OBJECTIVE To gain an understanding of adolescent Suicidality Drug abuse Relationship between the two Risk factors and how to recognize them Some intervention strategies Suicide Risk factors ID: 920013
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Slide1
Adolescent Issues
Leo O. Lanoie, MD, MPH, FCFP, CCSAM, DABAM
Slide2OBJECTIVE
To gain an understanding of adolescent:
Suicidality
Drug abuse
Relationship between the two
Risk factors and how to recognize them
Some intervention strategies
Slide3Suicide – Risk factors
Gender – males 4 times more likely to complete suicide than females. Females make more attempts.
Age – Age 15-24 have increased risk; males over 75 have highest risk, women 45-54 also high risk.
Depression = hopelessness – what are some contributing factors to hopelessness?
Slide4Suicide – Risk factors
Prior history – have you tried before?
Alcohol and drug abuse
Loss of rational thinking
Loss of support system
Organized plan – Ask not only about suicidal thought. Do you have a plan? Past attempts – how well were they organized?
No significant other
Sickness – AIDS, Cancer 20 fold increase in risk.
Slide5Slide6Suicide
Always ask – it doesn’t plant the seed.
Offer support
Bottom line
Our ability to predict suicide is very poor.
Slide7Common Mental Health Issues
Anxiety
Depression
Bipolar Disease
PTST
ADHD
ARND
Slide8Anxiety
Worried sick – when there is no need to worry
Common at all age
Try to avoid medication, especially benzodiazepines.
Don’t foster “a pill for every ill mentality”
If treatment needed use and SSRI or and SNRI
In severe acute cases can use a
benzo
for a short period of time.
Slide9Anxiety
Caution: Benzodiazepines are easy to start but almost impossible to stop.
Special types of anxiety disorders:
Phobias
OCD
Slide10Panic Attacks
Cognitive behavioral therapy (CBT) most effective.
CBT – how you feel is determined by what you think.
Panic attacks are caused by a catastrophic misinterpretation of body sensation.
Slide11Depression
Common at all ages
It is normal to feel bad about certain things
“Positive negative feelings”
True depression will respond to CBT in the first two years.
Antidepressants may be needed
Slide12Bipolar Affective Disorder
Characterized by mood swings
Bipolar 1 – full manic episodes followed by depression
Bipolar 2 – hypomania followed by depression
Cyclothymia
– less severe mood swings
Bipolar disease typically appears for the first time in adolescence
Slide13Bipolar II
Significant comorbidity with Borderline Personality Disorder
Strong family history
Usually have one or more first degree relatives that are bipolar (may not be diagnosed)
“By way of gestalt, the pedigree of a bipolar patient is often “ugly” with large numbers of relatives depressed, anxious, addicted or acting out in some way”
J. Sloan Manning, Bipolar disorder in primary care, Current Psychiatry, March, 2003
Slide14ADHD
Always present in childhood, but not always recognized
Inattention, hyperactivity, impulsivity
Carries on into adolescence and adulthood
Hyperactivity tends to decrease with age but inattention and hyperactivity does not
High risk of drug use, unwanted pregnancy, criminal activity and life failure
Slide15ADHD
Respond well to treatment with stimulants.
Many health care providers are afraid to treat.
Can be
desasterous
not to treat.
Ritalin,
Concerta
,
Vyvanse
,
Straterra
Slide16Fetal Alcohol Spectrum Disorders
In Canada 4000 babies born with this every year.
Trouble with the law – 60%
Confinement – 50%
Alcohol/Drug problems
FASD is a spectrum, not a diagnosis
Slide17Fetal Alcohol Spectrum Disorders
Fetal Alcohol Syndrome – with historical confirmation (of maternal drinking)
FAS without confirmation
Partial FAS = (pFASP - some but not all of the facial dysmorphology)
Alcohol-Related Birth Defect (ARBD)
Alcohol-Related Neurodevelopmental Disorder (ARND)
Slide18Alcohol Related Neurodevelopmental Disorder
Commonest non hereditary cause of mental retardation
Motor abnormalities
Language difficulties
Behavioural manifestatiosn
IQ ranges from 20-120 with average 68
Slide19Alcohol Related Neurodevelopmental Disorder
Executive function – eg planning ahead
“Gap in Links” difficulty in linking what is heard with appropriate behaviour. They can “talk the talk” but can’t “walk the walk”. Memory tends to be spotty.
“Gaps in Association” Learn information is isolated pieces. Difficulty in predicting outcomes.
Slide20Drug abuse
Slide21Most Common Drugs are?
Tobacco
Use Declining
Still kills more Canadians annually than HIV, HEP C, Homicides and Suicides combined
ALCOHOL
Has a lethal synergy with tobacco – 40 pack year smoker with alcohol dependence has a 47% chance of dying before age 65
George E Valiant
Slide22Alcohol
Is the gateway drug
People don’t drink because they smoke, smoke because they drink
Alcoholism is a genetically transmitted condition, with variable expression.
The younger a person starts drinking, the greater the risk of lifelong addiction.
Slide23Alcohol Dependence or Abuse in Past Year in Adults By Age of First Use
14 years or younger = 16.5%
15-17 years = 9.4 %
18- 20 years =4.4%
Aged 21 year or older = 2.5%
Source: NSDUH 2009, SAMHSA
Slide24Slide25Slide26Take home lesson
Watch for alcohol use in adolescent
Family
hx
of alcoholism
ADHD
CRAFFT
Slide27CRAFFT
C – ever ridden in a CAR driven by someone (including yourself) who was high on alcohol or drugs?
R –do you use alcohol or drugs to RELAX?
A – ever use alcohol/drugs when your ALONE?
F – ever FORGET things you did while using?
F – Family or FRIENDS ever tell you to cut down?
