FAMILY AND ADOLESCENT MENTAL HEALTH: THE PEDIATRICIAN S ROLE Mark Cavitt, M.D. Medical Director, Pediatric Psychiatry All Children s Hospital/Johns Hopkins Medicine OBJECTIVES Review the prevalence of psychiatric disorders Review screening tools including the Patient Health Questionnaire and PHQ-A as content examples for primary care mental health screening Review Motivational Interviewing 1
WHY SHOULD WE BE CONCERNED? 11-20% of children and adolescents have a mental health disorder with functional impairments Suicide is the 2 nd to 3 rd leading cause of death in ages 15 to 24 years and 6 th in ages 5 to 14 years There may be twice as many children who do not meet DSM-5 criteria who have clinically significant impairments Half of U.S. adults with a mental health disorder had symptoms before age 14 years Only 20 % of children with mental health problems receive care Unidentified mental health co-morbidities can significantly drive medical service utilization Economic impact of mental illness in youth in the US is estimated to be $247 billion per year Psychiatric disorders are heritable, thus an affected child frequently other affected family members WHY PEDIATRICIANS? A longitudinal, trusting relationship with children and family members Understanding of the social, emotional and educational problems of the child and family members Medical home with chronic care principles Opportunity for early interventions to promote healthy lifestyles and anticipatory guidance for the child and family Routine medical care seeking may result in identification of mental health problems Experience collaborating with mental health professionals 2
PREVALENCE OF PSYCHIATRIC DISORDERS IN RANK ORDER (DSM-5) Tobacco use disorder: 20 % in adolescents/13% in adults/m:f 1:1 Adjustment Disorders: up to 20% Specific Phobias: 5% in children/16% in adolescents/7 to 9% in adults/m:f 1:2 Major Depressive Disorders: 7%/M:F 1: 1.5 to 3 Social Anxiety Disorder: 7%/M:F 1:1.5 to 2.2 Sleep Wake Disorders: 5 to 10%/ M:F 1:1 Illness Anxiety Disorder (hypochondriasis): h i 3-8%/M:F 11 1:1 Somatic Symptom Disorder: 5 to 7%/M:F 1:1+ Attention Deficit Hyperactivity Disorder: 5% in children/2.5% in adults/m:f 2:1 PREVALENCE OF PSYCHIATRIC DISORDERS IN RANK ORDER (DSM-5) Conversion Disorder: 5%?/M:F 1: 2 to3 Alcohol Use Disorder: 4.6% in adolescents/8.5% in adults/m:f 2:1 Conduct Disorder: 4%/M>F Separation Anxiety Disorder: 4% in children/1.6% in adolescents/0.9 to 19% in adults/m:f 1:1 Cannabis Use Disorder: 3.4% in adolescents/1.5% in adults/m:f 2:1 Post Traumatic Stress Disorder: 3.5%/M:F 1:1+? Oppositional Defiant Disorder: 3.3%/M:F 1.4:1 Generalized Anxiety Disorder: 0.9% in children/2.9% in adults/m:f 1:2 Panic Disorder: 0.4% in children/2 to 3 %/M:F 1:2 3
PREVALENCE OF PSYCHIATRIC DISORDERS IN RANK ORDER (DSM-5) Hoarding Disorder: 2 to 6% Intermittent Explosive Disorder: 2.7%/M:F 1.5:1 Phencyclidine Use Disorder: 2.5%? Disruptive Mood Dysregulation Disorder: 2 to 5 % prior to age 10 yrs./m>f Premenstrual Dysphoric Disorder: 1.8 to 5.8% Body Dysmorphic Disorder: 2.4%M:F 1:1 Agoraphobia: 1.7%/M:F 1:2 Excoriation Disorder: 1 to 4 %/M:F 1:3 Trichotillomania: 1 to 2%/M:F 1:10 Obsessive Compulsive Disorder: 1.2%/M:F 1:1 PREVALENCE OF PSYCHIATRIC DISORDERS IN RANK ORDER (DSM-5) Bipolar Disorders: 0.6% in children/1.8%/m:f 1.1:1 Autism Spectrum Disorder: 1%/M:F 4:1 Persistent Depressive Disorder (dysthymia): 0.5 to1.5%/m:f 1: 1 to 4 Bulimia Nervosa: 1 to 1.5%/M:F 1:10 Binge Eating Disorder: 0.8 to 1.6%/M:F 1:2 Opioid Use Disorder: 1% in adolescents/0.37% in adults/m:f 1.5:1 Schizophrenia: 0.3 to 0.7%/M:F 1:1 Anorexia Nervosa: 0.4%/M:F 1:10 Inhalant Use Disorder: 0.4% in adolescents/0.1% in adults/m:f 1:1 Sedative/Hypnotic Anxiolytic Use Disorder: 0.2 to 0.3%/M:F 1:1 to 2 Stimulant Use Disorder: 0.2%/M:F 1:3 Other Hallucinogen Use Disorder: 0.5% in adolescents/0.1% in adults/m:f 1-2:1 4
SUMMARY OF PREVALENCE IN YOUTH (NON-DSM-5 SOURCES) ADHD 6.8% Conduct Disorder 3.5% Anxiety 3.0% Depression 2.1% Autism Spectrum Disorder 1.1% Substance Use Disorder 4.7% Alcohol Abuse 4.2% Cigarette Dependence 2.8% Suicide second leading cause of death; 15-20% of high school juniors and seniors seriously contemplated and/or attempted suicide UNDERSTAND THE BIO-PSYCHO-SOCIAL ENVIRONMENTS OF THE CHILD & FAMILY Medical evaluation of the identified patient Medical Family History Psychiatric Family History Developmental/Cognitive/School Functioning Family Environment: marital discord, economic stressors, separation/divorce, custodial parents, guardianship, abuse and neglect, sibling competition/support Peer environment: positive/negative, sports, hobbies, violence/bullying, substance use 5
MENTAL HEALTH SCREENING FOR PRIMARY CARE Reliability: The measure produces consistent results Validity: The ability to discriminate between a patient with a problem and one without t the problem Sensitivity: The accuracy of the test in identifying a problem Specificity: Accuracy of identifying individuals who do not have a problem Sensitivity and specificity levels at 70 80 % are acceptable for mental health screens in that symptomatic, subsyndromic individuals who may benefit from monitoring and guidance can be identified Screening tools should capture the most common mental health conditions as well as those that while less common may have high morbidity/mortality Educational/developmental levels, language, culture and time to complete must be considered Clinician scoring and review time must be considered Repeat use bias should be minimized MENTAL HEALTH SCREENING FOR PRIMARY CARE American Academy of Pediatrics: Mental health screening tools lists 59 different instruments Selection of tools will be based on target populations, target symptoms/syndromes, computer based vs paper, costs to obtain, ability to charge for scoring and analysis, etc. Screening family members in addition to the identified patient may be considered as psychiatric disorders are frequently familial and children may be an emotional barometer of parental and sibling problems 6
