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

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

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?

A recently published study about the relationship between sleep time and depression in teens (http://behavioralhealthcentral.com/index.php/20100111172002/Special-Features/teens-who-dont-get-enough-sleep-risk-depression-and-suicide.html) has many people confused.  It was a co-relational study and thus does not confirm causality.  So it is not possible to conclude that going to bed late causes depression in adolescents.  On the other hand, the study does bring the spotlight back on the well known scientifically but less well appreciated complex relationship between sleep and depression in teens.

We have known for a long time that sleep is disturbed in teen depression.  We have also known for a long time that the usual sleep architecture (that is how the different stages of sleep happen during the night) is disturbed in teen depression.  We also know that some teens who get depressed show subtle changes in their sleep architecture before they get depressed. Many years ago my research team reported those findings and we also showed that there were abnormalities in hormone secretion at night in depressed teens. And, we know that forced waking early in the morning may improve symptoms in depression.  So there is clearly something happening in how the brain controls mood and how it controls sleep.

But, it is simplistic and wrong to assume that setting late bedtimes for teen’s causes depression.  This is not the case and it would be foolish to try to tell parents and teens that going to sleep before midnight is protective against depression.  However, there is much for us to learn about sleep and depression in teenagers.  And there is a growing interest amongst researchers in this area.  So stay tuned!

–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

Great post on Teens Who Self-Harm by Marie Hartwell-Walker, Ed.D. over at Psych Central.

In the blog Marie Hartwell-Walker encourages that “Self-harmers need to be understood, not scolded. They need to unlearn the idea that their feelings are “wrong” and learn that it’s okay to feel them. Most important, they need to learn new ways to manage stress and emotions that they find overwhelming.”

Also we just linked up with Dr. Mary Kay Nixon and her team of the Interdisciplinary National Self-Injury in Youth Network Canada (INSYNC). Lots of great info for youth, families and professionals.

For some interesting and powerful reading on self-harm I recommend the books Cut by Patricia Mccormick and Skin Game: A Memoir by Caroline Kettlewell

Teenagers are known for risk-taking, novelty seeking, reckless behaviour and impulsivity.

Risk-taking behaviour can take on many different forms, including the misuse of alcohol or drugs, engaging in unprotected sexual activity, some types of criminal activity or risky, adrenaline-producing sports like skydiving or motocross. While you may not have done all of these things, the majority of adolescents and young adults report participating in one or more risk-taking behaviours.

One reason for this is that the teenage brain is less able than the adult brain to inhibit impulsive behaviours. Adolescents become more able to control their behaviour as their brains mature, but efficient control of impulsive acts is not fully developed until adulthood. When teenagers are faced with a reward, the “reward” systems of their brains are disproportionately active compared to the “control” systems (which are later to mature). This makes it difficult for teenagers to be in command of their reward response, and makes them biased towards immediate gain over long-term gain.

A recent article on medicalnewstoday.com highlighted this shortsightedness of youth

According to popular stereotype, young teenagers are shortsighted, leaving them prone to poor judgment and risky decision-making when it comes to issues like taking drugs and having sex. Now a new study confirms that teens 16 and younger do think about the future less than adults, but explains that the reasons may have less to do with impulsivity and more to do with a desire to do something exciting.

Compared with adults, the researchers found, teenagers consider the future less and prefer immediate rewards over delayed ones (for example, $700 today versus $1,000 a year from now). But it may not be impulsivity that guides their lack of forethought. Instead, the study found that teens are shortsighted more due to immaturity in the brain systems that govern sensation seeking than to immaturity in the brain systems responsible for self-control.

While the origins of risk-taking behaviour in adolescents have been debated for a centuries and many explanations ranging from hormones to social pressures have been endorsed. But the truth is we are still not completely sure why adolescents and young adults are more prone to risk-taking behaviours.

We do however know that part of the answer lies in the way that brain development occurs during this part of the life-span and that risk-taking behaviors often decrease as the young person matures into adulthood. It’s the complex interplay amongst brain development, personality characteristics and the environment that lead to differences in risk-taking behavior amongst young people.

Interestingly, recent research suggests that the perception of risk does not vary greatly with age, but rather within the type of decision-making information that adolescents and adults use. So even though adolescents may be more prone to engage in risky behaviour, they are not irrational, unaware, or believe they are more invulnerable than adults. These findings suggest that young people certainly have the frontal lobe capabilities to self modulate risky behaviors – provided they understand how to do so.

(Great article from UC Davis Magazine about “What parents should tell college students about risky behavior . . . even if they don’t listen.”)

~ Dr. Stan Kutcher