The Cundill Centre for Child and Youth Depression at The Centre for Addiction and Mental Health (CAMH) is proud to launch its free, interactive online tool that summarises best practices for supporting youth as they manage their depression. This is a recording from a session on Tuesday 9 November 2021.
The slides from the event can be downloaded as a pdf version.
ACAMH Members can receive a CPD certificate, simply email and let us know the date and time that you watched the recording.
About the event
Following the May 2021 ‘CAMHS around the Campfire’ with Dr. Stephanie Ameis, on ‘ADHD in CYP with autism, and pharmacological treatment’, Stephanie returns with an evidence-based clinical resource is meant for primary care providers and other frontline clinicians and takes about 20 minutes to complete. The tool was created by clinician-scientists, youth, and other experts from the Cundill Centre. Watch this spoken word poem to learn more.
Joined by Dr. Peter Szatmari, who spoke at our 2021 Jack Tizard Memorial Lecture and Conference, and Renira Narrandes, this session features a live demonstration of the tool and a panel discussion with Melanie Asselin, a Youth Advisor, and Dr. Karin Euler a Family doctor, Georgian Bay Family Health Team.
Transcript
Speaker key:
PS Peter Szatmari
RN Renira Narrandes
Matt Matt
SA Stephanie Ameis
MA Melanie Asselin
V6 Narrator on video
KE Doctor Karin Euler
AC Alex Conway
[00:00:00.610] – Recorded voice
Hello. We are the Association for Child and Adolescent Mental Health, or ACAMH.
[00:00:08.310] – PS
Thank you, Matt, for that introduction. And yes, welcome from Canada. It’s a lovely, chilly morning. We don’t yet have snow on the ground here. In fact, we won’t have snow for quite a while, but it is a lovely, crisp fall morning… It’s morning for us… and it’s wonderful to be with you all. My name is Peter Szatmari. I am the director of the Cundill Centre for Child and Youth Depression. I’m a child and youth psychiatrist who works at CAMH. The Centre for Addiction and Mental Health. Note the similarity in the acronym. And it’s lovely to be with you. We’re so grateful that you’ve given us an opportunity to talk to you a little bit about this new decision aid or online tool for the treatment of youth depression that the Cundill Centre has developed and I hope you’ll find the presentation interesting. I know ACAMH well. I was an editor of JCPP, an associate editor of JCPP a number of years ago, so I know the team there well. And I did the final year of my training in the UK at the Royal Manchester Children’s Hospital and at Booth Hall Children’s Hospital, which sadly no longer exists.
[00:01:41.330] – PS
So why don’t we get started? Next slide, please, Renira. So I’m going to do the introduction. Renira’s going to do a poem. We’re going to have the demo. We’ll have some input from youth engagement in the project and also then we’ll have a panel discussion. Next slide. Just a word about child and youth depression. I don’t need to convince you of this, but I think you’ll all agree that child and youth depression is indeed a public health challenge. It’s a common disorder of children and youth. The prevalence is roughly 10%. Those youth who seek services do experience many barriers to care. That’s true in Canada. I’m sure it’s true in the United Kingdom as well. The response to treatment is not good enough. It’s only around 40%. And even worse is the fact that many children and youth drop out of treatment before the treatment has been completed. Roughly 50% will go on to another more severe episode, which then recurs over time. And then we’ll have a significant long-term impact on the ability to finish school, have an occupation, and then there are a number of adult mental health problems and challenges that will occur as a consequence.
[00:03:12.460] – PS
And perhaps one of the most disheartening facts is really that I don’t think there have been significant advances in treatments over the last 40 years or so. Next slide. So the Cundill Centre, which is the result of a philanthropic gift, was established at the Centre for Addiction and Mental Health, CAMH, in Toronto a number of years ago, and our focus is on developing best practices for the screening, prevention, and treatment of child and youth depression. We aspire to have a global impact on research and care and knowledge exchange, and that’s why this opportunity to do this webinar with you folks is such a welcome activity for us because it allows us to develop international partnerships. We already have a number of partnerships in the UK at Cambridge and elsewhere, and I’m hoping that today’s event will lead to new ones. We want to keep in touch with you if you have interest in some of the work that we’re doing.
[00:04:18.870] – PS
Next slide. A big part of the work of the Cundill Centre is knowledge translation and exchange. Knowledge translation and exchange is a dynamic and iterative process that includes the synthesis, dissemination, and exchange of ethically sound, evidence based knowledge to improve the health of Canadians and elsewhere. This comes from a document developed by the Canadian Institute of Health Research, and there is a well-known finding that it takes about 17 years for knowledge to translate from the journals or from its discovery into having an impact on clinical care. And one of the objectives of the Cundill Centre is to shorten that gap considerably. And we’re trying to do that with the development of these online tools and other clinical tools from our toolbox. So with that introduction, I’ll hand it over to Renira to continue on. Thank you.
[00:05:22.470] – RN
Thanks, Peter. Hi, everyone. My name is Renira Narrandes and I am the knowledge translation specialist at the Cundill Centre. Before I go on, I wanted to take the time to acknowledge everyone who has contributed to this tool. So we have a team at the Cundill Centre, which provided a lot of the clinical advice on the tool, but we also have a team from what we call the Provincial System Support Programme at CAMH. We had a web developer and we also received support from the Youth Engagement Initiative, which is supported by the Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health and the Child, Youth and Emerging Adult Programme at CAMH.
[00:06:01.090] – RN
Now what I’m going to do is summarise our entire project in about three and a half minutes in a poem. Some of you may have already seen the video. Now it does go a little bit quickly, so if you have any questions about our development process or any other questions, please feel free to ask us a little bit later in the Webinar. How many adolescents in Canada do you know? Put 25 in a room and almost two at some point will show major depressive disorder. And when this happens, we’ve got to treat it pretty soon, but the problem is there’s this giant waiting room and the kids are not getting in. Tap, tap, tap. Do you hear that drumming on the door of primary care? It’s knuckles knocking on wood, wishing there’s hope in there. It’s the kids, it’s youth, it’s parents. It’s all of us coming to that first door hoping it’s enough, but it isn’t always. Some family doctors will tell you they really don’t feel prepared to manage mental health concerns, so they refer to higher levels of care, to paediatricians, to psychiatrists, you know, the ones whose appointments can be a little more rare.
[00:06:57.670] – RN
And all this results in that wait for mental health care. Look at our study of Ontario. Services differ depending where kids go. And don’t ask me if all these services are evidence based because, well, I’d have to say no, but we could say yes if we find evidence based practices to treat and assess, if we build primary care capacity to do their best. This was our quest. Build a brief, interactive online tool for primary care providers from east to west. Outline evidence based practices for youth depression that are the best. Step one, systematic review. Look at all the clinical practice guidelines out there. Rate the quality, compare, choose the best one. Read over 200 pages. Then step two, strip it bare. Make a skeleton, develop a decision aide, work with clinicians to contextualise for primary care. Step three, make the tool. You’ll need one instructional designer, one web developer, three youth advisors, your subject matter experts, and me, a knowledge broker. And that’s it, you’re prepared.
[00:07:51.550] – RN
It was actually a bit more complicated than that, but click, click, click. Can you hear the sound of a mouse navigating our online tool? Four sections, 20 minutes and you’ll be through. You’ll start with the overview. Learn basic depression facts, if this is something new. If not that’s cool. Jump to assessment review. Watch our simulation video and check out assessment tools. And then the biggest part of it all, the treatment pathways, the reason we’ve been called. Click on mild, click on moderate severe. There are two pathways with pop-up boxes to make everything clear. And finally, our resources, practical tools we’ve made with youth and clinicians by joining forces. Clap, clap, clap. Can you hear how excited we are about this tool? Do you wonder how you can access it? Are you feeling fuelled? Go to our website or drop us a line. The tool is free and it’s just in time because tap, tap, tap. I can hear the drumming on the door of primary care, the knuckles knocking on wood, wishing there’s hope in there. The kids, the youth, the parents, all of us coming to that first door. I hope one day it’s enough. So thanks for listening to the poem.
