The key steps in investigating mental health concerns in most young people are:

• Discussing the problem(s) and identifying any underlying causes, precipitating factors or events which have led the young person to experience the problem at this time
• Assessing the young person’s circumstances, home or living environment and available sources of support from family or friends

This may include providing a “listening ear” and emotional support, helping the young person to define their problems and offering them suggestions for addressing these problems. Adopting a strengths-based approach is a strategy that can help all young people facing psychological difficulties (see: “Building resilience”).

Try to involve the young person’s family/whānau as much as possible (with the patient’s consent), bearing in mind that this may not be appropriate if family/whānau issues are the cause of the problem. Utilise local resources and support services, such as youth clinics, community health workers and Pukenga Atawhai (specialist Māori mental health workers).

If young people represent a threat to themselves or others, they should be referred to a specialised mental health service. The use of a screening questionnaire, such as the Ask Suicide-Screening Questions (ASQ), PHQ-9, Substances and Choices Scale (SACS) or bestpractice decision support tools for suicide risk and depression can assist in identifying young people in need of urgent or immediate assistance.

For further information and links to screening questionnaires, see: www.bpac.org.nz/BPJ/2015/October/wellbeing.aspx | www.bpac.org.nz/BPJ/2010/January/assessment.aspx

Building resilience: A positive step for all youth

A strengths-based approach is useful to both prevent and treat mental health issues, and therefore can form a part of every consultation with a young person. This takes into account the person’s circumstances and personal characteristics, e.g. aspects of their family environment, social circles and wider community connections, to encourage resiliency and promote wellbeing. This may be particularly useful for Māori and Pacific young people where traditional models of wellbeing, such as Te Whare Tapa Whā or Fonofale, have a focus on collectivism rather than individualism.¹ The strengths and interests of the young person can be used to promote resilience by encouraging engagement in activities which provide a sense of belonging and contribution, e.g. a sport or cultural group or club related to their hobbies.

Factors which help young people maintain a good state of emotional wellbeing include:^{1, 5}

• Family dynamics – warm caring relationships, such as parents who express affection but set clear boundaries with reasonable consequences and negotiate boundaries as competency grows; participating in family activities such as eating meals and talking together
• Out of school/work interests – engaging in extra-curricular and social activities such as sport, drama or music
• Peers – good friendships and healthy romantic relationships
• School environment – feeling connected to school and believing that the school has their best interests at heart
• Confidence and coping – feeling that they can cope with whatever comes their way
• Culture and faith – greater connection to their culture, engaging in cultural and religious activities

For further information on assessing a young person’s strengths, see: www.bpac.org.nz/BPJ/2015/October/wellbeing.aspx

For further information on Māori and Pacific models of health, see: www.health.govt.nz/our-work/populations/maori-health/maori-health-models | www.health.govt.nz/publication/pacific-peoples-and-mental-health-paper-pacific-health-and-disability-action-plan-review

Healthy living, healthy thinking

A healthy lifestyle can help strengthen a young person’s resilience to adversity.^{6, 7} Poor sleep is associated with increased levels of anxiety and depression, increased vulnerability to stress, and it can affect academic performance and decrease school or work attendance.⁶ Low levels of physical activity and an unhealthy diet are also associated with depression in young people.⁷

Getting a good night’s sleep, eating a balanced diet and participating in regular exercise and social activities are simple steps young people can take to positively influence their psychological wellbeing. Dedicated “time off” may also be important for some young people, e.g. high academic or sporting achievers.

