Sasha Fehily，Leon Piterman，F(xiàn)iona Judd，Grant Blashki，Hui Yang

Sasha Fehily，Leon Piterman，F(xiàn)iona Judd，et al.全科醫(yī)學(xué)中的心理健康病案研究(十八)——全科醫(yī)學(xué)中的青少年病人[J].中國(guó)全科醫(yī)學(xué)，2013，16(6)：1821-1826.[www.chinagp.net]

對(duì)于大多數(shù)全科醫(yī)生來說，當(dāng)身為父母的人擔(dān)心自己青少年的孩子有行為問題的時(shí)候，總會(huì)感到很棘手。全科醫(yī)生所面臨的困難是難以區(qū)分青少年的正常行為和心理問題。其實(shí)這種挑戰(zhàn)不僅僅只有中國(guó)才有，世界各國(guó)的全科醫(yī)生也面臨同樣的挑戰(zhàn)[1]。2000年澳大利亞開展了一項(xiàng)《全國(guó)心理健康和幸福調(diào)查》，該調(diào)查顯示，兒童和青少年的心理健康問題流行率大約為19%[2]。

1　病史

一位姓劉的女學(xué)生，今年16歲，兩年前她隨父母一起從中國(guó)移民到澳大利亞。他們一家人工作非常勤奮，整天從早忙到晚，辛苦地經(jīng)營(yíng)一家食品店。父母對(duì)她的學(xué)業(yè)非常地關(guān)心，希望她今后能上個(gè)好大學(xué)，找個(gè)好工作。直到3個(gè)月前，劉同學(xué)還是一名非常出色的學(xué)生，在學(xué)校成績(jī)拔尖，絕大多數(shù)課程都得到A的成績(jī)。

不過，最近3個(gè)月以來，劉同學(xué)變得越來越具有“破壞性”，而且她的學(xué)習(xí)成績(jī)直線下降。在家里，她經(jīng)常跟媽媽爭(zhēng)吵，變得非常粗暴無禮，這與她以往的性格相去甚遠(yuǎn)。上個(gè)星期學(xué)校校長(zhǎng)給她爸爸打電話，詢問家里是不是出了什么事。校長(zhǎng)的電話讓劉同學(xué)的父母非常擔(dān)心，于是他們決定帶劉同學(xué)來你的診所看病。

你先跟劉同學(xué)的父母交談了一下，得知這個(gè)孩子的一些表現(xiàn)。劉同學(xué)的睡眠情況不是很好，她經(jīng)常很晚才睡覺，深夜里跟朋友煲電話粥，在網(wǎng)上跟朋友聊天，早上不愿意起床去學(xué)校。她父母說她穿衣服的風(fēng)格跟以前都不一樣了，而且經(jīng)常跟學(xué)校的一群新朋友混在一起，而一般人都認(rèn)為這些都是“壞孩子”。

你請(qǐng)劉同學(xué)的父母在候診室里稍候，然后按照慣例，跟劉同學(xué)在診室里單獨(dú)地談?wù)?。你詢問劉同學(xué)一些比較具體的問題，她說自從移居到澳大利亞以后，就一直感到心情很不好。從中國(guó)的學(xué)校轉(zhuǎn)到澳大利亞的學(xué)校，學(xué)校是陌生的、周圍的人也是陌生的，這讓她感到很發(fā)憷。在最初的那個(gè)階段，她感到學(xué)校沒有一個(gè)人理她。她說那是自己最困難的階段，而且那個(gè)時(shí)候她臉上和后背長(zhǎng)了不少“青春痘”，她認(rèn)為自己很難看，對(duì)自己的看法越來越消極。她說自己不喝酒，也沒有使用毒品，飲食習(xí)慣也沒有改變。不過她說最近半年自己的體質(zhì)量減輕了3 kg。

2　健康檢查

你給劉同學(xué)做心理狀態(tài)檢查。她看上去很安靜、很內(nèi)向。她坐在那里，眼睛看著下面，不斷地搬弄自己的手指。她的情感是憂傷的。她不認(rèn)為自己有任何妄想，也不認(rèn)為自己有幻覺。她對(duì)時(shí)間、地點(diǎn)和人物的定位還是比較清楚的。你給她做軀體健康檢查，結(jié)果表明她是一個(gè)正常的健康女孩，只是在臉頰和背部有比較嚴(yán)重的囊腫性痤瘡。生命體征也都正常，其他軀體檢查也沒有發(fā)現(xiàn)不正常的情況。她的體質(zhì)量是57 kg。你一邊檢查，一邊告訴她檢查的結(jié)果都是正常的，你這種“實(shí)況評(píng)述”的做法是安慰她，讓她放心地知道自己是正常的。

