Transcript Recognizing Depression in Youth:

Successfully
Dealing With Teen
Self-Harm Behavior
Oregon School-Based
Health Care Network
Annual Institute
October 12, 2007
Kirk D. Wolfe, M.D.
Goals
 To Recognize:
– The Major Impact of Youth Depression
And Suicide on Our State
– Risk and Protective Factors With Suicide
– Keys in Evaluating a Suicidal Student
– Keys to Treating Suicide/Depression
Oregon Youth Suicide Facts1990’s
 Rate Was 30-40% Above The US Average
 Rate Increased 400% In 40 Years
 #2 Cause of Death
 75 Suicides Every Year
 2/3 With Firearms
Oregon Youth Suicide Facts1999-2005
 ~63 deaths per year- 16 % decrease
 Why the decrease?
Youth Risk Behavior Survey2005
 U.S. High School Students, Past Year:
 28.5% Depressed 2 Weeks or Greater
 17% Seriously Considered Suicide
 13% Report Specific Plan
 8.4% Suicide Attempt
 2.3% Attempt Leading to Medical Attn
U.S. Youth Suicide Facts1990-2003
 #3 Cause of Death
 Highest Psychiatric Risk- Major Depression
 Peak rate- late 1980’s
 28% Decrease in Rate through 2003
 Why the decrease?
U.S.Youth Suicide Facts2004 vs. 2003
 8% Increase, largest in 15 years
 76% Increase, Females aged 10-14 yrs
 32% Increase, Females aged 15-19 yrs
 9% Increase, Males aged 15-19 yrs
 Why the increase?
U.S. Youth Suicide FactsRates per 100,000, Females, 2004
 Ages 10-14 years:
All methods 0.95
Hanging/suffocation (72%), poison (16%)
 Ages 15-19 years:
All methods 3.52
Hanging/suffocation (49%), firearm (28%)
 Ages 20-24 years:
All methods 3.59
Hanging/suffocation (34%), firearm (32%)
U.S. Youth Suicide FactsRates per 100,000, Males, 2004
 Ages 10-14 years
All methods 1.71
Hanging/suffocation (73%), firearm (27%)
 Ages 15-19 years
All methods 12.65
Firearm (51%), hanging/suffocation (37%)
 Ages 20-24 years
All methods 20.84
Firearm (53%), hanging/suffocation (32%)
Risk Factors for Youth Suicide
 Later adolescence/young adult
 Male
 Ethnicity- Highest Rate- Native American
Greatest Number- Caucasian
 Stressful Life Events
 Previous Attempt(s)
 Access to Lethal Means
 Contagion/ Imitation
 Chronic Physical Illness (esp. epilepsy)
Risk Factors for Youth Suicide
 Youth Psychiatric Disorder
- Major Depressive Disorder
- Substance Abuse
- Bipolar Disorder
- Conduct Disorder- Aggressive/Impulsive
 Physical/ Sexual Abuse
 Hopelessness or Isolation
 Sexual Orientation
 FH of mood disorders/suicide/substance abuse
Protective Factors
 Family Cohesion
 Good Coping/Problem-Solving Skills
 Help-Seeking/ Advice-Seeking
 Academic Achievement
 Social Integration
 Access/care for mental/physical/subst. d/o’s
 Responsibility for others/pets
 Religion/spirituality
Teen Psychological AutopsyCase-Control Study
 Brent et al, JAACAP, 1993,32,3:521-529
 Psychiatric Risk Factors for Teen Suicide:
(1) Major depression (OR=27.0)
(2) Bipolar mixed state (OR=9.0)
(3) Substance abuse (OR= 8.5)
(4) Conduct disorder (OR= 6.0)
 ~31% depressed suicide deaths-
depressed <3 months
Columbia Teen ScreenScreening for Suicide
 Focus: on depression, suicide, substance use
 Need parental and student consent
- Brief self-report screen (Teen Screen)
- DISC if positive screen
- Clinical interview if DISC positive
- Make referral for further assessment
 74% teens with SI not of concern to school
 50% with prior attempt not of concern to school
 30% of highest risk unknown to school or MHP
 www.teenscreen.org
Evaluating a Suicidal StudentThorough Assessment Essential
 (1) Evaluate the suicide attempt thoroughly
 (2) Evaluate for underlying mental illness-
this will determine treatment
 (3) If no underlying mental illness-
- still need to take safety precautions
- get second and third sources to corroborate
- need to look for underlying cause(s)
- look to support the student (and family)
- remain vigilant with close follow up
MDD/Suicide Risk Tip Offs
