Connecticut Tragedy: A reasonable vehicle for addressing mental health needs in young people?

Recent media coverage, sensationalistic and omnipresent as it is (and, by the way – has anyone noticed the correlation between frequency of school shootings and this type of media coverage?) has raised numerous issues about the relationship between the tragic story in Connecticut and youth mental health.  Largely the story line has gone something like this: oh my gosh, this young man had a psychiatric diagnosis; his mental illness likely made him act this way; why can’t our society do a better job of identifying youth who are likely to have this kind of negative impact; we need to fix our mental health services.

Have we ever wondered where that kind of story line takes us?  Does it take us to a rational and evidence based understanding of mental health and mental disorders?  Does it take us to a place where we can logically develop mental health care that meets the needs of young people and their families?  Does it provide reliable information about what a mental illness is and how a mental illness may or may not lead to specific behaviors and outcomes? OR – does this kind of knee-jerk reporting maybe increase the stigma associated with mental illness, lead to inaccurate understanding of what a mental disorder is and how that relates to specific kinds of behaviors and in both the long and short run, do a disservice to all those who are living with a mental disorder, their families and those who work to help them get well and stay well?

We know that easily accessible, responsive and best quality mental health care is not readily available for most young people who need it. We know that most young people with mild to moderate or non-complex mental disorders can be appropriately and effectively treated in primary care (click here to check out the child and youth mental health components.) We also know that it is the tiny minority of young people with a mental disorder who require intensive and high acuity mental health care.  And, we know that is only a tiny minority of those who may have a mental disorder of the type that leads to the tragedy recently played out in Sandy Hook.  So why is this event even considered to be the poster child for mental health reform?

I think we need to have many adult conversations that this tragic incident forces us to consider.  The most obvious one is that of: how to best deal with the killing capacity of the final common pathway – automatic/semi-automatic weapons and handguns.  The Dunblane school shootings in Scotland led to popular protest that led to changes in gun related legislation that has been associated with a substantial decrease in deaths of young people from shootings.  This is a no-brainer – or maybe this is the problem.

We also need to fix the mess that is mental health services for young people – everywhere.  Just because we live in Canada does not mean that we are doing what needs to be done – on the contrary.  But we don’t need to have a tragedy to address this reality, we need commitment from all of us and political will.

-Stan

Stimulant medications and automaton kids: Sociobable or substantive concern?

It is fashionable in some domains of public discourse to denigrate psychostimulant medications and their therapeutic impact on young people living with ADHD.  In particular, it is not uncommon to find armchair philosophers, scientologists or even research naïve journalists happily spouting off about the way that psychostimulants turn young people into robots, take away their feelings and generally make them less than human.

These medications are, in the mouths of those espousing such opinions, at best dehumanizing and perhaps worse. 

They are supposed to take away the mind and the soul of those to whom they have been prescribed. They are supposed to make young people less authentic as individuals and are supposed to block their ability to make critical considerations about their ability to function, on or off the medications.  In short, they are a challenge to authenticity and damage moral agency.

An interesting aspect of this pontificating has been the strength by which these opinions are held, interestingly enough not supported by data addressing authenticity or moral agency. This certainly does not mean it is unimportant, only that it needs empirical evidence to either support or refute the opinion. This would therefore classify it as an informed opinion, not simply an opinion.

So, what does the data show us? Click here to view an interesting article recently published by the British Medical Journal. Interestingly, the author asked what young people’s experiences and considerations were. Further interesting, the conclusion states: “drawing on a study involving over 150 families in two countries, I show that children are able to report threats to authenticity related to stimulant drug treatments, but the majority of children are not concerned with such threats. On balance, children report that stimulant drugs improve their capacity for moral agency, and that they associate this capacity with an ability to meet normative expectations.” In other words, children treated with these medications appreciate their therapeutic value while at the same time preferring not to be taking them and not liking the side effects.

Wow. We would expect the same response from young people taking insulin or medications that treat heart problems or cancer. Interesting however, is the observation that armchair philosophers, scientologists, sociobabblers and others do not set their vitriolic sights on those other types of medication treatments. Maybe treatments for traditional “physical” conditions are okay, but treatments for traditional “mental” conditions are not. Maybe there is a gross misunderstanding that mental actually means brain and brains can get sick, just like the pancreas or the heart. We seem to miss out on the data, i.e. the facts that speak to this exact reasoning which can shed some light to the notion that the difference should not exist.

