FINALLY, the Lancet (one of the world’s top medical journals) has retracted their publication of one of the most misleading articles in the history of modern medical  science – the now totally discredited piece on the relationship between autism and the MMR vaccine http://www.cbc.ca/health/story/2010/02/02/autism-mmr-lancet-wakefield.htmlt.

What took them so long?  It seems that the Lancet editors where the last in the world to know that the article was basic bunkum.  And why did they even print it?

If you can find me another article that uses the same low level of scientific evidence and flawed thinking that the Lancet has published in the last decade as this one used I will buy you a chocolate cookie. (Only one cookie per customer, just in case).  I for one have no idea about what the answer to either of those questions is.  But the fallout has been substantial.  It seems that large numbers of children died because they were not vaccinated.  And to what end?  Because a researcher (who it seems was in the employ of lawyers making lots of money suing vaccine manufacturers) published such poor science and because a learned journal did the publishing?

So what is a possible lesson here?   Although there are many, one most certainly is that one swallow does not a summer make.  That is, scientific knowledge is not built on one study, but on many, conducted by different and independent investigators, using best methods and techniques and scrutinized by peer review.  Is there the possibility that some studies will show one thing and others will show another?  For sure. Science is nasty, brutish and long.  Remember the word attributed to Mark Twain: “be careful reading a medical text book.  You may die of misprint”.

–Stan

So it was late afternoon and I was chatting with some of my young, active and thoughtful research team members.  And guess what came up?  We need a mental health break during the “dog days” of winter.  The more I thought about it, the more I liked it.

We know that the winter blues are very common at northern latitudes – such as all of Canada.  We know that there is a mental disorder, called Seasonal Affective Disorder that is linked to the relative lack of sunlight during our winter months.  We know how long that stretch of going to work when it is dark and going home when it is dark is – especially between Christmas and the first holidays in the spring.  Apparently there is even some anecdotal evidence that work and school problems peak in February.  And, we know how important a good down day – preferably one in which we can go exercise outside in the sunshine- is for our mental health.

So here is my proposal (actually it is the proposal of Jess Wishart and Christina Biluk), but I am putting forward as mine.  Let’s have a national holiday in early February.  Lets call it mental health day.  Why not?  We can just prorogue for a while.  I bet that it will be good for all of us. And the researchers can study to see if the two weeks after the day show less work and school stress than the two weeks before the day.  Or they could do a controlled trial – one part of the country with the day off and the other part without.  Hah.  Maybe we should just take the day off!

Last week, there appears an article in the San Francisco Chronicle about suicide deaths due to jumping from the Golden Gate Bridge http://www.sfgate.com/cgi-bin/blogs/inmarin/detail?&entry_id=55733.  According the Chronicle, last year there were 31 deaths, the year before that there were 34.  Over 1,300 people have died by suicide from jumping from the bridge since it was built.

And what is the essence of the story?  Apparently the Marin County Coroners Office wants to recommend suicide prevention barriers and this is controversial.  And guess what – more studies are apparently recommended.

Now, readers of this blog know how committed I am to research.  You also know that I am committed to action.  Will putting up an appropriate barrier decrease the rate of successful suicides by jumping from the bridge?  Highly likely.  Is this a good thing.  For sure.  So why is it not being done.  Who knows?

I remember the hard work that went into getting barriers erected on the Bloor St. Viaduct in Toronto.  There the effort was lead by a young man with lived experience of mental illness.  I know of the hard work that went into getting a barrier erected on the MacDonald Bridge in Halifax.  There the effort was lead by a mother who had lost her son to suicide from the bridge.

It the courageous activity of people like those Toronto and Halifax citizens that seems to be necessary before authorities can act.  I am so proud to know and support those leaders and I thank them for everything that they have done and continue to do in this regard.  What I don’t get is this.  Why is it so hard to do the right thing when it comes to mental health action?

Arguably, the area of mental health is the newest domain of health in using independent, empirically valid and scientific approaches to determining what works, for whom, at what financial cost and with what potential harm.  Perhaps because of this “newness” we seem to spend a lot of unproductive time arguing or discussing what we should be doing and frequently confusing opinion with evidence and often not understanding that all evidence is not equal.

The Health Development Agency of the National Health Service (United Kingdom), in a 2004 critical review of youth suicide prevention programs provided the following four criteria to be used in the application of all mental health programs:

1 – Apply good and effective interventions
2 – Avoid ineffective interventions
3 – Eliminate harmful interventions
4 – Facilitate public accountability

These seem pretty reasonable to me.

The problem we seem to have is making sure we do each of these things.  This is especially a difficulty when our pet theories or personal perspectives do not stand up to independent, substantive and appropriate scrutiny.  Yet these are the things that we need to do.

So here is a suggestion.  Before implementing any mental health program can those people charged with doing that simply tic off each of these four criteria.  Have you clearly and with the proper and most substantive type of evidence demonstrated that the interventions are good and effective?  Are you using programs or other interventions that have none or inadequate evidence of effectiveness?  Are you sure that your programs or other interventions do not cause harm?  Have you been open with the public about the effectiveness, cost effectiveness and safety of all the programs and other interventions that you have in place?

If not, why not?

Recently, my research team published a scientific commentary in the Canadian Medical Association Journal dealing with an important mental health concern.  We conducted an assessment of the information dealing with psychological debriefing in schools and found that there was no substantive evidence to support the use of that kind of intervention following traumatic events.  We also found that the best available evidence in studies of adults showed that these type of interventions were not helpful, and indeed in some studies turned out to be harmful (see: Psychological debriefing in schools, www.cmaj.ca Online publication, January 4, 2010)…

Yet, these interventions have been very popular and used so frequently that they have become commonplace.  Who has not heard the news on the radio that grief counselors have been dispatched to a school after a traumatic event?

This raises a very important issue.  That is, before we start wide-scale mental health interventions we need to be pretty sure that they work and we need to be really sure that they do not cause harm.  If we put programs into place that do not work we are creating a false sense of security and using scare resources; money and people, to no good end.  Furthermore, because of our investment in such programs we may be less interested in considering other options – options that may actually work.  In other words, what seems like a good idea may not be a good idea and if that gets codified or ingrained in an organization or institution it may have more negative than positive consequences.

So, what is to be done?  First, when we do get solid substantive evidence that what we are doing does not really work, is not cost effective, could be done better in a different way or may cause harm – we should stop doing whatever that is that we are doing.  Sounds simple but it is not so easy.  Usually because there has been a big investment in the initial program and there may even be a big industry and local champions pushing for its continuation.  Second, before putting in a program we should demand solid substantive evidence that the program really works and that it causes no harm. Third, if we decide to put programs in without the kind of evidence we need to have, we better make sure that we also provide the kind of independent and unbiased research that is needed to help us determine if the program works or not, if it is cost effective and it does not lead to harm!

We have to do the right thing, not just do something.

–Stan