Recovering from Child Abuse

The prevalence of child abuse in Canada is approximately 1%. This may seem not to be very high but the impact child abuse has on those affected has far reaching consequences. This is best illustrated by more statistics, so I am going to summarize these over the next few paragraphs. While you review them, I suspect that, like me, you will find yourself asking how any of these children ever recover and, when they do, you will wonder how they managed.

Thirty percent of children who are abused do not finish high school (Lansford, Miller-Johnson, Berlin, Dodge, Bates, & Petit – 2007). They are 26 times more likely to be homeless (Herman et al, 1997), 4 times more likely to be arrested as a young offender and twice as likely to be arrested as an adult (Lansford et al, ibid.). They are 3 times more likely to have an unplanned pregnancy (Irish, Kobayashi, & Delahunty, 2009). All these circumstances interfere tremendously with becoming a productive adult and so the gifts these children might have brought to the world may be lost forever.

The impact of the trauma they have suffered does result in serious mental illness in these children and youth. They are 4 times more likely to experience suicidal ideation and self-harm (Irish et al, ibid.) Not surprisingly, some studies show that as many as 100% of these children suffer from some symptoms of Posttraumatic Stress Disorder and 37-50% develop Posttraumatic Stress Disorder (Trask, Walsh, & Dilillo, 2011). They have 4 times as many contacts with mental health services as adults than the rest of the population (Spataro, Mullen, Burgess, Wells & Moss, 2004).

When I contemplate the histories of the young people that I see in the tertiary care psychiatric hospital where I work, these numbers – other than the 100% – seem low. I suspect, however, that this is because the youth we see have usually had significant mental health services even before they were seen in our programs and so those who are eventually seen in tertiary care likely have a higher prevalence of child abuse.
The young people who have been victims of child abuse also have more contact with the general medical system as 90% of them have worse health than the general population (Springer, Sheridan, Kuo & Karnes, 2007).

I am looking up these statistics for the purposes of determining to what degree mental health programs must consider their impact as they design programming for conditions beyond trauma. For example, to what degree must a program for youth with psychotic disorders allow for a history of childhood trauma? In fact, this is likely the wrong question.

The question that must be asked is: how do mental health programs ensure that the specific needs of those children and youth who are victims of child abuse get services that will also address their psychological trauma, as well as the other programs they require?

The traits that ensure that a young person can recover from the impact of child abuse, based on numerous studies examining longer term outcomes, focus on the development of resilience. You don’t have to do more than scrape the surface of the resilience literature to determine that remaining positive about one’s talents, about one’s ability to recover and about the future are the keys that unlock the development of resilience. As mental health care providers, it is our task to ensure that everyone can feel positive about themselves and their future., no matter which mental health condition they suffer from.

What I like best about this is that it is a simple lens through which to examine programming. You examine each facet of a mental health program asking: Does this foster the development of a positive attitude toward the patient, their recovery and their future? If the answer to the question in any circumstance is “no”, then changes are needed until the answers and the approach is positive.

I do find it personally helpful to be mindful of this when I see a young person who has been the victim of child abuse. If I can focus on helping them to be positive about the future, we can usually figure out what services they need to move forward.

“Note to self: Every time you were convinced you couldn’t go on, you did.” (Anon.)

Let’s remember to Look After Mental Health Advocates

January 31, 2018 is Bell Let’s Talk Day. For the last month, a series of short video clips has been circulated by Bell to promote its important fundraising and awareness raising day. The video clips feature people who have experienced mental illness and they are worth watching because they are so inspiring. I can never listen to these stories without being moved. Everyone who knows me knows that I cannot help but be affected by these stories. I even become tearful, to my chagrin, because I am so amazed that there are people so willing to share their stories and their pain so that others can be helped. (Note: My daughter, who has this same affliction, has called this “the stupid, emotional gene”. We both find it embarrassing.)

I am privileged to know individuals who are, have been, or likely will become mental health advocates. In my experience, they are entirely motivated to prevent other people having to experience the degree of pain they have suffered. To do this, they tell their own story. They have stories of recovering from their own mental illness; to remind others that recovery is possible and not to give up. They have stories of a loved one who did not recover; they work to build the services their loved ones didn’t have and they remind us not to give up. They have stories that finding mental health can be an ongoing struggle but not to give up. That is the overwhelming message: Don’t Give Up!

