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Uh I did a lot, Scavo Proximo. I'm Paul Wilkinson. I'm a child adolescent psychiatrist from Cambridge. And I'm going to give you a talk about depression in Children and adolescents. There'll be a chance for questions at the end. So I just want to start off the lecture with a health warning. It can be really upsetting to hear about depression and self harm. It's important you learn about it but sometimes it can be close to home. So if after this lecture, you're worried about yourself, please do speak to somebody you trust such as friends, family, a tutoring or university or a doctor. And if this talk makes you worried about somebody else, please speak to them and advise them to get help. So I'm going to cover the following things in my talk. I'll start by explaining what depression is. I'll then talk about how we assess it in Children and adolescents. I then talk about the epidemiology, how common it is than the etiology. What causes depression, a section on treatment and finally prognosis, what the long term outcome is for young people who do have depression. So start off what is depression. It's important to say that depression is more than feeling sad. It's a real illness that can be severe and disabling. It's also quite common and the way we define whether somebody has depression or not, it's based on two main things. It's having a certain set of symptoms and certain number of those symptoms. And they also need to be functionally impaired. Those symptoms need to be making a difference to their life and making it hard for them to live normally. So, what kind of symptoms are they? Well, we see symptoms in four main areas. We see emotional symptoms in particular, feeling sad, but also irritability is quite a common symptom. Um We see depressive thoughts, people that get negative thinking, they feel negative about themselves. The world, the future depression has physiological symptoms such as poor sleep, poor appetite, tiredness, depression affects people's behavior. They go out less, they stop saying their friends, um sometimes they have suicidal acts. It's important to say that these things go together in a vicious circle and they interact and they make each other worse. So if you can imagine if you feel sad that's going to lead to negative thoughts, which makes you feel more sad. If you feel sad and you feel tired as a part of the depression, that's going to make you think more negatively. But also mean, you're less likely to go out and see your friends. And if you're not going out to see your friends that's going to cause sadness. So these things spiral and magnify when somebody gets depressed. So which of the precise symptoms? Well, um depression and other mounted illnesses, in fact that all illnesses are defined by the World Health Organization and they have criteria about what cancers, the illnesses and they've done this for depression. It's been recently revised. The manual is called I C D 11. And what I see D says is that to be depressed, somebody needs to have at least five symptoms from this list. And at least one of those symptoms must be a real core symptom of depression. If you don't have one of those, then it isn't depression and those core symptoms are, I guess the obvious one is depressed mood, feeling sad most of the time, most days or something called anhedonia, which means that people have reduced interest, they don't enjoy things, they have reduced motivation. Um Again, normally, if people are depressed, they do have the depressed mood. But you can get people who don't identify that the other symptoms are biological symptoms such as reduced concentration, guilt or low self esteem, hopelessness, suicidal ideation. And then the more biological one's sleep is affected. Normally it goes down but it can go up appetite and weight of affected, they can go down but they sometimes go up. Next one is people's movements change, they can be really agitated and fidgety and twitchy or the opposite. There slowed down, which is what we call psychomotor retardation. And then the last one is tiredness, fatigue, reduced energy. So, to be depressed, people need to have at least five of those and one of them must be depressed mood or anhedonia. That's the symptoms. That's not all you need the diagnosis. Now, the other thing that's important is people do need to be functionally impaired if you just have a set of symptoms and it doesn't actually cause a problem in your life. That's not really an illness. So, if I cough, mm, that's a symptom. It doesn't mean a milk. It's just a cough. How if, however, that cough is accompanied by a fever and I feel really tired and exhausted and I can't speak full sentences because they've got an asthma exacerbation that would be an illness. So, when people are depressed, they get those symptoms, but they also impaired. And the main areas we need to ask about here at school. So if somebody's depressed, they'll find it harder to concentrate at school, they find it harder to do their work. It will affect how they socialize at school. It also often affects friendships. If people are depressed and can't be bothered to go out, they don't see their friends and it can affect things in the family. Um, young people may not want to mix with their family. They want to stay in their room and feel because they feel miserable. Um, they might get more bad tempered