ACAMH’s International Development Director, Gordana Milavić discusses mood disorders and her role at ACAMH with freelance journalist Jo Carlowe.
The two discuss how conceptions of mood disorders have changed throughout Gordana’s career, shockingly Gordana mentions whilst in training it was thought that children were unable to get depressed. As a pioneer, involved in setting up the mood disorder clinic at the Maudsley Hospital, developing a specialist service for treating depressive disorders and bipolar disorders in children, Gordana highlights what we know already and future developments. They continue to discuss the increase of prevalence and causes, the role of medication, it’s limitations and concerns and differentiating between a quiet child and a depressed child.
Gordana touches upon her role at ACAMH, making links with other countries and establishing branches where there is interest, as well as digitally providing mental health resources to other countries where they are not as readily available.
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Dr. Milavić is a Consultant Child and Adolescent Psychiatrist at the Maudsley Hospital, London. She has over 40 years of experience in acute clinical practice, teaching and training. During her career she has been at the forefront of the organisation of mental health services for children and adolescents in southeast London. She is a Trustee and medical advisor of a number of mental health charities in the UK and internationally.
Intro: This podcast is brought to you by the Association for Child and Adolescent Mental Health, ACAMH for short. You can find more podcasts and other resources on our website, www.acamh.org, and follow us on social media by searching ACAMH.
Interviewer: Hello. Welcome to the in-conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlow a freelance journalist with a specialism in psychology. Today I’m interviewing consultant child and adolescent psychiatrist Dr. Gordana Milavić who was the Clinical Director of the Child and Adolescent Mental Health Service at South London and Maudsley NHS Foundation Trust for many years. Much of Gordana’s clinical and research experience has focussed on mood disorders in children and young people. Gordana, welcome. Thank you for joining me. Can you start by introducing yourself?
Dr. Gordana Milavić: Sure. Well, I’ve trained in general psychiatry and then specialised in child and adolescent psychiatry. I spent about 17 years working in Oxleas, a large neighbouring mental health trust, and then I spent a great amount of time developing services. So, I was the Clinical Director and Service Director, and alongside that did a lot of clinical work, but it was a very happy time.
It was a time when we developed services and knew our colleagues and worked very closely with the general hospital, the paediatricians, we knew our GPs and social workers, and the community. So, that was in many ways the springboard for my move to the South London and Maudsley NHS Foundation Trust where I very soon on assumed the role of Clinical Director.
Interviewer: You’ve had over 40 years of experience in acute clinical practice, teaching and training, and as you mentioned you’ve been at the forefront of developing child and adolescent services. What initially brought you into that field?
Dr. Gordana Milavić: I’ve always been very interested in psychiatry, and as a medical student I did an elective in psychiatry in London, and when I qualified that was the specialty I really wanted to practice in. So, I suppose an interest which developed in my undergraduate days.
Interviewer: And, specifically child and adolescent?
Dr. Gordana Milavić: No, I think it was just general psychiatry and working in the field of child and adolescent mental health came later because of the training that I was involved in and the people I met and the opportunities which arose.
Interviewer: Thank you. We’re going to focus mostly on mood disorders in this podcast. Can you start by giving some sense of how mood disorders present in the under 18s?
Dr. Gordana Milavić: Well, in many ways there are a great number of similarities between childhood and adolescent depressions and those that one encounters in adulthood. But, at the same time there are huge differences in terms of the symptoms which the children present with, especially young children and in terms of all the other developmental attributes that follow the course of depression towards childhood and adolescence.
So, for instance, very young children may be more irritable, or have more somatic complaints of things like tummy aches and belly aches and leg aches and so on. And, as they grow up they will develop perhaps a number of other anxieties or symptoms, and by adolescence it’s all much more like adulthood depression with a great deal of melancholia and sadness and physiological changes. And, of course, that’s the period when suicidal ideation occurs as well.