[00:08:58.810] – RN
You would have seen a few bits of the tool in the slides there, but Stephanie and I are going to take you through a live demonstration of the tool. First though, I believe we have some polling questions. So, Matt, if you wouldn’t mind bringing those up for us. There they are. [Short pause 00:09:16-00:09:28]. I’m not sure, Matt, if it automatically closes the question or if you want me to cue you when to move to the next one?
[00:09:37.590] – Matt
No, it’s fine. We’ve just got a few more people. Give me the last three or four seconds and I’ll move on to the next one. Do you want me to move onto the next one immediately?
[00:09:45.470] – RN
No, no, no. We won’t go through the answers now. We’ll do it at the end of our demonstrations [short pause 00:09:56-00:10:03].
[00:10:04.210] – Matt
So just let me know when you want the next one.
[00:10:05.990] – RN
Oh, yes, the next question, please.
[00:10:07.920] – Matt
Alright. [Long pause 00:10:10-00:10:25]. So Just while you’re filling this in, just to remind you, you can use the chat to network with each other, also to ask questions to the panel, and obviously the Q&As, and the [inaudible 00:10:33] as well. So I’m going to shut this one now.
[00:10:33.320] – RN
Yes please.
[00:10:33.320] – Matt
Do you want me to share the results or go onto the next one?
[00:10:42.770] – RN
We can move to the last one. Thanks. [Long pause 00:10:44-00:10:59]. Actually, sorry, Matt, if you could share, I know the second one is already gone, but if you could share the results for the third one too, that would be great.
[00:11:06.630] – Matt
I’ll see if I can get the second one as well, if you’d like. [Long pause 00:11:09-00:11:21]. This is the second one. [Long pause 00:11:22-00:11:34].
[00:11:34.290] – RN
Okay, great. Thanks, Matt, for popping those up for us. We will go through the answers at the end of our live demonstration. But now let’s start. So, Stephanie, you are the associate director of the Cundill Centre most of the time. Correct?
[00:11:49.920] – SA
That’s correct, yes.
[00:11:51.750] – RN
And now you are not for the next 10 or 15 minutes. Please tell everybody who you are now.
[00:11:58.050] – SA
So this morning I’m going to be playing the role of a family doctor.
[00:12:04.390] – RN
Doctor Stephanie Ameis, nice to meet you. How long have you been a family physician?
[00:12:10.330] – SA
Oh, please Renira, call me Stephanie. I’ve been a family physician for about 10 years now.
[00:12:15.550] – RN
And do you see a lot of young people with emotional or behavioural concerns?
[00:12:20.830] – SA
Yes, I do. There’s a lot of young people who are coming through my practice with anxiety, with depression, especially after the pandemic.
[00:12:30.250] – RN
So when these young people do come to your practice, how do you know what to do? How do you approach the whole assessment and treatment process?
[00:12:38.530] – SA
Well, I do what I think is the right thing to do, what I was trained to do. I do an assessment, I ask them some questions, I try and figure out what’s going on, and then think about what the best approach is to provide treatment. But I think that it may be that if a young person comes through my door versus one of my colleagues, they might have a very different experience.
[00:13:03.190] – RN
Would it be helpful do you think to have a guideline that was based on evidence, and something that was easy to share so you could show it to your colleagues, and that maybe they could follow a similar approach?
[00:13:14.290] – SA
That sounds awesome, but I haven’t seen such a thing.
[00:13:19.390] – RN
You haven’t seen such a thing? Have you not heard of the Cundill Centre online tool for the treatment of youth depression?
[00:13:24.950] – SA
Not yet.
[00:13:26.470] – RN
What? You haven’t heard of the… Oh, my gosh. Just give me a moment. I can’t process this information. Phew. Okay, I’m okay now. It’s okay. Everything is okay, everyone, because I am going to show it to you right now. So give me a moment, Stephanie.
[00:13:41.120] – SA
Awesome.
[00:13:42.030] – RN
I’m going to pull up the computer and we’re going to… Well, we’re on the computer now… and we’re going to look at it together. So can you see this?
[00:13:49.460] – SA
I can see it.
[00:13:50.860] – RN
Okay, great. So this is our Cunhill Centre online tool for the treatment of youth depression. You can access it by going to cundelldepressioncaretool.camh.ca, but don’t worry if you didn’t catch that. I’ll show it to you again later. So what it looks like when you pull it up, and you would simply just click begin to start. So over the next three screens, you’ll get an orientation to the tool. The first screen will link you to the evidence based clinical practice guidelines that the tool is based on. So if I click on that, you’ll see you can go to the NICE guidelines and you can read them in detail, if you like. On the second screen, you’ll get some basic facts on depression, which you probably already know. It’s probably not too new to you. And then the third screen in the overview section will link you to this depression fact sheet that we developed. So I’ll go ahead and click download, and you can see it will pop up. Now you don’t need to be in the online tool to access this resource. I can show you how to get to it separately later. You can print this, you can link to it, you can email it. This resource was developed by young people on our team for young people, so it’s very easy to understand.
[00:15:02.110] – SA
Oh, that’s awesome. Young people were actually involved in the development of this tool?
[00:15:06.930] – RN
Yes, not just involved, but they did most of the heavy lifting. That reminds me, we should talk about youth engagement a little bit later. So if you click next section, you’ll be taken to the assessment section. Here we provide a definition of depression, and we also allow users to quickly access the DSM-5 criteria by clicking that box.
[00:15:32.230] – SA
That’s really handy. So I don’t have to go and look at the criteria. It’s right there for me.
[00:15:37.820] – RN
Yes, we really wanted it to be handy. And on the next screen, we have the simulation video that we developed. In this video, you’ll see a young person in an appointment with their primary care provider and the primary care provider is trying to assess. Whoa, hold on a second. Am I seeing double or is that your twin or your doppelganger or something?
[00:16:02.530] – SA
That’s really strange. That person looks a lot like me, and they seem to be in the same place that I am right now.
[00:16:10.310] – RN
I’m really frightened. Why don’t we skip this? Because we actually have a youth advisor who’s going to tell us all about the video. So let’s just click next and move on.
[00:16:18.210] – SA
Keep going.
[00:16:19.490] – RN
Okay, good. In this section, we have more tips for assessing depressed youth. So it’s important to assess the young person’s social network. Also important to work with young people to ask them, what are their personal treatment goals? What outcomes do they want to see at the end of their treatment?
[00:16:35.870] – SA
Oh, and I see there you have some information about when to refer on to mental health specialty services. That’s really helpful.
[00:16:44.330] – RN
Great. We’re glad it’s helpful. In the next section, we have assessment [inaudible 00:16:51]. This one we talk about how to set up a comfortable environment for young people. On the second screen, we outline why depression in teens might be missed. And in the final screen in the [inaudible 00:17:04] section, we have tips on how to assess for complexity and risk. So it’s very important to ask about alcohol and drug use, as well as any experience with being bullied or abused. Also important to assess safety because of the risk of self-harm and suicide. Now we have a section on assessment tools. Do you use any assessment tools in your practice?
[00:17:28.470] – SA
I do, but I use different ones. I’m not sure which is the best.
[00:17:34.530] – RN
Well, we’ve got a couple of examples here. When you do use the assessment tools, do you use them to help you monitor changes in how a young person is doing?
[00:17:45.150] – SA
I’m not sure what you mean.
[00:17:47.490] – RN
Well, if you repeat the same questionnaire over the course of treatment, it can help you track whether symptoms are changing, in addition to using your intuition as a clinician, of course. You might be able to spot changes earlier and then make changes to treatment if they’re needed. This is what we call measurement based care. I’ll show you what I mean when we go through the treatment pathways. We’re actually almost at the pathways. I’m wondering Stephanie, do you have a young person in your care who we could maybe test this out on?