and have more arguments and there needs to be a problem, at least one of those areas. So when we do the assessments, we need to ask about this. The other things that you need for it to be depression is firstly, it can't be just down to a medical condition or medication. Some medical conditions do cause what looks like depression, but it isn't depression, it's the medical problem and you need to treat that. So things like hypothyroidism, some autoimmune disorders, severe anemia can give the same picture. And the other thing that's important to say is bereavement is a real thing. People are affected when they lose somebody close to them. Um, and they can have a whole list of symptoms which look like the psa list of symptoms for depression. However, it's not right to medical is that if someone's got bereavement treated as bereavement, don't say it's depression, that's an illness and it's a different thing that needs a different approach. Yeah. Um, now you may think why have we got five symptoms to make depression? Why is it not four symptoms or six symptoms? And you may think, hey, this, it must be some magic number. There must be something about five symptoms that makes these really clever people choose it as a cut off. Actually, that's not the case. It's very arbitrary. There's nothing magic about five. If you have five symptoms, that's a bit worse than having four and not as bad as having six. Um And in fact, if you look at the relationship between number of symptoms and functional impairment as the number of symptoms go up. If you do this, if you kind of survey thousands of people, as people have more symptoms, they have more functional impairment, but it just goes up as a straight line. There isn't a big step that says five is particularly bad. Um I suppose what we do know is that we have this criterion, we have these rules to make depression and we know that if people have that diagnosis, we know what it means and what treatments work because they go into studies. So that's depression had to be assess it. Um While we take a full psychiatric history, um as we do with any other mental illness, we ask people about their symptoms, their functional status, their family history, their background history. It's really important when we take any psychiatric history, but particularly when we suspect depression that we ask about people suicidal thoughts and self harm as these depression is a great risk for those. And it's important we know about them and do something about it. As we're seeing Children or teenagers, they, if they live with their family, we do need to see them with their parents because the parents will have noticed things that the young person may not tell us. Um or it may be that they actually know more about the background history with which the kids don't know about and so only the parents can tell us that, but it's always important to see the teenager on their own. If possible, there's certain things they'll tell you that are really important, but they won't tell you if they're parents are there. It might be. But I think the main reason why they won't do is they just don't want to worry their parents. The thing about depression is it lies to you, it tells you you're not worth much. It tells you your parents don't care and they shouldn't be bothered about you. So you want them to know how old you are. But sometimes it may be that the parents are actually maltreating the teenager and they find it very hard to say that in front of their parents. So always given the chance to speak alone if you can do other things to consider um in the assessment. Now, the first thing is to say is a lot of young people who have depression don't go to the doctor and say, hello doctor, I have depression. Can you treat me? They can present with a whole range of things such as anxiety, irritability, social withdrawal, doing badly at school work. And our job as a doctor is to take a history and work out what's causing those problems. And it may be an anxiety disorder, but it may well be depression or it may be both. In fact, it's really important even if you think somebody has depression to check about other psychiatric disorders because 50 to 80% of teenagers with depression do have another psychiatric problem. The most common or anxiety disorders, other important ones are obsessive compulsive disorder and behavior disorders. So that's the assessment. So, epidemiology, how common is depression? I'm it's quite hard to do good studies because they depend on asking the right people. But most of the estimates suggest that over a six month period, around 6% of teenagers. So in other words, kind of 13 and upwards have depression in around 2% of teenagers have got severe depression. So that's quite a lot. So if there's a class of 30 people, there's going to be one or two people with depression in that class. If you have a school year of 100 there'll be to be severe depression. The prevalence goes up through adolescence. Um and probably by the end of adolescence, by the time people hit 18, around 15% have had depression, that's a lot of people. Um It's the depression is certainly a disorder where there's a big gender difference. So it's much more common in girls than boys in adolescents ratio of about 2 to 1. Um It's probably more common in boys before adolescence, there's different risk factors that drive it in different age groups. Um Key thing is that