Adolescent Mental Health

Question 1

What are the first two tiers of CAMHS?

Answer 1

Tier 1 = universal services consisting of all primary care agencies
Tier 2 = combination of some specialist CAMH services and some community based services

Question 2

What are tiers 3 and 4 of CAMHS?

Answer 2

Tier 3 = specialist multidisciplinary outpatient CAMH teams

Tier 4 = highly specialised inpatient CAMH units and intensive community treatment services

Question 3

How common are mental health issues in children and young people?

Answer 3

1 in 10 children and young people aged 5-16 suffer from a diagnosable mental health disorder

Question 4

How many adults with mental health problems are diagnosed in childhood?

Answer 4

Over 50% = less than half were treated appropriately at the time

Question 5

What do mental health problems in children have an impact on?

Answer 5

Educational attainment and social relationships

Question 6

What does mental health problems in children have strong links with?

Answer 6

Social disadvantage

Question 7

What is parental mental illness associated with?

Answer 7

Increased rates of mental health problems in young people

Question 8

What are some features of anxiety?

Answer 8

One of most common mental health disorders = incidence increasing, likely to persist into adulthood if untreated

Question 9

How does anxiety affect children and young people?

Answer 9

Young people usually have more than one type of anxiety

Up to 6% of young people may have a disorder severe enough to need treatment

Question 10

What are the genetic factors that influence anxiety?

Answer 10

Biological vulnerability to fearful disposition
Abnormal function of 5-HT, NA, dopamine and GABA
Overactive limbic system
Irritable, shy, cautious and quiet temperament

Question 11

What behavioural factors influence anxiety?

Answer 11

Acquisition of fear through classical conditioning
Maintenance of fear through operant conditioning
Observational learning

Question 12

How does classical conditioning cause acquisition of fear?

Answer 12

Individual associates threatening stimulus with non-threatening stimulus

Question 13

How does operant thinking allow fear to be maintained?

Answer 13

Negative conditioning is manifested by avoidance and/or escape learning

Question 14

What cognitive factors influence anxiety?

Answer 14

Attentional biases, selective attention, distorted judgement, negative spin on non-threatening situations, select avoidant situations, selective memory processing, tendency to remember anxiety-provoking experiences, perfectionistic beliefs, inflated sense of responsibility

Question 15

How is mild anxiety treated?

Answer 15

Cognitive based therapy

Question 16

How is unresponsive or moderate-severe anxiety treated?

Answer 16

SSRIs for 1 year = up to 12 weeks to take effect

Benzodiazepines may be used = need initial titration, cause paradoxical agitation

Question 17

What are some features of depression?

Answer 17

More common than reported and symptoms can be easily misunderstood
Estimated 4-8 of 100 young people suffer from depression

Question 18

What are some groups of young people particularly vulnerable to depression?

Answer 18

Young offenders and young people in gangs
Looked after children and homeless youths
LGBT, unemployed young people and disability
Ethnic minorities = Asian women, Pakistani, Bangladeshi

Question 19

What are some predisposing factors for depression?

Answer 19

Family history, conflict with family and divorce
Negative perception of environment and self
Conflict with friends, school stress and bullying
Social disadvantage and loss of someone important

Question 20

How is mild depression treated?

Answer 20

Watchful waiting for 2 weeks then CBT for 2-3 months

Question 21

How is unresponsive or moderate-severe depression treated?

Answer 21

Start with individual CBT, family therapy or psychodynamic psychotherapy for 4-6 weeks
Trial fluoxetine and then give sertraline/citalopram

Question 22

What is the most effective psychotherapy for mood disorders?

Answer 22

Cognitive based therapy

Question 23

What are some features of cognitive based therapy?

Answer 23

May be individual or in groups
Learn ways to manage stress and to think more positively about the future
Do things to improve mood

Question 24

What are some other psychological therapies used to treat depression?

Answer 24

IPT, EMDR, solution focused therapy, CAT, psychodynamic psychotherapy

Question 25

What is pharmacological therapy useful for in treating depression?

Answer 25

Effective in improving clinical symptoms especially in combination with psychotherapy

Question 26

What are some features of pharmacological therapy for depression?

Answer 26

Response takes several weeks
Neuronal plasticity may aid recovery
SSRIs are first line
Venlafaxine/mirtazapine in older group may be alternative to SSRI

Question 27

When should you consider augmentation with an antipsychotic to treat depression?

Answer 27

If there has been poor response to at least 2 SSRIs

Question 28

What are the rues for pharmacological management of depression?

Answer 28

Start low and go slow
Polypharmacy often needed if severe
Allow time for adequate trial
Change one drug at a time
Always combine with psychosocial interventions

Question 29

What are some cautions for depression?

Answer 29

Suicidal thoughts and increasing self harm
Agitation and hostility
Increase or decrease in appetite

Question 30

How common is self harming behaviour?

Answer 30

Prevalence = 7% of 14-16 year olds at school, 13% of 11-16 year olds in community
1 in 12-15 young people deliberately self harm
40% of A and E attendances

Question 31

Why do people self harm?

Answer 31

To cope with intense emotions
To communicate distress
To re-connect with self and others
In an attempt to end their life

Question 32

What effect does self harm have on the brain?

Answer 32

Promotes release in endorphins = brings temporary distress reduction so tends to be repeated due to negative reinforcement

Question 33

What are some predisposing factors to self harm?

Answer 33

High emotional reactivity, emotional numbing, poor distress tolerance, thought suppression, early abuse, family hostility, poor communication and problem solving skills

Question 34

What are some features of non-suicidal self injury?

Answer 34

Periods of optimism and some sense of control
Successful decrease in discomfort
Frequently chronic and repetitive
Intent to relieve unpleasant emotions
Uncomfortable but intermittent psychological pain
Choices available = “temporary solution”

Question 35

What are some features of suicidal self injury?

Answer 35

Hopeless and helpless central
No release of discomfort after self injury
Generally not chronic or repetitive
Intent to escape pain or end consciousness
Unendurable persistent psychological pain
Tunnel vision = “one way out”

Question 36

What is the link between self harm and suicide?

Answer 36

Rate of suicide increases to between 50-100 times
Men who self harm are more than 2x likely to die by suicide
25% who die by suicide would have attended general hospital following self harm the previous year

Question 37

How common is recurrence of self harm?

Answer 37

1 in 6 people who attend A and E following self harm will self harm again in the following year

Question 38

What is the initial management for self harm?

Answer 38

Educate about signs of distress in themselves and others
Use of positive coping skills
Refer to specialist mental health professional for assessment of risk and underlying causes