Instructor: Katherine Gordy Levine, MSW. LECTURE NOTES. THE MORE THAN
MOODY BLUES. According to the US Office of Technology Assessment reports ...
COLUMBIA UNIVERSITY SCHOOL OF SOCIAL WORK Course Title: Normal and Pathological Aspects of Adolescence: T-6603 Instructor: Katherine Gordy Levine, MSW LECTURE NOTES THE MORE THAN MOODY BLUES According to the US Office of Technology Assessment reports one in four teens reports experiencing high levels of emotional distress. The 1987 National Adolescent Student Health Survey of eighth and tenth graders found that 61% reported feelings of depression and hopelessness. 45% found their home environment and social environment stressful and hard to deal with and 36% felt they had nothing to look forward to and finally, 34% had considered suicide. One in seven tenth graders reported attempting suicide. The three leading causes of death among adolescents are homicide, accidents, suicide. Although a number of items are considered predictive of suicide, a recent review of a wide variety of studies (Predicting Suicide published in the March 1995 edition of Psychiatric Services and written by James Randolph Hillard, M.D.) noted: Many studies have identified factors that have positive and substantial correlation with suicide in certain populations. However, none of these studies has identified factors that successfully predict suicide by an individual. Predicting suicide at the level of the individual patient is currently not possible. He went on to make the point that the inability to predict which individual is at greater risk of suicide than another individual does not relieve mental health practitioners from assessing risk. Some acting out is harmless. Some depressed youngsters are at risk some are not. When trying to decide if a youth needs to be hospitalized for depression, do not rely on your own knowledge, seek supervisory help or psychiatric consultation. YOUTH DO NOT SHOW THE SAME SIGNS OF DEPRESSION AS ADULTS. It is important, therefore, to understand how depression manifests at different ages as some 12 year olds when asked if they are depressed do not know they are. Why? They have never known any other way of feeling. Some don't feel sad, just irritable or angry. Others are feeling good at the moment you ask them and when the feelings are good, the youth does not remember or feel he or she is depressed. Here are the common ways depression manifests developmentally. 1. Ages one to three common symptoms are: failure to thrive, sleep problems and feeding problems, tantrums, and lack of playfulness. 2. From three to five a depressed child may be accident prone or suffer from phobias. Depressed children may be excessively guilty or full of self reproaches. 3. From age six to eight somatic complaints, aggressive behaviors, and low self esteem are the chief markers. 4. From nine to twelve, depressed youth day dream, have morbid thoughts, and blame themselves for problems. ©by Katherine Gordy Levine and Emotional Fitness Training, Inc. Visit www.emotionalfitnesstraining.com for support and more psycho-educational material.
5. Adolescents are expected to be moody and depressed and therefore are often under diagnosed or misdiagnosed. Adolescent symptoms resemble adult symptoms and include: appetite loss, a sense of hopelessness, oversleeping, and suicidal thoughts. DEPRESSION AND OTHER MOOD DISORDERS ARE NOT JUST THE MOODY BLUES OR FLYING HIGHS A mood is a prolonged emotional that colors the whole psychic life. Mood disorders are marked by persistently, most of the day and every day, abnormal elation or unhappiness that interfere with functioning and is not caused by organic or other mental disorders. Depression if marked by a depressed or irritable mood, loss of interest or pleasure, and presence of associated symptoms such as: appetite disturbance sleep disturbance decreased energy tearfulness brooding somatic complaints feelings of guilt difficulty thinking delusions of major illness recurrent thoughts of death
change in weight psycho motor agitation or retardation fatigue anxiety or panic attacks obsessive rumination nihilistic ideas feelings of worthlessness poor concentration voices berating self or suggesting killing self suicidal ideation
Bipolar disorder often begins in adolescence. Think bipolar if the onset is sudden, accompanied by severe lethargy and delusions. Rather than adult type of mania, adolescents tend to be angry, irritable, and uncomfortably restless. Hallucinations, paranoid thoughts and delusions are not uncommon. Also important to consider. Adolescents may cover up feelings of depression buy using drugs and alcohol to make themselves feel better. Adolescents also deal with depression by being angry or by doing dangerous things. WHEN FORCED HOSPITALIZATION IS INDICATED Legal Standards are identical to those for adults: appearance of mental illness and a likelihood of danger to self or others. No need for parent’s approval or permission to hospitalize. Mental health professionals are often called to evaluate a youth because something the youth does bothers someone else. That something may or may not be a symptom of an illness. Examples: conduct disorder versus juvenile delinquency versus irritable depression? Non-life threatening self mutilation versus suicidal attempts? Psychosis or a cultural belief in spirits. Must be able to figure out the differences. Not always clear cut. In order to reach as accurate a diagnosis as possible, but take the following measure: Must obtain accurate information. In order to do this must: 1. Must ally with both family and youth. ©by Katherine Gordy Levine and Emotional Fitness Training, Inc. Visit www.emotionalfitnesstraining.com for support and more psycho-educational material.