PRIME-MD PATIENT HEALTH QUESTIONNAIRE (PHQ) PHQ is designed to screen for somatoform disorders, depression, suicidality, anxiety, bulimia, binge eating and alcohol abuse. Self-administered with 57 items Ages 18 and older Multiple languages Free at PHQscreeners.com Sensitivity 75% Specificity 90% 85% of physicians reviewed results in 3 minutes or less Can be repeated periodically Doesn t cover tobacco, other substances or guns 7
PRIME-MD PATIENT HEALTH QUESTIONNAIRE (PHQ) After provisional diagnosis with the PHQ, additional information needed would include the following Have current symptoms been triggered by psychosocial stressors? What is the duration of the current disturbance and has the patient received any treatment for it? To what extent are the patient s symptoms impairing his or her usual work and activities? Is there a history of similar episodes and were they treated? Is there a family history of similar conditions? PATIENT HEALTH QUESTIONNAIRE FOR ADOLESCENTS Similar to PHQ Self-administered 86 items Age 13-18 Includes screening for alcohol, tobacco, cannabis, cocaine, hallucinogens, inhalants, stimulants Free from American Academy of Pediatrics Does not include guns Overly sensitive and not specific enough for suicidality thus may have to use and additional rating scale like the Columbia Suicide Severity Rating Scale 8
CLASSIC SCREENING DEVICE: ASK QUESTIONS! During the past month have you felt depressed or down? During the past month have you been bothered by having little interest or pleasure in doing things? 83% sensitivity and 92% specificity for MDD in adults 9
RESPONSES TO POSTIVE SCREENING Obtain additional information including that listed on slide 12 Syndromal: initiate appropriate practice parameter for the diagnosis e.g. primary care treatment of a depressive disorder which might include education, support, pharmacotherapy, referral for psychological evaluation and therapy, psychiatric referral, follow-up Near Syndromal: All of the above except pharmacotherapy Subsyndromal: Education, support, possible referral and consider Motivational Interviewing especially for lifestyle and substance use change. MOTIVATIONAL INTERVIEWING Based on stages of readiness for change: Pre-contemplation, contemplation, planning for change, implementation and maintenance of change Non-judgmental, non-confrontational and non-adversarial Goals are to enhance patient awareness of a potential problem, consequences and risks and envision a future without the problem Focus is on the present and resolving ambivalence about change by weighing the pros and cons of change vs. status quo Interviewer uses open ended questions, affirmations, reflective listening and summary statements in a directive fashion to motivate change Change process may begin with easily achievable goals moving toward the more difficult problem change Repeating the change process and affirming even limited success builds for more iterations of the change cycle and ultimate problem resolution 10
CONCLUSIONS Up to 1 in 5 youth may have a mental illness The prevalence of mental illness impacts the individual, family and community Mental and behavioral disorders of the young represent a major public health issue Costs of mental illness in youth in the US may exceed $247 billion Pediatricians stand at the center of the medical system for screening, treating, referring and following the affected youth and their families Screening tools like the PHQ and PHQ A may improve consistency of screening in families and youth It may be more important t to use a few screening tools consistently tl than a wider range sporadically Motivational Interviewing techniques may enhance the probability of change in target behaviors REFERENCES Diagnostic and Statistical Manual of Mental Disorders (DSM-5), American Psychiatric Association, 2013 American Academy of Pediatrics. The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care. Pediatrics Vol. 124 No. 1, July 1, 2009 pp. 410-421 421 American Academy of Pediatrics. Mental Health Screening and Assessment Tools for Primary Care. January, 2012 Diamond, et. al. Development, Validation, and Utility of Internet-Based, Behavioral Health Screen for Adolescents. Pediatrics online June 21, 2010, pp. e163-e170 Spitzer, et.al. Validation and Utility of a Self-report Version of PRIME-MD: The PHQ primary Care Study. JAMA, November 10, 1999 Vol. 282 No. 18, pp. 1737-1744 www.phqscreeners.com Gardner, et.al. Screening, Triage, and Referral of Patients Who Report Suicidal Thought During a Primary Care Visit. Pediatrics online April 12, 2010 pp. 945-952 Miller, W.R., Rollnick, S. Motivational Interviewing, 3 rd. ed. Guilford Press, 2012 Biederman, J. Diagnosis& Assessment in Pediatric Psychopharmacology. Massachusetts General Hospital Psychiatry Academy: Child &Adolescent Psychopharmacology, March 14-16, 2014 11