Learning Disabilities

I was twenty-one years old when I first truly understood learning disabilities. I was in my clinical clerkship at McGill University in a psychiatry rotation. One of the patients I was following had dyslexia. Like every good medical student, I read everything I could about the condition. But it was the definition that was personal for me: “the general term for disorders that involve difficulty in learning to read or interpret words, letters, and other symbols, but that do not affect intelligence.” I am not sure where the definition is from because I have copied it today from the journal I kept at the time.

This disorder was important because of how my mother had always described her own academic abilities. My mother always told us that she “could never spell” and was “a slow reader” and that her younger sister was “the smart one”. My brother and sisters and I were given very easy to spell names because my mother had struggled to spell her own beautiful given name, which was Othelia. She didn’t like this name, I suspect because it always made her feel “stupid”.

“I can’t even write my own name,” she’d say.

But, on the other hand, she could talk your ear off and no one could recount family stories as wonderfully as she could. Her vocabulary was sophisticated, her grammar perfect and, if she could have written them down, she would have produced some of the best stories about life on a small Ontario farm in the Ottawa Valley during the Great Depression. She also got the best marks in math in her family and, for many years, made her living as a bookkeeper.

The more I read about this condition, the more I realized that this was exactly my mother’s problem. Educational institutions were just beginning to accommodate for learning disabilities in the 1970’s and I astounded my supervisor with the amount of work I did to get those accommodations for my patient, who was struggling to complete the mandatory English credits to get her Architecture degree. This young woman had been discouraged from studying architecture because “it’s a difficult job for a woman”. That’s another quote taken from my journal.

Female medical students were just as rare as female architecture students in the 1970’s, which was another factor that kept me engaged. Not to mention enraged, when a senior resident at rounds suggested that part of the management plan ought to be for my patient to switch to a “woman’s career”, like “teaching”. I had a great supervisor at the time, a former Associate Dean of Admissions at McGill University’s Faculty of Medicine who was committed to bringing more women into medicine. He said to me, “I can tell by the look on your face what’s about to come out of your mouth, but don’t say it.”

With my supervisor’s assistance, I appeared with my patient in front of the School of Architecture’s Examinations Appeal Board. I provided clinical records that proved that her mental health had been affected by an Acute Depressive Episode, a well-recognized medical condition. Then I brought documentation on Dyslexia and requested that she be able to have accommodations to allow for this condition. Universities weren’t used to providing accommodations at the time, but a Professor of Medicine and former Associate Dean is hard to argue with and so we were successful.

Fresh from this success, I went home, thinking to convince my mother, who had just started Community College, to get accommodations for her own education. She had decided to go back to school to get a postsecondary education, which was a dream for her. She was failing all her essay assignments and exams for reasons that were now completely obvious to me. I tried to explain dyslexia to my mother, all my articles and research in my hands. Of course, those articles were meaningless to her because she couldn’t read a word.

” I’m not as smart as you,” she said. I felt like I was being mean to her when I convinced her to let me try to get accommodations for her. She came with me to the student advisor at the College, who was more enlightened about learning disabilities than Professors in the School of Architecture had been. From then on, my mother was allowed to complete her exams and assignments orally. She graduated with honours, of course.

Today, when I am working with a youth with a learning disability, what I remember most vividly is how “stupid” my patient and my mother felt all those years ago. Working with my patients now, I can always find skills they have that demonstrate how they intelligent they are. There is much more information now about learning disabilities, including this web site which shows what text can look like to someone with dyslexia.

After my psychiatry rotation, my supervisor stayed in touch with me. Medical school exams were difficult for me because they were multiple choice. I have failed every multiple choice exam I have ever written the first time I wrote it. When I look at a multiple choice exam, I feel like a starving person with a menu and I feel stupid that I cannot pick out the correct answer. Ironic, isn’t it?

(Note: Dr. Alan Mann, Professor of Psychiatry at McGill University and Psychiatrist-in-Chief at the Montreal General Hospital, former Associate Dean of Admissions in the Faculty of Medicine, had the most influence in my career of any of my teachers. It was one of the greatest honours of my life to serve as Chief Resident at the Montreal General Hospital during his tenure.)

(Credit: This image is from Time Magazine.)

