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7/6/2011

When Everything Seems Unreal: Psychosis at School

Objectives Review the history of psychosis and psychotic disorders, current definitions and symptoms.

S bi Abidi Sabina Abidi, MD MD, FRCPC IWK Health Centre Dalhousie Department of Psychiatry

y Know the markers that helpp identifyy youth at risk for psychosis and psychotic disorders. Discuss the importance of early identification and treatment of youth with psychosis and psychotic disorders.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Psychosis – What Is It?

“So…let’s talk about psychosis…” What IS IT? Who knows? Definition Cases

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

1


7/6/2011

Psychosis A BRAIN DISEASE

Psychosis Psychosis is a brain disorder. A medical illness - affects more than 3000 Canadians at any point in time a serious disturbance in an individual’s reality testing A process whereby the senses are distorted, making it difficult for the person to distinguish between real and unreal Affects a person’s ability to think, perceive and act Thinking, feelings, perception and behavior affected

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Normal Teen Brain Development

Onset of Psychiatric Disorders in Adolescence Prevalence in Childhood

Prevalence in Adolescence

Depression (1-2%) Bipolar Disorder (rare) Psychosis (rare) Anxiety Disorders (6-8%) Anorexia Nervosa (rare)

Depression (6-8%) Bipolar Disorder (1%) Psychosis (1%)?? Anxiety Disorders (10%) Anorexia Nervosa (0.2%)

Total (7-10%)

Total (15 – 20%)

Lenroot & Giedd (2006)

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

y p disorders per 1000 children/adolescents

Symptoms of Psychosis

In males particularly, psychotic disorder(s) is a major Boys disorder of adolescence Girls

8

Hits adolescents in their prime – leads to a disruption in education-attainment, career building, employment Alters relationships relationships, family interactions, interactions Alters sense of self, esteem, productivity

6

4

What are common types of psychotic experiences?

2 (Reprinted) Spady et al. Prevalence of Mental Disorders in Children Living in Alberta, Canada, as Determined from Physician Billing Data. 2001.Arch Pediatr Adolesc Med. 155: pp.1156.

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Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

Positive Symptoms

Positive symptoms include: Hallucinations

Positive symptoms are things added in to people people’ss senses/thoughts/feelings/behaviour that are not normally there.

Delusions Thought Disorder Disorganized or Unusual behaviour

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Hallucinations Hallucinations can affect all senses: Sensory perceptions that occur in the absence of any real stimulus but appear to be the result off faulty f l messages in i the h brain. b i Hearing (auditory) Seeing (visual) Touch (tactile) Smell (olfactory) Taste (gustatory)

Delusions Fixed beliefs created by illness which are held only by the person experiencing the psychosis. These can include: B li f in Belief i special i l abilities bili i off self lf or others h Belief that physical health is changed Belief that unusual coincidences have a special importance Belief that one is being controlled

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Thought Disorder

Disorganized or Bizarre Behaviour:

Problems organizing thoughts. Thoughts coming to fast or too slow. Problems thinking and therefore speaking logically. Problems keeping on topic.

Everyone’s behaviour is a response to how they interpret what is going on around them. People with psychosis may behave differently than they usually do. may become extremely active or agitated, may laugh inappropriately or display inappropriate appearance, hygiene or conduct. may behave in ways that reflect their thoughts

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Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

Negative Symptoms

Negative symptoms may include: Problems getting motivated

Negative symptoms refer to behaviours or experiences i that th t have h been b reduced d d or lost l t because of the illness.

Problems taking joy in things Problems getting words out Seeming flat and blunted

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Cognitive Symptoms Refers to problems with learning and concentration Find it difficult to focus and pay attention find it hard to filter out all the various stimuli in their environment. (may be highly sensitive to sounds sounds, lights and even the regular activities occurring in their immediate environment.) Easily distracted Trouble with working memory Classroom/Tim’s example

Cognitive Symptoms find the ability and speed in processing information and reaction time may be slowed experience difficulties with memory, problem solving l i ability bilit andd judgement. j d t find it hard to organize activities in their lives, for example to manage the time and tasks needed to get their schoolwork completed.

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Mood Symptoms The person can be:

Anxious, irritable D Depression i Anger and unpleasant behaviour Rapid changes in mood

Key Point Sometimes people with psychosis cannot recognize that they are ill and believe that nothing is wrong with them. This lack of insight can make it hard to get the person to accept treatment.

