Disruptors Revisited: Youth Mental Health in the Age of Covid

Speaker 1 [00:00:01] Hey, it’s Theresa. I think it’s fair to say that this past year has been unlike any other, we are all looking forward to a return to something that looks just a bit like normal this fall. For some, it might mean those tentative first steps back into the office. For others, it could involve seeing a live show somewhere, anywhere with other people sitting next to us. But perhaps no group is more excited or anxious, or probably both about the return to this new normal than Canada’s youth. After a year of on again, off again in person learning, students are coming back en masse to the classroom in September in many cases. Unfortunately, they’ll also be bringing with them a year’s worth of mental health baggage. Covid presented a singular challenge to the mental well-being of all Canadians. But youth who are so reliant on social interactions for their development were particularly hard hit. This past May, the Children’s Hospital of Eastern Ontario in Ottawa reported that 50 percent of all patients visiting its emergency department since the start of the year sought treatment for some form of mental health issue. Mental health is a growing concern for our educational system, our health care system and ultimately our economy, according to the Mental Health Commission of Canada. Mental illness is estimated to cost the Canadian economy 50 billion dollars annually. If we’re to address the cascading issues surrounding mental health, we need to intervene sooner. We need to develop the tools, technologies and approaches that will ensure that the youth of today become the healthy and prosperous leaders of tomorrow. This is Disruptors and RBC podcast, I’m trying to raise a. On today’s episode, we revisit an in-depth conversation between my co-host, John Stackhouse, and two of Canada’s top experts in the field of mental health. This is a cause close to our hearts here at RBC. Since 2008, we’ve invested more than 40 million dollars to help support the mental health of children and young people in Canada in 2020 alone. We raised eight million dollars through the reimagined virtual RBC race for the kids. We also partner with a wide variety of national organizations that are similarly committed to the cause. The need for action on mental health is growing. And as John explains in this conversation, which first aired last fall, so too is the need to do something different.

Speaker 2 [00:02:54] Consider just a few alarming statistics,

Speaker 3 [00:02:56] three quarters of mental illnesses emerge between the ages of 16 and 25

Speaker 2 [00:03:01] when most people are just joining the workforce. One in five Canadian post-secondary students is depressed or battling other mental health issues. And Canada’s youth suicide rate is the third highest in the industrialized world. Mental health is a journey that no one should take alone. And in that spirit, I’m joined today by two remarkable leaders in this field. Dr. Joanna Henderson is a clinical psychologist and director of the Center for Addiction and Mental Health here in Toronto. She’s passionate about models of care for young people. Dr. Yuri Quintana cut his teeth here in Canada and is now the chief of the Division of Clinical Informatics

Speaker 3 [00:03:39] at the Beth Israel Deaconess Medical Center.

Speaker 2 [00:03:42] He’s also an assistant professor of medicine at Harvard Medical School. Joanna, Yuri,

Speaker 3 [00:03:50] thank you for being here and welcome to RBC Disruptors. Thank you. Thank you very much. What do you specifically focus on young people with your work?

Speaker 4 [00:03:58] Young people have, as you were pointing out, some of the highest rates of mental health needs. And they’re also our opportunity to change the future. Young people are on developmental trajectories that take them through their childhood, their adolescence, into young adulthood and into the next stage of life where they start to function autonomously and they need the skills and support to be able to do that successfully. If we don’t intervene early, we miss a tremendous opportunity to support young people in their development,

Speaker 3 [00:04:33] as we mentioned earlier. Young people are at a much higher risk of mental illness, yet they also have access and an affinity to technology that previous generations didn’t have is not an advantage or disadvantage.

Speaker 4 [00:04:46] From my perspective, it’s an advantage. It’s unavoidable that young people are connected to technology. It brings with it some risks. It brings with it some challenges to young people. And it also brings opportunity for us to leverage their connection to technology to in my view, what we should be doing is co designing with young people the kinds of technologies and interfaces with technology that help them in their lives.