 Major Problems Home/School/Peers/Job/Hygiene
 Overall Very Negative Presentation
 History of Loss, Abuse, Exposure to Violence,
Significant Life Stress
 “Superachievers” With Vegetative Changes
 Hallucinations
 Substance Abuse
 FH Mood/Anxiety Disorders, Suicide,
Substance Abuse, Jail
Impact Of Depression
Emotional
 Youth
 Family
 Peers
 Classroom
 Workplace
 Juvenile Justice System
Physical Effects
 Obesity
 Smoking
 Alcohol
 Drugs
 Heart Disease
Financial
 19 Million Americans Yearly
 More Than 1 In 5 Oregon Youth
 $23.8 Billion in Absenteeism And Lost
Productivity
 Education System
 SOSCF
 OYA
 Medical Costs
Possible Signs Of Depression
 Low Self Esteem
 Anger Management Problems
 Alienation Or Withdrawal From Others
 Running Away
 School Avoidance
 Decreased Or Failing Grades
 Cruelty To Animals
Possible Signs Of Depression
 Gang Involvement
 Violent Behavior
 Fire Setting
 Legal Problems
 Early Pregnancy
 Nutrition Problems / Obesity
 Physical Health Problems
Possible Signs Of Depression
 Becoming A Smoker
 Using Alcohol Or Drugs
 Homicide Attempts
 Death By Homicide
 Suicide Attempts
 Death By Suicide
Why Youth Become Depressed
Biopsychosocial Approach
 Biological
 Psychological
 Social
Depression Is A Medical Illness
Evaluating Suicidal Thinking
 Look for in times of stress- empathic connection-
“Some teens will think about hurting or killing
themselves.”
 “Have you ever felt like hurting yourself?”
 “Have you ever felt like killing yourself?”
 “Have you ever wished you were dead?”
 Look at non-verbal cues in response
 “Ever had a plan? Would you be able to?”
 “What kept you from doing it?”
 “Ever try to kill yourself?Tell me what happened.”
 “Anyone in your family attempt / die by suicide?”
Evaluating a Suicide Attempt
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Connect in non-judgmental manner
What was done? Lethality? Perceived lethality?
When?
Where?
With whom? CONTEXT OF RELATIONSHIPS
Why then? IDENTIFY STRESSOR(S)
How long planned? The final straw?
What did student hope would happen?
Who else knows?
CUTTING BEHAVIOR- TIP OF ICEBERG
Evaluating Past Attempts
 Identify each attempt
-lethality
-context of relationships
-theme with stressors
-awareness/reaction of others?
-receive treatment?
-type of treatments? Compliant? Helpful?
Evaluating a Suicide Attempt
 Getting a Second (and third) Informant
 Issues of Safety- Loss of confidentiality yet
need to maintain alliance
 Empathic Connection with StudentCan student put self in parent/peer/school
shoes in looking at student’s self-harm?
Want student to understand why you are looking
to get support for the student
Major Depressive Episode
 Represents A Change
 2 Weeks Or Longer
 Depressed Or Irritable Mood
 Loses Interest In Most Activities
 Most Of The Day, Nearly Every Day
 Causes Problems
 Need 5 Or More Symptoms
Depressed Or Irritable Mood
 Easily Irritated
 Rebellious Behavior
 Rarely Looks Happy
 Crying Spells
 Wears Somber Clothes
 Music Has Depressing
Or Violent Themes
 Friends Are Depressed
Or Irritable
Decreased Interest
 “I’m Bored”
 Spends Much Time In Their Room
 Declining Hygiene
 Changes To More Troubled Peer Group Or
Activity
Change In Appetite Or Weight
 Being A Picky Eater
 Eats When Stressed
 Quite Thin Or Overweight
Changes In Sleeping Patterns
 Delayed Sleep
 Multiple Awakenings
 Sleeps More Than Normal
Psychomotor Agitation Or
Slowing
 Agitated
 Always Moving Around
 Moping Around The House Or School
Fatigue Or Loss Of Energy
 Too Tired To Do Schoolwork, Play or Work
 Comes Home From School Exhausted
 Too Tired To Cope With Conflict
Feelings Of Worthlessness Or
Inappropriate Guilt
 Sees Self As “Bad” Or “Stupid”
 No Hope Or Goals For The Future
 Always Trying To Please Others
 Blames Self For Causing Divorce Or Death
Decreased Concentration
 Often Responds “I Don’t Know!”