In my opinion, this is either a lack of knowledge writ large or a familiarity with knowledge submerged in prejudice.  It is hard to know which would be worse, but the stigma that this vitriol contributes to is real.

-Stan

Media reporting of youth suicide: What has happened to responsible reporting?

Once again the issue of media reporting of youth suicide has raised its head. Upsetting reports of a B.C. teenager’s suicide have flourished throughout the media. Details regarding the persons actions, method of suicide and other intense details have been revealed and given this teen a prolific profile in the media. The death has certainly taken the country by storm and opened public’s eyes to bullying and teenage suicide. But, some worry that these reports and continuous updates will affect youth in similar situations and could result in copy-cats.

Over the past week, I had the opportunity to touch on this subject where I discussed ways the media can report these tragedies responsibly and provide the public with useful information. Click here to view an article from the Chronicle Herald.

These sensational reports of youth suicide seem to be increasing throughout Canadian media. Evidence shows that this type of reporting is linked to increased rates of suicide, especially in young people. Some research data shows that there is a “dose response curve” with suicide rates increasing proportionally to the amount of media exposure. On the opposite side of the spectrum, data shows responsible reporting of suicide is associated with decreased rates of suicide in young people.  So why are vulnerable young people being exposed to sensational media stories about suicide? 

A study conducted in the USA found that many reporters were not aware of the degree of negative impact that sensationalized reporting of suicide had on young people.  However, it also showed that many of those did know or did not believe that to be the case.  Personal bias (or maybe some other factors) trumped the data.  I frankly, do not know which is worse, not knowing or knowing and not caring.

Responsible reporting includes, but is not limited to:

• Do not explain suicide stories, undue prominence and avoiding sensational headlines
• Do not provide details of the method
• Give a balanced description of the victim (do not create a model for those considering the same act)
• Do not publish photos of the deceased
• Do not romanticize or provide simplistic explanations (such as bullying being the causation of suicide)
• Provide information about depression and substance abuse - as important factors in youth suicide
• Provide information on where to get help and examples of positive outcomes for young people in similar circumstances 

Is following these guidelines too much to ask?

Teens are known to be substantially impacted by media. Youth who are struggling with suicide intent may be particularly vulnerable. Most young people who are planning to take their own life are not certain that they want to go through with the act.  So, what can tip the balance towards choosing life or death? There are many causes of suicide. Media influences are one of the tipping points, which could push the young person in one way or another.

I am not saying that the media should never report on suicide, just that the reporting needs to be done responsibly.  Most suicides never get reported, meaning there is a choice the media is exercising regarding on what suicides they will report and how they will report them. 

Can they not exercise this choice in a way that does not cause harm to vulnerable people?  The media does not have to compromise their right to let the public know about important issues and events, but they need to know that the matter, in which they choose, can be part of the solution or part of the problem.

I have heard some argue that the public’s right to know, trumps all.  This may or may not be the case all the time. Frankly, I wonder if those who make this argument have other factors at play. I have noticed how commonly people can wrap themselves in the cloak of public interest to cover up their self-interest. It is important to have this conversation, but can we not have it in a positive and constructive manner? When it comes to reporting on suicide, the media has the power to provide useful information and hope, instead of a recipe for death.

-Stan

Below are some resources and associations who have worked to underscore scientific evidence on the negative impact of sensational reporting of suicide to urge the media to report on these issues responsibly.

• Canadian Psychiatric Association
• World Head Organization
• National Institute of Mental Health
• Media Contagion and Suicide Among Young People 
• Media contagion and Suicide Among the Youth, American Behavioral Scientist, May 2003, vol. 46, no. 9, 1269-1284
• American Association to Suicidology
• American Foundation for Suicide Prevention
• Annenberg Public Policy Center
• Office of Surgeon General of the USA
• Centers for Disease Control
• Substance Abuse and Mental Health Services Administration

ADHD Medications: Real concern or media hysteria?

Recently, sensationalized reports of health problems associated with the use of some medications used to treat ADHD have appeared in the media.  Check out some of the stories here:

The Spec

Digital Journal

Metro News

It can be frightening to read about incidents of severe adverse effects to medication, but it's important to keep a critical perspective when reading about these sensational stories.

