I am sitting in the comfort of a rustling train as it bumpingly floats its way through the winter-white Nova Scotia countryside,  heading back home after four days of work in a rural part of a neighbouring province.

I am reading yesterday’s Globe and Mail.  The lead editorial headlines: “Those who read well at 15 succeed”.  And, the story is about a Canadian study reported by the OECD that young people who can read well at age 15 tend to do well in life and that young people who can not, do not.  It also reports the truly amazing finding (here I am being fascitious) that those youth who study do better than those who do not!

What insights! What revelations! What a surprise!  Teenagers who read well and study hard do well?  This is news?

Well, the news here is that reading ability is a good proxy measure for many problems.  We have known for a long time that the inability to read at grade level in grade three is predicitive of poor educational, social and vocational outcomes.  Seems that is also the case at age 15.  Reading is a complex skill.  Reading difficulties can be the result of psychosocial adversity, mental disorder, learning disability, or combinations of many factors.  Whatever the reason, reading ability is a “marker” that can be used to identify young people who may need help in sorting out what the problem is and then they can be given  personal assistance in addressing the problem so that they can become successsful.

So why are we not doing this?  Why are we not assessing reading levels in grade three and at age 15 in every single school in this country and using that assessment to identify young people and develop personal interventions that can help them be as good as they can be?  Why are we wasting large amounts of money on building self-esteem and other similar programs when the issue is not self-esteem?  Why are so hesitant to put our money and our efforts into those areas that are likely to bring the best results, particulary for those who need it?

From what I have seen, one reason may be that it is difficult and costly to provide the assessment and intervention services that young people who are having difficulty need.  So it is easier and perhaps cheaper to provide programs for the many that do very little, than interventions for the minority that may do a lot.

There is also a highly discriminatory ideology at play – not manifest but latent.  We do not want to “label” those who need help so we do not identify them and we do not provide them with what they need for success.  You see, “labelling” would hurt their self-esteem and would thus be unfair.  Instead we shunt them aside in favour of “helping” everyone (including mostly those who do not need any extra help).  This of course is more “fair” to those who need help as it denies them what they really need and sets them solidly on the road to poor outcomes. “Oh well, at least they were not labeled and their self-esteem did not suffer as a result”.

Is this fair?   Is this the right thing to do?  Not in my book.

–Stan

FINALLY, the Lancet (one of the world’s top medical journals) has retracted their publication of one of the most misleading articles in the history of modern medical  science – the now totally discredited piece on the relationship between autism and the MMR vaccine http://www.cbc.ca/health/story/2010/02/02/autism-mmr-lancet-wakefield.htmlt.

What took them so long?  It seems that the Lancet editors where the last in the world to know that the article was basic bunkum.  And why did they even print it?

If you can find me another article that uses the same low level of scientific evidence and flawed thinking that the Lancet has published in the last decade as this one used I will buy you a chocolate cookie. (Only one cookie per customer, just in case).  I for one have no idea about what the answer to either of those questions is.  But the fallout has been substantial.  It seems that large numbers of children died because they were not vaccinated.  And to what end?  Because a researcher (who it seems was in the employ of lawyers making lots of money suing vaccine manufacturers) published such poor science and because a learned journal did the publishing?

So what is a possible lesson here?   Although there are many, one most certainly is that one swallow does not a summer make.  That is, scientific knowledge is not built on one study, but on many, conducted by different and independent investigators, using best methods and techniques and scrutinized by peer review.  Is there the possibility that some studies will show one thing and others will show another?  For sure. Science is nasty, brutish and long.  Remember the word attributed to Mark Twain: “be careful reading a medical text book.  You may die of misprint”.

–Stan

Arguably, the area of mental health is the newest domain of health in using independent, empirically valid and scientific approaches to determining what works, for whom, at what financial cost and with what potential harm.  Perhaps because of this “newness” we seem to spend a lot of unproductive time arguing or discussing what we should be doing and frequently confusing opinion with evidence and often not understanding that all evidence is not equal.

The Health Development Agency of the National Health Service (United Kingdom), in a 2004 critical review of youth suicide prevention programs provided the following four criteria to be used in the application of all mental health programs:

1 – Apply good and effective interventions
2 – Avoid ineffective interventions
3 – Eliminate harmful interventions
4 – Facilitate public accountability

These seem pretty reasonable to me.

