Challenges in general practice in consultations with youths

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Challenges in general practice in consultations
with youths

• Seminar in youth medicine for 9th semester
  medical students
• by Ole Rikard Haavet

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How are ethe relation??
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Case study part I

• A 15 year-old boy arrives for a consultation at
  the local doctors office. The boys 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.

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Biopsychosocial model
Triggering factors Biological Psychosocial Infecti
ons Dramatic incidents Trauma Chronic difficulties
Predisposing factors Children Biological (sex,
age, heredity) Psychological Family Parent-related
Childhood Surroundings Physical health Mental
stress Place of residence
General practitioner
First outbreak of ill-health
Subsequent morbidity
Moderating factors Preventative measures Inner
spirit (Løvetannfaktorer) Treatment
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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

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We need dynamical ways of thinking concerning
adolescents
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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

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What is normal what is healthy?
Problems in job Healthy food/eating
disorders Sport problems Drug addiction/
dope/smoking Sexuality
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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)

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Main constituents

• Statistisk sentralbyrås (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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The Oslo Youth Survey. Health services used last
12 mounth in of all answered gt1(red),
gt3(blue) times and sex.
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Biopsychosocial model
Triggering factors Biological Psychosocial Infecti
ons Dramatic incidents Trauma Chronic difficulties
Predisposing factors Children Biological (sex,
age, heredity) Psychological Family Parent-related
Childhood Surroundings Physical health Mental
stress Place of residence
First outbreak of ill-health
Subsequent morbidity
Moderating factors Preventative measures Inner
spirit (Løvetannfaktorer) Treatment
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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

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Adolescents health treats seems to be some of
the same everywhere
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Most common diseases - and diseases related to
negative life experiences
Eczema, skin problems and asthma (SSB et al.)
Respiratory tract infections (SSB et al.)
Streptococcal throat infections (Meyer)
Anxiety Depression Fibromyalgia and arthritis
(Vandvik)

• 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

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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)

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15- and 16-year old adolescents (n7343)
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)
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15-20 of all youths struggle with psychological
problems daily (tidsskr 25/2001)
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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 ?

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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).

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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).

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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.

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What is the boys problem?3 minutes of summing
with your neighbour
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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.

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Biopsychosocial model
Triggering factors Biological Psychosocial Infecti
ons Dramatic incidents Trauma Chronic
difficulties
Predisposing factors Children Biological (sex,
age, heredity) Psychological Family Parent-related
Childhood Surroundings Physical health Mental
stress Place of residence
First outbreak of ill-health
Subsequent morbidity
Moderating factors Preventative measures Inner
spirit (Løvetannfaktorer) Treatment
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What can we learn from survivors?
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Three main characteristics of survivors(Kauai-stu
dy)

• 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

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(No Transcript)
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The teenagers welcome health promotion in general
practice consultations (Walker, 2002, Murdoch,
1996)
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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

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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

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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

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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

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

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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.)?

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Adolescents health problems seems to be some of
the same everywhere
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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 (gt 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.