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BC CHILDREN'S HOSPITAL Patient Loc-Svc: 3M-PM DISCHARGE SUMMARY Admitted: [**2020-03-05**] (DD/MM/YYYY) Discharged: [**2020-08-05**] (DD/MM/YYYY) DISCHARGE DIAGNOSES 1. Polysubstance use disorder (marijuana, alcohol, opiates, stimulant (cocaine/amphetamines)). 2. Persistent depressive disorder, early onset, with intermittent major depressive episodes. 3. Unspecified anxiety disorder. MEDICATIONS ON DISCHARGE 1. Fluoxetine 50 mg p.o. daily. 2. Quetiapine 50 mg p.o. t.i.d. 3. Lisdexamfetamine 20 mg p.o. daily. Methylphenidate 90 mg p.o. q.a.m. was discontinued in hospital and Lisdexamfetamine 20 mg p.o. q.a.m. was started for ongoing ADHD treatment. This change was made to reduced the risk of medication diversion and misuse in hospital. A prescription was provided to [**Last Name (un) 1**] mother at the time of discharge for a duration of 2 weeks, with 1 available repeat (total 30 days of medication). MENTAL STATUS EXAMINATION AT DISCHARGE [**Last Name (un) 2**], "[**Last Name (un) **]", is an adolescent Caucasian male who appears his stated age. He was dressed in casual clothing; sneakers, jeans and a hooded sweatshirt. His hygiene and grooming were adequate. He made appropriate eye contact. He was agreeable to assessment. Rapport was superficial. [**Last Name (un) **] was unreliable; he seemed superficially engaged, but motivated to leave hospital. His speech was fluent and coherent. He spoke with a normal rate, rhythm and volume. His mood was stated as "good". Affect was euthymic and mildly anxious. He demonstrated a normal range in affect; he responded appropriately and their was no significant lability. Thought form was organized and goal-orientated. No delusional content was present. [**Last Name (un) **] is precontemplative with regard to his substance use. He denied suicidal ideation, intent, or plan. He denied homicidal ideation, intent, or plan. No perceptual disturbances were noted. He was no observed to be responding to internal stimuli during assessment. His cognition grossly intact, although not formally tested. He was orientated to time/place. His insight appeared to be fair with regard to his substance use and impact this has on his mental health, and family. His judgment appeared to be at baseline; he is agreeable to ongoing community follow-up and treatment. RISK ASSESSMENT [**Last Name (un) 1**] history of prior suicidal thinking and behaviors, family history of mental health and substance use, and substantial parental/role model loss increase his chronic risk for suicide. [**Last Name (un) 1**] active polysubstance use also increases his risk in the community, particularly when intoxicated with substances. At this time [**Last Name (un) **] is precontemplative about addressing his ongoing substance use. He declined inpatient admission during the course of this admission. He will require ongoing services in the community to support him with substance use recovery, and improve his coping skills/distress tolerance. At the time of discharge, [**Last Name (un) **] denied ongoing suicidal ideation, intent or plan. He reported his family, girlfriend, his current employments as protective factors. Additionally, a safety plan was discussed with [**Last Name (un) **] prior to discharge. POSTDISCHARGE FOLLOW-UP 1. [**Last Name (un) 2**] was discharged from hospital on [**2020-06-07**], to his grandmother's home. He was discharged to his grandmother's home as [**Male First Name (un) 3**] (mother) does not want Zachary' to return home until he address his active substance use. We discussed with the family the possibility of placement within a group home/foster placement given these ongoing concerns; however, the family did not want to pursue this option at this time. 2. [**Last Name (un) 2**] will benefit significantly from ongoing community supports to address his concurrent symptoms of depression, anxiety and ongoing substance use. He would benefit from an residential treatment program. Unfortunately, he was declined from the [**Location (un) 4**] treatment program. [**Last Name (un) **] also declined a voluntary admission to the inpatient unit at [**Hospital 5**] Hospital (P2). Dr. [**First Name4 (NamePattern1) 6**] [**Last Name (NamePattern1) 7**] (psychiatrist) and [**Last Name (un) 8**] (CYMH counsellor) will continue to follow [**Last Name (un) **] through the Provincial Concurrent Disorders Program as an outpatient. A message was left with [**First Name8 (NamePattern2) 9**] [**Last Name (NamePattern1) 10**], the program assistant for the Concurrent Disorders program asking them to arrange and appointment with the family at the earliest times available. We have also asked the family to contact the office directly if they do not hear back from them within 1-2 days time. 3. [**Last Name (un) **] is agreeable to ongoing substance use counselling privately arranged by parents. He will continue to meet with [**First Name8 (NamePattern2) 11**] [**Last Name (NamePattern1) 8**] following discharge from hospital. A message was left with [**First Name8 (NamePattern2) 11**] [**Last Name (NamePattern1) 8**] to arrange a follow-up appointment with the family. [**Male First Name (un) 3**] will also contact [**Male First Name (un) 11**] in the next 1-2 days to confirm an appointment time with him. We have notified family that if [**Last Name (un) 1**] does not want to attend ongoing follow-up with [**First Name8 (NamePattern2) 11**] [**Last Name (NamePattern1) 8**] alternative counselling is available; the family decline to pursue alternative options at this time. 4. [**Last Name (un) **] has been intermittently attending the DEWY Day Program and is agreeable to continue with this program. [**Last Name (un) **] will meet with with [**Last Name (un) 12**] from the DEWY Day program on [**2020-06-08**]. [**Male First Name (un) 3**] arranged this follow-up appointment prior to the time of discharge. 5. [**Last Name (un) **] will meet with [**Last Name (un) 13**], his Child and Youth Mental Health Outreach worker from the Tricities Mental Health Team. [**Last Name (un) 13**] will meet with [**Last Name (un) **] on [**2020-06-09**]. [**Male First Name (un) 3**] arranged this appointment prior to the time of discharge. 6. [**Last Name (un) 1**] medications were adjusted in hospital. Methylphenidate was switched to lisdexamfetamine to reduce the risk of medication diversion/misuse. [**Last Name (un) **] did not report any side-effects or change in symptom response with this medication change. Lisdexamfetamine can be titrated based on tolerability and response by his psychiatrist Dr. [**First Name4 (NamePattern1) 6**] [**Last Name (NamePattern1) 7**]. [**Last Name (un) **] will continue on fluoxetine 50 mg p.o. daily and Seroquel 50 mg p.o. t.i.d. This medication was not adjusted in hospital. [**Male First Name (un) 3**] was provided a prescription for these medications for a duration of 2 weeks with 1 available repeat at the time of discharge (total 30 days of medication). TREATMENT/COURSE IN HOSPITAL [**Last Name (un) 2**], "[**Last Name (un) **]", Muir is a 17-year-old Caucasian male who lives between his mother and grandmothers home. His mother is his legal guardian. He has two biological sisters aged 16 and 5. He has a past psychiatric history of persistent depressive disorder, unspecified depressive disorder, ADHD and significant polysubstance use (marijuana, nicotine, cocaine, amphetamines, opioids, alcohol). In the community, he is followed by the Provincial Concurrent Disorders Program, which includes Dr. [**First Name4 (NamePattern1) 6**] [**Last Name (NamePattern1) 7**], Dr. [**First Name4 (NamePattern1) 14**] [**Last Name (NamePattern1) 7**] and [**First Name5 (NamePattern1) 8**] [**Last Name (NamePattern1) 15**] (CYMH counselor). He is connected to the DEWY Day Program and has a private substance use disorder counsellor, [**First Name8 (NamePattern2) 