Do medical treatments have risks?  Absolutely!  Every treatment does.  What must happen when a treatment is prescribed is that the patient, parent and health provider must agree that the benefit is likely to be greater than the risk.  For some treatments, risks can range from mild to severe, or either common or uncommon.  For example, the risk of a heart attack may be 1/10,000 as a side effect of that medication, while the risk of a stomach ache may be 1/100 or a headache 1/10.  Compare that to the risk of dying by being struck by lightning (1/79,700), dying in a bicycle accident (1/5,000) or dying in a car accident (1/84).Check out the annual risk of death during one's lifetime.

Determining whether the benefit is greater than the risk is the key issue to almost everything we do.  Indeed, this is part of the government’s assessment of regulated treatments, such as medications (through institutions such as Health Canada), whether they be deemed safe and therefore available as self-selection products (such as over-the-counter medications and natural health products) or deemed to require the opinion of a “learned intermediary” (such as a licensed prescriber) to support their necessary and judicious use. It’s the latter group of prescription medications that carry more risk, but are still considered potentially helpful when used by the right person.  

In order for the patient and parent to be properly informed, they need good and valid information to be able to make a decision about accepting the treatment recommendation or not. Many of the adverse effects reported recently in the media may not be caused by ADHD medication. That’s the difference between correlation and proven cause and the only evidence that’s able to tell us if the medication is causing the adverse effect is solid scientific research. This can be a problem. Sometimes the right information is hard to find. The information can be confusing or even contradictory. There tend to be a lot of misinformation or even disinformation out there. Sometimes the health provider does not give you the information needed.  So what is the patient or parent to do?

It’s essential that all legitimate health providers use the best evidence available to suggest treatments to patients. Patients however need to have a high degree of comfort that what is being suggested is driven by credible evidence, not anecdote, conjecture or simple association. And, they need transparent, clear information.  It can be difficult getting that information and it can be hard ensuring that your health provider is giving you what’s needed. You may require additional help in getting all the information you need.

This is why I suggest young people and parents use guides and health related tools to help them in interacting with health providers.  It’s important to know what questions to ask to help ensure that they get the best possible care.  We have created a number of useful aids for youth and parents. They fall under the rather boring heading of “Evidence Based Medicine”. Boring name, but crucial stuff to countering sensational and uncritical assertions and inferences. It may be a good idea to use them in order to ensure that you get the information needed to make better judgments about the potential risks and potential benefits of any treatment! Click here to view an outline on what you should ask health care providers. 

Another good resource is a mental health medications guide and treatment tracking booklet, called Med-Ed. It was specifically developed to support patients, parents and health providers do a better job in choosing and monitoring medication treatments – checking on their risks and benefits carefully and consistently. The tool promotes something very important - open, clear communications about the benefits and risks of medication treatment between the patient and their prescriber. 

Oh yes – one other thing.  The media stories suggest that regulatory agencies are not doing a good enough job to monitor possible adverse outcomes of regulated treatments. I, for one, would agree, and so do many others who’ve examined Canada’s systems and regulations for assuring that only acceptably safe medications are available to Canadians.  I think that we need to have a properly functioning national adverse events surveillance system and we need to have a solid feedback loop to the regulatory mechanism to make sure we have the ability to better determine risks and benefits of treatments in the long term.

The reports in media may not turn out to be scientifically valid in the long term, but perhaps they will generate some positive benefits if patients begin to ask their health provider some hard questions – not just about their ADHD medications, but about all the treatments that they’re getting. This would be in the best interest for the health of all Canadians.

-Stan

Supporting a friend with mental illness

Some of the most common concerns teen patients have when discussing going back to school and reconnecting with their friends are often surrounded around their social relationships. Things such as, what will my friends think? What will my friends say? What will my friends do?

In our clinical service, we spend a lot of time helping young people determine the best way to mention their living with a mental illness to their friends, teachers and other social networks. As much as we try to help, the transition can sometimes not go as smooth as planned. Sometimes friends won’t fully understand.

One thing that we often tend to not pay enough attention to is helping people understand what they can do to be supportive. It now occurs to me that some of the people we complained about not being helpful and supportive may actually have wanted to be, but didn’t know how. 

Maybe it wasn't always the friends avoidance or apprehensive behaviour that was the result of stigma. Maybe some of that could be been due to awkwardness and not knowing what to say or do – something like what happens when you go to a funeral.  You know, what do you say to someone who has just lost a parent?  It’s never easy.

So, maybe it’s the same thing when supporting a friend who has a mental illness.  What do you say? What should you do?  It’s not always easy.

