Cases camhs transcript — SMP305 lecture transcript

OK, um, can you all hear me OK? Up at the back as well? Grand, OK. So, um, a hot afternoons, a lot of them, but, uh, we've got a few hours of CAMHS teaching. Um, you will get another block in your paediatric part. Um, but this is the main bit, uh, today for your mental health block. So my name's Doctor Margaret Loban. I was a consultant who used to work in, um, Beckton. Uh, I think most of you will be doing an attachment there at some point. Um, and I work in the training department now. OK, so, um, we'll try and keep this as interactive as possible. Partly to keep ourselves awake, but also because it to help you sort of get engaged with, with the topic. Um, in terms of exams, I'm not sure, but, um, there have been questions on. Probably to give you a hint, the early part of this. Not that you can fall asleep after that, but um it's more the the first part where there have been exam questions in the past. The way it works, we put in exam questions, but we don't know which ones are picked, so. OK, so please put your hand up or come to me at the end if you've got any questions. I know some of some of this can be difficult. Um, it might bring up things for yourself or with friends. So please, if there's anything you want to come and speak to me about, please, please do. OK, so we're going to start off talking about systems and depression in young people. Now, systems are something that affects every area of learning really, um, and health, um, but it's particularly relevant for for young people and we'll have a think through why why that is. OK, so we're gonna look at the systems first of all around young people. We're going to briefly look at mental health conditions in in CAMHS, um, just to orientate you so that you can sort of have a think, OK, which ones am I learning about in adult mental health that'll cross over? Which ones are different and I need to learn separately, OK? Um, so CAMHS, someone asked me, sort of, um, a very important question. What does it stand for? So it's Child and Adolescent Mental Health Service, and it's the standard term for young people's mental health services. Across the country, and then we're going to look at depression in young people. OK, so we're gonna start off with a quiz just to get ourselves thinking about how much we do know, um, already about the subject. OK, so which of the following is true? Um, so it can be one or, or two or three of them. Children under 10 years do not present with depression. In CAMHS, the young person and the family are always interviewed. Developmental stage has no effect on presentation of the mental mental illness. OK, so, show of hands for the first one. Children under 10 do not present with depression. Hands up if you think it's true. OK, so I'm gonna take that as a as a no. Um, in CAMHS the young person and family are always interviewed. Uh, a fluttering of hands there, so definitely more people saying yes than no. OK. Um, developmental stage has no effect on presentation of mental illness. True. OK, so that looks like a very, a very definite one. OK, oops, I thought I'd, um, so going back to that one, so yeah, so you're right for the first one. Children under 10 can present, um, with depression. It's not common, but it does occur. OK, um, young person in the family, if at all possible, um, occasionally the, the parents might not be there. Um, so there may be occasional circumstances where, where you wouldn't, but they have to be very rare. So even if you thought there were child protection issues, You might want to interview people separately, but you'd want to get some information from the parents. Um, developmental stage does affect the presentation. Um, if you can imagine, um, we'll come on to that later, but, you know, a young child of 5 is going to express feeling sad in a very different way from a teenager, just at that basic level, even from the level of their development, so how, how they're able to verbalise and understand their own feelings. OK, the following are possible diagnoses in young people, anxiety. Any further truth for that? Um, flurry of fans, a few more, so I'm not sure. Alzheimer's disease? OK, no hands up there for that one. And obsessive compulsive disorder. OK, so definite for that one, right? OK. Um, so, so yeah, so the first one is true. Um, you do get anxiety disorders in young people. Um, they're common. Um, Alzheimer's disease, no, you do talk, you do hear about early onset or young adult. But that may be very occasionally 20s, usually 30s when you're talking about people young. I've never heard of it, um, in anyone under 20. Um, you can prove me wrong, but I've, I've not, I'm not aware of it. OCD, yes, yes, you do get that in, in young people. Is that correct? Brilliant. Uh, so common symptoms of anxiety in young people are palpitations. So yep, good for you for that. Hallucinations. OK, nobody for that one. and refusal to go to school. OK, excellent, yeah. So palpitations, so if you're if you're revising for anxiety, the symptoms of anxiety, the core symptoms of anxiety for young people are the same as in adults. So in adults you'd obviously get palpitations, nausea, sweating. Um, and that's the same in young people. Hallucinations. So occasionally people mistake it. Young people, when they're anxious, will sometimes hear a sort of running commentary, as adults do. So if someone's very anxious, I don't know about their driving test, they might be going, OK, I need to think about this, I need to think about this. So they've sort of got a very loud running commentary in their head. And the difference obviously with hallucination is it's external. Um, so, so, not, not in anxiety. Um, refusal to go to school, yes. Um, so that's one of the, um, types of anxiety that obviously you only find in, in young people. OK, so