Melissa Deuter, MD€¦ · Addressing Mental Health Needs in Children Before They Reach the ED...
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Melissa Deuter, MD
Transcript of Melissa Deuter, MD€¦ · Addressing Mental Health Needs in Children Before They Reach the ED...
Melissa Deuter, MD
Dr. Deuter has disclosed that neither she nor members of her immediate family have any actual or potential conflict of interest.
Why talk about adolescent depression and suicide?
Rising rates of Depression Rising Rates of Self‐Harm Rising Rates of Suicide
What causes depression in teens? Genetics? Stages of brain of development? Stresses?
Overscheduling Pressure to perform academically Social media
Trauma and abuse” Elevated ACES scores
What causes depression in teens? Genetics? Although we talk about genetics in depression, the search for depression genes has not yielding the answers as expected
What causes depression in teens? Stages of brain of development?Probably play a major role in the onset of symptomsPruning: Trimming back of connections in the brain related to puberty
What causes depression in teens? Stresses? Overscheduling Pressure to perform academically Social media
There is evidence that that each of these factors play a role in stress and rising rates of youth depression and suicide, although there is no single factor that stands out in research… except:
What causes depression in teens? Trauma and abuse”
Elevated ACES scores
Most strongly correlated as an underlying cause of mental illness in all age groups
Elevated ACES scores
Developmental Stages Preteen Hormone changes
Affect moods, thoughts, and overall mental health
Tricky stage because: Still a child in many aspects Teen‐like elements creep in
Developmental Stages Preteen Caregivers must balance increasing need for independence with new
safety concerns: Risk taking Drugs, alcohol, sexual behavior
Body image Social media Cyberbullying Grooming by abusers
Developmental Stages Preteens Mental health symptoms may be induced by social stressors
Stressors that occur outside the reach or awareness of caregivers Peer conflicts Social rejection Experiences for which kids are not developmentally ready (secrets, sex, etc.)
Developmental Stages Teen
Adult‐like in many aspects Differs from adults in: Risk taking and reward seeking Experience Primary fears Social rejection versus physical danger
Developmental StagesTeens Fear Social rejection more than death by shark attack Steeped in Peer Culture (which doesn’t include parents) Brain undergoes Pruning Round 2
Can lead to moodiness Changes in behavior Onset of mental health symptoms
Developmental Stages Teen Caregivers:
Supervise/maintain safety Explicitly teach emotion regulation Provide opportunities for safe practice Teach skills for adulthood Prepare for independence
Developmental StagesTeensMental health symptoms may be induced by Brain changes (pruning) Genetics Stressors (peer relationships, family, academics) Substance use
Developmental StagesEmerging Adult Teenager Part 2 Age 18‐29 The brain is not finished yet Social roles and dependency
Developmental Stages Emerging Adult
May be legally adult, but still dependent
Parents Focus on Teaching Adult skills Accountability & responsibility Transition to Independence
Developmental StagesEmerging AdultCaregivers: Have to make their own rules Level of dependency varies
Emotional/financial Stage of gradually letting go
Developmental StagesEmerging AdultMental health symptoms may be caused by Failure to navigate role transitions Stressors (intense life change) Brain changes Genetics Substance use
Teen depression and teen suicide Are on the rise Underlying causes for the increase are not fully known
Pediatric emergency department visits for deliberate self‐harm rose 329% from 2007 to 2016, while emergency visits for children with a substance use disorder grew 159%, according to a study published online in the journal Pediatrics.
“Over the 10‐year study period, pediatric emergency department visits were stable; however, pediatric emergency department visits for all mental health disorders rose 60%,” researchers reported. “Importantly, we observed a threefold increase in emergency department visits for deliberate self‐harm, similar to trends reported by authors of other studies, suggesting that children are increasingly engaging in self‐harm.”
The 159% increase in pediatric emergency department visits for a substance use disorder was accompanied by a 39% decrease in visits for children with alcohol‐related disorders over the 10‐year period. With continued escalation of the opiate epidemic, the increase in substance use disorder visits despite a decline in alcohol use disorder visits warrants attention and further investigation, researchers advised.—Jolynn Tumolo
Lo CB, Bridge JA, Shi J, Ludwig L, Stanley RM. Children's mental health emergency department visits: 2007‐2016. Pediatrics. 2020;145(6):e20191536.
