Transcript Suicidal ideation

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.
www.pspbc.ca
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
2
Sharing the Learnings from the
Action Period
3
CYMH Roles & Referrals
4
Mental Health Screening Q’s
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
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
5
Mental Health Screening Q’s
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
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6
Mental Health Screening Q’s
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.
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7
Adolescent
Major
Depressive
Disorder
(MDD)
8
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Depression Screening Question
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
Key Steps
for Treatment of MDD in Adolescents
1.
2.
3.
4.
5.
6.
Identification of youth at risk for MDD
Screening & diagnosis in the clinical setting
Treatment template
Suicide assessment
Contingency planning
Referral flags
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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
1. Childhood onset ADHD
2. Family history of suicide 2. Substance abuse
3. Family history of a
mental illness (especially
a mood disorder, anxiety
disorder, substance abuse
disorder)
3. Severe and persistent
environmental stressors
(sexual abuse, physical
abuse, neglect) in
Childhood.
4. Childhood onset anxiety 4. Head injury (concussion)
disorder
1. School failure
2. Gay, lesbian,
bisexual,
transsexual
3. Bullying (victim
and/or
perpetrator)
Clinical Major Depressive Disorder
Screening in Primary Care
Who to Screen?
Adolescents with:
› Risk factors
› Persistent low mood
 Recent onset
› Academic problems/failure
› Substance misuse
› Suicidal ideation
Refer to
Risk Identification Table
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Methods for Clinical Screening
& Diagnosis
Kutcher Adolescent
Depression Scale
(KADS-6)
Screen at clinical contacts
Including contraception
& sexual health
visits
Explain purpose of test
& give feedback on results
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KADS Score of 6+
1st appointment
 Discuss issues in youth’s life & environment
› Use TeFA – Teen Functional Activities Assessment
 Problem solving assistance
› Use PST – Psychotherapeutic Support for Teens as a
guide
Strongly encourage and
prescribe:
Positive Social
Activities
Regulated Sleep
KADS Score of 6+
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 email
 If problems continue, book appointment ASAP
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KADS Score of 6+
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
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MDD Highly Probable if…
 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 complete KADS-11 item
› Five or more items score 2+ = diagnosis of
MDD
› Initiate treatment plan
Visit 1
KADS
TeFA
Use PST
and MEP
CONTACT
Visit 2
KADS
TeFA
Use PST
and MEP
CONTACT
Visit 3
KADS
TeFA
Use PST
and MEP
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
Phone, Email or Text
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.
Phone, Email or Text
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
Additional Psychosocial Interventions
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
Dealing
with
Depression
Confident Families:Thriving Kids
 Children aged 3 to 12
 Physician referral
 No cost to patients
 Via telephone
 Operational hours
include evening and
weekend
Table Discussion
 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?
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
Anxiety disorder is suspected:
if score of 25 or higher
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Visit 1
SCARED Function
Use PST & MEP
as indicated and as
time allows
CONTACT
Visit 2
SCARED, Function.
Use PST & MEP
CONTACT
Visit 3
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.
Phone, Email or Text
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.
Phone, Email or Text
If SCARED remains > 25 or shows decrease in function,
proceed to diagnosis (DSM-IVTR criteria) and treatment
SCARED, Function.
Use PST & MEP
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.
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
Psychosocial Interventions
Cognitive Behavioural
Therapy (CBT)
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Medication Intro
Psychotherapeutic
Support
 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
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Do not rush into
medication
subscribing!
Do not use
to treat mild symptoms
or for “usual” stress
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Antidepressants
 Not all anxiety or depressive disorders require
medication
 Recommended first line treatment
> Cognitive Behavioral Therapy Approach e.g. CBIS
> Selective serotonin reuptake inhibitors (SSRI)
oFluoxetine or Sertraline
> If not tolerable refer child to mental health services
 Medication should not be used alone
> Anxiety and mood management strategies
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Antidepressants
Combine with:
CBT
Support
Education
Self Help Strategies
Wellness Activities
 Minimal evidence in < 7 yrs
 SSRI’s:
> Fluoxetine
> Sertraline
 Do not use alone
 Suicidal ideation & self harm behavior
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12 Steps to SSRI Treatment
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
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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
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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
Short Kutcher Chehil Side Effects
Scale (sCKS) for SSRIs
Item
None
Mild
Moderate
Severe
Headache
Irritability/Anger
Restlessness
Diarrhea/Stomach
upset
Tiredness
Sexual Problems
Suicidal Thoughts
Self Harm Attempt
Other problems
Yes:
No:
If yes, describe:
Was this a suicide attempt (attempt to die)? Yes:
1.
2.
No:
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
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 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
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Monitoring Treatment of
Adolescent
Major Depressive Disorder
Tool
Baseline
Da
y1
Day
5
Wk
1
Wk
2
Wk
3
Wk
4
Wk
5
Wk
6
Wk
7
Wk
8
KADS
x
x
x
x
x
x
TeFA
x
x
x
x
x
x
sCKS
x
x
x
x
x
x
x
x
x
x
x
Monitoring Treatment
of Anxiety Disorders
Tool
Baseline
Day
1
Day
5
Wk
1
Wk
2
Wk
3
Wk
4
Wk
5
Wk
6
Wk
7
Wk
8
SCARED
x
x
x
x
x
TeFA
x
x
x
x
x
sCKS
x
x
x
x
x
x
x
x
o Children – SCARED & sCKS
o Teens – SCARED, TeFA, sCKS
x
x
x
8 Weeks* of Dosage
3 Possible Outcomes
3 Different Strategies
ALWAYS CHECK ADHERENCE
TO MEDICATION TREATMENT!!!
OUTCOME 1
OUTCOME 2
OUTCOME 3
Patient not better or only
minimally improved
SCARED > 25 and little or
no functional improvement
Patient moderately improved
SCARED < 25. Some
functional improvement.
Patient substantially improved.
SCARED < 25 and major
functional improvement.
Strategy
Strategy
Strategy
Increase medication
gradually
If medication is well tolerated,
increase slightly
Continue
monitoring/interventions for 2 4 wks
Reassess
If no substantial improvement
Refer
Continue current dosage
Gradually decrease visits; every 2
wks for 2 mths and then monthly
Educate patients/caregivers on
need to continue medications
And identifying relapse
Refer to
Specialty Child/Adolescent
Mental Health Services
Continue weekly monitoring
and all other interventions
until consultation occurs
(50-60% as determined from the
TeFA)
If medication or increase not
well tolerated continue at
current dosage with monitoring
and intervention for 2 wks
Reassess
If no substantial improvement
Refer.
If first episode continue
medications for 9- 12 mths.
If discontinuing, choose a low
stress period. Decrease gradually
over 4-6 wks monitoring
every 2 wks.
“Well checks” every 3 mths
If 2nd or further episode obtain
mental health consultation on
treatment duration
Medication
Adherence
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)
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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
If relapse occurs…
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
Action Planning
Measures
Aim
Change Ideas
Changes to try
 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
Action period planning – team activity
 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
When in doubt – Ask the Experts!