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

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

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

So what is this with sleep anyway?

Given what we know at this time, sleep is necessary for brain growth and development.  It is also fundamentally necessary for academic success.  For example, when we sleep, we learn.  Important memories from the previous days are consolidated and the capacity to learn for the next day is refreshed.  And, during the teen years, with the accelerated brain growth and re-organization that occurs during those years – youth actually need more sleep than when they were children.

During the teenage years the child pattern of getting up early and going to bed early shifts to going to bed later and getting up later.  And at the same time, the brain’s need for total sleep time increases – as much as an hour or more per night.  When accentuated by the digital and light enhanced evening environment, staying up later and later becomes the norm for many teens.  And, because the school day usually starts fairly early, students (as the research has shown us) are frequently sleep deprived, sleepy and not at their optimal learning capacity – especially in the first hour or two of classes.  This pattern leads to not enough sleep during the week and this leads to sleep debt – time that needs to be repaid – you guessed it – on the weekend!  This results in a pattern of about 2 hours difference between usual sleep/wake patterns between school days and weekend days for many teenagers.  This is equivalent to a jet lag of 2 hours.  And that happens mostly every week!

One obvious solution to this problem is starting the school day later for high school students.  Indeed, some studies have reported that this results in improved academic performance and one study in Kentucky also found fewer automobile accidents during the later school start trial.  However, this accomodation to the changing teen brain has not proved to be popular with education officials and across most of Canada and the USA, schools still start early and teenagers still come to class tired and not ready to learn.  And guess what?  In many places, exams (including those that take an enormous amount of concentration – such as mathematics) are frequently scheduled for early in the morning! 

So what can be done about this?  Well, changing the school day is not likely to happen, but that would be a really good idea.  Just think, setting up a school protocol to meet the needs of the students – what a novel idea!  For the individual student, trying to get to sleep a little earlier (even one hour earlier) would pay big dividends.  And if that is just as hard as changing the school start time – at least get a good nights sleep before your exam.  Staying up all night and cramming is not helpful.  Getting your beauty rest is.  Isn’t science grand?  Did your grandmother tell you this at some time?

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

We’ve had a lot of great feedback from our post on schools as the next frontier for mental health education.

We all know the problem. Mental disorders represent the most common and disabling condition affecting young people and therefore have major implications for students and for schools. In short, mental health problems affect a student’s emotional well-being, their ability to learn, are a factor in why some students drop out of school.

But too often we focus on the problems instead of the solutions. In a recent article entitled “Mental health in schools: how teachers have the power to make a difference” for Health and Learning Magazine, Dr. Kutcher, Leigh Meldrum and I outlined a three-pronged approach to address mental health problems in schools. Here’s an excerpt:

Schools can be an important location for mental health promotion, early identification and intervention, combating stigma associated with mental illness and possibly providing interventions and ongoing care. But as a teacher, what can you do to make a difference in the mental well being of your students? The answer is not always easy, and requires cooperation at all levels of the education system and a positive collaboration with health care providers.

Using the classroom for stigma reduction

One of the largest obstacles facing youth with mental illness is the associated social stigma against people living with a mental disorder. While the scientific understanding and treatment of mental disorders, as well as the awareness of the importance of mental health in all aspects of life, has advanced considerably in the past decade, the public’s perception about people with mental illness has been much slower to change.

In the classroom, stigma associated with mental illness can affect how teachers, classmates, and peers treat the student living with a mental disorder. School-based anti-stigma activities present an opportunity to enhance understanding of mental illness and improve attitudes towards people living with mental illness. Furthermore, school-based anti-stigma activities reach people on all social levels, from teachers, principals and administrators to parents and community members to most importantly, the students themselves.

Identify and intervene!

Early identification and effective intervention for youth with mental disorders is critical. If left untreated, the symptoms of a mental illness may increase in severity, and its effects may become more serious and potentially life threatening. Educators and school personnel are in an ideal position to recognize behavioural or emotional changes, which may be symptomatic of the onset of mental illness.

By providing training related to youth mental health and mental disorders in young people that is specific to educators we will be better equipped to protect and promote the mental health of our youth. Educator-specific programs, such as Understanding Adolescent Depression and Suicide Education Training Program, addresses the signs and symptoms of depression, as well as risk factors for suicide, methods of identification and appropriate referral of high-risk youth. The basis of this innovative Canadian program is supported by documented evidence of effectiveness and has been demonstrated to improve mental health literacy in educators and health professionals.

School curriculum meets mental health promotion

A potential starting point for the integration of mental health care into existing school health systems is through the implementation of a gatekeeper model. A gatekeeper model provides training to teachers and student services personnel (such as social workers, guidance counseling, school psychologists) in the identification and support of young people at risk for or living with a mental disorder. It also links education professionals with health providers to allow for more detailed assessment and intervention when needed.

Schools can also address students’ mental health through the implementation of mental health promotion strategies through innovative curriculum initiatives. Improving mental health literacy through curriculum development and application could enhance knowledge and change attitudes in students and teachers alike, and embedding mental health as a component of health promoting activities could enhance mental health while decreasing stigma associated with mental disorders. Two examples of recently developed Canadian mental health curriculum for schools are: Healthy Minds, Healthy Body (Province of Nova Scotia) and the Secondary School Mental Health Curriculum (Canadian Mental Health Association).

Read the full article online in the May 2009 issue of Health and Learning.

~ David Venn

FOR IMMEDIATE RELEASE July 30, 2009

As millions of college students graduate college this year, mtvU, MTV’s 24-hour college network and The Associated Press today revealed the results of a new poll examining the emotional health of college students as they face a global recession and a receding job market, finding that more than half of college seniors are worried they won’t be able to secure a job after graduation.

