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PSP Child and Youth Mental Health Learning Session 2 © 2012 British Columbia Medical Association and Dr. Stanley P. Kutcher. Health educators and health providers are permitted to use this publication for non-commercial educational purposes only. No part of this publication may be modified, adapted, used for commercial or non-educational purposes without the express written consent of the BCMA and Dr. Kutcher. www.pspbc.ca Agenda Sharing and Learning from the Action Period Identify, assess, treat and manage children and adolescents for Anxiety Identify, assess, treat and manage adolescents for Depression Medications for Depression / Anxiety MOA role (to be created by PSP Coordinators) Planning for the Action Period 2 Faculty/Presenter Disclosure Speaker’s Name: Speaker’s Name Relationships with commercial interests: - Grants/Research Support: PharmaCorp ABC - Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd - Consulting Fees: MedX Group Inc. - Other: Employee of XYZ Hospital Group 3 Disclosure of Commercial Support This program has received financial support from [organization name] in the form of [describe support here – e.g. educational grant]. This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support]. Potential for conflict(s) of interest: - [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. - [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [enter generic and brand name here]. 4 Mitigating Potential Bias [Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to “Quick Tips” document 5 Sharing the Learnings from the Action Period 6 CYMH Roles & Referrals 7 Mental Health Screening Q’s 1. Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? › If YES – consider a depressive disorder › Apply the KADS evaluation 2. Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? › If YES – consider an anxiety disorder › Apply the SCARED evaluation › Proceed to the Identification, Diagnosis and Treatment of Child and Adolescent Anxiety Disorders Module 8 Mental Health Screening Q’s 3. Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? › › › If YES – consider ADHD Apply the SNAP-IV evaluation Proceed to the Identification, Diagnosis and Treatment of the Child and Adolescent ADHD Module www.freedigitalphotos.net by Boaz Yiftach 9 Mental Health Screening Q’s 4. There has been a marked change in usual emotions, behaviour, cognition or functioning (based on either youth or parent report) If YES – probe further to determine if difficulties are on-going or transitory. Consistent behaviour problems at home and/or school may warrant referral to Strongest Families. www.freedigitalphotos.net by Boaz Yiftach 10 Adolescent Major Depressive Disorder (MDD) 11 www.Dreamstime.com 1345216 Depression Screening Question 1. Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? › If YES – consider a depressive disorder › Apply the KADS evaluation Key Steps for Treatment of MDD in Adolescents 1. 2. 3. 4. 5. 6. Identification of youth at risk for MDD Screening & diagnosis in the clinical setting Treatment template Suicide assessment Contingency planning Referral flags www.dreamstime.com 310430 Step 1: Major Depressive Disorder in Youth Risk Identification Table Well established and significant risk effect Less well established risk effect Possible “group” identifiers (these are not causal for MDD but may identify factors related to adolescent onset MDD) 1. Family history of MDD 1. Childhood onset ADHD 2. Family history of suicide 2. Substance abuse 3. Family history of a mental illness (especially a mood disorder, anxiety disorder, substance abuse disorder) 3. Severe and persistent environmental stressors (sexual abuse, physical abuse, neglect) in Childhood. 4. Childhood onset anxiety 4. Head injury (concussion) disorder 1. School failure 2. Gay, lesbian, bisexual, transsexual 3. Bullying (victim and/or perpetrator) Clinical Major Depressive Disorder Screening in Primary Care Who to Screen? Adolescents with: › Risk factors › Persistent low mood Recent onset › Academic problems/failure › Substance misuse › Suicidal ideation Refer to Risk Identification Table Stockxchng ID: 63460_4774 Methods for Clinical Screening & Diagnosis Kutcher Adolescent Depression Scale (KADS-6) Screen at clinical contacts Including contraception & sexual health visits Explain purpose of test & give feedback on results www.dreamstime.com ID:983365 KADS Score of 6+ 1st appointment Discuss issues in youth’s life & environment › Use TeFA – Teen Functional Activities Assessment Problem solving assistance › Use PST – Psychotherapeutic Support for Teens as a guide Strongly encourage and prescribe: Positive Social Activities Regulated Sleep KADS Score of 6+ 1st appointment (continued) Screen for suicide risk › Use TASR – Tool for Assessment of Suicide Risk › ‘Check-in’ 3 days following initial appointment Via telephone (3 – 5 mins.), text message or email If problems continue, book appointment ASAP www.freedigitalphotos.net by Zirconicusso KADS Score of 6+ 2nd appointment Mental health checkup › 15 – 20 minutes › 1 week from first visit › Include: KADS, TeFA, PST › Monitor suicide risk 3rd appointment Mental health checkup › 15 – 20 minutes › 1 week from 2nd mental health checkup › Include: KADS & TeFA › Monitor suicide risk www.freedigitalphotos.net by Nutdanai Apikhomboonwaroot Dreamstimefree 836493 MDD Highly Probable if… KADS scores remain