Suicide 2nd leading cause of death in youth ages 15‐19 (CDC, 2017) In 15‐24 year olds, males are 3.6 times more likely to die by suicide
than females. In the general population. . .
9% of teens have made an actual suicide attempt 19% of teens have reported suicidal ideation
In teens with depression. . .35‐50% of depressed teens have made a suicide attempt
2008 to 2015: Number of Youth Seen in Children’s Hospitals for Suicidal Ideation or Self‐Harm Doubles Annual percentage of encounters identified as suicidality or self‐
harm more than doubled over the study period (Plemmons et al., 2018)
Increasing from 0.67 percent in 2008 to 1.79 percent in 2015. Significant increases in visits were noted in all age groups but were
higher among older children
Risk Factors for Suicidality Current or lifetime mental health condition (mood disorders most
common) History of previous attempts or self‐injurious behavior High situational stress Insomnia Parental psychiatric conditions Family discord Childhood maltreatment history History of peer victimization (bullying)
LGBTQ people aged 10–24, suicide is one of the leading causes of death
LGBTQ youth are 4 times more likely and questioning youth are 3 times more likely to attempt suicide, experience suicidal thoughts or engage in self‐harm than straight people
Between 38‐65% of transgender individuals experience suicidal ideation
Individuals who faced rejection after coming out to their families were more than 8 times more likely to have attempted suicide than someone who was accepted by their family after revealing their sexual orientation
Clinical indicators of increased risk:HopelessnessImpulsivityLack of affect regulationPoor problem‐solving skills Social skills deficitsHostility and aggressionDrug or alcohol abuse
Brent et al. (2000) found that suicide completion risk is increased if family has a handgun in the home
Peer and media influence (“suicide contagion”) For recent review, see Cha et al., 2018, The Journal of Child Psychology & Psychiatry
Protective Factors for Suicidality Positive relationship with family Positive connection between child and school; adult and work
Academic or work success
Pro social peer group Religious affiliation Fair number of reasons for living • Future goals Treatment adherence
Addressing Mental Health Needs in Children Before They Reach the ED February 20, 2020 Diane Felder, MD
Across the country, hospital emergency departments (EDs) are experiencing a sharp increase in the number of children and teens seeking treatment for mental health conditions.It’s a sign that children and teens aren’t getting the help they need for behavioral health conditions until these conditions reach a critical state. It’s also a reflection of both the stress children and teens face—particularly in an era of rapid‐fire social media exposure—and their increased awareness of the impact of anxiety and depression on their health.
EDs are ill‐prepared to treat youth who struggle with mental health challenges. They typically lack the specialized expertise to properly diagnose and assess treatment options for adolescents in mental health distress. Even when children with anxiety and depression are properly identified, a shortage of behavioral health specialists means kids may not get the help they need in a timely fashion, especially if they live in rural areas or are economically disadvantaged. The impact: repeat ED visits by teens for mental health challenges and high rates of ED‐to‐inpatient admissions.
Recent data point to the complexities of treating mental health issues among youth who present in the ED:
Major depressive disorder was the most common diagnosis among youth 18 and younger in Colorado, according to a three‐year review of claims.
Nearly 60% of mental health‐related ED visits among teens and young adults in California involve self‐harm.
Teens who come to the ED with self‐harm injuries face increased risk for repeat ED visits for self‐harm or suicide attempts and are eight times more likely to die from suicide. They are also three times as likely to die within five years of any cause, one study shows.
Rising rates of mental health ED visits among kids in California correspond with higher rates of suicide among teens and young adults.
For EDs in rural areas or in towns with limited access to behavioral health specialists, virtual care can help bridge the gap. Another option: digital mental health modules that make it easy for children and their parents to access behavioral health services jointly and independently. It’s an approach that eases convenience for children and teens in working families, as barriers such as lack of transportation and work conflicts can impede access to mental health services.