Speaker 3 [00:05:15] When you think about technology and mental health, a friend or foe, I think when it’s properly applied, it can be very beneficial to many people, not just patients, but also people who are friends of the person that’s needing help. And for health care providers, unfortunately, sometimes technology is poorly implemented or people use it for purposes that weren’t approved. And so there are some potential dangers. But when properly applied, it can certainly provide more access to services, to knowledge and support services. And we’re trying to help individuals as well as organizations use that technology in the best way possible. It’s still early days, early months in this pandemic and in terms of some of the social change it’s led to. But the increase in screen time is phenomenal for all ages, but particularly for young people. Do we know yet if that is causing significant risks to mental health, Yuri? Well, I think the evidence with technology and apps is still in its early stages compared to other fields. Certainly, I think not having connection with other people face to face is something that people are looking at very strongly in terms of the detrimental effects of that. But the reality is that because of the infectious nature of this disease, we do have to keep physical distance and maybe social distance isn’t the right word, you know, because I think we do need to remain connected with each other. So I think technology can enable us to remain connected with our friends, with our health care providers. But it’s also true that spending too much time connected to technology doesn’t allow you sort of individual time to disconnect and decompress. And so there are some innovative technologies that, for example, monitor your screen time and alert you when maybe you do need to sort of disconnect and spend some time on nature. So I think we need to find novel ways to use this technology such that it complements our lifestyle rather than gets us even more addicted to the technology and isn’t helping us.

Speaker 4 [00:07:18] I think one of the challenges with technology and the interfaces that we’re currently using to connect, they lead to a sense of monotony, a lack of engagement, a lack of productivity. And we haven’t really been able to leverage the capacity of technology, I think, in ways that can really create opportunities. Given that we have to use technology so much, we need to be able to use it intentionally to support young people and continuing to feel productive. And I think there’s a risk in talking to a computer screen or staring at a computer screen for many hours, for example, of not feeling productive. And so it’s figuring out how do we support young people in doing what they need to do, like school or other things through technology, and pair that with actual activities that engage them with the real world and allow them to have that feeling of belonging and productivity that’s so essential at this developmental stage

Speaker 3 [00:08:24] and enjoying what you’re doing some of that through. Can you give us a better sense of what you’ve been working on and how that’s playing out?

Speaker 4 [00:08:31] Sure. So with Youth Wellness Hubs Ontario, where a network of mental health services across the province that up until the pandemic had a strong focus on being placed based so espace in the community where young people had co created the space. And could go to that space when they needed support and were able to access services with the pandemic, we needed to transform the way we offered service to young people in the context of our doors being closed, physically closed in some cases, or our physical services, our in-person services being greatly reduced. Initially, what happened was because we were in the context of the pandemic, people retreated to a position of, well, this isn’t a space for youth engagement. This isn’t a space where we can connect with youth to figure out the solutions to this big problem of how are we going to offer services. And instead, it is one that serves Ontario. We really pushed and we invested in continuing to have youth at the table to design our response. And we were able to really understand from young people that using technology to deliver services isn’t just about taking what we do in person and then offering it through the technological interface, but is instead thinking about how do we take the robustness of technology to offer new kinds of services and to use the kinds of things that young people already using technology to also deliver the supports that we need to deliver in the pandemic.

Speaker 1 [00:10:15] During the show, we also heard from Shanna McCracken, Shanna is the executive director of Frame, an Ottawa based network that connects mental health, health and social services framework’s with youth and young adults to accelerate the integration and implementation of youth care in Canada. Here’s what she had to say about gaps in our system that were revealed by covid.

Speaker 5 [00:10:38] What we’ve heard resoundingly over and over again from young people and their families is that, no, we do not have enough access. We are not seeing impact in their lives in the way that we would hope to as a system. And so I think what covid has done is that covid has really laid back there any sort of barrier or any gap that existed previously has been further highlighted through covid and the rapid pivot that our system has had to do to virtual service. Not all young people in their families have access. Not all young people in their families, and now even fewer than before, have the ability to navigate a very complex and often siloed and fragmented mental health and substance use system.

