that some bright inventor decided to apply restaurant technology to hospital clinics and ER waiting rooms. So, (wait for it) here is the amazing way forward! Yes, you guessed it – beepers. http://www.thestar.com/news/sciencetech/article/828089–the-wait-is-over-laval-inventor-tackles-waiting-room-frustration. Mrs. Jones, your table, er… guernsey is waiting. Please slip on this johnny gown with the gap at your backside and wait behind this curtain. Your health provider will be here sometime before H-ll freezes over. Actually, if you happen to be a patient with a mental health crisis it could take much longer than that.

If I had a dollar for every hour that a patient with a mental health crisis had to wait to be seen by the emergency physician in many of the hospitals that I have known, I could have retired a wealthy man. Why is it that people who have a mental disorder end up at the back of the line? Surely it can not be because of stigma in health providers? Surely it can not be because of inefficient care pathways? Surely it can not be because of inadequate numbers of mental health providers?

Maybe it is all of the above. In that case, you can hand out as many beepers as you want and nothing will happen. Mrs. Jones, your bed is ready for you. Sorry it took seventeen hours to get you there. If only you had a broken leg instead of a depressive psychosis accompanied by severe suicidal ideation we could have done a bit better. And your beeper? Please put it in that box over there. Mr. Watson will be needing it next. We only have one available for psychiatric patients and he has already been here six hours.

–Stan

We have known for a long time that the majority of mental disorders begin before age 25. We have also known for a long time that early onset mental disorders are a risk for many poor short and long term outcomes – indeed that is why we recommend early identification and early effective treatment. So that we can try and prevent poor outcomes and enhance good outcomes.

So a recent study, just published has found that for each person (on average) who has an early onset mental disorder it costs her/him over ten thousand dollars per year when they are an adult – that is correct: PER YEAR. This is compared to what their siblings make. ! OUCH!

So, as you know, I am a strong advocate of early identification and early effective treatment for mental disorders. It is simply not right that we do not meet the mental health needs of children and youth at the time that they need the help most – right after they get sick! We know that not providing care early leads to a host of poor outcomes for the person and for our society. Now we have additional information – this is the personal cost – over ten thousand dollars per year! Think of the effect that has on life and wellbeing. Think of what negative spiral effect that could have – poverty, use of food banks, etc. Think of the loss of tax revenue and the impact of lower incomes on the lives of their families and the wellbeing of their children. Not only is this not economically unacceptable, it is simply not fair.

Hey governments. Hey society. Hey banks and wealthy corporations. Hey citizens. It is time we made the investments early on. We can not afford not to do that!

–Stan

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

Wow.  Shocking.

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

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

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

So – bottom line.  Show me the evidence.

–Stan

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

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

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

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

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

–Stan

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

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

Last week, there appears an article in the San Francisco Chronicle about suicide deaths due to jumping from the Golden Gate Bridge http://www.sfgate.com/cgi-bin/blogs/inmarin/detail?&entry_id=55733.  According the Chronicle, last year there were 31 deaths, the year before that there were 34.  Over 1,300 people have died by suicide from jumping from the bridge since it was built.

And what is the essence of the story?  Apparently the Marin County Coroners Office wants to recommend suicide prevention barriers and this is controversial.  And guess what – more studies are apparently recommended.

Now, readers of this blog know how committed I am to research.  You also know that I am committed to action.  Will putting up an appropriate barrier decrease the rate of successful suicides by jumping from the bridge?  Highly likely.  Is this a good thing.  For sure.  So why is it not being done.  Who knows?

I remember the hard work that went into getting barriers erected on the Bloor St. Viaduct in Toronto.  There the effort was lead by a young man with lived experience of mental illness.  I know of the hard work that went into getting a barrier erected on the MacDonald Bridge in Halifax.  There the effort was lead by a mother who had lost her son to suicide from the bridge.

It the courageous activity of people like those Toronto and Halifax citizens that seems to be necessary before authorities can act.  I am so proud to know and support those leaders and I thank them for everything that they have done and continue to do in this regard.  What I don’t get is this.  Why is it so hard to do the right thing when it comes to mental health action?

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

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