Just Ask

I consider myself to be a very fortunate doctor because I do not often have to deal with the death of my patients. My patients usually recover from their illnesses and, because they are young, I am often able to see them live out the promise of their lives.
The deaths in my practice, however, always continue to haunt me because they are deaths by suicide and suicide is such an insidious outcome that even those of us who see it most often can forget that suicidal ideation and attempts are serious symptoms of a severe illness. We should know better, but we still forget that this severe illness is very difficult to recognize.

Severe illnesses in youth are so difficult for all of us to comprehend. Depression and suicide are even more difficult because they are symptoms that often occur in young people who can present a cheerful countenance to the world – who have a gift of helping others to feel happy. Have you not heard this? Do you not know of a situation in which this was exactly the case?

On the weekend, I read J. Kelly Nestruck’s article in the Globe and Mail about Jonah McIntosh, a young actor at the Shaw Festival who died by suicide in July. He recorded how the Artistic Director at the Shaw Festival saw Mr. McIntosh: “always smiling and making everyone around him smile”. Mr. Nestruk also documented that a death such as the young actor’s suicide was not one the theatre company had experienced, which seemed surprising to me. There is a suicide every forty seconds in the world and artists and actors have a suicide rate of 24 per 100,000, higher than physicians or teachers or nurses.

The article underlined for me once again that those of us who work in mental health fail to educate the public about how difficult it is to predict the course of depression – we have not communicated how a smiling face cannot be assumed to be an accurate reflection of mood. Many people with depression leave their friends and family, leave their doctors’ offices, with a smiling face even when they are plagued by persistent suicidal thoughts, with plans to act on their troubling symptoms. Most of these people have brought joy to their families and friends, but have never found it for themselves.
At this stage in my career, I no longer think about whether I am asking the question sensitively. I just ask, “Are you thinking of suicide?” “Do you have a plan to kill yourself?” People ask all the time if these questions could cause a person to think of suicide but this is not the case.

Just ask, I tell people. If the person you ask seems shocked, or makes some protest, just say,”I am so worried about you and I do not want to make the mistake of not asking about suicide.” We would not hesitate to ask about the serious symptoms of heart disease. We must begin to do the same for depression and suicide. We can save these wonderful lives if we ask. We can prevent suicide.

(On September 10 at 8 pm I put a candle in my window to show my support for suicide prevention and for those who die by suicide and for those who survive.)

A Public Health Campaign for Legal Marijuana

When I first reviewed the Government of Ontario’s approach to legal marijuana, I was disappointed. I was hoping for an approach with a strong foundation in public health. I feel strongly about this and wrote about my concerns for the Ottawa Citizen.

As I read the views of other health stakeholders in legal marijuana, I could not help but notice that many of these felt that the government had addressed many of their concerns. Both Ontario Public Health and the Canadian Medical Association reported being satisfied with a legal age of 19 for marijuana, even though both had advocated for a higher age. The article I read said these organizations described the government’s approach as “pragmatic”. Why am I not satisfied?

This pragmatic approach focuses on regulations and where marijuana will be sold and the public health relies on regulation to manage the age of use. However, as all clinicians working in youth mental health and addiction, I know that the key to changes in behavior and attitude lie in education, specifically public education through health communication campaigns. In mental health, we are very familiar with how successful these campaigns can be. In the past ten years, vigorous health communication campaigns have  been able to neutralize the stigma that existed for centuries against mental illness and persons with a mental illness. I had hoped that, right from the beginning, the Health Minister would have pledged the funding for a sophisticated health communication campaign to ensure that all citizens understood the health risks of marijuana, especially youth for whom the impact on the developing brain can be significant. There was the promise that such a campaign would be developed, but no firm details were provided as to what steps have been taken to implement the campaign.

The campaign I wanted would include persuasive communications informed by social marketing strategies, with messaging designed for different target groups. The public health messages must be accurate, interesting and stimulating so that different communications might be needed for different groups and especially different age groups. I know that the Ministry of Health and Long Term Care can manage this level of sophistication. In fact, I even found a presentation entitled Developing health communication campaigns on the Public Health Ontario website.

The campaign I wanted would start now so that awareness of the risks of cannabis use and information about safe practices for using legal marijuana would be known by the time legalization comes into effect  in July 2018.

The campaign I wanted for youth would reflect the reality that Canadian young people are already the highest users of marijuana in Canada by age group. It would recognize that rules and regulations cannot be the only tools we use to prevent marijuana overuse and addiction.