The recent edition of Moods Magazine has an article that can help people who have a friend living with a mental disorder.  It’s called, “Ten ways you can support a friend with a mental illness”.  For example, here’s the list of ten – in the order they appear in the article, not necessarily in order of importance.

1. Get in touch with your friends
2. Understand that its not your fault, in fact it’s no one’s fault
3. Don’t task yourself with changing your friend
4. Listen, listen, listen!
5. Get our of the house
6. Put yourself first
7. Be positive
8. Be a resource
9. Be respectful
10. A list of web resources is provided in the article

So there you have it.  A few practical and helpful hints on how you can help be more supportive to your friend or loved ones.  Give them a try and create some of your own.

-Stan

Mental health and back to school

Over the past week, I've had conversations with people who have this idea that upon a young person’s return to school, it can cause mental health problems – due to the increase in stress. We've seen this scenario discussed in the paper, in the news and on the radio this past month. Friends have told me that some schools are getting ready to deal with a “tsunami” of counseling needs when students return.  

A parent recently raised (to me) the implausible specter of creating a support group for junior high students to help them go back to school successfully. If Chicken Little were around, she would say that going back to school is causing the sky to fall.

Why is it that we’re beginning to think like this? Like there is this need to make normal like, pathological. Why are we beginning to merge positive stress (leads to improved performance and positive adaptation) with negative stress (leads to poor outcomes and leads to non-adaptation)? Why is it that we seem to continue to think that everyday stress leads to mental illness?

Is going back to school a stressor for young people? Of course it is, but so is getting up in the morning!  This does not mean that going back to school is a bad thing or something that will lead to a disaster.  What happened to the view that going back to school was a positive thing? For most young people, school is an exciting step in the journey of life.  Going back to school should cause anticipation, enjoyment and be fun – even in the presence of some “butterflies”.

The reality is that going back to school is a regular and expected part of normal life. The anxieties that most young people feel are appropriate and signaling that adaptation will need to happen.  And most already know exactly how to adapt –buy some new books and pencils, get a new school bag, link up with their friends, ride their bikes to the school yard and have a look.

Sure, there will be some who will have difficulty with that transition. Either because they may have a mental disorder or because the transition is greater than their adaptive capacity, they may struggle. Schools need to prepare for these students, while at the same time – not buy into the hype that the usual positive stress of going back to school can cause mental health problems.

So here we have it – going back to school is something that most look forward to. As parents and educators, we need to take a deep breath and stop focusing on the negative and start focusing on the positive. Don’t put your head in the sand because their will always be some young people who need help - but don’t make a mountain out of a molehill. Let’s stop this tendency to create pathology out of normal, everyday experience.  We help our youth become resilient by facing and successfully adapting to life stresses - not by seeking to protect them from it.

-Stan

Depression in young people can lead to early death

While we have know for many years about the varied negative impacts that clinical Depression can have on the lives of young people (including its negative long term impacts on personal, social and economic outcomes and increased risk for suicide), some new research is showing that it may also shorten life – specifically by increasing the risk of dying earlier from physical illnesses.  In a recent study published in the Annals of Epidemiology (July 26, 2012) both males and females who had experienced an episode of Depression in their youth had much higher rates of early death from physical causes than those who had not.  Death due to heart disease was mostly to blame!

Unfortunately, I could not determine from the study if this included young people who had been successfully treated for their illness or not.  This of course is an important issue, as early and successful treatment of Depression may change the long-term outcomes for those who have experienced it.  It will be good to know if this also applies to early death from heart disease.

In any case, this information is very important to have.  For too long we have thought that the brain and the body are separate.  They are clearly are not!  The brain has a substantial and ongoing impact on all aspects of body function and vice versa.  The old Latin saying “mens sana in corpore sano” holds. Meaning "healthy mind in a healthy body" (or something like that - its been over 45 years since I took Latin in high school and was not so good at it then). Check it out the full meaning here.

So, let’s do whatever we can to help our brains get healthy and stay healthy.  That means eating properly, exercising vigorously and getting enough sleep.  It means moderate and parsimonious use of alcohol and avoiding substances that can cause brain damage.  It means taking the appropriate precautions to help decrease the risk of head injury.

If we do all that, can we be sure that Depression will not darken our doorstep?  Unfortunately not, but if Depression happens we need to make sure we recognize it early and get the best evidence supported help that we can, as soon as we can.  Overall, not dying early from having a heart attack is a good thing, don’t you think?

