7/6/2011
When Everything Seems Unreal: Psychosis at School
Sabina Abidi, MD, FRCPC IWK Health Centre Dalhousie Department of Psychiatry
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Objectives Review the history of psychosis and psychotic disorders current definitions and symptoms. symptoms disorders, Know the markers that help identify youth at risk for psychosis and psychotic disorders. Discuss the importance of early identification and treatment of youth with psychosis and psychotic disorders. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Psychosis – What Is It?
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
“So…let’s talk about psychosis…” Wh t IS IT? Who Wh knows? k ? What Definition Cases Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Psychosis Psychosis is a brain disorder. di l illness ill ff t more than th 3000 Canadians C di i t in i A medical - affects att any point time a serious disturbance in an individual’s reality testing A process whereby the senses are distorted, making it difficult for the person to distinguish between real and unreal Affects a person’s Aff ’ ability bili to think, hi k perceive i and d act Thinking, feelings, perception and behavior affected
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Psychosis A BRAIN DISEASE
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Normal Teen Brain Development
Lenroot & Giedd (2006)
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Onset of Psychiatric Disorders in Adolescence Prevalence in Childhood
Prevalence in Adolescence
Depression (1-2%) Bipolar Disorder (rare) Psychosis (rare) Anxiety Disorders (6-8%) Anorexia Nervosa (rare)
Depression (6-8%) Bipolar Disorder (1%) Psychosis (1%)?? Anxiety Disorders (10%) Anorexia Nervosa (0.2%)
Total (7-10%)
Total (15 – 20%)
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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y p disorders per 1000 children/adolescents In males particularly, psychotic disorder(s) is a major Boys disorder of adolescence Gi l Girls
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Hits adolescents in their prime – leads to a disruption in education-attainment, career building, employment Alters relationships, family interactions, Alters sense of self, esteem, productivity
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2 (Reprinted) Spady et al. Prevalence of Mental Disorders in Children Living in Alberta, Canada, as Determined from Physician Billing Data. 2001.Arch Pediatr Adolesc Med. 155: pp.1156.
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Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Symptoms of Psychosis
What are common types of psychotic experiences?
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Positive Symptoms
Positive symptoms are things added in to people’s senses/thoughts/feelings/behaviour that are not normally there.
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Positive symptoms include: Hallucinations Delusions Thought Disorder Disorganized or Unusual behaviour
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7/6/2011
Hallucinations Hallucinations can affect all senses: Sensory perceptions that occur in the absence of any real stimulus but appear to be the result of faulty messages in the brain. Hearing (auditory) Seeing (visual) Touch (tactile) Smell (olfactory) Taste (gustatory) Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Delusions Fixed beliefs created by illness which are held y by y the pperson experiencing p g the psychosis. py only These can include: Belief in special abilities of self or others Belief that physical health is changed Belief that unusual coincidences have a special importance Belief that one is being controlled Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Thought Disorder Problems organizing thoughts. Thoughts coming to fast or too slow. Problems thinking and therefore speaking logically. Problems keeping on topic. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Disorganized or Bizarre Behaviour: Everyone’ss behaviour is a response to how they Everyone interpret what is going on around them. People with psychosis may behave differently than they usually do. may become extremely active or agitated, may laugh l h inappropriately i i l or display di l inappropriate i i appearance, hygiene or conduct. may behave in ways that reflect their thoughts Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Negative Symptoms
Negative symptoms refer to behaviours or experiences that have been reduced or lost because of the illness.
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Negative symptoms may include: Problems getting motivated Problems taking joy in things Problems getting words out Seeming flat and blunted
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7/6/2011
Cognitive Symptoms Refers to problems with learning and concentration Find it difficult to focus and pay attention find it hard to filter out all the various stimuli in their environment. (may be highly sensitive to sounds, lights and even the regular activities occurring in their immediate environment.) Easily distracted Trouble with working memory Classroom/Tim’s example
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Cognitive Symptoms find the ability and speed in processing information and reaction time may be slowed experience difficulties with memory, problem solving ability and judgement. g find it hard to organize activities in their lives,, for example to manage the time and tasks needed to get their schoolwork completed.
