From the Editor
“There’s one fact on which we all agree: people are suffering. People with mental illnesses, their families and friends, and society at large are all touched by a set of disorders that affect one in five people globally. What is also evident – to every worried parent or partner, to every citizen strolling down a busy downtown street, to every guard working in a prison, to every teacher spending the majority of children’s weekday waking hours with them – is that the status quo is unacceptable.”
Dr. David Goldbloom (of the University of Toronto), who serves as the Senior Medical Advisor at the Centre for Addiction and Mental Health, makes these comments in his new book.
Can we do better? Those with mental health problems wait for almost all care, and the quality of care is uneven. This week’s Reading is an excerpt from Dr. Goldbloom’s new book, We Can Do Better: Urgent Innovations to Improve Mental Health Access and Care. The excerpt, like the book itself, strikes an optimistic note, observing the incredible innovation already present in mental health care.
A special word of thanks to Catherine Whiteside of Simon & Schuster Canada for making this Reading possible.
DG
Selection: “Introduction”
David Goldbloom
We Can Do Better: Urgent Innovations to Improve Mental Health Access and Care, 2021
I stroll along La Rambla, the broad avenue in central Barcelona, on a sunny spring day in 2017. I slow my pace along the tree-lined street, giving my mind a chance to wander. It might be the jet lag, but there is something vaguely hallucinogenic about the waves and curves of the city’s modernista architecture. Every building has its own personality and seems to tell a unique story. I pause outside of a century-old home to peer up at the statues adorning it. One figure with a jaunty moustache holds a large, box-shaped camera, while a statue of a stern woman across from him plays a small gramophone—novelty objects now, but ones that would have been at the forefront of technology when the house was built. Sunlight filters through the trees and onto the pavement around me, and I stand still, basking in its warmth and admiring the way the design opens up the streets and gives passersby the ability to see around the corner.
Being open and peeking around the corner are the exact reasons why I am in this charming city in the first place. I am here to attend the twenty-third annual International Conference on Current Issues and Controversies in Psychiatry. Before I am confined to a windowless conference centre for several days, though, I plan to cram in as much tourism as possible. Today is my final day of exploration, so I pull myself away from the streetscape and run to hop on the nearby city bus.
So begins Dr. Goldbloom in the Introduction of his new book.
Dr. David Goldbloom
He writes about several things. I highlight three:
On psychiatry’s paradigm shift
“I came of age as a psychiatrist in 1985, when the field was in a state of major change. A seismic shift had occurred when psychiatry turned its back on its heritage of psychoanalysis (still today the popular public perception of the discipline). As psychiatry made its somewhat delayed entry into the mainstream of scientific medicine, it was finally abandoning the long-held views of the origins of mental illnesses—namely, that they could be primarily attributed to early childhood experience and faulty parenting. It was becoming increasingly clear that those traditionally endorsed views could no longer be propped up—we needed a new paradigm.”
On the bust of the neuroscience revolution
“Further, the neuroscience revolution did not deliver new treatment tools. Interventions like electroconvulsive therapy, lithium, antidepressants, antipsychotics, and anti-anxiety medications were all available before 1970. While new drugs came along, they generally did not outperform the ones that preceded them but rather offered more therapeutic options and different side effects. And while psychotherapies became briefer in terms of numbers of sessions, more standardized in terms of the actual interventions, and more supported by research evidence, there was no sudden emergence of dramatic superiority of one type over another.”
On his book
“What follows is a journey through possibilities. In each chapter, I describe a typical (if there is such a thing when you look closely) case of someone suffering a particular, common illness, although each case is a composite of thousands of patients seen over my career. Each person serves as a springboard for a dive into a new pool of knowledge and treatment. I have purposely not explored those exciting areas of research that may bear fruit in a generation; instead, I have sought out the lowhanging fruit of approaches and models that could make a difference in the lives of patients and families, if accessible to everyone, in the next three to five years.”
A few thoughts:
- The book is excellent. Thoughtful, well written, and carefully researched.