The problem we seem to have is making sure we do each of these things.  This is especially a difficulty when our pet theories or personal perspectives do not stand up to independent, substantive and appropriate scrutiny.  Yet these are the things that we need to do.

So here is a suggestion.  Before implementing any mental health program can those people charged with doing that simply tic off each of these four criteria.  Have you clearly and with the proper and most substantive type of evidence demonstrated that the interventions are good and effective?  Are you using programs or other interventions that have none or inadequate evidence of effectiveness?  Are you sure that your programs or other interventions do not cause harm?  Have you been open with the public about the effectiveness, cost effectiveness and safety of all the programs and other interventions that you have in place?

If not, why not?

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

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

Another  World Suicide Prevention Day (September 10, 2009) has passed and in many locations a variety of activities were underway across Canada, for example, community suicide awareness walks such as the one that has been initiated in New Minas/Kentville Nova Scotia and one that will be occurring in Halifax on the weekend following. The Canadian Broadcasting Corporation has presented a number of stories on the topic and the London Free Press newspaper has announced that it will publish obituaries in which suicide can be identified as a cause of death. The president of the Canadian Association for the Prevention of Suicide is quoted as saying that a national suicide prevention strategy is needed. All in all, there is increasing awareness of the importance of this issue nationwide.

Unfortunately, in all the media reports I have seen or heard on this issue there has been not one mention of what I consider to be the most important item that needs to be addressed. That is, based on solid scientific evidence we already know what to do to decrease suicide rates, so why are we not doing those things? Marches are good for raising awareness but do we need to march to put effective programs into place?

So what do we know helps bring down suicide rates? First of all is the identification and effective treatment of people who are living with a mental illness – especially depression, bipolar disorder and schizophrenia. Second is the reduction of access to lethal means – be that through control of handguns or barriers on bridges. Third is the creation of “gatekeeper” programs in organizations such as schools or similar institutions. In this way those individuals at highest risk can be identified and interventions provided to them. None of these are difficult to do. None of these are costly to develop and implement. So why are they not universally in place?

Health care systems are notoriously inert – change comes very slowly and often inefficiently. Stigma against the mentally ill pervades the health care system and providers are not immune from its insidious effects. Could this be a reason why those relatively simple and proven effective approaches are not already in place everywhere? Where are our legislators - provincial/territorial and federal? Why are they not demanding that these approaches are in place and properly supported? Perhaps it is because they feel no pressure to do so. Perhaps the scientific evidence and moral imperatives are not enough. Perhaps they need a push from the people.

So, what do I have to say about this? Walk on. Speak out. Demand change. Demand that what we already know works be implemented. Demand that we learn more. Crush the stigma and let the science lead us to do what works best!

Dr. Stan Kutcher

Sun Life Chair in Adolescent Mental Health

IWK and Dalhousie University

Promoting student health and well-being in school has long been a component of education. Traditionally, varsity athletics, school intramural sports programs and gym classes have stressed the importance of staying physically healthy through exercise. More recently, school-based sexual education programs have informed young people about the importance of sexual health, exposing students to issues of contraception use, gender identity, reproductive rights, and sexual behaviour. Nutrition has also made headway, with some schools banning high-caffeine/energy drinks and introducing healthier eating options into school cafeterias. But despite these advances, mental health – a fundamental part of student health and well-being – still remains largely absent from the education agenda.

According to the World Health Organization, mental disorders are the single largest health problem affecting young people. In Canada, approximately 15 to 20 percent of children and adolescents suffer from some form of mental disorder; which translates to one in five students in the “average” classroom. Furthermore, most major mental disorders onset prior to the age of twenty-five, making adolescence a critical time for the prevention and treatment of mental health problems.

Mental disorders can lead to serious consequences if untreated. They may impede a student’s emotional well-being and social development, leaving young people feeling socially isolated, stigmatized and unhappy. Mental disorders may also present significant barriers to learning. For example, students with mental disorders may have difficulty meeting academic standards or reaching their academic potential. These barriers can be so difficult to overcome that they may lead to chronic absenteeism or even school drop-out.

Early and effective treatment of mental health problems can substantially improve emotional and behavioural difficulties, thus reducing the number of days of school missed and reducing instances of contact with law enforcement. Treatment can also lead to improved social and behavioural adjustment, school performance, and enhanced learning outcomes. The earlier that mental health problems are addressed through appropriate effective interventions, the more likely that beneficial effects will be achieved in both the short and long term.