2. Explain role to family and youth 3. Maintain a nonjudgmental posture. 4. Must interview youth and family separately and then together. Must know the signs of mental illness and be able to do a mental status exam. Must understand youth’s mental age and level of thought. Pre-operational or magical, operational or concrete, and abstract or formal. Must speak so the youth can understand you. Examples: Killing self, not suicide. Killing another, not homicide. Must understand cultural components and act as much as possible within that framework. For example in a patriarchal culture must deal with the father. Also important to think of co-morbidity. 50% of all youth meeting one criteria for a psychiatric illness also meet criteria for a second one. 1/3 of all youth with a major mood disorder also have conduct disorder. Bipolar disorder has an even higher co-morbidity with conduct disorder. Substance use is commonly under diagnosed and may be due to self medicating. The more identifiable disorders, the more serious the youth’s condition. Must know how to document the criteria for forced hospitalization. Must be able to state why adolescent appears to have a mental illness. Must be able to state how adolescent poses a danger to self or other. dangerousness include:
Indicators of
Risk taking behaviors--running out in street, to roof, playing with fire. Hopelessness. Feelings nothing will help. Possession of a weapon or knowledge as to where one can be obtained. Thoughts of harming self or others (include animals). Thoughts of killing self or others (include animals). Past plans to harm self or others (include animals). Past plans to kill self or others (include animals). Past acts involving harm to self or others (include animals). without intent to kill. Past acts involving harm to self or others (include animals) with intent to kill. Current plans to harm self or others (include animals). Current plans to kill self or others (include animals). Current acts involving harm to self or others (include animals) without intent to kill. Current acts involving harm to self or others (include animals) with intent to kill. Unwillingness to contract for safety: Ways to get the necessary information? 1. Start by finding out what lead someone to call you. Interview that person separately from the youth or youth. ©by Katherine Gordy Levine and Emotional Fitness Training, Inc. Visit www.emotionalfitnesstraining.com for support and more psycho-educational material.
2. Interview primary care-takers first separately from youth and then with youth when discussing your findings. 3. Interview child first separately and then with primary care-taker as described above. 4. From everyone you interview, find out if this is the worse episode of problematic behavior. If not find out what has been the worse. 5. Teach the child or adolescent a self-rating feeling thermometer and ask youth current level, when lowest, if ever considered or tried to kill self and what level then. When attempting to establish a safety contract for a youth that admits to thoughts of self or other harm, do so in the presence of the primary care-giver, the following guidelines have proved helpful: 1. 2. 3. 4.
Have the youth identify three positives about themselves, their lives. Have the youth identify three stressors that lead to thoughts of harm Have the youth identify three strategies for dealing with those thoughts. Have the youth identify three people he or she can contact to help deal with these thoughts.
If the youth cannot do these things the best path to pursue is an immediate psychiatric evaluation. If the youth can and will contract not to harm self or someone else, the contract needs to be clear and time limited. The mental health professional making the contract is responsible until the youths treatment passes onto another professional. When training crisis teams responsibledeciding whether or not to hospitalize a child, I also suggest: You should act on a combination of what your intuition tells you and what your analytically mind tells you. The two must work together. You must listen to your intuitive sense and you must be able to explain logically when you decide any of the following: 1. 2. 3. 4.
Call 911 and have the youth transported to the hospital, Elect to personally escort the youth to an emergency evaluation Have a family member escort Why you feel the evaluation can be delayed for a few days or longer.
