Presented by: Panel Webinar • Dr Mary Emeleus, GP An interdisciplinary case study • Dr Simon Kinsella, psychologist panel discussion • Dr Peter Parry, psychiatrist DATE: • Ann Garden, mental health nurse November 12, 2008 Adolescent mental health: depression, suicidality and cyber-bullying . Facilitated by • Dr Michael Carr-Gregg Tuesday 1 st March 2011 Supported by The Royal Australian College of General Practitioners, the Australian Psychological Society, the Australian College of Mental Health Nurses and The Royal Australian and New Zealand College of Psychiatrists Depression & anxiety - the greatest burden of mental Adolescent mental health disorders (AIHW 2007) • 75% of all mental illnesses begin before 25 years of age • 1 in 4 young people will have a mental health problem • 30% seek professional help • 50% of the students with the most serious issues never get recognized Who is Tim? Tim: a case study • 17 year old year 11 student • Reluctant attendee • Mo thinks he is irritable, argumentative, poor ADOLESCENT MENTAL HEALTH academic performance • No PH but sensitive • FH Mo tense, father heavy drinker, paternal uncle bipolar 1
Tim….. Tim: the GP’s perspective • Tim thinks Mo is a nag Engagement • Some tension with father • is critical with • Some tension with a school teacher the young person • Recent fall out with friends Parent/carer • No interest in school • No clear sense of future • Start with less challenging topics first, earn • Complains of fatigue the right to ask about sex, drugs and death Tim: the GP’s perspective Tim: the Psychologist's perspective HEADSS assessment Introduction from the GP Risk: if they say yes to screening questions, don’t panic, • The more information the better. ask more (the discussion itself might be therapeutic) • Presenting problems and diagnosis are very What is important to the client (may not be what mum important sent him for, but may result in engagement). • Useful to know about Tim’s reluctance Goal setting “how will you know it’s been helpful?” • Useful to know that mum was miffed about not Medication use in depression in young people (and what getting enough air time if there isn’t a psychologist in town?) Tim: the Psychologist's perspective Tim: the Psychologist’s perspective WHAT IS THE HEADSS ASSESSMENT TOOL? 4 Ps: Structured clinical interview covering the biopsychosocial aspects: Predisposing • Home & Environment • Education & Employment Precipitating • Activities • Drugs Perpetuating • Sexuality • Suicide/Depression Protective 2
Tim: the Psychologist’s perspective Tim: the Psychologist’s perspective MEETING TIM AND HIS FAMILY PROBING DEEPER • Engagement is number one, without it you won’t get • Assessing the quality of the therapeutic relationship anywhere • Using the HEADSS or 4 P’s • Setting the boundaries of confidentiality • The power of acknowledgement • Dealing with the presenting problem REFERRING ON GIVING FEEDBACK • The need for further opinions • The art of presenting your view • Knowing your limits • Collaboration • Mitigating risk • Keeping everyone engaged in the process Tim: the Psychiatrist’s perspective Tim: the Psychiatrist’s perspective • Lifestyle treatment of depression: the evolutionary paradigm. Dynamic biopsychosocial case formulation - Hunter-gatherer tribe. • More individualised and meaningful than a DSM diagnosis. • Feedback to Tim Evolutionary paradigm • How out of sync is life with natural niche for 17 year old member of homo sapiens? • Attachment theory • Rank theory Narrative of his life Tim: the Psychiatrist’s perspective Tim: the Psychiatrist’s perspective The role of stress Further “natural antidepressants” Acute stress = good, chronic stress = bad • Nature deficit disorder • Out of sync with design manual = chronic stress • Sympathetic N.S. in overdrive = depressogenic inflammation • Sleep deprivation & circadian rhythm – Amygdalas ↑, frontal lobes ↓, SNS ↑ = tachycardia, hyperventilation, • Poor diet – lack omega-3 etc muscle tension, GIT spasm, clammy etc • Lack exercise – Fight/flight/freeze response • Vit D Relaxation – Parasympathetic N.S. = vagus nerve stimulation • Cooperative tasks – bonding, humour, group success – Diaphragmatic breathing • Group entertainment & ritual – Sigh, yawn, laugh, sob, – yoga – “ ujjayi ” breath – Athletes and public speakers “Therapeutic Life Changes” (TLC’s) – see Walsh, R. Lifestyle & mental health – Dogs and chimpanzees in American Psychologist, Jan 17, 2011 – Practice it in session. 3
Tim: the Mental Health Nurse’s Tim: the Psychiatrist’s perspective perspective Framework of Professional Assessment and an Intervention Tool Psychotherapy and pharmacotherapy Psycho-social and emotional state assessment of children & adolescents - 5P’s model • Individual psychotherapy – meaning/narrative self Presenting problems • Family therapy • who is concerned, who wishes referral, what are they saying? • Liaison with school teacher/counsellor Precipitating factors • Antidepressant drugs second line (unless rare • why now, what has happened lately, present situation? melancholic presentation), explain side-effects Predisposing factors • why this child/adolescent? developmental, cognitive, speech & language, • Omega-3 supplements first line sensory, family factors (genogram 3 generations). • Placebo effect Perpetuating factors • Instill hope – non-specific benefits therapeutic relationship • child/adolescent’s mental state, family dynamics, social/environmental factors. Shedler, J. The efficacy of psychodynamic psychotherapy. American Psychologist, Protective factors 2010 • child/adolescent’s strengths, support systems. Tim: the Mental Health Nurse’s Tim: the Mental Health Nurse’s perspective perspective Family Centred Interventions -Narrative, systemic and strategic models • Use genograms in the therapy room as a therapeutic intervention • Externalise the problem as the problem - not the person as the problem • Improve communication patterns • Address family systems and attachment issues • Clarify family roles, strengthening relationships and subsystems • Negotiate or validate relationships • Explore shared experiences such as trauma, loss and grief, mental health concerns of other family members • Clarify misinformation and misunderstandings • Identify intervention for other family members if needed Systems Approach to Intervention in Collaboration - Does it matter? Child & Adolescent Mental Health • Pros Who pays can determine treatment Who is available and skilled to provide intervention outcomes – Multiple inputs are integrated • GP • MBS - bulk billing • Mental health nurse • – Each person adds value to the next ATAPS • Psychiatrist • headspace – Each person knows what the other is doing • Paediatrician • Mental Health Nurse Incentive • Psychologist Program – Address multiple needs simultaneously rather than • Social Worker • CAMHS sequentially • OT • Community health centres • Speech pathologist • • Cons School based counsellors • Youth worker – Time consuming • Family support agency Who is the client ? • Drug and alcohol counsellor – Uncertain evidence of benefit in mental health care • Family violence counsellor Who else in the family needs/is • Teacher/school welfare • Do competent professionals need to work together willing to have professional • Other intervention ? or just do their own job well? 4
Collaboration Mental health collaboration • What helps? – Knowing the other professional Thank you for your contribution and – Easy to contact participation – Concise, prompt feedback – Case conference items, but not easy to use • What doesn’t help? – Not knowing the other professional – Little or no feedback – Inadequate role clarification, Mx advice, or contingency plan 5
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