Factors which could help a young person sleep better and improve their mood include:⁸

• Regular exercise
• Relaxation techniques, such as progressive muscle relaxation or mindfulness
• Going to bed around the same time each day
• Avoiding caffeine and energy drinks in the afternoon or evening
• Avoiding alcohol in the evenings and reducing any nicotine intake (although acute smoking cessation can disrupt sleep)
• Not using the computer, video games or mobile phone near bedtime
• Reducing noise in the bedroom or moving to a quieter room, if possible

For further advice for patients on how to get a good night’s sleep, see: www.bpac.org.nz/BPJ/2008/June/insomnia.aspx#treating

Structured problem solving in general practice

Structured problem solving is a treatment strategy which incorporates principles of cognitive behavioural therapy (CBT – see: “What is cognitive behavioural therapy?”) but does not require specialised training to conduct, and is well suited to general practice. Structured problem solving reduces depression symptoms, is better than no treatment and compares favourably with other forms of psychosocial therapy when delivered in primary care.¹¹ A limited number of studies suggest it is also useful for patients with anxiety symptoms.^11,12

Structured problem solving: How do I go about it?¹²

1. Work with the patient to identify their problems. For example, a young person with depression may be under stress with exams, had a falling out with parents after an argument, had a friend move away and have begun using alcohol and drugs to make themselves feel better. Overwhelmed by their situation they may not identify each of these as distinct issues or may feel they cannot control any of these problems.
2. Identify which aspects of problems are within the young person’s ability to change. For example, exam dates cannot be changed but strategies for dealing with stress and thoughts about success or failure can be addressed. Addressing one issue may resolve or alleviate other related problems.
3. Have the young person propose a goal for this problem. A useful mnemonic is to make sure the goal is SMART: Specific (to the problem), Measurable (outcomes can be easily assessed), Achievable (the young person can do this themselves or with little extra support), Relevant (the goal relates back to the problem) and Timely (achievable within a useful timeframe). In the example, a goal of cutting alcohol and drug use and finding more positive ways to respond to the stressful situation achieves all of the SMART requirements.
4. Brainstorm ideas with the young person that they could put into action to address the problem. For example, the young person could write a letter to their parents to re-establish communication, expressing how they feel, anything they wish would have happened differently, and how they would like things to be, without the pressure of saying it in person. It is important that the young person take the lead role in proposing ideas to develop their own problem solving skills.¹
5. Assess the proposed ideas. Go over the strengths and weaknesses of each idea, and jointly select one or more to move ahead with.
6. Put the idea into action and follow up. Come up with a plan with the young person for following through with the idea and an appropriate time frame to see if their goal has been achieved.

For more mature young people, structured problem solving is something they could work through on their own as a form of self-help, e.g.: www.depression.org.nz/waythrough/self+help/problem+solving

Online self-delivered CBT resources

Online CBT resources (e-therapy) are most appropriate for young people with depression and anxiety, but may also be useful to teach coping skills to any young person experiencing mental health difficulties.¹⁶

Randomised controlled trials in young people with mild to moderate depression and anxiety show e-therapy is a beneficial treatment option compared to no treatment or treatment as usual in general practice, but is probably not as effective as face-to-face CBT.¹⁷ A recent randomised controlled trial in the United Kingdom in adults aged 18 years and over with mild to moderate depression suggests e-therapy is no better than usual care for patients taking antidepressants and that adherence may be an issue.¹⁸

E-therapy is most likely to be useful as an additional treatment option to assist young patients where there are long wait times for face-to-face counselling. This aligns well with the views of young people in New Zealand who report a high acceptability of e-therapy and consider it could be used in addition to other therapy, or as something they can work through prior to seeing a counsellor or therapist.^{19, 20} Clinicians should keep in mind that internet-based resources or tools may not be suitable for some people due to access, privacy or language barriers.

Directing young people to e-therapy resources

1. Ask if they have already used e-therapy resources; young people with ongoing symptoms despite e-therapy may require a different approach, such as face-to-face or group therapy
2. Demonstrate an e-therapy website; this can increase acceptance
3. Set a goal of completing a few modules and follow up with the patient in a week or two to see if they are using the resource and finding it useful, or if they would prefer face-to-face therapy

The Goodfellow Unit offers a free one hour course for practitioners to learn about e-therapy, and its place in clinical practice: www.goodfellowunit.org/courses/e-therapy-youth-depression

E-therapy resources in New Zealand

SPARX (Smart, Positive, Active, Realistic, X-factor thoughts) – www.sparx.org.nz

SPARX is an online e-therapy tool developed by researchers at the University of Auckland, and funded by the Prime Minister’s Youth Mental Health Project. It is primarily aimed at high school-aged students. SPARX takes the form of an interactive game, designed to assist young people to learn skills to cope with feeling “down” or stressed. It has been assessed in clinical trials involving young people aged 12 to 19 years with mild to moderate depression.^{20, 21}

The game contains seven modules (played as levels – each taking 20-40 minutes to complete) to deliver content and teach strategies usually incorporated into CBT programmes.²⁰ In a randomised controlled trial, 60% of young people using SPARX completed the entire course content.²⁰ SPARX does not require a formal referral to access; users must register with a username and password.