11**] [**Last Name (NamePattern1) 8**], in the community. He is connected with a CYMH Outreach Worker, [**Last Name (un) 13**], through Tricities Mental Health. He is enrolled an online school program, completing grade 11 course work. He has a girlfriend, [**Name (NI) 16**], in the community. He does not have any children. He enjoys hockey, and golf. [**Last Name (un) **] was brought to hospital by EMS on [**2020-06-01**] under section 28. Police were called by his mother, [**Name (NI) 3**], after [**Last Name (un) **] told her he wanted to "take drugs and not wake up". He was acutely intoxicated upon arrival in the emergency department and was unable to provide a reliable history. [**Male First Name (un) 3**] reported [**Last Name (un) **] had left Creekside Detox Facility against medical advice earlier in the day. Based on collateral documentation [**Last Name (un) **] had ingested cocaine, MDMA, Xanax, and bath salts after leaving Creekside. Initially, on presentation to the emergency department, [**Last Name (un) **] was able to ambulate but became sedated shortly after arrival. Preliminary investigations demonstrated an elevated Acteaminophen level, with no corresponding increase in liver enzymes. Poison Control was consulted for possible acetaminophen overdose, and the NAC protocol was initiated. Pediatrics was consulted, and [**Last Name (un) 2**] was admitted to the Clinical Teaching Unit (CTU) for ongoing treatment and assessment. Fortunately, [**Last Name (un) 2**] was asymptomatic with respect to his Tylenol overdose/ingestion. He was medically cleared after receiving the NAC protocol on [**2020-06-02**]. He was transferred to the CAPE unit under the care of Dr. [**First Name4 (NamePattern1) 17**] [**Last Name (NamePattern1) 18**] for ongoing psychiatric assessment. [**Last Name (un) **] reported a longstanding history of depressive symptoms and anxiety while admitted to CAPE, dating back at least 2 years time. He described experiencing a number of substantial loses from [**2009**] to present which have contributed to these symptoms. These include: witnessing his mother experience significant complications and admission to hospital following abdominal surgery (2007); biological father dying from fentanyl overdose (2004); acute loss of grandfather from myocardial infarction (2016). Most notably are the losses of [**Last Name (un) 1**] father and grandfather. [**Name (NI) **] was beginning to establish a relationship with his father around the time of his death and this represented a significant loss to him. Additionally, [**Last Name (un) 1**] grandfather served a role model and parental figure for [**Last Name (un) **] for much of his life. The loss of his grandfather was a substantial loss for both [**Last Name (un) **] and his family. While in hospital, [**Last Name (un) **] reported that his mood been on average a "[**01-05**]" prior to hospital. He denied ongoing suicidal ideation, intent, or active suicidal plans. He reported that he had only threatened to end his life prior to admission because he was "high and did want to return to rehab." [**Last Name (un) **] also reported that he only feels suicidal when he uses drugs, and recognized that this was a pattern for him. [**Last Name (un) 2**] reported that this suicidal threat was insincere and not something that he intended to act on. He reported wanting to live for his girlfriend, [**Name (NI) 16**], and family. He also reported living for his job at a local golf course. [**Last Name (un) 1**] reported no change in his appetite, or energy level prior to admission. He denies any restrictive intake behaviors and has not experienced any weight change. He reported sleep disturbance, which is likely complicated by active substance use. He did not report any thoughts/feeling of guilt and/or hopelessness. [**Last Name (un) 1**] substance use is an active component of his current presentation. Collateral history from [**Male First Name (un) 3**] indicates it has been difficult to engage him in substance use related treatment and follow-up in the community despite several community support in place. Understandably, [**Male First Name (un) 3**] is concerned about [**Last Name (un) 1**] substance use worsening and the possibility that he will die from an overdose. She reports that he has stolen from both her and his grandmother to support his drug use. She reports there have been concerns from [**Last Name (un) 1**] employer about his behavior at work and that he has been using on the job. [**Male First Name (un) 3**] also reports that [**Last Name (un) **] has not been willing to attend residential treatment despite the families persistent encouragement. In hospital, [**Last Name (un) **] was found to be precontemplative with regard to his substance use. He seems to appreciate the significant risks associated with his substance use, but is inconsistent in his willingness/motivation to address this pattern of behavior. In consultation with his community team, [**Last Name (un) **] was referred to the residential [**Location (un) 4**] Substance Use Program. Unfortunately, [**Last Name (un) **] was not accepted into this program as he fell outside of the programs cachement. [**Last Name (un) **] was offered an admission to the BCCH inpatient adolescent psychiatry unit (P2) for ongoing treatment of his concurrent substance use and psychiatric diagnoses. Despite numerous attempts to engage [**Last Name (un) 2**] with this option for an inpatient admission [**Last Name (un) 2**] decline admission. [**Last Name (un) **] was willing to engage outpatient follow-up including: attending appointments with Dr. [**First Name4 (NamePattern1) 6**] [**Last Name (NamePattern1) 7**] and [**First Name5 (NamePattern1) 8**] [**Last Name (NamePattern1) 19**] through the Concurrent Disorders Program; attending appointments with [**First Name8 (NamePattern2) 11**] [**Last Name (NamePattern1) 8**]; attending the Dewy Day program; attending NA meetings with [**Male First Name (un) 3**]. He is also agreeable to follow up with his youth outreach worker, [**Last Name (un) 13**], from the tri-cities mental health team whom he has a strong alliance with in the community. On the unit [**Last Name (un) **] remained settled. There were not significant behavioral/safety concerns noted. He communicated and engaged with staff appropriately. He did not use substance while in hospital. He had several passes with family off the CAPE Unit prior to discharge that went well without any significant concerns. While in hospital, [**Last Name (un) **] and [**Male First Name (un) 3**], received psychoeducation about concurrent psychiatric and substance use disorders. A number of harm reduction interventions occurred while in hospital including: naloxone training, medical work-up for IVDU related infectious disease; and medication change to reduce prescription misuse/diversion. Both [**Male First Name (un) 3**] and [**Last Name (un) **] received Naloxone training in hospital, and were provided with a Naloxone kits. [**Last Name (un) 20**] infectious serology for HCV, HBV, HIV and syphilis were negative. [**Last Name (un) 20**] ADHD medication was changed in hospital to further reduce the risk of diversion/misuse. Prior to his discharge from hospital, a family meeting was held to review disposition planning. We discussed the available community supports and plan for ongoing follow-up with [**Male First Name (un) 3**] and [**Last Name (un) 2**]. [**Male First Name (un) 3**] was disappointed that [**Last Name (un) **] was not accepted to residential treatment. The rationale for the referral being refused, and other available options was also discussed. It was also determined that [**Last Name (un) 2**] would live with his grandmother outside of hospital, but with conditions that he would agreed to ongoing followup and supports in the community as well as a number of new limitations within the household (no vehicle use/cellphone use; supervised visits with girlfriend). The limitations were discussed with [**Last Name (un) **] prior to discharge and he was seemingly agreeable. A prescription for new medications was also provided to the family. Following the meeting, [**Last Name (un) **] was discharged from hospital. Thank you for the opportunity to be involved in [**Last Name (un) 1**] care. Please do not hesitate to contact us directly if you have any questions and/or concerns regarding his admission to hospital. [**Signature 21**] Dictated By: [**First Name8 (NamePattern2) 22**] [**Last Name (NamePattern1) 23**] (Res), MD [**Signature 21**] Dictated For: [**First Name4 (NamePattern1) 17**] [**Last Name (NamePattern1) 18**], MD Psychiatry LD/MODL Job #: 966632 Doc #: 32253046 D: [**2020-08-05**] 18:43:31 T: [**2020-09-04**] 09:38:34

