All posts by mross109

Private Health Care

By Dr David Laing Dawson

As Donald Trump famously said, “Who knew health care was so complicated?”

In Ontario recently, with the Ford government, the words “privatization” and “health care” were connected in the same sentence.

At the least it seems privatization once again surfaced as a possible means of fixing two persistent problems in our publicly funded care. The first of these problems is wait times for certain investigative procedures and certain kinds of surgeries. (For the most part these are all investigations and surgeries that can wait; that is they are not life threatening emergencies. And when I do get my appointment for an MRI of my knee I know I may have to wait a few hours, or be bumped if some urgent case arises.)

The second is so called hallway medicine. People admitted to hospital lying on gurneys in the hallways waiting for beds. This is indeed a complicated issue but not one that can be resolved by throwing the word privatization around.

But rather than address these issues I am writing this to call out a seldom mentioned problem with a “private” system of health care. And that is over treatment. If the patient is rich or his insurance very good the many private clinics in the USA are given an incentive to over investigate and over treat. Scans, blood tests, pills, surgeries, and residential care.

And to some extent the nature of the over treatment is then dictated by what the insurance company is willing to pay for. This is one aspect of the opioid epidemic. In many cases medicare or insurance will pay for pills being prescribed but not physiotherapy or gym membership. And over treatment is not benign.

Some early democratic presidential candidates are promoting medicare for all. Immediately other “experts” and politicians are saying we (the USA) can’t afford medicare for all. Nobody points out, and this is true, if you take all the money the US pays now for Medicare and divide it by the entire population, their per person cost is already higher than our (Canadian) per person cost and we cover everybody.

It is, compared to Canada, the wild west down here (as I am writing this in Florida). I have just watched TV ad after TV ad for prescription medicine, surgeries, assistive devices paid for by medicare, and then, seemingly unrelated but pertinent I think, an ad for a little packet of spring water along with testimonials of curing cancer, being able to walk again after paralysis, and good fortune in the form of a lottery win that paid off the mortgage and a check for $17000 inexplicably arriving in the mail.

I think the experts mentioned above are right. The USA cannot afford a full public universal health system, at least not without a massive public health information/promotion/prevention campaign, and not without accepting a whole bunch more regulation and over sight.

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Reflections on Marx, Religion and Opiates For the Masses

By Dr David Laing Dawson

When Karl Marx opined that religion is the opium for the masses it was not the throw away line it is today. I am writing this as I watch the sun set over the gulf of Mexico and smoke my $5 robusto and sip my $20 dollar bourbon.

Within my limited historical scholarship it seems to me that humans, ever since evolution bestowed upon them the awareness of suffering, temporality, and death, have been seeking substances to dampen, or ideas to vanquish, the horrifying experience of that reality.

While some of those substances (LSD, mescaline, ecstasy, opium!) give one a temporary sense of alternate and eternal realities, others merely dampen it.

As I write this the clouds briefly accrue a God-like glow of crimson and then slip into filaments of white against the darkening sky, and the temperature drops a few degrees at this moment on this region of a small planet. I go inside to replenish my glass. Our two dogs come with me; one, oblivious to my thoughts, wants to share his chew toy with me.

While religions, all of them, from the old and organized, to new and old ideas of enlightenment and “oneness with the universe” attempt to obliterate the terror of being sentient beings with limited life spans, substances like marijuana and alcohol merely dampen that reality.

And while religion works for many it has also been the unholy source of corruption, perversion, suffering and death for others.

With a sweater it is warm enough to sit outside and miraculously the WiFi reaches a chair by the barbecue. The sky has become both misty and mystical. A scattering of stars appears between the low clouds. I know I should leave my cigar alone, for the second half will give me an overdose of nicotine and a dry mouth through the night. The replenished glass of bourbon with much ice to soften it will let my eyes linger on the beauty of the night without too many intrusive thoughts.

Marijuana would let me do the same I’m sure.

It is one of those realities that could be used to argue both for and against intelligent design: anything that can make us feel good, or relieve us of the terror of existence, when used excessively, can harm us. I will leave the cigar butt in the ashtray and I resolve to not replenish my glass again. The dogs lie on the cool patio stones beside my chair.

My companion comes out to join me, commenting how lovely it is, and asking if I would like a refill. My resolve vanishes as quickly as a startled gecko.

