Transcript Learning Session 2 Presentation Slides

PSP Child & 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.
Presenter’s name here
Location here
Date here
www.pspbc.ca
Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
2
Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
3
Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
4
Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
5
Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
6
Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
7
$1,540.18
$160.00
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
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Sharing the Learnings from the
Action Period
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CYMH Roles & Referrals
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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?
›
›
›
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If YES – consider an anxiety disorder
Apply the SCARED evaluation
Proceed to the Identification, Diagnosis and Treatment of Child and
Adolescent Anxiety Disorders Module
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)?
›
›
›
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If YES – consider ADHD
Apply the SNAP-IV evaluation
Proceed to the Identification,
Diagnosis and Treatment of the
Child and Adolescent ADHD
Module
www.freedigitalphotos.net by Boaz Yiftach
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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Adolescent
Major
Depressive
Disorder
(MDD)
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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
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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
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
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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)
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
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Refer to
Risk Identification Table
Stockxchng ID: 63460_4774
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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www.dreamstime.com ID:983365
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
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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 e-mail
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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www.freedigitalphotos.net by Nutdanai Apikhomboonwaroot
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Dreamstimefree 836493
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
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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
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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 selfharm 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
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Dealing with
Depression
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Confident Families:Thriving Kids
 Children aged 3 to 12
 Physician referral
 No cost to patients
 Via telephone
 Operational hours
include evening and
weekend
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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?
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Childhood & Adolescent Anxiety
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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?
›
›
›
31
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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32
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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
SCARED, Function. Use
PST & MEP
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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
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
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 Positive social activities
Psychotherapy
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Pharmacological Treatment of
Adolescent Depression/Anxiety
Disorder
Children & Adolescents
36
Psychosocial Interventions
Cognitive Behavioural
Therapy (CBT)
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www.freedigitalphotos.net by Master Isolated Images
Medication Intro Support
Psychotherapeutic
 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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www.freedigitalphotos.net by Scottchan
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
41
 Minimal evidence in < 7 yrs
 SSRI’s:
>Fluoxetine
>Sertraline
 Do not use alone
 Suicidal ideation & self harm behavior
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www.freedigitalphotos.net by Tungphoto
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
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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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www.freedigitalphotos.net 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
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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
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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
48
 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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ID 1319195 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
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ID 1209407 stockxchng
Monitoring Treatment of
Adolescent
Major Depressive Disorder
Tool
Base
-line
Da
y
1
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
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x
x
x
x
x
x
x
Monitoring Treatment
of Anxiety Disorders
Tool
Base
-line
SCARED
x
x
x
x
x
TeFA
x
x
x
x
x
sCKS
x
52
Day
1
x
Day
5
x
Wk
1
x
Wk
2
x
Wk
3
x
Wk
4
x
o Children – SCARED & sCKS
o Teens – SCARED, TeFA, sCKS
Wk
5
x
Wk
6
x
Wk
7
x
Wk
8
x
8 Weeks* of Dosage
3 Possible Outcomes
3 Different Strategies
ALWAYS CHECK ADHERENCE
TO MEDICATION TREATMENT!!!
53
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.
(50-60% as determined from the
TeFA)
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
54
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
55
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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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
57
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
58
Action Planning
59
Measures
Aim
60
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
61
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
62
When in doubt – Ask the Experts!
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