Another public health element that I was seeking was the commitment of support for further research to evaluate the impact of legal marijuana. This will help us to understand how the Government’s approach might be improved in the future. It will reassure the public, including mental health professionals, that the Government is prepared to be prudent in ensuring that legal marijuana is introduced safely.

Finally, with the growing demand for mental health services, another element that I had hoped to see was a commitment to improved funding for services for addiction. While I do not believe that the legalization of marijuana will necessarily lead to higher rates of marijuana addiction, we know that the province’s coffers will benefit from increased tax revenues. Many groups were hoping for a commitment to improved services, services that are already much needed.

The legalization of marijuana is an opportunity for the Government of Ontario to demonstrate understanding that addiction is a mental health problem and that those people with an addiction should be assisted and not shunned. The young people that I see with marijuana addiction have higher rates of many psychiatric symptoms including psychosis and suicidal ideation and attempt. Many of the young people I see who are now in recovery would provide great advice on how the public health approach to legal marijuana could engage youth in its safe introduction. I hope the Government will seek the advice of those most at risk – people under 25.

Normal and Bored

There are six million young Canadians starting school this week. From busy, excited little kindergartners to oh, so bored almost adults in their finally final year, yellow buses and slower streets will signal the end of summer as nothing else does.
At the psychiatric hospital where I work, we have four classrooms, all part of the M. F. McHugh Education Centre, and the young people who are receiving treatment for their mental health conditions will continue to have access to education, even though they are not all well enough to benefit from that educational experience as much as we would like or hope.
As a clinician, one of the elements I value most about the McHugh classrooms is that they are a constant reminder to my young patients that there is a normal life waiting for them once they are feeling well. The very presence of these classrooms and their teachers is a reminder that everyone working with these patients has every intention of helping them get back into an academic life, a normal life.
Whatever age you are, becoming mentally ill turns your life upside down as no other life circumstance can. Often you cannot manage the very basics of getting up in the morning, or washing your face, or putting breakfast into your mouth. The idea that, on top of this, you’re expected to read Hamlet or learn about cell structure or get from classroom to classroom can be overwhelming. Imagine a classroom that supports you to manage exactly those studies while, fifty yards away, in another part of the same building, on an inpatient psychiatry unit, you are learning to cope with the voices telling you to kill yourself. It’s a lot to put together.
For a young person who is struggling with mental illness, or other difficulties, school can often be the most stabilizing influence in their life. If your dad left home on Tuesday, on Wednesday your class will still be reading Hamlet. If your grandmother passes away on Friday, and you saw your grandfather crying for the first time in your life, it really can help that cell structure does not shift in one week. If, all of a sudden, your mind is just not making sense, it helps to have a classroom where the teacher knows that this has not always been the case and that you will not feel this way forever. I think it especially helps to have a person who can bridge you back to the world where Hamlet and cell structure are important, and you can be a normal person again.When I was younger, I had wanted to be a teacher. The normality of life is one of the things I most miss about my life as a doctor. Like every physician, even when I focus on the person with me, I am often still focused on how well they are. Can they concentrate? Are they enjoying soccer once again? Is their mother back to nagging them about their room being a mess?
When you see a psychiatrist, and you’re sixteen years old, you know you don’t have a normal life. But, if every weekday morning you can sit in Mrs. Scott’s English class, listen to Mary Jo Jones be Ophelia and Sam Smith try to be Polonius, you can feel as though your life is as blessedly normal as everyone else’s. You can go back to being bored and everyone who knows you will think it’s a good thing to be normal and bored.

(Note: As a new school year starts, I will be hoping for the best year for students and teachers and especially for those students and teachers in the McHugh classrooms around Ottawa.)