We sit together in the balmy night air, breezes bringing mist from the gulf, the dogs at our feet, and I think how quickly time passes, and I tell myself to stay in the moment.

Marijuana and Schizophrenia – Part II

By Dr David laing Dawson

It struck me recently the reason marijuana has been such a popular recreational drug is that while it causes distortions in perception (time passing, speed, sound, colour, light, music, intensity, memory, touch, focus etc) thanks to THC, it also contains differing amounts of CBD, a potent anti-anxiety, anti-arousal agent.

Usually such distortions in perception, especially for the naïve user, would lead to anxiety, arousal, sometimes fear and panic, and could obviously hasten along an evolution to psychosis. And some people do report very negative experiences after smoking a joint.

Clearly it is the CBD portion of the drug that allows those perceptual distortions to be pleasurable.

I am absolutely sure that marijuana does not cause schizophrenia, but it could easily hasten it along, especially with heavy use. On the other hand CBD is an effective, and so far apparently safe, anti-anxiety drug and possibly safer for controlling anxiety than prescription lorazepam.

But, as I have pointed out to teenagers who asked for marijuana prescriptions to quell the pain of a breakup, impending exams, getting a part-time job, they should and need to be experiencing anxiety. Some anxiety is necessary for growth, for learning, for engaging with the world.

Many boys who smoke daily from, say age 16 to 23, are still obviously, in many ways, 16 when you meet them at 23.

CBD yes as a good medicine.

Marijuana in moderation, at least until achieving some level of maturity.

Marijuana and Schizophrenia

By Marvin Ross

pot
Courtesy of pixaby.com

Now that marijuana is legal in Canada and in many US states, understanding the role of this substance in the development of schizophrenia is even more crucial. Schizophrenia has long been thought to be associated with pot smoking but the causality has been in doubt.

In my book, Schizophrenia Medicine’s Mystery Society’s Shame published in 2008, I cited the research that was current at that time.

The classic study was that of a long term follow up of Swedish conscripts aged 18-20 in 1969-70. A total of 50,087 young people representing over 97% of that country’s 18-20 male population reported on their use of cannabis, other drugs and on several other social and psychological characteristics. The researchers then looked at hospital admissions for schizophrenia amongst this group. It was found that cannabis was associated with an increased risk of developing schizophrenia. The greater the use then the greater the risk. The researchers concluded that there was no question but that the link between the two was causal. Cannabis use caused schizophrenia and the link was not explained by the use of other psychoactive drugs or personality traits.

However, it has also been hypothesized that schizophrenia leads to a greater use of marijuana likely because people are trying to medicate themselves. A number of years after the above study was published, Scottish researchers looked at all the studies that had been done on the link between cannabis and schizophrenia between 1966 and the end of 2004. That study agreed with the original findings. Early use of cannabis does appear, it said, to increase the risk of psychosis and that cannabis is an independent risk factor for both psychosis and the development of psychotic symptoms. Again, it has been argued that prodromal symptoms of schizophrenia lead to an increased use of marijuana. Then, while the disease is developing, being stoned speeds up the developing deficits of the disease.

Malcom Gladwell in the New Yorker and New York Times reporter Alex Berenson recently wrote about the correlation between marijuana use and violent crime. Gladwell cited a National Institute of Medicine research report and Berneson produced a book on the topic called Tell Your Children: The Truth about Marijuana, Mental Health and Violence.

Marijuana researchers objected strenuously to the link of marijuana to crime and I tend to agree. But Gladwell also linked pot use to schizophrenia and that too set off the marijuana researchers. Ziva Cooper, one of the authors of the National Academy of Medicine report, objected to the association of marijuana with schizophrenia. She said that the National Academy did find a link between marijuana and schizophrenia but that they also found a link between using cannabis and improved cognitive outcomes for people with psychotic disorders.

Now that I can also believe but the researcher is mixing apples with oranges. Marijuana is comprised of THC which is the hallucinogenic and CBD which is not. It is the THC that can push people to psychosis and when smoking pot, you do not know how much of each is in the joint. And, of course, the potency of pot today is much greater than it was in my day.