3　輔助檢查

你給她安排了血液檢查，結(jié)果證實(shí)全血計(jì)數(shù)檢查、電解質(zhì)檢查、肝功能檢查、尿液檢查都是正常的。

4　提問

4.1在給青少年做全面評(píng)估的過程中，你應(yīng)該詢問哪些關(guān)鍵的醫(yī)學(xué)方面和社會(huì)方面的問題？

4.2你應(yīng)該給劉同學(xué)做哪些鑒別診斷？

4.3如果你考慮給青少年使用抗抑郁藥，必須要考慮到哪些關(guān)鍵問題？

4.4在管理青少年心理疾病的時(shí)候，應(yīng)該考慮到哪些與家庭有關(guān)的關(guān)鍵問題？

5　解答

5.1解答1：詢問關(guān)鍵的醫(yī)學(xué)方面和社會(huì)方面的問題在青少年中心理健康障礙的流行率很高，但是很多衛(wèi)生專業(yè)人員經(jīng)常不能識(shí)別出青少年的這些問題。全科醫(yī)生給青少年看病的過程，實(shí)際上是發(fā)現(xiàn)他們心理-社會(huì)健康問題的絕好機(jī)會(huì)，全科醫(yī)生可以對(duì)青少年心理問題做出診斷，并可以給青少年提供早期干預(yù)的服務(wù)。

有一個(gè)非常有用的篩查工具，名稱為HEADSS，全科醫(yī)生可以用這個(gè)工具來采集青少年的心理-社會(huì)病史[3-4]。這個(gè)工具的名稱是六個(gè)敏感的篩查方面的縮寫。全科醫(yī)生在使用這個(gè)工具之前，應(yīng)該先與青少年建立起很融洽的關(guān)系[4]。

HEADSS青少年心理-社會(huì)篩查工具：

H 家庭情況(Home situation)

·了解青少年的家庭情況是很重要的，可以讓全科醫(yī)生知道青少年病人和誰在一起生活，他們之間相處狀態(tài)如何。

·有證據(jù)表明，與家庭的關(guān)系不好和(或)無家可歸的情況是青少年心理健康問題的危險(xiǎn)因素。

E 教育/就業(yè)/經(jīng)濟(jì)情況(Education/Employment/Economic situation)

·很有必要掌握青少年病人在學(xué)校的行為、他們的學(xué)習(xí)成績(jī)以及他們的行為和成績(jī)?cè)诮诘淖兓?/p>

·詢問青少年病人在家里遇到的壓力或者在學(xué)校和工作場(chǎng)所受欺負(fù)的情況，這可以讓全科醫(yī)生洞察到青少年可能遭遇到的社會(huì)緊張性刺激因素。

A 活動(dòng)(Activities)

·興趣愛好和活動(dòng)參與可以預(yù)防心理障礙的發(fā)展。

·對(duì)女性青少年來說，詢問飲食情況和身體鍛煉情況是非常適合的。同時(shí)通過了解飲食和鍛煉情況，也能了解青少年病人是否有健康積極的生活方式。

D 毒品/吸煙/酒精(Drugs/Smoking/Alcohol)

·在了解青少年的行為危險(xiǎn)性方面，掌握物質(zhì)使用方面的詳細(xì)信息，這是非常重要的。需要了解的信息包括使用什么物質(zhì)、使用的頻率是什么、使用物質(zhì)的社交場(chǎng)景是什么。

S 性活動(dòng)(Sexuality)

·某些性活動(dòng)(如性失禁)可以是精神病學(xué)診斷的依據(jù)。此外，有必要提供性傳播疾病的篩查服務(wù)和妊娠檢查。

S 自殺危險(xiǎn)/心理學(xué)癥狀(Suicide risk/Psychological symptoms)