BC CHILDREN'S HOSPITAL Patient Loc-Svc: ED-MH DISCHARGE SUMMARY Admitted: [**2020-02-04**] (DD/MM/YYYY) Discharged: [**2020-05-06**] (DD/MM/YYYY) DSM-V WORKING DIAGNOSIS 1. Generalized anxiety disorder, 300.CO2. 2. Persistent major depressive disorder (dysthymia, early onset, with current episode, 300.4). 3. Unspecified somatic symptom and related disorder, 300.A2. THERAPEUTIC RECOMMENDATIONS UPON DISCHARGE 1. Safety: Please note that Pearl was admitted for 2 nights and 3 days on our CAPE unit. During this time, she was very settled and cooperative with nursing staff. She was able to tolerate an evening pass with her mother off the CAPE unit the day before discharge without incident. She has gone over a detailed safety plan which was reviewed with nursing staff and Pearl as well as with her mother during our discharge meeting. Essentially, Pearl states that during times of hopelessness, she knows to reach out to friends, and she is also aware that if her safety plan does not work, that coming to BC Children's Emergency Department is a reasonable option during times of acute destabilization. In addition, I have discussed with Pearl and her mother that between the date of discharge and her appointment with CART next Thursday, that she can continue to contact the CAPE nursing staff for any further advice on deescalation techniques or supports. Cross-sectionally, she denied any suicidal ideation, homicidal ideation, or urges of self-injurious behaviors, and she was no longer deemed certifiable under the Mental Health. She was discharged safely with her mother back to her home in Vancouver. 2. Biological: We have started her on a trial of fluoxetine at 10 mg p.o. daily. Upon discharge, she was given a prescription to increase her fluoxetine by 10 mg on a weekly basis until she reaches 30 mg p.o. daily. We have gone over psychoeducation materials from the [**Last Name (un) 1**] Mental Health website. We have gone over common side effects, including worsening GI symptoms which she already has at baseline, including nausea, decreased appetite, and stomach upset. We have also discussed that her frequency of headaches may increase with the titration of this medication. We have also discussed the rare side effect and the black-box warning of selective serotonin reuptake inhibitors in adolescents, which include increase of suicidal ideation which is more pervasive and perseverative in nature. We have not offered any refills after the 30 mg of fluoxetine is achieved, as we will leave that to the treating community team at this time. We have also encouraged her to use melatonin 3-12 mg p.o. 30 minutes before bedtime, as this may help with her initial insomnia. 3. Psychological: Pearl has been going through depressed moods, anxiety, and somatic symptoms for approximately 2 years. She states that things have specifically gotten worse since summer, which was a time when she was abruptly transitioned to her biological father's home after her mother found cannabis in her bedroom. This transition was very destabilizing, not discussed with her, and interrupted her trust with her mother. She agrees that she requires 1-on-1 supportive therapy and is willing to try this with the CART team. In addition, we discussed that phase II of her treatment would include cognitive behavioral therapy for depression and anxiety once things are more stable. We have also gone over grounding strategies and mindfulness strategies, which can be found on the Mind Shift app as well as Calm Meditation app. 4. Social: Pearl states that she has a stable relationship with her boyfriend and was very happy to be discharged and spend time with her boyfriend and her peers. We have discussed healthy living strategies, including routine times of daily meals as well as sleep hygiene habits. We have also discussed that body movement is important, and physical exercise on a daily basis is recommended in this age group. 5. Academic: We have discussed that a gradual return to school is important, and she was given a sick note during her time in hospital. As you know, she has a history of school truancy, and this needs to be dealt with Delicately but also taken very seriously. We have discussed that avoidance fuels further anxiety and that it is important for her to be attending as many classes as possible. Her mother is very concerned about this, and we agreed that this should be part of the discharge planning as well as transition planning in the community. Pearl agrees for the next month, it might be a difficult transition. But we have discussed to aim not to miss more than 1 day of school a week for the next few weeks during this acutely stressful period. It may be prudent to also screen her for ADHD inattentive type in case she is struggling academically and with focus that is beyond the neurovegetative shift of depression. 6. Cultural nuances and psychoeducation: Please note we had an extended family meeting upon discharge with Mom. [**Name (NI) 2**] states that the main issue is the discrepancy in her mother's understanding of mental health issues. She described that her mother thinks that depression is a "choice." Pearl, myself, and her mother had a long discussion about the importance of treating mental health like a biological illness that it is. We have also discussed the biopsychosocial model of depression and anxiety, which seemed to have resonated with her mother. At the end of the discussion, Pearl felt more supported, knowing that her mother is aware of the treatment plan and continues to be resistant with the medication trials but is more open. We have also discussed that medication trial of selective serotonin reuptake inhibitor in adolescents should be maintained for at least 1 year before it is reviewed. Lastly, I have sent them to web sites of [**Last Name (un) 1**] and anxiety Disorders BC for further information. They were also given handouts regarding the medication as well as a model of the treatment of depression in adolescents. COURSE WHILE ON CAPE All details will not be repeated on this dictation. Please refer to dictation on [**2020-07-02**], which was created by [**Initials (NamePattern4) 3**]. [**First Name8 (NamePattern2) 4**] [**Last Name (NamePattern1) 5**] and her resident. Essentially, Pearl has been struggling for approximately 2 years with depressive and anxiety symptoms. During our discharge meeting, Pearl was able to state that the main issues at hand have been: 1. The lack of support with mental health issues between her and her mother. 2. The recent spontaneous transition of her going to her father's home in Edmonton after not seeing him for approximately 5 years. 3. Ongoing academic challenges and social peer challenges. 