a 14 year old boy presents with temper tantrums, irritability, and isolation at school. Which of the of the following are possible diagnoses? I take that the last one's not a diagnosis, but one of your jobs as a doctor is sometimes to undiagnose something. So someone comes and says, I'm absolutely convinced this person's got ADHD. Your job may well be to say no, they don't. So it's, it's, it's frequently uh something that you do as well as diagnosing you undiagnosed. And it's really important that you do that because. It a diagnosis has to be clear, OK, so ADHD, how many you think it could be? A few, OK. What about psychosis? Again, it can, it can be all of them. OK, um, rebellion? Definitely the most, I think the most frequent, but most of you not, not, not, not buying this one at all. So this is the sort of referral you would get in CAMHS from a from a GP. It's not an untypical one for, for an adolescent. Um, so really what they're telling you often is that this is a change in behaviour. It could be, that's one of the things you have to clarify, but often it is that this young person has become more irritable, has become isolated. Um, although ADHD is a lifelong condition, um, if it's secondary school, sometimes kids manage in primary because they've got a very supportive school. Um, and then when they hit secondary, so they've always had the neurodevelopmental disorder, but in a new environment where more is expected of them, less support, then it can become obvious. Um, it certainly can be psychosis, so young people, um, may tell their parents, for example, that they're hearing voices or they've got paranoid ideas, but more often they hide that, um, but will be. irritable because of their fears and their anxieties associated with their psychosis. Um, and I've certainly had a presentation of a couple of young lads and that that's been the initial presentation. Um, and rebellion, yes, so, so that's just emphasising that you need to check out it's just not every day because teachers are worried, parents are worried, people don't like the behaviour doesn't mean it's mental illness. So the devil's in the detail with that one. OK, so the following are true of assessment and treatment in CAAMHS. You can treat the young person without considering the system they're part of. I think that's a bit of a loaded question. So anyone's true for that? OK. Um, so, so, no, we'll come onto that, so, um, and why that is. Um, it doesn't matter about interviewing the young person on their own. Anyone think that's true? OK, so, so it's it's really important with young people, because the majority of young people won't tell the whole story in front of their parents. A whole bunch of reasons, they're not used to talking about these sort of things in front of their parents. Very, very often they don't want to worry their parents, so they're not going to tell you. How bad it is in front of the parents. Sometimes they've got completely different views. So the parents worried about school work, they're worried about something completely different. So it's really important. Um, obviously occasionally with younger kids, they won't want to speak to you on their own, but if at all possible you do. Um, the young person's age can affect how an illness presents. Yeah, so yeah, we've touched on that, and it does, it very much does. OK, so well done. Um, so how CAMHS differs from adult mental health. So again, it's just really orientating you, um, when you're trying to think about what you're what you're looking at, what you're learning. Um, so in adult mental health, it tends to be individual focused. You've got your patient, you might speak to the relatives occasionally, but it's the patient that you're dealing with. Um, and when you're talking about family history, when you're doing your assessment of mental health, you're talking about a family history of mental illness. So has anyone in the family got schizophrenia? Has anyone got anxiety? In CAAMHS, um, the young person is part of the family system for very obvious reasons. You, you know, you're not going to be able to make a decision without involving the parents, particularly with a younger child. Um, and legally the parents have to know, but also they're the people who can. Also help look after the child. Um, in CAMHS, when you do family history, we also do, um, which you can find online easily to look at a family tree. So we look at who's in the family, who's in the current house. You might have a separated family, so you might have. Stepfather, stepmothers, broader, and you also have grandparents, and that tells you about the world the child lives in. It also tells you if there's been recent life events. So if there's been a recent bereavement in the family, for example, or a recent divorce, um, these events can affect young people. So you get a picture of of where things are, as well as the family history of um the the genetic aspect of mental illness. OK, and we, we've mentioned and, and development is part of what you're looking at in CAMHS. OK, so we're now going to look at systems and we're going to look like right through from assessment right through to to treatment. OK, so I want you to have a think. So, um, get our thinking caps going. So I want you to think with the people beside you, the person beside you. What challenges. So we interview the young person with the parents and the carers, that's usually how we'd start with the whole family. Um, so what do you think the challenges that would bring you? So if you were asked just right now, you're gonna interview a family. About this young person who's presenting with an anxiety disorder, what would be the challenges and what would be the advantages of of doing that. So I want you to just to have a chat with the person beside you and then we'll we'll bring that together.

