Putting the focus back on the patient

An article published in the December 1st edition of The Chronicle Herald:

IWK hopes to whittle down wait for youth mental health services

By John McPhee, Health Reporter

Add value and keep it simple.

It sounds like a business marketing pitch but actually it sums up an increasingly popular system for treating young mental health patients.

Two child psychiatrists from Britain have been working with staff at the IWK Health Centre in Halifax this week to see if the Choice and Partnership Approach will work there.

About 1,100 people are on the waiting list for child and adolescent mental health services at the IWK Health Centre in Halifax. That wait can be as long as 18 months, compared with the standard acceptable wait of about a month.

"They’ve noticed some of their systems haven’t helped users as well as they would like," Steve Kingsbury [pictured], a child and adolescent psychiatrist based in London, said in an interview Tuesday during a break in the training session at a Halifax hotel.

"How you organize services (and) the paperwork you have to do? And I don’t think they could see any way of doing it better until they heard about this."

Kingsbury and Ann York, who also works in London, have taken the "reduce bureaucracy and focus on the patient" message to 11 countries in the past six years. They and other clinicians came up with the system as a way of tackling long wait times and unacceptable outcomes, York said.

"The central premise is how to design services to make things better for the young person and their family, a better experience and more effective for them. All the things we then do organizationally and clinically are around having them at the heart of it."

The usual treatment approach would see a doctor do a thorough assessment of the patient. But recommendations are often made based solely on such assessments, without finding out what makes sense to the family or the child or what they want, the doctors said.

The question of wants, not needs, is crucial to the Choice and Partnership Approach. If the patient is asked what they want, the list is usually short and can be addressed right away by giving the patient and family goals to work on at home.

"They wouldn’t be put on a waiting list for something," York said. "They would go away with an appointment in their hands to see somebody with the right skills to help them with the goals they wanted."

This method has reduced wait times at their London clinics from a year to several weeks. Similar successes have been reported in the countries where they have trained staff and managers. Those countries include the United Kingdom, Australia, New Zealand and Belgium.

York and Kingsbury came to Nova Scotia on the recommendation of a doctor now working in Halifax who underwent the training in New Zealand.

The IWK couldn’t provide an exact cost of the three-day session, but York and Kingsbury said they don’t charge full consultant’s rates. Rather they are paid the equivalent of what they would earn as clinicians in London. It is their first visit to Canada and they combined the working sessions with their vacation.

"It’s not our day job," joked York, who said they continue to work full-time as psychiatrists and devote an average of one day a month to their consultant work.

Sharon Clarke, clinical leader for mental health services at the IWK, said she was impressed by the Choice and Partnership Approach just from reading the material on the website.

"The exciting part for me is that they’re taking a business approach, in the sense of lean thinking, and using these ideas of demand and capacity to really be able to have an accurate assessment of what the needs are in the system — to put people in the right places, to do the right job at the right time."

The IWK will begin using the system in wait list interventions in January and it will be fully implemented by April.

(jmcphee@herald.ca)

Image credit


Also see:

The Choice and Partnership Approach Website

Evaluation Of The Choice And Partnership Approach In Child And Adolescent Mental Health Services In England

Child and Yourth Mental Health

Please click on the image to magnify it.

To download this special issue of Healthcare Quartly (PDF), please click here.

Broken Promises

Please click here to view a larger version.

Also see:

Operation Maple

One mom's fight to get her daughter help

And article posted on December 15th by MSN News:

By Michael MacDonald, The Canadian Press

Maureen Bilerman [pictured, left] knew something was wrong when her normally shy 13-year-old daughter suddenly became incorrigible, her thoughts and actions disjointed, sometimes destructive.

"It was a light-switch effect," recalls the mother of two, her even tone hinting she has told this story many times before. "She cut our leather chair ... and became really defiant in a way she never was. Her thinking became skewed, distorted. So we right away tried to get her help."

But Bilerman's sense of urgency soon turned to frustration and anger — raw emotions common among parents and critics across Canada who say provincial governments are failing mentally ill children and youth.

"We're the best-case scenario and she's still falling through the cracks," says Bilerman, a newly minted mental health activist who has struggled for the past three years to get her daughter Sarah the help she needs.