at 6+ › For over 2 weeks › At each of the three assessment points Suicidal thoughts or self harm behaviors School, family or interpersonal functioning declines › Assess using TeFA If above occurs, on 3rd visit complete KADS-11 item › Five or more items score 2+ = diagnosis of MDD › Initiate treatment plan Visit 1 KADS TeFA Use PST and MEP CONTACT Visit 2 KADS TeFA Use PST and MEP CONTACT Visit 3 KADS TeFA Use PST and MEP If KADS is 6 or greater or TeFA shows decrease in function – proceed to steps 2 and 3 If KADS < 6 and TeFA shows no decrease in function – monitor again (KADS, TeFA) in two weeks – advise to call if feeling worse give instructions to call if suicide thoughts or plans or acts of self-harm occur - screen for depression TASR-A Phone, Email or Text If KADS remains > 6 or TeFA shows decrease in function – proceed to steps 4 and 5 If KADS < 6 and TeFA shows no decrease in function – monitor again (KADS, TeFA) in two weeks – advise to call if feeling worse – give instructions to call if suicide thoughts or plans or acts of self-harm occur. Phone, Email or Text If KADS remains > 6 or TeFA shows decrease in function – proceed to diagnosis (KADS 11) and treatment If KADS < 6 and TeFA shows no decrease in function – monitor again (KADS, TeFA) in two weeks – advise to call if suicide thoughts or plans or acts of self-harm occur Additional Psychosocial Interventions CBIS Depression CBT/IPT tools › Evidence based psychotherapies available (CBIS) › Application recommended – manual provided › Can be implemented at any time during the process › Education about medications should be added Dealing with Depression Confident Families:Thriving Kids Children aged 3 to 12 Physician referral No cost to patients Via telephone Operational hours include evening and weekend Table Discussion How can these tools fit into practice workflow? What about applicability to school or other practice environments? (for example screening tools) How can other team members use the information from these tools? How can information from other environments be used to complete them? How can team members in non-providers roles contribute to administration and completion of these tools? Childhood & Adolescent Anxiety Mental Health Screening Q’s 2. Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? › If YES – consider an anxiety disorder › Apply the SCARED evaluation › Proceed to the Identification, Diagnosis and Treatment of Child and Adolescent Anxiety Disorders Module Use of SCARED in Assessment Anxiety disorder is suspected: if score of 25 or higher 29 29 Visit 1 SCARED Function Use PST & MEP as indicated and as time allows CONTACT Visit 2 SCARED, Function. Use PST & MEP CONTACT Visit 3 If SCARED is 25 or greater (parent and/or child) or shows decrease in function, review WRP/Stress management strategies and proceed to step 2 in 1-2 weeks. If SCARED < 25 and/or shows no decrease in function, monitor again (SCARED) in a month. Advise to call if feeling worse or any safety concerns. Phone, Email or Text If SCARED > 25, and shows decrease in function, utilize PST strategies, review WRP and proceed to step 3 within a week. If SCARED <25 and shows no decrease in function, monitor again in a month. Advise to call if feeling worse or any safety concerns. Phone, Email or Text If SCARED remains > 25 or shows decrease in function, proceed to diagnosis (DSM-IVTR criteria) and treatment SCARED, Function. Use PST & MEP If SCARED <25 and shows no decrease in function, monitor again (SCARED) in one month. Advise to call if feeing worse or any safety concerns. Teen Anxiety Disorder is Suspected SCARED score is 25 or higher Discuss issues/problems in the youth’s life/environment. Teen Functional Activities Assessment (TeFA) Supportive, non-judgmental problem solving assistance – Psychotherapeutic Support for Teens (PST) as a guide Strongly encourage and prescribe: • Exercise • Regulated sleep • Regulated eating • Positive social activities Psychotherapy 32 Pharmacological Treatment of Adolescent Depression/Anxiety Disorder Children & Adolescents Psychosocial Interventions Cognitive Behavioural Therapy (CBT) www.freedigitalphotos.net by Master Isolated Images Medication Intro Psychotherapeutic Support Medication Intro > Provide rationale, expectations & education > Explain how medication works > Warn of potential side effects > Health Canada Warnings o Suicidal thoughts and behaviors > Provide timeline o Titration o Treatment response www.freedigitalphotos.net by Scottchan Do not rush into medication subscribing! Do not use to treat mild symptoms or for “usual” stress www.freedigitalphotos.net by Salvatore Vuono Antidepressants Not all anxiety or depressive disorders require medication Recommended first line treatment > Cognitive Behavioral Therapy Approach e.g. CBIS > Selective serotonin reuptake inhibitors (SSRI) oFluoxetine or Sertraline > If not tolerable refer child to mental health services Medication should not be used alone > Anxiety and mood management strategies ID 498987 stockxchng Antidepressants Combine with: CBT Support Education Self Help Strategies Wellness Activities Minimal evidence in < 7 yrs SSRI’s: > Fluoxetine > Sertraline Do not use alone Suicidal ideation & self harm behavior www.freedigitalphotos.net by Tungphoto 12 Steps to SSRI Treatment 1. Do no harm 2. Ensure diagnostic criteria are met 3. Check for other psychiatric symptoms/stressors 4. Check for other psychiatric