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

Memory deficits Poor attention Poor organization Concrete thinking

The psychosis continuum or spectrum of symptoms

Cognitive deficits

Psychotic experiences and impairment

Negative symptoms

Mood disturbance

Lack of: Energy Motivation Drive Socialization reactivity Emotion Slowed thoughts/speech

Anxiety Depression Irritability Rapid swings anger

disorder

Positive symptoms

Hallucinations Delusions Disorganized and Bizarre behavior

Psychotic disorder (schizophrenia)

Psychotic y like experiences p (normal variant) PLEs associated with other disorders

PLEs + markers of risk

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Types of disorders which present with symptoms of psychosis Schizophrenia Schizophreniform Disorder Brief Psychosis Schizoaffective Disorder P h i NOS Psychosis Delusional Disorder Drug Induced Psychosis Bipolar Disorder (with psychosis) Psychotic Depression Secondary to a medical conditio

To be normal in adolescence it itself abnormal A Anna F Freud d

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Prevalence of children’s mental disorders in Canada any disorder any anxiety disorder ADHD conduct disorder

Why the focus on psychosis/psychotic disorders?

any depressive disorder substance abuse PDD OCD eating disorder Tourette syndrome schizophrenia bipolar disorder

0

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estimated prevalence % Adapted from Table 2. Waddell et al. 2002. Child Psychiatric Epidemiology and Canadian Public Policy-Making. The state of the science and the art of the possible. Can J Psychiatry

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Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

• Common among prison and homeless populations • 80% will abuse substances during their lifetime

•More hospital beds in Canada are occupied (8%) by people with schizophrenia than by sufferers of any other medical condition

• 15 15--25x more likely to die from a suicide attempt than the general population • 10% or patients die from suicide most often in the first 10 years after diagnosis

“Youth’s Greatest Disabler”

World Health Report 2001 (WHO, 2002) schizophrenia and other forms of psychoses affecting young people rank third worldwide as the most disabling condition

If left untreated, there is a continuing slow increase in impairment for years

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Epidemiology Schizophrenia causes massive human and financial costs Affects more than 1% of the world’s population

Patients with schizophrenia itself die 12-15 years earlier before the average population – some quote up to 25 years earlier

Affects all races, ethnicities, cultures equally Schizophrenia causes more lives lost than cancer and physical illness

More severe presentation in men

Mostly due to poor medical care, suicide and deteriorating physical illness

Allow for a more broader definition of psychotic disorder (include psychosis NOS, brief episodes, delusional disorder) lifetime rate increases to 2-3%

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

The vast majority of psychiatric disorders have their onset in adolescence The age of maximum incidence for schizophrenia sc op e a in males a es iss 15-25 5 5 yea yearss and a d 188 35 years in females

Life potential (social, occupational, financial…)

Onset Of illness

Successive illness relapses

If left untreated, there is a continuing slow increase in impairment for years.

17 Age

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Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

Outcomes of psychiatric illness in adolescence Attainment – in life

X – onset of psychiatric illness

X – onset of treatment effort

X – delay in treatment effort 12

15

20 Time - age

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Psychosis – why/how?

Phases of Illness Birth

First Signs of Illness

Premorbid Phase Prodromal Phase

Onset of Psychosis

First Treatment

Duration of U t t d Untreated Psychosis

Recovery/Stabilization Phase

Residual/Stable Phase

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Etiology Risk Factors Genetic Family history of psychotic disorder/bipolar disorder

Environmental Higher incidence in urban populations Immigrant ethnic groups - social isolation Areas of Social defeat Childhood trauma exposure Cannabis exposure Perinatal factors

There is a definite interplay of genes and the environment

Genetics 50% of identical twins with a twin having schizophrenia will develop the disorder. 13% risk for children with one parents with schizophrenia. 2% risk for first cousins of a person with schizophrenia >1% risk for the general population.

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

Stress-Vulnerability Model of Schizophrenia

It is important to remember that psychosis is not caused by:

High Less severe

Stress

-adverse acute & chronic life events

Family upbringing

Psychotic symptoms

Psychotic-like

- developmental

Symptoms or

challenges

Problems with other people

Prodromal symptoms

No symptoms

Having a “weak” character

Low Low

High Vulnerability

-family history of psychotic disorders -Obstetric complications Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Dopamine in Brain Function

Dopamine Pathways

Dopamine is important in three areas of brain function: Four pathways:

Mesolimbic-frontal cortex circuits

1. 2. 3. 4.

( psychotic symptoms) symptoms).

Basal ganglia (control of muscle movement).