Unfortunately, her story is not that unusual.

In a typical Canadian class of 30 students, six will suffer from some form of mental illness, but only one will receive treatment.

"I don't care in what province you're talking about, what town or what service you're looking for, you will find a waiting list that is unacceptable," says pediatrician Diane Sacks, a mental health expert and a member of the Mental Health Commission of Canada.

"There's just not enough services for kids."

For Bilerman, a writer with a background in marketing and broadcasting, that harsh reality became apparent in the spring of 2008, when Sarah overdosed on a bottle of Tylenol.

At the hospital, she was told all six beds at the Child and Adolescent Psychiatric Unit at the Moncton Hospital were full.

"They said, 'There's nothing we can do.' So they sent us home."

But Sarah was still having suicidal thoughts.

For the next six weeks, Bilerman monitored the girl 24 hours a day.

"She would be at the end of her rope, beyond suicidal, in a total state," Bilerman says, adding that the pair would head to the local emergency ward almost every week.

Again and again, they were told the Moncton facility was full and there was no other place for them to go.

The girl was prescribed drugs to stabilize her moods, but they didn't help much.

Bilerman didn't give up. She pushed hard, finally persuading health officials to admit her daughter to the unit, where a month-long stay produced a diagnosis of bipolar disorder, otherwise known as manic-depressive illness.

By that time, it had been almost a year since Sarah started showing signs of mental distress.

The diagnosis represented a big step forward for the Bilerman family, but it was only the beginning of another difficult journey.

Sarah, now 16, has since overdosed three more times.

Doctors have prescribed 20 different combinations of medication, none of which have stabilized her for very long.

The girl often stays out all night long, leaving her mother worried for her safety.

The constant stress has left its mark on the rest of Bilerman's family, which includes husband Shawn and 13-year-old daughter Rachel.

However, Bilerman's life took a sudden, positive turn four months ago when she heard a radio interview with the province's child and youth advocate, Bernard Richard.

The former cabinet minister, who is pushing for creation of a centre for children and youth with "complex needs," inspired Bilerman to take action.

She later learned that Richard has been advocating for a short-term treatment and co-ordination centre ever since he completed a disturbing report in 2008, titled Connecting the Dots.

"It was like the story of our life," says Bilerman, who recently founded DOTS NB, which stands for Development of Treatment Services for mental health in New Brunswick.

Richard's report includes graphic accounts of the challenges faced by children and youth with mental illness, suggesting too many of them are ending up in jail, penalized for behaviour that requires treatment, not punishment.

The proposed centre would offer a safe place for youth in crisis, intensive help for families dealing with mental illness and programs that would help troubled children and youth make the transition back into the community.

"The response has been amazing," Bilerman says, adding that she has been delivering speeches — up to five a day — to universities, churches, service groups and other groups.

Earlier this month, Bilerman led about 1,000 people in an unusual demonstration that grabbed the attention of the provincial government. At one point, the protesters joined hands, creating a kilometre-long human chain linking Fredericton's community mental health centre with the provincial legislature — a symbolic connecting of the dots.

Later, Bilerman presented Premier David Alward with hundreds of letters that tell stories similar to her own.

Bilerman wants Alward to approve Richard's proposal.

"It's integration of services across the province and closing some of the gaps that we know youth are falling through," she said after the rally.

Richard said the government has to act.

"When we don't provide the right responses to these kids, they end up in the justice system, in the prison system, over and over again costing millions of dollars over their lifetime," he said. "That's not to mention the hurt and damage they cause to their families, to themselves, and their neighbours and friends."

Alward said the province must do better.

"We have a responsibility, certainly as a people in New Brunswick, to move forward," he said.

The province's social development minister, Sue Stultz, says she is awaiting Richard's final report early next year before deciding how to proceed.

Photograph by David Smith, The Canadian Press

First symptoms of psychosis evident in 12-year-olds

An article posted today by Lab Spaces:

Children normally experience flights of fancy, including imaginary friends and conversations with stuffed animals, but some of them are also having hallucinations and delusions which might be the early signs of psychosis.

A study of British 12-year-olds that asked whether they had ever seen things or heard voices that weren't really there, and then asked careful follow-up questions, has found that nearly 6 percent may be showing at least one definite symptom of psychosis.

