Best-Practice Assessment and
Treatment of SMI in
Adolescents
Michael G. McDonell, Ph.D.
Acting Assistant Professor
Department of Psychiatry
University of Washington School of
Medicine
mikemcd@u.washington.edu
Tax induced psychosis
SED-SMI (Alphabet Soup)
SED
Children
Any Disorder
+
Level of Impairment
SMI
Adults
Schizophrenia
Bipolar
MDD
Axis II?
Why talk about SMI in
Adolescents?
• Disorders often present in adolescence/early adulthood
• They present unique challenges to the child mental
health system and child/adolescent clinicians
– Focus on psychotherapy rather than case
management in the youth system
– Little expertise in treating these disorders in
child/adolescent clinicians
• Current controversies make treatment challenging
– Diagnostic uncertainty
• Disagreement about diagnostic criteria for children
• Little data on diagnostic stability (e.g. bipolar
disorder) across time
– Little awareness of available treatments
SMI Assessment and Diagnosis
Occam’s Razor: its horses not
zebras
•
Rare cases are usually
explained by
– Simplicity: simplest
explanation
– Most reasonable: most
common/obvious
explanation.
• SMI (bipolar &
schizophrenia) is a zebra
• Other childhood disorders
are horses
• Assessment is a process
of Ruling Out other
disorders
Prevalence of Adolescent Onset
Schizophrenia
• Adult onset Schizophrenia
– Lifetime prevalence of 1%
– Onset mid 20-30s
– Females 5 year later onset (Loranger, 1984)
• Adolescent Onset: Onset <18 yoa
– Rare: < 15 yoa (14/100,000)
• Very EOS (VEOS) < 12 years of age
– Extremely rare: (1.6/100,000)
– Mostly males
Adolescent Onset Schizophrenia
Symptoms (McDonell & McClellan,
2007)
• Symptoms
– Positive symptoms (more common in older
adolescents)
• Hallucinations
• Delusion: organized delusions less common
– Thought disorder
•
•
•
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Loose associations
Illogical thinking
Impaired discourse skills
Less common: incoherence and poverty of
speech/thought
– Negative symptoms
• Impaired social functioning, typically a change from
previous functioning
• Decreased self-care, motivation
Onset/course
• Onset:
– Prodromal phase
– Acute onset vs. Insidious onset
• Course is typically episodic and chronic
Best practice assessment
(McDonell & McClellan, 2007)
• Multi-method/multi-informant
assessment
• Comprehensive medical exam
• Record review
– Medical, psychiatric, educational
• Clinician administered structured
interview
– With youth and parent
• Mental status exam/observation
• Data from collaterals (including school)
• TIME, TIME, TIME
Epidemiology of Early Onset
Bipolar Disorder (EOBD)
• Adult Prevalence
– Lifetime prevalence of
– Bipolar I = 0.4% to 1.6%
– 0.5% Bipolar II (APA, 2000)
– ~ 6 % when including sub-threshold or “spectrum”
cases (Judd and Akiskal, 2003)
• EOBD Estimates vary widely
– .6-22% (Yongstrom, 2007)
– Its appears to be a US phenomenon
• Onset???
– 50% of adults report first symptoms <18 yoa
(Kessler et al, 1997)
– Depressive symptoms typically precede mania
Symptoms that may differentiate
based on research (Yongstrom,
2007)
• Elated mood: extreme, impairing, situation
inappropriate, episodic
• Grandiosity: episodic and associated with mood
• High energy: MUST be episodic, not hyperactivity
• Decreased need for sleep, not insomnia
• Mood swings: intense, with longer periods, beyond what
is developmentally appropriate
• Hypersexuality: R/O abuse
• LOW ability to differentiate: Irritable and distractibility
• Assessment: very similar to assessment of EOS
– Mood diaries also helpful
– Monitoring over time is important
Just thinking about evidence based
treatments gives me a headache…
Treatment of SMI in adolescents
• There are few empirically supported treatments for this
population
• Most treatment options are based on evidence based
adult approaches
Evidence based/informed txs for SMI
in adolescents
1. Psychiatric medications: 1st line treatment, but have
serious side effects with less (or more recent) evidence
of efficacy, relative to adult populations.
2. Multi-informant monitoring and case management
3. Specific psychosocial interventions
• Family psychoeducation (Miklowitz, Fristad, others)
• Other promising approaches
– Dialectical behavior therapy (DBT)
• Self-harm
• Emotional dysregulation
– Interpersonal and social rhythm therapy for bipolar
disorder (Stephanie Hlastala, Ph.D, Seattle
Children’s/UW)
Family psychoeducaton and
support interventions
• Best-practice for adult schizophrenia and bipolar
disorders
– Have been adapted and demonstrated efficacy for
adolescents with mood disorders
• Focus is on:
– Education about the causes, triggers of relapse, and
treatments
– Patients and families bring their expertise to treatment
and become “experts” in the treatment of SMI.