puberty is a really big thing that's important for depression, that depression is much more common in people after puberty than people before puberty, which is different to disorders like anxiety, which you see at all ages. So that's how common it is. So it's common disorder, a couple of kids in each class. Next one. What causes depression? Now in psychiatry, it's always important that we think about the physical, the psychological and the social factors that should lead to a disorder. And I hope this has already been covered in some of the earlier lectures. Um We need to ask about all these and we need to think about them. So what are the risks are physical? First, genetics is very important, probably depression's 45% ear edita ble. So if there is a family history of depression and the kids have inherited their parents' genes that does increase the risk. Um It's important to say that having depressed parents doesn't make teenagers depressed just because of the genes, actually living with depressed parents has an effect in terms of it being they may have struggled with parenting, they may have passed on negative thinking stars because of the way they talk. So I need to ask about family history, physical illnesses, another big risk for depression and maybe direct effects of the illness. So if somebody has something like epilepsy, which is a brain disorder affects how the brain synapses, talk to each other, that's also going to affect other things in the brain such as depression. So we know that neurological illnesses do have a significant risk of mental illness, but it may not be the direct effects like that. Maybe as a life event if you, the young person has cancer and they're in hospital for a year and they miss out on going to school, they miss out on seeing their friends actually, that it's that in itself that can lead to the depression, even if the cancer is better. Another important things, major, major injuries, if somebody had a big injury and they can't live the life as they could before, that's difficult psychological factors. Next. And this is really about people's style of coping about the way they think about things. We know that people who've got a low self esteem naturally are more likely to get depressed. We know that certain personalities make people more likely to get depression. So first one is unstable, affect people's whose mood go up and down a lot. People are anxious as an anxious personality and people who have an obsessional personality. But the next one is social risk factors. Um So acute life events, things that happened with a big risk for depression. Again, when I see teenagers of the depression, most of them have had something really bad happened to them just before they got depressed. Um In particular, we know that loss events where somebody has lost something or lost, somebody are particularly prone to lead to depression more than things like anxiety. And that may be bereavement, um losing a person, it may be a friend leaving school at the end of a romantic relationship. Um having to move and be a refugee because of illegal invasions in your country and you lose your old way of life. These things are really difficult to deal with and they lead to, they can lead to depression, but it's not just these acute events, it's also chronic long term difficulties. People have got long term problems with their family, with their friends, with bullying, with behavior problems with A D H D. All of these long term problems increase the risk of being depression. And when we often see in somebody is as long term risk factors that make them vulnerable and then a bad thing happens and that bad thing is what leads to depression. Now, when taking a history of social events, we shouldn't just think about risk factors. We should also think about the protective factors because we know that positive social experiences can be productive. A really good best friend and ex relationship with their mum. These are all really positive things and help can help people not to get ill, but can also be things that you make the most of in use when you try to get somebody better. So that's etiology. Next, going to talk about how we treat depression. Um You may recognize this slide from earlier. I hope you do when we think about treatment, we need to think about physical treatments, social treatments and psychological treatments and think in all three areas. The reason why we always think about etiology in these same three areas is actually we need to think about what's led to the depression and then do what we can to treat it. And I always start with social treatment cause this is something we need to think about for everybody. We need to look at what social factors are causing depression and trying to treat them. So if somebody's depressed because they're being badly bullied at school, do you think giving them a tablet make them feel better? But of course, it's not what you've got to do is try and work and stop the bullying. And that may mean speaking to school and getting school to stop it because it's a psychiatrist can't stop it if somebody's being abused by their parents again, given them a tablet won't make them better. Um It's about stopping that abuse. Um Something that we commonly see with depression is that teenagers find they can't concentrate their illness, they then can't concentrate at school and their school grades go down