[00:18:16.650] – SA
Sure. I actually just saw a young person the other day. They’re 16. They’re having a lot of difficulty with low moods and irritability, having a lot of trouble keeping up with school, paying attention, not really engaging with their friends too much.
[00:18:38.070] – RN
Oh, sorry to hear this person isn’t doing well. On this screen you’ll be able to see definitions to help you determine whether their depression is mild, moderate or severe. It sounds like things are pretty severe, so I’ll click on that box.
[00:18:55.770] – SA
Yes, for sure. This young person has a number of symptoms that are substantially in excess of what you would need to make a diagnosis of depression. So I think severe makes sense.
[00:19:07.050] – RN
Okay, great. So now that we know that, let’s move on to the treatment section. We’ve got two treatment pathways here, one for mild depression and one for moderate severe depression. As you know, young person present differently. And so there are different recommendations for different types of presentations. Since Charlotte likely has severe depression, let’s look at the moderate severe pathway. We would suggest referring this young person to a youth mental health specialist, but we know that the waitlist can be long. Would you say that’s the case in your practice?
[00:19:42.450] – SA
Yes. It’ll take about six months to actually get my young clients to be seen by a mental health specialist.
[00:19:50.170] – RN
Yes, that’s a long time. We would still want to start the young person on treatment right away while they’re waiting. Since the depression is moderate severe, we know from the evidence that starting on medication and treatment would be the best. At the same time, it’s important to talk to the young person about lifestyle factors like diet, exercise and sleep. This is something that we recommend for all young people. Let me show you this section before we move on to medication and psychotherapy. So if you click on this, you’ll be able to see evidence based recommendations for exercise, for sleep, for diet, some information on anti-bullying strategies. And we also link to some resources that we’ve developed for young people and with young people to help educate them on these strategies as well.
[00:20:46.610] – SA
So it looks like I should go through the lifestyle and psychosocial strategies, but go right immediately to making the decision about whether to start medication and psychotherapy or psychotherapy. So it says, if they are agreeable or not agreeable, you make a different decision. Can you explain that?
[00:21:06.890] – RN
That’s true. Some young people might not be open to medication and some might not be open to psychotherapy. It’s really important to work with the young person and see what’s right for them. We do recommend medication and psychotherapy for young people with moderate severe depression. So I’m going to go ahead and click on that. And when I do, you’ll see that there are separate recommendations now for medication and psychotherapy. Let’s click on the medication box. And you’ll see here that fluoxetine is the recommended first line medication. The young person you’re seeing now, do you know if they’ve tried fluoxetine?
[00:21:44.270] – SA
Young person has never been on any medications for mental health.
[00:21:49.730] – RN
Okay, then we would recommend trying fluoxetine first. And if the young person doesn’t respond, you could try sertraline or citalopram. So you can see here we’ve got titrating, monitoring and tapering information for all three of the medications.
[00:22:05.090] – SA
Well, that’s really handy.
[00:22:06.750] – RN
Great. Again, that’s what we wanted to do with this tool. Now, since this is going to be the young person’s first time on antidepressants, you may want to give them a handout or something so that they could learn more about the medication, and we actually have one right here. So if you click here, it takes you to this handout that was again developed by young people on our team for young people. In this handout, it explains in very simple language that’s easy to understand what SSRIs are, how young people might know if the medication is working for them, what side effects they may experience and if they do, what some tips are in order to help with that. So it’s a two-page package. And again, you can print it, download it, email it, whatever you would like to do.
[00:22:55.020] – SA
That’s great.
[00:22:57.650] – RN
Great.
[00:23:02.130] – SA
Now, it says then I have to make a decision about psychotherapy. So I’m not really sure which psychotherapy to offer.
[00:23:10.290] – RN
Right. So let’s click on psychotherapy. And you’ll see that we say individual CBT should be tried first, if possible. But if that’s not possible, you could try some of the others. So there’s interpersonal psychotherapy, family therapy, psychodynamic therapy and care management or problem solving. Now, after four to six weeks, you want to check to see how the young person is doing, so let’s click on that. You would check how the young person is doing by looking at three things: one, your own clinical judgement, two, the assessment tool that you would have used earlier for the initial assessment. Do you remember when we talked about measurement-based care?
[00:23:52.380] – SA
Yes, I do remember that.
[00:23:54.320] – RN
Yes, so you would repeat the same questionnaire here and look at the results to see if things have changed. The third thing you would look at is how the young person is doing with their personalised treatment goals.
[00:24:04.450] – SA
So how do I know what a response is?
[00:24:07.630] – RN
So you can click on this tab here called Definitions and you’ll see, we’ve defined response, partial remission, full remission, relapse, recovery, and recurrence.
[00:24:17.610] – SA
Okay.
[00:24:19.930] – RN
So if Charlotte… or if the young person has responded… Let’s say that they have… we would continue the treatment for three months and then you would check the response again. You would look at the same three things: clinical judgement, the assessment tool and personalised treatment goals. And let’s say the young person is in remission. In that case, you would continue the medication for six months, develop a relapse prevention plan, and reduce the number of appointments that you have with the young person.
[00:24:49.990] – SA
Wow. Renira, thank you so much for taking me through this pathway. I love how all the steps are laid out and it looks like it would only take me about 15 or 20 minutes to really go through and make sure I learn it step by step before I see somebody. And I can also just use it very quickly when I have a young person in front of me if I forget one of the steps.
[00:25:12.730] – RN
Great. Well, we’re really glad that you like it and that was the aim to make it quick, 15 to 20 minutes. There is one more thing I want to show you, but I’m a little bit nervous. I’m not sure if I should show it to you.
[00:25:26.590] – SA
Oh, don’t be nervous. Go ahead.
[00:25:29.450] – RN
And you promise you won’t be annoyed?
[00:25:31.870] – SA
No.
[00:25:33.010] – RN
Okay, okay. So you see this little clipboard here in the bottom left?
[00:25:37.820] – SA
Yes.
[00:25:38.790] – RN
Okay. And you know what? It’s not just in the moderate severe pathway. Let’s go up here and switch to the mild depression pathway. You see it’s here again?
[00:25:45.750] – SA
Yes.
[00:25:45.750] – RN
Now, if you hover over this, a quick question pops up. It’ll take you one second to answer. And the question is, will you implement any new practices based on the information in this tool, so you can answer yes or no. We hope the answer is yes. We also hope that you’ll take a little more time to complete our evaluation survey. So if you click on this, our feedback survey will come up. And this is really important to help us understand if the tool is helpful to you or if there’s anything we can improve. It says it’ll take five minutes, but really, I think it’ll take like two minutes and 17 seconds or something like that. It really isn’t that long.
[00:26:26.230] – SA
Okay, well, I do dislike surveys, but if it’s going to help you improve the tool, then I’ll do it.
[00:26:32.750] – RN
Okay. Amazing. That’s what I wanted to hear. Music to in my ears. Thank you so much. There’s one last section that we haven’t gone through yet, and that is our resources section. So I’m going to click next and next again. So these are a series of resources that we’ve developed at the Cundill Centre and most, if not all of them, we’ve developed with young people. These are our videos on psycho-education and lifestyle advice. The one on the left is on depression. It describes depression to young people in a way that’s very easy to understand. And the one on the right is on how food, movement and sleep can have an impact on you. This one is very popular. It’s got something like 32,000 views in the last year and a half and counting. It’s also being used now in schools in the United States, so I highly recommend you watch these. They’re very short, four or five minutes, not even five minutes.