Beating the Blues – www.beatingtheblues.co.nz

This site was developed with funding from the Ministry of Health, and delivers online psychotherapy for patients with depression and anxiety. Beating the Blues is aimed at adults and therefore may be a suitable option for more mature young people for whom SPARX may not be as appropriate. General practitioners must refer patients to the site via ManageMyHealth; instructions on how to do this are provided on the Beating the Blues website. It is free for people aged over 18 years in New Zealand. The site offers eight courses of approximately 50 minutes each and clinicians are able to check patient progress. Beating the Blues is supported by a randomised controlled trial conducted in primary care involving patients with depression and anxiety.²²

For further information on referring patients to Beating the Blues, see: www.managemyhealth.co.nz/content/Help/default.aspx

Other e-therapy resources may be available via funding from local PHOs or DHBs, e.g. BRAVE-Online in Canterbury.

Depression

Symptoms and signs of depression in young people include:¹

• Irritable mood or persistent sadness
• Loss of interest in activities they enjoy
• Loss of energy
• Feelings of worthlessness or inappropriate guilt
• Recurrent thoughts of death or suicide
• Sleeping problems (insomnia or oversleeping)
• Difficulty concentrating
• Psychomotor agitation or retardation
• Changes in appetite or body weight

The number and severity of symptoms determines whether depression is classified as mild, moderate or severe.²³ Young people with several, e.g. five or more, of the above symptoms, where the symptoms are marked or distressing, meet the criteria for severe depression and should be referred to secondary care services.^{1, 23} Asking patients how they see their life next month or next year can be useful to assess how hopeful they are about their future.

Young people with fewer, less severe symptoms, e.g. four or less, can be treated in primary care with the intention of reducing symptom severity with the least intrusive intervention.¹ A stepped care approach involves initial diagnosis, determining an appropriate treatment with input from the patient, review of progress and escalation of treatment if symptoms do not improve.

Psychological therapy is recommended for all patients with depression; there is no clear evidence that one particular form of therapy is better than others.^{1, 24} Encourage the young person to reduce or eliminate any recreational drug or alcohol use, discuss strategies for improving sleep, exercise and nutrition and explore their strengths and resiliency. Clinicians can consider extended appointments with a young person to conduct structured problem solving. Other treatment options include referral to a counsellor or youth worker, the use of self-help and internet resources or referral to an appropriately trained health professional for CBT sessions or family therapy.

A plan should be set up for monitoring and follow-up. Two-weekly follow up, either face-to-face or by telephone, is recommended for initial management of most young people with mild to moderate depression. A face-to-face reassessment is recommended within two to four weeks of the initial consultation.¹

For young people who report:¹

• An improvement in two to four weeks’ time – continue treatment with monitoring every one to two months until remission of symptoms and return to normal function
• A deterioration in symptoms in two to four weeks’ time - intensification of treatment is necessary (see below)
• No improvement after six to eight weeks – referral to secondary mental health services is advised

Intensification of treatment can include an escalation in the form of psychological therapy being used, e.g. to face-to-face meetings with a counsellor or therapist, or referral to secondary care. The use of an antidepressant medicine may also be considered in some circumstances.

The appropriate use of antidepressant medicines in young people will be discussed in the next article in the series.

