Brian McKain, RN, MSN Christina Hanna, MS 1. Identify and explain the components used to assess and diagnose depression 2. How to share the wealth with both patients and their parents 3. Understand that the educational process is an ongoing process throughout the course of treatment Beginning the Psychoeducational Process: The Intake The educational process begins with the first phone call! Phone intake Assessment Determination of the diagnosis Course of treatment: Introduction and beyond The Psychoeducational Process and Elements throughout Care Psychoeducation : the transmission (sharing) of information about the diagnosis and treatment of psychological conditions Phone Screen Presenting Complaint Current suicidal thoughts/plans/intent? Previous suicidal behaviors? Past suicide attempts? Current or past psychiatric treatment? School problems? Medical problems? Family crisis? Family history of psychiatric problems? Phone Screen Affective Symptom Checklist Mood, irritability, sleep disturbance, appetite disturbance, anhedonia, concentration, fatigue, psychomotor agitation/retardation, guilt, worthlessness, increased energy Drug and Alcohol Use Anxiety Symptom Checklist Physical complaints, shyness, worries, school refusal, panic attacks, separation problems Conduct Symptom Checklist Violation or rules, truancy, suspension, running away, stealing, fighting, trouble with the law. 1
Phone Screen Make sure the caller/parent is informed of the following procedures: Safety plan Removal of weapons and medications STAR availability Use of ER and RESOLVE 302 Information Offering interims as needed The Start of the Educational Process The educational process begins with the phone call to schedule an intake Continues at the assessment with determination of a diagnosis And onward through the course of treatment The Psychoeducational Forum Phone Intake Assessment Treatment Process Parent Educational Forum Exit Strategy Following the End of Treatment Rationale for Psychoeducation in Psychiatric Care Get s everybody on the same page with the same language and common ground, including: Team members Teen patient Parents Outside clinician associated with the transfer of care Depression Diagnosis: Identifying the Symptoms that Define the Diagnosis Diagnosing Depression: Mood dysphoria Most of the day for two weeks Part of the critical five Onset Frequency Intensity Level of Impairment 2
Depressive Symptoms: Mood Irritability and anger Changes in energy Psychomotor agitation Psychomotor retardation Loss of interest and pleasure Changes in sleep patterns: Insomnia dfa/mid awakening/ema Hypersomnia restorative sleep Changes in eating patterns Weight changes can occur possible increase in appetite Changes in socializing patterns : What was normal for the teen before? What are they doing now? possible decrease in appetite Inability to concentrate or slowed thinking: Effects school/work Socialization Guilt/worthlessness Can feel guilty about being depressed and not doing well in school, with friends or at home Family life 3
Hopelessness: The continuum from discouragement to despair to hopelessness Suicidal ideation and behavior PDW SI without method or plan SI with method and/or plan Interrupted attempt Aborted attempt Suicide attempt Suicide completion Discouragement Despair Hopelessness Intent Psychosis as a part of depressive disorder The Three Pillars of Recovery Mood Cognitive Physiological Depression Myths Depression will go away on it s own some people may have spontaneous remission but an untreated depression may last for months or even years Depression can be self treated by people simply pulling themselves up by their straps in fact the person suffering from depression cannot control on their own at least not without professional support Depression Myths Teens who are depressed and talk about suicidality will not act on it in fact those that do talk have engaged in suicidal behavior attempted and/or completed Talking to teens about suicide will put the thought in their head a child who is contemplating suicide will have already been thinking about it talking about suicide saves more lives than it puts at risk. 4
Diagnosis Major Depressive Disorder Bipolar Disorder Persistent Depressive Disorder Seasonal Affective Disorder Treatment Treat to full recovery: Symptom relief and return to function Continue medication for 6 months to one year post full recovery Know the symptoms of depression that brought you into treatment, as they can serve as warning signs for recurrence Awareness Stay alert to symptom return and the possibility of other family members having symptoms What to Watch for: Signs/symptoms of depression or functional impairment Long duration of depressive episode History of Persistent Depressive Disorder What to Watch for (Cont.): Co existing condition of Anxiety Disorder Increased fighting/conflict in the family Untreated depression or other psychiatric illness in parent Alcohol/substance use or abuse in patient or parent Functional and Social Impairment School = occupation Social interaction Family communication Loss of interest in activities that use to be enjoyable 5