The study finds that although financial pressures are a major source of daily stress, they do not surpass worries about academic performance. The economy has definitely taken a toll with concerns about finding a job ranking high among stressors, and intensified struggles reported by the almost one in five students whose parents have experienced job loss. Additionally, an alarming number of college students are struggling with mental health issues, but many are not actively seeking out the help that they need. Despite all of this, young people are generally happier than they were last year, are adapting to their environment by switching their majors, going to graduate school or making other proactive changes in their lives, and maintain positive attitudes about the value of their college experience.

The mtvU and Associated Press study follows a month of on-air and online mtvU programming exploring how college students are impacted by increasing financial pressures as part of mtvU and The Jed Foundation’s ongoing “Half of Us” campaign. A similar study examining the impact of stress, mental health struggles, the economy, and other issues facing college students was conducted in 2008 by mtvU / AP in conjunction with “Half of Us.”

Detailed findings from the 2009 study include:

STRESS ON CAMPUS

With 85 percent of students reporting that they experience stress on a daily basis, up from 80 percent last year, it’s clear that stress is a prevalent factor on college campuses today. However, even in light of larger national issues, academic concerns like school work and grades, with 77 percent and 74 percent respectively, maintain their positions as the top drivers of student stress. Financial woes followed close behind, with 67 percent stating that money matters accounted for a lot or some of their daily stress.

In the face of stress and uncertainty, 82 percent maintain positive attitudes surrounding their college education, feeling that it has been worth the time and financial investment.

At the same time, the study shows that stress is taking a serious toll on the everyday lives of college students, affecting them academically and socially:

• Six out of 10 students report having felt so stressed they couldn’t get their work done on one or more occasions.
• 53 percent of students report feeling so stressed they didn’t want to hang out with friends on one or more occasions.

DEPRESSION, SUICIDAL THOUGHTS AND GENERAL MENTAL HEALTH

The mtvU/AP polls from 2008 and 2009 confirm that mental health struggles are common among the college audience and continued efforts are needed to educate students on avenues for seeking support. When stress becomes excessive and impacts a student’s ability to function, it can have severe consequences, especially for students with a mental health condition. Low energy levels, sleep troubles and appetite issues are among the most common indicators of emotional health problems experienced by students, and nearly one out of every 10 students are reporting signs of moderate to severe depression, and an alarming number of students have reached crisis mode:

• 17 percent of students overall report that their friends have talked about wanting to end their lives.
• 10 percent report having a friend who has made a suicide attempt.
• Seven percent report that they have seriously thought about ending their own lives in the past year.

84 percent of students know where they would go for help if they were coping with emotional distress, with 77 percent turning to friends and 67 percent reaching out to their parents for help. Only half of students report that they are familiar with counseling resources available on their campus, and even fewer students actively seek them out. Among students reporting symptoms of moderate to severe depression, 47 percent of state that they are not familiar with the counseling resources available on their campuses, and only 32 percent received any support or treatment from a counselor or mental health professional since beginning college.

Additional findings from this poll can be found at http://www.halfofus.com/press.aspx.

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)

Excerpt from the latest issue of Canadian Psychiatry Aujourd’hui:

Mental health problems are the single most disabling health disorder affecting young people, according to the World Health Organization. In fact, about 15 to 20 per cent of children and adolescents in Canada are suffering from some form of mental disorder.

The adolescent years are thus a critical window in which mental health can be promoted and problems can be addressed in a manner that will improve mental health and de-stigmatize mental illness.

Within the “average” classroom, three to four students will suffer from some form of mental disorder, making schools an ideal place to address mental health promotion, introduce targeted mental health interventions and stigma reduction, as well as address the linkage between mental disorders and learning.

Many schools, particularly at the post-secondary level, are trying their best to help their students recognize and address problems. Early identification of mental health issues is an important first step. If left untreated, they can affect student success in three major ways.

First, mental disorders affect the emotional well-being of students. If left untreated, they can hinder a young person’s social development, leaving them feeling isolated, stigmatized and unhappy. To deal with these problems, some may turn to socially or personally inappropriate methods of coping, such as violence, drugs or alchohol. Mental disorders may also impact a young person’s capacity to develop and keep a strong and supportive peer network, including positive relationships with adults.

Second, mental disorders may present considerable barriers to learning since most mental illnesses are characterized by unique learning challenges. Studies have shown that poor social-emotional functioning and difficulty meeting academic standards are two common obstacles for students with mental disorders. Some illnesses, such as learning disabilities and attention deficit disorder, present distinct challenges to successful learning. These problems can then continue as young people transition to the workplace, thus decreasing the likelihood of vocational success.

And third, mental disorders are a factor in why some students drop out of school. About 15 per cent of youth attending post-secondary school drop out before finishing their program (Statistics Canada, 2004). Students cite many reasons for dropping out of school, but near the top of the list are reasons relating to their mental health. Sadly, many of these dropouts could be prevented with early and effective interventions.

When you combine these issues with all of the other social and academic pressures facing young people, it is no wonder that some students find the transition from secondary school to college or university to be difficult.

The transition into a new educational and social environment can create stress that some students are ill-equipped to manage. Moreover, the period between the ages of 18 and 25 is the time when many mental disorders, such as depression, psychosis and anxiety disorders, first present. All of these factors (and others) can affect the transition to college or university for some students.

So what can be done?

Read the rest of the article on Canadian Psychiatry Aujourd’hui

More info:
Teenmentalhealth.org - Transitions: Student Reality Check
University Affairs article
Collegiate mental health gets a better exam