According to a research update in Psychiatric Times “Cannabidiol (CBD), the second most active ingredient in marijuana, has been hypothesized to have antipsychotic effects—in contrast to tetrahydrocannabinol (THC), which may promote or worsen psychosis”. Recent research in the American Journal of Psychiatry found that “CBD has beneficial effects in patients with schizophrenia. As CBD’s effects do not appear to depend on dopamine receptor antagonism, this agent may represent a new class of treatment for the disorder”.

However, people should be aware that when you smoke a joint or nibble an edible, you have no idea how much THC or CBD is in the product.

And, as the brain continues to develop till about the age of 25, those under that age should be cautious particularly if they have a family history.

Thoughts on Addictions and Illness

By Dr David Laing Dawson

One of the foundations of a civilized, organized society is the assumption that each member is personally responsible for his or her behaviour and will be held accountable. Then, over time, we cautiously make some exceptions through our laws and courts.

Before the western disease model developed as a way of understanding illness, most cultures, in different ways and to different degrees, held individuals morally responsible for their illnesses, especially, of course, mental illness.

Though we understand the western model of disease as an assumption of biological causes and pathways, of equal importance historically was the removal of moral culpability from the sufferer. (the illness was no longer ascribed to moral lapses that allowed the devil in).

Even so, if the sufferer committed a crime he or she was still held morally and legally accountable until the M’Naghten trial in 1840. Since then each western country has developed variations of the three factors that could, through due process, allow a judge or jury to arrive at a finding of not guilty by reason of insanity or mental defect, or, now in Canada, Not Criminally Responsible. These are: labouring under the influence of a defect or illness of the mind, and did not appreciate the nature or consequences of his actions, and could not distinguish right from wrong.

It is also a relatively recent development that we do not hold children accountable for crimes they commit, or some mentally handicapped or demented citizens, and adolescents are given a modified pass.

It is certainly compassionate to consider an established addiction an illness, and at least from that point, not consider the addict’s seeking and using of drugs a moral failure, quite apart from the assumption of biological determinism. But as for crimes an addict might commit he or she would have to satisfy all three of the precepts listed above for a finding of “not criminally responsible”.

The assumption of free will and personal responsibility is in itself a determinant of human behaviour. What happens when we remove that responsibility?

I think it fair to say that the incidence of schizophrenia or serious depression would not increase. But what about addiction? No matter how you slice it, the addict must do something (seek out, ingest, inject, snort) to continue being addicted. Of course not doing that thing brings about illness and suffering as well.

The general wisdom often voiced in the therapy world is that addicts and alcoholics will only change or engage in a rehab process when they are ready to, or have decided to. But that wisdom has always struck me as too generous. Experience indicates they will enter treatment and try to stay clean when they have to. When they have to or else face some serious legal, employment, medical, or social consequences. As I have written before this is not a particularly strong condemnation of addicts, for all humans mostly engage in the hard work of changing behaviour when they “have to”. (the wake up call of a heart attack eg)

Addicts also have certain striking personality traits. They are not tolerant of delayed gratification. They tend to ascribe cause and responsibility to someone else or some factor beyond their control, and they lie. True of all humans I suppose but definitely traits that make helping addicts problematic.

Now before you think I am being harsh on the illness of addiction please note that the treatment, rehab, and recovery programs for alcoholism and addiction all tacitly acknowledge these traits. They do so in their forms of group therapy that all emphasize taking personal responsibility, in the lie detector urine test before methadone is handed out, in the AA twelve step program.

It is definitely more compassionate to think of addiction as an illness rather than a moral failing deserving our scorn and condemnation. But to do this naively will help no one.

We have already made the mistake of administratively blending addiction services with those for the mentally ill with the consequence of attitudes toward each, models of care toward each, models of security and protection for each bleeding both ways, helping neither.

More on Homelessness and Mental Illness

By Dr David Laing Dawson

With seemingly intractable social/medical problems we tend to rant about them or offer sweeping, global, feel better (they make us feel better) but useless proposals such as “talk about it” for suicide, and more affordable housing or shelters for homelessness.

And we forget history.

In the seventies our community psychiatry teams (at least the ones I was involved with) made home visits, ensured patients stayed on their medication, intervened with landlords, and one team member was official liaison with all, what was then called, second level lodging homes.

In the eighties our Psychiatric Hospital formed a special team to help prepare patients for discharge and settle them in appropriate housing, and connect them with all the treatment and support they would need.