Note these are guidelines, suggestions. If in doubt, always act in the interest of safety first. These guidelines apply to both those at risk of hurting self and at risk of hurting others. CALL 911 OR YOUR EQUIVALENT OF EMERGENCY MEDICAL SERVICES UNDER THE FOLLOWING CIRCUMSTANCES 1. Any condition in which immediate medical treatment is needed to preserve life. Excessive bleeding. The person is unconscious or loosing consciousness. 2. Pill ingestion If the person admits to or there is evidence or even fairly strong suspicion ©by Katherine Gordy Levine and Emotional Fitness Training, Inc. Visit www.emotionalfitnesstraining.com for support and more psycho-educational material.
pills have been ingested, 911 should be called immediately. The dispatcher should be told there has been a pill ingestion, the type and number of pills that appear to have been taken. In most situations an ambulance will be dispatched as even a small amount of pills such as Tylenol can do harm. This is a decision EMS needs to make. Call 911 or arrange for an immediate psychiatric emergency room evaluation even if the ingestion occurred a day or two before. Tylenol for example may not kill you at once, but if enough are taken can destroy your liver. So call 911 for help. Call 911 even if you are not sure pills were actually taken, but have some evidence that this might be a possibility. Be safe, not sorry. Unless absolutely certain you know exactly what and how much has been ingested, make it clear something has been taken, you aren't certain what, and you believe the person is at risk. 3. Situations in which current intent to harm self or other exists. A teen has a knife and locks herself in the bathroom. A kid with suicidal ideation runs to the roof, saying he wants to kill himself. 4. Situations in which current intent is present and judgment and impulse control are severely limited by age or mental impairment particularly hallucinatory processes involving suggestions or commands to harm self or others. CONSIDER ESCORTING SOMEONE TO AN IMMEDIATE EVALUATON WHEN 1. Suicidal or homicidal ideation present, but no plan to act on intent formed but past impulsive dangerous attempts have been made and person's judgement is incapacitated by age or active psychotic processes. Person who has history of suicidal or homicidal ideation, and who has no current ideation, but who suffers from a deteriorating mental condition or who has stopped taking prescribed psycho-tropic medication. 2. Situations in which you have defused immediate intent, but feel the family or individual will not remain calm without your constant assistance or in the face of renewed stress. ARRANGE PSYCHIATRIC CONSULTATION WITHIN A WEEK WHEN 1. Suicidal or homicidal ideation are present, but intent to act has not been formulated into a plan and person contracts to seek help and maintain ongoing contact with the evaluator. 2.Vegetative signs of depression exist, but no suicidal ideation. 3. Psychotic processes are present but do not involve command hallucinations or suggestions to harm self or others 4. Self mutilating behavior unconnected to suicidal or homicidal ideation. 5. Person admits to bulimia or presents with symptoms of anorexia nervosa...extreme thinness, believing self to be fat, menses have stopped are indicators.
©by Katherine Gordy Levine and Emotional Fitness Training, Inc. Visit www.emotionalfitnesstraining.com for support and more psycho-educational material.
REFER TO COMMUNITY MENTAL HEALTH FOR OTHER MENTAL HEALTH CONDITIONS AND WHEN FAMILY WANTS SUCH HELP WHEN FAMILY OR ADOLESCENT IS UNWILLING TO SEEK MENTAL HEALTH SERVICES, EXPLORE ALTERNATIVE TREATMENTS AS LONG AS THE FOLLOWING CONDITIONS ARE MET: 1. No evidence of current suicidal or homicidal ideation or behavior. 2. No evidence of psychotic processes involving destructive behavior. 3. No evidence of an eating disorder.
OTHER THOUGHTS You must be sure what you plan doing is right. Always check with other team members. They can help you make sure you: 1. 2. 3. 4.
Are acting within the law and the policy of those paying you Haven’t missed something Haven’t lost objectivity Would do the same if your child, sibling, other relative, loved one or friend was the one you were trying to force to see a psychiatrist
WHAT IF THE ADOLESCENT OR CHILD REFUSES TO TALK? Use all your persuasive skills. 1. Be genuine 2. Self disclose in terms of your worries, your professional obligations. 3. If you are truly concerned about safety, do not let the adolescent leave your care without obtaining a consultation from your supervisor or a consulting psychiatrist. 4. If the adolescent walks out on you, immediately consult your supervisor or a consulting psychiatrist about what to do. 5. Notify family of your concerns. 6. Call adolescent on phone, keep lines of communication open. RARELY DO YOU NEED TO HOSPITALIZE SOMEONE AGAINST THEIR WILL, BUT IF YOU FEEL A YOUTH IS NOT SAFE THAT IS WHAT YOU MUST DO. ALWAYS ERR ON THE SIDE OF SAFETY. TREATMENT When a person is depressed the feelings of sadness are so deep and dark, the person cannot just snap out of it. Often medication is needed. The best course of treatment combines support, cognitive behavioral approaches, and medication. Two handouts are attached. One is humorous, the other serious. Depending on the adolescent either can be effectively used to help.