·在給青少年病人看病過程中，自殺危險(xiǎn)評(píng)估是必須要做的內(nèi)容。

5.2解答2：青少年心理問題的鑒別診斷青少年最常見的心理健康障礙包括心境障礙、焦慮障礙、物質(zhì)濫用障礙、行為障礙。2001年世界衛(wèi)生組織根據(jù)國(guó)際研究的結(jié)果，指出10%～20%的兒童和青少年有一個(gè)或多個(gè)心理或行為問題[5]。因此，當(dāng)你遇到劉同學(xué)這樣近期有行為改變的青少年病人時(shí)，必須要保持高度的警惕。

正常青少年：青少年表現(xiàn)出暫時(shí)的偏離行為(比如常見的冒險(xiǎn)行為和違法行為)，這是正常的。我們知道大多數(shù)青少年并沒有心理健康問題，不過“問題青少年”中有四分之一需要進(jìn)行精神病學(xué)診斷，并需要進(jìn)一步的干預(yù)治療。

劉同學(xué)近來的行為改變，是家長(zhǎng)和學(xué)校都能夠觀察得到的。她不愿意上學(xué)、課堂上舉止不當(dāng)、改變穿衣的風(fēng)格、結(jié)交朋友上的變化，都是非常常見的青少年行為變化。不過，劉同學(xué)還有睡眠上的問題、心境低落的問題，而且自信心也有變化，那么就很有必要進(jìn)行下列鑒別診斷。

抑郁：青少年的抑郁不總是表現(xiàn)為典型的抑郁癥狀，如心境低落、睡眠紊亂、快感缺乏、體質(zhì)量降低、食欲下降。青少年的主訴更傾向于軀體化癥狀，或者行為上的改變。在劉同學(xué)的案例中，她在表現(xiàn)出很多常見抑郁癥狀的同時(shí)，也表現(xiàn)出一些行為的改變。全科醫(yī)生應(yīng)該注意到一個(gè)關(guān)鍵點(diǎn)，即她剛從中國(guó)移民到澳大利亞，讓她面臨著很多適應(yīng)問題，包括對(duì)環(huán)境、學(xué)校、社交網(wǎng)絡(luò)的適應(yīng)，在診斷的時(shí)候必須要考慮到病人的這個(gè)背景。劉同學(xué)近來面臨的這些生活緊張性刺激，提示全科醫(yī)生考慮到她出現(xiàn)心境障礙。

物質(zhì)濫用：年輕人的物質(zhì)濫用問題，不僅僅物質(zhì)依賴問題，而更經(jīng)常是讓青少年面臨短期內(nèi)受到傷害的危險(xiǎn)。在青少年中，狂飲酒精是非常常見的。在澳大利亞，大約10%的青少年使用安非他明。劉同學(xué)的軀體檢查和實(shí)驗(yàn)室檢查都沒有發(fā)現(xiàn)物質(zhì)濫用的證據(jù)，而且她也否認(rèn)使用酒精和非法藥物。如果發(fā)現(xiàn)青少年有物質(zhì)使用的情況，那么全科醫(yī)生一定要進(jìn)一步了解使用物質(zhì)的種類和方法，以便掌握濫用行為的危險(xiǎn)程度。而且，最好進(jìn)行尿液篩查。

進(jìn)食障礙：青少年和成人的進(jìn)食障礙診斷標(biāo)準(zhǔn)是相同的。按照特定的進(jìn)食障礙診斷要求，病人的臨床特征包括自我強(qiáng)迫地饑餓、使用瀉藥、過度鍛煉、固執(zhí)地追求苗條體形，以及各種與適應(yīng)不良行為相關(guān)的軀體癥狀和體征。

適應(yīng)身體形象的變化，這是青少年心理-社會(huì)發(fā)育過程中要完成的一個(gè)重要任務(wù)。2011年《澳大利亞年輕人調(diào)查》結(jié)果顯示，三分之一的年輕人擔(dān)心自己的身體形象。雖然劉同學(xué)對(duì)自己的外表形象有負(fù)面的想法，但她主要是關(guān)注自己臉上的“青春痘”。通過詢問我們知道劉同學(xué)體質(zhì)量減少了3 kg，不過她否認(rèn)自己改變飲食習(xí)慣。需要注意的是，進(jìn)食障礙往往與抑郁同時(shí)存在，因此很有必要繼續(xù)觀察劉同學(xué)的飲食習(xí)慣和體質(zhì)量變化。