So. I I thinking about that. And I. I. It might be. Yes. Yeah yeah. Yeah. Let me just make some. I guess that's. Yeah. Just saying. OK. I want to press that. Oh. we see. cost Please. OK. I. she I can Yeah. I So. It's just. OK. Yeah. Yeah. I The Nazi Catholic culture, he said. what you OK. OK. I. I I. Um. Yeah. It. challenging. That. 6 months. I Yeah. So my dogs. Yeah, like. 4 on the surface that's not the same. And like you can easily fit. That. yeah. That's like my, I left my cheese. 8. No, that's the size. Yeah. Yeah. Yeah. You. She Sho. OK, so some, some really interesting, um, thoughtful responses there. So a lot about how difficult it might be for the young person feeling that they were worried about what they would say and how the parents would react. The important bit is setting the scene for everybody that you're going to have this discussion to get the information, but you're going to speak to the young person on their own afterwards, and then that gives them the control as to when and what they choose to tell you. Um, in terms of, of yourself, it can be quite daunting. One of the most difficult things is you get different people with different views, and also One person might come anxious, one person might come angry. Um, so it can be quite difficult, and it's sometimes just about slowing it down if you get that situation and giving people separate time to to be heard. Um, and just and just being aware, um, I guess, again, normalising that, that you would expect everyone to have slightly different views of the situation. Um, and that makes it, you know, it's not. Uh, Dad feels he's not being heard, so he has to shout louder. Like that's OK that he's got a different view. You would expect that in the situation, um, and it's actually quite useful, um, and siblings as well, they, they have, um, their perspective that can, can give a lot of clarity.

OK. Let's start off by talking about your asthma, how's that been recently? Um, it's getting worse. I do take my pumps regularly, but. It's not really working. OK, I'm sorry to hear things haven't been as good as they have been, but I'm pleased to hear that you're taking your inhalers regularly. I wondered if now might be a good time to have that chat with just the two of us, if that's alright with you both. I don't know, I'm OK. You sure? Yeah, I'm sure. OK, I'll, I'll just be outside if you, I'll see you in a minute then. OK, fantastic. I'll come and grab you in 5 minutes and we'll, we'll have a chance to catch up at the end. OK. All right, thank you very much. See you in a minute. So, this asthma's not so good, is it? No. OK, let's find out a bit more about it. OK, and any thoughts from what we're talking about, um, what you picked up with dad or what you might wonder about how dad's feeling or his, his reactions? Any thoughts?

Slightly uncomfortable you might have to leave like quite Yeah, but he's quite sort of anxious, isn't he? Are you OK? So yes, he, he also wants out, but he's also sounds like he's a bit worried about what, what might be going on, what's out. So I mean, the other thing is reassuring him, which, at, at the, you know, the doctor is very reassuring, isn't he, that, you know, he'll come back and he'll explain it as well. Um, so there's major things he's not going to be kept out of it. But yeah, he did. He certainly looked anxious, didn't he, about the whole, whole situation? What, what was his role really? What's he supposed to do? And I think it's very difficult for parents because, you know, they're used to speaking for 5 year old, 10-year-old, and they get to about 12. Should they speak? Shouldn't they speak? It's difficult for them to know sometimes how much they should be involved. So setting the scene for everybody is, is, is, is really helpful. OK, so, so that's assessment, um, and we've seen about the systems and and how much the system can tell you. Um, I mean, the other thing the system tells you is in the acute situation, you can often see the positions that the people have got into the family. So one person has got into the role of being the worrier, one person's got the role of sorting things out. Um, and that that can be helpful, but sometimes it's about allowing people to say, well, actually, as well as feeling really anxious, I'm quite annoyed. So it's allowing people a bit more a bit more space within that system. Um, so this is looking at the cause of the aetiology. So this isn't an old piece of research, but um, gives a very clear example about um systems and how they work on mental illness. Um, so it was done by Vaughan and Leff in '76. It has been replicated, um, since then. Um, and what it looked at was that, um, in families where they, their definition was overcritical or over-evolved or um. Yeah, overcritical or over anxious, um, with the person, the patient, um, and what it showed was that there was a huge difference. So, um, even if you had someone on medication, Um, that helped a bit, but if you had someone on no medication and what they call high expressed emotion, the relapse rate was about 90%. So it had a huge chunk of effect with or without medication. Um, now, there's a lot of criticism about research saying, well, OK, um, in different cultures, in some cultures, people, you know, speak very loudly and animatedly anyway, um, and you might be calling them critical when that's just the way they are. So they replicated it and actually it's still replicated. And I would say it's it's also in the clinical situation, and you do find that people who are not used to looking after people with psychosis do sometimes, including nurses and doctors fall into. Being critical of the patient or very anxious for them, so saying don't, you know, don't be ridiculous, of course, you know, you haven't caused that accident on the motorway, um, and, and I think it's um, It's very difficult for people, often when they're dealing with someone's psychosis, they get quite frightened themselves, and that translates into being critical or over anxious. Um, and we, we certainly have certainly worked in family therapy