Suicide and Suicidal Behavior Increased risk of suicide when depressed Associated with hopelessness and feelings of worthlessness Not every depressed person is suicidal but depressed adolescents are 30 times more likely to complete suicide Greatest risk for suicide is for those who are hospitalized for suicidality during or immediately following the psychiatric hospitalization Risks Factors for Adolescent Suicide Depression or Bipolar Disorder High hopelessness Drug and alcohol abuse Availability of firearms High suicidal intent Previous suicide attempt Co existing condition such as anxiety Risk Factors (Cont.) Talking about death/saying goodbyes/giving away possessions/making wills Engaging in self destructive behavior Behavior problems Physical or sexual abuse In the midst of a legal or disciplinary crisis Lack of treatment Exposure to completed suicide: An element of contagion Safety Plan Causes of Depression There is no single cause for depression: Elements of depression: Genetic/familial Biochemical Cognitive distortions and social skills Environmental and other factors Treatment Approaches Cognitive Behavioral Therapy (CBT) Dialectical Behavioral Therapy (DBT) Medication 6
Cognitive Behavioral Therapy Focuses on cognitive triad: Thoughts, feelings, behaviors Uncovering automatic thoughts and identifying underlying core beliefs: Going after the root source of cognitive disotrtions Dialectical Behavioral Therapy There is more than one way to get there Thinking in shades of grey I m doing the best I can and I want to do better. A person can believe two very different things at the same time. Medication A variety of medication: SSRI (Selective Serotonin Reuptake Inhibitor) Mood stabilizers Anxiolytics Combined Treatment Approach Talking therapy and medication: Individual sessions Medication management Ongoing Family communication sessions : Formal education sessions monthly Regular occurring sessions with parents to update on progress and keep in touch Range of Care Intensity of Care Levels of care: Intensive Outpatient Program (IOP) Partial Hospitalization Program Individual therapy Family therapy Family Based Services (FBS) Assessment IOP 4 to 6 weeks Treatment Timeline: Transitioning of Care Individual therapy 16 to 24 weeks Continuation group therapy 6 to 12 bi weekly group sessions Maintenance group therapy 6 to 12 monthly group sessions Post STAR 7
Impact of Depression on the Family: Changes in routines for the family Increase in anger, frustration, and irritability Feelings of guilt or blame Feeling resentful and ashamed of the depressed person and what s happening to the family Impact of Depression on the Family: Experiencing anxiety and fear about the illness: Wondering when it will go away; who else will become depressed Feeling the need to walk on eggshells Common Responses and Feelings of Family Members Sometimes family members can feel helpless and frustrated Careful about reassuring as it can be perceived as patronizing or dismissive Helping the Depressed Person Important to continue to function as a familyput your oxygen mask on first Continue to maintain functioning as much as possible: Other family members do what they are supposed to do Recognize if other family members are depressed: Parent is to take care of self and the rest of the family all will do better if they are treated Communication Within the Family Communication between parents and teensdirect communication Avoid letting little things build up Speak to the issue so it does not feel like you are criticizing the whole teen rather the specific behavior Communication Within the Family Communicate directly and calmly even if angry Help identify symptoms changes both increase in intensity of symptoms as well as improvements in symptoms ( better sleep, more active, more socialization, etc) Changing expectations with improving mood and functioning 8
Effective Coping Strategies Be hopeful Encourage person to remain in treatment Encourage person to take medication as prescribed even if beginning to feel better (parents in charge of meds) Take care of yourself go on with your life Be direct in communicating Effective Coping Strategies (cont.) Provide feedback about positive changes you noticed Always take suicide talk seriously let your care provider know Make school aware of what is occurring find an ally Remember the illness is causing the person s changes avoid taking angry comments personally Effective Coping Strategies (cont.) Look for gradual improvement Encourage the person to follow through with specific plans or steps but avoid overprotecting or overdoing for the depressed person. Gentle assertiveness may be required to assist the depressed person especially if withdrawn Get treatment for self if needed Please call us with any questions or concerns Remember: Depression is one of the most treatable of all the mental illnesses. Progress in research in all areas related to the depressive illnesses has been made and is continuing. Although there remains a lot we do not know yet, we look to the promise of continued research. Kim Poling, L.S.W. (from, Living with Depression: A Survival Manual for Families, 3 rd edition) We acknowledge with gratitude the Pennsylvania Legislature for its support of the STAR Center and our outreach efforts. 9