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Adolescent Mental Health

Ron Marino, DO, MPH, FACOP

Associate Chairman, Pediatrics

Winthrop University Hospital

Professor of Clinical Pediatrics

NYIT College of Osteopathic Medicine

Stony Brook University Medical School

Disclosures

I do not intend to discuss an unapproved/investigative use of a commercial product or device in my presentation.

I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or providers of commercial services discussed in this presentation.

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Goals and Objectives

• Appreciate the magnitude and types of mental health problems occurring in adolescents

• Cite socio cultural factors that impact on mental health

• Utilize mental health screening techniques in primary care

• Implement primary care management strategies

• Appropriately refer for mental health services

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Typical Adolescent Development

Mood swings

Black and White thinking

Risk Taking

Peer Group Dominance

Explore sexuality

Family time

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Today’s Context

Digital Generation

Social Media

Cyber bullying

Sexting

Nature Deficit Disorder

Hurried Child

More than 1 America!

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The Neighborhood Context of Adolescent Mental Health*

CAROLS.ANESHENSELUniversity of California, Los Angeles

CLEA A. SUCOFFRAND Corporation

Journal of Health and Social Behavior 1996. Vol. 37 (December):293-310

Mental health disorders in adolescence are pervasive, often carry into adulthood, and

appear to be inversely associated with social status. We examine how structural aspects of neighborhood context, specifically, socioeconomic stratification and racial/ethnic segregation, affect adolescent emotional well-being by shaping subjective perceptions of their neighborhoods. Using a community-based sample of 877 adolescents in Los Angeles County, we find that youth in low socioeconomic status (SES) neighborhoods perceive greater ambient hazards such as crime, violence, drug use, and graffiti than those in high SES neighborhoods. The perception of the neighborhood as dangerous. in turn, influences the mental health of adolescents: (the more threatening the neighborhood, the more common the symptoms of depression, anxiety, oppositional defiant disorder, and conduct disorder. Social stability and, to a lesser extent, social cohesion, also emerge as contributors to adolescent disorder. This investigation demonstrates that research into the mental health of young people should consider the socioeconomic and demographic environments in which they live.

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I feel that others don’t care about

me

I feel powerless, and not in control of

my life

I don’t like

myself I feel good about the

future

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Mental Health Issues of Adolescents

Anxiety

ADHD

Depression

Substance Abuse

Gender Issues

Internet Addiction

Prevalence of the Mental Health Challenges in US Children and

Adolescents

2724211815129630

Autism Suicide ADHD Depression Anxiety

Prevalence % of Children

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CC: I think I have ADHD

My friends Adderall really helped my guitar playing.

School history – honor student. Freshman in College

P.E.: Vitals WNL

Negative Physical

Assessment Plan?

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#1 Mental Health Disorder of Adolescents Lifetime Prevalence 25% 13 – 18 year olds

Incidence tripled between 2003-2011

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• Separation Anxiety

• Phobias

• Panic Disorders

• Generalized Anxiety Disorder

DSM-V

Disruptive mood dysregulation disorder

Major Depressive Disorder

Persistent depression

Premenstrual dysphoric disorder

Substance induced depressive

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Scope of Problem

• 1/5 teens have a hx of depression at some point during adolescence

• In PC setting, point prevalence rate of depression is as high as 28%

• 2-3 times higher in girls

• Between 2010-2016 incidents increased by 20%

Suicide

2nd leading cause of death.

Rate increasing in females.

Intention vs. gesture

2000 Deaths/yr

16 % high school students report thoughts of self harm 8 % attempt.

WHS 2015

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Sexual Orientation

Paradigm of Sexuality

Gender Identity

SexualBehavior

Sexual Attraction

Biological Sex

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The Williams Institute and The American Foundation for Suicide Prevention 2011

Substance AbuseIn the last 30 days,

LGBTQ youth are more likely to have used:

Tobacco

59.3% vs. 35.2%

Alcohol

89.4% vs. 52.8%

Cocaine

25.3% vs. 2.7%

LGBTQ youth are more likely to have used

substances before the age of 13:

Tobacco

47.9% vs. 23.4%

Alcohol

59.1% vs. 30.4%

Cocaine

17.3% vs. 1.2%

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61%

56%

25%

5%

LGBT Teens Who Are “Out”

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“We’re afraid of everyone, afraid of the sun, Isolation”. -John Lennon