teams where we've done quite a lot of work, just giving the family space to say. I just feel terrified, um, or like I just don't understand, like it doesn't make sense and it makes me cross. And giving them the space meant that they were able to be calmer with the person. Um, so it's interesting what that's about, but certainly it's very clear. research. Although interestingly, not very often used. So I think that's just I'll leave you with that thought about the unscientific nature of of science that people for other reasons don't always pick up on what's very clear evidence. OK, so then intervention. So this is going to the core of why it's so important with young people. So if you have an adult who has a depressive illness, he's being bullied at work, and you're obviously going to treat them and talk them through it, and you'll probably work out plans with them to say, well, OK, do you think you want to stay in this job, or would it be better to move? Or do you want to get things sorted out first and then look for another job? So you can look at ways that they can get support. And change their environment. The young person can't do that. So if the young person's being bullied at school, they can't move schools. They can't sort it out. So therefore you're dependent on the systems around about them, the family and the school and to deal with the environment because giving someone therapy when the environment is the main factor. Probably doesn't work very well, and I would almost say it isn't particularly ethical. I think it's questionable. So if you know that somebody's in a very bullying environment, Just dealing with the anxiety without dealing with the bullying isn't right, because really the problem is a bit like, um, I don't know what it's like medically, I can't quite think of the right analogy, um. Yeah, maybe not giving the antibiotics, you know, not dealing with the actual problem, just dealing with the symptoms. Um, so that's, that's why it's vital that you look at the system round about the young person. OK, you'll be able to look at these slides, so I won't, I won't go into that in detail. Uh oh. So with with schools, I'll pause that one a minute.

Whether you're gang. Um, so with schools, um, you do have primary mental health workers who are CAMHS trained and work into schools. So that's, that's a really helpful way of of, um, communicating with the school about whether there's bullying going on, about what can be done. About it as as an example. OK, so I've mentioned treatment I mentioned already about family therapy. Um, this is a bit of a silly cartoon. It's quite a difficult thing to describe. You you basically have the whole family in, and you have a one-way screen and you'll have um Usually a whole team, so there's usually about at least 4 of you. 2 of you might be in the room and 2 behind the screen. Um, so the one I was saying about, um, young lad who had psychosis, and we all, um, spoke to each, so we sort of each paired up with a member of the family, spoke to them separately, and then we came in and told their stories and they watched. So it gave them that psychological space to think about what it was like for for everybody else. But it's it's giving that that space. So this gives you a little bit of an idea um of what it's about.

OK Oh, sorry, it's um. Whether you're Genghis Khan or the Dalai Lama, a nightmare family is sure to get you down. So it's surprising just how little attention therapists used to pay to the systems their clients lived in, such as family and work. In the early days, they focused on the individual, on how they saw and dealt with the world. And they certainly wouldn't invite families into a therapy session, which was considered highly unethical. But from the 50s onwards, pioneers like Virginia Sotia started looking beyond the client to the systems they live in. Satia invited families into therapy and found that not only do problems extend to the family, they often come from them. Systemic therapists began viewing families as balanced systems with interconnected parts. A change in one part of the system affects the rest. So what looks like one person's problem, like a child's bedwetting, is actually a sign that the system is unbalanced, in this case, by tensions between the parents. Within these systems, people can get stuck repeating stress causing patterns, which is where each person's behaviour maintains the others. Dad might nag mum because she always ignores him, whereas mm ignores dad because of his incessant nagging. These ideas chimed with critics of individualised therapy, such as RD Lang. His studies showed that many emotional problems are in fact rooted in families, schools, workplaces, and wider society. For Lang, the client is just expressing the problems within a system. So if Dad's got low self-esteem, he can't ignore the fact that he's out of work or the problem of unemployment in his community. This idea of looking to the systems a client inhabits is now firmly established in therapy because no one's an island. Not even you, Genghis.

OK, any thoughts or, or questions? I mean, it's not, it's not at all about blaming anybody, but understanding. So, you know, a, a very common situation might be, um, you're speaking to the child and you very quickly think this mum's depressed, um, and you might have to have a bit of time with her on her own, and then quite quickly you might have to set up some support. For her, some intervention for her. Um, the one example of that being unemployed, and it's again, it's about just gently saying, OK, how is that affecting everybody? Um, and it's just that when people are in the thick of the problems, sometimes they don't have space, but it can be difficult for them to see how everything's interacting. Um, so that that's a very useful way, but, but also like we've seen, it can be supportive for parents because what they're distressed about is the child's illness. So it's a system and a circular thing and you're working out which bit can we help with, which bit needs the help urgently in the system.