To read the entire article, please click here.

I thank Terri Vernon for bringing this article to my attention.

Also see:


Etiological and Clinical Features of Childhood Psychotic Symptoms: Results From a Birth Cohort

Childhood Psychotic Symptoms: Etiologic and Clinical Features

A four-part series on young people with mental illness ...

... written by John Gillis and published in the Chronicle Herald.




Part One
‘It’s not him, it’s the illness’
Mom stands by son who choked her; she hopes his court-ordered stay at forensic hospital will finally help him

Part Two
Mom pleads for timely help

Part Three
‘It seemed so real’
Imaginery noises led to bipolar disorder diagnosis for bright young teenage girl

Part Four
Treat mental health problems early, avoid trouble later
The last in a four-part series on young people and mental illness

Life of Francis

From the October 23rd edition of The Weekly Albertan:

By Michelle Lindstrom

Earlier this month during Mental Illness Awareness Week, a group of about 15 people from Calgary's medical community and those affected by mental illness gathered to view A Map of the mind fields: Managing adolescent psychosis, and to discuss the stigma of mental illness.

Later, outside the group setting, Francis, a brown-haired artsy-looking girl with glasses, approaches and offers to tell her story to The Weekly Albertan.

To read the entire article, click here.

Photograph courtesy of The Weekly Albertan.

Doctor confronts mental health stigma

From the August 30th edition of The Edmonton Journal:

Gov't pledges $50M to improve service to young people at risk

By Alexandra Zabjek

EDMONTON - Raj Sherman stood on the side of a highway, staring at the approaching headlights, then deliberately stepped in front of an oncoming car.

He was 16 years old, the child of an immigrant family in small-town British Columbia, where many children's parents either worked two jobs or didn't work at all.

Luckily, that night the car swerved and just grazed his side. He later told his family the bruises were from sports injuries and told his teachers he had hurt himself at work.

Now parliamentary assistant to [Alberta] Health Minister Ron Liepert, Sherman recounted the story Friday morning at a funding announcement where his government pledged to pump $50 million into children's mental health services over the next three years.

"The reason you have to tell these stories is to break down the stigma about mental health," Sherman said of his experiences.

The funding plan sets benchmarks for how long it should take for children to receive mental-health services in the province -- those in crisis should receive care within 24 hours, those with less urgent cases within two weeks, and those with scheduled visits within 30 days.

To read the entire article, click here.

Photograph of Dr. Raj Sherman by Candace Elliott, The Edmonton Journal.

Three cheers for outspoken health bureaucrat

From the August 28th edition of The Chronicle Herald:

By Marilla Stephenson (pictured)

CHERYL DOIRON is one of those bureaucrats who, happily for us, is more concerned about doing the right thing than she is with fawning over her political masters.

That’s why the deputy health minister is on the top of my Three Cheers list for her honest assessment of the dismal state of mental health services in Nova Scotia.

Even better, Doiron’s explosive missive was delivered in public, damn the torpedoes and other potential consequences.

She is exactly the kind of bureaucrat Nova Scotia could use more of.

At the Canadian Mental Health Association’s national conference in Dartmouth last weekend, Doiron issued a plea for mental health organizations and the public to push harder to have politicians direct more money into mental health services.

"It’s very hard to get it to be the primary issue, particularly for politicians who are making budget decisions . . . because they are not getting the same pressure about mental health as they get about cancer and coronary disease and diabetes," Doiron told delegates in a speech.

"We, working from the opportunity we have within government, organizations such as (the national association) and the Nova Scotia (association) and other groups, and all of us, collectively need to be doing something much more significant to make this a burning-bridge issue for decision-makers."

Doiron’s primary concern is the long wait times for psychiatric care for people suffering from mental illness, especially children. She noted that while spending for mental illness by her department has increased in recent years, the percentage has decreased in proportion to the total health-care budget.

To read the entire article, click here (as of February 8th, 2010, the entire article is no longer available).

Photograph of Marilla Stephenson courtesy of The Chronicle Herald.

Continual struggle

A letter to the editor published in today's The Chronicle Herald:

Re: "A passionate call for mental health services" (Aug. 23).