And this is the moment to intervene and to focus resources: preparation for discharge. Discharge from hospital, addiction treatment centers, and from jail. This is the moment to spend resources and money, finding, securing, settling in with all necessary supports. And those supports can include intervening with landlords, attendance at AA daily, a sponsor, a visiting nurse with anti psychotic medication in a syringe, community treatment orders, help with shopping, budgeting, ADL’s, peer support etc.

Many factors have combined to produce the current problem: loss of low skill jobs, epidemic of opioid addiction, lack of affordable housing, psychiatric treatment shifting to short stay general Hospital treatment and specialty outpatient clinics, and a well-intended but damaging shift to protection of individual rights at any and all cost, and an institutionalized denial of mental illness combined with a paradoxical acceptance of addiction being an “illness”.

(in this strange world of ours a man who believed he was born of the stars and a professor was deemed by the Supreme Court of Canada to be competent to refuse treatment though it meant he would be incarcerated the rest of his life, and another court reinstated a nurse who stole opioids from her patients to feed her addiction on the grounds that “her addiction was an illness”

Emergency shelters, delivering blankets and food to the homeless, clean injection sights, mental health teams working with the police, street homeless watch, a differently designed clothing donation box are all worthwhile band aids but if we want to actually make a difference over a long period of time we need to focus resources to help people through that difficult transition from hospital, treatment center, or jail into a settled housed life within a community including all necessary support to remain housed and stay on the medication that prevents depression, psychosis, or mania.

Some years ago while giving a talk in The Netherlands about treating “borderline personality disorder” I was told it was illegal for Dutch hospitals to discharge someone to the street. I don’t know the details of that illegality, and it is a bit extreme for our social contract in Canada, but we certainly could keep patients in hospital a little longer while a special team ensured successful housing and compliance with treatment post discharge.

Band Aids are not a Solution to Homelessness

By Marvin Ross

It’s winter in Toronto and, as can be expected, there is a cold snap. Not surprising of course but with every serious drop in temperature, the medical officer of health announces a severe cold weather alert so that agencies can look after the homeless.

The city opens special shelters so those poor souls do not freeze to death as often happens in the winter. The number of homeless in Toronto and other Canadian cities is a blot on our supposed safety net. Our solutions to homelessness are totally inadequate.

This past week, a poor woman sleeping in an alley in an attempt to keep warm was run over and killed by a garbage truck backing into the alley as the driver did not see her. As a consequence, one charitable group is handing out visibility sashes to protect the sleeping souls from this happening to them as well.

https://globalnews.ca/video/embed/4865296/

Shortly before this event, another woman died when she was trapped in a charity box used to collect clothing items as she had presumably gotten into it to keep warm . I find it totally disgusting to see the numbers of homeless in downtown Toronto sleeping on sidewalk grates in the financial capital of the country (Bay St) with all their possessions piled around them. They are invisible as humans as the bankers, stock brokers and other business types walk around them failing to see the human beings hidden under the blankets.

One year, driving into Toronto for a meeting, I watched as I was stuck in the rush hour traffic as a van pulled up blocking the curb lane. The driver got out with breakfast for the just waking up homeless on the sidewalk.

It is nice to have breakfast in bed wherever you are but this was and is a totally useless exercise. In 2018, the number of homeless in Toronto was 6000 but today it is 9000. Project Winter Survival (one of the many aid groups in Toronto) has been besieged with requests for survival kits this year: homeless aid groups sought 21,000 kits, up 60 per cent from last year. Jody Steinhauer, the founder of Project Winter Survival was quoted in the Toronto Star stating that “we need to put the pressure on the city of Toronto: open up 1,000 shelter beds, get people into housing long-term with support solutions so that next year at this time, we can be indoors and being proud.”

According to the Homeless Hub at York University in Toronto, “30-35% of those experiencing homelessness, and up to 75% of women experiencing homelessness, have mental illnesses. 20-25% of people experiencing homelessness suffer from concurrent disorders (severe mental illness and addictions). People who have severe mental illnesses over-represent those experiencing homelessness, as they are often released from hospitals and jails without proper community supports in place.”

One study carried out by McGill University in Montreal, found that it is costing over $50,000 a year to provide support to one homeless person without resolving the problem. These costs were comprised of services such as supportive housing, treatment for substance use, emergency department visits, ambulance trips, hospital admissions, police and court appearances, social assistance and disability benefits, and incarceration.

