Interesting story in the Toronto Star. Seems that some bright inventor decided to apply restaurant technology to hospital clinics and ER waiting rooms. So, (wait for it) here is the amazing way forward! Yes, you guessed it – beepers. http://www.thestar.com/news/sciencetech/article/828089–the-wait-is-over-laval-inventor-tackles-waiting-room-frustration. Mrs. Jones, your table, er… guernsey is waiting. Please slip on this johnny gown with the gap at your backside and wait behind this curtain. Your health provider will be here sometime before H-ll freezes over. Actually, if you happen to be a patient with a mental health crisis it could take much longer than that.

If I had a dollar for every hour that a patient with a mental health crisis had to wait to be seen by the emergency physician in many of the hospitals that I have known, I could have retired a wealthy man. Why is it that people who have a mental disorder end up at the back of the line? Surely it can not be because of stigma in health providers? Surely it can not be because of inefficient care pathways? Surely it can not be because of inadequate numbers of mental health providers?

Maybe it is all of the above. In that case, you can hand out as many beepers as you want and nothing will happen. Mrs. Jones, your bed is ready for you. Sorry it took seventeen hours to get you there. If only you had a broken leg instead of a depressive psychosis accompanied by severe suicidal ideation we could have done a bit better. And your beeper? Please put it in that box over there. Mr. Watson will be needing it next. We only have one available for psychiatric patients and he has already been here six hours.

–Stan

We have known for a long time that the majority of mental disorders begin before age 25. We have also known for a long time that early onset mental disorders are a risk for many poor short and long term outcomes – indeed that is why we recommend early identification and early effective treatment. So that we can try and prevent poor outcomes and enhance good outcomes.

So a recent study, just published has found that for each person (on average) who has an early onset mental disorder it costs her/him over ten thousand dollars per year when they are an adult – that is correct: PER YEAR. This is compared to what their siblings make. ! OUCH!

So, as you know, I am a strong advocate of early identification and early effective treatment for mental disorders. It is simply not right that we do not meet the mental health needs of children and youth at the time that they need the help most – right after they get sick! We know that not providing care early leads to a host of poor outcomes for the person and for our society. Now we have additional information – this is the personal cost – over ten thousand dollars per year! Think of the effect that has on life and wellbeing. Think of what negative spiral effect that could have – poverty, use of food banks, etc. Think of the loss of tax revenue and the impact of lower incomes on the lives of their families and the wellbeing of their children. Not only is this not economically unacceptable, it is simply not fair.

Hey governments. Hey society. Hey banks and wealthy corporations. Hey citizens. It is time we made the investments early on. We can not afford not to do that!

–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?

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

Neuroimaging has indeed revolutionized and continues to revolutionize our understanding of mental disorders, because it is based on learning about how the brain grows, develops and functions.

This is so far removed from earlier ideas about how “society” or “the environment” or “culture” or “religion” or “monsters” created mental illness, that some people whose beliefs or other investments are in these explanations will have problems accepting its value. When linked to other new tools of understanding such as genetics and molecular biochemistry, we are beginning to learn how the brain functions in health, when it is challenged by the environment and in disease.

The recent article in the Globe and Mail by Elizabeth Scott brings to life the importance of this technologically enabled explosion in understanding. She shows us how valuable this harnessing of new methodologies can be as we pull away the shrouds of uncertainty and begin to lift the veil of confusion caused by centuries of invalidated explanations of why mental illness occurs.

The real challenge however will be in changing our perspective based on new knowledge. Simply put, old ideas die hard and the new understanding will be strongly resisted by those who either do not or will not wish to be informed. On the other hand, this new information will need to stand the rigorous and unfriendly critical scrutiny of science, as different researchers conduct different studies and argue about what their results mean. This is a messy business and science is not about “the truth”. It is merely about being less wrong, most of the time.

All of which brings me to an exciting study recently published in the Proceedings of the National Academy of Sciences which demonstrated an almost 1/3 reduction in the right cerebral cortex (the outer cell layer on the right side of the brain) in the brains of people who have a family history of depression. These changes were associated with a number of difficulties in thinking and when the left side showed thinning, these difficulties became part of the syndrome of what we call major depression.

To me, these findings suggest that depression (at least the type that runs in families) may be a degenerative brain disorder. That’s right, a degenerative disorder – much like Parkinson’s disease or Alzheimer’s disease. And the thinking problems that we have noticed in people with depression may not be the result of the mood problem but may actually be part of the same disease process that gives rise to the depressed mood. That is, our theories that negative thoughts cause depression are likely wrong. Both the mood problem and the thinking problems are due to the same disease process in the brain.

This finding supports observations that many researchers and clinicians have been making for years. And, this finding suggests that we may have to change how we search for better treatments for depression. Maybe we should be looking at medications that can arrest brain degeneration or maybe we should be looking at medications that can improve cognition. Whatever the outcomes, these findings are exciting, offer new hope for future research and challenge what we “believe” to be true. Stay tuned – the story will unfold as it should!