Nigrostriatal Mesolimbic Mesocortical Tuberoinfundibular

Parkinson’s disease; loss of dopamine cells

Hypothalamus-Pituitary (control of the hormone, prolactin).

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Duration of Untreated Psychosis (DUP) Historically youth experience long DUP before coming into contact with psychiatric services 2-5 years Long DUPS translate to very poor clinical and social i l outcomes

TREATMENT

We now know that if this illness is caught early, prognosis can be very positive with effective treatment

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

Rational Therapy for Psychotic Disorder Antipsychotic medication along with therapy/education are the cornerstone of

Antipsychotic Medications All antipsychotic medications influence communication between brain cells involving the neurotransmitter, dopamine.

effective treatment programs when dealing with a known chronic psychotic illness such as schizophrenia

Each medication may also influence a number of other neurotransmitters in the brain, but the effect on dopamine seems to be one common factor in reducing psychosis.

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

First and Second Generation Antipsychotics “Traditional” or “First Generation” antipsychotic medications (1950-1988) (dopamine blockade): Haloperidol, Chlorpromazine, Thioridazine and many others.

Second Generation antipsychotics (serotonin-dopamine antagonism) “Clozapine / Clozaril (1990) Risperidone / Risperdal (1992) Olanzapine / Zyprexa (1996) Quetiapine / Seroquel (1998) Ziprasidone / Zeldox (2008) Paliperidone / Invega (2008) Aripiprazole (Abilify, 2009)

Side Effects First generation (due to Dopamine receptor blockade): Extrapyramidal (movement) symptoms (EPS) Muscle stiffness, restlessness, involuntary movements. Th use off anti-parkinsonian The i ki i “side “ id effect” ff ” meds. d Prolactin (hormonal) elevation. Ammenorhea and sexual dysfunction “Dysphoria” (feeling bad). Difficulty with concentration and memory.

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Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Side Effects Second generation antipsychotics: Sedation (early in treatment) Sexual dysfunction Weight gain y g Metabolic dysregulation Dylipidemia Hypertriglyceridemia Risk for diabetes Cardiac dysfunction Glaucoma Stroke

General Treatment Guidelines Individual basis Try to treat with one medication at a time. If there is an insufficient clinical improvement after 3-6 months, try a different medication. Use continuous treatment with medication for as long as possible.

Extrapyramidal side effects still a concern

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Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

Treatment: How Long? Current guidelines suggest that patients should continue on medication for at least two years after remission (no evidence of any ongoing y p ) symptoms) After 2 years studies show that about 20% may be able to come off of the medication and stay well

Treatment: How Long? 50% of patients who do not take medication in the first year will relapse 40-60% with effective treatment (medicine, therapy, education, rehabilitation) can lead productive lives achieving life goals had prior to the onset of illness

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Key Points Psychosis is treatable. Medication is a necessary, but not sufficient, part of a total treatment plan.

Challenges to Treatment Non-adherence Depression/risk p of suicide

The stress-vulnerability model helps us understand treatment.

Substance use/abuse

Adherence with treatment, including medications, is a critical issue.

Excessive stress/expectations

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Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Definition of Non-Adherence Non-adherence (or non-compliance) means not following the recommended treatment, possibly including a refusal to take medication Taking less than prescribed Taking medication erratically (missing doses) Completely stopping medication

Predictors of Non-Adherence Denial of illness Symptoms of Illness Delusions Depression Cognitive impairment

Belief that medications no longer needed (I’m cured). Attitudes of family and friends

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Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Support Network Stigma Insight Distressed by side effects Drug induced dysphoria (feeling bad) or akathisia (restlessness) Cost of Medication

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7/6/2011

Challenges: Substance Use/Abuse

Depression Major depression during course of illness : 60%

Substance use is very common in first episode psychosis

Post-psychotic Depression: 25% Up U tto 80% Attempted suicide: 25% - 40% Cannabis and alcohol are most frequently abused substances

Successful suicide: 10% - 13%

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Cannabis and Early Psychosis

Common Issues in Recovery

People with psychotic disorders have higher rates of cannabis use than the general population

Daily Life

Relationships

Lack of structure/disorganization Lack of supports required to return to school or work Negative experiences No plan to help recovery Lack of motivation

Cannabis use is associated with poorer functional and clinical outcomes in this population, e.g. greater psychotic symptom severity the effects of which can last up to 4 years later Cannabis misuse associated with 4 times the risk of psychotic relapse One of the strongest predictors or risk factors associated with the onset of psychotic illness