The Answer

I have not written much all summer because there is only one medical story on my mind. I have resisted publishing this story until I had something to say that might be helpful for others in a similar situation. Recently, one realization comes back to me again and again and for that reason I write about it now.
My beautiful baby sister is dying. I have been travelling to Halifax to spend time with her, knitting and talking while she lays in bed. I spend the days after these visits with a heartache that will not stop and I find now that I cannot stop thinking about her.
My sister has lived at least five years longer than her doctors thought she would. She has been able to see her daughter start and almost finish nursing school. She was happy to have been well enough to attend our mother’s funeral. If she has any pain, she minimizes it. If she has suffered any distress, she hides it behind her sense of humour. She is suffering from visual hallucinations, likely because of medication. Her thoughts on this: “At least it gives me something interesting to watch.” She is a true believer in positive thinking.
My sister is a great raconteur and she spends these Saturdays telling me the stories of her life. She talks of her friends from elementary school, high school and nursing school, most of whom she has found on Facebook. I am trying to write down what she tells me. When I read it back to her, she listens to my account and says, “Stick with quilting for a hobby.” She laughs at her own joke and then reminds me of how bad a baker I used to be. She tells me about patients she had cared for as a nurse and about how the most important parts of nursing involve “no science at all”. In the middle of one story, she stops and says to me, “I am so glad to see you. I don’t want you to be sad, you know.” I do not want to cry and the heartache inside me intensifies.
I have been contemplating how I will be a comfort to her. I want to be a welcome visitor regularly for as long as possible. It is easy for me to listen, as this is something I do most days at work. I only rarely struggle with people’s painful, emotional stories at work, but my sister is not my work. I have always been very good at separating work from family and, as much as I am diligent at work, I believe that my family needs me not to be a doctor, but someone better. Not that I don’t think being a doctor is important, but I really want to be a good sister in this time when she needs a sister.
This experience with my sister helps me to understand what it is like to be relying on doctors and nurses, how helpless one can feel, even when one has great knowledge. I find myself asking: “Do I remember how helpless a patient or their family member feels when I am speaking with them?” I know that my excessive emotional investment in a person’s care can lead me to errors – mostly sins of commission, rather than omission – but do I do what I can to help people feel at ease with being helpless?
I have been remembering the first time one of my patients died in my internal medicine rotation as a medical student. She was an older lady not expected to live. Her family took turns sitting at her bedside, day and night. I remember stopping to speak with them, day and night, getting them coffee or bringing them things to read or answering questions. I felt so badly because there was nothing I could do. I would sit with them and listen to their stories of their mother.
Thinking of my sister, I read through my journals of the six weeks I spent with this family and realized that I had the answer all those years ago, when I believed I had no answers at all. What on earth happens to doctors over the years that, as we become less helpless professionally, we seem to lose all the answers?

(Note: This is an image of Lawrencetown Beach, the Nova Scotia beach closest to my sister’s home.)

Seria Una Cruz Verde?

I am watching the news from the Venezuelan election and wondering what I would do if I were a doctor in Venezuela today. The election is the most recent assault on the people of Venezuela by their President, Nicolas Maduro. By the end of the day, or within a few more days, he will become the dictator of Venezuela. The making of a dictator is the undoing of security in a country and many young Venezuelans have seen their country go from being the richest country in South America in the 1980’s to having an 86% poverty rate in 2017.
Since April, over 100 young people have died in protests in Venezuela. That total increased by 19 this weekend as protests over the election intensified. Venezuela’s neighbours, Brazil and Colombia are bracing for a refugee crisis. The country is experiencing a food security crisis and medicines are not at all available.
The scale of the humanitarian crisis was confirmed by Dr. Douglas Leon Natera, President of the Medical Federation of Venezuela. Natera is reaching out to colleagues in the region. This is a communication to Dr. Maite Sevillano, Vice President of the South American Region of Medical Women’s International Association:
“To the friends: The health sector being headed by the doctors is only attending emergencies, trying to continue to give priority to children, pregnant women and the elderly. These resolutions are being followed by 96% of doctors in public services and 85% in private.” (Personal Communication to dra Sevillano)
Venezuelan physicians are especially concerned about the impact on children, who have been most affected by the food insecurity. Also, youth have been the majority killed in protests against the Maduro regime, according to Dr. Natera.
In Venezuela, however, some of the heroes are also young. Medical students and recent graduates of the Central University of Venezuela have banded together as volunteers to provide first aid and whatever care they can to those injured in protests, on both sides. However, despite the group’s impartiality, government forces usually see them as part of the protest. As they help, some have been injured and one of the volunteers was killed. To identify themselves, the volunteers wear white helmets with a green medical cross and carry white flags bearing the same green cross. Cruz Verde (Green Cross) is what they are called and those injured in protests call out for them, and pray for them.
As most of the volunteers are in their twenties, they were born when their country was still wealthy. They have witnessed its disintegration. They are studying – and learning – the basics of public health, emergency medicine and the impact on health of a humanitarian crisis in the most unfortunate way. Their older colleagues, led by Dr. Natera, are also working to provide basic medical care to starving and desperate Venezuelans. When I read about their work and watch youtube videos of their working conditions, my own first world medical concerns dissolve into this philosophical question:
“Seria una Cruz Verde?”