It is disheartening to see the continual struggle for the mind and brain to be given equal treatment to the heart, cancer and pancreas. This state risks institutionalizing the stigma described in Michael Kirby’s Senate report "Out of the Shadows at Last."

A wait of six to 12 months for a child or youth feels like a lifetime. Lest children’s mental health service is kept as the "orphan’s orphan," we would like to note a few points.

Most mental disorders in adults begin in children and youth. Parity of resources, clinicians and research funding for child and youth mental health is even more dramatically unbalanced than for adults. Many of the problems in childhood have long-term consequences for adult functioning and multiple service problems and needs. In a knowledge-based economy, without helping all children and youth reach their optimal mental health, we sacrifice the economic health of our society.

We applaud Deputy Health Minister Cheryl Doiron’s alert to society that we must all attend to mental health, and in particular we support the need to bring services for the minds and brains of children and youth up to par with other systems and organs of the body.

Margaret Steele, MD, President,

Wade Junek, MD, President-Elect,

Canadian Academy of Child and Adolescent Psychiatry

A passionate call for mental health services

From today's edition of The Chronicle Herald:

By John Gillis, Health Reporter

Deputy minister makes rare appeal for public support

Nova Scotia’s deputy health minister called on mental health organizations and the public Friday to help her light a fire under politicians to do more to help people with mental illnesses.

In a passionate off-the-cuff speech at the opening of the Canadian Mental Health Association’s national conference in Dartmouth, Cheryl Doiron said her department has put more money into mental health services over the years, but spending has declined as a proportion of the overall health budget.

"It’s very hard to get it to be the primary issue, particularly for politicians who are making budget decisions . . . because they are not getting the same pressure about mental health as they get about cancer and coronary disease and diabetes," she said.

"We, working from the opportunity we have within government, organizations such as (the national association) and the Nova Scotia (association) and other groups, and all of us collectively need to be doing something much more significant to make this a burning bridge issue for decision makers."

Mental health spending accounts for just over 3.5 per cent of the $3.2-billion provincial health budget.

Ms. Doiron said the relatively small amount of funding for those services means the province is failing to provide "absolutely essential help" to children and others.

She gave the example of an adolescent mental health program at the IWK Health Centre. The in-patient treatment lasts 12 to 18 months. But the 13- to 19-year-olds who might benefit from the intensive program have to wait that long just to be admitted.

Ms. Doiron said she pleaded the case to cabinet and was able to secure extra funding of $1.5 million this year and about $2 million in subsequent years to expand to 18 beds from 12.

An enduring bias against people with mental illness means people are often reluctant to speak about their conditions, and society doesn’t know they should be treated just like people with physical ailments, Toronto psychiatrist David Goldbloom told the conference in his keynote address.

"I think one of the challenges around mental illness is that its unique properties include affecting our thinking, our moods and our behaviour: the very dimensions that define us as individuals," he said. "That makes it a lot tougher to separate the illness from the person."

And while growing numbers of people report in surveys that they have had direct experience with mental illness, either personally or through a friend or relative, the perception that people with mental illnesses are dangerous or violent has increased, Dr. Goldbloom said.

That attitude is exemplified by reporting on events such as the recent beheading of a passenger on a Greyhound bus and crime dramas like CSI and Law and Order, he said.

"The reality of mental illness, its mundane reality, is virtually never depicted," he said. "The same applies to the newspapers, because somebody recovering from mental illness or somebody simply making a great adaptation to mental illness is about as newsworthy as a plane landing safely at the airport."

Dr. Goldbloom said research shows that negative perceptions are formed very early, so young children should be a focus of efforts to erase stigmatization.

Workplaces should be another major target, he said.

Finding and keeping meaningful work goes a long way toward helping a person with mental illness develop a sense of self and social connections; mental illness is the leading cause of short-term disability keeping people out of the workforce, Dr. Goldbloom said.

The Mental Health Commission of Canada, of which he is vice-chairman, says mental illness drains $51 billion from the Canadian economy each year.

But there is hope that negative attitudes can be broken down, Dr. Goldbloom said.

He recalled that when he was an intern in the early 1980s, hospital staff were "terrified" of the gay men who appeared with symptoms of what was later identified as HIV/AIDS, only touching them with triple-gloved hands.