4. Self-esteem and body image issues; however, it does not appear to be in keeping with disorganized eating, but rather a lot of her hunger cues are erratic secondary to somatic symptoms. With regard to her mood symptoms upon discharge, she was able to contract a safety. She continues to have low appetite, low energy, and overall feels unmotivated towards completing school, because she feels she is not smart enough and that she does not have a future anyway. She continues to feel hopeless and states that she has been feeling this way for years now; however, although she does not immediately believe that the help we are giving her will actually contribute to decreasing her depression, she is open to trying it out. She was very settled on our unit and was able to complete most of her meals. She was mostly isolating in her room, however, came to the common areas and was able to complete her safety plan and also engage with nursing staff. She was compliant taking her medications and only reported of a headache on the first night; however, she states that she already feels a little bit better. MENTAL STATUS EXAMINATION ON DISCHARGE Pearl was appropriately dressed for this interview. She had her make up fully done and was pleasant on all accounts. Her eye contact was variable and at times downcast. She was able to respond to all questioning appropriately and with limited detail. Her speech was of normal rate, rhythm, and prosody. There were no abnormal orofacial movements noted or tics noted. There was no evidence of psychomotor retardation or agitation. At times, she was looking to the side when her mom was present during the interview; however, she was able to focus for the most part. Her thought content: No delusions, no perceptual disturbances. She was quite fixated on feeling "hopeless" and was not sure what the future entails for her. Her thought form was organized and goal directed. Her insight was limited but somewhat improving, knowing that she does need help and that she is open to trying whatever in order to decrease her baseline level of depression and anxiety. Her judgment was limited, given her recent suicide of note on impulsivity around the same. We thank you for trusting us in the care of this pleasant young woman. If you have any questions or concerns, please do not hesitate to contact the undersigned. Sincerely yours, [**Signature 6**] Dictated By: [**Name6 (MD) 7**] [**Name8 (MD) 8**], MD Psychiatry SN/MODL Job #: 030442 Doc #: 32654440 D: [**2020-06-06**] 10:09:38 T: 09/10/2017 11:07:00

BC MENTAL HEALTH CENTRE AND SUBSTANCE ABUSE Patient Loc-Svc: CPE-MH DISCHARGE SUMMARY Admitted: 21/10/2017 (DD/MM/YYYY) Discharged: 25/10/2017 (DD/MM/YYYY) ADMISSION DIAGNOSES 1. Attention deficient hyperactivity disorder. 2. Disruptive behavior disorder. 3. Posttraumatic stress disorder. 4. Query neuroleptic malignant syndrome. DISCHARGE DIAGNOSES 1. Attention deficient hyperactivity disorder, combined type, severe. 2. Insecure attachment with separation anxiety. 3. Posttraumatic stress disorder. 4. Neuroleptic malignant syndrome was ruled out but he had elevated CK from dehydration and ongoing restraint in hospital. IDENTIFICATION AND COURSE ON THE UNIT Please see other records including the excellent admission note dated [**2020-07-17**], by Dr. [**Last Name (STitle) 1**]. [**Last Name (un) 2**] is an 11-year-old boy who has a long history of inconsistent, abusive, and rejecting parenting through much of his life and already by age of 8 or 9, he had been in foster care a few times and had been in long-term residential therapeutic placement to try to manage his disruptiveness and PTSD symptoms. In [**2020-01-26**], after being in foster care again, he was transferred from Saskatchewan under the care of his mother to maternal grandmother, and he has had a fluctuating pattern of disruptiveness. In part, this may reflect undertreated ADHD, as he was often cheeking his medications. He seemed to have some degree of behavioral activation and agitation from guanfacine when it was increased to 4 mg while in [**Location (un) 3**]. In Saskatchewan, when he had a trial of guanfacine this led to headache, chest pain, and agitation. There have been multiple visits to emergency and RCMP calls, and difficulty attending school due to his impulsive disruptive behavior, property destruction, as well as suicidal and homicidal threats when distressed. [**Last Name (un) 2**] is always genuinely remorseful and trying to make amends after these rage episodes. Maternal grandmother was clear that his Concerta 54 mg p.o. q.a.m. starts working around 11 in the morning, and wears off by 4 p.m., so he spends most of his days dysregulated. After an episode when he was tinkering with chemicals, a common pastime, he nearly set a building on fire. When this was challenged, [**Last Name (un) 2**] threatened to kill others, kill himself, he was chasing family members and violent to the family dog. He was taken to [**Location (un) 3**] Emergency where he was very dysregulated and violent to the point that he was in restraints, needed multiple medications, referred to CAPE, and transferred by air ambulance. When he was first seen in our emergency is his CK was very high. This was seen is secondary to dehydration and the use of ongoing restraints rather than neuroleptic malignant syndrome, and with intravenous rehydration and being out of restraints, his CK quickly dropped into the normal range. Investigations while on the unit were unremarkable. While on the CAPE unit, he generally presented as a pleasant and charming boy, who was clearly hyperactive, very apologetic for his behavior and we did not see the extreme disruptiveness that was noted in [**Location (un) 3**]. That being said, he had extreme separation anxiety and great difficulty when his grandmother would leave to use the phone, take a break, or go to sleep elsewhere in the evenings. From information from grandmother as well as from [**Last Name (un) 2**], it does appear that the formulation seems correct that he has a biological loading for impulsive violence and substance abuse. His biological father apparently still remains in jail for violent crimes. He was raised in a chaotic and neglectful environment with very little consistency, leading him to be insecurely attached, become quickly overwhelmed, and have a catastrophic sense of real or perceived abandonment. Additionally, his adoptive father was physically violent and demonstrated violence and rage episodes as an acceptable way to cope with the inner distress. Within this context of modeling of behavior and lack of consistency as well as significant ADHD symptoms, [**Last Name (un) 2**] has developed an entrenched pattern of acting out in silly ways which is disruptive, preventing him from doing well at school, and explosiveness when distressed, most significantly by anxiety. He improves when he has been in a therapeutic placement. He is clearly attached now to his grandmother and if he sees any threats to his placement there as intensely distressing, it is leading him to blow up. [**Last Name (un) 2**] has strengths in that he sees himself as creative; that he is not destroying property or harming animals for the joy of it, but rather in reaction to inner distress. He has been able to maintain a place on a hockey team, clearly wants to do well in school, and is remorseful for his actions between outbursts. PLAN While in hospital, as he was so settled, we focused on the importance of counseling for his PTSD symptoms and is already connected to the [**Location (un) 3**] Child and Youth Mental Health Team with Cat. Dr. [**Last Name (STitle) 4**] is providing occasional psychiatric consultation when he flies into Cranbrook, and Dr. [**Last Name (STitle) 5**] is providing pediatric consultations. He does not need a larger team at the moment. While in hospital over the weekend, he was seen by multiple different doctors, who suggested multiple medication options. I reviewed all of those in great detail with the grandmother including the quick acting medications such as risperidone, clonidine, or benzodiazepines. [**Last Name (un) 2**] and his grandmother noted great improvement with clonazepam on the unit, but they recognize that this is addictive and given his family history of addiction, it is