Interviewer: Right. How good are clinicians at recognising and identifying mood disorders in children and young people? You’ve mentioned that when children are quite young it might present as somatic symptoms?
Dr. Gordana Milavić: So, when I started training, for instance, it was thought that children couldn’t get depressed –
Interviewer: Goodness. Right.
Dr. Gordana Milavić: – because why should they get depressed, they were happy, and they were not cognitively capable perhaps of experiencing depressive cognitions and feelings? But we now know that that’s not right, and that very young children can get depressed and indeed the NICE guidelines for depressive disorders in children and young people address the range from four onwards. We should really be alert to the fact that even very young children can get depressed.
Interviewer: You were a consultant psychiatrist with the CAMHS Mood Disorder Service, looking back over your career what changes have you seen in terms of how young people present, the prevalence of mood disorders and also treatment approaches? What has changed over the years?
Dr. Gordana Milavić: We set up the Mood Disorder Clinic at the Maudsley Hospital in 2008, and this was an initiative I was specifically tasked with. And, together with my psychology colleague Patrick Smith we went about developing a specialist service for depressive disorders and bipolar disorders in this young age.
In order to set up our clinic we tried to establish what the prevalence of incidence rates were in our own community, and we realised that, as I said before, many of those cases were not being identified. But, as a rule of thumb it was always assumed that school age children and young children presented with – about 1% of that population would present with depressive disorders and as adolescence approaches that rate increases to something like 3-5% in the general population.
But, more recent epidemiological studies have indicated that those rates are even higher, and they reach about 8%, and are even higher in terms of lifetime prevalences. So, many young people report that they’ve been depressed at least once during the course of their young adulthood, and those sort of figures go up to 20%. So, we’re dealing with something which is quite prevalent. The other thing to say is that it doesn’t often occur on its own. It’s a disorder which is quite likely to have a heterogeneous profile.
Interviewer: So, what might be a typical comorbidity that you might see?
Dr. Gordana Milavić: Very often depressive disorders occur with anxiety. They will occur with conduct disorders as well. Children who have ADHD will often present with depression. The range of these comorbid disorders is quite vast, and of course we always have to make that differential diagnosis between unipolar depression. So, straightforward depressions and bipolar depressions, because bipolar disorders can sometimes start just with a depressive episode.
Interviewer: Right. I just want to check something on prevalence. Has the prevalence gone up because it really has gone up, or is it to do with better identification?
Dr. Gordana Milavić: There were a number of epidemiological studies which indicated that those rates were not in fact going up, but I know that in adults those rates are increasing steadily, and the WHO predicts that depressive disorders are going to be the most important burden of disease by 2030. It would appear that those rates are also increasing in childhood and adolescence as well.
Interviewer: Is there any cause for optimism?
Dr. Gordana Milavić: I think there is in the sense that we’re in fact learning so much more about what depressive disorders are all about. We now know that there are theories and hypotheses which point to the origin of depressive disorders. So, we’re talking about genetic influences and developmental influences, and we have seen in the last decade or two inflammatory theories of depression. And, of course, as in other mental disorders and situations where young people experience, and adults in fact, mental health difficulties, we now know how important maltreatment and adverse experiences in childhood are.
Interviewer: When I think about the US, I think about possibly overuse of medication in young people and children. I’m wondering what the role of medication is in the treatment of mood disorders in children and young people in the UK? Are there limitations or concerns about the use of medication in this particular patient group?
Dr. Gordana Milavić: Well, the NICE guidelines are very specific as to what can be prescribed and what can’t be prescribed, and in 2004 we had the black box warning which was the result of a number of studies which established that the rate of suicidal ideation increases in association with the prescribing of some antidepressants.
The pattern’s changed considerably, and NICE proposed that medication be prescribed only after psychological therapies, and in conjunction with psychological therapies should medication be necessary. So, that has been very much the trend in this country.
There is always alarm that young people and children in particular are being prescribed an inordinate amount of antidepressants, but when one looks at the actual statistics those numbers, particularly in prepubertal children, are very low, and later on in adolescence, in this country, I think are judiciously prescribed.
