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.

2 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

3 Sharing the Learnings from the Action Period

4 CYMH Roles & Referrals

5 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 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

6 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 by Boaz Yiftach Mental Health Screening Q’s

7 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. by Boaz Yiftach Mental Health Screening Q’s

Adolescent Major Depressive Disorder (MDD)

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 Depression Screening Question

1.Identification of youth at risk for MDD 2.Screening & diagnosis in the clinical setting 3.Treatment template 4.Suicide assessment 5.Contingency planning 6.Referral flags Key Steps for Treatment of MDD in Adolescents

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 2. Family history of suicide 3. Family history of a mental illness (especially a mood disorder, anxiety disorder, substance abuse disorder) 4. Childhood onset anxiety disorder 1. Childhood onset ADHD 2. Substance abuse 3. Severe and persistent environmental stressors (sexual abuse, physical abuse, neglect) in Childhood. 4. Head injury (concussion) 1. School failure 2. Gay, lesbian, bisexual, transsexual 3. Bullying (victim and/or perpetrator)

Who to Screen? Adolescents with: › Risk factors › Persistent low mood  Recent onset › Academic problems/failure › Substance misuse › Suicidal ideation Clinical Major Depressive Disorder Screening in Primary Care Stockxchng ID: 63460_4774 Refer to Risk Identification Table

Kutcher Adolescent Depression Scale (KADS-6) Methods for Clinical Screening & Diagnosis Explain purpose of test & give feedback on results ID: Including contraception & sexual health visits Screen at clinical contacts

1 st appointment  Discuss issues in youth’s life & environment TeFA – Teen Functional Activities Assessment ›Use TeFA – Teen Functional Activities Assessment  Problem solving assistance PST – Psychotherapeutic Support for Teens as a guide ›Use PST – Psychotherapeutic Support for Teens as a guide KADS Score of 6+ Exercise Regulated Sleep Positive Social Activities Regulated Eating

1 st appointment (continued)  Screen for suicide risk TASR – Tool for Assessment of 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 e- mail  If problems continue, book appointment ASAP KADS Score of 6+ by Zirconicusso

2 nd appointment  Mental health checkup › 15 – 20 minutes › 1 week from first visit › Include: KADS, TeFA, PST ›Monitor suicide risk 3 rd appointment  Mental health checkup › 15 – 20 minutes › 1 week from 2nd mental health checkup › Include: KADS & TeFA › Monitor suicide risk KADS Score of by Nutdanai Apikhomboonwaroot

Dreamstimefree

 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 3 rd visit complete KADS-11 item › Five or more items score 2+ = diagnosis of MDD › Initiate treatment plan MDD Highly Probable if…

Visit 1 CONTACT Visit 2 Visit 3 CONTACT Phone, or Text 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 KADS TeFA Use PST and MEP Phone, or Text KADS TeFA Use PST and MEP 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. KADS TeFA Use PST and MEP 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

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 Additional Psychosocial Interventions by Idea Go

Dealing with Depression

 Children aged 3 to 12  Physician referral  No cost to patients  Via telephone  Operational hours include evening and weekend Confident Families:Thriving Kids

 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? Table Discussion

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 26 Anxiety disorder is suspected: if score of 25 or higher 26

Visit 1 CONTACT Visit 2 Visit 3 CONTACT Phone, or Text 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. SCARED Function Use PST & MEP as indicated and as time allows Phone, or Text SCARED, Function. Use PST & MEP 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. If SCARED remains > 25 or shows decrease in function, proceed to diagnosis (DSM-IVTR criteria) and treatment 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. SCARED, Function. Use PST & MEP

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 29

Pharmacological Treatment of Adolescent Depression/Anxiety Disorder Children & Adolescents

Cognitive Behavioural Therapy (CBT) Psychosocial Interventions by Master Isolated Images

 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 Psychotherapeutic Support Medication Intro by Scottchan

Do not use to treat mild symptoms or for “usual” stress Do not rush into medication subscribing! by Salvatore Vuono

AntidepressantsAntidepressants  Not all anxiety or depressive disorders require medication  Recommended first line treatment >Cognitive Behavioral Therapy Approach e.g. CBIS >Selective serotonin reuptake inhibitors (SSRI) o Fluoxetine or Sertraline >If not tolerable refer child to mental health services  Medication should not be used alone >Anxiety and mood management strategies ID stockxchng

AntidepressantsAntidepressants Combine with: CBT Wellness Activities Support Education Self Help Strategies

 Minimal evidence in < 7 yrs  SSRI’s: >Fluoxetine >Sertraline  Do not use alone  Suicidal ideation & self harm behavior by Tungphoto

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 12 Steps to SSRI Treatment 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 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

ItemNoneMildModerateSevere Headache Irritability/Anger Restlessness Diarrhea/Stomach upset Tiredness Sexual Problems Suicidal Thoughts Self Harm AttemptYes: No: If yes, describe: Was this a suicide attempt (attempt to die)? Yes: No: Other problems1. 2. Short Kutcher Chehil Side Effects Scale (sCKS) for SSRIs

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 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 stockxchng

Tool Base- line Da y 1 Day 5 Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 KADSxxxxxx TeFAxxxxxx sCKSxxxxxxxxxxx Monitoring Treatment of Adolescent Major Depressive Disorder Monitoring Treatment of Adolescent Major Depressive Disorder

Monitoring Treatment of Anxiety Disorders Tool Base- line Day 1 Day 5 Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 SCARED xxxxx TeFA xxxxx sCKS xxxxxxxxxxx o Children – SCARED & sCKS o Teens – SCARED, TeFA, sCKS

8 Weeks* of Dosage 3 Possible Outcomes 3 Different Strategies ALWAYS CHECK ADHERENCE TO MEDICATION TREATMENT!!!

MedicationAdherence

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

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 If relapse occurs…

Action Planning

Aim Measures Change Ideas

 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 Changes to try

 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 Action period planning – team activity

When in doubt – Ask the Experts! 57