not optimal. We also reviewed the longer-term options such as the use of Strattera which can target anxiety and ADHD, though low chance of success. Clonidine to target ADHD and inner distress, though it seems to be given 4 times a day, or fluoxetine as a slow-acting agent for anxiety. After reviewing the usual and serious side effects, pros and cons of each of these options, Grandmother had opted for a clonidine 4 times a day trial. The plan is to optimize this dose and then to look to add in fluoxetine to treat anxiety. Hopefully, with this combination, there may be less of a need for Concerta and the dose could be lowered at some point. Grandmother was clear that she is generally against medication but recognizes the degree of distress as such that medications are required in part until the counseling and stability of placement can have more effect on [**Last Name (un) 2**]. MEDICATIONS ON ADMISSION 1. Concerta 54 mg p.o. q.a.m. 2. Guanfacine 4 mg was recently stopped as he had recurrence of agitation on this higher dose. MEDICATIONS ON DISCHARGE 1. Concerta 54 mg p.o. q.a.m. 2. Clonidine 0.025 mg p.o. q.a.m., q.11:00, q.14:00, and q.18:00. In 1 week, this will re-increased at 0.05 mg per dose and Dr. [**Last Name (STitle) 5**] may need to do more adjustment thereafter to get the best benefit with fewer side effects. After this has been optimized, we suggested waiting at least 1 week after the last dose change and starting fluoxetine 10 mg p.o. q.a.m. I provided prescriptions for these medications. It will be useful for Dr. [**Last Name (STitle) 4**] to be available to the team as backup around reassessment and medication management. In addition, we recommend that [**First Name4 (NamePattern1) 6**] [**Last Name (NamePattern1) 7**] and Youth Mental Health team put [**Last Name (un) 2**] on the wait list for a planned admission to P1. If this combination of medications settles down his disruptiveness, he may not need a planned admission, but if when he gets to the top of the wait list, he is so disruptive that his placement with his grandparents in jeopardy, it is well worth having that option. MENTAL STATUS EXAM ON DISCHARGE [**Last Name (un) 2**] presented as a smiling, verbally impulsive, somewhat active boy, who was pleasant, cooperative, eager to talk about his workshop, and tinkering with rebuilding engines. He was looking forward to returning to school in community and denied any suicidal ideation, and these threats seem only to come up in moments of rage rather than being a persistent thought. Overall, he appeared to be of average or possibly below average intelligence, with partial insight as he is remorseful after the fact, but he has such intense anxiety and distress, that he has difficulty controlling his reactions. That being said, he reports that he is much less anxious even on the starting dose of clonidine, so it may be effective in treating both ADHD and anxiety. Regarding other issues, [**Last Name (un) 2**] was flown by air ambulance without any ID. He has had photocopies of ID faxed to hospital and additionally, we wrote a letter that hopefully will allow him to fly using these photocopies of ID. [**Signature 8**] Dictated By: [**First Name11 (Name Pattern1) 9**] [**Initial (NamePattern1) 10**] [**Last Name (NamePattern1) 11**], MD Psychiatry AWF/MODL Job #: 074977 Doc #: 32884687 D: 24/10/2017 15:13:50 T: 24/10/2017 15:54:43

BC MENTAL HEALTH CENTRE AND SUBSTANCE ABUSE Patient Loc-Svc: CPE-MH DISCHARGE SUMMARY Admitted: 15/11/2017 (DD/MM/YYYY) Discharged: 20/11/2017 (DD/MM/YYYY) ADMISSION DIAGNOSIS Not given. DISCHARGE DIAGNOSES 1. Borderline personality organization. 2. Persistent depressive disorder/dysthymia. 3. Social anxiety. MEDICATIONS ON DISCHARGE 1. Sertraline 150 mg p.o. nightly. 2. Lorazepam sublingual 0.5 mg. MEDICATIONS AT DISCHARGE 1. Sertraline 175 mg p.o. nightly for another 3 days then increase to 200 mg p.o. nightly. 2. Lorazepam 0.5 mg as a p.r.n. for anxiety. 3. Gravol 25 mg q.6 h. p.r.n. internal agitation. TREATMENT PLAN AFTER DISCHARGE 1. Return to the TRACC program to be followed by [**First Name5 (NamePattern1) 1**] [**Last Name (NamePattern1) 2**]-[**Last Name (un) 3**] for dialectical behavior therapy. 2. Continue with Dr. [**Last Name (STitle) 4**] [**Name (STitle) 5**] for medication management until the [**Location (un) 6**] psychiatrist is available to take over care. IDENTIFICATION AND COURSE ON THE UNIT Please see other records for more details. In brief, [**Female First Name (un) 7**] is a 14-year-old young woman who has had many years of depressive symptoms. Many years of suicidal thoughts and described making a commitment to herself to kill herself by the age she was 11 and the commitment to kill herself by that time she was age 13, and that she reports an increase in suicidality in the 2 weeks prior to admission without any clear stressors or other factors adding into this. She was seen as having a change in clinical status leading to an admission to clarify her current issues, to ensure that she has appropriate followup, possibly adjust medications. While in hospital, she presented as bright, cheery with her co-patients and in fact it appears they have formed a cadre of like-minded individuals who had exchanged phone numbers and contact information, and over the weekend had all secretly planned to sabotage either passes in order to get back on to the unit to continue socializing. We certainly worry about regression or developing new symptoms or contagion and parents were specific that she was eating much less when she would be out on pass that they wonder if this might be secondary to influence from a co-patient with some eating disorder symptoms. Despite her looking bright and cheery with co-patients, clearly enjoying herself on meeting with psychiatrists, she was fairly consistent in saying that she was despondent, that she would kill herself if she went on pass; but then would go on pass without any suicide attempt, though she also cuts for self soothing, and cut on her Saturday pass, and cut again on her Sunday pass. Given [**Female First Name (un) 8**] resistance to looking at ways to try to improve and her efforts to try to remain on the unit to socialize with other patients; although she was clearly distressed it was felt that hospitalization for a longer period of time would not be helpful and was already becoming harmful. INVESTIGATIONS IN HOSPITAL CBC was unremarkable. Electrolytes and liver function was unremarkable. Total cholesterol 4.17, triglyceride 0.89, HDL 1.26, LDL 2.51, TSH was in the normal range at 1.55, and serum insulin was normal at 38. MENTAL STATUS ON DISCHARGE [**Female First Name (un) 7**] presented as a well groomed 14-year-old young woman with braces who presented as somewhat guarded, and unlike other interviews was not tearful through the time. She was able to describe years of suicidal thoughts and reported that her risk of suicide was higher, but it does not appear that she has come close to acting on her thoughts, and this is more of a chronic pattern. Interestingly, she endorsed that, unlike the fluoxetine, her dose of sertraline was quite helpful to make her thoughts clearer and to completely get rid of suicidal thoughts, and the urge to cut. [**Female First Name (un) 7**] reports having so many years of suicidal thoughts and cutting that this change was unnerving as if she no longer knew who she was if she was not suicidal, and she described trying to force herself to think of suicide and forcing herself to cut, even though there is no longer release from distress. [**Female First Name (un) 7**] describes ongoing dysthymic symptoms, though she is clearly enjoying herself on the unit. This initial clearing of thoughts and lightening of mood has not been sustained. Despite [**Female First Name (un) 8**] clear ongoing reports of suicidality going back many years. It appears that her risk is moderate for a suicide