What makes mental health advocacy successful? This study of how mental health advocacy was established in Sierra Leone considers the factors that led to its success and the barriers that it faced. Before this advocacy began, there was almost no consideration of mental health in this poor African country so this elegant study allows us to extrapolate from its prima facie case to our own situation in Canada, where mental health advocacy is not new. A review of the factors that helped and the barriers is striking in that there is little difference between Canada and Sierra Leone. Consider what this means: our mental health advocates in Canada must overcome the same barriers to achieve their goals as those in a country that most would consider to be far less sophisticated. If you talk to a Canadian Mental Health advocate for five minutes, you will find out how evident this is – and how discouraging.

Why do mental heal advocates do this work and what do you need to know if this is a path you’ve chosen? This article by Erin Hodgson, who leads the Jack Talks program at Jack.org addresses these two questions. My favourite part of this article are her six self-care strategies. These are important for everyone, but especially important for mental health advocates who, in my experience, give so much to their work. While you’re reading the article, you can find out about Jack.org itself and their important advocacy work with young people.

Mental illness comes close to all of us. It doesn’t take the usual six degrees of separation to find someone who has suffered from a mental illness – most of us know well someone who has had a mental illness and, often, we are that person. Personally, my father and two brothers died before I was twelve. My father’s death brought other losses and I am, in many ways, an expert at loss and grieving and they have been my window on mental illness. I consider myself lucky to have suffered no worse affliction. During my days of listening and watching others cope with the heartache and aftermath of mental illness, I am awestruck by people’s persistence and courage. I don’t know if I could manage as they do, I often don’t know how they manage and I consider it a privilege to help them do this. When these people decide that they must work for others, I am always blown away.

I have seen too many advocates become overwhelmed by their memories and the task they have chosen for themselves. I also know that the system offers little organized support and so I try to keep my door open for them. I am not trying to be their caregiver, unless it is clearly my job, but I will try to find them the help they need. My goal is to be an enabling factor as described in the Sierra Leone Study, or the nudge to remember the self-help strategies that Hodgson says advocates need.

Mental Health Advocates need our support, and by that I don’t mean professional help. I mean they need all of us to remember that they are doing something we could all do if we wanted to, if we had their courage. I am not that brave and so I will support mental health advocacy by supporting them. On Bell Let’s Talk Day, I will be one of the best tweeters and Facebook posters. It’s the least I can do.

(Note: Image from Sydney.edu.org)

It’s Not Your Fault

I am thinking about families today, and especially the families of those who have attempted or completed suicide. Suicide is the most serious consequence of having a mental illness and a suicide attempt and suicidal thoughts are always reminders of how dangerous a mental illness can be.

When someone dies of a suicide attempt, those who know and loved them suddenly become victims of the stigma that continues to plague mental illness. How does that stigma manifest itself?

The stigma is evident in the fact that most family members and friends will ask themselves, “Was there something more I should have done?” For the most part, if your mother or your sister or your child dies of cardiac arrest or cancer, you do not ponder the circumstances, concerned that you were neglectful or remiss. But suicide and suicide attempts are different in that there are always lingering doubts about what signs we might have missed. We go over final statements and conversations, finding meanings that we believe we should have caught.

I want very much for everyone reading this, who has had someone close to them lose their life because of suicide, to read the next sentence carefully, knowing it is the most important thing to remember about suicide and suicide attempts.

It’s not your fault. It’s no one’s fault. The problem is that suicide and suicide attempts are symptoms of a serious mental illness.

I wanted to emphasize those sentences and that paragraph above, but I mean this plea to be gentle, a reminder of how insidious mental illness can be. Mental illness has a different contagion. It is as if we can catch the guilt and low self esteem of our loved one from their suicide or suicide attempt. No other illness does this.

Next week, January 31, is Bell Let’s Talk Day. Already the Commercials are playing, raising awareness about mental illness more effectively than any other campaign. During the campaign, we will hear from people with great courage who speak about their mental illness, in voices that systematically work against the stigma that still marks the afflicted.