~ Dr. Stan Kutcher

This week the Globe and Mail is revisiting the issue of Canada’s mental health crisis in a week long expose. Saturday’s article addressed child and youth mental health. Kudos to Anderssen and Picard for bringing attention to an issue that is often underreported and often misunderstood by mainstream media outlets.

The piece has some important points to make - most notably about the absurd double-standard we have about mental health care in this country:

“If only one in six adults who needed a hip got one, there would be a revolt,” says Simon Davidson, a psychiatrist at the Children’s Hospital of Eastern Ontario. “So how can we tolerate a situation where one in six sick children get care?”

The article also successfully highlights the many ways that mental illness affects all aspects of a child’s life, especially relationships with parents and teachers. The complexity of understanding mental disorders in children and youth, as well as the complex health systems in place for youth to get help are indeed barriers that need to be addressed.

“Most young people with mental illness suffer in silence … Sometimes their parents are oblivious, or put it all down to a phase. But often their families suffer with them, unsure of where to turn in a system bogged down by turf wars, waiting lists and funding shortages.”

The need to address mental health problems early in is also clear. Dr. Waddell’s metaphor is apt: “If we wait until adulthood to treat these problems, it’s like using a teacup to bail out the boat”.

However, for all the positive points addressed in the article, the authors somewhat undermine their own message by using language that only seeks to enhance the stigma associated with mental illness. By telling the stories of youth who have “violent rages”, and by using phrases like “locked in their rooms, cutting themselves, crying and plotting suicide”, and suffering from some kind of “Dr. Jekyll and Mr. Hyde” syndrome, the authors are not providing a very balanced viewpoint about youth with mental disorders.

The challenge is to give mental illness a “face”, without giving it a face that paints a very extreme picture of what people with mental disorders experience. So much of the public understanding of mental illness is informed by these extreme pictures - people who are violent, out of control, hallucinating, etc. - when in reality people who experience those episodes comprise a very small percentage of the population.

if we are truly going to normalize and destigmatize the issue of mental illness we need to start telling stories from different perspectives that reflect the wide spectrum of experiences that youth and families dealing with mental illness have.

~ D. Venn

There is no health without brain health. A healthy functioning brain is the foundation for all successful learning, social, civic and economic development. The school environment is an important component of healthy brain development. Just as schools are locations in which physical health can be encouraged and improved, so are they locations in which brain health can be encouraged and improved.

How and when a young person’s brain develops affects how they learn. An understanding of how a young person’s brain functions may help us better create brain-healthy environments and educational approaches that can enhance learning outcomes.

The human brain is the most complex entity in the universe. It has more connections than there are stars in the Milky Way. It is the organ of adaptation and of civilization. What we are, what we think and what we do, as individuals and as a human species are the outcomes of how our brains work. That in turn is influenced by a variety of other factors including our genetic endowment, the way our brains naturally develop over time, and the impact of the environment on the way our brains develop and on how they work.

The adolescent years (puberty to about age 25) are characterized by a second major period of brain development (the first is during the early years of development). New brain connections are developed, old connections are pruned, and complex systems that guide emotional integration, motivation, craving-induced behaviors and the capacity for good executive functioning (impulse control; problem solving; empathic/cognitive integration; etc.) come online.

(more…)

Knowledge translation (also known as KT) is one of those important things that has been going on since the dawn of time, but has now been given a name and a scientific grounding. Many things that we have learned have been from knowledge translation - someone who “knows” has taken that knowledge and put it into a format that helped us learn. This is great as long as the knowledge is correct.

But what happens if it is not?

We could learn something that will not be of maximal value to us and may even be unhelpful or harmful. So here is where the science of KT comes in. Over the last few years a methodology for doing KT has been developed and extensively tested. It consists of systematic and reproducible techniques of finding and evaluating all the available knowledge on any particular topic or issue. These techniques are necessary because all information out there is not of equal quality - some is better and some is much better than others. Some may be more likely to be correct and some more likely to be wrong. The techniques used to evaluate the information are very stringent and have been developed to try and ensure that when the information is synthesized the syntheses is more likely to be correct than not correct. So knowledge will have been translated from scientific studies into a common and more certain bundle of information.

Then the next step comes in — taking that bundle of information and putting it into a format that meets the needs of various users. Because what good is KT if it is not used by people to improve what they are doing and to better understand the world around them?

The Sun Life Chair group does both kinds of KT. We conduct systematic literature evaluations and critical analysis to provide the best available evidence on a variety of topics. For example, one recent topic was that of school-based programs designed to prevent suicide. Guess what we found — although there are many such programs (and I think that some people are making quite a bit of money by selling them) there is very shaky evidence that any are effective.

Indeed, we could not find one that clearly demonstrated it decreased suicide rates in young people! So this is very important information for people making health and education policy and for people who want to buy some of these programs. We think that it’s better to use those things that work instead of those things that do not work or that we do not know if they work or those things that may be harmful.

I recently filmed a video with Insider Medicine talking about knowledge translation. Check it out for more info.

Cheers - Dr. Stan Kutcher

In the Spotlight - Dr. Stan Kutcher, MD, FRCPC, Professor of Psychiatry at Dalhousie University, Discusses Knowledge Translation