Matthew Pearce, the head of Montreal’s Old Brewery Mission, told the CBC that “homelessness is not the problem. It’s a symptom of a problem” and that “It’s a symptom of inadequate services for people with mental illness. It’s a symptom of inadequate options for affordable housing for individuals.”

The researchers said that there is a “need for a comprehensive response” to the problem, and the importance of preventing vulnerable people from finding themselves in that situation in the first place.

Yes, the homeless need to be kept warm and safe but they also need to have treatment for the conditions that allow them to become homeless in the first place. Until we start to do that as a society, we will only be putting band-aids on the problem not solving it.

Books Based on Mind You Blog Now Available

By Marvin Ross

We are pleased to report that you can now get Mind You the Realities of Mental Illness: A Compilation of Articles from the Blog Mind You and Two Years of Trump on the Psychiatrist’s Couch in either print, kindle or Kobo versions.

Both print editions are distributed by Ingram which supplies almost all bookstores everywhere. The print editions are listed in Amazon world wide, Barnes and Noble, Books a Million, Chapters/Indigo. Kindle editions are, of course, available in all Amazon websites internationally and Kobo is also sold internationally.

A tip for Canadian purchasers. Amazon is selling the books at the US price of around $17.95 whereas Chapters is charging $23.95 for each of the books.

All reviews welcome.

cover dawson trumpcovermindyou

Time to Relegate Anti-Stigma to the Garbage Heap – Part Two

By Dr David Laing Dawson

There is a moment for most of us sometime in second year University studying linguistics, humanities, philosophy, psychology when questions of truth, reality and delusions become quite interesting. Is there really a difference between the man who believes the CIA is watching him (assuming they are not) and the man who believes Jesus turned water into wine without the aid of grapes and fermentation.

Is what we call a delusion just a lived experience no different than a thousand other unfounded beliefs the rest of us live by? Is it just a social judgment by which we differentiate?

The answer is no. Though it may not be readily apparent to other than a family member or someone who has spent years treating schizophrenia.

First of all the delusion, the false belief of the schizophrenic is almost always tormenting: being watched, controlled, denigrated, persecuted. And when it is not that, when it endows the schizophrenic with a power to right these wrongs, it is dangerous.

And secondly, most clearly differentiating a delusion from an ordinary unfounded belief is the accompanying cognitive deficit.

This is not a cognitive deficit that shows up on an IQ test. This is rather a more subtle and complex social information processing deficit. It is a deficit in the ability to stay grounded in this social moment including having a governing awareness of the effect we are having on others and of the consequences of what we say and do. It is this deficit that differentiates the disheveled man ranting about God on the street corner and the Jehovah’s witness knocking politely on my door.

Schizophrenia is a brain illness for which we have effective treatment.

And as Marvin points out, stigma is not reduced by railing against it. When the subject of the stigma is a frightening illness, stigma is reduced by naming that illness, understanding that illness, and ensuring that it is treated.

Time to Relegate Anti-Stigma to the Garbage Heap

By Marvin Ross

I am so terribly tired of all the effort and money spent on fighting the stigma of mental illness. I don’t really think it is that much of a problem. What is a problem is discrimination – the fact that mental illness does not get the health funding that it should when compared to other illnesses. There is a lack of beds, a lack of community supports, a lack of support for family caregivers and I could go on.

I feel a bit like Howard Beal did in the classic 1976 film written by the brilliant Paddy Chayevski and I am mad as hell. His famous line can be seen here

A couple of things have set me off. The first was the appointment to the Order of Canada of Professor Heather Stuart who holds the Bell Mental Health and Anti-Stigma Chair, the world’s first anti-stigma research chair at Queen’s University in Kingston, Ontario. I’ve met Heather, have corresponded with her a number of times, and years ago I backed her getting a grant from the Schizophrenia Society of Ontario to conduct a study of stigma by health professionals against those with schizophrenia so I’m pleased for her to win recognition. Sadly, her efforts to promote anti-stigma do not improve the treatment for anyone.

As an advocate in Kingston Ontario continually tells me, the streets of downtown Kingston are filled with ever increasing numbers of obviously untreated mentally ill. Maybe Heather should get off her endowed chair and try to get them some help.