精神?。涸谇啻浩诤统扇嗽缙?，可以出現(xiàn)各種精神病性障礙。因此，全科醫(yī)生要保持高度的警惕，以便能夠盡早地診斷和管理精神病性障礙。在當(dāng)下，劉同學(xué)沒有表現(xiàn)出嚴(yán)重語言雜亂無章的情況，也沒有思維和行為的嚴(yán)重混亂。而且，她也否認(rèn)有負(fù)性癥狀，如妄想和幻覺。

劉同學(xué)學(xué)習(xí)成績(jī)下降、衣著變化、爭(zhēng)辯行為，可能與精神病發(fā)作的前驅(qū)階段的癥狀是相同的。精神病前驅(qū)階段通常出現(xiàn)在精神病癥狀發(fā)作前一年。前驅(qū)階段的癥狀往往是很不特異的，如注意力降低、社交回避、古怪行為、忽略個(gè)人衛(wèi)生、學(xué)業(yè)失敗。因?yàn)檫@些前驅(qū)行為很不特異，所以很難做出精神病的診斷。不過，全科醫(yī)生在今后對(duì)劉同學(xué)的隨診過程中，要一直保持警惕。

5.3解答3：青少年使用抗抑郁藥應(yīng)該注意什么最重要的一點(diǎn)，是在可能的情況下，最好使用非藥物治療方法。全科醫(yī)生應(yīng)該識(shí)別出可能影響青少年的各種環(huán)境因素，并采取有針對(duì)性的措施。認(rèn)知行為療法和人際關(guān)系療法是對(duì)輕度和中度心境障礙的青少年病人的一線管理措施。

對(duì)4～6次心理學(xué)治療無效的病人以及嚴(yán)重抑郁的病人，可以考慮采用藥物治療措施。藥物治療應(yīng)該是綜合性管理計(jì)劃的一部分，在用藥的同時(shí)，必須嚴(yán)密監(jiān)測(cè)任何可能出現(xiàn)的副作用，并對(duì)副作用進(jìn)行恰當(dāng)?shù)墓芾?。自殺想法和自殺行為是可能出現(xiàn)的副作用。在開抗抑郁藥處方之前，必須要對(duì)青少年病人及其家長(zhǎng)/照顧者進(jìn)行教育，告訴他們識(shí)別自殺想法和自殺行為的步驟[6]。

在澳大利亞，選擇性5-羥色胺再攝取抑制劑(SSRIs)是最主要的抑郁治療藥物。對(duì)于青少年病人，一線藥物是氟西汀(商品名為百憂解)。澳大利亞藥物副作用顧問委員會(huì)提供的指南，是全科醫(yī)生給青少年病人開選擇性5-羥色胺再攝取抑制劑的臨床指南。該指南要求全科醫(yī)生要采取適宜的副作用監(jiān)測(cè)措施，并在整個(gè)藥物治療過程中，持續(xù)地評(píng)估病人的心理狀況和一般療效。藥物管理的關(guān)鍵時(shí)間是開始用藥或改變劑量的24 h內(nèi)，以及用藥的7～10 d內(nèi)[7]。

如果選擇性5-羥色胺再攝取抑制劑無效，或者病人無法耐受藥物副作用，全科醫(yī)生應(yīng)該先尋求專家的建議，然后再?zèng)Q定改換其他的抗抑郁藥。應(yīng)該避免讓青少年病人使用三環(huán)類抗抑郁藥(TACs)，因?yàn)檫@類藥會(huì)在服藥過量時(shí)導(dǎo)致心臟毒性反應(yīng)，并可能導(dǎo)致死亡。此外，目前的文獻(xiàn)表明，三環(huán)類抗抑郁藥對(duì)青少年抑郁的療效不可靠。

5.4解答4：與家庭有關(guān)的關(guān)鍵問題保密問題：對(duì)使用全科醫(yī)學(xué)服務(wù)的青少年來說，保守他們的秘密是非常重要的服務(wù)內(nèi)容。很多青少年之所以不愿意尋求醫(yī)生的治療服務(wù)，是害怕醫(yī)生泄漏他們的隱私。當(dāng)你把劉同學(xué)的父母請(qǐng)出診室，并與劉同學(xué)單獨(dú)談話的時(shí)候，你一定要向這位青少年病人清楚地說明你為她保守秘密的原則，并且要核實(shí)她是不是明白了你的保密承諾。全科醫(yī)生必須按照承諾去做；只有在明確的例外情況下，并且同時(shí)也得到青少年病人容許的情況下，才能向其他人(包括最親近的人)提供涉及病人的信息；這些例外情況是指青少年可能傷害自己或別人的情況[8]。鑒于抑郁病人中自我傷害的比例比較高，所以說明特定情況下向別人提供信息是非常重要的。之所以要這樣做，是為了保護(hù)青少年病人的安全。