©by Katherine Gordy Levine and Emotional Fitness Training, Inc. Visit www.emotionalfitnesstraining.com for support and more psycho-educational material.
RECIPE FOR CURING A DEPRESSION 1. Do all the things your mother and your doctor say are good for your health: Get enough sleep, but not too much. As soon as you get up, exercise for half an hour, shower and get dressed. Eat a healthy breakfast, lunch and dinner. 2. Make and read daily a list of things you have done that you are proud of. 3. Make and read daily a list of people who care about you. 4. Make a list of things you hope to have or do some day. Include your small as well as your large wants. 5. Develop a mission statement for your life. How do you want to be remembered? When it is all over, what would you like others to say about you? 6. Set goals and work toward those goals each day. Make some goals something you can accomplish within a week. 7. Move confidently, look the world in the eye and smile a lot. 8. Spend ten minutes a day looking at. listening to or reading something beautiful and uplifting. 9. Volunteer regularly to help others. 10. Make a list of people you have hurt. Make amends to those people. 11. Make a list of ways you have hurt yourself. Make amends to yourself. 12. Before you fall asleep at night, remember humans aren't perfect, we all do the best we can, one day at a time. Remember you are you and there is no one else in the world like you. Find someone to encourage you, coach you, help get you started. If you can't find a friend or help mate to be your coach, find a professional counselor or support group. If you can't do at least half of these things everyday, you probably need professional help and some medicine to get you jump started. Depression can be cured. Do not let stigma keep you from getting the help you need.
LIFE CAN BE BETTER ©by Katherine Gordy Levine and Emotional Fitness Training, Inc. Visit www.emotionalfitnesstraining.com for support and more psycho-educational material.
SONG SUNG BLUE Song sung blue Everybody knows one Song sung blue Every garden grows one Me and you are subject to the blues now and then But when you take the blues and make a song You sing them out again Sing them out again Neil Diamond IMPORTANT FACTS ABOUT THE BLUES No one is happy all the time. At the same time no one should be unhappy all the time. Most people when sad, know the sadness will pass. Depressed people don’t know the sadness will pass and do think of killing themselves. HOW TO CURE THE EVERYDAY BLUES Sing a song Dance a jig Visit a friend
Jog a mile Watch a funny TV show Play a game
Help someone Draw a picture Talk to someone
MORE IS NEEDED WHEN Just as we can set a broken bone by ourselves, sometimes we need professional help to cure the blues. Such help is available and you need to ask for it when: 1. You cannot do what you need to do, get up, get to school, eat right, take good care of yourself. 2. When you hate yourself. 3. When you cannot enjoy the things that used to give you pleasure. 4. When you are angry or irritable most of the time. 5. When your anger makes you hurt or think of hurting others. 6. When you see or hear things so one else hears. 7. When you think things will never get better. 8. When you take dangerous risks hoping or thinking you might die. 9. When you plan to kill yourself or someone else. DON’T LET STIGMA KEEP YOU FROM GETTING HELP, LIFE CAN BE BETTER WHEN OTHERS HELP YOU DEAL WITH THE BLUES. People to ask for help include: Caring relatives, teachers, preachers, coaches, school counsetors or social workers, and your doctor. Warning: these people might offer lots of reassurance that you are fine and just need to snap out of the Blues. Caring, but not helpful. Which is why sometimes going right to a mental health professional is best. Here are some numbers to call for help connecting to a mental health professional in your area: Suicide help lines: 1-800-SUICIDE 1-800-784-2433 or 1-800-273-TALK 1-800-2738255. Here is a link to the website that can connect you to the help line in your state. WITH THE RIGHT HELP, LIFE CAN BE BETTER. ©by Katherine Gordy Levine and Emotional Fitness Training, Inc. Visit www.emotionalfitnesstraining.com for support and more psycho-educational material.