Speaker 3 [00:11:26] Joyner, what goes through your mind when you hear that

Speaker 4 [00:11:29] Shawna’s right on the mark, we hear that over and over again from youth and families, that their experience of the system is that it is fragmented, that there are multiple barriers, that it’s very difficult to access the services they need and want to be able to achieve optimal outcomes. The pandemic has definitely created even further gaps for young people who are particularly disadvantaged. We had young people who didn’t have enough food to eat. It’s really hard to address mental health concerns if you don’t have enough food to eat. And so we really need to think holistically about the needs of young people. We no longer can think of a system that’s divided up, you know, takes one young person and divides them into their physical health needs, their mental health needs, their educational needs. These are not separate things. Young people need to be thought of holistically. And the services we provide need to cut across all of those different areas. And we as a system have an obligation to work holistically and to integrate our services in ways that make sense.

Speaker 3 [00:12:34] So if I could pick up on that, I think the two key points that both China and China have mentioned is access is very important. And the types of wellness hubs that China has been meeting really creates a very welcoming, non-threatening environment where you can sort of access a whole range of support services. But we also need to sort of create virtual environments where people can access information services. One understudied area is social determinants of health. These are sort of different challenges that people have, economic circumstances or educational circumstances or where they live geographical. And so we need to start learning how to scale. And here’s where technology could help. But it needs to be done in a way that’s sensitive to the diversity of circumstances that people have. And so this Covid pandemic, as horrible as it is, really has sort of woken up people to the need to make services more accessible to everyone. Right now, we’re physically challenged because of the infectious disease nature. But how do we make this available to rural areas? How do we help those people who have other factors? And so I think a comprehensive evaluation of this needs to look at social determinants of health and how do we personalize services both on site and online that meet the individual’s needs. You both touched on the question of safety. I wonder if I can draw you deeper into that, because it’s hard for anyone of any age to discuss mental health and certainly to open up about it to and to seek help, given the massive disruption we’ve had to the way we live, the way we study, the way we commute. I wonder what you’re learning about the way that young people seek help. They’re no longer necessarily around the social safety of a school, for instance, or of a place of worship or of a community center where they may feel more comfortable. How is that being addressed? The challenge of safety in a more virtual world, even when it’s in a new physical environment like the kind you’ve been creating?

Speaker 4 [00:14:46] I think it’s a critically important issue to address. We’ve heard from young people in part their reluctance to engage in virtual counseling, where it’s a conventional in-person counseling, but now delivered virtually stems from concerns about being able to engage with mental health professionals safely and structurally as a system. We also make that worse by sometimes putting in place policies and procedures that are intended to protect the service provider, perhaps from liability or other things, like requiring people to be in a fixed place while they engage in virtual therapy so that if there was an emergency, we’d be able to locate them. But what that means is young people who might, when they want to have a confidential conversation, go for a walk or sit in a car so that they can feel comfortable. They have confidentiality. Those options aren’t open to them. So systemically, we’re creating barriers to young people being able to safely engage. And I think we you know, the pandemic has really shone a light on our failure. I think we really can look back now and see that we didn’t take those into consideration. And going forward, I would strongly advocate that youth need to be at the table in thinking about pandemic planning. They have great ideas, but we need to engage them and we need to engage them in the planning stages.

Speaker 3 [00:16:10] What should we have done differently in pandemic planning?

