MENTAL HEALTH Updated July 2016 1

OBJECTIVES 1. Differentiate normal and abnormal psychological functioning during adolescence 2. Recognize the main alerting symptoms of common mental health problems 3. Assess and manage mental health problems & disorders, including risk & protective factors 4. Identify situations which need referral to a mental health professional, including suicidal conducts 2

A CHALLENGE. . Today, about 450 million people suffer from a mental or behavioural disorder. According to WHO’s Global Burden of Disease 2001, 33% of theyears lived with disability (YLD) aredue to neuropsychiatric disorders © World Health Organization 2003; http: //www. who. int/mental_health/media/investing_mnh. pdf 3

A divorced mother comes to consultation with her son Bill, a 16 year-old only child, complaining about the fact that he is withdrawn and has hardly talked to her for two months. The boy himself denies any problem, despite the fact that he is skipping school often and his grades are dropping. The boys sees his father every two weeks, and the father, according to the mother, doesn’t seem to be troubled by his son’s situation. Until the age of 14, Bill was a bright, talkative, active kid. After his father left home two years ago to live with another women, Bill’s situation has gradually worsened, according to the mother, with a lot of conflicts around the issue of social outings and school duties, and a deterioration of his behaviour at school. Over the three last months, Bill skipped school several times because of headaches and stayed alone in his room, playing his guitar. He quit his football club 4 months ago, and has not seen his friends for two months. The consultation was prompted by the fact that the mother discovered an entire package of sleeping pills in her son’s desk. 4

DEFINITIONS Mental health is defined by the World Health Organisation as “a state of well-being whereby individuals recognize their abilities, are able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution their communities” A mental disorder is: v Behavioural or psychological v Of clinical significance v With a concomitant distress and/or a handicap, an elevated risk of death, or an important loss of freedom v Not the expected cultural response to any situation 5

“NORMALITY” ü Often difficult to define. Must be assessed over time ü Flexible behavior evolving over time ü Capacity to keep a creative activity in any domain ü Network of (supporting) friends ü Lack of fixed persisting symptoms (~3 months)

WHY FOCUS ON MENTAL HEALTH PROBLEMS ? Many disorders appear during adolescence Increasing prevalence around the world Comorbidity, co-occuring problems Violence Substance use School failure Problems in the area of sexual/reproductive health Often diagnosed too late 8

Burden of disease: contribution of the 20 leading global risk factors in the world Disability Adjusted Life Years The sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability 9 Ezzati & al. Lancet 2002

PREVALENCE RATES 10

Use of psychotropic medication in USA: 1996 -2012 Olfson & al, NEJM, 2015 11

Group work: List the main symptoms of mental health problems in Bill’s situation 12

MAIN SYMPTOMS OF MENTAL HEALTH PROBLEMS/DISORDERS Signs of overt mood depression, low mood, tearfulness Lack of interest in usual activities Somatic complaints such as headache, stomach-ache, backache or sleeping problems Self-harming behaviours, aggression Isolation, loneliness Deviant behaviour such as theft and robbery, disappearance of money Change in school performance or behaviour Use of psychoactive substances (including over-the-counter medication) Weight loss or failure to gain weight with growth 13

Risk & protective factors for mental health disorders PROTECTION Family connectedness School results/environmt. Religiosity Connectedness with peers Pro social activities Long-term perspectives Mother’s education VULNERABILITY Parents’ mental disorders Familial violence SES, migration, war Poor school environment Bullying Isolation, lack of peers Chronic condition Bereavement Questions on sex. orient.

RESILIENCE : Why do adolescents chronically facing a stressful situation cope with it and engage in a fruitful existence? 15 Werner E, 1955

RESILIENCE Constitution Family climate Community support STRESS Family problems War Migration Chronic condition ADAPTATION Physical, mental health Well-being Economical autonomy

CONSTITUTIONAL FACTORS ü ü Effective and flexible adaptation strategies ü Social maturity, search for responsibilities ü High self-esteem, autonomy ü 17 Capacity in raising the adults’ interest External locus of control

ENVIRONMENTAL FACTORS ü ü The family is providing opportunities to take responsabilities ü Stress on moral/religious values ü Strong network of peers / friends ü 18 A stable relationship over time with an adult referee Good school climate and appropriate pedagogic approaches