symptoms/stressors 5. Check for agitation, panic or impulsivity 6. Check for family history of mania or bipolar 7. Measure patients current somatic symptoms before beginning treatment › Restlessness, agitation, stomach upset, irritability 12 Steps to SSRI Treatment 8. Measure the symptoms › Pay special attention to suicidality 9. Provide comprehensive information › About disorder and treatment options 10.Provide family and child with SSRI info › Side effects & timelines to improvement 11.Start with small test dose of medication 12.Slowly increase dose 13.Take advantage of the placebo response Rawich freedigitalphotos.net Initiating Pharmacological Treatment Fluoxetine > Best level one evidence > Do not use alone > May increase… o Suicidal ideation ??? o Self harm > Assessment of suicide risk ongoing www.freedigitalphotos.net by Zole4 Fluoxetine Treatment START LOW & GO SLOW Begin 5-10 mg/day for 1-2 wks (2.5-5 mg if significant anxiety symptoms) Liquid form: 2.5 – 5 mg/day; smaller increases Target dose 20 mg/day for min. 8 wks Expect continued improvement for a few months at same dose if initial response is positive Side Effects: If problematic cut increases back by 5 mg for 1 week and then add the extra 5 mg to dose. Discontinuation: Taper gradually over several months at low stress times Short Kutcher Chehil Side Effects Scale (sCKS) for SSRIs Item None Mild Moderate Severe Headache Irritability/Anger Restlessness Diarrhea/Stomach upset Tiredness Sexual Problems Suicidal Thoughts Self Harm Attempt Other problems Yes: No: If yes, describe: Was this a suicide attempt (attempt to die)? Yes: 1. 2. No: Three important side effects to look for when initiating treatment with SSRI’s are… Hypomania Suicidal ideation Suicidal behaviors Rare side effect 1. Decreased sleep 2. Increase in activity > Idiosyncratic/inappropriate 3. Increase in motor behavior (including restlessness), verbal productivity and social intrusiveness Discontinue medication Urgently refer to mental health services Family history of bipolar disorder ID 1319195 stockxchng May onset/exacerbate once medication is started but overall a substantial DECREASE > Stop medication immediately due to safety risk > Most common in first several months of medication ID 1209407 stockxchng Monitoring Treatment of Adolescent Major Depressive Disorder Tool Baseline Da y1 Day 5 Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 KADS x x x x x x TeFA x x x x x x sCKS x x x x x x x x x x x Monitoring Treatment of Anxiety Disorders Tool Baseline Day 1 Day 5 Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 SCARED x x x x x TeFA x x x x x sCKS x x x x x x x x o Children – SCARED & sCKS o Teens – SCARED, TeFA, sCKS x x x 8 Weeks* of Dosage 3 Possible Outcomes 3 Different Strategies ALWAYS CHECK ADHERENCE TO MEDICATION TREATMENT!!! OUTCOME 1 OUTCOME 2 OUTCOME 3 Patient not better or only minimally improved SCARED > 25 and little or no functional improvement Patient moderately improved SCARED < 25. Some functional improvement. Patient substantially improved. SCARED < 25 and major functional improvement. Strategy Strategy Strategy Increase medication gradually If medication is well tolerated, increase slightly Continue monitoring/interventions for 2 4 wks Reassess If no substantial improvement Refer Continue current dosage Gradually decrease visits; every 2 wks for 2 mths and then monthly Educate patients/caregivers on need to continue medications And identifying relapse Refer to Specialty Child/Adolescent Mental Health Services Continue weekly monitoring and all other interventions until consultation occurs (50-60% as determined from the TeFA) If medication or increase not well tolerated continue at current dosage with monitoring and intervention for 2 wks Reassess If no substantial improvement Refer. If first episode continue medications for 9- 12 mths. If discontinuing, choose a low stress period. Decrease gradually over 4-6 wks monitoring every 2 wks. “Well checks” every 3 mths If 2nd or further episode obtain mental health consultation on treatment duration Medication Adherence Checking Adherence to Treatment Predict non-compliance > Openly recognize probability o Missing one or more doses of medication > No need to feel guilty Occasional misses… …a little change in fluoxetine (long half-life) …a difference in missing sertraline (shorter half life) Michal Marcol freedigitalphotos.net Assessing Treatment Adherence 3 Methods 1. Enquire about medication use from child 2. Enquire about medication use from parent 3. Pill counts are sometimes useful If relapse occurs… Evaluate the following Compliance with treatment Medical illness Onset of stressors that challenge patient Onset of substance abuse Alternative diagnostic possibility • Depression, anxiety disorder, bipolar disorder Refer to mental health specialist if relapse occurs despite adequate ongoing treatment Action Planning Measures Aim Change Ideas Changes to try Identification and screening of children and youth Creation of a registry Treatment processes Team-based care - GP’s, Schools, other care providers Linking with community programs and supports Action period planning – team activity With your community team (e.g. GP, MOA, School Counselor, Mental Health Clinicians…), discuss what changes you will test in the action period Fill out the action planning form Write the PLAN for your first Plan, Do, Study, Act cycle When in doubt – Ask the Experts!