“Everybody’s on the phone we’re all connected but we’re all alone.” -Jimmy Buffet

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80% of households had 1

32% of children < 18 had 1

JAOA 105:85, 2/05

Empirical Article Clinical Psychological Science 1-15The Authors (s) 2017Reprints and permissions:Sagepub.com/journalsPermissions .navDO1: 10.1177/2167702617723376222.psychologicalscience.org/CPS

®SAGE

Increases in Depressive Symptoms, Suicide-Related Outcomes, and Suicide Rates Among U.S. Adolescents After 2010 and Links to Increased New Media Screen Time

Jean M. Twenge', Thomas E. Joiner", Megan L. Rogers", andGabrielle N. Martin''San Diego State University and "Florida State University

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“….Results show a clear pattern linking screen activities with higher levels of depressive symptoms/suicide related outcomes and non screen activities with lower levels”

Twenge .et al. 2017

Tyler Clementi

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• 2-6 year olds spend 4 hours a day watching screens

• 6 to 8 year olds spend 7.5 hours a day watching screens

• 40% of 3 month olds watch TV regularly

• 25% of 2 year olds have TV in their rooms

• 90% of 2 year olds watch TV regularly

Some Scary Statistics

Computer Play

A rapidly evolving culture

Not going away

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Bizarre Computer Behaviors

• Swatting

• Digital Self Harm

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Challenges of Computer Play

Sedentary

Time consuming

Addicting

Isolating

Commercial

↑ Violence

Cognitive Overload

↓Contemplation, reflection

Anonymous

Potential Good of Computer Play

Opportunities to share

Virtual creativity

↑ Scanning and skimming skills

Potential parental involvement

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The Teenage Brain

Media Multitasking Matter volume in ACC

Social Media Use Dopamine

Finding Balance

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Longitudinal humanistic relationship based primary care!

The Primary Care Advantage

Longitudinal, trusting, and empowering therapeutic

relationships

Family‐centered medical home

Opportunities for prevention

Understanding of common social, emotional, and educational problems in the context of a child’s development and environment

Experience working with specialists and serving as a Care Coordinator

Familiarity with chronic care principles and practice improvement methods

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Surveillance Screening Evaluation

Check in on

Abuse

Gender identity

Internet gaming

Substances

Lifestyle

Bullying

School Attendance

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Warning Symptoms

School Functioning or Attendance

Change in eating pattern

Social isolation

Temper outbursts

Screening

a brief process

designed for those thought to be developing normally (asymptomatic)

identifies those in need of further assessment

does not provide a diagnosis,

helps to formulate referral questions

Barbara Ward‐Zimmerman, Ph.D. (August, 2012). The Integration of Routine Behavioral Health Screening Into

Pediatric Primary Care. Unpublished paper presented at APA Annual Convention, Orlando, Florida.

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PSC 17PHQ – 9Columbia Depression ScaleScaredStrengths and Difficulties QuestionnaireVanderbilt Rating Scales

Interview Logistics

• Parents Role

• Confidentiality

• Physical Environment

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Clinical Approaches

It’s in the Rapport!

Do Ask!

Depression

Sleep disturbance

Interests (anhedonia)

Guilt – self esteem

Energy

Concentration

Appetite

Psychomotor agitation/retardation

Suicidal ideation

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Open Ended Questions

Understanding

Compassion

Commitment

Connections

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“Everybody feels sad”

Screening questions:

Have you lost interest in things you used to enjoy?

Have you had any change in your sleep patterns?

Have you had any thoughts about hurting yourself?

Have you been feeling sad, down, or depressed much of the time?

Questions to ask Regarding Suicide Risk

Do you have thoughts of death or dying?

Do you wish you were dead?

Do you believe that things would be better if you were dead?

Do you have any intent to kill yourself or any plan to do so?

If you have a plan, what is it?

Do you have the means necessary to carry out your plan?

Have you ever tried to kill yourself or hurt yourself before?

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Initial Management

Educate and Counsel patient and families about

depression and options for treatment, including a discussion of confidentiality

Develop a treatment plan, set goals in key areas of functioning: home, peer, school

Share info about community links

Establish a safety plan

Treatment

Mild: Consider active support and monitoring first

Mod‐Severe: Consider consultation with MH Professional

Recommend scientifically tested and proven treatments (psychotherapies such as CBT,IPT), SSRIs

Monitor for adverse effects during SSRI treatment

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Help Prevent Suicide!