Public health concerns Anti‐stigma places mental health distress front of mind Sensationalizing suicides of public figures Stressed out teens, pressured
Public health concerns
Medications May not work the same in teens as adults Kids who begin treatment with an antidepressant can sometimes get
worse
Assessment of treatment of the individual patient
Triage (Teach to parents) Basic first aid
Bad day or bad week Time to treat with medical/psychological interventions
Problem not resolving, or too difficult to figure out Crisis
Danger
Basic first aid (Teach to parents) Bandage their emotional wounds and get them back on their feet Soothe when kids are struggling at any stage Comfort and supervise Teach skills /emphasize important learning opportunities
Recommend counseling if: Kid doesn’t seem okay emotionally May need a diagnosis Problems are beyond caregiver expertise Need coping skills Caregivers feel overwhelmed or don’t have the answers Communication breaks down Caregivers are worried and uncertain what’s going on
What is a crisis? Immediate threat to safety of kid or someone else Family cannot manage without help Requires ER or hospital
#1 Refer teens with diagnosed mental health issues to a psychotherapist Always, 100% of the time Therapy is the first line intervention for teens Safest course of action, and as effective as medications Find someone who routinely works with teen
Skills based therapies like CBT, DBT, and Mindfulness Teach coping skills Distress tolerance Mood Re‐regulation
IF medications are necessary Plain old vanilla Fluoxetine and Sertraline In low to medium doses More is not better Don’t get fancy Don’t be tempted to give newer (unproven) meds because you have
samples, or have seen those meds work in adults
Fluoxetine Start at 10mg Dose 10‐40mg in the morning Follow weekly for the first month
Sertraline Start 12.5‐25mg Dose morning or evening Follow weekly for first month
Brown‐Stanley Safety PlanAbout Safety PlanningThe purpose of the Safety Planning Intervention is to provide people who are experiencing suicidal ideation with a specific set of concrete strategies to use in order to decrease the risk of suicidal behavior. The safety plan includes coping strategies that may be used and individuals or agencies that may be contacted during a crisis. The Safety Planning Intervention is a collaborative effort between a treatment provider and a patient and takes about 30 minutes to complete. The basic steps of a safety plan include (a) recognizing the warning signs of an impending suicidal crisis; (b) using your own coping strategies; (c) contacting others in order to distract from suicidal thoughts; (d) contacting family members or friends who may help to resolve the crisis; (e) contacting mental health professionals or agencies; and (f) reducing the availability of means to complete suicide.
Brown‐Stanley Safety PlanStep 1: Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be developing:1._________________________________________________________________________________________________________________________________2.________________________________________________________________________________________________________________________________3.________________________________________________________________________________________________________________________________
Brown‐Stanley Safety PlanStep 2: Internal coping strategies – Things I can do to take my mind off my problems without contacting another person (relaxation technique, physical activity):1.___________________________________________________________________________________________________________________________________________2.___________________________________________________________________________________________________________________________________________3.___________________________________________________________________________________________________________________________________________
Brown‐Stanley Safety PlanStep 3: People and social settings that provide distraction:1. Name: __________________________________________________Phone: _________________________________2. Name: __________________________________________________Phone: _________________________________3. Place: ___________________________________________________ Place: __________________________________
Brown‐Stanley Safety PlanStep 4: People whom I can ask for help:1. Name: ____________________________________________________ Phone: ________________________________2. Name: ___________________________________________________ Phone: _______________________________3. Name: ___________________________________________________ Phone: _______________________________
Brown‐Stanley Safety PlanStep 5: Professionals or agencies I can contact during a crisis:1. Clinician Name: ____________________________________________ Phone: ______________________________Clinician Pager or Emergency Contact #: _________________________________________________________2. Clinician Name: ____________________________________________ Phone: ______________________________Clinician Pager or Emergency Contact #: _________________________________________________________
Brown‐Stanley Safety PlanStep 5: Professionals or agencies I can contact during a crisis:1. Clinician 3. Local Urgent Care Services: __________________________________________________________Urgent Care Services Address: _________________________________________________________________Urgent Care Services Phone: _________________________________________________________________4. Suicide Prevention Lifeline Phone: 1‐800‐273‐TALK (8255)
Brown‐Stanley Safety PlanStep 6: Making the environment safe:1._________________________________________________________________________________________________________________________________2.________________________________________________________________________________________________________________________________
Refer to child psych, even if it’s for one‐time consultation and treatment recommendations for you as treating doctor
Best Strategies for primary care practitioners Screen Teach parents to triage and offer mental health first aid Stay up to date about new risks (new apps that are used for
dangerous purposes) Listen to teens about what they experience, and what they need Make conversations about mental health normal and safe Believe teens who say they are facing problems
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