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Mood Symptoms The person can be:
Anxious, irritable Depression Anger and unpleasant behaviour Rapid changes in mood Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Key Point Sometimes people with psychosis cannot recognize that they are ill and believe that nothing is wrong with them. This lack of insight can make it hard to get the person to accept treatment. treatment
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7/6/2011
Memory deficits Poor attention Poor organization Concrete thinking
Cognitive deficits
Psychotic experiences and impairment
Negative symptoms Lack of: Energy Motivation Drive Socialization reactivity Emotion Slowed thoughts/speech
Mood disturbance Anxiety Depression Irritability R id swings Rapid i anger
disorder
Positive symptoms
Hallucinations Delusions Disorganized and Bizarre behavior
The psychosis continuum or spectrum of symptoms
Psychotic disorder (schizophrenia)
Psychotic like experiences (normal variant) PLEs associated with other disorders
PLEs + markers of risk
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7/6/2011
Types of disorders which present with symptoms of psychosis Schizophrenia Schizophreniform p Disorder Brief Psychosis Schizoaffective Disorder Psychosis NOS Delusional Disorder Drug g Induced Psychosis y Bipolar Disorder (with psychosis) Psychotic Depression Secondary to a medical conditio Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
To be normal in adolescence it itself abnormal Anna Freud
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Prevalence of children’s mental disorders in Canada any disorder any anxiety disorder ADHD conduct disorder any depressive disorder substance abuse PDD OCD eating disorder Tourette syndrome schizophrenia bipolar disorder
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estimated prevalence % Adapted from Table 2. Waddell et al. 2002. Child Psychiatric Epidemiology and Canadian Public Policy-Making. The state of the science and the art of the possible. Can J Psychiatry
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Why the focus on psychosis/psychotic disorders?
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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• Common among prison and homeless populations
• 80% will abuse substances during their lifetime
•More hospital beds in Canada are occupied (8%) by people with schizophrenia than by sufferers of any other medical condition
• 15 15--25x more likely to die from a suicide attempt than the general population • 10% or patients die from
“Youth’s Greatest Disabler”
suicide most often in the first 10 years after diagnosis
World Health Report 2001 (WHO, 2002) schizophrenia and other forms of psychoses affecting young people rank third worldwide as the most disabling condition
If left untreated, there is a continuing slow increase in impairment for years
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Epidemiology Schizophrenia causes massive human and financial costs Affects more than 1% of the world’s population Affects all races, ethnicities, cultures equally More severe presentation in men Allow for a more broader definition of psychotic disorder (include psychosis NOS, brief episodes, delusional disorder) lifetime rate increases to 2-3%
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Patients with schizophrenia itself die 12-15 years earlier before the average population – some quote up to 25 years earlier Schizophrenia causes more lives lost than cancer and physical illness Mostly due to poor medical care, suicide and deteriorating physical illness
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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The vast majority of psychiatric disorders have their onset in adolescence The age of maximum incidence for schizophrenia in males is 15-25 years and 1835 years in females If left untreated, there is a continuing slow increase in impairment for years. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Life potential (social, occupational, financial‌)
Onset Of illness
Successive illness relapses
17 Age Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Outcomes of psychiatric illness in adolescence Attainment – in liffe
X – onset of psychiatric illness
X – onset of treatment effort
X – delay d l iin treatment effort 12
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20 Time - age
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Psychosis – why/how?
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Phases of Illness Birth
First Signs of Illness
Premorbid Phase Prodromal Phase
Onset of Psychosis
First Treatment
Duration of Untreated Psychosis
Recovery/Stabilization Phase
Residual/Stable Phase
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Etiology Risk Factors Genetic Family history of psychotic disorder/bipolar disorder
Environmental Higher incidence in urban populations Immigrant ethnic groups - social isolation Areas of Social defeat Childhood trauma exposure p Cannabis exposure Perinatal factors
There is a definite interplay of genes and the environment Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Genetics 50% of identical twins with a twin having disorder schizophrenia will develop the disorder. 13% risk for children with one parents with schizophrenia. % risk s for o first s cous o a person pe so with w 2% cousinss of schizophrenia >1% risk for the general population. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Stress-Vulnerability Model of Schizophrenia High Less severe
Stress
-adverse acute &
Psychotic symptoms
Psychotic-like
chronic life events
- developmental
Symptoms or
challenges
Prodromal symptoms
No symptoms
Low Low
High Vulnerability
-family history of psychotic disorders -Obstetric complications Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
It is important to remember that psychosis is not caused by: F il upbringing bi i Family Problems with other people Having a “weak� character
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7/6/2011
Dopamine in Brain Function Dopamine is important in three areas of b i function: f ti brain Mesolimbic-frontal cortex circuits ( psychotic symptoms).
Basal ganglia (control of muscle movement). Parkinson’s disease; loss of dopamine cells
Hypothalamus-Pituitary (control of the hormone, prolactin).
