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

Just had a chance to read a report put out by well meaning people on the topic of suicide prevention in youth. In that report the author kept repeating about the many community and school-based programs that have been proven to prevent youth suicide. While I wish that this was true, it is simply not the case. So I am going to write a few blogs about how we know if a program actually prevents youth suicide or not. The first issue is what does the program measure as an outcome?

If a program intends to prevent suicide it must measure suicide. No other measure can be substituted. To my knowledge, there is no data available on this key outcome variable in reports about these community and school-based programs. Instead, we read that some programs increase knowledge about suicide or even decrease the incidence of self-harm behaviors over a short period of time. These are what we call proxy measures and these do not predict changes in suicide rates. We have many examples of interventions that change proxy measures and yet have no impact on the key outcome measure. You can not determine the depth of a well by measuring the length of the pump handle!

Unfortunately, too many people use these proxy measures as “proof” of suicide prevention and go about putting these programs into place. This is a big problem. Not only do we not know if these programs decrease suicide or not, but we do not know if they do any harm! Some early research showed that well intended school interventions actually increased suicide rates! And, guess what, the decrease in suicide rates begin well before suicide prevention programs were put into place and occurred in locations where these programs never existed!

“Fools rush in where angels fear to tread”. “It is not enough to do something. It is imperative that we do the right thing”. “The road to hell is paved with good intentions. Remember all these cautions?” Could be that they apply to so called suicide prevention programs also?

–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

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?

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