OK. So if there's any other questions about this and you think of them later, please come, come and ask. Um, common mental health disorders. So we're just gonna have a quick whistle stop tour just so that we know how it, how it looks in um in CAMHS. So these are your main categories. Um, so developmental disorders are the common ones you'll be familiar with are ADHD and ASD, and the lectures from the, these you get in your paediatric block and you get it not from CAMHS, you get it from, I think it's psychologists or it might be paediatricians, but it's in your paediatric block. Um, word of warning, you might get examined in your mental health block. I know that sounds a bit daft, but it has happened before, although I said, um, actually they're not getting taught it in this walk, but anyway, so just, just remember that you, although you get taught in that walk, you might get examined in your mental health walk. Um, conduct disorders, um, emotional disorders, eating disorders, and psychosis. So that's a very, very brief, as I say, you will get lectures on these, but um, ADHD is a triad of poor concentration, overactivity and poor attention. Can't be diagnosed till someone's over 6, treated with parenting advice and medication. Um, just I'm I'm aware from reading things and speaking to to friends. People are a wee bit focused that if you've got poor concentration, you've got ADHD. Uh oh, no, no, no, no, no. Poor concentration comes up in just about every mental health condition, depression, anxiety, psychosis, so it's one of the factors, it's not diagnostic. Um, if you're doing an ADHD assessment, if it's a proper ADHD assessment, it's extensive, and you have a long assessment to look at the possible symptoms. ASD, um, triads of difficulties, of social understanding, um, of rituals and preoccupations and language difference. Um, again, a multidisciplinary um assessment. Um, and the treatment for ASD it's about supporting people in the environment. OK, um, attachment disorders, um, I won't go into that as we're coming into that in the lecture later this afternoon. Um, but that is another, um, part of developmental disorders. Conduct disorder. So conduct disorder is described as a person with behaviour, um, for example, tantrums or stealing or breaking things, um, that makes them contravene the law or society saying controversial as a medical diagnosis because it's describing a social situation. Very often, young people with this have um very troubled backgrounds, um, and I would say that's the main direction you're often looking in. OK, so these are the emotional disorders, and in the diagnostic category, that's how they're described as one sort of group. And these are the different um categories I would say in CAMHS. So post-traumatic stress disorder, which we're coming to next, self-harm, um, depression, anxiety disorders, and OCD, um. And most of them are very similar to um adult mental health. Anxiety disorders have some different types, as as you've described, um, in terms of you mentioned when we talked about it earlier, you about school refusal. OK, you will get a lecture on eating disorders as well, so I won't go into that. Um, psychosis is, uh, very similar to to what you learn in adult mental health. Um, so the key symptoms are the same. Um, specific diagnosis is less clear. Um, sometimes you get a clear manic illness or clear schizophrenic illness, but usually there's a sort of mixture of symptoms. Um, most common onset in late teens. Um, you, the most common symptom is hallucinations. You do get ideas of reference and delusions. Uh, thought disorder, as in people believing these thoughts put into the head or taken out of the head, is, is unusual. OK, so these are the key symptoms um in a delusional illness. So, the delusion is a false, unshakable belief out of keeping with your cultural background, and the hallucination is perceiving something in external space. So as I mentioned earlier, it's not an internal voice, um. And you can't control it, or will it to happen. Um, and it's just just important knowing that, particularly with young people, um, occasionally you get, um, families or schools who, um, think that the child's, um, Imaginary friend is, is a hallucination. So it's just, you know, if the child wants that, there is willing it, then obviously, then that's not a hallucination. OK, so delusional and overvalued ideas. So, um, just, just worth remembering this in terms of when you come across people with delusions, um, is it, as we've mentioned before, it can be anxiety provoking. So just thinking a bit about how you approach somebody. Um, it can be tempting to try and persuade someone that their belief is untrue, using sort of facts and logic and information. It it won't work and it will make them very distressed. So it's about agreeing to differ. It's also not saying, yes, yes, I, I, you know, I do believe that you've started the war. In the Middle East, so you're saying, well, we're going to have to agree to differ. I know that's how you feel, what you think, but I don't believe that. Um, and then focusing on their emotions, focusing on how that makes them feel and how you might be able to help them with that. OK, um, So, yeah, agreeing to differ is, is, is the phrase to remember. OK, so we're going to look at depression now in young people. So, depression, um, is a persistent low mood. That's in essence, in essence what it is. So, I'm sure some of you have um read or seen some of these, um. Like, like in all medicine, but particularly in mental health, um, being able to put yourself in someone's shoes as to what it feels like, um, so we know we can work out the symptoms and the signs and the diagnosis, but understanding what that might be like to be in that place, um, can be really helpful. So Hamlet, which, um, won a lot of prizes, and book and a film, um, gives a very good description of Shakespeare being depressed. Um, Darkness Visible by William Stirton is a sort of novel, but really about his own life and about his depression. Um, David Nichols writes about sweet sorrow and again describes his dad in that one, with depression. Goodwill Hunt Good Will Hunting is Robin Williams, which again, very clear description. And I don't know if you've, any of you've seen It's a Wonderful Life. It's um, it's a brilliant, I think it's a brilliant film. It does describe someone with depression but also manages to be a feel-good Christmas film, which I think is quite an achievement. Um, it's it's a lovely film and, and a very, very compassionate, um, description. OK, key symptoms of depression. Um, so these ones down on the left are your core symptoms, as we've said, the persistent sadness or low mood, a loss of interest or enjoyment, and a lack of energy. And then the associated symptoms, a lot