B3 Untangling the terrors of

teenage turmoil

Untangling the Terrors of Teenage Turmoil

Dick Churchill, Chair, RCGP Adolescent Health Group

Maryanne Freer, Charlie Waller Memorial Trust Associate

David Shiers,GP Advisor to the National Mental Health Development Unit

Quick Quiz

How many young people have a mental health problem?

How often do young people consult a GP?

What proportion of young people who consult their GP have a mental health problem?

What proportion of young people with a mental health problem are identified by their GP?

What proportion of adult mental health problems start in childhood / adolescence?

Quick Quiz

How many young people have a mental health problem?

10 - 20%

Quick Quiz

How often do young people consult a GP?

2-3 times a year

Quick Quiz

What proportion of young people who consult their GP have a mental health problem?

About 1 in 3

Quick Quiz

What proportion of young people with a mental health problem are identified by their GP?

About 1 in 3

Quick Quiz

What proportion of adult mental health problems start in childhood / adolescence?

More than 50%

Summary

Lots of young people have mental health problems.

Many go unrecognised until they cause problems in adulthood.

Young people who visit their GP are more likely to have mental health problems.

Zoe’s Story

Zoe Craddock is 15 and lives with her mother, step-father and step-brother.

Zoe isn’t very happy at home; she seems to get ill very often, and has to have time off school.

Her mum isn’t very sympathetic… she brings her to the GP with yet another sore throat and talks about how frustrated she is. Zoe remains silent!!

What’s going on?What would you do next?

Presentations in General Practice

Physical symptoms – headaches, abdominal pain, unexplained pain, sleep problems.

Frequent attendance with varying problems.

Parental concerns – behaviour / conflict, educational issues

Emotional – mood swings, tearfulness, anxiety

Self-harm – overdose, cutting.

Causes of under-detection in Primary Care

Key symptoms not presented or apparent

Lack of training, experience or confidence – fear of opening ‘Pandora’s box’

Belief that problems will be transient

Treatments and / or services are not readily available should a diagnosis be made

Avoidance of potential stigmatisation as a result of a mental health ‘label’

Perceived parental resistance to a mental health diagnosis

Problems incorrectly identified as being part of normal development.

Zoe’s Story continues… A week later Mrs Craddock comes to see you – she is very, very

concerned. She has left her husband at home to look after Zoe; She says ‘“WE’RE DESPERATE - THIS JUST ISN’T OUR ZOE”

Mum tells you how its been a bad week – Zoe is refusing school - won’t see her best friend – and she’s pacing her room into the early hours. She has spoken to Zoe’s teacher - Zoe won’t go out at break - sits by herself, remote, and won’t open up. There seems no obvious reason - no ‘friend’ crisis.

The night before, prompted by Zoe muttering loudly, mum entered her room to find Zoe under the bedclothes, trembling with fear. Zoe had screamed “leave me alone!”. It was 2am – they then stayed awake all night. Zoe couldn’t be consoled.

“There’s no problem at home – it’s just Zoe.. We all got on so well before – it now feels like we’re the most unhappy family I have ever known?” “What have I done? I must be an awful mum”

You decide to visit Zoe at home later that day. Mum takes you up to her bedroom where she is sitting on the bed. She is dishevelled, restless and pre-occupied, avoids eye contact, takes several seconds to reply “I’m OK” to your “how are you doing?”.

You check if she wants mum to stay - you sit down facing Zoe and gradually she comes round a little. She admits she can’t sleep. She can’t explain why she feels so bad. No obvious fall-out with her two best friends - but she feels wary of them and thinks they are talking about her behind her back.

What are your concerns?

Are there more questions to ask?

What would you do now?

What explanations should I consider?

Adolescence and emerging adulthood: a high risk time for mental disorders

“Roughly half of all lifetime mental disorders in most studies start by the mid-teens and three quarters by the mid-20s. Later onsets are mostly secondary conditions. Severe disorders are typically preceded by less severe disorders that are seldom brought to clinical attention”

Kessler et al, Current Opinion Psychiatry, 2007

Contrast with other disabling conditions

A first episode of psychosis?