(Photo credit: Christian Science Monitor)

Journalism and the Scientific Method

Three years ago, I reviewed Seth Mnookin’s book The Panic Virus. In that review, I noted the importance of science reporting in assisting the public’s understanding of scientific research and science in general. Keeping this in mind, I want to highlight an article from the Ottawa Citizen by Elizabeth Payne, a Postmedia health reporter. The article addresses the question, “Could infections cause Alzheimer’s?”

In her article, Payne considers the controversy about the link between microbes and Alzheimer’s disease. She reports that those scientists who favour the microbe hypothesis have made a widespread plea that the public “embrace” their hypothesis.

Payne’s reporting is factual and clear. It leaves the reader with the opportunity to consider whether the microbe hypothesis research supporters or the plague hypothesis supporters are more credible. It calls upon us implicitly to consider both theories, but to remain open to the results of the ongoing research on Alzheimer’s disease. To be open to possibility, to be able to assess alternatives as revealed by rigorous study, is the essence of science. Through her reporting, which points out the conundrum of a controversy in scientific research, Ms. Payne makes it clear why the public should not, in fact, “embrace” a hypothesis until the research and much more consideration yield a clear result.

I am a clinician, not a researcher, but I work in a university teaching hospital affiliated with a research institute and so I have participated in clinical studies. When focused on one’s own research study, it is easy for a researcher to become attached to trends that one believes are emerging from one’s research. I have done enough research to realize how dangerous this is. I have learned that one must be faithful to the scientific method that has fostered the real breakthroughs.

The scientific method is systematic and allows for the modification of the hypothesis. Learning the scientific method is one of the first lessons in science class in elementary school. I remember having to devise experiments in Grade 3, not for a science fair project or research but to demonstrate that I understood the scientific method. That same lesson was repeated at the beginning of many grade school science classes for years to come. The scientific method is fundamental but, like all fundamentals, it is more easily expressed than understood. Ms. Payne’s excellent article reported some news from medical science and reminded us of how difficult it is to learn the scientific method.

(Note: The excellent graphic depicting the Scientific Method included here comes from the Science Buddies Website. Science Buddies is an award-winning, not-for-profit organization dedicated to building scientific literacy.)

Book Review: The One Memory of Flora Banks

I read The One Memory of Flora Banks (Author: Emily Barr at www.emilybarr.com)  last weekend when I was on call at the Children’s Hospital of Eastern Ontario. On a day when I was providing service to a busy emergency room, it grounded me to be considering the plight of a young person who had suffered considerable trauma and had lost her memory because of it.

This is the adventure of a 17 year old girl named Flora Banks who has anterograde amnesia, which means that she cannot remember anything that happened after the event which caused the amnesia. To help her manage her life, Flora writes down every important thing that she must remember. Many, many things she wants to remember are written into notebooks, but the most important things are written on her hands. Of the important messages, one is prominent and it is a tattoo that says: Flora be brave.

Flora’s memory problems, we are told at the beginning, are the result of a brain tumour that was removed at age 10. The book is written in Flora’s voice and so the reader can experience what it is like to live inside Flora’s brain. To an observer, it would seem as though Flora has lost a lot of her capacity. But from inside Flora’s brain, the reader realizes that this is not the case. One of the most important messages of this book is never to underestimate a person’s abilities.

Even though Flora is capable of more than is evident, she is very hopeless about what she has lost and worries about what her life holds. One evening this changes when a boy kisses her and Flora remembers this kiss for longer than her usual several hours. Immediately, Flora is hopeful that this boy, or his love, holds the answer to her regaining a functional memory. She sets off to find him, despite the limitations of her memory and without anyone supporting her.

There are many days in my work as a psychiatrist for youth that I see young people coping with having a chronic medical condition that could limit what they might achieve. Like Flora, they have periods of hopelessness when they sadly wonder what their lives will bring. But many of them, like Flora, refuse to be defeated by despair. I don’t care if they disagree with me about their medications, or their symptoms or their diagnosis. I hope that I am true to the spirit of hope that lives in them, and I work to be worthy of that positivity.

This is an important book because we can all benefit by knowing Flora. Not all of the people who love Flora trust her hope any longer, but she meets a lot of new people in her voyage to find love and her memory and they do trust Flora’s hope. Please read about Flora and resolve to help at least one person stay hopeful.

(Note: I read the 2017 Penguin Random House edition of The One Memory of Flora Banks. The photo is the cover of that edition.)