Adolescent Psychiatry in General Practice

1. Adolescent Psychiatry in General Practice Anne Stewart Consultant Psychiatrist Oxford

2. Adolescent Development Definition of adolescence wide Time of change (physical, cognitive, emotional, social) Time of conflict Most adolescents cope Importance of earlier life experience Interactions between the context and the individual

3. Developmental tasks of adolescence Adjusting to biological changes Establishing relationships Developing skills Developing identity Achieving autonomy

4. Prevalence 10 - 15% of adolescent population Early detection and intervention is encouraged PCAMHS has developed to provide early intervention Severe cases referred on to Specialist CAMHS

5. Remodelling of services(Every child matters/NSF) More emphasis on community based rather than clinic based Importance of engaging young person and family Increase in outreach services and support workers Close links with schools (PCAMHS) Emphasis on safe care management (CPA approach � for complex patients) PCAMHS � first point of referral (apart from urgent/emergency) Establish shared understanding of young person�s emotional, behavioural and mental health needs (CCR)

7. Local Services CAMHS Oxford City, Banbury, Witney, Abingdon Children, young people and families department (SW, mentor system, foster care, residential homes) Education (ESW, EdPsych, Connexions, Behavioural Outreach Team) See-Saw PCAMHS YOT Face to face counselling/school counselling Inpatient units � JR Adolescent Unit, Highfield Drug and alcohol services (Evolve)

8. Risk factors for child and adolescent psychiatric disorder Factors in the child Factors in the family Factors in the environment

9. General aspects of consultation Engagement Time Respect Observation Confidentiality

10. Case scenario 1 13 year old boy Refusing to go to school Withdrawn, at home, unhappy Complains of feeling sick frequently in the morning Sleeping poorly Parents do not know what to do

11. Possible causes of low mood Physical illness Problems at school Problems at home Psychiatric disorder

12. Features of depression in adolescence Affective symptoms (low mood, anxiety, agitation, lack of pleasure, suicidal ideas) Cognitive symptoms (poor concentration, difficulty in coping with school work, poor memory) Behavioural symptoms (social withdrawal, irritable behaviour, slowing of movement) Motivational symptoms (bored, unmotivated) Vegetative symptoms (poor appetite, weight loss, sleep disturbance) Somatic complaints Psychotic symptoms (hallucinations, ideas/delusions of worthlessness/guilt)

13. Assessing the severity of depression in primary care (NICE) Key symptoms Persistent sadness or low mood Loss of interest and/or pleasure Fatigue or low energy Associated symptoms Poor or increased sleep Poor concentration or indecisiveness Low self confidence Suicidal thoughts or acts Agitation or slowing of movements Guilt or self blame Mild depression � 4, Moderate depression � 5 or 6 Severe � seven or more, with/without psychotic features

14. Assessment for depression Consider current context (school/home) Experience of being bullied, abused Quality of family relationships Potential co-morbidities (e.g. anxiety, psychotic illness, learning disability) Current physical health Alcohol and drug use Family background or current mental health problems in parents Self harm, ideas about suicide

15. Management (stepped care model) Early detection of symptoms (Tier 1) Recognition of depressive disorder (All tiers) Mild depression (Tier 1 or 2) Moderate to severe (Tier 2 or 3) Unresponsive depression (Tier 3 or 4)

16. Management in primary care Detection of depression Risk profiling �Watchful waiting� (up to 4 weeks) Supportive therapy/general advice Enlisting family support Self help literature/websites (as part of a planned package of care)

17. What can you do in a short consultation? Engaging adolescent Providing continuity Brief family consultation Understand triggers and maintaining factors Problem solving Life style advice (diet, sleep, exercise) Activity scheduling Relaxation techniques Provide information (self help, web sites) Using CBT principles in general practice Confidentiality issues Young person�s rights/family�s responsibility

18. Referral to Tier 2/3 Multiple risk factors Depression where one or more family members have multiple-risk histories for depression Low level of social support Moderate or severe depression Signs of recurrence of previous depression Unexplained self-neglect - at least 1 month No response (after 2-3 months) to management for mild depression Active suicidal ideas or plans Urgent referral if significant ongoing self neglect and/or high recurrent risks of acts of self harm/suicide

19. Summary of NICE Guidelines, 2005 Treatment Anti-depressant medication should not be used for the initial treatment of mild depression Moderate- severe depression - psychological therapy first line (CBT, IPT or short term family therapy) - at least 3 months Anti-depressant medication only in combination with psychological therapy (unless young person declines). Fluoxetine first line. Careful monitoring Long term follow-up needed (for two years) Use of ECT very rare for life threatening conditions

20. Case Scenario 2 14 year old girl Poor eating Moody, irritable Loss of weight

21. Prevalence of eating disorder 1-2% of adolescent girls have eating disorder 13% have serious eating control problems or over-concern about weight and shape 40-50% diet at some point Those that diet are at increased risk of eating disorder

