全科医学中的心理健康病案研究(十八)——全科医学中的青少年病人

Sasha Fehily，Leon Piterman，Fiona Judd，Grant Blashki，Hui Yang

Sasha Fehily，Leon Piterman，Fiona Judd，et al.全科医学中的心理健康病案研究(十八)——全科医学中的青少年病人[J].中国全科医学，2013，16(6)：1821-1826.[www.chinagp.net]

对于大多数全科医生来说，当身为父母的人担心自己青少年的孩子有行为问题的时候，总会感到很棘手。全科医生所面临的困难是难以区分青少年的正常行为和心理问题。其实这种挑战不仅仅只有中国才有，世界各国的全科医生也面临同样的挑战[1]。2000年澳大利亚开展了一项《全国心理健康和幸福调查》，该调查显示，儿童和青少年的心理健康问题流行率大约为19%[2]。

1　病史

一位姓刘的女学生，今年16岁，两年前她随父母一起从中国移民到澳大利亚。他们一家人工作非常勤奋，整天从早忙到晚，辛苦地经营一家食品店。父母对她的学业非常地关心，希望她今后能上个好大学，找个好工作。直到3个月前，刘同学还是一名非常出色的学生，在学校成绩拔尖，绝大多数课程都得到A的成绩。

不过，最近3个月以来，刘同学变得越来越具有“破坏性”，而且她的学习成绩直线下降。在家里，她经常跟妈妈争吵，变得非常粗暴无礼，这与她以往的性格相去甚远。上个星期学校校长给她爸爸打电话，询问家里是不是出了什么事。校长的电话让刘同学的父母非常担心，于是他们决定带刘同学来你的诊所看病。

你先跟刘同学的父母交谈了一下，得知这个孩子的一些表现。刘同学的睡眠情况不是很好，她经常很晚才睡觉，深夜里跟朋友煲电话粥，在网上跟朋友聊天，早上不愿意起床去学校。她父母说她穿衣服的风格跟以前都不一样了，而且经常跟学校的一群新朋友混在一起，而一般人都认为这些都是“坏孩子”。

你请刘同学的父母在候诊室里稍候，然后按照惯例，跟刘同学在诊室里单独地谈谈。你询问刘同学一些比较具体的问题，她说自从移居到澳大利亚以后，就一直感到心情很不好。从中国的学校转到澳大利亚的学校，学校是陌生的、周围的人也是陌生的，这让她感到很发憷。在最初的那个阶段，她感到学校没有一个人理她。她说那是自己最困难的阶段，而且那个时候她脸上和后背长了不少“青春痘”，她认为自己很难看，对自己的看法越来越消极。她说自己不喝酒，也没有使用毒品，饮食习惯也没有改变。不过她说最近半年自己的体质量减轻了3 kg。

2　健康检查

你给刘同学做心理状态检查。她看上去很安静、很内向。她坐在那里，眼睛看着下面，不断地搬弄自己的手指。她的情感是忧伤的。她不认为自己有任何妄想，也不认为自己有幻觉。她对时间、地点和人物的定位还是比较清楚的。你给她做躯体健康检查，结果表明她是一个正常的健康女孩，只是在脸颊和背部有比较严重的囊肿性痤疮。生命体征也都正常，其他躯体检查也没有发现不正常的情况。她的体质量是57 kg。你一边检查，一边告诉她检查的结果都是正常的，你这种“实况评述”的做法是安慰她，让她放心地知道自己是正常的。

3　辅助检查

你给她安排了血液检查，结果证实全血计数检查、电解质检查、肝功能检查、尿液检查都是正常的。

4　提问

4.1在给青少年做全面评估的过程中，你应该询问哪些关键的医学方面和社会方面的问题？

4.2你应该给刘同学做哪些鉴别诊断？

4.3如果你考虑给青少年使用抗抑郁药，必须要考虑到哪些关键问题？

4.4在管理青少年心理疾病的时候，应该考虑到哪些与家庭有关的关键问题？

5　解答

5.1解答1：询问关键的医学方面和社会方面的问题在青少年中心理健康障碍的流行率很高，但是很多卫生专业人员经常不能识别出青少年的这些问题。全科医生给青少年看病的过程，实际上是发现他们心理-社会健康问题的绝好机会，全科医生可以对青少年心理问题做出诊断，并可以给青少年提供早期干预的服务。

有一个非常有用的筛查工具，名称为HEADSS，全科医生可以用这个工具来采集青少年的心理-社会病史[3-4]。这个工具的名称是六个敏感的筛查方面的缩写。全科医生在使用这个工具之前，应该先与青少年建立起很融洽的关系[4]。

HEADSS青少年心理-社会筛查工具：

H 家庭情况(Home situation)