and teachers respond by saying that's a lazy child. They need to work harder and they tell them off, they give them a hard time. Do you think that helps you if you're depressed? No, it doesn't. So the key thing to do is to speak to school if the child agrees and say, look, this child's depressed, they're unwell, they're struggling to concentrate. Just keep the pressure off for a bit until we get them better. Makes a big difference. So look at the social environment, look at what you can do to improve it. Some things you can't change, but look at changing what you can. So next psychological treatment, talking therapy is a big mainstay of depression for Children and young people. And normally treatment guidelines suggest that we should start with talking therapy before giving medication. And there's lots of different ways you can do talking therapy and lots of different levels. So simple counseling, giving somebody where the young person can go and talk about their problems and feel supported and the person sympathetic can make a difference. Sometimes we need more specific talking therapies, which are more expensive but works better than just counselling. And the main ones are cognitive behavioral therapy where you look at people's thoughts and what they do when they get depressed and look at ways to help them to have more positive thoughts and do more positive activities. And the other therapy with a good evidence based for depression is interpersonal psychotherapy where you look at people's interpersonal relationships and have a link with the depression because we know that if things go wrong in your relationships, that can make you feel sad if you feel sad, that can also affect your relationships because you don't go out as much. So you look at helping young people to understand those links and trying to improve those relationships because that should hopefully improve the symptoms. Sometimes when depression is caused by family problems, family therapy is very helpful and you work with the family and try and improve those problems. However, on its own, it doesn't really work. You do need to give individual treatment as well. So it's really just an add on therapy. So physical treatment next, before we even go down the route of tablets, it's important that we advise people to have a good diet to exercise, to sleep properly because those things can make a very big difference to depression as with any other mental illness. But sometimes we want to use antidepressants to, as I said, would normally try talking therapy first. So which antidepressants, the only class of antidepressants with evidence for effectiveness against adolescent depression, a selective serotonin reuptake inhibitors. Um The one of the best evidence is FLUoxetine also known as PROzac. And there is very good evidence that FLUoxetine is better than placebo for depression. For example, in the biggest friend demised controlled trial called the Tad study. 61% of teenagers for depression given just FLUoxetine got better in 12 weeks as opposed 2035% with placebo. So a big difference. However, 61% isn't great. Okay. That means 39% are getting better, which is why you need to do other things as well. Those numbers aren't as impressive for other drugs, sertraline and esque, it'll a prom certainly they're better than placebo, but not by much. And you may have heard of lots of other antidepressants they get used in adult depression like Matassa pine and Venlafaxine. Um, tricyclics. The evidence suggests they don't work for adolescent depression. So, why don't we give antidepressants to everybody? Um, well, because I guess they cause side effects. So why give somebody a treatment that causes side effects if you can get them better without tablets. The side effects are usually mild and they usually wear off after a couple of weeks. So it's really important to warn people about this and say, look, you want these tablets, they won't work for a couple of weeks, but you may get side effects the first few weeks. So you might feel worse before you feel better. The most common side effects are physical ones such as headaches, stomach aches, nausea, tiredness. They can also cause psychiatric side effects. They can make people more agitated or more anxious, which may kind of feel a bit strange the patient because you give them this drug that you said will help their depression and their anxiety because they're very good drugs against anxiety. Yet they actually get more anxious, not better warn them about this and say the anxiety may get worse, but it should get better event after a few weeks, the other side effect we really worry about. And this is one reason why we don't use antidepressants. First line normally is that they can cause teenagers and young adults to have thoughts of wanting to hurt themselves or other people. It's a very real side effect that I've seen quite a few times and it's quite dramatic. Maybe 1% of people given antidepressants, but it's there and you do need to warn patient's in their families about it because if they don't want to risk this side effect, then they shouldn't have antidepressants. So what do you do? In reality? We kind of, I've talked about social, psychological and physical treatments. It's not a choice of one or the other. It's actually thinking about what works in combination, depends on what the family want, it depends what's available. Um Always we