22. Anorexia nervosa Weight loss of at least 15% or failure to gain weight Attempts to lose weight Intense fear of gaining weight Disturbance of the perception of weight and shape Hormonal disturbance

23. Bulimia nervosa Recurrent episodes of binge eating Recurrent compensatory behaviour (e.g. self-induced vomiting, laxative misuse, diuretics, fasting, excessive exercise) Self-evaluation unduly influenced by body shape and weight

24. EDNOS/atypical eating disorders Eating disorder of clinical severity Not meeting diagnostic criteria for AN or BN NB this is the most common eating disorder

25. How does anorexia nervosa develop?

26. Early intervention in general practice Regular monitoring of weight Calculation of minimum target weight Dietary advice, provision of education and information Motivational approach Support to individual Encourage family to take it seriously, work together and enable their daughter /son to improve eating Early referral if no change

28. Motivational approach Therapeutic stance Techniques

29. Treatment approach in CAMHS Family-based work Individual therapy Parent groups Inpatient/daypatient Close links with GP very helpful

30. Case Scenario 3 16 year old boy Parents ring urgently from home Behaving oddly Talking in a bizarre way about his special powers Hardly slept for last couple of nights Eating poorly Aggressive if asked to do anything

31. Compulsory treatment MHA Section 2 for assessment 4 weeks (GP, ASW and Psychiatrist) Section 3 for treatment 6 months (GP, ASW and Psychiatrist) Parental consent Children Act MCA

32. Causes of psychosis in adolescence Drug induced Depressive psychosis Mania Bipolar disorder Organic psychosis Schizophrenia Stress induced psychotic episode

33. Case scenario 4 14 year old girl Recent viral infection Tired, low in mood Not wanting to go to school Becoming increasingly inactive

35. Management of chronic fatigue Exclude treatable physical illness Treat depression if present Psycho-education Behavioural approach � graded exercise Refer on if problems persist CBT has good evidence basis

36. Case scenario 5 15 year old girl Parents ring up from home Daughter has taken overdose of 10 paracetamol

37. Risk factors for repetition of self harm Characteristics of recent attempt Current and lifetime suicidality Negative life events Psychiatric disorder (depression, substance misuse) Psychological characteristics (hopelessness, impulsivity, aggression, poor problem solving) Gender Family factors (family dysfunction, abuse, psychiatric disorder) Social/community circumstance Availability of lethal agents

39. Risk assessment following self harm P Have you had problems for longer than a month? A Were you alone in the house at the time? T Did you plan the overdose for more than three hours HO Are you feeling hopeless about the future? S Were you sad for most of the time before the overdose?

41. Assessment of suicidal risk Identify triggers (? Still operating) Assess characteristics of the attempt (suicidal intent, lethality, motivation) Current mental state and suicidal intentions (? Mental illness) Identify risk factors (social/family/individual) Access to lethal agents Identify current supports/protective factors

42. Outcome following admission for self harm Limited follow up by self harm service (Barnes Unit) Referral to PCAMHS or other agencies Referral to Specialist CAMHS Discharge back to GP Review/monitoring Problem solving Encourage supportive peer relationships Promote coping strategies and taking responsibility Encourage support from family Promoting help seeking Involvement of Social and Health Care if abuse

43. Case Scenario 6 16 year old Attends with flu-like symptoms On examination, you notice multiple scars on both arms

44. Who self-cuts? Borderline personality traits Learning disability and organic conditions Psychotic illness Severe depression Habit in young people who are otherwise well adjusted (may be influenced by peers) Those in institutions (e.g. adolescent unit, prison)

47. Case scenario 7 15 year old boy Mother drags a reluctant teenager Difficult behaviour, unco-operative, swears, rude at home, aggressive to younger siblings, lack of interest in school work, lazy, stays up late. Mother feels �there must be something wrong with him�

48. Case scenario 8 13 year old boy Constantly washing his hands and checking the light switches Parents have tried to talk him out of it but unsuccessful Gets extremely anxious if he cannot check On occasions gets his mother to check things for him

49. Obsessional compulsive disorder in adolescents Obsessional thought Compulsive behaviour Management

50. Case study 9 14 year old boy Increasingly low in mood Has no friends Spends a lot of time on the internet Has found it hard coping with move to a new school when the family moved Parents are concerned about him

51. Diagnosis of Aspergers Qualitative impairment in social interaction Restricted, repetitive, stereotyped patterns of behaviour, interests and activities Usually normal IQ and language development (unlike autism) The disturbance causes significant impairment in social/educational/occupational functioning Can become obvious in the adolescent years Co-morbidity with depression, anxiety, OCD, psychosis

52. Management in general practice Refer on for diagnosis Encourage access to self help groups Be alert to co-morbidities

53. Any other scenarios?