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Dopamine Pathways
Four pathways:
1. 2. 3. 4.
Nigrostriatal Mesolimbic Mesocortical Tuberoinfundibular
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Duration of Untreated Psychosis (DUP) Historically youth experience long DUP before coming into contact with psychiatric services 2 5 years 2-5 Long DUPS translate to very poor clinical and social outcomes We now know that if this illness is caught early, prognosis can be very positive with effective treatment
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
TREATMENT
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7/6/2011
Rational Therapy for Psychotic Disorder Antipsychotic medication along with therapy/education are the cornerstone of effective treatment programs when dealing with a known chronic psychotic illness such as schizophrenia
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Antipsychotic Medications All antipsychotic medications influence communication between brain cells involving the neurotransmitter, dopamine. Each medication may also influence a number of other neurotransmitters in the brain, but the effect on dopamine seems to be one common factor in reducing psychosis.
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
First and Second Generation Antipsychotics “Traditional” or “First Generation” antipsychotic medications (1950-1988) (dopamine blockade): Haloperidol, Chlorpromazine, Thioridazine and many others.
Second Generation antipsychotics (serotonin-dopamine antagonism) “Clozapine / Clozaril (1990) Risperidone / Risperdal (1992) p / Zyprexa yp ((1996)) Olanzapine Quetiapine / Seroquel (1998) Ziprasidone / Zeldox (2008) Paliperidone / Invega (2008) Aripiprazole (Abilify, 2009) Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Side Effects First generation (due to Dopamine receptor blockade): Extrapyramidal (movement) symptoms (EPS) Muscle stiffness, restlessness, involuntary movements. The use of anti-parkinsonian “side effect” meds. Prolactin (hormonal) elevation. y Ammenorhea and sexual dysfunction “Dysphoria” (feeling bad). Difficulty with concentration and memory.
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7/6/2011
Side Effects Second generation antipsychotics: Sedation (early in treatment) d f i Sexuall dysfunction Weight gain Metabolic dysregulation Dylipidemia Hypertriglyceridemia Risk for diabetes Cardiac dysfunction Glaucoma Stroke
Extrapyramidal side effects still a concern
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
General Treatment Guidelines Individual basis Try to treat with one medication at a time. If there is an insufficient clinical improvement after 3-6 months, try a different medication. Use continuous treatment with medication for as long as possible.
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Treatment: How Long? Current guidelines suggest that patients should continue on medication for at least two years after remission (no evidence of any ongoing symptoms) After 2 years studies show that about 20% may be able to come off of the medication and stay well Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Treatment: How Long? 50% of patients who do not take medication in the first year will relapse 40-60% with effective treatment (medicine, therapy, education, rehabilitation) can lead productive lives achieving life goals had prior to the onset of illness
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Key Points Psychosis is treatable. Medication is a necessary, but not sufficient, part of a total treatment plan. The stress-vulnerability model helps us understand treatment. Adherence with treatment, including medications, is a critical issue. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Challenges to Treatment Non-adherence Non adherence Depression/risk of suicide Substance use/abuse Excessive stress/expectations Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Definition of Non-Adherence Non-adherence (or non-compliance) means not following the recommended treatment, possibly including a refusal to take medication Taking less than prescribed Taking T ki medication di i erratically i ll (missing ( i i doses) d ) Completely stopping medication
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Predictors of Non-Adherence Denial of illness Symptoms of Illness Delusions Depression Cognitive impairment
Belief that medications no longer needed (I’m cured). Attitudes Attit d off family f il andd friends
Support Network Stigma Insight Distressed by side effects Drug induced dysphoria (feeling bad) or akathisia (restlessness) Cost of Medication
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7/6/2011
Depression Major depression during course of illness : 60% Post-psychotic Depression: 25% Attempted suicide: 25% - 40% Successful suicide: 10% - 13%
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Challenges: Substance Use/Abuse Substance use is very common in first i d psychosis h i episode Up to 80% Cannabis and alcohol are most frequently abused substances
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Cannabis and Early Psychosis People with psychotic disorders have higher rates of cannabis use than the general population Cannabis use is associated with poorer functional and clinical outcomes in this population, e.g. greater psychotic symptom severity the effects of which can last up to 4 years later Cannabis misuse associated with 4 times the risk of psychotic relapse One of the strongest predictors or risk factors associated with the onset of psychotic illness There is little evidence that the high rates if cannabis are is related to selfmedication for distressing symptoms or side effects of meds
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Common Issues in Recovery Daily Life Lack of structure/disorganization Lack of supports required to return to school or work Negative experiences No plan to help recovery Lack of motivation
Relationships Trying to establish independence from family Loneliness/Separation from social groups Increased anxiety in social groups Difficulties in re-establishing relationships
Recovery takes time
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Why Early Intervention
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Prevalence of Psychotic spectrum disorders per 1000 children/adolescents Boys
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In males particularly, particularly schizophrenia is a major disorder of adolescence Hits adolescents in their prime – leads to a disruption in education-attainment, career building, employment Alters relationships, family interactions, support Alters sense of self, esteem, productivity
Gi l Girls
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4
(Reprinted) Spady et al. Prevalence of Mental Disorders in Children Living in Alberta, Canada, as Determined from Physician Billing Data. 2001.Arch Pediatr Adolesc Med. 155: pp.1156.