used to, we think about social intervention, we always think about what we can change and what we can help the family to change in their environment. Often you psychological therapy at some level, maybe counseling, maybe CBT or I PT. And we sometimes use antidepressants. And one of the things that does happen certainly happens in the UK is that there isn't enough psychological therapy available, which is a shame. And we kind of do get people in the situation where they get given a choice. You can either have CBT in one year's time or antidepressants next week. Um Most people might say I want CBT next week, but that's not an option. So sometimes antidepressants, are you simply because of the lack of availability of talking therapy. Um So it's important with these options rather than just decide yourself as a doctor, what you should give is talk to the patient and their family about the different treatments they could have and the benefits how they could help but also the side effects. But it's important in this to discuss the availability in the waiting list so they can make an informed decision. So, summary of this section on treatment, we need to think about social treatments, improving the social environment. We need to think about psychological treatment and this could just be low level counseling and support. It could be a specific therapy and we need to think about physical treatments, looking after the body and possibly antidepressants, but consider all three. So the last section is about prognosis. What happens in the long run? Too young people with depression? So what we find is with good treatment at six months, about 60% are much better, which is great for them. 20% are a bit better, which is quite good, but we want better. We do find 20% haven't changed or have got worse. And this is something we see in lots of studies, there is this hard core group. It's very hard to treat. The other thing we sometimes see is we may get the depression better but they still have another mental illness which was there in the first place like anxiety or OCD. So we need to watch out for that and don't just focus on treating the depression. Um, as I've said, the majority get better. A lot of people who get better, get depressed again and around 60% of teenagers have got depressed again by the age of 17. And even if you don't get a recurrence when you're a teenager, a lot better recurrence as an adult. So it's really important to warn people about this and be realistic because really if they get depressed again, you want them to be able to recognize it and come for treatment quickly because they're more likely to get better if they get that. So what makes people more likely to be in this group with a poor outcome? Um, not surprisingly, the biggest risk factor is having more severe depression in the first place and having higher levels of symptoms. Um because as we find with pretty much any illness, the more, well, you are, the harder it is to get better are the things that are shown to be risk factors. And multiple studies are suicidal thoughts again, suggests a more severe group. But even if you control for severity, suicidal, suicidality is a risk obsessive compulsive disorder. We've done a couple of studies showing that there's something about people with OCD that means it's harder to treat their depression. And then the last area is ongoing social stress. If people continue to have difficult life events, they're more likely to stay depressed, which maybe isn't surprising. Um, suicide attempts want to talk about next because that, as I said earlier on, depression is a strong risk factor for suicide and it's something we need to watch out for. We need to ask our patient's about it and work with them and their families to reduce the risk. So what increases the risk of suicide attempts who do need to be particularly worried about? Well, firstly, it's not surprisingly if people have made suicide attempts in the past or have had suicidal thoughts, they're more like to make a suicide attempt later because the past does predict the future in most things. But it's important to say it's not just suicide attempts themselves that increase the risk of further suicide attempts. A couple of studies know now showing that non suicidal self injury also increases the risk of suicide attempts. So it's wrong to think if somebody cuts themselves, oh, they're just cutting themselves. It is a risk that things could get worse. We also know that family problems make people more likely to attempt suicide. On the converse of that. If people have good family support, they're much less likely to attempt suicide. So it's not surprising if there's family problems makes it worse. So I'm going to finish with my conclusions about depression in Children and adolescents. I want to just remind you of the health warning. If you found this difficult. Please do speak to somebody, if you're worried about somebody else, please speak to them about it and advise them to get help. My conclusions are the adolescent depression is an important and relatively common illness. Um Therefore, we need to think about it with teenagers, with problems and ask about it because often we won't know about it unless we ask the right questions. And when treatment, we need to consider all areas, social, psychological and biological. That is the end of my talk and Slava Ukrainy and over to you for any