www.pspbc.ca

PSP Child and Youth Mental Health

Sheraton Wall Centre VancouverOctober 4 & 5, 2011

AdolescentMajor Depressive Disorder(MDD)

Dr. Stan Kutcher

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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

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Early identification & early effective treatment

› Decreases short-term morbidity

› Improves long-term outcomes Decreased mortality

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Fast Facts

Adolescent Depression

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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

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1. Identification of youth at risk for MDD2. Screening & diagnosis in the clinical setting3. Treatment template4. Suicide assessment5. Contingency planning6. Referral flags

Key Steps for Treatment of MDD in Adolescents

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Step 1: Major Depressive Disorder in Youth

Risk Identification TableWell established andsignificant risk effect

Less well establishedrisk effect

Possible “group”identifiers

(these are not causal for MDD but may

identify factors relatedto 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 persistentenvironmental 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)

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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

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If Youth is High Risk…

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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

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If Youth is High Risk…

Kutcher Adolescent Depression Scale (KADS-6)

Methods for Clinical Screening & Diagnosis

Explain purpose of test

& give feedback on

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Including contraception

& sexual health

visits

Screen at clinical contacts

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Distress vs. DisorderDistress Disorder

Associated with a precipitating event May be associated with a precipitating event or may onset spontaneously

Functional impairment is usually mild Functional impairment may range; mild–severe

Transient – will usually ameliorate with change in environment or removal ofstressor

Long lasting or may be chronic, environment may modify but not ameliorate

Professional intervention not usually necessary

External 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 used Medications may be needed. Must use properly

Social supports and specific psychological interventions are helpful

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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

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Refer to

Risk Identification Table

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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

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1st appointment Discuss issues in youth’s life & environment

› 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

Strongly encourage and prescribe:

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1st 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+

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2nd appointment Mental health checkup

› 15 – 20 minutes› 1 week from first visit› Include: KADS, TeFA, PST› Monitor suicide risk

3rd appointment Mental health checkup

› 15 – 20 minutes › 1 week from 2nd mental health checkup› Include: KADS & TeFA› Monitor suicide risk

KADS Score of 6+

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Use the tools

Address important issues

Three -15 minute office visits

Use KADS routinely

Suicide intent/plan/attempt

= Emergency

Mental Health Assessment

Don’t Get Overwhelmed!!

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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 3rd visit review DSM-V criteria› Five or more items + = diagnosis of MDD› Initiate treatment plan

MDD Highly Probable if…

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 3If 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 5If 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 treatmentIf 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

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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

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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

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Monitoring CGI TeFA TASR-A KADS (6 item)

Interventions (these do not replace medications or psychotherapies)

PST MEP

Monitoring and Intervention Tools: Depression

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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

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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

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Dealing with Depression

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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)

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KADS-6

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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