Anxiety

The most common anxiety disorders in young people are generalised anxiety disorder, separation anxiety, social anxiety and panic disorder. Young people with generalised anxiety disorder may report excessive worry, difficulty concentrating or sleeping, restlessness or irritability. Separation anxiety may manifest as a refusal to go to school or work, but differs from truancy as parents or caregivers are likely to be aware of the situation and the young person may be well behaved in other respects. People with social anxiety disorder may avoid social situations or only get through them with difficulty, affecting their studies, work or relationships. Panic disorder is associated with recurrent episodes of fear, increased heart rate and palpitations, sweating, dry mouth or other physiological symptoms, where these responses are not appropriate for the situation.¹

Initial treatment in primary care involves determining the specific symptoms the young person experiences, how long these symptoms have been occurring, particular situations which are feared or avoided, safety-seeking behaviours and how they feel or what they do building up to an event they think will cause anxiety.

Brief practical advice for young people with anxiety disorders includes:

• Avoiding “catastrophising” and challenging negative thoughts – encourage patients to reappraise negative thoughts such as “things will go badly” or “in social situations people will know I am anxious” and challenge these with a question or alternative frame of mind, such as “how often do things actually go badly? Most of the time things probably go well or okay” or “people will not be able to see how you feel, or will be too interested in something else to notice.”
• Reassuring patients with panic disorder that they are not in physical danger during these episodes and that the symptoms will pass. Emphasise to patients that trying to fight or control symptoms may make the sense of anxiety worse; instead to try to focus on something else during the episode until symptoms subside²⁵
• Relaxation for generalised anxiety disorder – exercise, listening to music or specific relaxation exercises such as focusing on progressively relaxing different muscle groups²⁶

Self-help, such as referral to printed or online resources, may be useful for young people with generalised anxiety and panic disorders; this could include SPARX or Beating the Blues.²⁶ This can be followed by referral to an appropriate health professional for CBT if the patient’s symptoms do not improve.

For further information on diagnosis and treatment of generalised anxiety disorder in adults, see: www.bpac.org.nz/BPJ/2009/December/anxiety.aspx

Self-harm

Patients presenting with self-harm behaviour should be referred to secondary care if they are assessed as being at serious risk of suicide. Young people may self-harm without any clear suicidal intent, e.g. by cutting, burning, hitting or slamming into solid objects, as a way of coping with emotional distress. However, even in the absence of obvious suicidal intent, young people who repeatedly self-harm are at an increased risk of suicide and may have other untreated mental health disorders, such as depression.⁵

Self-harm can arise from a wide variety of causes, including psychological distress, but may also be a desire to fit in with peers who are self-harming. Often the self-harm can be a form of emotional regulation in response to overwhelming feelings or situations in an attempt to relieve tension and provide distraction. Ask the young person to explain their feelings and understanding of their behaviour in their own words to identify underlying reasons for the self-harm, e.g. “What was going through your head when you were doing it?”.²⁷ Discuss the dangers of self-harm with the young person and work with them to address underlying causes.²⁷ A key aspect of management is to reinforce other positive ways of coping and regulating emotions.

Bullying and social isolation

Key practice points:

• Ensure that an appropriate authority has been made aware of the bullying so that action can be taken to prevent it
• Take steps to promote self-esteem and resiliency
• Ask young people presenting with mental health issues about their experiences of bullying as this may be an ongoing contributor to the problem

Ask young people being bullied if a person in authority, e.g. at a school or workplace, has been made aware of the bullying. If not, encourage them or their parents or caregivers to raise the issue. The Ministry of Education guidelines recommend that young people who present for medical attention for injuries or mental health concerns due to bullying should be referred to the police after their injuries have been treated.²⁸ This also includes young people with mental health issues arising from cyber-bullying.

Encourage young people to focus on their strengths and help them build self-esteem as a means of counteracting the negative influence of bullying. Young people who identify as LGBTI (lesbian, gay, bisexual, transgender or intersex) are at greater risk of being bullied and can be reassured that their problems arise from social norms, not that there is anything wrong with them. Assess for the presence of other psychological symptoms, such as depression and anxiety, in young people experiencing bullying or social isolation. Local anti-bullying initiatives and peer support programmes are available in some areas.