T – Ever gotten into TROUBLE while using drugs/alcohol?
Slide28Number one of illicit drugs?
Marijuana – Cannabis
Many studies in many jurisdictions find 30-40% high school students use cannabis.
Not harmless
Causes anterograde amnesia, cognitive failures, decreased risk awareness, increases reward awareness.
Blunted affect
AMOTIVATIONAL SYNDROME – never proven
OR for schizophrenia is
+
2.0 for marijuana smokers
Slide29Marijuana
Well documented withdrawal syndrome similar to nicotine withdrawal.
No longer use for the pleasure but to avoid the pain.
The younger you are when you first use the greater the likelihood of becoming a heavy lifelong user.
Medicinal marijuana?
Slide30Herbal Marijuana Alternatives
Spice
, K2
Combination of herbs and synthetic cannabinoids (JWH-018, 073 250…), – not chemically related to THC so negative on UDT.
Anxiety, paranoia, avoid eye contact, delusions, sweating, tachycardia, red eyes and dry mouth
HMAs may be less popular in Canada than in US where marijuana laws are more draconian
Slide31Number 2 on the elicit list?
Prescription opioids
The younger they start the more likely they are to be life long abusers.
Slide32Slide33Slide34Slide35Slide36Prescription drugs
Adolescents get them from the family drug cupboard.
Since 2004 has caused more deaths than heroin, cocaine and all other illicit drugs combined.
Slide37Slide38Other Prescription Drugs
Benzodiazepines
TOLERANCE develops rapidly – soon
pt
gets no benefit
DEPENDENCE also develops rapidly – soon
pt
can’t quit because of withdrawal
High potency
benzos
Lorazepam
1 mg – 5mg diazepam
Alprazolam 1 mg - 10 mg diazepam
Clonazepam 1mg - 20mg diazepam
Slide39Saskatchewan Flavor Rx
Gabapentin
In high demand by stimulant abusers.
Snorted
Now has to be written as a “triplicate”
Banned from federal correctional facilities with rare exceptions – seizure, documented neuropathic pain
Slide40Saskatchewan Flavor Rx
Buproprion
Inhibits reuptake of norepinephrine and dopamine.
Stimulant
Injected
Slide41The Stimulants
Methamphetamine leads the way, cocaine is number 2, then .
Stimulants cause a hyper adrenergic state: hypertension, accelerated arteriosclerosis, hypertrophic cardiomyopathy, contraction band necrosis of myocardium – all of which lead to an early death.
Do permanent brain damage – Parkinson like syndrome,
Cocaine bingers can inject 20 or more times a day - BBV
Slide42Methamphetamine
Methamphetamine induced psychosis. Can last a
long time
Slide43Bath Salts
Synthetic
canthinones
Canthinone
=
Khat
– an herb that is grows in East Africa and Arabia and is chewed for energy
There are at least 9 different synthetic
canthinones
.
Chemically related to amphetamines but more hydrophilic therefore less potent.
Slide44Bath Salts
Stimulants
MDVP (3,4
Methylendioxypyrovalerone
) is the one I have heard of in PA. It is more potent than most of others.
Effect start in 14-30minutes and can last up to 7 hours
Death from infarction and myocarditis due to
Mephedrone
and MDVP reported world wild
Slide45Stimulants and canthinones
Remember never to use a Beta blocker if these are suspected.
Slide46Piperazine Derivatives
BZP (1-Benzylpepirazine);CPP, MBZP, MEBP,
MeOPP
,
MeP
, TMFPP - all end in P.
Serotonergic – direct receptor
agonism
and reuptake inhibition.
Clinical effect indistinguishable from amphetamines
Slide47Club Drugs
MDMA (
Methylendioxymethamphetamine
)
Ecstacy
Social drug
Used in Raves
Hyperthermia – most often associated
hyponatremia
.
Fatal hyperthermia
Slide48Club Drugs
GHB (
GammaHydroxyButyrate
)
A date rape drug
Causes a 4 fold increase in growth hormone secretion – likely to see it in body builders.
Therapeutic index of 5 – easy to OD on
Euphoria, dizziness,
hypersalivation
, hypertonia, amnesia.
Bradycardia
and hypothermia
Slide49Dissociative anesthetics
PCP –
Phenylcyclidine
–
Nystagmus
(
virt
or rot)
Ketamine
Anesthesia without respiratory depression
Dissociation,
Derealization
, hallucinations
Flashbacks
Dextromethorphan
NMDA antagonist - similar to ketamine in effect
Methoxetamine
–
Legal Ketamine
Slide50Hallucinogens
LSD - Lysergic Acid Diethylamide
Mescaline - Peyote
Psilocybin – Mushrooms
1
m
LSD = 100
m
Psilocybin= 1000
m
Mescaline
Synethesias
, perceptual alterations
5-HT
2A
Slide51KRATOM
Mytragynine
(from Asian tree
Mitragyna
speciosa
)
Mu and Delta opioid receptor agonist. Also has some serotonergic and noradrenergic properties.
3 time more potent than morphine
Used as an opioid substitute.
Slide52Salvia
From
Saliva
divinorum
,
a herb from the mint family found in Mexico
Is a Kappa Opioid receptor agonist
Hallucinogen
Slide53SBIRT
S – Screen – suspect, ask
B I – Brief intervention
R – Refer
T – Treat
Most important for Alcohol, tobacco, stimulants, opioids and prescription drugs
Club drugs, hallucinogens,
dissociatives
– of the seen only in ER
Slide54Brief Interventions
F – Feedback – Outline findings and concerns
R – Responsibility – It is really up to the patient
A – Advice –Upside and downside of
pt’s
behaviour
M – Menu of options
E – Empathy
S –
Self efficacy