[00:27:24.670] – RN
And if you click next, you’ll see that we have a psycho-education package, which we called Mood Foundations. I’m going to go ahead and click download. The first page you’ve already seen. It’s the depression fact sheet I showed you earlier, but if you scroll down, you’ll see there’s one page each that provides tips on sleep, on exercise and on healthy eating. Again, this was developed in partnership with young people. Click next again and we have some videos that we’ve developed around assessment. The one on the left is on why using measurement tools can help inform care for young people. We talk about measurement-based care in this video. The one on the right is on a specific measurement tool called the Revised Children’s Anxiety and Depression Scale. Both of these are very short, about two or three minutes.
[00:28:14.350] – RN
And then if you click next, we’ve got a quick guide for the RCADS, the same assessment scale I just mentioned. I’ll click download so you can take a look. This is about five pages, and it just provides a little bit more information on the RCADS tool for someone who’s not familiar with it, and a little bit more information than what’s contained in the video as well. And here we just link again to some more of the recommended assessment tools. Then we come to our treatment section. Here you’ll see the medication handout again. Here we have a problem solving video for young people developed by young people that explains what problem solving is and how it could be an important ingredient in tackling depression. Here we have some worksheets on problem solving and on cognitive restructuring. I’ll just show you this one. It’s about three pages, again developed by young people. And that’s it. The next sections are more localised for the Canadian context, so we’ve got links to various organisations within Ontario and Canada, so may not be relevant to everybody. And then finally, we’ve just got a reference section. So that’s it.
[00:29:35.550] – SA
That’s wonderful. If I said some information about some of those crisis supports in other local areas, would you potentially include them in the tool?
[00:29:45.900] – RN
Yes, of course. We’re always open to including information that could be useful. So please send us an email and let us know.
[00:29:54.090] – SA
That would be great because this whole package is so amazing. It will allow me to take the guesswork out of my work and just follow step by step to make sure that I’m following the best evidence for my youth with depression.
[00:30:09.330] – RN
Great. I’m so pleased to hear that. And thanks for giving me your time and allowing me to show you the tool.
[00:30:16.290] – SA
Alright.
[00:30:18.930] – RN
Alright. So thanks, everyone, for listening to Stephanie and I. That is the end of our live demonstration. What we want to do next is revisit some of those polling questions, and there’s a new question in there as well. So, Matt, if we could pull those up again, that would be great.
[00:30:39.610] – Matt
Sure. Is this the correct one?
[00:30:40.730] – RN
Yes, that’s the correct one. Thanks.
[00:30:46.010] – Matt
I’m sure everyone agreed that was a fantastic session there. It was really engaging and interactive. Please show your love on the chat for that. Really good to have something that’s interesting and not boringly dry, so well done both of you. I’m just going to close this one now. Would you like me to share it straight away?
[00:31:07.930] – RN
Yes, please.
[00:31:11.710] – Matt
There we go.
[00:31:14.050] – RN
Great. Very great to see. Stephanie is actually going to take us through the answers as we go. So I’m going to pass it over to Stephanie to walk us through from here.
[00:31:21.970] – SA
Matt, would you bring up the results from the first question? So the question is all youth with depression should be offered antidepressant medication treatment. And so most of the polling answers indicate false, which is the correct answer. So as you saw when we went through, there are differences. And if you go through the tool, you’ll see that for mild depression, there are a different set of recommendations compared to moderate severe. And for mild depression the starting point is actually to start with psychosocial and lifestyle interventions and then quickly to offer psychotherapy if those interventions are not helpful in terms of reducing symptoms, but for the moderate to severe, that’s where we start with medication. And the reason is because the evidence shows that different approaches are suitable and helpful for different types of presentations. And we want to start with the least invasive types of interventions, if that’s effective for reducing symptoms of depression.
[00:32:30.830] – SA
So, Matt, second question please. So the question is there is no specific medication recommended as first line for the treatment of youth depression, and 60% said that’s true; 40% said that’s false. So if you look at some of the reviews, systematic reviews and meta-analyses to look at effect sizes of the different antidepressant medications, there are some subtle differences, and that’s why the first line medication choice that has been recommended by the NICE guidelines and what we show in our pathway is fluoxetine, Prozac. And then there are two others that we recommend as second line if that first line medication is not helpful.
[00:33:16.410] – SA
So the third question please, Matt. Finally, the psychotherapy options recommended for youth with mild depression and youth with moderate severe depression are the same. So 40% said that’s true. And 60% said that’s false. It’s actually false. If you look through our depression pathway, you’ll see that the mild psychotherapy suggestions are slightly different than the moderate to severe. The mild tend to use digital or group based psychotherapeutic options to help a larger number of people who have milder depression and to reserve more intense services, that would be one on one psychotherapy options, for those folks who have moderate to severe presentations. Okay, Renira, I’m going to pass it back to you.
[00:34:10.690] – RN
Okay. Thanks, Stephanie. I want to bring up these links again, and I think Shanika* is with us. Shanika is our social media and event support. I think she’s put some of these links in, but just so you have them again, the direct link to the tool is there. We also have all of the other resources that I showed you are available separately, so you don’t need to be in the online tool to access them. We actually just yesterday added a cognitive behavioural therapy manual. So you might be interested in that CBT manual. It’s meant for adolescents with depression and that we worked on with young people on our team as well. So that was published yesterday. It’s up on our website. And if you have any questions, if you want to leave comments or if you want to sign up to hear about our latest tools or events, then send us an email. We may not know a lot of you. I think this is our first time or mine at least presenting with this audience, so we really love if you wanted to connect with us. Feel free. You don’t even need to say anything. You can just send us an email and say sign me up or whatever you want to say. That would be great.
[00:35:13.810] – RN
Now I want to introduce our panellists. We’ve got two. We’ve got Melanie Asselin, who is a youth advisor and has done such an amazing job working on this project with us. Melanie is going to talk about youth engagement. And then after Melanie, we have Doctor Karen Euler, who is a family doctor with the Georgian Bay Family Health Team in Collingwood, Ontario, and Doctor Euler and her team have also been involved in a really exciting implementation project where we’ve all together with other partners, have taken the basic guidelines and the online tool and have worked on contextualising them and implementing them in a different setting. So Doctor Euler will tell you more about that when we get to her portion. First up, we have Melanie and Melanie is going to talk to us about how we engage young people in this project. Before Melanie, I just wanted to reiterate that a lot of the tools, a lot of the resources that are in the online tool have been developed with young people by young people.
[00:36:19.190] – MA
Okay. So we can begin and talk a little bit about youth engagement and why that was important. So of course, youth are important members of the process when it comes to learning how to manage their own depression and their own symptoms. So working closely with clinicians to discuss the options that work best for them is an incredibly important part of the process. So with this tool, myself and a few other young people worked with the team here to develop various aspects of the tool and also share our input when it was all finished. Hold on one second. Yes, so in looking to get feedback from youth, we brought the tool to our youth advisory group, but also we did have three young people and a youth engagement coordinator who reviewed the tool initially. We looked at the whole tool together, and then we also looked specifically to a video that was included within the tool.
[00:37:17.670] – MA
So together with a group of about 15 young people, we discussed tips for conducting a good assessment. So the original video that was included in the tool was a YouTube video that was created by a different organisation, and we weren’t too big of a fans of that other video. So we wanted to get some feedback from our youth group, our youth advisers, and look at what we could do better to create a new video that would be a better example of client and clinician interaction. So for our original assessment video, there were a few things that people didn’t necessarily like. So in this original video, again which was not created by us, the clinician was not very empathetic. They had other criticisms that they brought up as well, the youth group. So it often felt like that clinician was reading from a checklist and just asking questions in order without building a lot of rapport with the young person. There was nothing really done to make the young person feel warm and welcome in the setting, and there could have definitely been a lot more empathetic statements there.
