Teenagers and young people have a lot on their plates and can easily feel bombarded by bodily and emotional changes. How can pharmacy help them, and their parents, address mental health issues?

The World Health Organization (WHO) defines health as ‘a complete state of physical, mental and social wellbeing, and not merely the absence of disease or infirmity’. This concept of wellbeing is also at the core of Public Health England’s work, and is included in its statement of purpose, but what exactly does wellbeing mean in relation to mental health?

According to the Health and Social Care Information Centre (HSCIC), mental health wellbeing is related to feeling meaningful, competent and autonomous, as well as having vitality and showing resilience in difficult situations. However, attaining these markers can be challenging for many teenagers who are dealing with the social and academic pressures that come with being the age that they are. In fact, one in ten young people will experience a mental health problem, according to Time to Change, the mental health anti-stigma programme run by charities Mind and Rethink Mental Illness.

What’s more, children and young people’s mental health charity YoungMinds states that the proportion of 15/16 year olds reporting that they frequently feel anxious or depressed has doubled in the last 30 years, from one in 30 to two in 30 for boys, and one in 10 to two in 10 for girls. So what is behind these rises?

Bullying behaviour

The HSCIC report Health and Wellbeing of 15-year-olds in England: Findings from the What About YOUth? Survey 2014 of 120,000 15-year olds in England found more than half (55 per cent) said they had experienced some form of bullying in the past couple of months, with around twice as many girls (19 per cent) than boys (10 per cent) reporting being cyber-bullied. Respondents who had experienced being bullied in the past couple of months were more likely to report low satisfaction with life than those who had not experienced bullying (19 per cent for those who had been bullied, compared with seven per cent for those who had not been bullied).

Data from YoungMinds shows that 55 per cent of children who have been bullied later developed depression as adults, and the HSCIC study claims that children with generalised anxiety disorder and depression had the most days away from school – a quarter had had more than 15 days absence in the previous term.

Andy Bell is deputy chief executive at the Centre for Mental Health, which works to improve the quality of life for people with mental health problems by influencing policy and practice in mental health and related services. He says that while “bullying is a risk factor for emotional problems in children such as anxiety and depression”, the trigger for the problems is “less important than getting help for the problem itself”.

Bell believes that it is often very difficult for parents of teenagers to identify the difference between what’s “simply normal teen behaviour – such as being surly or withdrawn – and what are signs of early mental health issues”, adding: “Lots of teens never get any support so if parents are concerned then it’s very important to seek help or find resources for getting help, which is where community pharmacy can help refer them on. For example, the YoungMinds parents’ helpline is the only dedicated resource for parents looking for help around this issue of their child’s mental health, and there is also MindEd (a free educational resource on children and young people’s mental health for all adults).

“We also know that teens themselves are least likely to seek help from formal sources, but instead turn to their friends and the internet, and there is good information available on the internet – such as from NHS Choices and YoungMinds – that pharmacy staff can also suggest.”

Body image issues

Young people are often bullied about the way they look, which can lead to them developing insecurities around their bodies that can escalate into eating disorders.

Data from YoungMinds shows the number of young people calling Childline for help about eating disorders has increased by 110 per cent since 2011, and the number of hospital admissions across the UK for teenagers with eating disorders has nearly doubled in the last three years (from 959 13 to 19-year-olds in 2010/11 to 1,815 in 2013/14).

The HSCIC survey found that girls were twice as likely as boys to think they were “too fat”; 46 per cent thought this compared with 23 per cent of boys. Only half (52 per cent) of all young people thought their body was ‘about the right size’, 12 per cent thought they were ‘a bit too thin’, and 2 per cent thought they were ‘much too thin’.

Perceptions of own body-image also varied by experience of bullying; those who had been bullied within the last couple of months were less likely to say they were ‘about the right size’ than those who had not been bullied (44 per cent compared to 63 per cent). 42 per cent who had been bullied thought they were ‘too fat’ in comparison with 25 per cent of those who had not been bullied.

Sitting targets

One way that young people can feel better about their bodies is by improving their fitness and activity levels. It is well known that regular moderate-to-vigorous physical activity (MVPA) has significant benefits to health, from increased musculoskeletal and cardiovascular health to psychological benefits such as reduced anxiety and depression, and WHO guidelines advise children to undertake at least an hour of MVPA daily.

Unfortunately, the increased use of screens for accessing all kinds of entertainment – as well as social interactions – is having an impact on the amount of time teenagers spend simply ‘moving around’.

The HSCIC report found that, on average, only one in seven (14 per cent) young people said they had participated in at least an hour of moderate/vigorous physical activity on every day in the last week, with seven in ten young people saying they usually spent seven hours or more per day undertaking sedentary activities on weekdays when not at school14 (29 per cent 7-9 hours per day, 42 per cent 10 or more hours per day).

While overall sedentary time did not differ greatly by gender, the patterns of behaviour did vary. Boys said they played computer games for an average of 1.8 hours per day on weekdays and 3.0 hours per day at the weekend, compared with 0.3 hours on weekdays and 0.6 hours on weekend days for girls. Girls, meanwhile, were more likely to say they spent time using a smartphone (mean 3.5 hours weekdays, 4.2 hours on weekend days compared with 2.3 hours and 2.8 hours respectively for boys).

