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

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

Today’s Los Angeles Times carried a front page local story regarding youth suicide in Palo Alto: “Palo Alto campus searches for healing after suicides”.   Although details are sketchy and of course incomplete, the story points out that there has been a cluster of suicides involving students from the same school campus over a short period of time, occurring in the same place and under similar circumstances.  As expected, such tragic events have caused substantive community consternation.

Youth suicide is a very emotional issue.  It cuts to the very core of our families and our communities.  It leaves scars in parents, siblings, grandparents, other family members, friends and many others.  It elicits strong responses from individuals or from communities.  Some of those responses are of grief – private and shared with only a few.  Some of those responses are very public – it is not clear what motivates them or how these differ from the private responses.  Some of these responses may be helpful – such as support and counseling from family and friends.  Some of these responses may be harmful – such as bringing in grief counselors and creating community emotional contagion in the wake of a suicide.  Some of these responses may be neither helpful nor harmful – but may be costly.  So, what can be done?

Here the evidence is not fully in yet and each situation begs careful assessment and considered planning before anything is started.  What is not helpful is putting into place those things we know do not work.  What is likely not helpful is grief contagion.  This can be created by mass grief counseling and enthusiastic and well meaning initiatives to “do something”.  What may be useful is identifying young people who know the victims and addressing their mental health needs and emotional concerns.  What may be useful is for the newspapers and television and radio stations to stop running front page stories and prime time news about youth suicide.  This does not mean that we do not talk about it.  This does not mean that we avoid the topic.  Not at all!  This means that we address this tragic and emotionally issue rationally and responsibly.

-Stan

September 22, 2009

Recent events in the National Basketball Association (NBA) involving two high profile players, Delonte West and Michael Beasley have highlighted the issue of mental health in the NBA.  And, this is an important step forward, not only for the NBA in specific but for professional sports in general.

Professional athletes are no less likely to suffer from mental disorders than the general population.  We can expect that approximately 10 to 15 percent of professional athletes will have significant and substantial mental health problems, including mental disorders.  The most common mental disorders will be: depression, anxiety disorders and substance abuse.  A few may have bipolar illness or other psychotic conditions.

These disorders will affect them in both their personal and professional lives.  Athletes living with mental disorders can expect to have the same challenges that people who are not athletes but who are living with mental disorders have.  These include but are not limited to personal problems and decreased job performance.  One important difference however is that professional athletes are very high profile.  Their lives are often lived in a public arena.  When they have problems these are difficulties are known to the many, not only to the few. 

When mental disorders in professional athletes lead them to experience personal and professional difficulties these can be publicly addressed in positive or in negative ways.  One positive way may be for their employers (professional sports teams) or their associations (players associations, professional leagues such as the NBA , the NHL and others) to publicly acknowledge these difficulties – much as they now do with physical illnesses or injuries.  Another way may be for the players themselves to be open about their problems and to discuss them much as they discuss any physical injuries or other similar issues.  Another way may be for the sports media to become more knowledgeable about mental health problems and mental illnesses and to write their stories from a position of understanding.

Mental disorders affect everyone – including professional athletes. How they, their employers and the media handle these issues may have an important impact on how society in general and youth in particular understand mental illness.  Its time for professional sports to get “on side” – so to speak.

-Stan

Recent reports from the BBC highlight the complexities of helping people with psychotic illnesses – specifically schizophrenia, live symptom free and positive lives. 

The first story “NHS ‘failed’ over cannibal killer” presents an all too common media response to the extremely rare and thus somehow newsworthy bizarre homicide involving a person suffering from a mental disorder and the problems encountered in better understanding and assisting such individuals from people working within the mental health system.  While better training and more careful assessment procedures are in and of themselves important, it is hard to see what such news stories accomplish – except to perpetuate the stigma against people living with a mental illness and those who treat them.