attempt, this is chronic and she is at her baseline level of risk. Keeping [**Female First Name (un) 7**] in hospital could increase her risk but could not decrease this. She already seemed to be regressing, becoming institutionalized and was starting to pick up symptoms from other patients. FORMULATION [**Female First Name (un) 7**] is a 14-year-old young woman with biological loading for depression who has had many, many years of low-grade low mood fitting with dysthymia with episodic dips into depression but also borderline personality structure and use of cutting as a way of self soothing. Unfortunately, it is only in the last 2 weeks that she has connected with a long-term therapist in [**Location (un) 6**] who will be providing DBT, so she has been managed mostly with medication and private therapy that has not lead to significant change, though she reports sertraline had been effective at changing her symptoms to the point that she was unnerved and seemed to be making deliberate efforts to have her suicidality come back. Within this context, it is unclear why over the last week or 2 there is persistence of depressed mood if she had had an earlier response to sertraline. Although she has had chronic suicidal ideation, she is at low-to-moderate risk chronically, and it seems to keep her in hospital was leading to regression and absorbing symptoms from others so a longer hospitalization would increase her risk and is relatively contraindicated. RECOMMENDATIONS As part of her treatment, since she had an early response to sertraline, Dr. [**Last Name (STitle) 5**] was increasing the dose up to 200 mg in a stepwise manner. Additionally, we had heard that she is just starting dialectical behavior therapy within [**Last Name (un) 1**] which is the treatment of choice for the borderline traits. We worked with parents to start to look at how to come up with family rules, expectations, to encourage her to return to school, etc., and the complex interplay between trying to keep her safe without being intrusive. I suspect there will be a lot more work that will need to be done in family therapy or with the support of [**Last Name (un) 1**]. Luckily parents or already connected to [**Last Name (un) 9**] Family Services for parenting support. We have worked on safety proofing the home and a return to her therapist with whom she has an appointment tomorrow, and return to school as soon as possible. In addition to the above, there was suggestion on the admission note of adding in a second-generation antipsychotics to augment her sertraline. At the time of discharge, it does not seem the best time to start that up; but I spoke with parents about how if lorazepam is not effective as a p.r.n., we often go to the older antihistamines such as Gravol, if that is ineffective or not tolerated, then there are the SGAs as were discussed on admission. After reviewing the possible benefits and side effects of Gravol, they are all comfortable with giving this a try; and parents know that they can speak with Dr. [**Last Name (STitle) 5**] about other treatment options if this is ineffective. As a team we recognize that [**Female First Name (un) 7**] is distressed, and unfortunately, there is no effective treatment in hospital, and she may be made worse in hospital despite her degree of distress; and we expect in the next short term, since she enjoyed being in hospital so much, she may be making efforts to be readmitted. Readmission is not absolutely contraindicated, but if [**Female First Name (un) 7**] presents to the emergency and is considered for admission, there would have to be a clear condition for which there is effective treatment in hospital as well as a discussion about the potential dangers of hospitalization including what we have already observed: [**Female First Name (un) 7**] seeing herself as an institutionalized patient and strongly affiliating with other borderline youth. Overall we believe that the dialectical behavior therapy is the treatment of choice; and assuming she can stick with this, she should be feeling much more stable and settled in the next 6 months or so. [**Signature 10**] Dictated By: [**First Name11 (Name Pattern1) 11**] [**Initial (NamePattern1) 12**] [**Last Name (NamePattern1) 13**], MD Psychiatry AWF/MODL Job #: 149550 Doc #: 33281086 D: 20/11/2017 14:13:47 T: 20/11/2017 15:18:22

BC CHILDREN'S HOSPITAL Patient Loc-Svc: T1ED-MH DISCHARGE SUMMARY Admitted: [**2020-03-08**] (DD/MM/YYYY) Discharged: [**2020-05-08**] (DD/MM/YYYY) [**Female First Name (un) 1**] was admitted to the CAPE unit on [**2020-09-01**] certified under the mental health act. This discharge summary should be seen together with the admission history, which was dictated on the date of admission. [**Female First Name (un) 1**] was discharged from BC Children's Hospital [**2020-09-03**] and transferred to child and adolescent psychiatric stabilization unit at Surrey [**Hospital 2**] Hospital. PATIENT IDENTIFICATION [**Female First Name (un) 1**] is a 16-year-old female in grade 11 at Delta Secondary School. She lives with her mother, father and her younger sister. She has a previous history of OCD, anxiety and depressive disorder that had resulted in the past in an admission to the Child Inpatient Unit at Children's Hospital. She has been stable and doing very well over the past 3-1/2 years. She was admitted to hospital after a 3-week decline in her mood that resulted in decreased concentration, decreased interest, increased social withdrawal, sleep interruption, decreased appetite, and increasing suicidal ideation. COURSE IN HOSPITAL [**Female First Name (un) 1**] settled onto the CAPE unit, spending much of her time in her room. She was withdrawn and did not interact with copatients on the unit nor staff. She remained in hospital pajamas. She was guarded. She disclosed frustration that her parents were trying to mobilize her out of her bedroom at home prior to admission, stating that she did want to be around people and found this difficult. This is an abrupt change from her usual outgoing socially engaging personality. She was observed to eat adequate amounts on the unit. She would come into interview without difficulty. However, it was difficult to engage her in much conversation and she did not respond well to open-ended questions. MENTAL STATUS ON DISCHARGE A 16-year-old female with long unkempt hair in hospital pjs, guarded, affect flat, mood depressed. There was evidence of psychomotor retardation and evidence of latency. Accessibility was limited. She denied on direct questioning any OCD symptoms or worsening anxiety. Eye contact was intermittent and avoided. Her speech was soft. Thought form was goal directed when she responded. There was no spontaneous interaction. She reported continued passive suicidal ideation but no intent or active plan. She denied continuing perceptual abnormalities. She reported at times hearing her name called but denied that was an ongoing issue for her. She does have some notable visual allusions that occur with lights but she has insight into these. Insight is partial. Judgment appropriate under the circumstances. DISCHARGE DIAGNOSIS Major depressive disorder, rule out with psychotic symptoms, moderate to severe. OCD by history well managed currently. DISCHARGE MEDICATIONS 1. Sertraline 50 mg in the morning, 150 mg at bedtime. 2. Quetiapine XR 200 mg at bedtime. 3. Melatonin 6 mg at bedtime. 4. She did not require p.r.n. medication through the course of her 2 days on the CAPE unit. She is followed by the mental health metabolic clinic and has had recent blood work done there, and as such her blood work was not repeated when she was admitted to CAPE. PLANS 1. Delta Child and Youth Mental Health Team was contacted and a referral was made for her to resume treatment with the team. 2. She currently sees Dr. [**First Name (STitle) 3**] who had been the psychiatrist with the Delta Child and Youth Mental Health Team several years ago when she was attending the team at that time. Apparently, he moved to the Surrey Child and Youth Mental Health Team but continued to follow [**Female First Name (un) 1**] and manage her medications through that team rather than transferring her care to an alternate psychiatrist. I believe that this was because she was doing quite well and he was only seen her once every 6-8 months. She will require either increased contact with him or transfer to a psychiatrist with the Delta Child and Youth Mental Health Team if they have 1 currently available. 3. Transferring her to the Child and Adolescent Psychiatric Stabilization Unit at Surrey [**Hospital 2**] Hospital for ongoing stabilization. [**Signature 4**] Dictated By: [**Last Name (un) 5**]-[**First Name4 (NamePattern1) 6**] [**Last Name (NamePattern1) 7**], MD Psychiatry JD/MODL Job #: 191294 Doc #: 33579779 D: [**2020-05-08**] 14:01:51 T: [**2020-05-08**] 14:34:44

