Transparent criteria for specialist level adolescent psychiatric care

Une échelle de triage en santé mentale, pratique émergente de la mesure, une valeur ajoutée pour l’usager en demande de service en santé mentale

Objectifs L’article vise à présenter deux études ayant soutenu le développement de l’Échelle brève de triage RIFCAS en santé mentale 0-99 ans, un instrument de mesure servant à établir la priorité d’une demande de service en santé mentale pour la clientèle de tout âge en considérant la gravité et l’urgence d’intervenir.

Méthodes Les deux versions ont été soumises à une mesure d’entente interjuges pour ensuite être mises en correspondance avec le jugement de professionnels et avec d’autres instruments de comparaison.

Résultats Les résultats obtenus des mesures d’entente interjuges traduisent une cohérence forte entre leur cotation. Il y a des correspondances significatives entre les priorités établies selon l’Échelle brève de triage RIFCAS en santé mentale0-99 ans, le jugement de professionnels experts et les instruments habituels utilisés.

Conclusion La version finale de l’échelle de triage propose une mesure objective sur la priorité à accorder aux demandes de service en santé mentale englobant l’ensemble des informations cliniques reconnues et essentielles. Les cliniciens peuvent s’appuyer sur un instrument fiable et valide pour mettre en priorité les demandes de service avant de les placer en liste d’attente. L’utilisation de cet instrument favorise le développement d’une vision commune entre les professionnels et elle assure un traitement équitable et sécuritaire des usagers.

Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development

BACKGROUND

Increasing numbers of adolescents present in adolescent gender identity services, desiring sex reassignment (SR). The aim of this study is to describe the adolescent applicants for legal and medical sex reassignment during the first two years of adolescent gender identity team in Finland, in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development.

METHODS

Structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013.

RESULTS

The number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common.

CONCLUSION

The findings do not fit the commonly accepted image of a gender dysphoric minor. Treatment guidelines need to consider gender dysphoria in minors in the context of severe psychopathology and developmental difficulties.

A brief intervention is sufficient for many adolescents seeking help from low threshold adolescent psychiatric services

Background

There has been a considerable increase in the need for psychiatric services for adolescents. Primary health care practitioners have a major role in detecting, screening and helping these adolescents. An intervention entitled SCREEN is described in this article. The SCREEN intervention was developed to help practitioners to detect and screen adolescent needs, to care for adolescents at the primary health care level and to facilitate the referral of adolescents to secondary care services in collaboration between primary and secondary health care. Secondly, the article presents the background and clinical characteristics of youths seeking help from the SCREEN services, and compares the background factors and clinical characteristics of those patients referred and not referred to secondary care services.

Methods

The SCREEN intervention consisted of 1 to 5 sessions, including assessment by a semi-structured anamnesis interview, the structured Global Assessment Scale, and by a structured priority rating scale, as well as a brief intervention for each adolescent's chosen problem. Parents took part in the assessment in 39% of cases involving girls and 50% involving boys. During 34 months, 2071 adolescents (69% females) entered the intervention and 70% completed it. The mean age was 17.1 years for boys and 17.3 years for girls.

Results

For 69% of adolescents, this was the first contact with psychiatric services. The most common reasons for seeking services were depressive symptoms (31%). Self-harming behaviour had occurred in 25% of girls and 16% of boys. The intervention was sufficient for 37% of those who completed it. Psychosocial functioning improved during the intervention. Factors associated with referral for further treatment were female gender, anxiety as the main complaint, previous psychiatric treatment, self-harming behaviour, a previous need for child welfare services, poor psychosocial functioning and a high score in the priority rating scale.

Conclusions

A brief intervention carried out by a team including professionals from both primary and secondary level services was sufficient for a considerable proportion of adolescents seeking help for their psychiatric problems. Referral practices and counselling in special level services can be standardized. In the future, it will be important to develop and assess psychiatric services for adolescents using randomised controlled trials.

Involuntary commitment and detainment in adolescent psychiatric inpatient care

OBJECTIVE

To evaluate whether adolescents committed to psychiatric inpatient care are the most disturbed, and whether psychosocial factors other than psychiatric symptoms are associated with commitment to and detainment in psychiatric care among adolescents.

MATERIALS AND METHODS

The case histories of 187 13- to 17-year-old adolescents consecutively admitted to the study clinic were scrutinized with the help of a structured data collection form. Psychiatric, demographic and family-related characteristics of those referred involuntarily (n = 93) and voluntarily (n = 94), and those detained involuntarily (n = 42) and treated on a voluntary basis (n = 145) were compared.

RESULTS

Involuntary referral and involuntary detainment were associated with psychotic symptoms, temper tantrums and breaking property, involuntary referral also with violent and hostile behaviours and suicidal ideation and talk. They were not associated to family adversities, previous treatment history or sociodemographic factors. The risk for being committed when presenting with aggressive behaviours was greater in girls.

CONCLUSION

Involuntary referral and detainment in adolescents is associated with symptom severity, and not with aspects of the adolescent's living conditions. This is in agreement with the legislation. Gender bias resulting in girls' greater risk of being involuntarily committed if displaying aggressive behaviours may be an ethical and legal problem.

Priority criteria tool for elective specialist level adolescent psychiatric care predicts treatment received

BACKGROUND

Little validation data has so far been published on scoring systems and the literature on prioritization in psychiatry is especially meagre.

OBJECTIVE

To explore if the priority criteria score for elective specialist level adolescent psychiatric care in Finland is associated with treatment received and whether the association between the priority criteria scores and treatment given is similar among different subgroups.

METHODS

Adolescents currently in treatment contact in three adolescent psychiatric outpatient clinics (n = 450) were rated according to the criteria of the priority rating tool for specialist level adolescent psychiatric care and information about adolescent's age, sex, diagnosis, and treatments was gathered using a structured form.

RESULTS

When sex, age and psychiatric diagnosis were controlled for, the likelihood of receiving specific therapies and medications was significantly associated with the highest priority scores. Except for very frequent individual therapy, there were no differences in the probability of receiving any psychosocial treatment or medication between the sexes. Receiving individual therapy, lengthy treatment contacts and medications were more frequent among older adolescents. The rating tool worked best among adolescents with affective or anxious disorders and worst among those with conduct disorders.

CONCLUSION

The present study indicates that the structured tool used in Finland, originally modified from a Canadian priority rating tool for child and adolescent psychiatry, is able to identify adolescents requiring specified, multiple and lengthy treatments, indicating a need for specialist level services. The scoring system tested is a good candidate for a transparent prioritization tool for European adolescent psychiatric services.