of these ones are what we call sort of um Organic symptoms, so the physical symptoms of difficulty in sleep, difficulty in appetite, poor concentration, feeling agitated or slowing down, and guilt. The poor concentration in young people can often present as a change in school work. So if you get a referral where Someone's been doing very well at school, um, they're suddenly not doing very well. Um, it might, you know, depending on, on the child, people might be worried or they might be cross saying you're not trying hard enough. So that's always something to think about if, if the school work's fallen away, is, is that what's, what's happened? OK, so we're going to look at um a case study. Um, again, just chatting to the person beside you and thinking about this case study for a couple of minutes. So Chloe's seen for review at the outpatient department. She presents as very tearful and withdrawn. She says she's not sleeping well. Parents say they forgot to mention at last appointment that maternal grandfather suffered from severe depression and had to be admitted to hospital. When you see her on her own, she tells you that she has thoughts of killing herself every day and thinks her family would be better off without her. So what else would you like to find out about Chloe? Um, and what other symptoms would you check? So just have a chat to the person beside you for a couple of minutes. And then we'll do that through.

so What's the, She It's not. Soappa Mhm. I see that. Yeah. I don't know what you said. Oh should be based on. Yeah. I'm just gonna. Yeah. Is. while it I. issue. the class. that too. I. Gosh. I really. Wait, wait. This is. I it just says Serena. You speak twice. Use a find your find your law. Yeah yeah. it. Just Yeah. Oh. OK. So they were like I like. I. Yeah. I just. I I I. About this. I was there. Yeah. I enjoy it. Yeah. Don't make a joke. I enjoy walking. Yes. I enjoy. I enjoy that. I mean, like, I. So. That's good. No. I, uh, my, problem with it. I I, I saw his soul was on. He's go. Yeah, he was just like yeah. It's cool. I was looking at Toby's the other day and his consistency is pretty impressive. It just does like 6. Do you know it shows like like, it's just a straight 6 km goes down 6 so funny. Consistency is good. OK, so, so lots of conversations going on there. And, you know, obvious things are obvious. You want to get the general psychiatric history. So you want to know what's happening at home, what's happening at school, because school's the equivalent of employment. You want to know about her early life from her parents. Has she had a previous episode before, past, um, psychiatric history? Checking your medical history? Is there anything contributing to that? Um, and then you've got quite significant suicidal thoughts there, so you clearly want to check that out in quite a lot of detail. Um, so you're wanting to know how often is she thinking like that? How severe are the thoughts? Has she made any attempt on her life in the past or no? Because she might not have told anyone. So, so you need to check that out always. Um, and a really key point for looking as to how severe it is, is people's hope for the future. So can they see a future? So if somebody's very, um, severely depressed, and it's part of the depression, we think, is they can't envisage the future. So they might have been a bright person who was very keen to become a dancer, but you know, they also wanted to play football, you know, there are lots of things that they were excited about in the future, and nothing matters anymore. And the same same with adults. So that sort of hopelessness is is a is a very key part of depression and a very significant factor, risk factor in terms of completed suicide. OK, so this is what you find out. Um, so you find out about her family, she's very close to her family. And somebody said you wanted to check, have there been any traumatic events, any what we call life events. Um, so, so it might not be traumatic, but it could still have a significant effect in terms of her bereavement, um, suffers from diabetes, um, and then you do have a traumatic event. She was raped at a party a few months ago, and that might be something she tells you and not her parents. Um, Chloe's appetite's been poor for several weeks, and parents think she's lost weight. She's lost interest and doesn't want to go out with her friends, feels sad all the time, and is finding school work very hard. So mild, moderate, or severe? So you're wanting to think about, you know, how high is the risk in terms of suicide and what kind, what severity of depression do you have. So this looks too simple to be too good to be true. It's from NICE guidelines, but it's actually really, really useful. It's a sort of almost ready reckoner of how severe a depression is. So in terms of the symptoms, how many do you think I'll I'll put it back to the previous slide. Do you think it's mild, moderate, or severe from the symptoms that we have? So, the ones at the bottom are depressive symptoms. Anyone from Miles? Anyone from moderate? I'll go back to this one, make it easier. Moderate. Yep, few for moderate. Any for severe? Yeah, I mean, she's she's on the moderate to severe. Yeah, she, I mean, she's definitely got suicidal ideas, she's got poor sleep, poor appetite, probably poor concentration, loss of interest, um, so she's definitely on, on that end, and that helps you to think about what sort of treatment, so there's different treatments for mild to moderate or severe. OK, so incident. Um, so depression, um, is very low, as we said, in under 10 year olds, um, but about around 3% in 11 to 16 year olds and 25% are detected and treated. So there's still a lot despite people being very aware of mental illness. Um, there's still, um, Yeah, quite a low detection rate from what we're we can tell. OK, so the causes of depression. So we want to know what can cause it, so we know how we can help it. So what might be the risk factors and what might be the protective factors? OK, so in the black one, the risk factors. So we've mentioned bullying. Learning difficulties is a risk factor for depression, and friendships are protective. In terms of the family, you do, um, when you're working for CAMHS, you do work with, um, families and young people where they've suffered abuse and neglect, um, and also domestic violence. Um, but family support obviously can be very, um, protective and and helpful going forward. So drugs and alcohol, alcohol's a depressant, so you do get young people who get into binge drinking and then get depressed when they come off the alcohol. And drink to get rid of the feeling of depression. So sometimes people see it as a sort of, I suppose a having fun drug. So people aren't always aware that it is actually a depressant.