·了解青少年的家庭情况是很重要的，可以让全科医生知道青少年病人和谁在一起生活，他们之间相处状态如何。

·有证据表明，与家庭的关系不好和(或)无家可归的情况是青少年心理健康问题的危险因素。

E 教育/就业/经济情况(Education/Employment/Economic situation)

·很有必要掌握青少年病人在学校的行为、他们的学习成绩以及他们的行为和成绩在近期的变化。

·询问青少年病人在家里遇到的压力或者在学校和工作场所受欺负的情况，这可以让全科医生洞察到青少年可能遭遇到的社会紧张性刺激因素。

A 活动(Activities)

·兴趣爱好和活动参与可以预防心理障碍的发展。

·对女性青少年来说，询问饮食情况和身体锻炼情况是非常适合的。同时通过了解饮食和锻炼情况，也能了解青少年病人是否有健康积极的生活方式。

D 毒品/吸烟/酒精(Drugs/Smoking/Alcohol)

·在了解青少年的行为危险性方面，掌握物质使用方面的详细信息，这是非常重要的。需要了解的信息包括使用什么物质、使用的频率是什么、使用物质的社交场景是什么。

S 性活动(Sexuality)

·某些性活动(如性失禁)可以是精神病学诊断的依据。此外，有必要提供性传播疾病的筛查服务和妊娠检查。

S 自杀危险/心理学症状(Suicide risk/Psychological symptoms)

·在给青少年病人看病过程中，自杀危险评估是必须要做的内容。

5.2解答2：青少年心理问题的鉴别诊断青少年最常见的心理健康障碍包括心境障碍、焦虑障碍、物质滥用障碍、行为障碍。2001年世界卫生组织根据国际研究的结果，指出10%～20%的儿童和青少年有一个或多个心理或行为问题[5]。因此，当你遇到刘同学这样近期有行为改变的青少年病人时，必须要保持高度的警惕。

正常青少年：青少年表现出暂时的偏离行为(比如常见的冒险行为和违法行为)，这是正常的。我们知道大多数青少年并没有心理健康问题，不过“问题青少年”中有四分之一需要进行精神病学诊断，并需要进一步的干预治疗。

刘同学近来的行为改变，是家长和学校都能够观察得到的。她不愿意上学、课堂上举止不当、改变穿衣的风格、结交朋友上的变化，都是非常常见的青少年行为变化。不过，刘同学还有睡眠上的问题、心境低落的问题，而且自信心也有变化，那么就很有必要进行下列鉴别诊断。

抑郁：青少年的抑郁不总是表现为典型的抑郁症状，如心境低落、睡眠紊乱、快感缺乏、体质量降低、食欲下降。青少年的主诉更倾向于躯体化症状，或者行为上的改变。在刘同学的案例中，她在表现出很多常见抑郁症状的同时，也表现出一些行为的改变。全科医生应该注意到一个关键点，即她刚从中国移民到澳大利亚，让她面临着很多适应问题，包括对环境、学校、社交网络的适应，在诊断的时候必须要考虑到病人的这个背景。刘同学近来面临的这些生活紧张性刺激，提示全科医生考虑到她出现心境障碍。

物质滥用：年轻人的物质滥用问题，不仅仅物质依赖问题，而更经常是让青少年面临短期内受到伤害的危险。在青少年中，狂饮酒精是非常常见的。在澳大利亚，大约10%的青少年使用安非他明。刘同学的躯体检查和实验室检查都没有发现物质滥用的证据，而且她也否认使用酒精和非法药物。如果发现青少年有物质使用的情况，那么全科医生一定要进一步了解使用物质的种类和方法，以便掌握滥用行为的危险程度。而且，最好进行尿液筛查。

进食障碍：青少年和成人的进食障碍诊断标准是相同的。按照特定的进食障碍诊断要求，病人的临床特征包括自我强迫地饥饿、使用泻药、过度锻炼、固执地追求苗条体形，以及各种与适应不良行为相关的躯体症状和体征。

适应身体形象的变化，这是青少年心理-社会发育过程中要完成的一个重要任务。2011年《澳大利亚年轻人调查》结果显示，三分之一的年轻人担心自己的身体形象。虽然刘同学对自己的外表形象有负面的想法，但她主要是关注自己脸上的“青春痘”。通过询问我们知道刘同学体质量减少了3 kg，不过她否认自己改变饮食习惯。需要注意的是，进食障碍往往与抑郁同时存在，因此很有必要继续观察刘同学的饮食习惯和体质量变化。

精神病：在青春期和成人早期，可以出现各种精神病性障碍。因此，全科医生要保持高度的警惕，以便能够尽早地诊断和管理精神病性障碍。在当下，刘同学没有表现出严重语言杂乱无章的情况，也没有思维和行为的严重混乱。而且，她也否认有负性症状，如妄想和幻觉。