Mental Health Measures Anyone Can Do

There’s something about the Samaritan’s #LittleThings campaign that really appeals to me. Every time I see or read their suggestions and material, I am reminded that the best public health measures are simple and straightforward. They are also easy to remember and often easy to manage, so I decided to offer three suggestions, taken from the #LittleThings campaign, everyone can use in a medical or mental health practice that have been proven to be helpful in improving mental health. These would also be useful to anyone struggling with a mental health problem, or their family members.

My first suggestion is to do hospitable things. In our offices and at the reception desks in our program, we leave out water and glasses, snacks and interesting reading material. We keep the space clean and tidy and welcoming. Research shows that people react positively to welcoming situations so positive greetings and just very simple but special items can really help. When I had a private office, we would put out handknit slippers in the winter. People really liked these, especially that my mother had knit them in all sizes for the office. To consider how this works, imagine yourself going to a doctor’s office, and what these are usually like. Then think how it would seem if there were something to drink, a kind voice to greet you, anything that helped you to feel valued and welcomed. I don’t think it’s surprising that the evidence supports that it is good for our mental health when first encounters are positive.

The next suggestion is to learn to listen well. There is a great blog, Just Keep Swimming, written by a person “who uses the mental health service in Ireland”. One of their blogs, The delicate art of listening, contains some good suggestions on how to listen well. There is much being made today of the benefits of health care providers listening to their patients, but all those benefits apply to our personal conversations as well. Again, it seems simplistic but another proven way that we can promote mental health is by listening.

The third suggestion is a little more complicated, because it would involve some expense for a practice or office, but its value psychologically is well established. It is to send personal greetings by regular mail. This is a good suggestion if a family member or friend is living with depression – send them a card or letter from time to time and it will help them to manage the negative feelings. In my practice, at the end of a person’s hospital stay, I will often have patients send themselves a postcard or card to remind them of some fact about themselves or some advice that is positive that they often forget. People in general don’t get real mail any longer and it can be encouraging to receive something personal when you least expect it in the mail.

So that’s it! I imagine some readers are thinking, “Well, that’s just more wellness nonsense. Who bothered to prove that scientifically?” Well, you can find that out in the #LittleThings material also. I have not put the case for wellness activities as a part of healthcare deliveries especially well and maybe I will work on that from a Canadian perspective, but Harry Burns puts it very well in this short piece in New Scientist. Harry Burns is a Professor of global public health at the University of Strathclyde and a former Chief Medical Officer of Scotland. So consider the advice of a public health expert in this and consider some of these suggestions.

Opioid Crisis 2018

There were 2861 apparent opioid-related deaths in 2017 and that number is expected to increase to approximately 4000 deaths in the coming year. The question is: Can this number predict at all how many new resources will be needed to improve the prevention of opioid-related deaths? Will we be able at least to stem the tide of what seems to be a worsening situation?

The data collected by the Government of Canada should be causing alarm in Canadians, but I wonder if we are becoming immune to alarming headlines. I am personally feeling overwhelmed by everything that I ought to feel alarmed about so, as my obsessive little way of managing, I am going to try to manage one or two alarming things that are problems that will affect my practice and the programs in my department. The opioid crisis is one of these since it is quickly becoming a big problem for those of us working in youth mental health.

Let me tell you what alarms me about opioids in youth psychiatry. First, consider that there are 16 opioid poisonings daily in Canada that lead to hospitalization. That is a 53% increase in hospitalizations for opioid poisonings over the past 10 years. Of that increase, 40% of the hospitalizations have come in the past 4 years, since fentanyl began to be important as a painkiller and drug of abuse in Canada. Of the opioid-related deaths in Canada analyzed this year, 74% have involved fentanyl. The 15-24 year old age group has the fastest growing rate of both opioid-related deaths and opioid-related hospitalizations. Also, an analysis of the hospitalizations shows that 31% of these are related to a suicide attempt. The fentanyl reaching Canada from China may be used more for a suicide attempt than for any other purpose – not that I believe there is any good purpose for it! Globe and Mail reporters Karen Howlett and Andrea Woo have done some great work on fentanyl, and I urge everyone to read their articles.

With so many youth suicide attempts linked to fentanyl, the public health response must reach out to youth directly. Here in Ottawa, Ottawa Public Health has developed a program for schools, which is a good step. Other Canadian cities are doing the same, and yet this crisis is still expected to deepen, as if there is no way to stop, or even halt, the burgeoning mental health crisis.