– Modification of family response to the illness to improve
communication (expressed emotion) and improve problem
solving
• Goal: to prevent relapse and achieve and maintain
recovery
• Duration: from 16 weeks to 2 years
•
•
Individual family (Miklowitz bipolar disorder) (Falloon
schizophrenia)
Multiple family groups (Fristad bipolar disorder) (McFarlane
schizophrenia)
Family focused therapy for
adolescents with bipolar disorder
(Miklowitz et al., 2008)
• Adaptation of his adult model
• 21 single family sessions over 9 months
• Family psychoeducation (7-10 sessions)
– Develop family understanding of bipolar
disorder
– Formulate a family relapse prevention plan
• Remaining sessions focus on
– Communication training
– Problem solving skills training
Multiple family group treatment
(MFGT) for schizophrenia
(McFarlane, 2002)
• Designed for adults, but applicable to adolescents with
EOS
• Delivered by 2 clinicians to 5-8 families over 2 years
• 4 phases
–
–
–
–
Joining (3-4 sessions)
Psycho-educational workshop (1 day)
Relapse prevention (24 sessions)
Social and vocational recovery (12 sessions)
• Relapse prevention is promoted through
– Family guidelines (set of science based principles for
relapse prevention)
– Problem solving skills for preventing relapse
MFGT Family Guidelines
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•
•
•
•
•
•
•
•
•
•
•
Go Slow
Keep It cool
Give each other Space
Keep It Simple
Lower Expectations Temporarily
Pick Up on early Warning Signs
Set Limits
Ignore What You Can’t Change
Follow Doctor’s Orders
No Street Drugs and Alcohol
Solve Problems Step by Step
Carry on Business as Usual
Typical MFGT problem solving
session
Structure
•
•
•
•
•
Initial Socializing
Go Around
Select a problem to work on
Solving a problem
Final Socializing
15 minutes
30 minutes
5 minutes
35 minutes
5 minutes
Why might DBT work for SMI
adolescents?
• In SMI populations
– Suicide and attempted suicide risk is high
– Emotional dysregulation is a primary symptom of
bipolar disorder and also an issue in schizophrenia
– Interpersonal skills are impacted by SMI
• Developmentally adolescents are more likely than
others to have
– Higher rates of suicidality
– More difficulties with emotion regulation &
interpersonal difficulties
– Engage in other problematic risk taking behaviors
(e.g., drinking/drug use, unprotected sex)
Adolescent DBT goals and tx
targets
•
Goals:
– Reduce Suicidal and non-suicidal self-injurious behaviors
– Improve emotional regulation and interpersonal skills
– Improve quality of life
•
Targets:
– Decreasing life-threatening behaviors
• Suicidal behaviors
• Non-suicidal life threatening behaviors
– Decreasing therapy-interfering behaviors
• Not completing homework/attending appointments on time
– Decreasing quality of life-interfering behaviors
• High risk impulsive behaviors
– Increasing behavioral skills
• Interpersonal skills
• Distress tolerance skills
Child DBT model (Miller et al,
2007)
•
•
•
•
Orientation and assessment (2 sessions)
Pretreatment/orientation and commitment stage (varies in
length)
1st Phase (16 weeks)
– Individual therapy (reducing self-harm, treatment
interfering behaviors, supporting skills learned in group)
– Multiple family skills group (adolescent & family)
– Phone consultation (adolescent = ind. therapist, family =
group therapist)
– Family sessions (as needed)
– Team meetings (weekly)
Graduate group (16 week modules)
– Graduate group (adolescents)
– As needed: Phone consultation, individual therapy, family
sessions, other non-DBT treatments
Evidence for DBT in adolescents
• No randomized trials have been completed
investigating DBT efficacy in adolescents.
• Inpatient/residential treatment studies
– Reductions in self harm, re-hospitalization,
behavior problems (Katz et al. 2004; McDonell
et al., in press; Rathus & Miller, 2002; Trupin et
al. 2004 )
• Outpatients
– Bipolar youth (Goldstien et al. 2007)
– 1 year of treatment
– Improved suicidality, emotional regulation and
depression in 10 pilot patients.
Now what should I do?
• Perform an accurate assessment and monitor individuals
over time
• Treatment
– Medication management
– Effective case management/coordination of care
– Multidisciplinary team
• Adolescent and family are an active part of the team
• Consult with experts in our area
– Integrate evidence based psychosocial treatments
into your practice
• Some tx are easier to learn/adhere to than others
– Get ready for transition to adulthood
• Many young do not engage in the adult mental health
system
Resources
•
•
Assessment
– Mash, E.J. & Barkley, R.A. (2007) Assessment of
childhood disorders, 4th Edition. Guilford Press: New York.
– AACAP (2007). Practice parameters for the Assessment
and Treatment of Children and Adolescents With Bipolar
Disorder. Journal of the American Academy of Child &
Adolescent Psychiatry. 46(1):107-125.
Treatment
– McFarlane, W. R. (Ed.). (2002). Multiple family groups in
the treatment of severe psychiatric disorders. New York:
Guilford Press.
– Miklowitz, D. (2007). The Bipolar Teen: What You Can Do
to Help Your Child and Your Family. Guilford Press: New
York.
– Miller A.L., Rathus J.H., & Linehan M.M. (2007).
Dialectical behavior therapy with suicidal adolescents.
Guilford Press: New York.