For all of these reasons, addressing the mental health of young people should be a priority for schools.

(Excerpt from “Mental Health: The Next Frontier of Health Education”, Education Canada, Spring 2009 - by Dr. Stan Kutcher, David Venn, Magdalena Szumilas)

Happy Canada Day!!

Canada has a proud history of valuing health care as part of the fabric of this country and as a basic right for all citizens. However, despite our commitment to overall health care, our attention to mental health care is overdue.

In Canada, approximately 1 in 5 children and adolescents experience some form of mental disorder. Most major mental disorders begin prior to the age of 25, making this period a critical time for the promotion and treatment of mental health problems.

One of the key initiatives of the Mental Health Commission of Canada is to develop a Mental Health Strategy for Canada. As part of the strategy the Child and Youth Advisory Committee of the Mental Health Commission of Canada will support the development of a framework specific to the needs of child and youth mental health.

We need your help!!

We invite all Canadians to share their thoughts and opinions in an online survey about values and principles relating to child and youth mental health.

TAKE THE SURVEY NOW

The survey will take about 30 minutes to complete (but you can save your answers and come back to it at any time).

It is important that we get the thoughts and opinions from as many different people as possible. Please pass this information along to your network, family, friends, or anyone who you think should join this consultation.

So after months of team discussion we have finally made our first foray into Facebook! Yeah I know … we are a little behind the trend - but better late than never.

Our goal is to get over 1,000 people to become a fan of our “Help Canada Create a Youth Mental Health Strategy” page.

The Facebook page is an offshoot of our Evergreen project - a collaborative initiative with the Mental Health Commission of Canada to produce a document to help improve policy and programming related to child and adolescent mental health across Canada.

We created the Facebook page for 4 primary reasons:

1. Engagement - we want people to share their opinions with us about what values and principles Canadians want to uphold in relation to mental illness and child and adolescent mental health services. On July 1st the public forum will be open for you to share your voice.
2. Education - an informed public is a strong public. Our Facebook page will feature some of the guides and information uploaded on our teenmentalheatlh.org site. We want to give people the best available info to make good decisions about their mental health.
3. Advocacy - the Mental Health Commission of Canada is committed to creating a comprehensive mental health strategy for Canada and are in support of a component specific to the needs of children and youth. Youth mental health will stay in the shadows unless we speak up and advocate for change - Facebook is just one of the ways you can speak up.
4. Connection - facebook is a great way to connect with people who share similar causes to you. By creating this page we want to connect people who care about youth mental health and want to make a difference to Canada’s mental health system.

Help make a difference for thousands of young people. Join “Help Canada Create a Youth Mental Health Strategy“.

Currently, Canada is the only G8 country without a National Mental Health Strategy. Recently, the Mental Health Commission of Canada (MHCC) was established with one of its key priorities to develop a Mental Health Strategy for Canada.

As part of the strategy the MHCC will support the development of a framework specific to the needs of child and youth mental health. The proposed framework, entitled Evergreen, will complement and provide child and youth context to the Mental Health Strategy for Canada.

What is Evergreen?

Evergreen is a collaborative project that will produce a framework to help improve policy and programming related to child and adolescent mental health across Canada.

What is a mental health framework and why is it important?

Think of a framework like a blueprint for a house. If we want to build the best house, we need to create the best plan to design it and hire the best people to build it. Canada’s mental health system is no different. Frameworks help keep everyone on the same page, working together towards a common goal – to develop a mental health system that effectively meets the needs of its consumers.

Who will Evergreen affect?

Everyone. There is no health without mental health. A national child and youth mental health framework can be useful to assist provinces, territories and organizations to enhance their child and youth mental health strategies, policies and plans. Evergreen can also help to raise public awareness of the importance of addressing child and youth mental health needs, while helping to decrease stigma associated with mental disorders.

How is Evergreen being created?

The Evergreen framework will be collaboratively constructed by professionals, youth, parents and members of the public from all regions across Canada who have expertise, interest or experience with mental health and mental illness. In the end we envision the framework to be among the most comprehensive and scientifically-based child and youth mental health frameworks in the world

WE NEED YOUR HELP!!

To make this framework truly unique and successful we need your input. We need you to tell us what values and principles Canadians want to uphold in relation to mental illness and child and adolescent mental health services. We also need you to help share this initiative with others who can contribute.

The public forum will be online July 1st. When it’s ready our site and MHCC will link to it. Until then … spread the word!