- The above paragraph is a good summary of this volume, which focuses on eight clinical problems and innovative projects in these respective areas. For instance, he discusses a young patient, Pierre, who has ADHD, and how his family finds help with the Strongest Families Institute (SFI) – an organization that trains parents to better cope with such problems, boasting a dropout rate of just 6%. SFI programs have been adopted in Finland, Vietnam, and New Zealand.
- fMRIs? They are fABSENT. New drugs and cutting-edge imaging aren’t considered; rather, Dr. Goldbloom looks at real-world programs.
- The book is optimistic, but are you? Turning back to the Strongest Families Institute, Dr. Goldbloom writes about their international success, but it should be noted that their programs aren’t available in the majority of Canadian provinces and territories. The book is thus optimistic, but perhaps somewhat bittersweet – a reminder of what can be done but, also, of what needs to be done.
- The book is highly readable and, in my opinion, a real service. (Disclaimer: I remind the reader that Dr. Goldbloom and I have collaborated on papers, and I have seen early chapters of this book.)
* * *
The following is from WE CAN DO BETTER: Urgent Innovations to Improve Mental Health Access and Care by David Goldbloom, M.D. Copyright © 2021 by David Goldbloom, M.D. Reprinted by permission of Simon & Schuster Canada, a Division of Simon & Schuster, Inc.
Introduction
I stroll along La Rambla, the broad avenue in central Barcelona, on a sunny spring day in 2017. I slow my pace along the tree-lined street, giving my mind a chance to wander. It might be the jet lag, but there is something vaguely hallucinogenic about the waves and curves of the city’s modernista architecture. Every building has its own personality and seems to tell a unique story. I pause outside of a century-old home to peer up at the statues adorning it. One figure with a jaunty moustache holds a large, box-shaped camera, while a statue of a stern woman across from him plays a small gramophone—novelty objects now, but ones that would have been at the forefront of technology when the house was built. Sunlight filters through the trees and onto the pavement around me, and I stand still, basking in its warmth and admiring the way the design opens up the streets and gives passersby the ability to see around the corner.
Being open and peeking around the corner are the exact reasons why I am in this charming city in the first place. I am here to attend the twenty-third annual International Conference on Current Issues and Controversies in Psychiatry. Before I am confined to a windowless conference centre for several days, though, I plan to cram in as much tourism as possible. Today is my final day of exploration, so I pull myself away from the streetscape and run to hop on the nearby city bus.
“Where is the stop for Sagrada Familia?” I ask the bus driver after several minutes of staring out the window. He answers in a rapid volley of Spanish that doesn’t seem to include the gesture to get out immediately. I politely repeat the question a couple of times with the same result. Eventually he points to the door, because either we have arrived or he is simply fed up with my pestering.
As I come around the corner, my first impression is complete awe. A grand and unfinished project that has outlived its creator, Antoni Gaudí, the Sagrada Familia has a scope and scale that challenges the imagination. It is massive and fantastical—it has the feel of Disney cartoons where trees come to life in a scary way. My eyes are immediately drawn to the church’s towers—ornate stone structures that pierce the sky. It must have taken such incredible imagination, I think.
As my gaze falls, I am surprised to see cranes and scaffolding dotting the towers and arches of the church’s exterior. The modern technology seems out of place, so I approach a nearby guide.
“Excuse me, but what’s the reason for the construction?” I ask.
“The church isn’t finished,” the guide says. “It was started in 1882, but it won’t be complete for another decade.”
My thoughts go back to the conference, the reason I find myself in this place. The construction of the Sagrada Familia has had to adapt to the rapidly changing urban environment that surrounds the church. Its construction was started at a time when horses were still the primary means of transportation; now a high-speed train runs underneath it. Everything about the church—the lofty ideals that inspired it, the ongoing construction, the mix of old material and new insight—reminds me of our incomplete understanding of and care for people with mental illness. If the church is completed in the twenty-first century, it will be the culmination of two centuries of progress, not all of it smooth. In much the same way, mental health science and treatment have been both controversial and evolving, and the construction is still under way.
The truth is that controversies exist throughout medicine, from the overuse of antibiotics to the value of arthroscopic knee surgery. It is not always easy to find the sweet spot between dealing with uncertainty in medicine and providing hope and reassurance to people who need it. But it’s vital that we try.
