Challenges in general practice in consultations with youths Seminar in youth medicine for 9th...

Challenges in general practice in consultations

with youths

Seminar in youth medicine for 9th semester medical students

by Ole Rikard Haavet

How are e

the relation?

?

Case study – part I

A 15 year-old boy arrives for a consultation at

the local doctor’s office. The boy’s mother made

the appointment earlier that same day: the boy

is often sick and during the past two weeks he

has been increasingly dizzy and pale. His

records show 14 consultations during the last

two years; 5 from emergency room attendings

and 9 from visits to your office. Diagnoses

included: muscle pain, eczema, 6 streptococcal

throat infections and a serious pneumonia.

Biopsychosocial model

Triggering factorsBiological PsychosocialInfections Dramatic incidentsTrauma Chronic difficulties

First outbreak of ill-health

Subsequent morbidity

Predisposingfactors

ChildrenBiological(sex, age, heredity)PsychologicalFamilyParent-relatedChildhoodSurroundingsPhysical healthMental stressPlace of residence

Moderating factorsPreventative measuresInner spirit (Løvetannfaktorer)Treatment

General practitioner

Most common disease groups

(SN 2000)

• 39% respiratory tract infections, allergies and asthma

• 22% headaches and migraines • 10-20% anxiety and depression • 12% muscle-skeletal problems

We need dynamical

ways of thinking

concerning adolescents

Common consultations: What is normal – what is healthy?

• Body appearance (nose,

ears, thin/thick, breasts

development and size,

extern genitalia etc.)

• Relation problems

(family/friends, lovers

etc.)

• School problems

What is normal – what is healthy?

• Problems in job

• Healthy food/eating

disorders

• Sport problems

• Drug addiction/

dope/smoking

• Sexuality

How often do young people with health problems seek help?

Norway:• evidence suggests that adolescents visit a general

practitioner approx. 3.3 times a year on average • 20 % of the total populations 15 000 000

consultations• 77% of all school aged children have consulted a

general practitioner during the last 12 months (psychologists 3%, for comparison). (SSB 2002)

Main constituents• Statistisk sentralbyrå’s (SSB) study on standard of

living showed that approx. 1 in 10 – corresponding to 90 000 young people – are the main constituents of consultations with a general practitioner.

• SSB defines these main constituents as those who have more than 5 consultations yearly, meaning one consultation every other month.

• The silent numbers? – Are there, for example, depressed youths who do not ask for help?

• What is the physicians reaction to repeated consultations by youths?

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20

30

40

50

60

70

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The Oslo Youth Survey. Health services used last 12 mounth in % of all answered; >1(red), >3(blue) times and sex.





Predisposingfactors



Negative life events with impact on health(Coddington, Youth-Hubro)

• pressure to achieve• longstanding negative daily

surroundings• separation/divorce of parents• death of a close family member• bullying• violence• sexual violation

Adolescents’ health treats seems to be some of the same

everywhere

Most common diseases - and diseases related to negative life experiences

Most common causes of encounter:

• 39% respiratory tract infections, allergies and asthma

• 22% headaches and migraines

• 10-20% anxiety and depression

• 12% muscle-skeletal problems

• Eczema, skin problems and asthma (SSB et

al.)

• Respiratory tract infections (SSB et al.)

• Streptococcal throat infections (Meyer)

• Anxiety

• Depression

• Fibromyalgia and arthritis (Vandvik)

Violence epidemiology

• New studies indicate that a substantial number

of youths have been exposed to violence (boys

29%, girls16% last year).• Girls are more vulnerable to violent acts from

adults than are boys• Boys are more vulnerable to violent acts

committed by other youths• This strongly predisposes for anxiety and

depression for those affected - for some the so-called Posttraumatic stress disorder (PTSD)

15- and 16-year old adolescents’ (n=7343) different negative life experiences correlated to health care seeking behaviour in real numbers (SHS = School Health Clinic, YHC = Youth Health Clinic, FP = Family Physician, ES = Emergency Service, POP = Psychologist or Psychiatrist)

0

500

1000

1500

2000

2500

3000

Pressure tosucceed

Parentsseparated

Death nearperson

Bullying Violence Sexual violation

SHSYHCFPESPOP

15-20% of all youths struggle with psychological problems daily (tidsskr 25/2001)

Treatment possibilities of depression

• 15-20% of all youths struggle with psychological

and somatic problems daily

• Of those HSCL-10 positive for anxiety and

depression (unpublished data)..

– 66.5% consult a general practitioner

– 7.9% consult a psychologist/psychiatrist

– 1 % are admitted to the hospital

– approx. 40-70 % represent a silent number ?

Posttraumatic stress disorder

2 - 7 % of school children (18-63000. School studies)

• importunate flashbacks of events (e.g.. disturbing thoughts, sensations, nightmares, strong reactions to similar situations).

• avoidance of stimuli associated with the event (e.g.. not wanting to remember, discuss or visit the place of occurrence, as well as avoiding other individuals involved, social isolation).

