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

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

Today I saw an article about the movie Avatar.  This article tells all who read it that this movie is causing people to become depressed and suicidal.  What a bunch of journalistic hokum. (http://www.news.com.au/entertainment/feature/avatar-perfection-causing-depression/story-e6frfnv0-1225819063598). 

What this likely illustrates is what a topic of a previous blog has been: the inappropriate use of the word “depression”.  People do not become clinically depressed after watching a movie; they may however experience a variety of negative feelings (or sometimes positive feelings).  We do not call the feeling state that a movie such as Chariots of Fire engenders “mania”.  No, on the contrary.  We call it; uplifting, joyous, awesome, elevating, etc.  Why do we call negative feelings “depression”?

There are so many other words to use.  Our language is so rich in words that describe affect.  So let’s use some of them: dispirited; demoralized; dysphoric; distressed; disgruntled; disaffected; pathic; etc. And while we are at it, lets give reporters who may not know how or can not be bothered to write clearly. (or  who are using emotive words to sell copy),  a clear message that these headlines are of no value in furthering our understanding of the human spirit.  Can a movie stir our emotions? Totally!  Does it cause mental disorder?  No!

–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

Recently I wrote a post on mental health in the palm of your hand - exploring how technology and iPhone applications were being used to share medical and mental health information.

Following that post I contacted Dr. Harvey Castro at Deep Pocket Series to ask him about Sad Scale - a self screening Depression test and iPhone application tool.

Understanding the need for a Depression scale for children, Dr. Castro worked with our team to adapt the Kutcher Adolescent Depression Scale (KADS) for use on the Sad Scale application.

The KADS, along with the Center for Epidemiological Studies Depression Scale for Children (CES-DC), are now available on the Sad Scale. These applications will give you a graph on your progress and will also allow you to email your health care provider the results of the test.

The iPhone application is available now and can be downloaded for $0.99 from iTunes.

We are now adapting the Kutcher Generalized Social Anxiety Disorder Scale for Adolescents (K-GSADS-A) … stay tuned! (literally)

~ David Venn

Last week I blogged about an animation film project we co-developed with ViewFinders. I posted some of the videos from the camps. Here are the rest of em. Enjoy!

This past March Break the Sun Life Financial Chair in Adolescent Mental Health partnered with the ViewFinders International Film Festival for Youth to host a free animation film camp for budding filmmakers (ages 12-18).

The purpose of the camp was to allow youth to express their creativity and learn about the film-making process. Participants were asked to explore the topics of mental health and mental illness and create a short films about what mattered most to them.

The films were screened as part of the ViewFinders International Film Festival last April and are now being taken on the road and shown to schools and community groups across Atlantic Canada.

The documentary was filmed during the week of the camp and highlights the importance of talking about mental health problems. I’ve uploaded three films created as part of the camp. I’ll upload the rest next week.

Thanks to all the youth, film instructors and ViewFinders organizers who made this possible! A special thanks also to the T. R. Meighen Family Foundation for their financial support.

DOCUMENTARY

ANIMATED MINDS FILMS

(Disclaimer: Youth participants were provided with information about youth mental health, however some of the statistics in the videos are inaccurate)