To my mind, controversy is, to quote Martha Stewart, “a good thing.” After all, who would want to work in a field where everything is known and agreed upon? It would bore me beyond belief. But more important, where there is controversy, there is room to learn and improve. That said, few other areas of medicine are as shrouded in uncertainty as psychiatry—from what causes mental illness to what are the most effective treatments—or as mired in controversy about diagnosis, its role in society, and even its theoretical underpinnings.
Physicians (psychiatrists, family doctors, and specialists) and other mental health professionals (psychologists, social workers, occupational therapists, nurses, and other counsellors) disagree on many of those things. But there’s one fact on which we all agree: people are suffering. People with mental illnesses, their families and friends, and society at large are all touched by a set of disorders that affect one in five people globally. What is also evident—to every worried parent or partner, to every citizen strolling down a busy downtown street, to every guard working in a prison, to every teacher spending the majority of children’s weekday waking hours with them—is that the status quo is unacceptable.
I came of age as a psychiatrist in 1985, when the field was in a state of major change. A seismic shift had occurred when psychiatry turned its back on its heritage of psychoanalysis (still today the popular public perception of the discipline). As psychiatry made its somewhat delayed entry into the mainstream of scientific medicine, it was finally abandoning the long-held views of the origins of mental illnesses—namely, that they could be primarily attributed to early childhood experience and faulty parenting. It was becoming increasingly clear that those traditionally endorsed views could no longer be propped up—we needed a new paradigm. That change wasn’t just a matter of updating a textbook or changing a few labels, though. A new direction meant new medical standards; psychiatry had to create an entirely new common language to talk about mental illness. And that, in turn, demanded novel tools and systems to diagnose and treat those illnesses.
At the same time, another insurgency was afoot: the neuroscience revolution was in full flower. Breakthroughs in imaging technology were giving us an unprecedented window onto the brain’s structure and function, more refined measures of brain chemistry were allowing us to develop new theories of illness, and genetics was helping us identify vulnerability and risk in new ways.
I was eager to be swept up by and to be a part of this change. When someone has achy joints, headache, sneezing, and a cough, there is a difference between diagnosing the flu based on those symptoms and diagnosing pneumonia based on a chest x-ray and a saliva test. Either illness could fit the symptoms, but better diagnostic tools can paint a deeper, clearer picture. As a young psychiatrist, the breakthroughs in neuroscience and psychiatric practice excited me no end. We were going to be able to help patients better than ever before. Who knew what the future might look like?
I hoped brain imaging might provide an answer. As CAT scans and, later, magnetic resonance imaging became more available technologies—despite the usual Canadian waiting lists—I was eager to order these for patients experiencing their first episode of illness. But no mysteries were ever decoded to guide my understanding or treatment. Although these investigations sometimes provided reassurance to myself and others that I wasn’t “missing something” in terms of a nonpsychiatric cause of symptoms, it also inadvertently reinforced for some families the idea that these illnesses weren’t “real” because they could not be medically visualized. At the same time, these families knew all too well every pixel of the image of pain and struggle that their son or sister was experiencing. No blood test, whether looking for a faulty thyroid gland or a low vitamin B12 level, triggered the “Aha!” moment of Sherlock Holmesian mystery solving. Nevertheless, the tests were dutifully done as part of thoroughness and reassurance of no stone unturned.
By the end of the twentieth century, psychiatry remained virtually alone among the specialties in medicine in its exclusive reliance on clinical symptoms, both observed by physicians and reported by patients, to make diagnoses, to classify disorders, and to guide treatment. Blood tests and brain images were of no help.
Further, the neuroscience revolution did not deliver new treatment tools. Interventions like electroconvulsive therapy, lithium, antidepressants, antipsychotics, and anti-anxiety medications were all available before 1970. While new drugs came along, they generally did not outperform the ones that preceded them but rather offered more therapeutic options and different side effects. And while psychotherapies became briefer in terms of numbers of sessions, more standardized in terms of the actual interventions, and more supported by research evidence, there was no sudden emergence of dramatic superiority of one type over another.