I believe that it is time to ask young people in Canada what more can be done to improve their mental health, especially since we do not have time to develop the system needed to treat their mental illnesses. The world that our young people live in, that drives them to suicide, needs to change but we need to ask them what would help.
For example, it is not uncommon in psychiatry for us to relegate patients with substance use disorders to their own little corner, saying that they must manage this condition before the mental health condition can be managed. Honestly, so many youth with mental illnesses are now doing their own medication trials with whatever substance they can find that this no longer makes sense. I can write Prozac prescriptions hoping they’ll be used but it doesn’t help when the fentanyl can be shipped across the country by Express Post. See the Globe and Mail reference if you think this is an exaggeration.

It makes more sense for all of us assessing and treating mental illness to just accept that most of our patients have Concurrent Disorders. It is also time to acknowledge that fentanyl, the flagship drug of the opioid crisis, is now commonly used to stave off the symptoms of mental illness and, if that doesn’t work, to kill yourself.
(Note: Concurrent Disorders is the term given when a patient has both a substance use disorder and a mental illness.)

I asked at the outset whether the numbers of opioid-related deaths in Canada could be used to predict what resources will be needed to prevent these deaths. In fact, all this evidence tells us, and what we can see from the British Columbia and Alberta experience where the crisis is further developed, is that we can never be ready for the impact of fentanyl.

In the world of youth mental health, the opioid crisis is an invisibility cloak for the mental health crisis, and most of us do not make the mistake of confusing the two. In my little corner of the world, I am going to be trying to convince everyone I can of the need to avoid fentanyl and opioids in general. I am going to try to catch whichever overdoses I can. I am going to support every single addiction and rehabilitation measure governments see fit to introduce. There will not be too many resources – the evidence is that there will never be enough.

(Photo credit)

How to Manage a Suicide Pact

Recently at a Montreal high school, 62 high school students made a suicide pact. As the story broke last week, the Montreal Gazette revealed that school officials had determined the three people who started the pact, who claimed that it was a prank. The article also quoted a school official as saying that “some of the students did not know what they were signing because only the first sheet indicated that it was a suicide pact”. No doubt school personnel were trying to allay the fears of the public, and more importantly, parents of students at College d’Anjou, a private high school in Montreal’s east end.

I learned about this situation when I was asked to comment and provide advice for Global News. I found the tone of school officials, as characterized by the Montreal Gazette, to be troubling. We know too much in 2017 not to be concerned whenever news of a suicide pact emerges, especially among youth between 15 and 24 years old. During these years, suicide is the second most common cause of death.

Some of the other facts that ought to have engendered more concern are the actual statistics about suicide and suicide attempts in Canada. The Canadian Mental Health Association has found that 34% of youth between the ages of 15 and 24 have contemplated suicide – one third. Also, the actual number of suicide attempts in this population in Canada is 8%. Both the rate of contemplation and the rate of attempts increases when there is a suicide pact. The acceptance implied in a suicide pact reduces a young person’s emotional barriers to suicide and so the risk increases.

What should happen when a school learns of a suicide pact? There are 3 direct steps that might help. The first step consists of education through assemblies. Bring all concerned together, in this case the entire student body along with their parents and other interested family members, e.g. siblings. Have an experienced resource person speak to this group about what to do to reassure themselves that their family member will be okay. This person can direct the assembly to resources for Mental Health First Aid as well as to local crisis and emergency services. There will be lots of questions about both the general subject of suicide and suicide pacts and about the specific situation. The resource person and school personnel should be prepared to address these. The school personnel must be prepared to address concerns openly, without judgment, and compassionately. This is not a time to be defensive. It is a time to make sure you have support moving forward should there be a need for further mental health assistance.

The second step must involve meetings with mental health professionals for each person involved in the pact. The best scenario is that one third of these youth were contemplating suicide and it is important to reach out and find help for these young people.

Finally, it is an important time to remind everyone of these three circumstances that indicate an increased risk of suicide in a young person:
1. Increased use of alcohol and drugs.
2. Giving away one’s belongings.
3. Signs and symptoms of depression or a history of depression.

Doing all of this is a good start to preventing suicide, but suicide and suicide attempts are symptoms of a serious medical illness. People die of serious illnesses. In some cases, such as this, these deaths can be prevented.