 Takes Much Longer To Get Work Done
 Drop In Grades
 Headaches, Stomach aches
 Poor Eye Contact
Recurrent Thoughts Of Death Or
Suicide
 Giving Away Personal Possessions
 Asks If Something Might Cause Death
 Wanting To Join A Person In Heaven
 “I’m Going To Kill Myself”
 Actual Suicide Attempts
The Blues vs. Depression
 Normal Reaction
 Medical Illness
 Hours-Days
 Weeks-Years
 Affects Mood Briefly
 Mood, Thinking, Body
 Not Cause Suicide
 Good Listener Helps
Functions
 Possible Suicide
 Needs Psychiatric
Treatment
Evaluation Of Depression
 Biopsychosocial Approach is Essential
 Identify Interests/Strengths and Use in Tx
 Distinguishing Normal vs. Abnormal is Critical
(e.g. sleep, bereavement, problems created)
 Determine (Impairment of) Function in Settingshome, school, peer activities, job
 Recognize Cultural Context
 Who Does the Student See as an Ally?
 Ask About Mania
 FH Can Make a Big Difference- now and in future
Substance
Use/Abuse/Dependence
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In utero Exposure?
Cigarettes/Alcohol/Drugs
Current Extent of Use/ Most Recent Use
Specific Use With Suicidal Ideation/Action
Problem Pattern of Use
- Legal Problems
- Failure to Fulfill Roles
- Recurrent Use Despite Problems
 Like Fuel to the Fire of Depression!
Completing The Evaluation
 Screening Q’s- Anxiety Disorders
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Psychosis
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ADHD
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Autism Spectrum Disorder
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Conduct Disorder
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Eating Disorder
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Sleep Disorder
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Personality Traits
Completing The Evaluation
 Past Psychiatric History
 Medical History- updated complete PE
 Developmental History
 Family History- Psychiatric and Medical
 Social History
 Mental Status Exam
Case Study
 High school student, h/o ADHD
 C.C.: gradual decline academically
h/o B/C’s, now D/F’s
stimulant med since age 8, helpful
now withdrawn, sad, poor hygiene
Goth attire, hair dyed black
 Diagnosis?
Evaluating Risk for SuicideLook at the Big Picture
 Low or Moderate Risk
- May have voiced suicidal thoughts but
no plan or access
- No past attempts
- Minor impairment in functioning
- Actively involved parents, good support
Evaluating Risk for SuicideLook at the Big Picture
 Extreme Risk
- Voiced active intent
- Had recent serious attempt
- May or may not have had past attempts
- Severe impairment in functioning
- Has access to lethal means
- Stressed family
Completing The Evaluation
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Sharing Your Impression
Recognizing This is a Tough Time
What Happened Was Serious
Help Student Understand Support Needed
Student Needs to Keep Self Safe
Treatment Will Be Essential
Will Need to Notify Parents, School Admin
How is Student Responding to Discussion?
Documentation
 Needs to be timely and legible
 Estimate:
-degree of risk
-known data
-basis for diagnosis
-planned interventions (e.g., consultation,
referral, notify parent/admin, med, follow-up)
 Develop (or update) treatment plan
Treatment
Safety
 Eliminate Access To Guns And Sharp Objects
 All Medications In Locked Cabinet
 Eliminate Hanging Materials
 Appropriate Support and Supervision
 Psychiatric Hospitalization May Be Necessary
 Intensive Services May Be Needed
 Don’t rely on a “safety contract”
TreatmentSafety on Ongoing Basis
 Close and Frequent Reassessment
 Has the student and family kept their word?
 Recognize the Teen Life and Mind-
NOT STATIC!
 Anticipate Future Stressors- preparing the
student to react safely
Treatment
 Reestablishing Connections:
- with family, school, friends (psychosocial)
- between neurons (biology)
TreatmentFocus on Relationships
 Utilizing Interests/ Strengths
 Individual / Family / Group Therapy
 Identify Possible Depression In Other Family
Members
 School Support
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Appropriate Expectations
Peer Mentor
Eliminate Harassment if Present
Special Education
Treatment
 Develop Interests
 Physical Exercise
 Good Role Models
 Spiritual Support
 The Dougy Center
 Support Groups
(e.g. OFSN, NAMI)
Treatment- Sleep
 Good night’s rest essential
 Review what’s normal vs. abnormal, how
impacts the student (and others)
 Focus on reprioritizing student’s life to get
sleep
 Focus on good sleep hygiene
 If not improving, consider medication
Treatment
Medication
 Rarely “The Answer”
 Keep In Mind Target Goals
 Takes Weeks To Months
 Fluoxetine
 Other SSRI’s
 Wellbutrin SR/XL
 Others
Prescribing Meds in Children
 Signs and Symptoms Should:
-Cause significant disturbance or distress
-Clearly impair expected, developmentally
appropriate functioning
-Be able to respond to medication
intervention based on research literature
Key Principles
Monitoring Meds in Children
 PARQ conference essential, need to document
 Meds should never be the sole treatment if
problems exist
 Recent complete physical exam essential
 Psychotropic treatment begins with appropriate
diagnosis and symptom assessment
 Regular appts., good student/parent and
practitioner communication encouraged
Key Principles
Monitoring Meds in Children
 Start low, go slow, encourage patience
 Don’t stop halfway with treatment if no
side effects
 Regular communication with tx providers
 Multiple meds may be the norm when
functioning severely impaired
 Parents should be involved with monitoring
Treatment of Adolescents
With Depression Study (TADS)
 439 teens, ages 12-17
 Dx of MDD at consent and baseline, at least
2 of 3 contexts for >5 weeks
 Excluded dx’s: bipolar, thought d/o, PDD,
substance abuse/dependence
 Excluded if hosp for danger within 3
months or “high risk” related to SI/attempt
 Excluded if past poor response to CBT or
fluoxetine
TADS
 Randomized
- Cognitive behavior therapy (CBT)
- Fluoxetine (initial 10mg/d, up to 40mg/d)
- CBT and fluoxetine
- Placebo
 Outcome: CDRS, CGI, SIQ-Jr
 Baseline, week 6, week 12
TADS
 Major Depressive Disorder
- 71% improved with both
- 61% improved with fluoxetine alone
- 43% improved with CBT alone
- 35% improved with placebo
 Baseline: 29% had significant SI
 End of study: 10% had SI
 No deaths by suicide
Antidepressants in Teens
 Prozac (fluoxetine)
- FDA- approved in teen depression
- more effective than placebo
- low lethality in overdose
- FDA- approved for anxiety (OCD)
Antidepressants in TeensBlack Box Warning
 Review of 23 Clinical Trials, 4300 kids
 Studies Involving Nine Antidepressants
 Spontaneous Sharing of Suicidal Thoughts
- 2% on placebo had SI/behavior
- 4% on antidepressants had SI/behavior
- NO deaths by suicide
Antidepressants in Teens
 Tricyclic antidepressants (Imipramine,
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Desipramine, Amitriptyline)
- No more effective than placebo for
depression
- May be lethal in overdose
- Avoid with suicidal teens
FDA- Black Box Warning
Antidepressants in Teens
 - Must balance risk with clinical need
 - When started or dose increased, observe
closely for worsening, suicidality,
unusual behavior change
 - Advise students/families of need for
close observation and communication
with prescriber
 - Applied warning to all antidepressants
Treatment- Cutting Behavior
Without Underlying Illness
 Do family, school, peers confirm:
- no underlying mental illness? No suicidal intent?
- no past suicide attempts? No access to means?
- underlying reason(s) for cutting? Address these.
- consider psychiatric consultation
 Discuss cutting negatives:
- damage, infection, scar
 Discuss safe ways of expression
 Determine how to motivate change-e.g. poor judgment so no driving privileges
 Remain vigilant, close follow up
Hesitant Families
 Don’t Recognize The Warning Signs
 Believe It’s Part Of Normal Adolescence
 Believe There Is A “Good Reason” To Be
Depressed
 Might Be Viewed “Crazy” Or “Weak”
 Lack Insurance
 Youth Refuses Treatment
Conclusions
 Youth Depression/Suicide Have a Major Impact
on Oregon
 Make Use of Risk and Protective Factors of
Suicide
 Evaluate the Suicide Attempt and Underlying
Mental Illness
 Focus on Safety and Reestablishing Connections
 Remain Vigilant and Supportive
 Youth Suicide Can Be Prevented!
References
 Gould, M., Greenberg, T., Velting, D., &
Shaffer, D.(2003), Youth suicide risk and
preventive interventions: a review of the
past 10 years. J Am Acad Child Adolesc
Psychiatry 42:386-405.
 Muzina, D.J. (2007), suicide intervention:
How to recognize risk, focus on patient
Safety. Current Psychiatry 6:30-46.
References
 Centers for Disease Control and Prevention,
Suicide Trends Among Youths and Young
Adults Aged 10-24 Years- United States,
1990-2004. MMWR 2007; 56:905-908.
- 2005 Youth Risk Behavior Survey
www.cdc.gov/HealthyYouth/yrbs
- 2005 Violent Death Reporting System
www.oregon.gov/DHS/ph/ipe/nvdrs/index.shtml
References
 2007 Oregon Healthy Teen Survey:
www.dhs.state.or.us/dhs/ph/chs/
youthsurvey/index.shtml
 2005 Adolescent Suicide Attempt Data
www.dhs.state.or.us/dhs/ph/chs/data/
arpt/05v2/chp8toc.shtml
References
 Lazear, K., Roggenbaum, S., & Blasé, K.
(2003). Youth suicide prevention schoolbased guide-Overview. Tampa, FL: Dept.
of Child and Family Studies, Division of
State and Local Support, Louis de la Parte
Florida Mental Health Institute, U. of
South Florida.
Special thank you to Lisa Moody,
Oregon Family Support Network