The suicide rate in Canada is 11.5 people per 100,000. The number of family members and friends affected by these deaths is too extensive to capture. Probably about one third of us have been affected by a suicide or a serious suicide attempt.

I am thinking about those of us who have been affected by a death by suicide or a suicide attempt. I am writing this so that we remind ourselves not to be infected by the contagion of stigma, not to fall into the trap of thinking that we were at fault for a death by suicide or a suicide attempt. I want us to remind each other, because I find it hard to remember this on my own.

(Note: Tabitha Suzuma is a British author of fiction for young adults. This image is from Pinterest.)

Seasonal Affective Disorder? Or a Bad Winter?

In Eastern Ontario, this has been a winter for the record books: long periods of deep cold alternating with difficult periods of precipitation and very few days of temperatures that make for a pleasant walk. Just this past week the temperature fell 30 degrees within 12 hours and the precipitation turned from rain, to freezing rain to snow. I find that whenever there is a difficult period of winter weather, more patients will ask, “Do you think I have Seasonal Affective Disorder?” Because of the weather, there are many more people asking that question this year so a brief primer and some references might be helpful for some of you.

Norman Rosenthal is the psychiatrist who, with his research team, first described Seasonal Affective Disorder (SAD) and his book, Winter Blues: Everything You Need To Know To Beat Seasonal Affective Disorder, is still one of the best references on the condition. It is available now in its fourth edition. The book is easy to read and still provides some of the most authoritative information with respect to SAD. He even has a blog and short video about what you need to know about SAD.

Since I see youth and young adults in my practice, I should point out that this group has a higher rate of Seasonal Affective Disorder. It is interesting that, in his blog about SAD in college students, Rosenthal suggests that parents can have a protective effect on youth vulnerable to SAD since they will remind them to get enough sleep and to care for themselves. When one is away from home for the first time, it takes awhile to learn selfcare and so these students might be more vulnerable to a condition that causes decreased energy and a sleep disturbance. This is Rosenthal’s contention so it follows from this that if you, or a family member, suffers from Seasonal Affective Disorder, a good way to support them is by helping them to maintain a reasonable schedule, especially with respect to getting enough sleep.

The symptoms of Seasonal Affective Disorder include:
1. Difficulty waking
2. Decreased energy
3. Difficulty concentrating
4. Increased appetite especially for sweets and starches
5. Weight gain
6. Anxiety
7. Decreased interest in socializing

These symptoms can interfere with a person’s capacity to manage their regular work or academic schedule and if you’re experiencing these, there are some things you can do that may be able to help.

First, look up the material I’ve included and consider whether you might have Seasonal Affective Disorder. Even if you’re not certain, there are some health measures you can take that have no risk and that could be helpful. Start with getting more light: go for a walk, especially a morning walk and find ways to let the sunshine into your home or workspace. You can use a timer or a dawn light at your bedside table to “start” the daylight a bit earlier. You can also get a specific light for Seasonal Affective Disorder. These are available in medical supply stores and some insurance plans even cover the cost.

You can also develop some basic Cognitive Behaviour Therapy techniques. Learn to recognize and manage negative thoughts and find some things to do that always help you to feel better. This last suggestion seems to be very hard for many people for whom depressed mood can be problematic. When there is a depressed young person on the inpatient unit, one of the most enjoyable and rewarding things to do is to help them find activities that always help them to feel better.

Finally, when should you see a doctor if you think you might have SAD? If your functioning at work or in school becomes affected, it’s time to discuss with your family doctor whether more treatment is required. Some cases of Seasonal Affective Disorder can be so severe that antidepressant medication will be needed.

All of this does not address whether a winter such as we’re having in Central Canada results in more cases of Seasonal Affective Disorder. Well, this does not seem to be supported by research. I cannot quite believe it myself. When I get ready to leave for work in the morning and I can’t quite face the 10-minute walk because it’s -30 degrees centigrade and there’s a wind chill factor on top, it would be great to feel justified in worrying about an increased risk of SAD. But it’s not the case. In fact, the short walk in the bright morning is likely just what I need to prevent the condition.