ASSESSMENT 19

WARNING SIGNS Non specific Drop in school grades Isolation Violence Physical symptoms and complaints No creative/leisure activities Sanci & al, 2011; Kramer & al, 2013

WHEN TO WORRY: THREE MAIN CRITERIA 1. problems lasting more than a few weeks should be considered as potentially harmful 2. persistence and severity of fixed symptoms. (normal adolescent progress is marked by fluctuations in mood and behaviour) 3. impact of symptoms on the young person’s general functioning and on the adolescent process 21

INVESTIGATE 1. Duration (any precipitating event ? ) 2. Persistence and severity 3. Impact of symptoms on the young person’s general functioning, suffering 4. Coping strategies 5. Developmental stage 22

INVESTIGATE Family life School environment District/area environment SES factors Migration q Don’t forget to assess protective factors 23

INVESTIGATE BEHAVIORS v v v v 24 Relations with parents Relations with peers Sexual life Leisure activities School functionning Exploratory behavior Eating behavior Substance use

INVESTIGATE BEHAVIORS v v v v 25 MENTAL HEALTH Relations with parents Relations with peers Sexual life Leisure activities School functionning Exploratory behavior Eating behavior Substance use v Self image v Projects and dreams v Creative activities v Tiredness, sleep problems v Anxiety and depression v Phobia v Delusions

A FEW EVIDENCES V. Patel, JAH, May 2013 There is some evidence that targeted and universal depression prevention programmes may prevent the onset of depressive disorders compared with no intervention Merry & al, Cochrane, 2010

Group work: Reflect on what can be offered to Bill 27

TREATMENT Support, brief interventions, MI Discussion with family, foster caring adults Modification of environment Medication Psychotherapy (by a specialist) 28 q Psychodynamic q Family therapy q CBT (cognitive behavioral therapy)

REFERRAL PROCESS Don’t be to hurried. . Explore the patient’s expectation Work with the family Remain active in the situation Co-consultation, go with the patient 29 Support the process after first consultation

SUICIDE AND SELF-HARM 30

OBJECTIVES 1. Recognize the importance & meaning of suicidal conducts and self-harm during adolescence 2. Identify the signs, symptoms and risk factors of suicide and self-harm 3. Successfully manage suicide crisis situations 4. Demonstrate skills in responding to a suicide attempt at an individual and collective level 31

Recognize the importance & meaning of suicidal conducts during adolescence 32

DEFINITION Suicide and suicidal conduct encompass all deaths and all self-harm events which result directly or indirectly from an act whose author knows the final result (Diekstra, WHO)

CONCEPTUAL PROBLEMS 50 -70% of those who commit suicide suffer from affect. disorders and 20 -40% have made a suicide attempt in the past suicide parasuicide 15% of affective disorders end up with a suicide affective disorders 10% of parasuicides will commit suicide within 10 years

RANGE OF CONDUCT Suicidal ideas Suicidal plan and menace Suicide attempt Death by suicide Suicidal equivalents Self-inflicted mutilations Risk-taking 35

INDICATORS ü Death by violent death ü suicide ü Accident/injury ü overdose ü Morbidity ü Data from hospital & ambulatory care ü Self-reported behaviour ü surveys

SUICIDE AND SUICIDAL CONDUCT Death by suicide Hospitalizations Ambulatory care Undisclosed / unrecognized events Suicidal ideas/plans ?

MORTALITY RATES: THE EXAMPLE OF SWITZERLAND

RATE BETWEEN THE MEAN PREVALENCE OF SUICIDE IDEAS, SUICIDE ATTEMPTS AND DEATHS BY SUICIDE Ideation : 40000 / 100 000 adolescents Attempt : 3000 / 100 000 adolescents Suicide : 20 / 100 000 adolescents

SUICIDE AMONG ADOLESCENTS 40

RECURRENCE q After a suicide attempt, there is a 30 -40% of recurrence. The recurrence occurs usually within 6 -12 months q The odds for a death by suicide are 20: 1 among those who have attempted suicide q Among those who engage in several suicide attempts, the risk of death is up to 10 -20% … but these numbers are based on clinical samples 41

CO-MORBIDITY Depression All mental health problems Substance use, addictions Schizophrenia Phobia Personality disorders Life events / circumstances Acute Chronic 42

