Oxleas CAMHS Dr Joanna Sales Clinical Director. Adolescent problems: Depression Deliberate Self Harm Early Intervention in Psychosis

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1 Oxleas CAMHS Dr Joanna Sales Clinical Director Adolescent problems: Depression Deliberate Self Harm Early Intervention in Psychosis

2 PREVALENCE At any one time, the estimated number of children and young people suffering from depression: 1 in 100 children 1 in 33 young people Prevalence figures exceed treatment numbers: about 25% of children and young people with depression detected and treated Suicide is the: 3 rd leading cause of death in year-olds 6 th leading cause of death in 5 14-year-olds

3 Providers SLAM inpatient and outpatient, Guys, St George s, St Thomas, London Specialist services, independent sector inpatient unit TIER 4 Tertiary-level Services Day Units Specialised O/P Teams Specialised Inpatient Units Specialist Oxleas CAMHS TIER 3 Services for more severe, complex or persistent disorders Child & Adolescent Psychiatrists & Psychotherapists Clinical Child Psychologists Community & Inpatient Nurses Occupational Therapists & Speech & Language Therapists Art, Music & Drama Therapists & Family Therapists Specialist CAMHS, Education Psychology, Behaviour Support Service, EWS, School Counsellors, YES, Family Centres, FWA, YOT, Community Paediatricians, Moorings, The Place to Be, Bromley Y TIER 2 Professionals Relating to Primary Care Workers Clinical Child Psychologist & Educational Psychologist Paediatricians with training in Mental Health Child & Adolescent Psychiatrists & Psychotherapists Counsellors & Community Specialist Nurses Family Therapists TIER 1 Primary Care Services GPs and Paediatricians Health Visitors & School Nurses Social Workers, Teachers, Juvenile Justice Workers Voluntary Agencies & Social Services

4 Diagnosing depression KEY SYMPTOMS ASSOCIATED SYMPTOMS persistent sadness, or low or irritable mood: AND/OR loss of interests and/or pleasure fatigue or low energy poor or increased sleep poor concentration or indecisiveness low self-confidence poor or increased appetite suicidal thoughts or acts agitation or slowing of movements guilt or self-blame jáäç ré=íç=q=ëóãéíçãë jççéê~íé RJS=ëóãéíçãë péîéêé TJNM=ëóãéíçãë

5 The stepped care model Focus Action Responsibility Detection Risk profiling Tier 1 Recognition Detection in presenting children All tiers Mild depression including dysthymia Moderate to severe depression Depression unresponsive to treatment/recurrent depression/psychotic depression Watchful waiting Non-directive supportive therapy/group cognitive behavioural therapy, guided selfhelp Brief psychological intervention +/ fluoxetine Intensive psychological intervention +/ fluoxetine Tier 1 Tier 1 or 2 Tier 2 or 3 Tier 3 or 4

6 Detecting depression Professionals in primary care, schools and community need to: be aware of risk factors engage in active listening and conversational techniques detect symptoms provide appropriate support know when to refer

7 Mild depression Treatment includes: up to 4 weeks watchful waiting non-directive supportive therapy group CBT guided self-help no use of antidepressants at this stage

8 Criteria for referral to Tier 2 or 3 CAMHS aééêéëëáçå=ïáíü=íïç=çê=ãçêé=çíüéê=êáëâ=ñ~åíçêë=ñçê= ÇÉéêÉëëáçå aééêéëëáçå=ïáíü=ãìäíáéäéjêáëâ=üáëíçêáéë=áå=~åçíüéê=ñ~ãáäó= ãéãäéê jáäç=çééêéëëáçå=~åç=åç=êéëéçåëé=íç=áåíéêîéåíáçåë=áå=íáéê=n= ~ÑíÉê=OÓP=ãçåíÜë= jççéê~íé=çê=ëéîéêé=çééêéëëáçå=eáååäìçáåö=éëóåüçíáå= ÇÉéêÉëëáçåF oéåìêêéååé=~ñíéê=êéåçîéêó=ñêçã=éêéîáçìë=ãççéê~íé=çê=ëéîéêé= ÇÉéêÉëëáçå råéñéä~áåéç=ëéäñjåéöäéåí=çñ=~í=äé~ëí=n=ãçåíüûë=çìê~íáçå=íü~í= ÅçìäÇ=ÄÉ=Ü~êãÑìä=íç=éÜóëáÅ~ä=ÜÉ~äíÜ ^ÅíáîÉ=ëìáÅáÇ~ä=áÇÉ~ë=çê=éä~åë vçìåö=ééêëçå=çê=é~êéåílå~êéê=êéèìéëíë=êéñéêê~ä

9 Moderate or severe depression-1 Tier 3 CAMHS Multi-disciplinary assessment and treatment Specific psychological interventions (IPT, CBT, FT) Prescribing

10 Moderate or severe depressionif unresponsive Repeat multidisciplinary review Try alternative psychological input Systemic family therapy of at least 15 fortnightly sessions Individual child psychotherapy (30 weekly sessions) Combine with anti-depressant

11 The place for antidepressants Should only be prescribed following assessment by a psychiatrist Should only be offered in combination with psychological treatments First-line treatment is fluoxetine Do NOT use: tricyclic antidepressants, paroxetine, venlafaxine, St John s wort Monitor for agitation, hostility, suicidal ideation and selfharm and advise urgent contact with prescribing doctor if detected * Fluoxetine does not have a UK Marketing Authorisation for use in children and adolescents under the age of 18 at the time of publication (Sept 2005)

12 The limited place for antidepressants Sertraline or Citalopram* as second-line treatment Add atypical antipsychotic if psychotic depression Continue for 6 months if remission, then phase out over 6 12 weeks Issues: Discussion, consent and written advice important Pre- and post-prescribing monitoring Continuation of medication post recovery *

13 Discharge to primary care Shared care best practice Review for 12 months after first remission (< 2 symptoms for 8 weeks) Consider follow-up psychological treatment if second episode to prevent relapse Review for 24 months if recurrent depression in remission Re-refer early if signs of relapse