"Think of how far it has come in the ensuing 25 years," Dr. Goldbloom said. "It’s really an extraordinary social transformation. Mental illness has not come anywhere near as far as HIV."

Photograph of Cheryl Doiron courtesy of The Canadian Institute for Health Information.

Recognizing the priority of child and youth mental health

From today's edition of The Chronicle Herald:

Canada celebrates its second National Child and Youth Mental Health Day today, during Mental Health Week (May 5-11), to increase awareness about mental health issues facing young people.

The adolescent years are a critical period of adjustment for both youth and families. Young people go through many physical, mental and emotional changes during adolescence. According to the World Health Organization, mental disorders account for almost one-third of diseases among adolescents worldwide. In Canada, between 15 and 20 per cent of youth suffer from a mental disorder that would benefit from appropriate care. However, accurate and up-to-date information on the scope of this issue is lacking in Canada.

Early, effective identification and intervention for young people suffering from mental illness is essential. Half of all lifelong mental disorders onset before 14 years of age and 70 per cent by age 24. Although effective treatments for many of these disorders are known, for a variety of reasons they are often not readily accessible to or accessed by young people who need them.

As parents and community members, it is important to be aware and understand how youth develop, the challenges they face, and the ways we can help them stay as physically and mentally healthy as possible. Parents are usually the first to notice the symptoms of a mental disorder in their child. But frequently they do not know what the problem is or what to do about it. Often, parents are struggling with their own mental health concerns that further tax their ability to help their child.

So figuring out what the problem is and getting the right kind of help in an effective and timely manner would be of value not only to the young people, but also to their parents and family. Talking to youth about the issue of mental health can be difficult, but it is the best way to understand what they are going through and if they need to get help.

At school, mental health problems can be equally challenging for children and adolescents. For many youth, the transition to new academic and social environments can be difficult and create stress that they are ill-equipped to deal with. Additionally, young adolescents may be experimenting with drugs and alcohol and beginning to engage in other risk-taking activity.

Learning to cope with these changes and build resilience is an important part of being successful in school, especially given that some of the most serious forms of mental illness emerge early in adolescence. Most schools do not supply students with the necessary support to help them address this transitional stage. Strong partnerships between schools and service providers can help educators identify and appropriately refer students who may be experiencing mental health problems.

The workplace is another area where the working parent, the parent’s child/family and the employer can contribute to mental health awareness. It is important for working parents to be well informed about mental disorders and treatments so they can advocate for their children and themselves. Enhancing mental health awareness of working parents and their children may promote mental health and well-being, improve early recognition of mental disorders, enhance appropriate early use of health services and lead to better health, social and economic outcomes for all.

The home, school and workplace are all important environments for advancing youth mental health, but none of these environments can hope to succeed without federal and provincial support. The recent establishment of the Mental Health Commission of Canada is a step in the right direction, as is the recent report Reaching for the Top by Dr. Kellie Leitch, which establishes a blueprint of recommendations for child and youth mental health care. But despite these advances, child and youth mental health care is still not high on many provincial or federal government agendas.

In Canada, only four of 10 provinces have created child and youth mental health policies/plans and there is no national child and youth mental health policy. Furthermore, only one in five of Canadian young people requiring mental health care receive it. Clearly the situation must change.

Mental health care for young Canadians is a right, not a privilege. What would happen in this country if only one in five adults needing hip replacements received them? Or how would we react if 15 to 20 percent of our young people suffered from cardiac disease? The access to mental health services and treatment should be no different for children and youth with mental health problems! The time has come to explore legislating access to timely mental health assessment and care based on the rights of children and youth.

Dr. Stan Kutcher is Sun Life Financial chair in adolescent mental health, director WHO Collaborating Center in Mental Health, Dalhousie University and IWK Health Centre. Dr. Simon Davidson and Dr. Ian Manion are on the executive, Provincial Centre of Excellence for Child and Youth Mental Health, Children’s Hospital of Eastern Ontario.