Trying to establish independence from family Loneliness/Separation from social groups Increased anxiety in social groups Difficulties in re-establishing relationships

Recovery takes time

There is little evidence that the high rates if cannabis are is related to selfmedication for distressing symptoms or side effects of meds

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Prevalence of Psychotic spectrum disorders per 1000 children/adolescents Boys

8

In males particularly, schizophrenia is a major disorder of adolescence Hits adolescents in their prime – leads to a disruption in education-attainment, career building, employment Alters relationships, family interactions, support Alters sense of self, esteem, productivity

Girls

6

Why Early Intervention

4

(Reprinted) Spady et al. Prevalence of Mental Disorders in Children Living in Alberta, Canada, as Determined from Physician Billing Data. 2001.Arch Pediatr Adolesc Med. 155: pp.1156.

2

0

Age

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9

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

12

15

18

11


7/6/2011

Phases of Illness

Research has shown that psychotic illness begins to have social and clinical consequences after puberty, in early adolescence even prior to the onset of identifiable psychotic symptoms

Birth

Premorbid Phase

First Signs of Illness

The prodrome

Prodromal Phase Onset of Psychosis

a substantial amount of the disability for which schizophrenia is traditionally heralded accumulates in this stage and may create a ceiling for eventual recovery.

Duration of U t t d Untreated Psychosis

First Treatment

Recovery/Stabilization Phase

shift to honing our ability to identify the markers of the prodrome or high risk presentations of possible transition to psychotic disorder

Residual/Stable Phase

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

• PACE Clinic (Personal Assessment and Crisis Evaluation) – Melbourne, AUS

• PRIME Clinic (Prevention through Risk Identification, Management & Education) – Yale University, US & Toronto, Ontario

Developed and validated criteria which can be applied to a population that is “help-seeking” (already ill to some extent) that might be timed to the onset of psychotic disorder - pick up on subsyndromal psychotic symptoms along with a recent worsening of functioning - goes beyond risk based only on genetic history - for the first time we can track the progression of schizophrenia

“It is not an easy task to recognize psychosis in the early stages and motivate a young psychotic p y person, p who might g have persecutory p y delusions or other delusional beliefs, to accept psychiatric treatment.”

Using these criteria, studies have quoted the ability to predict conversion to psychotic disorder in 11-35% - higher than the general population prevalence of schizophrenia of 1%

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Challenges in identifying the prepsychotic phase

Decide that help is warranted

The earliest symptoms identified are non-specific: Sleep disturbance Depressed mood Anxiety

Only 1 in 6 young people receive adequate care

The Problem:

Decide this is a problem

behavioral disturbance social withdrawal irritability

Want help

In youth, changes that occur as part of the normal developmental continuum ti can complicate li t psychiatric hi t i diagnoses. di Patient P ti t age, gender, developmental stage, identity, culture, belief system are all significant diagnostic and therapeutic factors r=0.00

The differential diagnosis for psychosis is widespread in youth and depends upon a number of environmental factors that must be examined 40% cases – initial diagnosis has cause to be changed in 3 months

Illness

Research studies world wide have shown that 1 in 5 young people have a diagnosable mental illness of some kind

Treatment

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7/6/2011

Recognition of youth in trouble

Recognition of youth in trouble Externalizing disorders

Less than ½ of child & adolescent psychiatric disorders are identified in primary care settings & only a fraction are referred for mental health services

Parent

 

Teacher Teenager

_

Friend Screening Tools Doctor

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Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Recognition of youth in trouble

Internalizing disorders _

  -

//    -

How can you help? Early identification

Direction of help-seeking behavior Help seeking beha behavior ior in adolescents is primarily directed to friends, family and teachers before physicians

What do these youth really look like?

Support R d Reduce stigma/increase i /i acceptance Substance use declining grades/functioning changes in behavior

Help access service/assessment Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Warning Signs Gradual onset of change in behavior, appearance, attitude etc “he’s not himself”, “something’s up with him” Isolation from friends, adopting new/unusual friend group Decline in grades and overall functioning over time Poor hygiene O t or increase Onset i in i substance bt abuse, b esp marijuana ij Odd or bizarre comments, beliefs, behaviors Easily distracted, sensitive to noise/light, wearing headphones often with little eye contact Appearing to be “out of touch” or daydreaming a lot, staring Low mood, frustration, irritability, sadness, confusion Avoiding hallways, crowds, buses Fatigue during day (poor sleep)

QUESTIONS

Studies are now showing with earlier identification there is a decline in the transition rate to psychotic disorder in youth at high risk.

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Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

13


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