Identify the signs, symptoms and risk factors of suicide and self-harm JL Terra & M. Séguin 43

Evaluation Risk : predisposing factors (personal & environmental) Urgency : to what extent is planning of suicide / suicide attempt present ? Potential lethality : accessibility of means, potential lethality 44

Group work What are the factors in Bill’s situation which potentially predispose him to suicidal conducts ? 45

Personal factors Gender, age Antecedents of suicidal conducts Mental health problems Low self esteem Homosexual orientation Temperament (impulsivity, rigidity aggressivity) Physical / mental handicap 46

Personal factors Isolation Substance misuse Breaking of a romantic / friendship relationship, conflicts Loss of an important person Unintended pregnancy Ancetedent of sexual abuse / violence Runaway Delinquency 47

Family & social factors Poor relationship with parents Parental conflicts Violence, abuse and neglect Early losses Parents with substance misuse/abuse Parents with severe mental health problems Parents with severe health problems Suicidal conducts among parents/relatives High expectations from parents 48

Urgency Probability of acting out within 48 hours: v Where v When v How 49

Urgency Low Ideation No real planning Medium High Ongoing planning Planning completed beyond 48 h. To be acted out within 48 h. 50

Potential lethality Lethality of the mean Firearms Railway Hanging Drowning Medication ? 51

Level of danger Accessibility of the mean Immediate access Firearms with munition available Medication in a large amount 52

Successfully managing suicide crisis situations 53

A divorced mother comes to consultation with her son Bill, a 16 year-old only child, complaining about the fact that he is withdrawn and has hardly talked to her for two months. The boy himself denies any problem, despite the fact that he is skipping school often and his grades are dropping. The boys sees his father every two weeks, and the father, according to the mother, doesn’t seem to be troubled by his son’s situation. Until the age of 14, Bill was a bright, talkative, active kid. After his father left home two years ago to live with another women, Bill’s situation has gradually worsened, according to the mother, with a lot of conflicts around the issue of social outings and school duties, and a deterioration of his behaviour at school. Over the three last months, Bill skipped school several times because of headaches and stayed alone in his room, playing his guitar. He quit his football club 4 months ago, and has not seen his friends for two months. The consultation was prompted by the fact that the mother discovered an entire package of sleeping pills in her son’s desk. 54

Taking care Establish a neutral but empathic relationship. Openly put the issue of suicide on the table Verbalize the suffering First listen, then find a solution with the adolescent Inquire about a precipitating factor 55

Formulation The professional should share his own perspective He should as well deliver his opinion that there alternatives to a suicidal gesture He should explore the adolescent’s resources and how the adolescent envisions practical solutions The professional must find a balance between a direct versus a respectful attitude He should summarize what should be done 56

Breaking isolation, supporting connectedness Identify available resources with the adolescent Look for alternatives that are immediately available and that allow the adolescent to take control of the situation Often, the patient himself finds alternatives 57

Make sure that the adolescent accepts a follow-up Establish a contract The adolescent accepts to give up the suicidal project, at least on the short term It allows to establish a health care framework Referral to a mental health professional … and if not possible, discuss the issue of hospitalisation 58

After a suicide attempt Address a tendency of the adolescent and his parents or guardians to deny the severity of the situation Provide follow-up consultation, if needed psychotherapy (individual, family) At least, see the adolescent again some weeks after 59

After a death by suicide Make sure that the family is assisted in its grieving process At the school or community level Be clear about what has happened, do not keep the situation secret Provide an opportunity to express feelings When appropriate, associate close friends to the funeral 60

Wrap-up: three vignettes 61

Paul is sent to you by the school nurse. The day before, he tried to jump off a bridge but was held back by a passer-by. He begs you not to tell the story to anyone, claiming that although he is still heavily depressed, he no longer wants to die. 62

Sue is a 17 year-old who was removed from a threatening home environment and placed in a protected living house. Although she claims to have adjusted to her new situation, she has been overheard screaming abusively on the phone to her boyfriend. A case worker found a diary in which Sue writes scenarios of killing herself. 63

Carol, a heavily depressed 16 year-old girl has refused any medical treatment for her depression. Her friend’s mother calls the practitioner to explain that the day before, the friend has discovered a rope under Carol’s bed. The parents don’t know anything about the story. 64