[00:38:36.700] – MA
So as a youth advisory group, we discussed that. We wouldn’t necessarily feel comfortable if the clinician was approaching us in that way. It was more cold, more structured, a bit too formal in terms of what we would initially look for in our own treatment for depression per se. We also thought it was a bit unrealistic, this original video. We couldn’t imagine getting to the point of a deep, personal conversation in such a short amount of time, again without any rapport building there. In that case as well, the young person did seem as though they knew a lot about depression and depression symptoms, so in that sense, it seemed a bit scripted. There was also a lack of mentioning confidentiality at the beginning of that video.
[00:39:28.260] – MA
So we decided to scrap this video and create our own. So here I was acting as a younger person in this video with Doctor Stephanie Ameis, and we created a new video. So the way that we improved it, we added different elements about safety, confidentiality, and also self-harm. When we created this new video, we wanted to make sure we weren’t recreating the same mistakes that the original video had. It was important for us to have a good example of both client etiquette and proper language during interactions with youth who were coming in to talk about depression. Of course, we know that it can be a difficult situation, especially if it’s your first time coming in to talk to a clinician about what you’re going through, and we wanted to make sure that it was both realistic and also a comfortable environment for the young person and the clinician to talk about future options.
[00:40:27.210] – MA
In this video, we also did add information about the virtual context, especially because youth may have concerns about privacy and confidentiality, especially now that a lot of our treatment options and appointments are still taking place online or through the phone. So we also talked about suicide and self-harm from there. We had more open-ended questions, and it felt like a more natural and empathetic conversation, as opposed to listing off options from a checklist. So we do have a quick clip of that video. I’m not sure if right now was when we wanted to put it up.
[00:41:04.650] – RN
It is right now. Let me switch over, and if it doesn’t sound right or if it’s glitchy, just let me know and I will stop it. We’re going to play it around… I think it was 2.15 or so.
[00:41:22.230] – SA
Melanie, would you say that you’ve lost interest or getting less pleasure from many of the things that you usually enjoy?
[00:41:29.910] – MA
Not as much. I don’t feel like I enjoy the things as much as I used to, but I still like my friends. It’s just not as much fun to go out with them anymore.
[00:41:42.450] – SA
I’m sorry to hear that. Do you also feel like your thoughts are more negative or you’re feeling down about yourself a lot of the time?
[00:41:50.910] – MA
Not really. I just feel like I want things to be the way they used to be. I feel like I’m disappointing my friends and family all the time.
[00:42:01.170] – SA
Sometimes when people are feeling really negative about themselves, they can also start to think things like they wish they weren’t around. Have you been having any of these kinds of thoughts?
[00:42:12.280] – MA
No, I haven’t.
[00:42:15.090] – SA
Melanie, have you been having any thoughts about wanting to end your life?
[00:42:19.470] – MA
No.
[00:42:21.510] – SA
Sometimes when people are feeling down, they may want to cause pain or injury to themselves without meaning to end their life. Have you ever deliberately harmed yourself in some way?
[00:42:32.050] – MA
No.
[00:42:33.810] – SA
It can be really hard to talk about these things, so thank you for your openness with me. I’d like to ask a few more questions to better understand how things have been going recently. And then we can talk about what might be helpful, including a note for school.
[00:42:47.530] – MA
Okay, thank you.
[00:42:52.990] – V6
Doctor Ameis continues the assessment, asking additional questions.
[00:42:58.910] – RN
I’m going to stop the video there. And I think, Stephanie, you’re going to take over from here with the rest of our panel.
[00:43:06.950] – SA
Sure. Thanks, Renira. So, Melanie, I’d love to start with you. You’ve been involved in this process from the get go. And I wonder what you think this tool could mean for young people. What impact do you think it could have?
[00:43:24.890] – MA
Right, so there’s definitely a lot of exciting possibilities when it comes to this tool and where it’s going to go in the future. I can speak especially to a personal experience as a young person as well. I was around twelve or 13. I experienced depression symptoms. I was living in a really small town at the time, and when I went to go see my primary care provider, there was definitely a lack of confidence when it came to those first steps and figuring out where to go and what to do because, of course, seeing a specialist, or a psychiatrist even, would take a long time. There would be a long wait time for that appointment.
[00:44:04.910] – MA
So in the meantime, while I was waiting for that appointment, which was going on seven to eight months for the waitlist, there was no treatment that was offered to me, so that was definitely a big struggle. So now flash forward a couple of years, I am currently a master’s social work student and working on this tool as well, it definitely provides me with a bit of hope when it comes to educating clinicians and helping clinicians feel a bit more confident when approaching children and young people with facing depression. Of course, it’s a very difficult situation for young people to be going through, so to have a clinician who feels confident and ready to offer them various solutions, of course, is the best possible route.
[00:44:55.790] – SA
Wow, that is really useful information. That’s I think really why we decided to embark on this endeavour to make sure that we could reach a lot of people and try and enhance capacity amongst primary care physicians, so that they feel comfortable to start something, so that you don’t have to wait for those rare appointments with mental health specialists. Thank you for sharing that, Melanie. I’m going to pivot to you, Doctor Euler. Thank you for joining us today. And I wonder, based on what Melanie just shared with us as well, there’s a question in the chat as to how do we help primary care physicians feel confident to start treatment right away, so that they don’t have to wait for those rare appointments. There’s actually a question in the chat about needing to have a culture shift that a lot of primary care physicians maybe don’t feel comfortable starting medications on their own, and they wait for mental health specialists because of that discomfort. Do you think we need a culture shift? And what advice do you have in terms of how do we get family docs to start?
[00:46:16.430] – KE
Yes, we definitely need a culture shift. As we said earlier, Covid has increased the amount of youth presenting specifically with anxiety but also with depression. And I think family doctors are often Jack of all trades, master of none. And what can change that is having the tools and the education right at your fingertips. So if it’s right there at the time that the person is in front of you, you know where to go to do a really good assessment and you have all the tools right there, it makes the visit less stressful for you as the clinician, but also really helpful for the person in front of you.
[00:47:06.890] – SA
Thank you so much. I’m going to ask you the same question that I asked Melanie, which is what impact do you think this tool has across the board? If we can get folks around the world to use it, what do you think could be the impact?
[00:47:25.730] – KE
The impact will be huge. We need to help people at the time that they’re asking for help, and we can’t have a six-month wait to see a specialist. We need to help the youth right away when they present with help. And I would say even just the information about sleep, diet, exercise, the impact of them having good evidence based lifestyle things they can implement immediately is going to be huge.
[00:48:01.010] – SA
Thank you so much for that. And now, Doctor Euler, are you going to share with us a bit of your experience in terms of translating our tool into your practice for your family health team? Take it away, please.
[00:48:17.870] – KE
Sure. So I’m a family doctor in a rural setting. My day goes like this. I check on my computer in the morning to see if I have any hospital patients. I rush over to hospital. I admit my patients. I drive half an hour out to my office and then I see patients every 15 minutes until 5:00pm, so when you have a youth that’s booked for a 15 minute appointment and they’re presenting with depression or anxiety, your immediate thought is Ah, I’m going to be an hour behind. This is a disaster for my day. But I don’t feel that way anymore because we, as a team, developed a pathway that I can just pull right up into the chart, and I’d like to share that with everybody. So I’m going to just share my screen. Hopefully this works out. Let me just try that. Is that working?
[00:49:25.450] – Matt
Yes.
[00:49:26.440] – KE
Okay, great. So what I’m showing you right now is an algorithm that I can pull up into the patient’s chart and I can start doing the assessment. This assessment takes about 15 to 20 minutes, so if you have a 15-minute appointment, you can absolutely do this and get the child and youth on the right path. I’ll just show you some of the features of the tool, just some general things. So we developed this with our family health team counsellors and our community counsellors. So we figured out what resources we have in our community for child and youth to receive psychotherapy. And we spent a lot of time working with the psychotherapist about how best to triage and get the child and youth into the right type of therapy. So that’s a huge thing that we tailored to our community.