--Stan

Exercise as a treatment for Depression: Hot idea or hot air?

It is very fashionable to include exercise as a complementary treatment in Depression.  In fact there are many studies that show that exercise has positive impacts on the brain.  And, in such as way as to possibly help improve depressive symptoms.  In addition, there are lots of studies that show a positive effect of exercise on depressive symptoms and even some systematic reviews that suggest exercise is a good addition to the usual treatment of Depression.  So there we have it – or do we?

A recent excellent research study reported in the British Medical Journal (2012: June 6) suggests that some of our enthusiasm may have been a bit over-extended.

This was a randomized controlled trial in over 350 adults with depression treated in primary care in the UK.  Everyone got the usual care but half received additional exercise coaching to encourage exercise in addition to their usual care.  The exercise group did show much more exercise (that is a good thing) than the treatment as usual group.  However there was no difference in any outcome measure of depression or its treatment over a period of one year!  Ouch!

Now, what does this mean?  Well, like any study this one was not perfect and the participants in the exercise group did not all achieve the recommended 150 minutes of vigorous exercise per week (at 30 minute per day aliquots).  So there may be been a dosing problem – not enough of a dose of exercise.  Or it may mean that exercise may be helpful for mild depressive symptoms – for psychological distress, but not for clinical depression.  Or, it may mean that the model used (an exercise coaching model) is not the best one by which to help people with Depression get the exercise that they need to help them get better faster or to a greater extent.  Or it may mean other things, too many to list.

So, does this mean we should not exercise to help us feel better?  Totally not!  Does this support using exercise as an alternative treatment for best evidence based care for Depression?  Totally not!  Should we keep suggesting patients exercise?  Totally yes – there are lots of other health benefits to exercise as we know.  Should we engage in more systematic study of this before we write the final chapter?  For sure we should!.

Oh well.  Enough reading about research and writing a blog.  I am off to walk quickly for 30 minutes followed by a nice relaxing summer drink.  It’s hot outside!

-- Stan

School Mental Health: Teachers perspectives and what to do

A new study just reported in the Canadian Teachers Federation publication gives us some sobering information about what teachers think about mental health in young people and their ability to address that in the school setting.

As we would expect, teachers overwhelmingly reported that they think addressing mental health needs of students is very important and that poor mental health leads to many negative outcomes, including poor academic achievement.  But, there is much more!

About half the teachers surveyed (there were almost 4000 of them), noted that at least 10% of their students needed mental health services but were not receiving them.  They also identified a number of barriers to access of these needed services.  Here is what over 80% of them said: lack of staff training about mental health/mental illness; lack of school based mental health services; lack of community based mental health care providers.  Seventy percent also identified that stigma was a barrier.

About two-thirds of teachers had not received professional development on mental health, especially those who had been teaching for five years or less!  Ninety-seven percent of teachers wanted training in mental health.  I assume it was training that was relevant to their work.

So, what are we to make of this information?

First, it is not new news.  But it is really good to have it so well quantified, and kudos to the Mental Health Commission of Canada for funding the study.

Second, it is essential that addressing school mental health include training of teachers be widely available.  However we need to make sure that this is not done through one-off PD days or brainless general courses but in best evidence based and contextualized training programs that fit and make sense in the educational setting.  This is where some of our unique and validated work comes in – through the Mental Health Curriculum Guide and its related training programs we can ensure that teachers get the mental health literacy that they need and that this is provided in a sustainable and cost effective manner.  The models of Nova Scotia and the Ontario Shores lead initiative in Ontario are good examples of how to do this well.

Third, we need to ensure that schools are seamlessly linked to health systems that can offer mental health care to young people.  This means building the capacity for identification and interventions in the school itself as well as enhancement of primary care competencies in diagnosis and treatment.  We have the training programs and tools to do this.  In British Columbia, the Practice Support Program of the BCMA is doing excellent work in this regard. 

So, we know what the problem is.  We know what to do about it.  No excuses any more!

--Stan

Having courage: Talking to our kids

The instinct to protect our children from harmful ideas or influences is strong. Unfortunately, this parental instinct combined with cultural stigma about mental illness can create a perfect storm of silence around issues of suicide, depression and self-harm. In Canada approximately 500 youth between the ages of 15 and 24 years die by suicide. Suicide is not, in itself a mental disorder, but it is often the tragic result of untreated mental illness or disorder. Globally, suicide is among the top three causes of death for young people.Suicide is often the result of a complex set of factors. Not all young people who die by suicide have a mental illness or disorder.