The other story “Embracing the dark voices within” describes the approach (one that is unencumbered by evidence) of a person described as psychologist Rufus May.  What I can glean from this story is that the so called treatment involves getting in touch with your psychosis (voices) in the absence of medication.  Oh dear – here we go again.  This is nothing new and we have seen the chaos and destruction of lives and families that such idiotic ideologies have created in the past.  Those of us old enough to remember the psychoanalytic schools of living through the psychosis or the negative impacts of community circles or the strange world views expressed by the popular “philosopher” R.D. Laing in his books: Bird of Paradise and Politics of Experience or the sad “treatment” described in the novel “I Never Promised You A Rose Garden” shudder when we see history repeating itself.

Schizophrenia is a highly complex and disabling brain disorder often striking in the teen years.  We have good evidence on how to provide treatment – evidence based on solid science and many years of improvements and the integration of biological, psychological, social, vocational and civic engagement strategies to promote recovery.  Regressing into the darkness of the uninformed past is not news – just as the rare and bizarre homicide is not news.  Neither serves the better understanding of mental illness and its optimal treatment. 

I would really like to see some stories about how young people have coped with and overcome their disability.  I would really like to see some stories about how families have struggled with the adversities wrought by the illness – and have come out on top.  I would really like to see some stories about the human relationship between care providers and those living with the illness – the relationships that have gone on for years and have provided the basis for recovery and success.  Now, who can we find to write those stories for the BBC?

-Stan

Try playing this little game with a friend, parent or co-worker.

Ask them to list three adjectives that describe a person with mental illness. Then ask them to list three adjectives that describe a person with breast cancer. Finally, ask them to list three adjectives that describe a friend.

More than likely the person will use words like “crazy”, “sad”, “depressed”, “lonely”, “patient”, “consumer or victim”, “scared”, “down”, “violent”, etc. to describe someone with a mental illness.

In describing someone with breast cancer they will likely use words such as “strong”, “confident”, “undeserving”, “survivor”, “thriving”, “family connection”, etc.

And in describing a friend the person will likely use words like “fun”, “caring”, “happy”, “smart”, “loyal”, “honest”, “responsible”, etc.

See the difference?

Whether you play this game with youth, parents, educators or even health professionals you get the same result - positive words to describe a friend or a  physical health problem like breast cancer and negative words to describe a mental illness like Depression.

And what if the your friend had Anxiety Disorder or Depression? Would that change your perception of them as a fun, smart, caring, loyal person? Would they suddenly be relegated to being a crazy, lonely, scared patient?

The stigma surrounding mental illness runs deep. It is embedded in our actions, our culture and our language.

Imagine a time when we describe and perceive people living with mental illnesses the same way we describe and perceive our friends or people living with physical health problems!

In the past few weeks I’ve come across several advertising campaigns aimed at raising awareness about mental health problems. Two in particular focusing on Autism and Eating Disorders caught my attention (you can see why below).

Advertisers know what “sticks” when it comes to marketing: sex, shock and emotion. These approaches can be effective ways to sell products or promote a brand identity - but how well do they transfer into the world social awareness? Or for that matter mental health?

SEXY

The people at Sociological Images alerted me to this Rethinking Autism ad campaign. The RA site maintains that:

“All too often in the world of autism, celebrity and sex appeal are used to promote pseudo-science that exploits autistic people, their family members and the public.  We decided to put those very same factors to work in service of the truth.”

This is a clever ad. It’s information is scientifically-based and it captures your attention.

But is it effective?

While I get the tongue-in-cheek reference that Autism has become a “sexy” topic of discussion, I question whether the core message gets buried beneath a sea of lingerie.

The Rethinking Autism website claims to want to “change the conversation one video at a time”, but are we changing the conversation towards Autism and debunking pseudo-science or does the ad instead meander towards a debate about the objectification of women as sex objects. If the latter then the message is lost.

EDGY

Next up is a series of ads from the Looking Glass Foundation for Eating Disorders based in Vancouver BC.

The ads are edgy alright - but their message is misleading. The tagline in the ads is “Not every note is a suicide note” - which falsely implies that eating disorders are a method of suicide. We know this is not true.

