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Transcript
Dr Jonathan Lyons ST5 in CAMHS Ivry House, Ipswich CAMHS gender ratios Options: 1:10 1:6 1:4 1:2 1:1 2:1 4:1 6:1 10:1 Select the female to male ratios for the following conditions A. B. C. D. E. F. G. Autism Asperger’s Adolescent depression Tourette’s syndrome Child ADHD Bulimia nervosa Childhood (pre-13) depression Co-morbidity in adolescent depression Co-morbidity among moderate to severely depressed adolescents attending routine NHS services reaches which of the following: A. 10% B. 30% C. 50% D. 70% E. 90% Treatment in adolescent depression Treatment of adolescent depression brings forward onset of recovery when compared to naturalistic outcomes by which of the following: A: 1 to 2 weeks B: 2 to 6 weeks C: 4 to 12 weeks D: 12 to 20 weeks E: 16 to 24 weeks Recovery in adolescent depression Up to what proportion of clinic referred cases with moderate to severe depression will recover within 2-4 weeks of assessment and early intervention: A: 1% B: 5% C: 10% D: 20% E: 40% Standardised measures in child and adolescent depression Which of the following applies to the Mood and Feelings Questionnaire: A: It is clinician rated B: It is a measure of impairment C: It has only been validated in community samples D: There is a short and a long version E: It screens for common co-morbidities Age of onset and sex ratio tend to go together ◦ Neurodevelopmental disorders characteristically begin early in life and are much more common in males Emotional disorders beginning in adolescence tend to be much more common in females ◦ E.g. Depression and eating disorders In childhood rate of depression comparable in boys and girls Female predominance in mood disorders first emerges in adolescence Evidence to support view that depression in adults has origins in adolescence Depression much more common in adolescents than in children ◦ Prevalence in pre-schoolers unknown ◦ 6-11 year olds, 12 month prevalence rates around 0.5-0.75% ◦ Rates increase with age, reaching 2-4% for 12-18 year olds ◦ 3-4 Year 11s (15/16-year-olds) out of group of 100 will have an episode of depression in any one year period Using ICD-10 criteria: Approx. 50-60% of diagnosed cases in the mild category 40-50% moderate to severe Rates of underdiagnosis and undertreatment higher in adolescents than in adults ADAPT – at best 10–12% of all depressed cases reach a specialist CAMHS per year Treatment utilisation higher when adolescents present with co-morbid disorders Associated with raised risk of suicide (odds ratio 11 to 27) Suicide represents 3rd leading cause of death in this age group (aged 14-19 years) Must ask about this during assessment Why is this important? Affects functional outcomes: 1. o ↑ level associated social problems, academic problems and global role impairment Deleterious impact on: 2. o o o Duration of depressive symptoms Response to treatment Recurrence of depressive episodes The rule for adolescents ◦ up to 90% comorbidity for at least one additional disorder among moderate to severely depressed adolescents attending routine services Common: ◦ ◦ ◦ ◦ ◦ Disruptive behaviour disorders (20-40%) Anxiety disorders (30-75%) Eating disorders Substance misuse ADHD, PDD 20-50% have two or more comorbid diagnoses Some evidence depression in adolescence emerges after comorbid disorder Possible exception of substance abuse and conduct problems ◦ ? Complication of depression ◦ May persist after episode remits Pre-pubertal depression – probably 2 types; 1. Co-morbid behavioural problems, parental criminality, parental substance misuse, family discord – more common, without increased recurrence risk into adulthood 2. Highly familial, multi-generational loading for depression, high rates of anxiety and bipolar disorder, recurrences of depression in adolescence and adulthood Adolescence - untreated episode median 7-9 months Sub-group, ? 