For a parent, the very thought of losing a child in this way is excruciating. We pretend suicide doesn’t happen. Often families who have lost someone to suicide will keep the cause of death a secret. It is as if somewhere between the pressures of stigma and a fear of being responsible for ‘introducing’ the idea into someone else’s head, we become paralyzed. Suicide must be talked about in responsible ways, without the sensationalism that is often offered in the media. If a suicide happens at your child’s school or in the community, you must find a way to discuss this with your children. If we behave as if we are embarrassed or fearful, we shut down important lines of communication. If we send them the message that the topic is taboo, they may feel ashamed to come to us when they need our help.

Kids need to know that at some point in their life they are going to have really bad feelings. Sometimes these bad feelings may come as a result of something that happens, or sometimes because our brains, like our tummies, can get sick. They need to know that if they are scared and feeling hopeless, that they can talk to us. If they are too scared to talk to us, then there are people they can call such as Kids Help Phone. They need to know that if they have a friend who is feeling hopeless, a friend they are worried about, that adults are here to assist them to find the best possible help. They need to know that there is no shame in getting help, and no shame in finding professional help for a friend they are worried about. If a friend is talking about suicide, whether in person or on the internet, then it needs to be taken seriously and trusted adults need to be notified.

Despite our best efforts to reach out, children and teens often lead private lives. Whether it is through a secret facebook or formspring account, or use of a chat room on the family computer when we are not home, they may be exposed to influences or ideas that may worry us. That is why it is extremely important to keep resources such as the Kids Help Phone on the family fridge or message board so they have a place to go for help if they have stumbled upon something they are afraid to share with us.

Talking about suicide is no easy task. If you find yourself in a situation where your child is asking questions or is aware of a suicide in the community, rest easy knowing that there are resources out there if we feel like we are ‘in over our heads’ with the tough questions.  For more information please visit: Suicideinfo.ca or TeenMentalHealth.org . Kids Help Phone may be reached at: 1.800.668.6868.

--Ardath and Stan

Pay attention to your diet when you are depressed

One of the clinical symptoms of Major Depressive Disorder is loss of appetite.  Sometimes the appetite loss is so extreme that people loose significant amounts of weight.  A key feature of the loss of appetite is that food becomes less appealing, less tasty and therefore less of a motivator to eat.  For some teens who experience Major Depressive Disorder they even can’t be bothered eating their favorite foods, such as pizza or chicken wings.  However, one thing that we do not know very much about is whether this loss of appetite has an effect on nutrition. 

A recent study (Davidson and Kaplan, BMC Psychiatry, 2012) evaluated the nutritional status of self-reported diets in people who were Depressed.  The results showed some interesting differences compared to existing population information about diet.  People suffering from depression ate significantly fewer amounts of: grains, vegetables and fruit and some macronutrients.  They also ate significantly larger amounts of: processed meats; sugar; fat; salt. 

So what does this mean?  Actually I do not really know.  It likely does not mean that the diet caused or is perpetuating the Depression.  Is the diet helping the Depression?  That we can also not answer.  Does this mean that people who are experiencing a Depression should pay extra attention to their nutrition?  That seems to me to be a reasonable thing to do.

-Stan

Teams help improve outcomes

You would think that health care providers by now would have learned to work together as teams.  While there has been some improvement in team work there remains much yet to be improved.  Over and over I hear from young people with lived experience (and their parents) how their care has “fallen between the cracks”, even within teams who are supposed to be working together to help them.

It has also been my observation that health care teams are often highly constricted to those providers who work in the same location.  While this is almost understandable, it is not to my mind the meaning of a team.  A health care team needs to be based on the needs of the person who is receiving care, not the location in which some or most of the care givers are situated.

And, the data shows that when we widen the team members, and when the team members work together in the interests of the patient, good things happen for the patient!  Great!  This is what our goal should be.

A recent study (it was in the journal called Schizophrenia Bulletin 37: 727-736; 2011) examined the role that pharmacists play in helping people who have chronic and severe mental disorders better understand the medications that they were taking.  These pharmacists also provided counseling about medications and what to do if the patient experienced any problems.  Guess what?  Patients who received this support were much more likely to take the medications that they needed to stay well.  Seems almost obvious to me.