在需要?jiǎng)⑼瑢W(xué)的父母參與的情況下，要使用一些技術(shù)來確保劉同學(xué)本人仍然有自己的授權(quán)能力。比如，你可以讓劉同學(xué)選擇怎樣把信息告訴別人，是讓全科醫(yī)生去跟她父母講，還是在全科醫(yī)生在場(chǎng)的情況下她自己跟父母講[3]。

家庭參與：盡管父母可以在青少年心理健康問題的康復(fù)過程中發(fā)揮很明顯的作用，不過青少年本人往往不希望父母介入治療過程。但是，在建議家庭參與之前，全科醫(yī)生一定要評(píng)估這個(gè)特定家庭的參與會(huì)不會(huì)反而妨礙了青少年的治療。通過對(duì)家庭的評(píng)估，全科醫(yī)生能夠知道父母應(yīng)該扮演什么角色。

在劉同學(xué)的案例中，家庭參與管理計(jì)劃可能會(huì)對(duì)青少年心理健康狀況產(chǎn)生積極的作用。全科醫(yī)生應(yīng)該向青少年病人做出解釋，把情況告訴她父母可以讓他們理解她面臨的困難，從而得到父母的支持。為了更好地管理劉同學(xué)的案例，你還應(yīng)該注意到影響家庭的其他因素，比如學(xué)校和劉同學(xué)的同伴。在青少年病人采用藥物治療的情況下，家庭參與顯得更加重要，因?yàn)榧彝コ蓡T可以觀察到嚴(yán)重的藥物副作用或心理狀態(tài)的急性變化。

1Remschmidt H,Belfer M.Mental health care for children and adolescents worldwide:A review [J].World Psychiatry,2005,4(3):147-153.

2Sawyer MG,Arney FM,Baghurst PA,et al.Mental health of young people in Australia[M].Canberra:Commonwealth Department of Health and Aged Care,2000:35-44.

3Sanci L.Common mental health problems in adolescence//Blashki G,Piterman L,Judd FK.General practice psychiatry[M].North Ryde(NSW):McGraw-Hill Australia,2006.

4Goldenring JM,Rosen D.Getting into adolescent heads:An essential update[J].Contemporary Pediatrics,2004,24(1):1-2.

5Murthy RS,Bertolote JM,Epping-Jordan J,et al.The World Health Report 2001:Mental health,new understanding,new hope[M].Geneva:World Health Organization,2001.

6Hawton K,Bergen H,Simkin S,et al.Toxicity of antidepressants:Rates of suicide relative to prescribing and non-fatal overdose[J].Br J Psychiatry,2010,196(5):354-358.

7Beyondblue fact sheet on antidepressants[EB/OL].http://www.youthbeyondblue.com/wp-content/uploads/2009/05/youthbeyondblue-fact-sheet-5-antidepressants.pdf.

8Duncan RE,Williams BJ,Knowles A.Breaching confidentiality with adolescent clients:A survey of Australian psychologists about the considerations that influence their decisions,psychiatry[J].Psychology and Law,2012,19(2):209-220.

·WorldGeneralPractice/FamilyMedicine·

【IntroductionoftheColumn】The Journal presents the Column of Case Studies of Mental Health in General Practice;with academic support from Australian experts in general practice,psychology and psychiatry from Monash University and the University of Melbourne.The Column′s purpose is to respond to the increasing needs of mental health services in China.Through study and analysis of mental health cases,we hope to improve understanding of mental illnesses in Chinese primary health settings,and to build capacity amongst community health professionals in managing mental illnesses in general practice.Patient-centred whole-person approach in general practice is the best way to maintain and improve the physical and mental health of residents.Our hope is that these case studies will lead new wave of general practice and mental health development both in practice and research.A number of Australian experts from the disciplines of general practice,mental health and psychiatry will contribute to the Column.A/Professor Blashki,Professor Judd and Professor Piterman are authors of General Practice Psychiatry.The Journal cases are helping to prepare for the translation and publication of a Chinese version of the book in China.We believe Chinese mental health in primary health care will reach new heights under this international cooperation.

