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

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

September 22, 2009

Recent events in the National Basketball Association (NBA) involving two high profile players, Delonte West and Michael Beasley have highlighted the issue of mental health in the NBA.  And, this is an important step forward, not only for the NBA in specific but for professional sports in general.

Professional athletes are no less likely to suffer from mental disorders than the general population.  We can expect that approximately 10 to 15 percent of professional athletes will have significant and substantial mental health problems, including mental disorders.  The most common mental disorders will be: depression, anxiety disorders and substance abuse.  A few may have bipolar illness or other psychotic conditions.

These disorders will affect them in both their personal and professional lives.  Athletes living with mental disorders can expect to have the same challenges that people who are not athletes but who are living with mental disorders have.  These include but are not limited to personal problems and decreased job performance.  One important difference however is that professional athletes are very high profile.  Their lives are often lived in a public arena.  When they have problems these are difficulties are known to the many, not only to the few. 

When mental disorders in professional athletes lead them to experience personal and professional difficulties these can be publicly addressed in positive or in negative ways.  One positive way may be for their employers (professional sports teams) or their associations (players associations, professional leagues such as the NBA , the NHL and others) to publicly acknowledge these difficulties – much as they now do with physical illnesses or injuries.  Another way may be for the players themselves to be open about their problems and to discuss them much as they discuss any physical injuries or other similar issues.  Another way may be for the sports media to become more knowledgeable about mental health problems and mental illnesses and to write their stories from a position of understanding.

Mental disorders affect everyone – including professional athletes. How they, their employers and the media handle these issues may have an important impact on how society in general and youth in particular understand mental illness.  Its time for professional sports to get “on side” – so to speak.

-Stan

Another  World Suicide Prevention Day (September 10, 2009) has passed and in many locations a variety of activities were underway across Canada, for example, community suicide awareness walks such as the one that has been initiated in New Minas/Kentville Nova Scotia and one that will be occurring in Halifax on the weekend following. The Canadian Broadcasting Corporation has presented a number of stories on the topic and the London Free Press newspaper has announced that it will publish obituaries in which suicide can be identified as a cause of death. The president of the Canadian Association for the Prevention of Suicide is quoted as saying that a national suicide prevention strategy is needed. All in all, there is increasing awareness of the importance of this issue nationwide.

Unfortunately, in all the media reports I have seen or heard on this issue there has been not one mention of what I consider to be the most important item that needs to be addressed. That is, based on solid scientific evidence we already know what to do to decrease suicide rates, so why are we not doing those things? Marches are good for raising awareness but do we need to march to put effective programs into place?

So what do we know helps bring down suicide rates? First of all is the identification and effective treatment of people who are living with a mental illness – especially depression, bipolar disorder and schizophrenia. Second is the reduction of access to lethal means – be that through control of handguns or barriers on bridges. Third is the creation of “gatekeeper” programs in organizations such as schools or similar institutions. In this way those individuals at highest risk can be identified and interventions provided to them. None of these are difficult to do. None of these are costly to develop and implement. So why are they not universally in place?

Health care systems are notoriously inert – change comes very slowly and often inefficiently. Stigma against the mentally ill pervades the health care system and providers are not immune from its insidious effects. Could this be a reason why those relatively simple and proven effective approaches are not already in place everywhere? Where are our legislators - provincial/territorial and federal? Why are they not demanding that these approaches are in place and properly supported? Perhaps it is because they feel no pressure to do so. Perhaps the scientific evidence and moral imperatives are not enough. Perhaps they need a push from the people.

So, what do I have to say about this? Walk on. Speak out. Demand change. Demand that what we already know works be implemented. Demand that we learn more. Crush the stigma and let the science lead us to do what works best!

Dr. Stan Kutcher

Sun Life Chair in Adolescent Mental Health

IWK and Dalhousie University

Recent reports from the BBC highlight the complexities of helping people with psychotic illnesses – specifically schizophrenia, live symptom free and positive lives. 

The first story “NHS ‘failed’ over cannibal killer” presents an all too common media response to the extremely rare and thus somehow newsworthy bizarre homicide involving a person suffering from a mental disorder and the problems encountered in better understanding and assisting such individuals from people working within the mental health system.  While better training and more careful assessment procedures are in and of themselves important, it is hard to see what such news stories accomplish – except to perpetuate the stigma against people living with a mental illness and those who treat them.

The other story “Embracing the dark voices within” describes the approach (one that is unencumbered by evidence) of a person described as psychologist Rufus May.  What I can glean from this story is that the so called treatment involves getting in touch with your psychosis (voices) in the absence of medication.  Oh dear – here we go again.  This is nothing new and we have seen the chaos and destruction of lives and families that such idiotic ideologies have created in the past.  Those of us old enough to remember the psychoanalytic schools of living through the psychosis or the negative impacts of community circles or the strange world views expressed by the popular “philosopher” R.D. Laing in his books: Bird of Paradise and Politics of Experience or the sad “treatment” described in the novel “I Never Promised You A Rose Garden” shudder when we see history repeating itself.

Schizophrenia is a highly complex and disabling brain disorder often striking in the teen years.  We have good evidence on how to provide treatment – evidence based on solid science and many years of improvements and the integration of biological, psychological, social, vocational and civic engagement strategies to promote recovery.  Regressing into the darkness of the uninformed past is not news – just as the rare and bizarre homicide is not news.  Neither serves the better understanding of mental illness and its optimal treatment. 

I would really like to see some stories about how young people have coped with and overcome their disability.  I would really like to see some stories about how families have struggled with the adversities wrought by the illness – and have come out on top.  I would really like to see some stories about the human relationship between care providers and those living with the illness – the relationships that have gone on for years and have provided the basis for recovery and success.  Now, who can we find to write those stories for the BBC?

-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

Try playing this little game with a friend, parent or co-worker.

Ask them to list three adjectives that describe a person with mental illness. Then ask them to list three adjectives that describe a person with breast cancer. Finally, ask them to list three adjectives that describe a friend.

More than likely the person will use words like “crazy”, “sad”, “depressed”, “lonely”, “patient”, “consumer or victim”, “scared”, “down”, “violent”, etc. to describe someone with a mental illness.

In describing someone with breast cancer they will likely use words such as “strong”, “confident”, “undeserving”, “survivor”, “thriving”, “family connection”, etc.

And in describing a friend the person will likely use words like “fun”, “caring”, “happy”, “smart”, “loyal”, “honest”, “responsible”, etc.

See the difference?

Whether you play this game with youth, parents, educators or even health professionals you get the same result - positive words to describe a friend or a  physical health problem like breast cancer and negative words to describe a mental illness like Depression.

And what if the your friend had Anxiety Disorder or Depression? Would that change your perception of them as a fun, smart, caring, loyal person? Would they suddenly be relegated to being a crazy, lonely, scared patient?

The stigma surrounding mental illness runs deep. It is embedded in our actions, our culture and our language.

Imagine a time when we describe and perceive people living with mental illnesses the same way we describe and perceive our friends or people living with physical health problems!

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