However, despite these worrying levels of inactivity, Bell recommends harnessing the power of digital communication to reach out to young people. “Every new technology that has ever appeared has caused scares around how young people are using it,” he says, “so rather than despairing of the fact that young people use the internet for most of their information and social interactions, we should try to find credible ways of working with them through these media.”

How to help

Community pharmacists can give young people lots of general health information around good nutrition and physical activity that can help improve their emotional wellbeing, but it’s also worth encouraging parents to get involved.

A recent survey by Time to Change, the mental health anti-stigma programme run by charities Mind and Rethink Mental Illness (http://www.time-to-change.org.uk/news/new-survey-shows-mental-health- per centE2 per cent80 per cent98nonversation per centE2 per cent80 per cent99-parents-0) found that over half (55 per cent) of parents in England have never spoken to their children about the topic of mental health (including wellbeing, stress, anxiety and depression), with 20 per cent saying they chose not to because they wouldn’t know what to say.

Unfortunately, it’s not just members of the public who don’t know how to handle the topic sensitively.

Sue Baker, Director of Time to Change, says: “Data since 2008 on attitudes and discrimination have shown us that … people using mental health services have reported reduced levels of discrimination from their family, friends, neighbours, dating and social life [but] what has remained almost static was the level of discrimination reported in mental health services and other parts of the NHS.

To address this, Time to Change is also working in partnership with the 2gether NHS Foundation Trust and the Northumberland, Tyne and Wear NHS Foundation Trust (NTW), and people with experience of mental health problems, to pilot approaches to tackle stigma and discrimination reported within mental health services (http://www.time-to-change.org.uk/news/pilot-project-set-tackle-stigma-and-discrimination-reported-within-mental-health-services).

Lisa Rodrigues CBE, voluntary chair of the project working group, says she has “high hopes”, adding: “There is absolute acceptance amongst those involved in this project, and many other mental health professionals, that things need to change.”

Be the change

With community pharmacy known for being the approachable experts, don’t be surprised if these campaigns draw more parents and young people in store for advice and signposting.

Lucie Russell, Director of Campaigns and Media at YoungMinds, suggest a variety of resources aimed at young people, parents and professionals, that can help: “As well as the YoungMinds site, HeadMeds.org.uk is a new portal created for young people with everything they might want to know about the most common mental health medicines and conditions, but didn’t want to ask.”

Written by an expert pharmacist and reviewed by the College of Mental Health Pharmacy, in partnership with the Royal College of GPs, Russell says it’s “amazing how it has taken off so far with young people, and we know parents and professionals are using it as well” – a user base that Andy Bell champions.

He says: “It’s the whole fabric of a teenager’s life that has an effect on their mental health, so as well as pharmacy staff being able to spot the signs of something through a short-term interaction, it’s also helpful to know what resources are available to refer them and their parents to.

“I’m aware that whenever I visit a pharmacy there are screeds of leaflets about physical health issues, but there might only be one on depression. Remember that a quarter of all ill health, and more than a quarter of child ill health, is vastly psychological. Time to Change is the big mental health anti-stigma campaign, Young Minds has brilliant resources, as does the Royal College of Psychiatrists – all of which are about creating opportunities for conversations. It might be a conversation starter like that which gives people the chance to pick up a leaflet, start thinking about mental health and be the prompt they need to ask for help.”

Knowing how to encourage someone sensitively and carefully to seek help is about having that knowledge and being able to have a conversation without either catastrophising the issue or saying it’s normal and everyone feels like that. As Bell says: “There is no wrong time or place in the health system to ask for help, and pharmacy staff are experienced enough to treat these situations with sensitivity and respect.”

Common health problems affecting children and teenagers

Headlice

Insecticide treatments – available from pharmacies and on prescription – contain an active ingredient which kills headlice, although lice are known to become immune to chemical preparations over time. However, many parents are concerned by the allergies and scalp irritations that may be triggered by these treatments, and prefer to use non-insecticide and herbal preparations as an alternative.

Whatever solution they choose, treatments should only be used where an infestation has been confirmed by the presence of a live, moving louse, and should be repeated a week later in order to deal with any lice that have hatched out since the first treatment.

Warts

Warts are small, rough lumps that often appear on the hands and feet and are very common in people aged under 20. They are caused by the human papilloma virus (HPV), which encourages a protein called keratin in the top layer of the skin to grow too much, producing the hard texture of a wart.

Close skin-to-skin contact can pass on the infection as the skin cells in warts release thousands of viruses. It can take weeks or even months for a wart to appear after you have caught the infection, and people with weak immune systems are particularly prone.

Most warts clear up on their own but this can take a couple of years, so the right treatment can usually help get rid of them faster. There are a variety of over-the-counter treatments available including creams, gels, liquids and medicated plasters, most of which contain the active ingredient salicylic acid.