For most GPs,the presentation of parents who are concerned about their adolescent′s behaviour can be a challenging consultation,because it is often difficult for the GP to differentiate between normal adolescent behaviour and a mental disorder per se.As in all countries around the world,in China,psychological problems in adolescents are very common[1].In the child and adolescent component of the Australian National Survey of Mental Health and Wellbeing from 2000,the prevalence rates of mental health problems in adolescents were approximately 19%[2].

1　History

Lu is a 16-year-old Chinese student living in Australia with her parents who migrated from China two years ago.They are working very hard at their family food shop,and are very focused on Lu succeeding in her schoolwork so that she can go to university and get a good job.Up until three months ago,she was an extremely successful student and was achieving straight A′s in most subjects.

However,in the last 3 months,she has become increasingly disruptive and her grades at school have dropped dramatically.She has also been arguing with her mother,and being very rude to her which is very uncharacteristic for her.Her parents are extremely worried,and last week when the school principal rang her father to find out if something was wrong at home,they decided to bring her to your practice.

On discussion with her parents you discover that Lu has not been sleeping well,has been staying up late talking to her friends on the mobile phone and the Internet,and in the morning has been reluctant to get up go to school.Her parents say that she has changed the type of clothing that she usually wears and is mixing with a new group of friends who are generally regarded at the school as the "wrong crowd".

You request that Lu′s parents wait in the waiting room,as it is part of your usual practice to interview the young person on their own.On specific questioning,Lu explains that she has been feeling down since moving to Australia and that it has been a very daunting process moving schools and meeting new people.During this time she feels that she has not had anyone to turn to.This has been a particularly difficult time for her,given that she has also been having increasing negative thoughts about her appearance due to the marked acne on her face and her back.She denies consuming alcohol or illicit drugs or changing her eating habits,despite noticing that she has lost 3 kg over the last 6 months.

2　Examination

On mental status examination she is quiet and reserved,sitting in the chair looking down and fidgeting with her hands.Her affect is sad.She denies any delusional thinking or hallucinations and is orientated in time,place and person.Her physical examination reveals a normal looking young woman,although she has quite severe cystic acne on both cheeks and on her back.Vital signs are normal and the rest of the physical examination is unremarkable.She weighs 57 kg.You provide a running commentary of the body systems you are assessing,all the while reassuring Lu about her normality.

3　Investigations

A basic set of blood tests reveals a normal full blood examination,electrolytes,liver function tests and her urine test is normal.

4　Questions

4.1What are the key medical and social questions to ask an adolescent as part of a full assessment?

4.2What are the differential diagnoses for Lu?

4.3If you were considering using antidepressants in an adolescent what are some critical issues to consider?

4.4In managing mental illnesses in adolescence,what are some important issues surrounding the family?

5　Answers

5.1What are the key medical and social questions to ask an adolescent as part of a full assessment?Despite the high prevalence of mental health disorders in adolescence,they are frequently under-recognised by health professionals.A consultation with the GP is an excellent opportunity to detect psychosocial health burdens,make diagnoses and instigate early intervention.

The HEADSS mnemonic is a screening tool for taking a psychosocial history from an adolescent[3-4].The headings cover sensitive areas,thus requires that the GP develop a good rapport with the adolescent before broaching these topics[4].

HEEADSS:

H-Home situation

·An adolescent′s home situation is important in establishing whom the patient lives with,and the dynamics amidst the people living there.

·Being homeless and/or having poor relationships are known risk factors for mental health problems.

E-Education/Employment/Economic situation

·It is important to establish the adolescent′s behaviour at school,their grades and whether or not there have been any changes.

·Enquiring about pressure from family,or bullying at school or work can provide insight into the stressors the adolescent may be experiencing.

A-Activities

·Hobbies and activities are often protective against the development of mental disorders.

·Eating and exercise is particularly pertinent in females,however it will also provide an understanding of whether or not the adolescent leads a healthy and active life.

D-Drugs/Smoking/Alcohol

·Details about the nature of substance use are extremely important when assessing how risky the behaviour is.Required information includes the type,quantity and frequency of use,as well as the social setting in which it is consumed.