[00:50:43.740] – KE
The second thing we wanted to do is monitor how we’re doing. So within our algorithm, we also made sure that we are documenting when patients are seen by their primary care physician, when they’re being started on medication, when they’re being referred for psychotherapy, when they’re being seen for psychotherapy, when they’re being re-evaluated, and we can track over time how we’re doing. I think these tools are not useful unless you re-evaluate how they’re being used and whether you’re having success. I’ll show you a couple of features of it. If I say this is an in-office screen, I can then choose which tool I want to use. So we have RCADS’ child screen and RCADS’ parent screen, and then a specialised, more detailed risk of suicide if the answer to the suicide question is positive. You can click here and say the office screening date, and then from the RCADS tool, you would be able to select whether the person in front of you, which category they’re in. And then when you click on that category, your resources come up.
[00:52:06.870] – KE
So when you click on your resources, then you can print out the lifestyle, print out to give to the child or youth and parent. You can watch a video with them, and you go right to the link of the video. You can then decide, is this a person that needs to be started on medication today or is this a person that we’re just going to review lifestyle and send for therapy? Then you can click whether you’re going to refer to our local therapy. The referral sheet comes right up for you, and you can fill it out, and the referral is done in three minutes. And you don’t have that hanging around for your charting at the end of the day. You’ve already done it because it just pops right up. If you determine through your screening tool that the person has more moderate to severe, in our community we decided to refer outside of our family health counsellors to people who have more expertise and can do longer term therapy.
[00:53:17.420] – KE
And so if you refer to that resource, that referral sheet pops up right away and you click, click, click; you’ve filled it out; the referral is done. As I move down the algorithm, we make sure that we’re having the client back into the office. We’re repeating the RCADS, both with the parent and the child or just the child, whatever you decide. Then you make a decision, are they going to continue with the therapy that they’re doing or do they need to have medication? We have a resource right in front of us. If the RCADS score is not improving, we then decide, what are we going to do about that? So are we going to just have a discussion with myself and the client and their caregiver? Are we going to consider medication? Are we going to do a referral to a paediatrician or psychiatry? Are we going to change the type of psychotherapy they’re having? Are we going to do more family therapy? If they’re in group therapy, are we going to consider one on one?
[00:54:25.700] – KE
Then we move on down. Every time we click off what we’re doing, the time and date is recorded. We have a way of doing an eConsult as well, and that referral pops up and we can do an eConsult if we’re struggling, which saves a lot of time. If you’re referring on to a psychiatrist, it’s going to be a fairly long wait. If you do an eConsult, we get ours back within 48 hours. Sometimes we just need to change the medication or change the type of therapy, but we need a little bit of help making that decision. And an eConsult gets us a specialist really quickly and their opinion. They have access to the full chart, so they can see what we’ve done. They have access to our algorithm.
[00:55:10.130] – KE
And then we also are assessing, deciding when the patient is discharged and they’ve done well. So we’re making sure we understand what remission is, what recovery is. Is the patient doing well? And then we can just click on this and it tells us how to taper the medication. It gives a [s.l. handout 00:55:31] for relapse prevention plan, which can be tailored to that patient. And then we know when to check back with that patient to make sure they’re doing well. So those are just a few of the resources and the ways that you can go, but essentially, you pull up one algorithm and you tailor it to the person in front of you, and just by clicking through it, you have all the answers to everything you need to do a review, and you’re using evidence based medicine and you’re reassessing with evidence based tools. So for me, this is a lifesaver. Now, if someone comes in with anxiety or depression instead of going, Oh, I’m going to be an hour behind. Now I go, I got this. I can do this in 15 to 20 minutes. So it’s been amazing. And it’s just been such an honour for me to be part of developing this tool specific for our region.
[00:56:36.990] – SA
Thank you so, so much for that, Doctor Euler. And I wonder what advice do you have to other family physicians who want to do the same kind of thing?
[00:56:48.930] – KE
Yes, I would say start with using the Cundill tool because that’s what ours is based on, and then take from the Cundill tool what you want to make specific to your organisation. I would say also involve all the players. This was a group project for sure. We involved CAMH, we involved our child and youth psychiatry specialists, we involved all our counsellors, we involved the community counselling service, we involved our IT people because they needed to make sure it fit into our electronic medical record system. You just need to have all of the people around the table from day one. For us it took… We met about every month to every three months, and it took us two years. I don’t think it would take two years. I think it would take maybe a few months to put it together because all the basic working parts are there now and the Cundill’s tool is up and online and 100% available, so you can just tailor it from that. All the evidence-based guidelines are there.
[00:58:11.670] – SA
Thank you for that. So if folks are listing and they service a broad population and they really want to help in partnership to think about how to implement, please reach out to us. Renira, I think I’m going to pass it back to you now.
[00:58:32.490] – RN
Well, I think we’re done actually and ready to open things up for any questions that anyone might have in the audience.
[00:58:41.670] – SA
Thank you so much, everyone, for being here with us and for listening, and especially Doctor Euler and Melanie for telling us about their experience, working with us and developing the tool. We have had some questions that have come into the Q& A, and there may be a couple that are open. So excuse me if I’m a little clunky here, but I’m going to just read out some of the questions and answers that are coming through. And Peter, please feel free to chime in if you want to elaborate on anything, or anybody on the panel. So the first question from Julia Hardman*, does this work for young people with ADHD and autism? And I had a bit of time to answer some of these questions. So the tool and the NICE guidelines recommend using the same pathway for young people with neurodevelopmental disorders and depression, so kids who have primary ADHD or autism who also meet criteria for major depressive disorder, but the evidence is not so strong, so we really don’t have a lot of rigorous studies.
[01:00:02.340] – SA
It’s pretty well nil in autism, especially ADHD. I know that literature a little bit less, but I think it’s pretty lacking as well in terms of really looking at whether the same evidence based approaches have the same efficacy, so actually improve depression in the same way in those kids who have co-occurring disorders, so those kids who have ADHD and major depression, or autism and major depression. And actually one of the things we’re working on within Cundill is trying to modify some of our pathways as well as our knowledge translation information to make sure we’re reaching those individuals as well, because there really are higher prevalence rates for depression in those populations, especially in autism and there’s a lot of concern about suicidality. What we can say is that we do recommend using the same pathways because it’s really good to have a standardised approach, but we really need a lot more research in those areas. Do you want to chime in, Peter? I think you’re muted, Peter. Oh there you are.
[01:01:22.750] – PS
I can’t resist chiming in, as you well know. I would just add that when the evidence base is not strong, the importance of measurement becomes even more important. So yes, I totally agree with you. It’s appropriate to use these in the context of depression in ADHD or depression in ASD. But it’s so important to then measure response to treatment using the RCADS, for example, or the MFQ to make sure that things are getting better because one of the advantages of measurement based care and using these measurement tools is that you can react much more swiftly if things are not going well and so people have a shorter course in treatment. In other words, you can make more rapid treatment decisions if you need to adjust.
[01:02:19.530] – PS
And so using these measurement tools becomes very important when the evidence base is not great. And we’ve recommended the RCADS, particularly because we went through an exercise with ICOM, the International Consortium of Health Outcome Measurement, which looks specifically at measurement based care in anxiety and depression for kids, and recommended the RCADS as the one that was most appropriate in these circumstances. You mentioned that, but I just thought I’d highlight it.
[01:02:50.150] – SA
Thank you, Peter. Also, just as you’re talking, it made me think that the other thing that we really recommend is shared decision-making…
[01:02:58.910] – PS
Yes.
[01:02:58.910] – SA
… especially when there isn’t the evidence there to really say this should be first, this should be second, and this is what you can expect in terms of outcome. You really have to talk about that with individuals to begin with, and let them know. I think that has a huge impact on engagement and rapport, and making sure that you have a partnership and people are aware that there isn’t really a magic bullet. As Peter was saying to begin with, we’re still working with what we have, but I think that can be really helpful in terms of keeping people engaged. The next question I’ll read out, Susan Withers*, what’s the age range of children that you can use this tool with? This tool is based on the pathway that’s recommended by NICE for 11 to 18 year olds. There is another pathway for younger children that NICE recommends. And so this is based on the best evidence for treatment of youth. Anybody want to elaborate on that?