BC MENTAL HEALTH CENTRE AND SUBSTANCE ABUSE Patient Loc-Svc: CPE-MH DISCHARGE SUMMARY Admitted: 31/01/2018 (DD/MM/YYYY) Discharged: [**2020-09-28**] (DD/MM/YYYY) CAPE UNIT DISCHARGE SUMMARY Date of admission: [**2020-10-27**]. Date of discharge: [**2020-10-28**]. MEDICATIONS ON ADMISSION None (sertraline prescribed). DISCHARGE MEDICATIONS 1. Fluoxetine 10 mg daily x1 week, likely will increase to a target dose of 30 to 40 mg. 2. Lorazepam 0.5 mg sublingually q.1h p.r.n. to a maximum of 1 mg per day, a 7 tablets prescription. ADMISSION DIAGNOSIS Major depressive disorder, with suicidal ideation. DISCHARGE DIAGNOSIS Major depressive disorder, with suicidal ideation. Anxiety traits and obsessive traits also present. TREATMENT/COURSE IN HOSPITAL [**First Name8 (NamePattern2) 1**] [**Last Name (NamePattern1) 2**] is a 14-year-old girl who lives with her family in Vancouver, British [**Location (un) 3**]. She has divorced parents and spends half time with her mother and half time with her father and stepmother. [**Female First Name (un) 1**] was admitted on [**2020-10-27**], after her 2nd presentation to the emergency department in 2 days. She had significant suicidal ideation on her time of admission, and was seen the next day for assessment and planning. In interview, [**Female First Name (un) 1**] presented as depressed. She endorses multiple depressive symptoms including loss of appetite, loss of energy, decreased sleep, decreased concentration, negative self talk and feelings of guilt and worthlessness, sadness, and lack of interest in normally enjoyable behaviors. She states that these things have been going on for a very long time and she cannot remember the last time, she felt well. She was just discharged from the hospital yesterday following presentation to emergency department for thoughts of wanting to cut her wrists, and she states that when she was discharged, the day was going relatively well although she had the background suicidal ideation, and then when she went to see her therapist was able to do a safety plan. However, shortly after that, she "quickly unraveled" and became suicidal once again and had to come to the hospital. Because of the rapid representation to the emergency department admission was an obvious choice and [**Female First Name (un) 1**] was admitted to the CAPE unit without any incident. [**Female First Name (un) 1**] did a lot of self isolation on the unit, primarily owing to the fact that she finds herself to be relatively socially awkward and anxious, and she had a very hard time introducing herself on the unit. As well, the unit milieu was somewhat intense with a patient with high needs, and she had some concerns that she might not be safe on the unit. This was not paranoia, it was well founded. [**Female First Name (un) 1**] spent her time in the patient room, drawing, and then when her mother brought a book, reading. [**Female First Name (un) 1**] states that she has a good relationship with Dr. [**Last Name (STitle) 4**] and looks forward to seeing her weekly. She notes that things have been deteriorating despite seeing Dr. [**Last Name (STitle) 4**] but was quite insistent that she fell that Dr. [**Last Name (STitle) 4**] was being helpful for her and wanted that relationship to continue. She did agree that she needs to try and start medication, and the prescription has been given but she had not yet taken it (only prescribed a few days ago). When we reviewed medication options, she was willing and eager participant, asking appropriate questions but clearly wanting to feel better. [**Female First Name (un) 1**] describes a long-standing suicidal ideation that has never quite left. She states the last few days have gotten more intense, however she also reaches out for help and recognizes that things need to get better. She is able to identify a number of future goals such as going to [**Location (un) 5**], graduating high school, becoming a microbiologist, seeing her friends, etc. She states that the thoughts of death and dying sometimes overwhelm her and recently she has been feeling less swayed by the idea that people around her would suffer and feeling more that she has such a failure that people around her would do better if she was dead. During our conversation she was quickly able to identify that as a maladaptive thought, and something that was more like "the depression talking." She admits that her depression has gotten the best of her over the last little while and she has noticed a significant decline. She finds it very hard to concentrate at school, even though she is getting very good marks. [**Female First Name (un) 1**] was able to share that she would like to get better and was willing to take medication, and by the end of our interview time she was working on a discharge plan. A meeting with mother revealed significant concern for the deterioration despite therapy. Mother was on board with medication and needed little convincing. Father was away in the UK but mother felt that their goals were aligned and father was available for a followup meeting that we will be scheduling. Mother agreed to the discharge plan as outlined below, and [**Female First Name (un) 6**] stepmother and grandmother also joined for the family meeting in consideration of the same. [**Female First Name (un) 1**] had no major incident on the unit and did relatively well. She received psychoeducation very well with respect to medication and continues to endorse to want to see Dr. [**Last Name (STitle) 4**]. She seemed to get along well with the writer and was happy to see me in follow up appointment next week, and when given the opportunity to stay in hospital overnight 1 more night or go home, [**Female First Name (un) 1**] chose to go home. She seemed to be in a good frame of mind, and understood that she could come back to the hospital at any time. She completed the safety plan with us which was similar to the one that she had with Dr. [**Last Name (STitle) 4**] the previous day. MENTAL STATUS EXAMINATION ON DISCHARGE [**First Name8 (NamePattern2) 1**] [**Last Name (NamePattern1) 2**] is a 14-year-old, slender, female, who looks her stated age. She had dark circles under her eyes. She was somewhat slow in her movements but not fully bradykinetic. She has good hygiene and good posture, was reciprocal and interactive during the conversation. Her language use was good and she was fluent in English. She was able to articulate herself clearly. Thought form was organized and goal directed. Thought content was free of any major delusions but she has overall depressive content with significant lack of self-esteem and over emphasis on negative judgment. Perceptual abnormalities were denied. Affect was sad but she was able to brighten up and showed good sense of humor in response to jokes. Mood was described as low and sad. Insight and judgment were appropriate for her age, and suicidal thinking is ongoing and passive, with no active thoughts