1. www.pspbc.ca PSP Child and Youth Mental Health Sheraton Wall Centre Vancouver October 4 & 5, 2011

2. Adolescent Major Depressive Disorder (MDD) Dr. Stan Kutcher www.Dreamstime.com 1345216 2

3. 3  Adolescence = puberty to mid-twenties  Affects approx. 6-8% of adolescents  Most experience 1st episode between 14-24 yrs old  Youth onset usually = chronic condition › Substantial morbidity › Poor economic/vocational/interpersonal/health outcomes › Increased mortality  Suicide  Other long term chronic illness: diabetes, heart disease, etc. Fast Facts Adolescent Depression

4. 4  Early identification & early effective treatment › Decreases short-term morbidity › Improves long-term outcomes  Decreased mortality www.freedigitalphotos.netwww.freedigitalphotos.net by Zirconicusso Fast Facts Adolescent Depression

5. 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 Depression Screening Question

6. 6 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 www.dreamstime.com 310430

7. 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 (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) 7

8. 8  Educate › About risk of familial mental disorders  Record › Family history of mental disorder  Agree › On a ‘clinical review’ threshold  Urgent and emergency clinical reviews (re: suicide ideation)  Arrange › A standing ‘mental health checkup’  15 minutes each 3 – 6 months  Use KADS tool during checkups www.freedigitalphotos.netwww.freedigitalphotos.net by Ambro If Youth is High Risk…

9. 9  Check for patterns › Declining grades › Frequent lates or absences  Confidentiality & informed consent › Both young person and parents/guardian(s) involved › Easier for youth to access care › Easier for parents to know what to expect www.dfreeigitalphotos.net www.dfreeigitalphotos.net by Idea Go If Youth is High Risk…

10. Kutcher Adolescent Depression Scale (KADS-6) Methods for Clinical Screening & Diagnosis Explain purpose of test & give feedback on results www.dreamstime.com ID:983365 Including contraception & sexual health visits Screen at clinical contacts 10

11. Distress vs. Disorder DistressDisorder Associated with a precipitating eventMay be associated with a precipitating event or may onset spontaneously Functional impairment is usually mildFunctional impairment may range; mild–severe Transient – will usually ameliorate with change in environment or removal of stressor Long lasting or may be chronic, environment may modify but not ameliorate Professional intervention not usually necessaryExternal validation (syndromal diagnosis: DSM*/ICD*) Can be a positive factor in life – person learns new ways to deal with adversity Professional intervention is usually necessary Social supports such as usual friendship and family networks help May increase adversity due to effect on creation of negative life events (e.g.: low mood can lead to relationship loss) Counseling and other psychological interventions can help May lead to long term negative outcomes (substance abuse, job loss, etc.) Medications should not usually be usedMedications may be needed. Must use properly Social supports and specific psychological interventions are helpful 11

12. 12 Who to Screen? Adolescents with: Risk factors Persistent low or irritable mood of recent onset Academic problems/failure Substance misuse Suicidal ideation Clinical MDD Screening in Primary Care Stockxchng ID: 63460_4774 Refer to Risk Identification Table

13. 13 Kutcher Adolescent Depression Scale (KADS) Kutcher Adolescent Depression Scale (KADS)  Self-reporting instrument › For diagnosis and monitoring › Scoring information included › KADS score 6+ = clinical depression suspected  Suggests a possible diagnosis  Use as a guide for further evaluation Assessment Tool

14. 14 1 st appointment  Discuss issues in youth’s life & environment TeFA – Teen Functional Activities Assessment ›Use TeFA – Teen Functional Activities Assessment  Assists in determining impact of depression  Problem solving assistance ›“Supportive rapport”  Use PST – Psychotherapeutic Support for Teens as a guide KADS Score of 6+ Exercise Regulated Sleep Positive Social Activities Regulated Eating

15. 15 1 st appointment (continued)  Screen for 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+ www.freedigitalphotos.netwww.freedigitalphotos.net by Zirconicusso

16. 16 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 6+ www.freedigitalphotos.net www.freedigitalphotos.net by Nutdanai Apikhomboonwaroot

17. 17 Use the tools Address important issues Three -15 minute office visits Use KADS routinely Suicide intent/plan/attempt = Emergency Mental Health Assessment Dreamstimefree 836493

18. 18  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 review DSM-V criteria › Five or more items + = diagnosis of MDD › Initiate treatment plan MDD Highly Probable if…

19. Visit 1 CONTACT Visit 2 Visit 3 CONTACT Phone, Email 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 KADS TeFA Use PST and MEP Phone, Email 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 (DSM-V) 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 19

20. 20 1.Determine what is known already 2.Identify areas of misinformation 3.Identify gaps in knowledge & provide information 4.Be knowledgeable, realistic, clear & helpful 5.Provide written materials /websites for self study ›Many think taking meds will lead to addiction 6.Discuss anticipated duration of medication use ›First episode = 6 – 9 months after they get well 7.Discuss how meds will impact lifestyle › Light alcohol use is usually ok; can drive with SSRI Provide Information

21. 21  Compassionate & non-judgmental attitude  Active listening › Eye contact, verbal/non-verbal cues  Clarification › “Help me understand”…  Emotional identification › “It seems you are feeling frustrated”...  Do not jump to conclusions › You are likely to be wrong  ASK, if you don’t understand  If you don’t know the answer – admit & find out Creating a Supportive Environment www.freedigitalphotos.netwww.freedigitalphotos.net by Idea Go

22. 22 Monitoring  CGI  TeFA  TASR-A  KADS (6 item) Interventions (these do not replace medications or psychotherapies)  PST  MEP Monitoring and Intervention Tools: Depression

23. 23 Risk Factors:  History of suicide attempt or self harm  Presence of Depression › Hopelessness  Family history of suicide  Family history of a mental disorder › Especially mood disorders  If one or more are identified use Tool for Assessment of Suicide Risk in Adolescents (TASR-A) Screening for Suicide Risk www.freedigitalphotos.net www.freedigitalphotos.net Risk Blocks by jscreationzs

24. 24 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 www.freedigitalphotos.netwww.freedigitalphotos.net by Idea Go

25. Dealing with Depression 25

26. 26 A tool like KAD-6 is tangible and helps us and the young person in front of us streamline the conversation to an extent (perhaps relieves some anxiety for us too)

27. 27 KADS-6

28. 28  How can these tools fit into GP 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