[01:04:08.030] – KE
I can. So in our algorithm we wanted to capture younger children. So we have the RCADS child screen so it can be used for children starting at age six. For me, if I have a six year old in my practice, I would do the assessment, I would get the lifestyle going, I would get the therapy going, but I might do an eConsult around the medication, or I might start to feel comfortable with medication if it looks like medication is indicated. So we’re using our algorithm for age 6 to 17.
[01:04:58.190] – PS
Yes, I think that’s a fair comment. The guidelines for younger kids are not all that different, and the most common presentation, of course, for younger kids will be anxiety, and the type of CBT will be different and the medication will be a little different but not much. And we’re working on an algorithm that will post a tool shortly, I think, on a similar tool for anxiety in kids.
[01:05:32.790] – SA
Wonderful. Thanks, Peter. Thank you, Doctor Euler. So the next question from Christopher Kowalski*. A wonderful tool and so useful. Thank you for that, particularly in primary care. Here in the UK, very few family doctors feel comfortable starting SSRIs and would rather rely on specialty mental health for starting SSRIs despite the wait list. So this is really what we were talking about earlier. It would require quite a culture shift to encourage family docs to prescribe while child is waiting for specialist care. Do you have any advice on how to affect such a culture shift? So I’m going to pass it on to Peter, who answered that in the chat.
[01:06:24.710] – PS
In our experience working with Karen and the Georgian Bay Family Health team, what I was… I don’t know if I’ve shared this with you, Karen, but what I found most compelling was when you said the medication is so simple because you had got so many different recommendations about different medications for kids with depression that your head was spinning. And when we said the NICE guidelines basically tell you it’s fluoxetine and then sertraline and you can forget the rest of them basically, you found that very compelling. And I think for me that was a very powerful hook, I think, to get the ball rolling in terms of what you in primary care would find useful and helpful. So I think spending time in a primary care setting, face to face interaction or as much as that’s possible between a CAMHs and a primary care setting, pick primary care settings that are interested in working on this project with you and make life easy for them. And I think that’s what we try to do. And I think those would be some of the ingredients for a culture shift, but don’t expect it to happen passively. I think that’s the other message. Culture shifts won’t happen passively unless you’re actively involved in making it happen at the ground level. Would you agree with that, Karen?
[01:08:03.210] – KE
Yes, and you need to… We marketed this to my colleagues. So once we had our algorithm set up, I did two educational seminars. I sent food and booze to the physicians’ houses so they would listen to me [laughter]. And they all just were like, Wow okay, I’m comfortable now. I’m going to try it. And the dosing was there. So that’s the other thing. You’re like, Which drug do I use? Okay, there’s only two. Great. This is just a little person. Like, Oh, I don’t know about the dosing. You just click and it’s right there. And then, you know this has been well thought out by someone else, and you’re not going to make a mistake. We also made it automatically populate into our prescription pad, so that you can’t mess it up. I going to do sertraline, and then it goes into our prescription pad with the right dose and the right amount.
[01:09:07.090] – KE
That’s the other issue that family doctors are like, Oh, but I don’t want too much in the home. I don’t know… It’s all set up. You click, click, click, and it’s done. And you someone else did that who’s got more bandwidth for this stuff than you do in the moment. So making it easy, showing them that it’s evidence-based guidelines and allowing them to make it idiot proof, I guess, is really what we did. We made it idiot proof, so that you don’t even question your knowledge about it. It’s just all there. And then you got to sell it.
[01:09:44.670] – PS
Well, and I think another key ingredient is having a champion on the inside.
[01:09:50.060] – KE
Sure.
[01:09:51.090] – PS
You played the role of that champion, which I think made all the difference because it gave the tool of credibility with your colleagues, and so that made it easier. And then I think the other thing I’ll have to say is your electronic medical record system is so flexible. It’s fantastic. I’m not sure a lot of other primary care settings… and I’d be interested our colleagues in the UK, what’s the electronic medical record system like in primary care? Because that was an essential part of implementation as well from what you’ve described.
[01:10:28.630] – SA
The other thing I will add to this is that a lot of our tools are designed to empower youth. We’ve worked with youth to provide information. It’s all out there. We really want youth to actually engage with our tools and maybe they can be part of the culture shift if they say, Well, wait a second. You’re not starting anything, but I know about the Cundill Centre, and I know about all these tools. What do you think of that, Melanie?
[01:11:03.950] – MA
Yes, I think that’s definitely an important aspect as well for youth to have that autonomy and engagement and being able to be aware for themselves what the standard practices would be. That way they can take more of the driver’s seat as well when conversing with their primary care provider about their own treatment. Yes, I think in terms of a culture shift that would definitely help with confidence on both ends and just acceptance of what would be next for the young person.
[01:11:39.290] – SA
Thank you.
[01:11:39.820] – KE
And I would say one side benefit that I’ve noticed from using the tool is we all know we can’t multitask. So if I’ve got the algorithm doing all the medicine for me, I have a lot of bandwidth to develop a rapport with the person in front of me. And that was something I wasn’t expecting, but that’s something that really… Because I can just click, click, click for all the knowledge, I can really pay attention to what the youth is saying, and I can really feel engaged with the… instead of me thinking, Oh, God, what drug? I’m just really listening. And I think the patients feel much more satisfied with the visit because I’m not trying to figure out what I should be doing. I don’t have to do that. I can just spend time really listening. And 15 minutes is a long time if you’re really listening.
[01:12:41.310] – SA
All right. We have 15 minutes. I’m just going to keep going through the questions that we have. There’s a few more. So from Nosie Ocheta*… I’m sorry if I’m mispronouncing… Who offers psychotherapy while the young person is waiting for CAMHs? And will you recommend starting antidepressants for mild moderate depression, even if there isn’t a professional to offer psychotherapy? So I’ll start and just read out what I wrote and I’m going to pass it off to you, Peter and Karen, for your input. So I can speak most to the context we have in Ontario, where we are in Canada, our province. Family physicians often, but not universally, have access to individuals in the community who are trained to provide psychotherapy that the physician can refer to, the family doctor can refer to in the meantime, before getting into long wait time referrals to mental health specialties. So these tend to be therapists who are trained, who are in the community and there’s greater access.
[01:13:51.710] – SA
Many family docs do start medication if they don’t have access to psychotherapy resources. And actually, that’s something that we’ve seen in the pandemic, that there have been long waits for psychotherapy resources, and so family physicians are reaching for the tools in their toolbox that they can reach for, that they can readily access to try and help their patients. However, the key is to advocate for better access, including access to psychotherapy tools that can reach broad audiences easier, so, digital tools, school based resources, virtual groups, especially for those individuals who have milder symptoms who are more likely to respond to those interventions. What do you think, Peter? Karen?
[01:14:42.750] – PS
No, I think that’s a great answer. I think our system is quite similar, actually, to the UK system. We’re more like you than we are like our brothers or cousins to the south that are a universe apart from us. So I think we struggle with the same issues. I think in some ways you guys are ahead of us. We’re copying the online structured psychotherapy programme that the guys in Oxford developed. I don’t know if they have one for younger people as well, but we’re piloting and working on a programme of online psychotherapy funded by the government for young people, and I think that will be ready soon. I’d be interested in what’s happening in the UK there.
[01:15:38.470] – KE
Yes, I don’t really have anything to add. Because this tool has given me, actually, the courage to start medication, even as I refer someone for psychotherapy, sometimes I really find that if the medication has already started working, the psychotherapy is a lot more helpful to the client. So sometimes I even say it’s okay if it’s a month wait before you start your therapy. I think let’s give them medicine a chance to work, so you’re sleeping, you’re concentrating, you’re able to do your psychotherapy homework. So I’ve had a really good experience with having the courage to just go ahead and start medication and with good results.