So while the ads are effective in shocking us, they do little to advance discourse because of their false message - in fact they may even perpetuate the myth that eating disorders are motivated by suicidal intent.

EMOTIONAL

Finally an anti-stigma ad campaign from the Mental Health Foundation of Nova Scotia (see video on their homepage).

The ad uses personal narratives, emotional music and dream-like backgrounds to tell a story. In under a minute the video captures the pervasive stigma that accompanies mental illnesses, touches on the scientific basis of mental disorders as brain disorders, points to the need to improved resources to meet the needs of those living with mental illnesses and challenges the viewer to talk more openly about mental illness and mental health.

Effective doesn’t have to be flashy and this ad is a great example of the power of emotion and story to communicate an important message.

~ David Venn

The case of Vince Li, the man who beheaded a victim aboard a Greyhound bus last year, made international headlines yesterday as judge ruled Mr. Li was not criminally responsible due to mental illness. The ruling means that Vince Li will be treated in a mental institution instead of going to prison.

While the ruling is probably the right one, the resulting media frenzy is doing little to dispel the myth that people with mental disorders are violent. It also begs the question: what is the role and responsibility of media in reporting on cases that involve mental illness?

A selection of headlines from major news networks clearly seek to sensationalize the case of Vince Li and in the process make a link between violence and mental illness :”Canada judge: Vince Li not responsible for bus beheading due to mental illness” (Associated Press), “Canada bus killer found mentally ill” (The West Australian), “Judge rules bus beheading suspect mentally ill” (CNN.com), “Crazy bus cannibal sent to mental institution” (Healthcare Industry Today). Even accompanying photographs (like the one above) attempt to “demonize” Li again reinforcing the idea that people with mental disorders look frightening.

While some people who suffer from mental illness do commit antisocial acts, mental illness does not equal criminality or violence - despite the media’s tendency to emphasize a suspected link (e.g. psychotic serial killers). In fact, people with mental illness are no more likely to commit violence than the general public, but they are 2.5 times more likely to be victimized and are more likely to inflict violent behaviours on themselves. Furthermore, the general public is more likely to be violently victimized by someone who does not have a mental illness rather than by someone who suffers from mental illness.

From Reuters:

According to Chris Summerville, the Chief Executive Officer of the Schizophrenia Society of Canada, the likelihood of violence by people with mental illness is exceptionally low. In fact, people living with mental illness are more often the victims of violence. “Fortunately, studies show that when people who were or would have been dangerous receive psychiatric treatment they are no more dangerous than people without a diagnosis. But they have to receive the treatment,” says Dr. John Gray, a board member of the British Columbia Schizophrenia Society.

Some evidence suggests that certain medications might rarely be associated with aggression, but this doesn’t mean there is a link between psychiatric medications and violent behaviour. In fact, the drug that is most often associated with aggressive behaviour is alcohol! Many medications used to treat mental disorders are also helpful in treating violent behaviour. It is important to remember that the best known predictor for future violent behaviour is past violent or criminal behaviour, not mental illness.

While a tragedy of this scale is awful, it can lead to constructive discussions about the need for improved care and a national mental health strategy.

This tragic event reinforces the urgent need for a national mental health strategy. Despite the significant health, economic and social costs of mental illness, Canada is the only G8 nation without a national strategy on mental illness. Summerville who is also a board member of the Mental Health Commission of Canada, says, “In many areas in Canada, there is a lack of psychiatric beds as well as lengthy wait times to access appropriate mental health care.” He adds, “If there were not a comprehensive hospital or community services for people with cancer, heart problems or other medical conditions, we as a society would be outraged. Stigma and the lack of social and political will have resulted in Canada’s failed mental health system.”

Canada has recently made some important strides in addressing mental health and mental illness. The establishment of the Mental Health Commission of Canada is indeed a vital step. But unfortunately it may be some time before the national discourse and media coverage of people with mental illness catches up, and we stop stigmatizing and sensationalizing people living with mental illness.

~ D. Venn & Dr. Stan Kutcher