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

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?

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?

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

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

According to a BBC article, a survey of of 27,000 teenagers found that “nearly one in two teenagers knows someone who has suffered from a mental health problem like paranoia after using cannabis.”

The research, which was carried out on networking website Habbo Hotel, found 64% of young people were aware cannabis could cause panic attacks, 41% knew it could bring on paranoia and 38% thought it could result in memory loss.

Over 50% of teenagers associated cannabis use with losing motivation and doing badly at school or college.

While the survey is far from scientific - it does point to some interesting trends among teens and their perception of marijuana use and how it affects mental health.

Recent research suggests that heavy use of cannabis may increase the risk of psychosis in some young people

The website Psychosis Sucks maintains that:

Psychosis can be induced by drugs or can be “drug assisted”. Some stimulating drugs, like amphetamines, can cause psychosis, while other drugs, including marijuana, can trigger the onset of psychosis in someone who is already at increased risk because they have “vulnerability”.

The risks associated with drug use for a person with psychosis include an increased risk of relapse, the development of more secondary problems (including depression, anxiety or memory problems), a slower recovery and more persistent psychotic symptoms.

The good news is that with early identification, treatment and support, people living with psychosis, substance abuse or a combination of these mental health problems can recover.

Because people with psychosis may have interlinked problems with substance use problems, treatment that combines both mental health and addiction services into one program is best.

ALSO - integrating treatment for psychosis and substance abuse into one program is an effective way
to help both problems at the same time.

Treatment programs include:

• Improving quality of life including belief in the possibility of recovery.
• Going beyond just eliminating symptoms of psychosis and substance use and emphasizing social and other supports.
• Motivation support to help you set and accomplish your goals.
• Taking medications as prescribed

For more info check out:

Psychosis and Substance Abuse Brochure for Youth (pdf)
Psychosis Sucks - Substance Abuse and Psychosis
Schizophrenia: A Journey to Recovery - A Consumer and Family Guide to Assessment and Treatment (pdf)
Rays of Hope - A reference manual for Families & Caregivers (pdf)
Nova Scotia Early Psychosis Program Resources

Great video on youth mental health produced by YoungMinds in the UK. But good advice for any country and its leadership.

“YoungMinds Very Important Kids (VIK), our national panel of young people with mental health problems, have launched a manifesto  and accompanying film to highlight to politicians the changes that need to be made to improve young people’s mental health.”

You can download the YoungMinds children and young people’s manifesto here

“Written in their words and including their own stories it covers 11 areas where they believe things must change so that all young people with mental health problems get the support they often so desperately need.”

Manifesto main points

1. Stigma still affects us; its about time we were able to talk about how we feel.
2. Dealing with problems when we are young; train primary school staff
3. Growing up is difficult; support us when changes happen in our lives
4. Getting what we need at secondary school; train everyone to understand teenagers problems.
5. Waiting lists and assessments just make it harder; make them shorter and provide us with one worker for all our care.
6. Some doctors don’t listen to us; they need to understand and support us
7. Going to Accident and Emergency can be traumatic; treat us with respect, see beyond our labels
8. Some psychiatric units feel like prisons; learn from the best ones
9. Someone to speak up for us; we all need advocates
10. Lost in the system; don’t forget about us when we are 16 plus
11. We’re the experts; start  listening to us

Happy Canada Day!!

Canada has a proud history of valuing health care as part of the fabric of this country and as a basic right for all citizens. However, despite our commitment to overall health care, our attention to mental health care is overdue.

In Canada, approximately 1 in 5 children and adolescents experience some form of mental disorder. Most major mental disorders begin prior to the age of 25, making this period a critical time for the promotion and treatment of mental health problems.

One of the key initiatives of the Mental Health Commission of Canada is to develop a Mental Health Strategy for Canada. As part of the strategy the Child and Youth Advisory Committee of the Mental Health Commission of Canada will support the development of a framework specific to the needs of child and youth mental health.

We need your help!!

We invite all Canadians to share their thoughts and opinions in an online survey about values and principles relating to child and youth mental health.

TAKE THE SURVEY NOW

The survey will take about 30 minutes to complete (but you can save your answers and come back to it at any time).

It is important that we get the thoughts and opinions from as many different people as possible. Please pass this information along to your network, family, friends, or anyone who you think should join this consultation.