Adolescent Mental Health Importance of Early Screening and Intervention

1. Adolescent Mental HealthImportance of Early Screening and Intervention Melanie Baca, MD April 3, 2019 Family Medicine Resident School

2. Objectives: -Demonstrate some understanding of Adolescent Mental Health trends in Bernalillo County and NM -Be familiar with screening tools used to dx Adolescent Depression and Adolescent Anxiety -Be familiar with treatment strategies for Adolescent Depression and Adolescent Anxiety -Be able to facilitate transfer/safety plan for actively suicidal patients

3. What is different about the Adolescent Brain • Sensitive period of development > sensitivity to stimuli • Don’t have full maturation of the frontal lobe (social skills) • -Inc. sensitivity to social cues, peer influence -significant rewards and threats - -sensitive to social rejection HIGH vulnerability

4. Different Types of Depression • Dysthymia- mild, chronic, feels a little down >1yr • Major Depression (Clinical) –severe, functional impairment, not enjoying life • Adjustment disorder with Depressed Mood – life stressor 3 m • SAD – change in seasons • Premenstrual Dysphoric Disorder - menses • Depression associated with Bipolar - have mood with extreme ups and downs • * Depressive disorders have been separated from bipolar and related disorders in the DSM-5

5. DEPRESSION: Why Should we Screen?

6. Females are at higher Risk

7. Other High Risk Adolescent Groups - LGB

8. Other High Risk Adolescent Groups - Homeless

9. Other High Risk Adolescent Groups – Native American

10. Why are rates so High?

11. Sleep -Media Use = later bed time, shorter duration -Teens need more sleep (9.25 hours), ave. 7.25 -25% <6 hours -Hormones released affected by sleep -Earlier bedtimes reduce rates

12. Bullying – Online or Face to Face • 20% bullied at school • Higher for LGB • inc risk for Dep/ SI • Cyber bullying – 20% victims • F and sexual minorities at higher risk • Inc risk of SI • CDC 2014 MMWR Surveillance summaries, CDC YRBS Results

13. What is different about Adolescent Depression (vs. Adults)

14. Unique Signs in Teenagers • Insomnia, daytime sleepiness • IRRITABILITY • Concentration issues • HA, stomach aches • Anxiety, worry, trouble relaxing (Anxiety) • Binge eating • NSSI • Risk Taking • Substance abuse • Risky sexual behaviors

15. DEPRESSION Screening Recommendations: • The USPSTF recommends screening for major depressive disorder (MDD) in adolescents ages 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. B Grade • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children age 11 years and younger. I Statement

16. Screening for Adolescent Depression • GLAD-PC • 2009 USPSTF endorsed universal adolescent depression screening in teenagers ages 12 to 18 years. • PHQ-2, if +… • PHQ 9 (aka PHQ-A) modified for teens

17. Gen Screen=SHQ

19. 89.5 % sensitive 78.8% specificity 21.2% false + 10.5 % false neg MDD >2 weeks of depressed mood/ LOI + functional impairment in social, occupational or educations settings

20. An Adolescent has a + Depression Screen, now what… • Help them deal with crisis • Manage life • Create sense of safety and hope • Create rapport – BOND • Start with helping them regulate their emotions and sleep • “Its not your fault, you're not alone, your reactions are normal, your emotions will change, have hope”

21. Depression Treatment • Psychotherapy (EBT are CBT, IPP or DBT), pharmacotherapy, or both • moderate to severe unipolar major depression, med + psychotherapy fluoxetine – only FDA approved med) plus cognitive-behavioral therapy (CBT) • If no improvementtry another SSRI– sertraline, Lexapro, ?Wellbutrin • same regimen be continued for at least 6 to 12 months

22. Resiliency Factors • Having a caring friend • Having rules at home • Caring adult in their life • Parent/Adult who is interested in their school work • Involved with activities, clubs, sports

23. For patients who don’t want to see a psychologist

24. HelpGuide.Org – Patient and Parent Guides for Depression

25. At follow up…

26. Adolescent Anxiety: Why Should we Screen? • Nearly one in three adolescents (31.9%) will meet criteria for an anxiety disorder by the age of 18 = MOST COMMON PSYCH D/O • ONLY 18% are tx • Specific phobia: 19.3% • Social phobia: 9.1% • Separation anxiety: 7.6% • PTSD: 5.0 % • Panic disorder: 2.3% • Generalized anxiety disorder: 2.2%

27. Anxiety : F>M • Social phobia: 11.2% females, 7.0% males • Specific phobia: 22.1% females, 16.7% males • Panic disorder: 2.6% females, 2.0% males • PTSD: 8.0% females, 2.3% males • Separation anxiety: 9.0% females, 6.3% males

28. What is different about Adolescent Anxiety (vs. Adult Anxiety) • Physical/somatic symptoms (stomach aches or HA) • Behavior issues (defiant behavior at home) • Common: school avoidance 2/2 social phobia

29. DDX: • Often co-occur with: • depression, Eating D/O, ADHD • R/O: • Hyperthyroid, migraines, learning disability, psychotic d/o, DM • Medication S.E. (asthma med) • Diet – caffeine (sports drinks, energy drinks, coffee), not eating regular meals

30. Screening for Adolescent Anxiety

31. An Adolescent has a + ANXIETY Screen, now what…Differentiating Type of Adolescent Anxiety

32. Prior to Treatment - What Type of ANXIETY? • Specific phobia • Social phobia • Separation anxiety • PTSD • Panic disorder • Generalized anxiety disorder

33. Treatment for Anxiety • PSYCHOTHERAPY: • Psychoeducation - PCP • Relaxation techniques - PCP • Exposure therapy/ systemic desensitization • CBT

34. Medical Treatment: • Per Walkup et al from Child/Adol Anxiety Multimodal study ~500 children 7-17 • BEST Combo Sertraline and CBT • Other RCT : Fluoxetine, Fluvoxamine, paroxetine and sertraline to be best • Other options–Citalopram, venlafaxine, nortriptyline, imipramine, doxepin

35. Follow up if on medication • children prescribed a medication should meet with the prescribing clinician: • Weekly for the first four weeks • Biweekly beginning the second month • Monthly beginning the third month (ie, 12 weeks following the start of medication) • DISCUSS BLACK BOX WARNING

36. After a positive Screen – Tool for Follow up

37. Dx for Teens = Adjustment D/O… with depressed mood/with anxiety • Charting concerns • Stigma of diagnosis • Extreme stress can cause adjustment disorder • yytFamilyhistory and genetics also play a role. Symptoms vary from insomnia, depressive mood, anxiety, and loss of appetite. Psychotherapy is the most common treatment; mood stabilizers and anti-anxiety drugs are helpful.

38. Why Should we Screen? • When left untreated, anxiety disorders starting in childhood tend to persist into adulthood, and are frequently associated with depression, substance abuse, occupational impairment, and suicidal behavior

39. Protocol For Dealing with Suicidal Teen In Clinic • Assess RISK • Columbia-Suicide Severity Rating Scale (C-SSRS) • DO NOT LEAVE PATIENT ALONE! • Initiate transfer to Mental Health • Stay engaged until warm hand off is made

40. Take Home Points • Genes and environment shape the brain and increase risk for MH disorders • Adolescence is a unique window – opportunity – brain is plastic and adaptive to changes with environment • There are many useful tools to aid in dx of adolescent mental health issues

41. Resident School Evaluation Form