20–30% who untreated will have disorders that may last years Treatments bring forward onset of recovery when compared to naturalistic outcomes by perhaps 3–5 months In specialist clinic referred cases with moderate-severe depression: ◦ Up to 20% recover in the first 2–4 weeks of assessment and early intervention ◦ Further 60% are likely to recover in the next 12–28 weeks of treatment ◦ Significant sub-group of treatment resistant cases – in the region of 20% Some evidence adolescents more at risk for developing depression than in the past Individuals born in latter part of 20th century at greater risk for mild/moderate mood disorders, manifesting at a younger age Cumulative probability of recurrence: ◦ 40% by 2 years ◦ 70% by 5 years Criteria in adolescents same as for adults ◦ DSM-IV allows irritability instead of depressed mood in children and adolescents Thus clinical questioning approach in adolescents should be similar to that used in adults BUT primary presenting concern may be different, i.e. vital to look past it ◦ ◦ ◦ ◦ ◦ ◦ Behavioural problems Substance misuse Anxiety symptoms School refusal Academic failure Unexplained physical symptoms All significantly associated with adolescent depression (reported odds ratios 10 to 29) From CPD online module Must see child/young person yourself BUT helpful to question parent(s)/carer(s) Check whether symptoms associated with impairment Consider use of standardised measures: ◦ MFQ – validated in clinic and community samples, patient/parent-rated symptom scale, short and long version ◦ CGAS – clinician-rated, measure of impairment Mood disorder secondary to general medical condition Substance-induced mood disorder Bereavement Adjustment disorder Bipolar affective disorder Individual factors Family factors Environmental factors Predisposing PPH Possible LD Poor social Individual LD, factors Possible early network parental Family factors misattunement Precipitating Sense offactors Mother’s New school year Environmental responsibility for admission to Predisposing admission hospital Maintaining BMs Mother’s mental Social care input LD, PPH Erratic Adolescent desire illness declined for independence Tired father Strained Possible LD Degree of role working all the relationship with reversal with mum time school Possible early parental misattunement Brother with Poor social network additional needs Protective Wanting help Writes diary/draws Committed father School supportive Close relationship with TA CAMHS gender ratios Options: 1:10 1:6 1:4 1:2 1:1 2:1 4:1 6:1 10:1 Select the female to male ratios for the following conditions A. B. C. D. E. F. G. Autism Asperger’s Adolescent depression Tourette’s syndrome Child ADHD Bulimia nervosa Childhood (pre-13) depression Gender ratios: ◦ ◦ ◦ ◦ ◦ ◦ ◦ Autism 1:4 Asperger’s 1:6 Adolescent depression 2:1 Tourette’s syndrome 1:4 Child ADHD 1:2 Bulimia nervosa 10:1 Childhood depression 1:1 Co-morbidity in adolescent depression Co-morbidity among moderate to severely depressed adolescents attending routine NHS services reaches which of the following: A. 10% B. 30% C. 50% D. 70% E. 90% Treatment in adolescent depression Treatment of adolescent depression brings forward onset of recovery when compared to naturalistic outcomes by which of the following: A: 1 to 2 weeks B: 2 to 6 weeks C: 4 to 12 weeks D: 12 to 20 weeks E: 16 to 24 weeks Recovery in adolescent depression Up to what proportion of clinic referred cases with moderate to severe depression will recover within 2-4 weeks of assessment and early intervention: A: 1% B: 5% C: 10% D: 20% E: 40% Standardised measures in child and adolescent depression Which of the following applies to the Mood and Feelings Questionnaire: A: It is clinician rated B: It is a measure of impairment C: It has only been validated in community samples D: There is a short and a long version E: It screens for common co-morbidities Rates of depression rise sharply after puberty, especially in girls, with immediate and long-term risks Consider possibility of depression even when child/adolescent does not present primarily with mood symptoms Adopt rigorous approach to assessment – think developmentally Carefully monitor suicidal risk CPD online module on child and adolescent depression authored by Raph Kelvin Rutter’s Child and Adolescent Psychiatry, Rutter et al Major treatment trials (RCTs) for those interested: ◦ TADS (The Treatment for Adolescents with Depression Study) ◦ ADAPT (The Adolescent Depression Antidepressant and Psychotherapy Trial) ◦ TORDIA (The Treatment of Resistant Depression in Adolescents)