If anyone reading this has questions, please ask. The best way to prevent suicide is to talk about it openly and without judgment.

Opioids and Social Capital

Over the weekend, I read the first article about the opioid crisis that made any sense to me. It was published in Scientific American last week and explained why so many of the strategies that we are using to combat the rising rates of opioid overdose have been ineffective in curbing the rate of overdose to any great degree.

The article summarizes the research that suggests that the best ways to address the abuse and dependence on opioids is to help communities strengthen the social ties between people. The author opines that the emotional reasons that we become dependent on any substance are factors that communities should seek to address in to reduce the morbidity and mortality related to opioids.

In one study published in the Journal of Health Economics, researchers looked at the impact of macroeconomic changes on opioid use in specific counties and states in the United States. For the region studied, researchers found that, when the county unemployment rate rose 1%, the opioid death rate per 100,000 rose by 3.6% and the opioid overdose Emergency Department visit rate rose by 7%. These statistics held throughout the state.

The article summarizes the science related to the body’s naturally occurring opioids – endorphins and enkephalins – these help us to moderate both physical and emotional pain. The science is outlined concisely and briefly and reminds the reader of those factors which increase the levels of these naturally occurring opioids. It also reminds us how this hormonal system insulates us from emotional pain in our lives.
I have never prescribed opioid medication myself, and most of the doctors I know are similar in practice to me so I have been bewildered about who all the doctors prescribing them could possibly be. I’ve seen the numbers, however, and I certainly know of physicians who have gotten into difficulties because of the way they prescribe opioids. I understand that physician regulatory bodies have sought to address the increasing rate of opioid abuse and overdose by offering courses on prescribing these medications.

To address this dangerously increasing use of opioids, communities have been distributing naloxone kits, setting up safe injection sites and running health prevention campaigns. I support these measures as urgent action must be taken in the moment to do what we can to prevent harm to those already at risk because of opioid use.
Having said this, it’s time to think about what can be done to address those social capital deficits. The OECD defines social capital as “networks together with shared norms, values and understandings that facilitate co-operation within or among groups”. These networks include such networks as family, friends, groups we belong to, or organizations that support us. According to the research, the loss of social capital is linked to increasing opioid use and all its attendant risks.

I’ve been thinking of social capital lately as I’ve worked to find supports in their communities for youth in my practice, supports such as groups where families might learn to cook or spend time with other families. As I did this research, I realized that some Ottawa communities are better at this work than others. It makes sense from this that communities might consider supporting community development as well as safe injection sites and naloxone kits.

Many reading this will believe that this is all about the social determinants of health but this is a reflection on the need for all of us to consider how we personally build communities. Do we go to groups? Do we initiate support activities? Do we go to community events? All things considered, cities can support communities but they can’t provide them the way they can buy naloxone kits or new services. They can’t make your neighbours neighbourly. That takes individual people getting out of their chairs, turning off the TV or their devices, and talking to people or working with people. While it does build a community to have skype meetings or online chats, this research is telling us that, if we truly want to have communities, then we must have some that we can walk to when we’re caught in a snowstorm or hurricane, or the power goes out. Perhaps if we volunteered at the food bank, it wouldn’t be so hard to go there for food, or even just company, when the need arose. Having community meals or parties or street events, bringing disparate parts of communities together, can help you find out what services you can have or help in your neighbourhood.

Last weekend, the Wellington West Community held an event on Wellington Street. As I walked along running my errands, I stopped off at a few services. I learned that one agency, Ottawa West Community Support, has a range of services to help seniors continue to live in their own homes. They told me that volunteering with them has helped many older people make the transition to using their services. That is social capital. I learned that the library helps anyone learn how to navigate the internet safely, from kids to seniors to newcomers. The library has an English Conversation Group. These are examples of building social capital.

This research and consideration has me thinking about how I could invest in social capital in my hospital practice and so I have been thinking about the kinds of groups that could most help youth in my community. I have a few ideas but would be interested in others’ ideas also. Please tell me. It seems a long way from the opioid crisis to me, but the research suggests that I am wrong. How do you build social capital? How do you think we could help?

(This photo has been in multiple places on the internet. I found it in Lawrence Wall’s twitter feed.)

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.