Interviewer: Okay. That’s good to know. What are the changes have you seen in terms of treatment approaches over the years?
Dr. Gordana Milavić: We haven’t had any breakthroughs in treating depressive disorders either in adults or in young people for a number of years. So, we’ve been looking – really the therapeutic interventions have focussed on psychological therapies and mainly cognitive behavioural therapy, interpersonal psychotherapy, which has proved very useful, particularly in adolescent depressions, and medication, which is very prescribed and very specific. In fact, there’s just one SSRI which is the recommended antidepressant for young people and that is fluoxetine, or Prozac as we know it.
And, it is only more recently that new treatments have come to the market, things like ketamine in adults, but we are far away from, apart from research situations, being able to prescribe that or use it in the treatment of depression in young people.
Interviewer: Right. And, are there any other changes, talking about clinical treatments, that you would like to see?
Dr. Gordana Milavić: Identification is terribly important, and referral onwards to more specialised centres. I think many community services consider that it is fairly straightforward to treat depressive disorders, and indeed they do so very successfully, but occasionally, probably about 10% of cases, one encounters depressive disorders which are resistant to treatment. And, I think in those situations one should really involve the more specialist centres at an earlier stage. Because we know that the longer the disorder is around and the more episodes a young person suffers with, the more likely it is that these depressive disorders will be resistant to treatment, and that young people may well graduate into adulthood, if I can put it that way, and continue to suffer with depression.
Interviewer: Right, and does that happen – ?
Dr. Gordana Milavić: It does. It does.
Interviewer: The early referral though, does that happen?
Dr. Gordana Milavić: The early referral? I think it does. Sometimes resources are implicated and funding the referral to more specialist settings is not possible.
Interviewer: And, how important is that early intervention? What does the research show in terms of it making a real difference if intervention is provided at an early stage, or an early enough stage?
Dr. Gordana Milavić: I think where one avoids the problem of recurrent episodes primarily and depressive disorders which are resistant to treatment. So, if a young person who is depressed, a child doesn’t necessarily cause any problems. They will sit quietly at the back of the classroom, not really participate in the learning process, be separated from their friends by their isolation and withdrawal, and sometimes can go unnoticed for a number of years. And, it’s very difficult to catch up with those sort of, I suppose, deficits eventually, developmental deficits later on.
Interviewer: Gordana, who notices the unnoticed child? How does one differentiate between a child who is quiet and a child who may be developing symptoms of depression?
Dr. Gordana Milavić: One hopes that a teacher or a teaching assistant will be the kind of person to identify a very quiet child or a withdrawn child. NICE guidelines recommend that a child who is sad or withdrawn or quiet, inordinately quiet, should really be watched for a while because something may be happening at home or there may be a particular life event that they’ve had to deal with or a bereavement of the birth of a baby sister or brother.
So, once a teacher knows some of these things that they can be informed of what’s going on in this particular child’s life, but if that sadness persists or the withdrawal continues, then the teacher or parent should really be asking the child questions. “What is making you sad?”
There is something to be gained from knowing that one should be able to ask questions and should be more confident and that asking about feelings should be destigmatised. Very young children, even children as young as four, are able to say they’re unhappy and one can use pictures and diagrams and play to establish what all that is about and what is going on in their lives.
Interviewer: We touched upon this earlier, we looked at the underlying causes of mood disorders in young people. Can you say a bit more about the role of neurobiological processes that underly depression in children and adolescents?
Dr. Gordana Milavić: There are a number of theories and hypotheses as to the causation of depressive disorders, which we have been taught over the years, and which we have applied to our treatment interventions. So, for instance, the antidepressants that we prescribe these days are based on the monoamine theory of depression, and we are talking, if I can simplify that, in terms of serotonin deficiencies and ways of replenishing serotonin at our synapsis.