Speaker 4 [00:16:13] I think if we look at the education system and the transitions that needed to take place, what we can see is that there was tremendous immediate focus on how do we ensure that the curriculum. Continues to be delivered. How do we ensure that young people continue their learning of academic skills and what people were slower to respond to, where the broader needs that school needs for young people? If we had engaged young people in a planning process? I expect that they would have flagged for us very early on that many young people get meals at school. Many young people have adult allies at school that help them stay safe, then help them identify when things are unsafe at home or unsafe in their personal lives, and that the social supports and their mental health needs are often being met in the school system. And when we pivoted in the education system, those pieces were not the immediate focus when in fact young people will tell you all of these other needs are also met in that system. So how are we doing that as well? And there has been important work to meet the mental health needs through the school system. Some important investments for sure, but it wasn’t there at the outset. So that might be one difference that would have been in place if we had planned together.

Speaker 3 [00:17:35] That’s a great way of describing some of the challenges that have been bubbling up over the last many months. It makes me think of the metaphorical but also real hallway conversations that exist, whether it’s in offices or schools, hallways and the like, are where we often have the most honest conversations, where we share our feelings, where we come to grips with our problems in ways that we might not want to do in the more formal setting. And I don’t think we’ve figured out yet how to use technology for the hallway conversation that we need.

Speaker 1 [00:18:11] Hey, it’s Teresa again. I hope you’re enjoying this encore presentation of disruptors. And our look back at the pressing issue of youth mental health. If you like what you’re hearing, I’d encourage you to check out some of the many conversations John and I have had with Canada’s top leaders over the past year, such as our recent look at the burgeoning world of virtual medicine, where I talked with three of Canada’s health care innovators. You can find past episodes of disrupters at RBC, dotcom disruptors or wherever you get your podcasts. Now back to John Stackhouse.

Speaker 2 [00:18:46] My guests today are Dr. Joanna Henderson of CAMH and Dr. Yuri Quintana of Harvard Medical School. I want to bring in another clip from Shawna MacEachern, of Frayme

Speaker 3 [00:18:56] we asked her about whether the shift to online mental health treatment during the pandemic is the right direction.

Speaker 5 [00:19:05] I think it depends what we do with it. I think it depends on if we will invest in understanding what works and what doesn’t. We can’t just keep adding things on to our system. We also need to make space to remove parts that are not meeting the needs. Covid could be a catalyst for us to take an opportunity and build something together that can be different. But I think it could also be something that creates a lot of damage. And I think we will see that for young people in their families and mental wellness overall in our country in the long run.

Speaker 3 [00:19:41] I sometimes think that this pandemic is like a white board for society and we have a chance to erase stuff that we want to leave behind and start drawing a new year. I’m wondering how we integrate online and virtual elements in mental health treatment while still staying in touch with the human aspect of keeping some of the traditions that we built up over the years. I think that’s a great question. And I think one of the challenges that providers will need to face is how to develop the right blend of services, both technology based and in person based for different individuals at different stages in their life. And so, for example, apps and in online systems could create new ways of communication, some which might be actually more beneficial and convenient. For example, text based chatting with a health care professional might actually be more beneficial for some people in certain circumstances. For example, if you don’t want to be overheard as to what you’re saying, but not everybody wants to have, for example, a text based chat or an online experience, and it depends on the particular circumstances. So part of what we need to do now is develop the research to understand what types of technology are appropriate for what types of individual and what kinds of situations.

Speaker 4 [00:21:01] I think another important point that Shonna made is just how do we also unemployment things that aren’t working because that challenges our system as well. And I think with technology, just like with in-person services, apps, other pieces of technological interventions as well as in-person interventions can become established without any evidence that they are actually helpful, then it becomes really difficult to implement them, to get people to stop using them or to stop practicing in a particular way. And that’s going to be as important as we shift to new ways of working. And we really think about transforming how we offer services. How do we get rid of old ways of working that may no longer be helpful or no longer contribute sufficiently to the well-being of young people? So that’s going to be important as well.

Speaker 3 [00:21:58] I think one of the quiet stresses of this crisis is the I’d call it the too much syndrome. There’s just too much of everything. It’s overwhelming. How are you thinking, both of you, about this incredible explosion of mental health apps that we’ve seen as not just during the pandemic, it was happening before. What does that tell you about the world around us? Joanna, maybe start with you.