Actually, when I think about it, I have been very lucky to have worked with two outstanding Pharmacists (both have their PhD in Pharmacy – it’s called the PharmD) for many years now, Dr. David Gardner and Dr. Andrea Murphy.  I have learned a ton from each of them.  They can show us the way for how all health providers can work together to help improve the lives of young people and their families.  And they worked with me to create an amazing resource called Med Ed which helps young people and their families get the best medications care.  Click here to learn more about MED ED.

-Stan

Suicide prevention in the water we drink?

Now, who would think that the kind of water we drink could possibly be implicated in the prevention of suicide.  If that was the case, what impact would that have on our community based, very expensive and not at all clearly impactful suicide prevention programs?  I mean, if prevention is in the water, what could that mean?

Now some very interesting epidemiological research (published in this month’s edition of the British Journal of Psychiatry) suggests that there actually be a link between the type of water we drink and rates of suicide.  Ok – be careful.  This is a co-relation so it does not prove causality, but the relationship has some solid other evidence to suggest it may be a strong finding.

The culprit (if you want to call it that), turns out to be small amounts of lithium!  Lithium is known to have therapeutic effects on mood control when given in specific doses that lead to specific blood levels.  Lithium is also known to have an anti-suicide effect for people who have a mood disorder.  That is, lithium treatment is linked to low suicide rates while discontinuing lithium treatment is linked to high suicide rates.   Lithium has also been successfully used to treat impulsive anger outbursts, and impulsive self-directed anger may be associated with suicide.  And, apparently the Roman’s used to send people who were suffering from mood disorders (depression and bipolar) to therapeutic spas whose waters were rich in natural lithium salts!

The study, which was conducted in Austria, showed that in regions where the water was lithium rich the suicide rate was about one-third less than in regions in which the water was lithium poor.  Now these were very small amounts of lithium; much less than are used therapeutically.

We do not know what impacts small amounts of lithium could have on brain function.  Perhaps there is a mood or impulsivity mediating effect – both of these factors are known to increase suicide risk.   In any case, this is an observation worth researching further, both at the level of epidemiology and at the level of understanding what small amounts of lithium can do to affect our emotions and behaviors.  Who knows what the outcome will be?

- Stan

Concussions are brain injuries...it's time to get BRAIN SMART

Martin was 16 years old, an excellent athlete, good student, fun to be with and very popular at his school.  Elise was 15 years old, relatively shy, hard working and dedicated to becoming a doctor.  Josh was a creative artist, avid environmentalist and raconteur.  Amanda was 14, loved to party – more than her parents were comfortable with but she was getting by at school.  Steven was 15 and struggling with overuse of alcohol that was getting in the way of his successfully completing his school year, and he had just agreed to get help.

Very different young people.  From all over.  One sad thing in common.

Before they could reach the next phase of their lives, their hopes and dreams and plans were derailed by a brain injury – a concussion.  Martin took a head shot while playing hockey.  Elise fell when climbing up a ladder to the roof of her house.  Josh collided with another bicyclist when riding to school.  Amanda got into a car driven by a friend – and was not wearing her seatbelt when the accident happened.  

Steven got drunk and got into a fight – he was knocked out.

Many of these unfortunate outcomes may have been prevented.  Many of these young people could have had a better recovery if they knew what a concussion was and what to do about it.  Martin for example, continued to play because he did not want to let his team down and took another hit to the head – ending up in hospital for a few days.

The life success of young people depends in great part on how their brains function.  After all, that is where civilization lives.  Our brains chart our lives for us, they do all our thinking, they house our emotions, they control our bodies, they signal us when something is wrong and they direct and guide our behaviors.  So, clearly, they are very important to all of us.

It is really important to have a SMART BRAIN and to help us do this we need to live BRAIN SMART.  Part of living brain smart is learning how to protect our brains against injury and what to do if we are unlucky to get injured (this can happen even if we are doing our very best to prevent it).  The first step is educating ourselves about brain injuries: how we can best try to prevent them, how to recognize them if they happen and what we should to help us recover and avoid further injury.

That is why we developed two Brain Injury Guides.  One version is for young people and one for parents, coaches, educators and all those that work with youth.  Find out more about living Brain Smart by clicking here. Share these links with your friends, family and adults who you hang out with.  Do your best to live BRAIN SMART. The brain you protect is yours!

-Stan

Head injury: Dealing with an important mental health concern in youth

Recently, the Globe and Mail reported that the Province of Ontario had decided to introduce legislation that would require schools to instate head injury prevention and management programs across the province. Read the article here.