questions you may have. So for the best thing to do, if you've got a question is put your hand up using the reactions bit uh Good to see a lot more people here. Assad. Yes. Before I ask my question, I have a question you do. In the beginning of the lecture, you said a Latin phrase. What was the meaning of it? What phrase uh Latin phrase in the Ukrainian phrase? I said uh which means hello and welcome to. Uh That's okay. Okay regarding uh one of the uh symptoms of the signs, you said like at least five uh behavior pattern should be shown uh to confirm the diagnosis. Now, I don't know uh like uh as not, I'm a Sigmund Sigmund Freud as well. I'm not that good itself observed. But looking back to my own times when I would say that if I would, I was clinical depressed, I saw a change in the appetite, whether sometimes, uh, I eat a lot or I don't eat at all. It's like, uh, trying to maintain it but not in a manner of that. You have a disinterested in eating or you eat too much, isn't, that could be one of the signs as well. Yes. Yes. It's on the list. So, it's on the list of the possible 10 symptoms that count towards depression. That one of those symptoms is your appetite changes. Sorry, I just ended up dropping a whole load of things. Hold on a second. Uh Okay. Sorry. Yes. So changing appetite is a big thing. Now, sometimes the appetite gets so low that people lose weight. Sometimes as I think you described in yourself, your appetite goes down and you don't enjoy food but you eat because you know, you should do. Um So yeah, the majority of teenagers and adults with depression do have their appetite affected um increased appetite and error, but we do some promising them. Got a question in the chat. Can we use the sleep as a method of treatment? For example, using tablets. I mean, what we prefer to do is get the depression better then people sleep will get better um on its own improving somebody's sleep probably won't be enough to get them better from their depression. Um We sometimes do you still, if sleep's really bad, then people struck really struggling with sometimes use melatonin or promethazine short term, but that's really just to help this one symptom. Okay. Is that, is that another question? Uh, yes, sir. Yes, sir. One of the, uh, uh, pattern of behavior pattern. I've also seen, uh, this is the person or the child or the, uh, teenager who is depressed, uh, they might avoid everything, studies, social contact, but somehow or the other, they do find something or someone, a person or a stranger, a friend quite, uh, to be a bit which they don't find at the moment they are not depressed at all. So it could be a friend. It could be a stranger, uh anyone and sometimes it could be also that they try deliberately, try to do the activity or stay close to that person as long as possible because it makes them feel good rather than sulking in a depression. And that person might feel that this person is trying to get clingy or something, which something many misinterpret and whether when it comes to activities when with a certain activity or certain hobbies, which makes them feel good. Some people might miss just as well that, oh, he's being lazy is wasting he or she's wasting time with this activity. She should be doing studies. You should be doing this. Absolutely. And I think with depression it doesn't, just because somebody's depressed doesn't mean they don't do anything. And actually a lot of people who are depressed do find this positive endurable things to do like sport. If I had an argument with a colleague at my university recently. He said this, how can this student be too depressed to study when she's playing rugby? And I said, well, actually rugby is different to studying, they're different things. And actually, we encourage people to do more positive things. As part part, the biggest bit of CBT that works for depression is encouraging people to do things that they enjoy and make them feel better and doing more of that means they're more likely to get themselves out of this depression spiral. Um And you're right, you also talked about how sometimes people depression spend more time with a certain person often that's basic attachment behavior. That what's normal as mammals is we when they're babies and toddlers, we want to spend time close to a really important parental figure, normally your mother, but it can be a dad or a grandmother. And as we get older, what happens is we separate and actually we were able to spend more time independently and don't need to be with them um all the time because it's safe to do that. Um What can happen when you get depressed is those attachment behaviors get stronger again and that can happen to adults, not just teenagers. And they do find they want to spend time with that attachment figure because that helps them feel safe and comfortable. Right? So next question are the studies to show that CBT work short term and patient's seem to return for treatment. So there's no good long term studies of CBT in adolescence, certainly in studies in adults, what they suggest is that people have CBT are more likely to stay well than people who just have antidepressants. So they can, it can probably does help in the long term. And I think this is because CBT doesn't just give you tactics to get better. It teaches you different ways of doing things which you can then use to keep yourself well. And if you start