Young people who identify as LGBTI can find support from organisations such as Rainbow Youth: www.ry.org.nz or LGBTI groups at a local university

Netsafe provides guidance and steps that families can take to address cyber-bullying, available from: www.netsafe.org.nz

Drug and alcohol misuse

The use of alcohol, marijuana and other drugs is common among young people in New Zealand. Young people who may benefit from assistance are those reporting excessive use, dependence or associated harms such as arguments about use with family or friends, physical altercations, injury while under the influence or problems with the justice system.^{29, 30} Ask the young person their reasons for drug and alcohol use as this can inform treatment approaches, i.e. did they start using it “for fun” but now their use is problematic, or do they see it as a way of cheering themselves up, calming down to deal with anxiety or means of escaping problems for a while?

Brief interventions in primary care, such as motivational interviewing, may be helpful for patients with alcohol or substance use problems. Motivational interviewing involves discussing the young person’s reasons for using alcohol or substances, offering support and encouragement to help them feel they are capable of decreasing intake and reducing their ambivalence to change. Discuss peer pressure, stress or particular psychosocial triggers which could be contributing to a young person’s misuse. Advise them to avoid scenarios likely to lead to drug or alcohol use and work with them to develop alternative strategies for coping with triggers, such as encouraging another activity they enjoy as a way of relaxing. Goal setting, e.g. an initial goal of not drinking or using drugs for one week, may assist young people to cut down their use.^{29, 30}

The alcohol and drug helpline (0800 787 797) can provide phone support to young people, and local counselling and treatment services can be found at: www.addictionshelp.org.nz/Services/Home.

For further information on the detection and management of alcohol, drug and substance use in young people, see:

www.bpac.org.nz/BPJ/2015/October/wellbeing.aspx

www.bpac.org.nz/BPJ/2012/february/substanceMisuse.aspx

www.bpac.org.nz/magazine/2010/june/docs/addiction_all_screening_tools_web.pdf

Eating disorders

People with anorexia nervosa, bulimia nervosa and binge eating disorder have disturbances of eating behaviours resulting from concerns about food, eating and body image. Eating disorders may be a form of self-harm or a way for young people to exert control in their lives. The estimated prevalence of eating disorders ranges from < 1% – 3%, with the peak onset during adolescence (age 10 – 19 years) and early adulthood.³¹ People with eating disorders may be of any body weight or gender; females and people who engage in pursuits which have a focus on body weight or image, however, are at greater risk, e.g. competitive gymnastics or modelling.³¹ Factors such as exposure to media where thinness is presented as desirable increases the risks of developing an eating disorder, but genetic and other hereditary factors are also involved.³¹

Symptoms and signs of eating disorders are not always apparent. There are, however, some distinguishing features, e.g. patients engaging in self-induced vomiting may have signs of roughness on the knuckle of their index finger, loss of tooth enamel or enlargement of parotid glands, depending on the duration and severity of purging behaviour.³¹ Young people with eating disorders are likely to have other mental health issues such as anxiety, depression or self-harming behaviours; rates of mental health co-morbidities range from 55% – 96% in different samples of patients with anorexia nervosa.³¹ Guidelines recommend a multidisciplinary approach to assist patients with nutritional, psychological and medical support, and may include family therapy.³¹

There are a diverse range of factors which influence the development of eating disorders and attempting to identify the cause during an initial assessment is not recommended. Young people with eating disorders are likely to be extremely nervous during an initial consultation. They may be fearful of the existence or extent of their eating disorder being uncovered and of treatment aimed at making them gain weight. Treatment priorities in primary care are to engage with the patient and ensure they are medically stable. Reversing the effects of the eating disorder and psychological treatment are undertaken in secondary care.³¹ Specialist regional treatment centres for eating disorders are located in Auckland, Wellington and Christchurch; patients can be referred from around the country.

For further information on assessing medical stability of patients with eating disorders, see: www.starship.org.nz/for-health-professionals/starship-clinical-guidelines/a/anorexia/

For further information on patient and family support, see: www.ed.org.nz

A list of eating disorder liaison officers across District Health Boards is available at: www.ed.org.nz/index.asp?pageID=2145862942