Best-Practice Assessment and Treatment of SMI in Adolescents

1. Best-Practice Assessment and Treatment of SMI in Adolescents Michael G. McDonell, Ph.D. Acting Assistant Professor Department of Psychiatry University of Washington School of Medicine mikemcd@u.washington.edu

2. Tax induced psychosis

3. SED Children Any Disorder + Level of Impairment SMI Adults Schizophrenia Bipolar MDD Axis II? SED-SMI (Alphabet Soup)

4. Why talk about SMI in Adolescents? • Disorders often present in adolescence/early adulthood • They present unique challenges to the child mental health system and child/adolescent clinicians • Focus on psychotherapy rather than case management in the youth system • Little expertise in treating these disorders in child/adolescent clinicians • Current controversies make treatment challenging • Diagnostic uncertainty • Disagreement about diagnostic criteria for children • Little data on diagnostic stability (e.g. bipolar disorder) across time • Little awareness of available treatments

5. SMI Assessment and Diagnosis Occam’s Razor: its horses not zebras • Rare cases are usually explained by • Simplicity: simplest explanation • Most reasonable: most common/obvious explanation. • SMI (bipolar & schizophrenia) is a zebra • Other childhood disorders are horses • Assessment is a process of Ruling Out other disorders

6. Prevalence of Adolescent Onset Schizophrenia • Adult onset Schizophrenia • Lifetime prevalence of 1% • Onset mid 20-30s • Females 5 year later onset (Loranger, 1984) • Adolescent Onset: Onset <18 yoa • Rare: < 15 yoa (14/100,000) • Very EOS (VEOS) < 12 years of age • Extremely rare: (1.6/100,000) • Mostly males

7. Adolescent Onset Schizophrenia Symptoms (McDonell & McClellan, 2007) • Symptoms • Positive symptoms (more common in older adolescents) • Hallucinations • Delusion: organized delusions less common • Thought disorder • Loose associations • Illogical thinking • Impaired discourse skills • Less common: incoherence and poverty of speech/thought • Negative symptoms • Impaired social functioning, typically a change from previous functioning • Decreased self-care, motivation

8. Onset/course • Onset: • Prodromal phase • Acute onset vs. Insidious onset • Course is typically episodic and chronic

9. Best practice assessment (McDonell & McClellan, 2007) • Multi-method/multi-informant assessment • Comprehensive medical exam • Record review • Medical, psychiatric, educational • Clinician administered structured interview • With youth and parent • Mental status exam/observation • Data from collaterals (including school) • TIME, TIME, TIME

11. Epidemiology of Early Onset Bipolar Disorder (EOBD) • Adult Prevalence • Lifetime prevalence of • Bipolar I = 0.4% to 1.6% • 0.5% Bipolar II (APA, 2000) • ~ 6 % when including sub-threshold or “spectrum” cases (Judd and Akiskal, 2003) • EOBD Estimates vary widely • .6-22% (Yongstrom, 2007) • Its appears to be a US phenomenon • Onset??? • 50% of adults report first symptoms <18 yoa (Kessler et al, 1997) • Depressive symptoms typically precede mania

12. Symptoms that may differentiate based on research (Yongstrom, 2007) • Elated mood: extreme, impairing, situation inappropriate, episodic • Grandiosity: episodic and associated with mood • High energy: MUST be episodic, not hyperactivity • Decreased need for sleep, not insomnia • Mood swings: intense, with longer periods, beyond what is developmentally appropriate • Hypersexuality: R/O abuse • LOW ability to differentiate: Irritable and distractibility • Assessment: very similar to assessment of EOS • Mood diaries also helpful • Monitoring over time is important

13. Just thinking about evidence based treatments gives me a headache…

14. Treatment of SMI in adolescents • There are few empirically supported treatments for this population • Most treatment options are based on evidence based adult approaches

15. Evidence based/informed txs for SMI in adolescents 1. Psychiatric medications: 1st line treatment, but have serious side effects with less (or more recent) evidence of efficacy, relative to adult populations. 2. Multi-informant monitoring and case management 3. Specific psychosocial interventions • Family psychoeducation (Miklowitz, Fristad, others) • Other promising approaches • Dialectical behavior therapy (DBT) • Self-harm • Emotional dysregulation • Interpersonal and social rhythm therapy for bipolar disorder (Stephanie Hlastala, Ph.D, Seattle Children’s/UW)

16. Family psychoeducaton and support interventions • Best-practice for adult schizophrenia and bipolar disorders • Have been adapted and demonstrated efficacy for adolescents with mood disorders • Focus is on: • Education about the causes, triggers of relapse, and treatments • Patients and families bring their expertise to treatment and become “experts” in the treatment of SMI. • Modification of family response to the illness to improve communication (expressed emotion) and improve problem solving • Goal: to prevent relapse and achieve and maintain recovery • Duration: from 16 weeks to 2 years • Individual family (Miklowitz bipolar disorder) (Falloon schizophrenia) • Multiple family groups (Fristad bipolar disorder) (McFarlane schizophrenia)