We also know that some depressive disorders occur in families and there is a great deal of longitudinal research which has demonstrated that. So, offspring of depressed parents are more likely to develop depressive disorders.
We also know that girls come adolescence seem to predominate in terms of prevalence rates in relation to boys, and the rates of depressive disorders rise for girls by contrast to boys. And, there’s a great deal of research, again, in that area as to what that is all about and whether it’s just hormonal or whether there are various other social reward systems which are operating.
The cognitive theories of depression point towards the ways in which thinking, and learning occur. Again, we’ve had cognitive behavioural therapy, which has been around for many years and is a successful intervention method which has verified some of those theories.
And, then more recently immunoinflammatory theories of depression point to the role of immunological processes and inflammation in creating depression. And, those inflammatory processes may occur from illnesses or infections, or may be the result of abuse and maltreatment where we have a more toxic picture of what happens in the brain.
So, we shall see really what we’re going to end up with, but we will probably end up with different depressive disorders being caused by different causative factors. The important thing to say is that the environment is hugely important in all of this, and that we cannot think about neurobiological processes without the influence of the environment.
Interviewer: I think it’s really fascinating, isn’t it? What else is in the pipeline with regards research or new innovations that excite you? I mean, you may have already touched on many of them, but ..?
Dr. Gordana Milavić: Well, I think we’re talking here about some of the new treatments, because we still end up with about 20-30% of cases which will not immediately remit, and where the chronic course of depression sets in, and where young people are resistant to our interventions and treatments, whatever they may be.
So, that’s really the area where we need to focus on, and we may see that ketamine ends up being a promising intervention. At the moment, there’s no evidence for that. There are still many risks, but perhaps in those really serious cases where nothing else has worked, a bit like ECT which is very, very rarely used for depressive disorders, but which is used nevertheless.
Interviewer: Is it ever used in children or young people?
Dr. Gordana Milavić: Very, very rarely, and only after consultation with many specialists, and we don’t have any control trials of ECT being successful, but we do have some open studies and retrospective studies which have proved that ECT can be useful in these very serious and life-threatening depressive disorders.
Interviewer: Gordana, you were at the forefront of developing child and adolescent services in South East London, looking back what are you most proud of?
Dr. Gordana Milavić: I think I’m most proud of developing services where there were none to start with, and where child mental health services developed on so called shoestring budgets as appendages either to adult psychiatric services or to paediatric services or community paediatric services where we have become a professional group in our own right, and where our services have expanded. You know, building something and developing it is probably something that I’m most proud of.
Interviewer: And, what developments still need to happen to ensure that children and young people get access to good evidence-based interventions and services?
Dr. Gordana Milavić: We have become much more structured, much more organised, much more evidence based. We have benefited from the enormous amount of research in child mental health, and some of the neuroscientific advances. We have become a serious academic discipline, and that’s reflected in our training. I think we can see from reports in the media that child mental health has suffered over the years from non-investment, from recruitment and retention difficulties.
So, we really need to train more people and establish more services. It is not acceptable that children should have to wait or go on waiting lists to be seen or to be treated. It is not acceptable that young people presenting to emergency departments should have no beds to go to, or that they should have to be admitted to beds far away at huge distances from their homes where their families can’t visit. And where, in addition to their presenting difficulties, they have to endure the unfamiliarity of new environments and separation from their families.
So, a lot has been done already. We’re seeing new investments, we’re seeing a transformation of services, there are training initiatives, but this will take a while. So, we need to speed up some of these processes.
Interviewer: I want to talk a bit more about training. I’m aware there’s a major recruitment and retention problem when it comes to child psychiatry. As someone who teaches and trains junior doctors and mental health professionals, what do you feel can be done to turn this situation around?
Dr. Gordana Milavić: We’ve known for a number of years that recruitment is a problem, and that getting people into the profession has been difficult. This has really been the case with adult psychiatry and child psychiatry, and training. So, the programmes in medical schools need to be geared towards enabling undergraduates to familiarise themselves with the world of psychiatry and child psychiatry in a more scientific way, because there are some fascinating and exciting neuroscientific discoveries.