In my opinion, this is a welcome and innovative direction for Ontario’s education system. Laurel Broten, Ontario’s Minister of Education, deserves high praise for this step forward.

Head injuries (or concussions) are a significant mental health problem in young people. While most are sports related, concussions can be the result of a car accident, a fall, foul play or other recreational activity. The fact is they can happen almost anywhere.

Concussions can range from mild to severe, depending on the strength of the impact and where the hit occurred. A little known fact is that with today’s technology and research, helmets do a good job preventing brain injuries. Although, just because your wearing a helmet, doesn’t mean your invincible.

There are some other facts that we should all become more aware of.  First off, teenagers who suffer a concussion may take longer to recover than adults do. Second, many teenagers who suffer a concussion return to play before they’re actually ready, which can increase the chances of worsening the damage to the brain. Third, depression can be the result of a concussion. Fourth, because the teenage brain is in a rapid and important phase of growth, damage at this time can cause long term problems. Lastly, treatment is very helpful, but teens need to understand it takes time. Be sure you’re cleared by a medical professional before returning to play.

The first step to effectively addressing this problem is awareness.  Our team at the Sun Life Financial Chair in Adolescent Mental Health will soon be launching two brain injury guides across Canada. Brain Injury Guide for Youth is written with the assistance of the Chair’s Youth Advisory Committee. This guide provides teens with the best available information about concussions, how to try and prevent them, what to do if they occur and how they can be helped if they receive one. Understanding Brain Injury in Adolescence is written for parents, coaches, teachers or any other adult working with youth. This guide helps the reader understand what a concussion is, what its signs and symptoms are, what needs to be done to help prevent concussions, what must be done if a concussion is suspected and what should be done if a young person sustains a traumatic brain injury. Together these guides will help create awareness, while educating youth and the people who care about them.

Keep an eye on our website TeenMentalHealth.org for future information.

- Stan

What causes or prevents mental disorders?

There is so much confusion about what the causes of mental disorders are and what prevents mental disorders.  There is so much confusion about what the concept of “risk factors” means and  what the concept of “protective factors” means.  And for many years, some of the research in these areas has been contributing to this confusion.

One of the most commonly held confusions is that about what causes or prevents depression.  In my opinion, there is probably more nonsense written about those issues than about almost anything else pertaining to mental health and mental illness – except maybe for medications used to treat mental illness. 

Much of this confusion comes from or is related to our very simplistic models of causality – that is, our thinking about what causes what.  We often think of causality as linear – so that something that comes before the event (or diagnosis) is considered to cause that event (or diagnosis).  As we know in our frontal lobes, this kind of linear model is rare.  Mostly causality is multi-factoral and sometimes the most substantive “causal” factors are not readily apparent.  So people get lazy in their thinking and go into brain default mode – choosing to assume that what comes first causes what happens after.  This of course is using our limbic systems as explanation.  Not a good way to be less wrong most of the time.

Depression does not arise in one day.  It takes a long time between when the illness begins and a diagnosis is made.  If you (as most researchers to date have done) look at events preceding the diagnosis of depression you will get a very skewed and biased idea of what may have “caused” the depression.  As a person is getting depressed, they may create events that are due to the depression and not the other way around.  Lazy thinkers then make a completely incorrect causal inference.  They could not be more wrong!

Enter some hard thinking researchers.  They decided to investigate the link between religion and depression.  Many who did earlier cross-section studies found that depressed people went to church less often than those who were not depressed.  So what did they conclude: that being religious prevented depression!  Ouch – and this idea has been around for so long that many people thought it was true!

So here is the new lens.  It’s a prospective study (so not a cross-sectional analysis) that followed people over time led by Dr. Joanna Maselko of Duke University and published in the American Journal of Epidemiology in February 2012: http://bit.ly/AmDqcl. 

And what did they find?  They found that contrary to current mythology, religion does not prevent depression!  What they found is that as people became depressed, they stopped going to church!  Social withdrawal was a result of the depression, not the other way around. 

So, is addressing spirituality for people a waste of time?  Likely not.  Will that prevent depression – no. 

What should we learn from this information?  We need to stop thinking about causality in linear fashion and we need to start doing research that can give us answers to questions in a best evidence way – not jumping to conclusions that reinforce our biases.  Isn’t science grand?  It’s the only system that we have that is independent of our ideologies.  We need to use it more – for everything.   

-Stan