getting the early warning signs of depression, you can use your CBT to start helping you to feel better. Um But sometimes as I said, depression is an illness where a lot of people get depressed again in future and while CBT might reduce the risk of occurrence, um it doesn't guarantee you won't get it again. So we do see people come back to us. Uh So next question as a doctor, can you suggest alternative treatment, the meditation or other holistic ways or would that be going outside the guidelines? Um I wouldn't, I would only recommend treatments whether an evidence based, I wouldn't recommend alternative therapies or complementary therapies. Um There's no evidence they work. I have no expertise. And then obviously, if patient's want to go ahead and do them, that's up to them. One thing we actually do be careful about with alternative therapies is there is a herbal remedy that people use for depression. Sometimes called Saint John's Wort. Now Saint John's Wart actually is probably a tricyclic antidepressant, which is why it works. Big danger is if you give, if somebody has a herbal treatment and it's, it may be something that's a load of nonsense that does no good or harm. But if it does some good, that means it's a drug which means it can cause side effects and have dangerous interactions and certainly giving somebody an antidepressant SSRI alongside Saint John's wort, which is probably a natural tricyclic can cause serotonin syndrome. So you do need to check whether people are using herbal remedies. Uh Another question. Uh Yes. Uh I've seen that in a change in the behavior pattern of a person, he's depressed that uh in a static state or when they're not moving, they do tend to a dozen the thinking of self worthlessness and, and if they're in a motion, well, it's, it's a kind of an exercise as well, but the an increased blood flow to the brain is uh one of the reasons where the change in the mood things occur. So we could say that the exercise could be the among all of them, the best way to cope up it, depression, I guess. Yeah, exercise can help. There is some vandalized controlled trials and adults to show that exercise can cause a small improvement in depression symptoms. No particular good studies in teenagers, but on its own, it probably won't be enough in some people it is, but again, part of good treatment is advising more exercise. Um Someone asked, what age can you start effective CBT, which is an excellent question. Um The evidence for CBT and depression is not as good for adolescents as it is for adults. And the reason why that is is because CBT is quite complicated. So younger Children find it very hard to actually understand the things. And in particular, with teenagers, you use behavioral techniques a lot more than cognitive because the cognitive techniques were a lot more complicated. Um The behavioral stuff, actually, you can do fairly young, but you're generally involved. Parents, if you try and do improving behavioral activity for a 12 year old on their own, they probably won't manage it. So you get the parents in um and get them to help. There's no real evidence to say what age CBT works and doesn't youngest I've ever done it for is a 12 year old. Um But there's lots of parental input. But the key thing is if someone, if you're patient doesn't understand the therapy and isn't able to do therapy, have a think about whether they're actually too young to understand it and get the parents in. Sorry, I was also going to add um you know, when somebody asked about the CVTS, um so CBT most correlated with somebody to a liability. So they can't have uh intellectual ability to comprehend the context of the treatment. They can't. So that's not gonna at all. So I think everybody sees CBT as a magic touch but it doesn't work for everybody. So I think main kind of um issue here is I think more about psycho educational and holistic approach is to uh you know, Children and also the families to get. Oh, and I think uh do you make a fair point? I think the key thing I'd say is rather than say it can, it works at a certain age, it doesn't work at another. It's a more graded approach is to say, as somebody gets younger, you've got to make it more simple and involve parental help a lot more. And I guess that's why we have specialists working with Children, adolescents in the UK rather than people working across age groups. Because we know about development, we think about it and we're quite good at grade adapting our treatment so that um it works for our patient's and same with the learning disip ations as well child than the lessons learning. A lot of treatments are actually tailored to, to make it more simple. But in terms of the effectiveness of the government is an outcome, sometimes it is uh uh when it's made, it's, it's, it's quite low compared to people with older ages in adolescents. Uh This is from a practical point of view. I mean, a practicing psychologist also, but in my final year of medicine. So, yeah, so you've done the psycho, you've done the treatment yourself. So you, you do speak from a position of expert. Yeah. Yeah. And again, learning disabilities. Another thing a and this is why we don't just say age above a certain age, we do below a certain age. We don't, a 14 year old with an I Q 150 is very different to a 14 year old with an IQ of 80 and definitely different tool with the IQ of 50. You've really just got to