At the same time, progress has been made in medicine more broadly. It has been argued that some of the marked reduction in death rates after heart attack has come not so much from the development of new treatments but rather from the standardization of treatments that we know make a difference. In parallel with neuroscience inquiry into basic underpinnings of mental illness, there has been a significant evolution in developing algorithms and clinical care pathways to guide physicians and patients toward the best evidence-based approaches. While it doesn’t eliminate the trial-and-error approach that permeates much of clinical medicine, it does provide physicians with a rationale for the trial sequence based on something more substantial than “the last guy I saw got better with this treatment, so I think I’ll try it again” or “the drug rep who came by with doughnuts for my staff said this new pill is really good.” Another important element has been measuring change. When we try to quantify the impact of our treatment, it leads to better outcomes because our treatment decisions are not guided by hunches or vague impressions.
Recently, I saw a patient who has struggled for years with a severe depression, at times requiring electroconvulsive therapy. He routinely completes rating scales related to details of his mood. Like many people when they recover from illness, details of his suffering can be mercifully fuzzy for him afterward. His rating-scale score for depression one particular day was low—and well within the range of a healthy, normal mood. He was able to look at his previous scores, and the items he had endorsed, as a way of understanding both how he had once been and the journey he had made. A paper-and-pen test is not expensive technology but rather a ready example of an approach to measurement that can improve care (research indicates that treatment of depression that is data-driven results in better outcomes) as well as patient participation and understanding.
Now, as I approach the latter phase of my career, my sense of the terra incognita of mental health care is even more acute, in terms of both the limits to our understanding and the obstacles to providing better care to more people in need. To put it simply: The status quo is unacceptable. We need to explore new ways of doing things, new routes to people feeling and functioning better. We have good but not great treatments. We have major challenges in accessing help for people who need it. We are nowhere near where we need to be in understanding the brain, the mind, and the interaction of both of them with the environment in ways that would allow us to better predict, prevent, diagnose, and treat. We are beyond choosing between nature and nurture, as we understand increasingly things like how genes can drive our behaviour and how life events and experience can shape our brains. As mental health awareness continues to go up—as it has dramatically in Canada in the last decade—and as stigma recedes, people will rightly expect more and better of mental health care.
For one thing remains constant: people and their experiences of mental illnesses. While clinicians and academics continue to argue over how exactly to use new tools, and quasi-religious schools of psychiatric thought battle for supremacy, people struggling with symptoms continue their journeys, looking for help and for hope.
For me, the core of my work as a psychiatrist has always been trying to understand and help patients and their families. Whether I am acting as a clinician, a teacher, a researcher, an administrator, or an advocate, that has been and always will be the goal. And as much as the first thirty-five years of my career have been rewarding and exciting, I’m still craning my neck around the corner to try to see what could make things better for the people my colleagues and I serve.
What follows is a journey through possibilities. In each chapter, I describe a typical (if there is such a thing when you look closely) case of someone suffering a particular, common illness, although each case is a composite of thousands of patients seen over my career. Each person serves as a springboard for a dive into a new pool of knowledge and treatment. I have purposely not explored those exciting areas of research that may bear fruit in a generation; instead, I have sought out the lowhanging fruit of approaches and models that could make a difference in the lives of patients and families, if accessible to everyone, in the next three to five years. That’s a short timeline for innovation. It has been estimated that the lag from scientific discovery to clinical implementation can be as long as seventeen years. But if you are suffering, even three years is a terribly long time to wait.
This journey through innovation isn’t meant to be comprehensive. The ideas in these pages are selective rather than exhaustive (and I hope not exhausting)—enticing trailers of brilliant coming attractions that I’m privileged to know about. Over the course of a long career, I have been lucky to meet researchers and clinicians doing exciting work, and so the examples here often come from friends and colleagues from all over the world. Mostly though, I’ve selected these innovations because together they point to what mental health care could look like if we only embraced such new initiatives.
Some of the pessimism I hear from people about mental illness comes from personal experience, from deep-seated stigma, and from fear of the threat that such illness represents to our uniqueness and identity. And some of it comes from the real failure of existing treatments to meet our high and at times desperate hopes, even though the success rate of most psychiatric treatments is equivalent to that of most medical treatments.