• lasting psychological affection (e.g. disrupted sleep, aggression, difficulties in concentrating, abnormal alertness).

Depression results in compromised immunity

Studies show that in cases of depression the right

frontal lobe of the cortex becomes dominant.

Corresponding serious life events seem to result in a

weakened immune response. Cellular defense

dominates at the expense of humoral. Additionally,

cellular defense mechanisms are weakened. T-cell

lymph proliferation and killer cells (Natural Killer cells)

seem to be reduced by up to 40%. (Liang, S-W 1997).

Case study - part II

The boy managed to produce work well above average at

school up until around Easter a year and a half ago, after

which his schoolwork has declined substantially. His parents

are not aware of any mobbing. They, themselves have been

very busy lately. i The family has almost no time together

during the week. Nor do they eat together. The boy has quit

his soccer team and sits, for the most part, in front of the

computer or the television. His grandfather, which he

describes as his only good friend, died during the Christmas

holiday nearly two years ago.

What is the boys problem?

3 minutes of summing with your neighbour

Case study part III first possibility

During an extensive consultation the doctor gets

the impression that the patient has had a high score

indicative of depression over many years. This,

however, becomes overshadowed by a clinical

finding of an enlarged liver and spleen. Blood tests

show a low blood percent. A blood smear gives the

impression of many immature cells. The patient is

therefore admitted to the hospital.





Predisposingfactors



What can we learn from survivors?

Three main characteristics of survivors

(Kauai-study)

• sought and found emotional support with at least one adult outside of the family

• had at least one good friend• participated in an extracurricular club

Temperamentthat

evokesgood will

Group 1

Utilizationof

own resources

Group 2

Reflectingcompetenceand a goodself-esteem

Group 3

Nurturingtrust

Door opener tothe future

Group 4

Open forpossiblities

betweenphases of life

Group 5

Five groupsof

protectivefactors

Temperamentthat

evokesgood will

Group 1

Utilizationof

own resources

Group 2

Reflectingcompetenceand a goodself-esteem

Group 3

Nurturingtrust

Door opener tothe future

Group 4

Open forpossiblities

betweenphases of life

Group 5

Five groupsof

protectivefactors

The teenagers welcome health promotion in general practice consultations (Walker, 2002, Murdoch, 1996)

How to facilitate the admission to the GPs office? {Kisker, 1996, Jacobson, 2001, Akinbami, 2003}

The teenagers report:• lack of knowledge of the services available

from primary care• a feeling of little respect for teenage health

concerns• poor communication skills• inaccurate information about confidentiality

policies• lack of resources • logistical barriers

How to facilitate the admission to GPs in office?

Logistic:• Easy to get the first appointment• Training god communications skills both

in the staff and among the doctors

• Consultations free of charge

Possible strategies of the GP

• Listen, listen and listen ... to the young person• Follow up, and when needed, suggest new

consultations at regular intervals• Participate in interdisciplinary teamwork• Write doctors certificate to teachers, schools

i.e. in adolescents with different needs, e.g.depression

• Adequate treatment

Diagnosis and treatment of depression

• Supplies for the diagnoses of anxiety and depression in youths

• Hopkins Symptom Checklist (HSCL 10)• Montgomery and Åsbergs Depression

Rating Scale (MADRS)• Cognitive therapy with homework in 6 - 8

consultations • Therapy with antidepressive medication if

needed

Diagnosis: depression and anxietyHopkins Symptom Checklist (HSCL-10)

Last two weeks Not Litle Much Very much

Sudden fear without any reason

Feeling frightened or anxious

Tiredness or dizziness

Feeling tense or jittery

Easily find fault with yourself

Sleep difficulties

Depressed, saddened

Feelings of worthlessness, of little importance

Feeling that everything is difficult

Feelings of hopelessness regarding the future

Case study part IIIsecond possibility

During an extensive consultation the doctor gets the

impression that the boy is depressed. He is assessed

using a test for depression, which results in a high

score. The boy is prescribed Fontex, a medication for

depression. Additionally, he comes to weekly

consultations following guidelines for cognitive

therapy. An attest is written to the school. After a

few months time, he begins to renew contact with

old friends and focuses his energy toward school and

other activities.

The GPs’ role in society?

• Make it more easy to take care of the health

• Generally make visible unhealthy environmental conditions?

• Trace schools and classes with high prevalence of health problems (bullying, violence etc.)?

QuickTime™ and aGIF decompressor

are needed to see this p icture.

Adolescents’ health problems seems to

be some of the same everywhere

Conclusions/challenges

• Adolescents in Norway are amongst the healthiest in the world. Many manage to do well, despite bad odds. Good health is however quite unevenly distributed.

• There is most probably a societal health problem that affects a substantial and increasingly large group of youth (> 90 000).

• As it stands today, help often comes too late.

• Children and adolescents are the future: It is therefore important to view the problem in an ecological perspective.

Challenges in general practice in consultations with youths Seminar in youth medicine for 9th...

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