Make the home safe: remove firearms, lock up or remove alcohol, medications, poisons

Ask about suicide: asking will NOT promote the idea

Watch for suicidal behavior: expressing self‐destructive thoughts; obsessed with death in drawings, music, video games, books, TV, internet; giving away possessions

Watch for signs of drinking

Develop a suicide emergency plan: exactly what to do if adolescent IS feeling suicidal – don’t leave alone

Active Monitoring

Appropriate first choice for new‐onset mild‐mod depression

Schedule frequent visits

Prescribe regular exercise and leisure activities

Recommend a peer support group

Review self‐management goals

FU with patient via telephone

Provide patient and family with educational materials

Taper with improvement, consider referral if no improvement

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Mental Health Apps

Aura

Calm

Relax Melodies

Take a Chill

Head Space

Calm Counter

The Relational virtues of a Healer

Genuine Compassion Respect Attentive Listening

“Listening is a magnetic and strange thing, a creative force. The friends who listen to us are the ones we move toward. When we are listened to, it creates us, makes us unfold and expand.”

Karl Menninger, MD

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Karl Menninger, MD

Touch releases Oxytocin

Oxytocin Trust and Tranquility

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Rx for Adolescents

Service

Outdoor Experiences

Adults who care

Pro Social Peers

Referral

•Know your resources

•Get written permission from patient and parent/guardian

•Have a clear plan tocommunicate information

•Have a clear plan to receive follow up information

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Co-Management

Stay actively involved – do not abandon your patient!

Have a clear plan (and patient/parental permission) to

exchange essential information

Establish your own PCP Chronic Care Management

Plan with the patient and family

I’ll tell you what this means, Norm… no size restrictions and screw

the limit

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• Lack of comfort/Training

• Lack of Time

• Lack of Adequate payment

10 ways to Improve Mood Naturally

1. Lighten up

2. Get plenty of sleep

3. Connect with someone

4. Eat wisely

5. Go for gratitude

6. Step it up!

7. Be kind

8. Turn off the TV

9. Address stress

10. Ask your doctor about supplements

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Medications

SSRI Starting Dose (mg/d)

Increments Effective Dose

Maximum Dose

Fluoxetine* 10 10-20 20 60

Setraline(zoloft)

25 12.5-25 50 200

Citalopram(Celexa)

10 10 20 60

Escitalopram(Lexapro)

5 5 10 20

Paroxetine(Paxil)

10 10 20 60

Fluvoxamine(Luvox)

25-50 25-50 150 300

Black Box Warning

In 2004, FDA reviewed reports of 23 clinical trials involving more than 4,400 children and adolescents who had been prescribed any of 9 antidepressants for treatment of major depression, anxiety or OCD.

No suicides occurred in any of these trials. But more who were receiving an antidepressant medication (4/100) spontaneously reported suicidal thoughts than those on placebo (2/100)

The medicine did not increase suicidality that had been present at the start of the study, and it did not induce new suicidality in those without prior suicidal ideation.

All studies showed a reduction in suicidality over the course of treatment

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Side Effects

Dry mouth

Constipation

Diarrhea

Sweating

Sleep disturbance

Sexual dysfunction

Irritability

“Disinhibition”

Agitation or jitteriness

Headache

Appetite changes

Rashes

More Serious Side Effects

Serotonin syndrome : fever, hyperthermia, restlessness,

Confusion

Akathisia

Hypomania

Discontinuation syndrome: dizziness, drowsiness,

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Preventing Adolescent Mental Health Problems

• Select your Parents Carefully!• Avoid Toxic Stress and ACE’s• Develop Pro Social Relationships• Avoid the technology trap• Pray!

Support Resilience!

• Lifestyle• Diet• Sleep• Social Connections

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Thank You

CC: Palpitations, Shakiness, Sweaty Palms and Hyperventilation. This occurs in anticipation of tests at college. Calls mother for emotional support.

No depression or Suicidality. Boyfriend in Army in Japan. Up late to Skype with him.

PE: Aesthenic appearing socially appropriate, H.R. 90 B.P. 124/70

Labs: WNL Including Thyroid

Assessment & Plan?

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CC: Wants to talk. Grades Falling. Bullied at school and on-line. Sad but no Suicidal. Gender identity female No ABUSE

SIGECAPS

Exam: Tearful Articulate

L Leg Hemimelia

Assessment and Plan?

L