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)

Hallowe’en and Stigma

In the last two weeks, several of my young patients have mentioned to me that they were being mocked by acquaintances about a seasonal attraction near Ottawa and their personal connection to a psychiatric hospital. With their families they have been asking me what they could do about this attraction, which has so negatively affected them. I have directed them toward this essay by a remarkable mental health advocate, Jean-François Claude.

Mr. Claude launched his website The Men’s D.E.N. in 2013 and was the driving force behind the City of Ottawa’s declaration of the Men’s Mental Health Day. He has been a tireless advocate for Mental Health and against stigma. Recognizing his tremendous contribution, the Royal Ottawa Foundation for Mental Health presented him with an Inspiration Award in 2016. His work was further recognized on June 23, 2017 with the Governor General’s Meritorius Service Decoration, presented by then Governor General David Johnston. Mr. Claude is ranked #5 in the Top 100 Mental Health Influencers on Twitter – please follow him @JFClaude. Mr. Claude has lived experience of mental illness, a circumstance that, instead of making him bitter or cynical, has strengthened his resolve. The world needs more people with his courage.

He has allowed me to copy his essay here, so that my readers have a chance to see it. Please also follow Mr. Claude on twitter and visit The Men’s D.E.N. website.

Here is the essay:

Why My Local Kiwanis Club Has Me sKreaming Against Halloween Stigma

Every Halloween season, the stigma against mental illness rears its ugly head, usually in the form of distasteful “dangerous crazies” costumes and asylum-themed decor. This year’s no exception.
But I’ve been so busy raising awareness and fighting stigma of mental illness on social media, that I was blindsided by what’s been happening in my own backyard of Orléans, a suburban community in the City of Ottawa’s east end.
sKreamers is the “demented and awkward child of the Kiwanis Club of Orléans.”
Their words, not mine. It says so right in the About section of the sKreamers website.
sKreamers is a so-called Halloween ‘attraction’ held annually at Proulx Farm in rural Cumberland, with the fictional Orléans Asylum for the Insane serving as its fictional backdrop.
It boggles the mind how a community service club like Orléans Kiwanis could find it acceptable to be teaching our youth that people with mental illness are to be feared.That denigrating people with mental illness as “bitchy, whiny inmates with very bad attitudes” is somehow all in good fun, in the spirit of the season.
Try telling that to the parent who’s lost a child to suicide, the #1 cause of non-accidental death among Canadian youth. Or to any of the 1.2 million Canadian children and youth who will struggle with mental illness this year.
This $20-admission ‘attraction’ features, among other activities, “The Escapee’s [sic] Insane Wagon Ride”, where you get to witness the “live-capture” and “beheadings” of in-patients from our local (fictional) mental health institution. As if that weren’t bad enough, you can also partake in “Shoot to Thrill” where, for a mere $5 more, Kiwanis volunteers will “train” you to take part in the “interactive inmate shooting gallery.”
Yes, you read that right. Because apparently open season on the mentally ill is what we want to be teaching our kids?
To call people with mental illness “uncontrollable” “assassins” is irresponsible at best, perpetuating the myth that those with mental ill health are dangerous killers, when they are much more likely to be victims of violence. So say the stats.
Labeling people with mental illness as “insane” or calling them “crazies” further fuels stigma. It shames into silence those who struggle with their mental health. Stigma is the single biggest barrier to people getting treated for mental illness.
And by the way, every single word in quotation marks above comes straight from the sKreamers website. It’s in their promotional material. Seems no one has taught Kiwanis members how the language we use matters… a lot.
One would think a service club whose motto is “Serving the Children of the World” would discourage name-calling and fear-mongering. And want to encourage our children to seek out mental health help and support when they need it.
Although too late in the season now, Orléans Kiwanis and their partners need to abandon the concept of a Halloween “asylum attraction” for 2018. It’s horrendous, hurtful and harmful to the 6.7 million of our fellow citizens diagnosed with mental illness. And its damaging to the Kiwanis brand.
But you can still do something about it for this year. Send Orléans Kiwanis an e-mail. Get your pumpkins from somewhere other than Proulx Farm. Spread the word by sharing this blog post.
And instead of heading out to sKreamers this weekend, donate the equivalent admission amount to The Royal Ottawa Foundation for Mental Health…and do so in the name of the Kiwanis Club of Orléans.

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.)