Speaker 4 [00:22:23] I mean, I think it tells me a few things. I think, you know, the market reflects and influences, you know, young people. And so young people want apps. They want helpful things on their phone that can guide their behavior to help them feel strong and resilient when they’re faced with challenges, you know, at the same time. For me, it’s very concerning because I think what we’ve seen we’ve seen good apps be developed using evidence based approaches, co creation commitments to concretion. Working in that way takes time and commercial sort of opportunities are simultaneously arising. They arise more quickly. You know, many, many apps are being made available that we don’t know. Not only do we not know if they’re helpful, but we don’t know if they could be harmful as well. And so it really, you know, although young people are really keen to have apps as part of what they can use to support themselves and to support their peers, they also want to be sure that those apps can be helpful and useful. And we as a system, I think, need to ensure that we have appropriate policies in place to to regulate some of that.

Speaker 3 [00:23:42] And that’s kind of scary that many of these apps could be harmful. How do you assess what makes a good app and what makes an app perhaps harmful? So in the work that I’ve done with Johanna and a whole range of experts both in Canada and the United States, we took both a pragmatic approach of evaluating the methodology of how it was designed, but also a scientific approach for evaluating the outcomes. And I think that’s very key because a lot of these apps, we don’t have any long term studies and some of them don’t have any studies. Many of them don’t have any studies evaluating that. And so we need to invest in doing these evaluations and then being able to transfer that knowledge to health care providers to guide them towards what is known to work or what isn’t working. I think because of the need, there’s a rush for people to commercialize this and nothing wrong with sort of developing a business. But in that. People may not be actually properly designing these, and some of the apps may not have the best intent in mind, and so one of the things that we call out is to actually know who is developing it and whether there’s any scientific or health care professionals involved in the creation of that. One of the dangers is that some of these apps may be collecting all kinds of information without consent and without the best interest of the patient who needs to be providing oversight. Is this something the government needs to regulate health bodies need to take more ownership of? Or is it up to the technology platforms or each of us as consumers and patients, if you will? So I think there’s a role for all of those groups. But definitely I believe that science and health professionals need to play a leading role in this. And those could be scientists within the government or the government working with universities and other institutes. You know, when you think of what kinds of medications you take, you wouldn’t take something that hasn’t been evaluated or a medical equipment that’s been used. You expect experts who are properly qualified without commercial bias to have evaluated the safety of those devices. And so that’s part of what we’re discussing through these roundtables is who should be involved and how do we organize this? It has been done in other areas. So, for example, cancer treatments are very well funded organizations and it is happening in mental health. But we need larger organizations, larger efforts, and we need to look particularly at the aspects of technology because there are ways of collecting massive amounts of data from your phone and sharing it. And that needs to be certainly regulated. Do there need to be warning labels or some sort of tagging on apps to say that someone like you, Yuri or Joanna have studied it? Canada has looked at this and acknowledges that efficacy? Probably likely. I mean, I think when you look at Cigarette’s, they have warning labels and there was a lot of pushback on those labels. I think when you look at medications that are dispensed, you know, there are government agencies that do that. Certainly, I think something that hasn’t been evaluated for therapeutic use needs to have some sort of label. And we need to have that discussion as to what should those labels be and how should they be informed and how should we be thinking about the data challenge, because everything we touch digitally systems, algorithms, learn more about us every time we use a device. But there’s dangers, particular dangers when it comes to mental health and mental health, perhaps. How should we be thinking about that frontier? Because I can also imagine maybe in some ways it could be helpful, but something we would want to approach with caution.