I began writing this book before a coronavirus transformed our world with the COVID-19 pandemic. As I write this paragraph, I am sitting at home instead of at the hospital where I work, seeing patients via secure televideo link rather than in person, maintaining physical distance while finding new ways to connect. While I am glad that people are talking more about the mental health impact of the pandemic on both people who are ill and people providing care for them, the limitation to the help that currently exists also gets highlighted. We are rightly worried about shortages of ventilators, masks, gloves, gowns, and COVID-19 diagnostic tests. But shortages of effective mental health care also need to be addressed as we cope with the impact of the pandemic and its aftermath.
It is a reflection of the growing public awareness of mental health that everyone in Canada, from political leaders to frontline workers in grocery stores and hospitals, is talking about it in the context of the pandemic. At the beginning of May 2020, Prime Minister Justin Trudeau announced a virtual mental health care tool for all Canadians and a commitment of $240 million to support it. A national online portal, Wellness Together Canada, was quickly created. It offers free of charge wellness self-assessment and tracking, self-guided resources and apps, group coaching and a community of support, and counselling by text or phone. It includes immediate linkage via text to crisis resources for youth, adults, and frontline workers. And it represents a coming together of government, community agencies, and the private sector in common cause to respond to an unprecedented national emergency. Change can happen quickly—within a couple of months of the pandemic disrupting the lives of all Canadians. But what happens when the heat of the crisis inevitably subsides? And what is the impact of COVID-19 on our mental health?
The first hints came from reports of medical workers in Wuhan, China, in February 2020 in terms of overwork, inadequate protection and fear of infection, lack of contact with families, and discrimination, resulting in stress, anxiety, and depression. By late January, guidelines for psychological crisis intervention in the context of the local outbreak had been developed. By March, a review of the evidence of the psychological impact of quarantine and how to reduce it appeared in a major medical journal, again pointing to greater awareness of the mental health impact of a pandemic. At the same time, this is about protecting the mental health of the general population, not that of people who are struggling with a mental illness, and so the solutions are generic and do not medicalize the problem.
Within two months of the onset of the pandemic in Canada, pollsters generated a snapshot of our national mental health through a survey of almost two thousand Canadians. Almost half felt worried or anxious, only 6 percent felt happy, but one-third felt grateful, which may speak to a quality that can help us ride out tough times. Half of Canadians felt COVID had worsened their mental health. That doesn’t mean half of Canadians have become mentally ill. In other words, it is actually normal to feel not normal.
But we cannot lose sight, now or later, of the one in five Canadians with mental illness before the pandemic. The pandemic’s restrictions on “business as usual” incentivize us to come up with new ways of addressing old problems; it is a helpful accelerant in that regard. And we need to be vigilant about the impact of the pandemic on suicide rates; at least one group has identified the risk as “a perfect storm” with regard to the factors that may increase suicide rates: economic stress, social isolation, decreased access to community and religious support and medical care, worsening of physical illness, and increased firearm sales. At the same time, shared experience and digital community may help to combat these forces.
In July 2020, the human resources firm Morneau Shepell issued its mental health index, which showed a significant decline for Canadians, with financial risk and social isolation driving it downward. In August 2020, the accounting firm Deloitte released its modeling report on the potential impact of COVID on mental health, based on modeling from previous crises and disasters. It predicts a profound impact through economic downturn, with particular impact on women when it comes to employment, income status, and mental health. Finally, a survey released in August 2020 by the US-based Commonwealth Fund, comparing the United States with a number of countries including Canada, shows Americans to be the most vulnerable with regard to lack of access to mental health care, negative economic consequences, and confidence in their government’s pandemic response.
COVID has fueled public expectations for faster and better results. Countries are sprinting to vaccine finish lines in months instead of a drug development process that historically was a marathon of many years. Televideo health services have supplanted office and clinic visits. Everything we took for granted about work, school, and social interaction has been challenged. Shaking hands with friends and hugging families now seems so 2019. The need for transformation is urgent, the opportunity is fertile, and the people in need are eager.
What comes next? What needs to change? Are there things already out there that are making a difference beyond our current standards of understanding and care? What holds hope for the future? I’m enough of an optimist—an admittedly incurable one—to believe things can and will be better. We can make a better future. The question is: What will it take?
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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