Rights of mentally ill youth must be a national priority

From the March 20th edition of The Chronicle Herald:

By Dr. Stan Kutcher, Dr. Simon Davidson and Dr. Ian Manion

According to the World Health Organization, mental disorders contribute almost one-third of the global burden of disease during adolescent years. In Canada, between 15 and 20 per cent of youth suffer from a mental disorder that would benefit from appropriate care. Early and effective identification and intervention for young people suffering from mental illness is essential because as many as half of all lifetime cases onset before 14 years of age and 75 per cent by age 24. Although effective treatments for many of these disorders are known, they are often not provided to young people who need them.

Furthermore, there may be insufficient attention being paid to fundamental human rights of some young people who are suffering from mental disorders. According to the United Nations Declaration of the Rights of the Child – 1959 (to which Canada is a signatory), "no child shall be subjected to torture or other cruel, inhuman or degrading treatment or punishment." This declaration goes on to state that "the child who is physically, mentally or socially handicapped shall be given the special treatment, education and care required by his particular condition."

The UN resolution [Principles for the] Protection of Persons with Mental Illness and the Improvement of Mental Health Care, 1991, states: "All persons with a mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person."

The Canada Health Act (1985) similarly seeks to protect and promote the physical and mental well-being of all Canadians. The rights to protect young people with mental disorders are in place, but the shortcomings fall within the enforcement and provision of these rights.

There is a critical situation of mental health care for young people in Canada, resulting from stigma, lack of easily available mental health care, lack of health providers trained in mental health competencies, complexities of addressing multiple needs of the mentally ill, and chronic underfunding of mental health services, among many other things.

Due to substantial gaps in appropriate mental health care, many young people are being placed in detention facilities simply because there is nowhere else to go. Behaviours rooted in mental disorders are being punished rather than being treated. Alarmingly, some observers have noted that youth detention centres may be the newly emerging youth mental health care system.

Identified as the "orphan of the orphan" in the Kirby Commission Report (2006), child and youth mental health care is not high on many provincial or federal government agendas. The recent establishment of the Mental Health Commission of Canada is a step in the right direction.

If 15 to 20 per cent of our young people suffered from cardiac disease, there would be a national campaign for the treatment of heart problems in every community. Yet, only one in five of young Canadians requiring mental health care receive it. And the provided "care" is not necessarily effective or consistent with the recognition of the human rights of those who receive it.

Clearly, the situation must change. In Canada, only four of 10 provinces have created child and youth mental health policies/plans and there is no national child and youth mental health policy. Current human resources are inadequate to meet child and youth mental health care needs, and traditional means of providing specialist care by single professionals, as compared to multidisciplinary teams, may impede accessibility to mental health care for young people.

Providers of mental health services may require upgrading of clinical training, as substantial changes in the understanding of the development and treatment of mental disorders in young people have been made in the last decade. These advancements have yet to be fully translated into treatment approaches. Although research funding into child and youth mental health care through the Canadian Institutes of Health Research has increased over the last five years, enhanced and targeted funding is needed to allow for the further identification of the most effective treatments and delivery systems.

Mental health care for young Canadians is a right, not a privilege. It must be provided in a manner that is equally based on the best available scientific evidence, the developmentally unique needs of children and youth, and recognition of the principles of the human rights of the child and of those suffering with mental disorders.

It is a tragedy that young people expecting appropriate mental health care are treated in a manner that offends their basic humanity. It is a tragedy that young people suffering from mental disorders do not have the right to care provided in a way that adheres to developmental issues. And it is a tragedy that young people suffering from a mental disorder do not have the right to care based on best scientific evidence.

Children and youth must work in collaboration with their primary care givers to advocate for appropriate care and systematic change at the government level. The time for talking has passed. It is time for provincial and federal governments to do what is right by putting child and youth mental health on the federal-provincial health agenda as a national health priority.

Dr. Stan Kutcher is Sun Life Financial Chair in adolescent mental health and director, World Health Organization Collaborating Centre in Mental Health, Dalhousie University and the IWK Health Centre. Dr. Simon Davidson is executive director, planning and development, and Dr. Ian Manion is executive director, operations, at the Provincial Centre of Excellence for Child and Youth Mental Health, Children’s Hospital of Eastern Ontario.

Also see:
Mentally ill youth: meeting service needs

Standards for Mental Health Services in Nova Scotia. Revised and Approved March 22, 2004.

Photograph of Dr. Stan Kutcher courtesy of the IWK Health Centre.