I I. So I'll be force to so. But that one. Yeah. Yes, yes. And Does that change your SSL? Suicide. What It. OK right. OK, so, um, yeah, a lot, a lot of interesting thoughts there. Um, a couple of you saying, um, a safety plan, and I think that's the first thing you think about because we know that this girl has got quite marked suicidal thoughts. So before you sort of, you know, you might be in casualty or you might be in GP practise or outpatient department, before you're doing anything, you're making a safety plan. Um, confidentiality with young people is always, um, got a clause, which, so the first time, so when you speak to that young person on the road, everything's confidential unless there's a risk to himself or someone else, and then you'll need to tell parents or an adult. You you don't want, um, and, and in that case, I don't think I've ever, I've had young people be cross with me, but they come back. Um, whereas if you, if the young person thinks you're going to keep it secret, and then you seem to break it, either you'll get caught in a difficult situation, or they'll be feel like they've been told something untrue. So always tell them that. And so with suicidal ideas, you, you would always tell the parents. And the only exception might be if you thought of child protection, but then you need to find another safe adult if you thought these parents can keep the child safe. And, and safety plan will include things like um keeping all medications locked away. Um, with a girl who's as severe as this, you're really talking about parents sort of being on call, um, and finding a way for the young person to tell when she's feeling that bad. So when the suicidal ideas are persistent. It might be sending a certain emoji to her parents, um, that they they agree on, or she says a word, you know, turquoise, whatever it is they decide that that will be a signal to tell the parents that she's feeling that bad. Um, and you need the parents need to be available. So sometimes, um, you will be saying to the parents, you know, what if he's going to need to be off work, um, and the time when you get concerned if parents really don't take that on board. They might be a bit shocked and have to take it, you know, you might have to spend a bit of time with them, but say, you know, this is like if you, if your child had pneumonia, you, you would be taking time off to be with them, and your child's at risk because I think people put these in quite different categories in their minds sometimes, um. Uh, and, and then distracting things. So what, what, what you work in quite a lot of detail to see what, what helps the young person take the mind, it might be music, might be watching TV or videos, um, and doing that with their parents to, to take their mind off the distress. Um, and then obviously, you're going to be seeing them quite soon to see how that's progressing. Um, or whoever's working with them. Um, as someone rightly said, um, CBT, someone mentioned IAT, which is absolutely right. She's probably, um, you said moderate to severe, she's probably in the too severe category for that, but And these thresholds change, so that's always worth checking out. And I would usually do forms of CBT, um, so if you're looking at CBT, you might be looking at family support or family therapy, um, and as somebody said, an antidepressant, so, um, nice guidelines, you don't use the antidepressant until you've done some psychotherapeutic work about 6 sessions. In reality, um, particularly with long waiting lists, you may well start the antidepressant, um, and it's usually fluoxetine. Is the main antidepressant used in young people. OK, so that's that's your sort of hierarchy. So if it's GP and it's a mild depression, you'd be looking at giving information, explaining to people about, um, depression, about the things that help with mild depression like exercise and socialisation, um, and then you've got community CBT which is a more basic level, and then specialists who who are, you know, trained for 56 years in in CBT interpersonal therapy, sort of what it says on the tin, so it's about. Look people looking at their relationships with other people and how they interact with other people and how that affects their mood. Family therapy and antidepressants. OK, so cognitive behaviour therapy, again hopefully in your, you will get more about this in your adult mental health. Um, it it misses it misses out emotion on it, so quite a few of my um. Psychodynamic colleagues, again, you miss out emotion. Well, it, it doesn't in practise. It just does in the title. So cognitive behavioural therapy looks at the relationship between your thoughts, your behaviours, and your emotions and sees them as a sort of cycle, and you can intervene at any point. So you can intervene with how someone's thinking. Say, OK, let's, um, with kids you use sort of thought capture like games like, OK, what's the thought that's going on there? And the thought is, um. The people that person didn't speak to me because everybody hates me. That would be a sort of typical cognitive depressive thought. Um, and then you, you, you work on looking at that, that's not capture and behaviour is changing the behaviour. So it's like, and often. people will say, well, there's no point, um, going to dancing because I used to love it. And you say, well, but is it OK? OK, it's all right. Do you feel better when you've done it? Yes, I do. So it's a bit lowering the expectations because what would have seemed wonderful. Doesn't seem wonderful because the person's depressed, but still these behaviours actually elevate their mood. So it's a bit sort of, or it might, it might be different activities. They might, you know, prefer to do something quiet where they usually have been bouncing around, um, but it's identifying them and and doing it sort of almost scientifically. OK, what was your mood beforehand? What was it afterwards? OK, we need to help you do more of the things that make you feel better.