tailor the treatment you give to the developmental stage of the young person you're with. And also think about parental abilities. Again, some parents have brilliant supports the CBT. Some will just totally sabotaged it. Um You've got to, uh I guess this is why medicine is practiced by human beings. And I don't think computers will ever take over because it needs quite a lot of experience and training to be able to work these things out. Any more questions. I'm going to finish in three minutes to give you a chance for a break before your next talk. Do you put your hand up or put more questions on the chat as that? Yes, sir. I've heard about logo therapy in which uh the patient is told to write down everything in a manner that uh they tell that why they feel in a certain way and then they're told to write 22 separate variants that what could go worse and how it can go worse. And the other way is uh how they can get better and in what way they could get better is it, uh, it's a, a mainstream way of treating people or it's just a variant of it that, uh, like under 80 variant, it's certainly not mainstream in the UK. And it's really important that when you've got treatments for a disorder where there's evidence that they work, we use those treatments rather than things with no evidence. And if people develop new therapies, they've got duty to actually test them properly. Especially important. This is a lecture for you as medical students. I'm not teaching you about the advanced practice of charge psychiatry and all the subtleties which you need to know if you want to be a consultant. Actually, as students, you're learning how to be doing your doctors and you need to know the basics and really focus on knowing about the treatments that work. That's what will come up in your exams. And that's what your patient's will tell you about and what you might prefer. Patient's too. And if they say they want to do something without any evidence, I think it's the same as if they have heart arrhythmias and they want to try something with no evidence. It's about recommending to them that actually there are things out there that we know work and they're better off trying the things that work rather than things that we don't know if they work and there's a lot of therapies out there that people have developed for mental illness with no evidence. Now, the evidence, there's no evidence because there's been no studies, they might make people better. They may make people worse. We simply don't know. But the safe thing to do is give the stuff that we know works is that yes, uh, in intellectual you said that, uh, girls are more prone to the depression compared to the boys and to while listening to it somewhat, I was disagreeing to it. But then I thought okay, maybe that my gender bias is is being Bladen while thinking of it. So how much of a like while treating or while examining the patient? How much of a how is we get rid of our biases, which is actually not easy, uh much harder than uh than to say it to be done. Um I think in this lecture, I can't tell you how to get rid of bias is it's a very tricky one. And the key thing is being aware of biases and being open to the fact that you might have biases about people who weren't like you. Um And there's biases and lots of areas, gender, ethnicity, um country. Um But I think in terms of the gender balance in um depression and teenagers, the evidence is very clear if you look in clinics, probably the ratio is 3213 times as many girls as boys come to clinics wanting help. Certainly in the UK, if you, then if you do a study out in the community and you survey lots of people and find out who has depression, you find the ratio's about 2 to 1. There's two times as many girls as boys. So not only is depression more common in girls, but also girls with depression more likely to come for treatment. Um but it's a very real thing or to say more of it as uh girls don't tend to feel shy. Uh because uh you could say that many people who feel depression don't come forward to think of it that there is something wrong with them, you just suck it in or you could say they just buried down inside of them. Yeah, only a minority of teenagers with depression seek help for it that in the UK um I don't know about Ukraine but said in the UK, girls with depression and more likely to seek help and speak to somebody about their problems. And we know that on average girls are more likely to speak to people like problems than boys. But also you kind of get biases in professionals that bias they think oh, depression is more of a girl disorder. Therefore, they're more like to refer girls and we like to think of depression in girls. So if it's a girl who's feeling very sad all the time, they'll think depression. If there's a boy who's being angry and irritable and punching things. They may not think about depression, but they should do okay. It's, I know it's only eight minutes to your next lecture. So I'm going to stop now to give you all a break. Um, I wish you all the best in your studies. I, I feel very sorry for the situation you're in both in terms of your studies being affected, but your homeland being damaged so much by an illegal invasion. And I hope this ends soon and I hope you get the Russians out of your country and you can live freely again. But in the west we care about you, we want the best for you. So, Slava Ukrainy are the best.