Verrucas

Often caught from the wet floors in changing rooms and swimming pools, verrucas manifest as warts growing up into the soles of the feet with a black dot in the centre surrounded by a harder, white area. It is common to have more than one at a time, and they can become more painful the longer they are left. Up to 80 per cent resolve themselves within about two years, but OTC treatments can treat them much faster.

Advise your customers to use these with care because they are generally tissue destructive. Many contain salicylic acid which breaks down the verruca, so should not be applied to healthy skin, which can be shielded with petroleum jelly of surgical tape. Cryotherapy treatments which freeze the verruca are also available over the counter, but again all surrounding healthy tissue must be protected. If your customer would rather not tackle the verruca themselves, you could recommend they see a podiatrist, who can do it for them and even apply stronger treatments.

Acne

Acne is very common amongst teenagers and often begins along with changes in hormones, such as during puberty or menstruation.

The spots are caused by a buildup of sebum, the natural oil produced by the body to keep skin moist and supple. When oil and dead skin cells block pores this can lead to acne breakouts. There is no evidence that eating chocolate of fried foods exacerbates the condition, but it is important to maintain a healthy and balanced diet. Keeping skin clean and washing and moisturising using gentle, non-comedogenic (in other words, non pore-blocking) products, rather than harsh scrubs which can irritate the skin, can help.

While acne will usually go away by itself, this can take years. There are some OTC treatments available for mild acne that contain active ingredients, such as benzoyl peroxide or nicotinamide, to kill bacteria and make the skin less oily. If the acne is more severe customers should talk to their GP who may be able to prescribe something stronger such as an antibiotic or retinoid cream or gel, or refer them on to a dermatologist who may prescribe a stronger medication called isotretinoin (Roaccutane).

Body odour

Everyone sweats and we all get caught out by body odour now and again. It is caused when harmless bacteria that live on human skin break down otherwise odourless sweat into acids that have that unpleasant ‘BO’ smell. Men tend to sweat more than women and there are other factors that can affect sweat production, such as being overweight or eating highly spiced foods.

The best way to avoid BO is by keeping clean and keeping areas that sweat as dry as possible. Deodorants simply mask the smell, whereas underarm antiperspirants contain aluminium salts and work by reducing the amount of sweat produced in the first place. Washing with an antibacterial soap may also help, and wearing clothes made from natural fibres allows the body to ‘breathe’ and let sweat evaporate quicker so it is less likely to go stale and start to smell.

If the sweating gets worse or has a ‘fruity’ or ‘bleachy’ smell your customer should see their GP, as these could indicate diabetes or liver or kidney disease.

Dandruff

Dandruff can either manifest itself as a very dry and flaky scalp or a very oily scalp with flakes, and both can cause itchiness. The most visible result is dry white/grey flaky skin sitting on the back of the neck and shoulders.

It is often seasonal, with the most severe bouts occurring in winter and the mildest in summer, but hormonal imbalance, poor health, allergies to chocolate, nuts and shellfish, lack of rest, emotional stress, excessive consumption of refined carbohydrates and a hereditary pre-disposition can also be contributing factors to dandruff.

There are several things a sufferer can do to help prevent dandruff. Vitamins A and E are good for general skin health, and gentle shampoos are more effective than the harsh ones.

Period pains

It is estimated that over half of women in the UK get period pains (dysmenorrhoea) which are caused naturally by contractions of the muscles of the uterus as the body releases prostaglandins, which help expel the lining of the womb during a period.

Whilst some women experience mild discomfort, others may suffer from very painful periods, which can affect their ability to get on with their ordinary, day-to-day lives. While your customer’s GP could prescribe a whole raft of strong pain relief, there are plenty of OTC options which you can recommend that she tries first.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can help alleviate pain and some, such as ibuprofen, can be bought over the counter. Paracetamol and NSAIDs such as aspirin or naproxen can also help. Another way to relieve the pain is with a hot water bottle, self-heating patch or pack that is heated in the microwave.

Useful contacts

 

Childline

Free 24-hour helpline for children and young people in the UK

0800 1111 childline.org.uk

 

Get Connected

A free service including a ‘webchat’ facility for young people advising on how to get the best help for a variety of issues

0808 808 4994 help@getconnected.org.uk getconnected.org.uk

 

MindEd

Free educational resource on children and young people’s mental health for all adults) that pharmacy staff can signpost to

minded.org.uk

 

 

Family Lives (formerly Parentline Plus)

Support to anyone parenting a child

Helpline: 0808 800 2222 familylives.org.uk

 

Samaritans

Emotional support for anyone feeling down, experiencing distress or struggling to cope.

24 hour helpline: 116 123 (freephone) samaritans.org

 

Young Minds

National charity committed to improving the mental health of babies, children and young people. Provides information for both parents and young people

020 7336 8445, Parents helpline: 0808 802 5544 youngminds.org.uk

 

HeadMeds

Advice for young people in the United Kingdom about mental health medication

headmeds.org.uk

 

Time to Change

http://www.time-to-change.org.uk/sites/default/files/imce_uploads/TTC_Infographics_Parents.png

Downloadable infographic to help parents start a conversation with their children about mental health issues