S-Sexuality

·Certain sexual behaviours,such as sexual disinhibition,are linked with psychiatric diagnoses,or may otherwise warrant medical investigation for sexually transmitted infection screening and pregnancy testing.

S-Suicide risk/Psychological symptoms

·A suicide risk assessment is an essential component to any consultation with an adolescent.

5.2What are the differential diagnoses for Lu?The most common mental health disorders that affect adolescents are mood and anxiety disorders,substance abuse and behavioural disorders.The World Health Report 2001 suggested that international studies have demonstrated that 10%-20% of children and adolescents have one or more mental or behavioural problems[5].Therefore it is imperative that you maintain a high index of suspicion when a patient such as Lu presents with a recent change in behaviour.

Normal:It is normal for teenagers to manifest temporary deviations in behaviour,which frequently include risk taking and delinquent behaviours.Whilst the majority of adolescents do not experience mental health problems,there will be approximately 1 in 4 requiring a psychiatric diagnosis and further intervention.

Lu has demonstrated a recent change in behaviour that was obvious to her parents and the school.Lu′s reluctance to attend school,her misbehaviour in class and change in clothing style and friendship group are extremely common patterns of behavioural change in a teenager.However,given that these changes are accompanied by difficulty sleeping,lowered mood and an altered self-esteem it is important to consider some differential diagnoses.

Depression:The presentation of depression in adolescents does not always manifest with the typical symptoms of lowered mood,sleep disturbance,anhedonia,loss of weight and appetite.Adolescents are more likely to describe somatic complaints or changes in their behaviour.In this case,Lu demonstrates a number of the common symptoms of depression in addition to several changes in her behaviour.Importantly,her recent migration and the resulting adjustments,including the changes in her environment,school and social network,must also be taken into context.This recent life stressor should raise concerns about an emerging mood disorder.

Substance abuse:The issue of substance abuse in young people usually refers to them putting themselves at risk of short-term harm,more so than that of dependence.In adolescents,binge drinking is extremely common and in Australia the use of amphetamines is as high as 10%.According to Lu′s history,physical examination and laboratory findings,there is no evidence to support this,particularly given that Lu denies ever consuming alcohol or illicit drugs.In the case of an adolescent revealing their use of a substance,it is important to enquire about the nature of its use to elucidate how risky the behaviour is.It may be useful to undertake a urine drug screen.

Eating disorder:The criteria for diagnosing eating disorders are the same for adults and adolescents.Depending on the specific diagnosis at hand,clinical features include self-induced starvation,purging,compulsive exercising,a relentless drive for thinness and medical symptoms and signs that correlate with the maladaptive behaviours.

Adjusting to the changes in body image is a critical psychosocial developmental task of an adolescent.In the 2011 National Survey of Young Australians,body image was a concern for 1 in 3 young people.Whilst Lu has been having negative thoughts about her appearance,her main focus is her facial acne.Upon questioning,Lu professes weight loss of 3 kg but denies any changes to her eating habits.It is important to be aware that eating disorders frequently co-exist with depression,therefore follow-up of Lu′s eating habits and weight is imperative.

Psychosis:There are a number of psychotic disorders that appear in adolescence and young adulthood,and it is important to have a high index of suspicion so that these disorders are diagnosed and managed as early as possible.It is evident immediately that Lu does not display grossly disorganised speech,thoughts or behaviours.She also denies the presence of positive symptoms including delusions and hallucinations.

Lu′s decline in academic success,change in clothing and argumentative behaviour may be consistent with the prodromal phase of a psychotic episode.A prodromal phase usually manifests a year prior to the onset of psychotic symptoms.The symptoms are non-specific and may include diminished attention,social avoidance,peculiar behaviour,impaired personal hygiene and school failure.As these symptoms are extremely non-specific,the diagnosis is not the most probable one,however a level of suspicion should be maintained throughout Lu′s follow up process.

5.3If you were considering using antidepressants in an adolescent what are some critical issues to consider?The most important consideration is that non-pharmacological treatment is preferred where possible.Factors in the adolescent′s environment which may be contributing to their disorder should be identified and addressed.Cognitive Behavioural Therapy and Inter-Personal Therapy are the first line management for adolescents with mild- moderately severe mood disorders.