17. Family focused therapy for adolescents with bipolar disorder (Miklowitz et al., 2008) • Adaptation of his adult model • 21 single family sessions over 9 months • Family psychoeducation (7-10 sessions) • Develop family understanding of bipolar disorder • Formulate a family relapse prevention plan • Remaining sessions focus on • Communication training • Problem solving skills training

18. Multiple family group treatment (MFGT) for schizophrenia (McFarlane, 2002) • Designed for adults, but applicable to adolescents with EOS • Delivered by 2 clinicians to 5-8 families over 2 years • 4 phases • Joining (3-4 sessions) • Psycho-educational workshop (1 day) • Relapse prevention (24 sessions) • Social and vocational recovery (12 sessions) • Relapse prevention is promoted through • Family guidelines (set of science based principles for relapse prevention) • Problem solving skills for preventing relapse

19. MFGT Family Guidelines • Go Slow • Keep It cool • Give each other Space • Keep It Simple • Lower Expectations Temporarily • Pick Up on early Warning Signs • Set Limits • Ignore What You Can’t Change • Follow Doctor’s Orders • No Street Drugs and Alcohol • Solve Problems Step by Step • Carry on Business as Usual

20. Typical MFGT problem solving session Structure • Initial Socializing 15 minutes • Go Around 30 minutes • Select a problem to work on 5 minutes • Solving a problem 35 minutes • Final Socializing 5 minutes

21. Why might DBT work for SMI adolescents? • In SMI populations • Suicide and attempted suicide risk is high • Emotional dysregulation is a primary symptom of bipolar disorder and also an issue in schizophrenia • Interpersonal skills are impacted by SMI • Developmentally adolescents are more likely than others to have • Higher rates of suicidality • More difficulties with emotion regulation & interpersonal difficulties • Engage in other problematic risk taking behaviors (e.g., drinking/drug use, unprotected sex)

22. Adolescent DBT goals and tx targets • Goals: • Reduce Suicidal and non-suicidal self-injurious behaviors • Improve emotional regulation and interpersonal skills • Improve quality of life • Targets: • Decreasing life-threatening behaviors • Suicidal behaviors • Non-suicidal life threatening behaviors • Decreasing therapy-interfering behaviors • Not completing homework/attending appointments on time • Decreasing quality of life-interfering behaviors • High risk impulsive behaviors • Increasing behavioral skills • Interpersonal skills • Distress tolerance skills

23. Child DBT model (Miller et al, 2007) • Orientation and assessment (2 sessions) • Pretreatment/orientation and commitment stage (varies in length) • 1st Phase (16 weeks) • Individual therapy (reducing self-harm, treatment interfering behaviors, supporting skills learned in group) • Multiple family skills group (adolescent & family) • Phone consultation (adolescent = ind. therapist, family = group therapist) • Family sessions (as needed) • Team meetings (weekly) • Graduate group (16 week modules) • Graduate group (adolescents) • As needed: Phone consultation, individual therapy, family sessions, other non-DBT treatments

24. Evidence for DBT in adolescents • No randomized trials have been completed investigating DBT efficacy in adolescents. • Inpatient/residential treatment studies • Reductions in self harm, re-hospitalization, behavior problems (Katz et al. 2004; McDonell et al., in press; Rathus & Miller, 2002; Trupin et al. 2004 ) • Outpatients • Bipolar youth (Goldstien et al. 2007) • 1 year of treatment • Improved suicidality, emotional regulation and depression in 10 pilot patients.

25. Now what should I do? • Perform an accurate assessment and monitor individuals over time • Treatment • Medication management • Effective case management/coordination of care • Multidisciplinary team • Adolescent and family are an active part of the team • Consult with experts in our area • Integrate evidence based psychosocial treatments into your practice • Some tx are easier to learn/adhere to than others • Get ready for transition to adulthood • Many young do not engage in the adult mental health system

26. Resources • Assessment • Mash, E.J. & Barkley, R.A. (2007) Assessment of childhood disorders, 4th Edition. Guilford Press: New York. • AACAP (2007). Practice parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 46(1):107-125. • Treatment • McFarlane, W. R. (Ed.). (2002). Multiple family groups in the treatment of severe psychiatric disorders. New York: Guilford Press. • Miklowitz, D. (2007). The Bipolar Teen: What You Can Do to Help Your Child and Your Family. Guilford Press: New York. • Miller A.L., Rathus J.H., & Linehan M.M. (2007). Dialectical behavior therapy with suicidal adolescents. Guilford Press: New York.