[01:16:28.510] – SA
Okay, thank you. So I’m going to switch… There’s a few questions that are open. I think we’ve talked about the other question from Christopher Kowolski. So many children have co-morbid anxiety with depression, do you think the presence of a mixed picture would make a big difference in how clinicians should use the tool?
[01:16:50.710] – MA
I can comment on that. So we specifically designed our algorithm for both because we know they overlap. And so the RCADS help sort out how much… It’s a screening tool for both anxiety and depression. And your question is exactly what our question was when we were doing our algorithms. You can’t just do depression with youth. You got to screen for both. So the RCADS screens for both, and it may categorise the client into one or the other, but the treatments are similar. And so the medications aren’t that different, and you’re screening for both and they overlap hugely. We try to… and Peter could maybe add to this… we try to say whether it’s anxiety or depression because each has different nuances, and the type of therapy might be different. But at the end of the day, medication and psychotherapy work for both of them. So we are very aware of that, and that’s exactly why we chose the RCADS as our screening tool because it screens for both.
[01:18:16.770] – PS
Yes, and I’ll just add, Karen, that these measurement tools are screening tools. They don’t replace clinical judgement. So you may get a score of 60 for anxiety and 50 for depression, and RCADS will say, Well, the anxiety score is higher, but your clinical judgement will allow you to take a history. How has this unfolded over time? Which started first? Are we missing some symptoms for some reason or another? There’s measurement error. So the tool is a tool, but clinical judgement is most important for you to decide whether you go along the anxiety pathway or the depression pathway. And I’ll just say that CBT, the type of CBT is slightly different. There is one CBT for anxiety and a modification for depression. Sertraline would be the first choice of medication for anxiety, the second choice of medication for depression. So those are slight nuances but worth keeping in mind.
[01:19:29.110] – SA
And we are planning to launch a tool that’s specifically focused on anxiety, so give us a little bit of time with that. And I think, based on the questions that are coming up, it may make sense to make a little modification to our tool to add a little bit of information for the family doc considering the comorbidity of anxiety and depression, and also maybe to address the neurodevelopmental disorder question that we had earlier. Renira, I think I saw a post in the chat. Did you want to pass it off to somebody who had their hand up? Are we able to do that?
[01:20:09.650] – RN
I’m not sure, Matt, if people are able to unmute themselves from the audience, but I can see that Alex Conway has his hand up. Is that possible Matt to…
[01:20:18.210] – Matt
Alex, if you want to speak, is that okay? I’ll see if I can do that for us.
[01:20:24.950] – RN
Oh, I see that the hand is down now. I don’t know if…
[01:20:27.780] – SA
There’s Alex.
[01:20:30.110] – AC
Sorry, my hand wasn’t meant to be up.
[01:20:33.530] – SA
Okay, but you did have a point that you wanted to make in the chat or in the Q&A to UK GPs that in your local area trusts, CCG could set up triggers on the GP software like EMIS that sends the GP a pop up telling them what to do if they note depression on young person’s health record. Wow, so there could be a very fast access point to a lot of GPs it sounds like, based on Alex’s comment. So another question, as we maybe just round out, there’s a couple more, just one more maybe. Can the tool be used with young people engaging in substance misuse who may also be presenting with mental health issues? So I can start. I can pass it off to you, Peter. What we tend to do at CAMH is we try and treat co-occurring disorders in parallel. So we try and engage individuals who have substance misuse in treatment for their substance misuse at the same time that we would treat their depression or another co-occurring disorder, so that they’re not waiting one after the other, but that there’s an integrated approach that really considers the whole person and the different aspects that go into what their mental health presentation is. So we would recommend engaging in elements of the pathway but personalising it to make sure that there’s engagement and to make sure that you’re addressing the goals of the individual person, so that the care is personalised to them. Peter?
[01:22:30.670] – PS
And the only thing I’d add is the important distinction between nicotine, cannabis and alcohol as one form of substance use. And I think what you say is very applicable there. When it’s harder substances, cocaine, other heroin opioids that takes a more aggressive approach to treating the substances first, I think.
[01:22:59.030] – SA
Alright, I think those are all of the questions that we have in the chat, and we’re rounding out to the end of our time. So I’ll just say, thank you so much for all of these incredible questions and for your engagement. It is such a pleasure to present alongside my good friends and panellists and to really share this tool that we’ve worked so hard on for a while, and we really hope that it will have impact broadly. Anybody else from the panel want to say any closing words?
[01:23:37.340] – PS
No. I think we’re so pleased that so many of you want to connect with us. Please stay in touch. I know that we’ll be actually in the UK in July at a conference, so we’ll let people know about that as well. And please keep in touch. Send us your thoughts and ideas and let’s work together to make the world a better place for young people that are struggling so hard. There’s so little resources for the size of the problem. The only way we can tackle it is working together.
[01:24:14.440] – Recorded voice
Find out more about becoming an ACAMH member and to be part of the Advancement of Child and Adolescent Mental Health visit www.acamh.org.
About the speakers
Dr. Peter Szatmari is Chief of the Child and Youth Mental Health Collaborative between CAMH, The Hospital for Sick Children and the University of Toronto. Additionally, Dr. Szatmari holds the Patsy and Jamie Anderson Chair in Child and Youth Mental Health.
Dr. Szatmari’s investigative interests fall broadly into areas of psychiatric and genetic epidemiology, specifically: 1) longitudinal studies of children with autism spectrum disorders and the factors associated with good outcome; and 2) the genetic etiology of autism including studying families with rare copy number variants and studies of infant siblings. Another area of interest is the developmental course of child and adolescent psychopathology including depression, eating disorders, oppositional behaviours and anxiety disorders, with a particular area of concern being measurement issues and sampling by family unit rather than by individuals. (Bio and image from CAMH)
Dr. Stephanie Ameis is the Associate Director of the Cundill Centre for Child and Youth Depression and a Clinician Scientist in the Brain Health Imaging Centre, The Margaret and Wallace McCain Centre for Child, Youth & Family Mental Health and the Campbell Family Mental Health Research Institute at CAMH. She is a child and youth psychiatrist at CAMH and is appointed to the Child and Youth Mental Health Collaborative at CAMH, the University of Toronto and SickKids. She is Associate Professor in the Department of Psychiatry in the Faculty of Medicine at the University of Toronto.
Dr. Ameis’ research spans across: (1) neuroimaging research, studying biological mechanisms related to clinical symptoms, social cognition, neurocognition and behaviour across transdiagnostic samples, including children, youth and young adults with a variety of mental health challenges, (2) interventional research, focused on studying novel interventions to treat mental health symptoms in youth, and (3) implementation science and knowledge translation to improve uptake of research findings in her work with the Cundill Centre for Child and Youth Depression. Dr. Ameis has a particular interest in developing evidence-based interventions to address depression and suicidal thinking in autistic youth. (Bio and image from CAMH)
Renira Narrandes is a Knowledge Translation Specialist at the Cundill Centre for Child and Youth Depression at the Centre for Addiction and Mental Health (CAMH) in Toronto, Canada. Her role is to find ways to help shorten the time it takes for research to have an impact on clinical practice. This involves developing tools and working with the people who will use them, including service providers, young people, and family members.
Dr. Karin Euler is a family doctor and physician mental health lead with the Georgian Bay Family Health Team in Collingwood, Ontario, Canada. She is also part of the Canadian African Community Health Alliance and travels to Tanzania regularly to lead medical missions for the people of the island of Ukerewe.
Melanie Asselin is a Master of Social Work Candidate at Wilfrid Laurier University, with a research focus on youth mental health and addictions. She is a youth advisor at the Centre for Addiction and Mental Health (CAMH) and is also actively engaged with several local non-profit organizations.