Speaker 4 [00:27:31] Absolutely. You have it exactly right. There’s potential. There’s opportunity there. The ways that people interact with their phones, the things that they may post on social media, may ultimately be able to provide us with early warning systems for young people who are really starting to struggle. However, having control over one’s data, being able to consent in a way that’s informed, having information shared with you that is digestible and understandable to the person reading the information is critically important. And ultimately, I would argue we need to have young people engaged in these conversations so that the policies we do develop keep their needs and their interests at the heart of the discussion because those easily get lost. When we start to, you know, talk about commercial interests and government regulation, we can lose sight of the views of young people who are profoundly impacted by some of these things.

Speaker 3 [00:28:33] This is such an important conversation and I’m so glad we’re having it. A lot of challenges here, a lot of unresolved problems. And as we move towards close, I want to get a sense of what keeps you optimistic, what motivates you. You both work with young people who are often more creative, strong and resilient in all sorts of ways during what’s keeping you motivated and hopeful about the state of mental health care for young people right now in the midst of this extraordinary pandemic. I think what’s keeping me optimistic is that I see a growing collaboration from all kinds of disciplines health care, basic science, engineering, social sciences, government, private sector nonprofits, a growing number of people who recognize that no one group can solve this problem alone. And I think that collaboration will be key to move forward. And so even though there is a lot of challenges, I think we just need to continue to build on these collaborations. And I’m very grateful to the collaboration that I have with many Canadians who I’ve been able to stay in touch with. Even though I’ve moved to different cities around the world and I think Canadians are generally much more collaborative and engaging and have a sense of values of society, and I think that will position Canada to be a great innovator in the mental health, space and technology space. Joint of these can be dark days, dark weeks, especially as we move towards winter. What’s keeping you optimistic about the future?

Speaker 4 [00:30:04] Definitely the young people I work with. We have many young people who have had terrible experiences at the hands of the system, and yet they still stand up and put their hands up and say, I want to be involved in making it better. We have community members. We have corporations who are coming together and across the country. We have so many people who understand that system transformation means that we need to work differently. We can’t just keep doing the same thing and expect different outcomes. So that’s what keeps me going and keeping a focus on really thinking about how we want the lives of young people to be different in the future.

Speaker 3 [00:30:42] This is a universal challenge, mental health. And I think we were moving towards accepting that before the pandemic hit. There’s not a family, not a community in this country that doesn’t have mental health challenges. And we’ve become more comfortable speaking about that with each other. Nowhere near enough, but we’re moving in the right direction. And this conversation has been really helpful. And the work we’re hearing about is critical to helping us as a society move towards a more critical approach to recognizing the quality and efficacy and value of those assets. We need them. We need technology, but as they say, handle with care. I’ve also learned from this conversation that while we need more science in all areas of our life and we need more science in mental health, we also need to think harder about patient centricity and finding ways for patients to actually lead what we’re doing in mental health. That may be harder in this remote existence that we’re all getting used to also may maybe easier. It’ll be easier if we make it so, and that, in a way, comes back to all of us. So while this is a universal challenge, it’s also a universal opportunity for us each to play a positive, constructive role in our journey towards a better state of mental health.

Speaker 2 [00:32:11] My guests today have been Dr. Joanna Henderson, director at the Center of Addiction and Mental Health in Toronto, and Dr. Yuri Quintana an assistant professor of medicine at Harvard Medical School. My thanks to both of you for this important and really timely conversation. Thank you. Thank you. I’m John Stackhouse

Speaker 3 [00:32:28] and this is RBC Disruptors.

Speaker 1 [00:32:31] And I’m Teresa Do. Thanks for joining us on this special look back on youth mental health. Here’s hoping for a better school year for all students. Join us next time for a brand new episode of Disruptors as we launch our third season in September. Talk to you soon.

Speaker 6 [00:32:53] Disruptors, an RBC podcast is created by the RBC Thought Leadership Group and does not constitute a recommendation for any organization, product or service. It’s produced and recorded by JAR audio. For more Disruptors content, like or subscribe, whereever you get your podcasts and visit rbc.com/disruptors.

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