GP guidance

Rarely presents in ‘neat parcels’

Be prepared to keep a watching brief

Take family concerns seriously

Think about risk

Diagnostic uncertainty

“Would I be surprised if this turned

out to be psychosis within the next

6 months”

A first episode of psychosis?

What should I do?

ACT!ACT! Early detection of psychosis and appropriate treatment are highly effective.

In England this specialised approach (14-35 yr olds) is usually provided by Early Intervention services. Make sure you know how to access them.

GPs are key pathway players for people like Zoe and her family

Zoe’s frank delusional symptoms = RED ALERT RED ALERT - Don’t assume ‘adolescence’ or ‘drug

misuse’- Don’t just wait and see if it will go away

So what is the essence of Early Intervention in Psychosis?

A mum’s view...

“The shock of my second son developing psychosis at the age of 15, as his elder brother had fifteen years earlier, pushed me into a deep depression. Our eldest son is still unable to work because of his health and …has never been well enough yet to achieve his potential…”

So how did we get to today, three years on,

where hope is back?

Michelle Gladden (2008)

A family centred approach / hopeand optimism about potential for recovery…

“EIS involved the whole family in L’s recovery… EIS gave us an individual map to help us find the way out of the hopeless place we were in” His hopes for the future are back …”

Evidence based interventions / cost effectiveness...

“Earning a place on a Masters Degree in Physics with Particle Physics and Cosmology at the University of Birmingham is pretty hard evidence that EI and family therapy has been worth any extra initial cost to the NHS”

Early detection / working acrosstransitions and agencies…

“…our GP made a very quick referral to CAMHS and L. was referred to EIS. We had support from CAMHS and EIS EIS helped us to work with other agencies to put in place much needed additional support. ”

A focus on broader outcomes /

supporting ordinary lives …

“L. is about to start University after managing to achieve A grades in

his GCSEs and A Levels despite his illness, long absences from school and side effects of medication”

Zoe’s Story continues…

Zoe returns to see you by herself you as arranged. She tells you how she thinks her sore throats are something very serious, like cancer, because they won’t go away. She knows that the sore throats stress her mum out because she takes time off work to look after her.

You look through the notes of Zoe’s previous consultations and see that there has never been very convincing physical signs of infection. She has had negative throat swabs and normal blood counts and glandular fever tests on a couple of occasions too.

Now Zoe seems happy to talk to you, you ask some more questions. Zoe bursts out saying how stressed she is. Her boy friend left her a few weeks ago. She didn’t tell her mother, but reacted by going out with her friends & drinking. This led to problems at school which have meant her mother was ‘on her case’ continually.

Previously close, the two of them fell out. For the last month, for three or four nights a week now Zoe cries herself to sleep listening to her mother & step-father argue about her. Every few days she feels so unhappy that she struggles to get up & out of bed.

Zoe says she used to go to dance classes but stopped 2 weeks ago as she can’t be bothered. Zoe goes on to admit that she has started to miss meals. She wants to get thinner. Zoe finishes by saying very hesitantly how she thinks she is useless and just cant seem to please anyone. She feels very lonely.

What could you do now?

What could you do now?

Some Management Issues Somatisation

? Teenage turmoil

If I “don’t” ...... Non stigmatising – watchful waiting Risk – life long mental health admissions,

suicide

If I “do”..... Prescribing Family practice & self care Referral

The Contact

Initial consultation

Confidentiality

Rapport building

Dealing with parents

Opportunistic screening question

Second consultation

Mental Health Framework Formulation Diagnosis Risk

Problem Solving

MH Promotion check list

Resource List

Tool 1: Mental health consultation framework

Life Situation/Practical Problem etc.

Altered thinking

Altered physical Altered mood

symptoms (emotions)

Altered behaviour

Tool 2 The problem solving guide

Primary Care Mental Health Checklist

Tool 3:Primary Care mental health checklist

What will you do now?

An Overview Don’t panic!

Be alert for warning signs

Use ‘tools’ to help

Get help early if indicated

Be patient

www.cwmt.org

www.youngpeopleshealth.org.uk