刘同学学习成绩下降、衣着变化、争辩行为，可能与精神病发作的前驱阶段的症状是相同的。精神病前驱阶段通常出现在精神病症状发作前一年。前驱阶段的症状往往是很不特异的，如注意力降低、社交回避、古怪行为、忽略个人卫生、学业失败。因为这些前驱行为很不特异，所以很难做出精神病的诊断。不过，全科医生在今后对刘同学的随诊过程中，要一直保持警惕。

5.3解答3：青少年使用抗抑郁药应该注意什么最重要的一点，是在可能的情况下，最好使用非药物治疗方法。全科医生应该识别出可能影响青少年的各种环境因素，并采取有针对性的措施。认知行为疗法和人际关系疗法是对轻度和中度心境障碍的青少年病人的一线管理措施。

对4～6次心理学治疗无效的病人以及严重抑郁的病人，可以考虑采用药物治疗措施。药物治疗应该是综合性管理计划的一部分，在用药的同时，必须严密监测任何可能出现的副作用，并对副作用进行恰当的管理。自杀想法和自杀行为是可能出现的副作用。在开抗抑郁药处方之前，必须要对青少年病人及其家长/照顾者进行教育，告诉他们识别自杀想法和自杀行为的步骤[6]。

在澳大利亚，选择性5-羟色胺再摄取抑制剂(SSRIs)是最主要的抑郁治疗药物。对于青少年病人，一线药物是氟西汀(商品名为百忧解)。澳大利亚药物副作用顾问委员会提供的指南，是全科医生给青少年病人开选择性5-羟色胺再摄取抑制剂的临床指南。该指南要求全科医生要采取适宜的副作用监测措施，并在整个药物治疗过程中，持续地评估病人的心理状况和一般疗效。药物管理的关键时间是开始用药或改变剂量的24 h内，以及用药的7～10 d内[7]。

如果选择性5-羟色胺再摄取抑制剂无效，或者病人无法耐受药物副作用，全科医生应该先寻求专家的建议，然后再决定改换其他的抗抑郁药。应该避免让青少年病人使用三环类抗抑郁药(TACs)，因为这类药会在服药过量时导致心脏毒性反应，并可能导致死亡。此外，目前的文献表明，三环类抗抑郁药对青少年抑郁的疗效不可靠。

5.4解答4：与家庭有关的关键问题保密问题：对使用全科医学服务的青少年来说，保守他们的秘密是非常重要的服务内容。很多青少年之所以不愿意寻求医生的治疗服务，是害怕医生泄漏他们的隐私。当你把刘同学的父母请出诊室，并与刘同学单独谈话的时候，你一定要向这位青少年病人清楚地说明你为她保守秘密的原则，并且要核实她是不是明白了你的保密承诺。全科医生必须按照承诺去做；只有在明确的例外情况下，并且同时也得到青少年病人容许的情况下，才能向其他人(包括最亲近的人)提供涉及病人的信息；这些例外情况是指青少年可能伤害自己或别人的情况[8]。鉴于抑郁病人中自我伤害的比例比较高，所以说明特定情况下向别人提供信息是非常重要的。之所以要这样做，是为了保护青少年病人的安全。

在需要刘同学的父母参与的情况下，要使用一些技术来确保刘同学本人仍然有自己的授权能力。比如，你可以让刘同学选择怎样把信息告诉别人，是让全科医生去跟她父母讲，还是在全科医生在场的情况下她自己跟父母讲[3]。

家庭参与：尽管父母可以在青少年心理健康问题的康复过程中发挥很明显的作用，不过青少年本人往往不希望父母介入治疗过程。但是，在建议家庭参与之前，全科医生一定要评估这个特定家庭的参与会不会反而妨碍了青少年的治疗。通过对家庭的评估，全科医生能够知道父母应该扮演什么角色。

在刘同学的案例中，家庭参与管理计划可能会对青少年心理健康状况产生积极的作用。全科医生应该向青少年病人做出解释，把情况告诉她父母可以让他们理解她面临的困难，从而得到父母的支持。为了更好地管理刘同学的案例，你还应该注意到影响家庭的其他因素，比如学校和刘同学的同伴。在青少年病人采用药物治疗的情况下，家庭参与显得更加重要，因为家庭成员可以观察到严重的药物副作用或心理状态的急性变化。

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

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

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

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

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

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

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

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

·WorldGeneralPractice/FamilyMedicine·

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

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

1　History

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

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

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

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

2　Examination

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

3　Investigations

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

4　Questions

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

4.2What are the differential diagnoses for Lu?

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

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

5　Answers

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

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

HEEADSS:

H-Home situation

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

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

E-Education/Employment/Economic situation

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

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

A-Activities

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

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

D-Drugs/Smoking/Alcohol

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

S-Sexuality

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

S-Suicide risk/Psychological symptoms

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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