For those patients not responding after 4-6 sessions of psychological therapy and those with severe depression medication may be considered.The use of medication should occur in the context of a comprehensive management plan which includes careful monitoring to ensure any adverse effects are identified and managed appropriately.Emergence of suicidal ideation or behavior is well recognized as a possible side effect.Prior to prescribing an antidepressant the adolescent patient and his/her parents/carers must be educated about steps to take should suicidal ideation or behavior be identified[6].

In Australia,SSRIs are the main stay of treatment for depression.In adolescents,the first line medication recommended is fluoxetine.Australia′s Adverse Drug Reaction Advisory Committee guidelines are currently available to GPs prescribing SSRI to adolescents.The focus of these guidelines is to ensure appropriate monitoring of side effects,mental state and general progress throughout the treatment.This is most important within the first 24 hours of commencing the medication or increasing the dose,and then within the next 7-10 days as well[7].

If SSRI′s are not effective,or cannot be tolerated due to side effects,specialist advice should be sought before trialing other antidepressants.TCAs should be avoided in management of adolescent depression because they are cardiotoxic in overdose and this can be fatal.Additionally,current literature suggests that the efficacy of TCAs in managing adolescent depression is equivocal.

5.4In managing mental illnesses in adolescence,what are some important issues surrounding the family?Confidentiality:Confidentiality is a valued aspect of health care for an adolescent accessing primary health services.The fear of health care professionals breeching confidentiality remains a barrier to young patients seeking treatment.Once Lu′s parents leave the room,it is important to address this matter with Lu,and equally important to assess her understanding of the subject.Confidentiality will be maintained unless Lu′s permission is granted otherwise,or importantly if she is at risk of harming herself or somebody else[8].Given the high rates of self-harm associated with depression this is particularly important.Emphasise that this is based on the purpose of your role to keep her safe.

If a situation arises requiring the involvement of Lu′s parents,there are a few techniques that can be implemented to ensure that Lu maintains a sense of empowerment.Examples of this include giving Lu the choice of either you informing the parents or having a meeting where she can inform the parents in your presence[3].

Family involvement:Often adolescents prefer their parents not having any in put in their treatment,in spite of the fact that family involvement usually contributes significantly to the recovery of a mental health problem.However,before suggesting this,it is important to assess whether or not in the particular case the parents might in fact be a hindrance to the adolescent′s management.So some common sense is needed in assessing what ought to be the role of the parents.

In Lu′s case,family involvement in the management plan is likely to have a significant positive impact on her state of mental health.It should be explained to Lu that informing her parents will provide them with an understanding of what she is going through,therefore allowing them to support her.In order to adequately manage Lu′s case,you should also attend to the impact it is likely to have on the family,the school and Lu′s peers.Family involvement is particularly important when starting an adolescent on medication,as they can observe and report if the adolescent is experiencing severe side effects,or acute changes in mental state.

1Remschmidt H,Belfer M.Mental health care for children and adolescents worldwide:A review [J].World Psychiatry,2005,4(3):147-153.

2Sawyer MG,Arney FM,Baghurst PA,et al.Mental health of young people in Australia[M].Canberra:Commonwealth Department of Health and Aged Care,2000:35-44.

3Sanci L.Common mental health problems in adolescence//Blashki G,Piterman L,Judd FK.General practice psychiatry[M].North Ryde(NSW):McGraw-Hill Australia,2006.

4Goldenring JM,Rosen D.Getting into adolescent heads:An essential update[J].Contemporary Pediatrics,2004,24(1):1-2.

5Murthy RS,Bertolote JM,Epping-Jordan J,et al.The World Health Report 2001:Mental health,new understanding,new hope[M].Geneva:World Health Organization,2001.

6Hawton K,Bergen H,Simkin S,et al.Toxicity of antidepressants:Rates of suicide relative to prescribing and non-fatal overdose[J].Br J Psychiatry,2010,196(5):354-358.

7Beyondblue fact sheet on antidepressants[EB/OL].http://www.

eyondblue.com/wp-content/uploads/2009/05/youthbeyondblue-fact-sheet-5-antidepressants.pdf.

8Duncan RE,Williams BJ,Knowles A.Breaching confidentiality with adolescent clients:A survey of Australian psychologists about the considerations that influence their decisions,psychiatry[J].Psychology and Law,2012,19(2):209-220.