And we need to capture the curiosity of undergraduates at this very early stage, and enable them to follow a medical career which incorporates the psyche and the soma, and which in some ways is much more exciting than physical medicine, if I can call it that way, because there are still so many unknowns.
Interviewer: You were co-chair of the Child and Adolescent Psychiatry Section of the World Psychiatric Association, what did that role entail?
Dr. Gordana Milavić: I was the chair for six years of the Section, and it was a very exciting time. It was my experience in the organisation of services and development of services and delivery that was really the motivator for joining the World Psychiatric Association, and co-chairing the Child and Adolescent Psychiatry Section. And, that work took us to a number of countries where mental health policies and child mental health policies are non-existent, where services are non-existent, where experts in child and adolescent mental health are not there.
And, I always quote some of these examples that in some of the countries where the childhood population under 18 is vast and amounts to almost 50% of the population, you may find that there are no or very few child and adolescent mental health professionals.
So, part of our task was to work on some task shifting, and enabling primary mental health services to take on some of these roles, but it also the work revolved around a number of conferences, workshop and travel to these places where they’re non-existent services.
Interviewer: Right. Gordana, you are a trustee and medical advisor to a number of mental health charities, both in the UK and internationally. Are there any particular projects or innovative schemes linked to these organisations that you would like to highlight?
Dr. Gordana Milavić: There us a particular charity called Nip in the Bud who I’ve worked with for a number of years, and the charity makes promotional films for primary school staff, teachers and parents of the children to promote mental health in young people. And, together with the national and specialist services at the Maudsley Hospital, the charity has made a number of films which focus on the most common disorders of childhood, and describe some of the main problems linked to some of these disorders.
We went into schools and the children in the schools were asked to participate in an acting capacity and enjoyed doing the films very much, and these films are now available on YouTube and can be seen by everybody.
Interviewer: And, if somebody wanted to access those what should they – ? Is there a website?
Dr. Gordana Milavić: So, Nip in the Bud is the website, and it’s available also on the ACAMH website.
Interviewer: Gordana, you are also ACAMH’s new International Development Director. What do you hope to bring to this role?
Dr. Gordana Milavić: It’s been an enormous privilege and honour to join the Board of ACAMH in this capacity. I am following a very influential and active previous officer who did an enormous amount of work, Anula Nikapota, who set the path for some of our further projects. We already have done a great amount of work in making links with other countries and colleagues in other parts of the world, and my hope is that we will continue to develop those links and establish more branches in areas where there’s interest.
For instance, we already have a branch in Malta. We are working on establishing an ACAMH branch in Egypt, and we hope through our website and digitalised services to reach some of the other areas where child mental health resources are not on a par with this country. That would be my main objective. It would be good to increase the international membership of ACAMH, be this through an ability for these colleagues to access our website and some of our educational programmes and also to encourage international attendees to attend our excellent conferences. So, already certain countries can access free membership of ACAMH and access our website and some of our training programmes.
One additional thing that I would like to see over the next few years is that of establishing improved links and more formal links with some of the international organisations of child and adolescent mental health. We are still, as a professional group, very small and we really on a global level need to start working together with each other and thinking about an affiliated group which could address some of these issues and resources used on a more global level.
Interviewer: Gordana, finally, what is your take away message for those listening to this podcast?
Dr. Gordana Milavić: I hope that child mental health services will become a priority for all health systems as we now know that so many problems start early in childhood. We’ve always suspected that, but we now have proof that many difficulties which present in childhood and adolescence, and which continue into adulthood, start very early and need to be rectified at that early stage.
Interviewer: Gordana, thank you every so much. For more details on Dr Gordana Milavic or on mood disorders, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelt, A C A M H.
Outro: This podcast was brought to you by the Association for Child and Adolescent Mental Health, ACAMH for short.
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