Once upon a time, that's a happy story start, right? Mine didn't feel so happy, really. It began with angry thoughts and then sad ones and confusing ones. Imagine a box filled with negative things, and wherever you go, the box is with you. No escape. I guess the saddest thing was that I wasn't the only one. Far from it, too scared to go to school. Nobody understands. My parents won't stop arguing. People bully me. Did you know that 1 in 10 young people have mental health difficulties? I didn't know it at the time, but I was one of those young people. I felt alone and I stopped hanging out with my friends. I couldn't stop crying and I found it really hard to concentrate at school. My mum noticed how much time I was spending by myself. I didn't think it would help, but she took me to the doctor for advice. The doctor referred me to this service for young people. I asked what that was, and the doctor told me that they were part of a child and adolescent mental health service, and they were there to help children and young people with their problems. When I went for my appointment, everybody was really friendly, and I saw a therapist called Phil who was trained in something called cognitive behavioural therapy as part of the CYP IAT programme. When I met with Phil, we talked about my problems. We decided that the best thing to do is meet once a week so he could help me understand why I'm having these thoughts and help me feel better. I was quite nervous before we started the session, but he really put me at ease, and every week he asked me how I felt and didn't judge me if I told him I wasn't feeling great. He helped me to think differently about my problems and we did exercises and relaxation techniques to help me cope. One thing we did was brainstorm ideas to help me think about different ways to tackle my problems. Then we decided which of these ideas I wanted to try first. The next time we got together, I told him this hadn't worked so well, so we tried another idea which was much better. As we went through the sessions, Phil kept checking how I was because we had written this down, it helped me keep track of how I was feeling, and I could really understand what helped me and what didn't. I had 8 sessions, and afterwards I felt much better. I think it really worked because it was good to talk to someone, and I felt that Phil and I really worked as a team to help me find a solution to my problems. It helped me challenge my negative thoughts, and I realised that I could think more positively. I felt really in control, and I know if I wanted to change something I could. Because we wrote down how I was feeling, I could understand how I felt and think about what I could do to change that. I know it's a long road and I still get negative thoughts sometimes, but the skills I learnt with Phil still help me. Talking helped me. If you think it could help you too, you can find out more online at. www.myap.org.uk. Once upon a time OK, um, so that just gives

you a little bit, um, of a sort of snapshot. Doesn't really go into all the details of the different the thought capture and how you work out, um, challenging, not in, in a sort of exploring way. So the young person who thought when someone didn't speak to them, everyone hated them. Um, you explore what the other options might be. So they're going to that assumption. OK, maybe they had something on their minds, maybe they didn't notice you, you know, so you go through what could the other options be, um. So an adolescent who has an episode of depression is 4 times more likely to have a further episode, so significantly more. However, CBT has likelihood. So as well as being CBT is is very well researched as being very effective in treating depression, but it's other great advantage is it's um it's a prophylaxis, it prevents the depression coming back. And, because the person's learned the techniques, so when they start to have these thoughts, they can say, OK, is that true? And use the techniques and and and actually pick up themselves that they're becoming depressed and get help early. Um, so it's it's a very, very useful treatment. OK, so a young person will be significantly affected, as we've noticed by the systems which are around them, and working with the systems which they can't control on their own is essential to helping them. Depression is a common condition in adolescence and is a major cause of suicide. It's treatable. So that despair that the young person feels, part of your job is to know that it can be made better and help them and their family have that hope that they'll get through it. Um, always look behind the behaviour, um, and ask why. So if someone has assumed that that behaviour means X behaviour means Y, um, it might do, um, but it's checking that out and, and having a broad view. Um, so it's being curious. OK, so um.