The other event this week was told to me by a Toronto advocate who notified me of a bioethics lecture at the University of Toronto entitled Reflection on Mental Health Stigma, Narrative, and the Lived Experience of Schizophrenia (you have to activate Adobe Connect to see it). The presenter was a PhD candidate in philosophy at York University in Toronto.

To his credit, the lecturer admits the existence of anasognosia and that people with schizophrenia do have cognitive deficits. However, he suggests that many people fear those with schizophrenia. I think many of us do if they are not treated and are in active psychotic states. He does seem to suggest that doctors should accept the delusions that people have and not ignore their lived experiences. He also suggests that people are told that there is no recovery.

What he did not seem to differentiate between was treated versus untreated and that is crucial. It is true that recovery to a totally healthy state is not normally possible but many people can and do recover to live as reasonable lives as possible. And some don’t. That is the reality.

The notion that people fear those with schizophrenia and distance themselves needs to be qualified. Maybe some do but they are not in the majority. Those people will also fear and distance themselves from people diagnosed with cancer or some other serious and chronic ailment. They are not in the majority. Most people are sympathetic and many will tell you of relatives or friends who also suffer. Despite some tragic examples involving the police, the majority are incredibly sympathetic and understanding.

I remember one case years ago when a man with schizophrenia took off (as often happens) and the police found him miles away from his home. As he was over 21 and not declared incompetent, the police could not take him back to his family but the officer phoned his father 3 hours away and told him he would keep an eye on his son till the father got there. He did, provided cell phone updates and kept it up even when his shift ended so the family could be reunited.

When David Dawson was shooting his feature film on schizophrenia, Cutting For Stone, we needed a police cruiser in the middle of the night for one scene. Two cruisers showed up for us and one of the cops commented that if any group needed more exposure it was people with schizophrenia.They were happy to accommodate (available on Amazon for streaming) and I got a chance to ride in the front with the sirens blaring.

Many people with schizophrenia are willing to expose themselves to the public by telling their stories in books. Many of them I’ve published thanks to the willingness of people like Sandra Yuen MacKay, Erin Hawkes-Emiru, the late Dr Carolyn Dobbins, and Sakeena and Anika Francis. Others have done the same in books and blogs like Christina Bruni, The Unashamed Schizophrenic and others. Some have exposed themselves in documentaries like the ones in the film The Brush The Pen and Recovery directed by David Dawson (available on Amazon for streaming).

The same goes for those with bipolar disorder like Victoria Maxwell and many others including a new book called Mad Like Me. This one was originally submitted to me but I turned it down for a number of reasons. The author, however, did take some of my suggestions, rewrote it and had it published. Or, a book that I reviewed in these pages called Shatterdays Bipolar Lives

I often receive requests from people with schizophrenia offering to tell their stories as I did last night from a gentleman in California. His e-mail to me stated “I have been contemplating writing this manuscript for several years,and have decided to now ,because I feel there is no shame in having a mental illness, as it is no different than having a disease such as Epilepsy. I wrote this book to be in an advocate/activist position to be able to speak for those who cannot. If my book, my story, can help just one person, one family, it will have been more than worth the effort of writing it.”

I think it would be well worth it for mental health agencies to run writing workshops for people with mental illnesses.

But, let me circle back to the issue of stigma. Who in their right mind would not be fearful of a dishevelled ranting, untreated schizophrenic wandering down the street. I almost hit one the other day when he suddenly walked out into the traffic of a busy street impervious to the traffic.

The best solution to this stigma was offered by Dr Stuart’s partner, the psychiatrist Julio Arboleda-Flórez, He wrote:

The lesson to be drawn from these papers is simple: helping persons with mental illness to limit the possibilities that they may become violent, via proper and timely treatment and management of their symptoms and preventing social situations that might lead to contextual violence, could be the single most important way to combat the stigma that affects all those with mental illness. While most myths about mental illness can be traced to prejudice and ignorance of the condition, enlightened knowledge does not necessarily translate into less stigma unless both the tangible and symbolic threats that mental illness poses are also eradicated. This can only be done through better education of the public and of mental health service consumers about the facts of mental illness and violence, together with consistent and appropriate treatment to prevent violent reactions. Good medication management should also aim to decrease the visibility of symptoms among patients (that is, consumers) and to provide better public education programs on mental health promotion and prevention.