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Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Research has shown that psychotic illness begins to have social and clinical consequences after puberty, in early adolescence even prior to the onset of identifiable psychotic symptoms The prodrome a substantial amount of the disability for which schizophrenia is traditionally heralded accumulates in this stage and may create a ceiling for eventual recovery. shift to honing our ability to identify the markers of the prodrome or high risk presentations of possible transition to psychotic disorder Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Phases of Illness Birth
First Signs of Illness
Premorbid Phase Prodromal Phase
Onset of Psychosis
First Treatment
Duration of Untreated Psychosis
R Recovery/Stabilization /St bili ti Phase Ph
Residual/Stable Phase
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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• PACE Clinic (Personal Assessment and Crisis Evaluation) – Melbourne, AUS • PRIME Clinic (Prevention through Risk Identification, Management & Education)
– Yale University, US & Toronto, Ontario
Developed and validated criteria which can be applied to a population that is “help-seeking” (already ill to some extent) that might be timed to the onset of psychotic disorder - pick up on subsyndromal psychotic symptoms along with a recent worsening of functioning - goes beyond risk based only on genetic history - for the first time we can track the progression of schizophrenia
Using these criteria, studies have quoted the ability to predict conversion to psychotic disorder in 11-35% - higher than the general population prevalence of schizophrenia of 1%
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
“It It is not an easy task to recognize psychosis in the early stages and motivate a young psychotic person, who might have persecutory delusions or other delusional beliefs, to accept psychiatric treatment.”
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7/6/2011
Challenges in identifying the prepsychotic phase The earliest symptoms identified are non-specific: Sleepp disturbance Depressed mood Anxiety
behavioral disturbance social withdrawal irritability
In youth, changes that occur as part of the normal developmental continuum can complicate psychiatric diagnoses. Patient age, gender, developmental stage, identity, culture, belief system are all significant diagnostic and therapeutic factors The differential diagnosis for psychosis is widespread in youth and depends upon a number of environmental factors that must be examined 40% cases – initial diagnosis has cause to be changed in 3 months
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Only 1 in 6 young people receive adequate care
The Problem: Decide that help is warranted Decide this is a problem
Want help
r=0.00
Illness
Research studies world wide have shown that 1 in 5 young people have a diagnosable mental illness of some kind
Treatment
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Recognition of youth in trouble
Less than ½ of child & adolescent psychiatric disorders are identified in primary care settings & only a fraction are referred for mental health services
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Recognition of youth in trouble Externalizing disorders Parent Teacher Teenager Friend Screening Tools Doctor
_
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Internalizing disorders _
/ -
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Recognition of youth in trouble Direction of help-seeking help seeking behavior Help seeking behavior in adolescents is primarily directed to friends, family andd teachers t h before b f physicians h i i
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
How can you help? Early identification What do these youth really look like?
Support Reduce stigma/increase acceptance Substance use declining grades/functioning changes in behavior
Help access service/assessment Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Warning Signs Gradual onset of change in behavior, appearance, attitude etc “he’s not himself”, “something’s up with him” I l i from Isolation f friends, f i d adopting d i new/unusual / l friend f i d group Decline in grades and overall functioning over time Poor hygiene Onset or increase in substance abuse, esp marijuana Odd or bizarre comments, beliefs, behaviors Easily distracted, sensitive to noise/light, wearing headphones often with little eye contact Appearing to be “out of touch” or daydreaming a lot, staring Low mood, frustration, irritability, sadness, confusion Avoiding hallways, crowds, buses Fatigue during day (poor sleep) Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
QUESTIONS
Studies are now showing with earlier identification there is a decline in the transition rate to psychotic disorder in youth at high risk.
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