today. RISK ASSESSMENT [**Female First Name (un) 1**] obviously struggles with long-standing suicidal ideation but she has a life long history of self-injury with multiple opportunities for further injuries that she has not seized upon. She is future focused and amendable to psychotherapeutic, as well as pharmaceutical treatment, and was able to construct a significant and reasonable safety plan. She has good supervision, good access to followup, and with her visit here that she is familiar with how to reach out to emergency services and get hospital help. [**Female First Name (un) 1**] was an active participant in her care and was a problem [**Name (NI) 7**], and though suicidal ideation is a major concern and I will always worry about her risk for suicide, at the time of her admission, and in planning for her discharge, her risk of death by suicide seems modest, particularly in the light of her intractability and problem solving. I have no doubt that she is struggling with depression but she was hopeful that medication treatment be helpful for her and liked the idea of using emergency medications instead of entertaining suicidal thoughts for very long. Overall, I do not think a longer hospitalization is warranted, and the exposure to risk on the unit with our more activated patient's right now does not seem a large benefit compared to her discharge to her loving and well supervised home, when she is willing and able to engage in both voluntary, as well as emergency treatment by accessing Hospital. With rapid followup and ongoing psychotherapeutic care, I believe that discharge is appropriate. PLAN 1. Follow up with Dr. [**Last Name (STitle) 4**] as previous. 2. I will contact Dr. [**Last Name (STitle) 4**] by phone at [**Telephone/Fax (2) 8**], and update regarding the admission today. As well, her school counselor, Mr. [**Last Name (Titles) 9**], who is available at [**Telephone/Fax (2) 10**] or [**Telephone/Fax (2) 11**], to discuss reduction of school burden. 3. We started medication as indicated above. 4. [**Female First Name (un) 1**] will come see me for followup on [**2020-11-04**], at 4:30 p.m. I will see her weekly while medication starting. 5. We will be available for [**Female First Name (un) 1**] long-term. If she needs to come back to the hospital she can present to the emergency department at any time, as well I provided my e-mail address and I am very comfortable with [**Female First Name (un) 1**] or her family emailing me as I am available generally the next day for any urgent concerns. It was a pleasure seeing [**Female First Name (un) 1**] and her family during this stay and we wish her the very best in the future. [**Signature 12**] Dictated By: [**First Name4 (NamePattern1) 13**] [**Last Name (NamePattern1) 14**], MD Psychiatry TB/MODL Job #: 332146 Doc #: 34369705 D: [**2020-09-28**] 17:03:45 T: [**2020-09-28**] 18:36:52

BC CHILDREN'S HOSPITAL Patient Loc-Svc: T1ED-MH DISCHARGE SUMMARY Admitted: 13/03/2018 (DD/MM/YYYY) Discharged: 19/03/2018 (DD/MM/YYYY) MOST RESPONSIBLE DIAGNOSIS Adjustment disorder. PRE-ADMIT DIAGNOSIS 1. Major depressive disorder. 2. Generalized anxiety disorder. POST-ADMIT DIAGNOSIS 1. Major depressive disorder. 2. Generalized anxiety disorder. PRE-ADMISSION MEDICATION 1. Fluoxetine 40 mg p.o. daily. 2. Clonazepam 0.25 mg p.o. q.a.m. and 0.5 mg p.o. at bedtime. MEDICATIONS ON DISCHARGE 1. Citalopram 10 mg p.o. daily with a goal of increasing every week until a target dose of 40 mg p.o. daily is reached. 2. Clonazepam 0.25 mg p.o. q.a.m. 0.25 mg p.o. at bedtime. The goal with the clonazepam is to taper and discontinue over a 2-week period of time. DISCHARGE DISPOSITION [**Female First Name (un) 1**] was decertified and discharged home to the care of her parents. POST-DISCHARGE FOLLOW-UP [**Female First Name (un) 1**] will follow up with the Pacifica Spirits Mental Health team. RISK ASSESSMENT On the day of discharge, [**Female First Name (un) 1**] reported that, despite having ongoing suicidal ideations "at the back of her mind," that currently she did not have any specific plans or intent. As such, her acute risk of suicide or significant self injury is low. However, [**Female First Name (un) 1**] has a longstanding history of having chronic suicidal ideations and as a result, will always be at risk of completed suicide. Despite this, the potential lethality of her plans remain of low risk. Her previous attempts of suicide and self-harm behavior include cutting herself, threatening to jump out of moving cars, or jumping down a flight of stairs. However, upon further exploration of her suicidal intent during her current admission, [**Female First Name (un) 1**] disclosed that there where several protective factors that prevented her from completing or going through with her plans which included the love that she has for her parents and having a relatively low pain tolerance. As such, [**Female First Name (un) 1**] remains a chronic risk for suicide or significant self injury; however, her current acute risk is low. TREATMENT/COURSE IN HOSPITAL [**First Name8 (NamePattern2) 1**] [**Last Name (NamePattern1) 2**] is well known to the CAPE unit from previous brief admissions and followup with Dr. [**Last Name (STitle) 3**] for medication management for her depressive and anxiety symptoms. Please see past consultations and discharge summaries for complete details. [**Female First Name (un) 1**] was brought to the ER on [**2020-12-07**], by the RCMP after her mother had found her cutting her wrists and after [**Female First Name (un) 1**] had attempted to jump out of the window as a suicidal attempt. She was assessed in the ER and certified under the Mental Health Act for further management and safety concerns. Over the course of her admission, [**Female First Name (un) 1**] did endorse having suicidal ideations while admitted in the CAPE unit, however, on daily assessments, began to deny having a specific plan or intent. She described how she could not identify any recent triggers or stressors that might have affected her presentation, though [**Female First Name (un) 1**] did disclose that she always has a plan at the back of her mind for how she would commit suicide when the opportunity presents itself. Despite this, she remained well settled on the unit and was compliant with her treatment plan. [**Female First Name (un) 1**], though, did mention how she felt that the fluoxetine 40 mg p.o. daily that she was taking was not entirely effective in managing her depressive and anxiety symptoms. As a result, [**Female First Name (un) 1**] was started on citalopram 10 mg p.o. daily, and the fluoxetine was discontinued. In addition, [**Female First Name (un) 1**] had psychological testing done with Dr. [**Last Name (STitle) 4**], which [**Female First Name (un) 1**] said she found very helpful and therapeutic. Dr. [**Last Name (STitle) 4**] also worked with [**Female First Name (un) 1**] on formulating and modifying her current safety plan. Several family meetings were held with her parents, where support was provided regarding [**Female First Name (un) 5**] safety, and approaches were suggested on how her parents should manage when [**Female First Name (un) 1**] has ongoing suicidal ideations or is engaging in self-harm behaviors. [**Female First Name (un) 5**] parents said that they felt well supported with the plan and also felt safe with regard to her being discharged under their care. On the date of her discharge, a meeting was held with her parents and [**Last Name (un) 6**], from Pacific Spirit, regarding post discharge followup with the mental health team as well as starting the process of referring [**Female First Name (un) 1**] for DBT therapy. On discharge, [**Female First Name (un) 5**] mental status was observed as being more engaged in conversation, she volunteered providing information on her own rather than being prompted. She was cooperative and more accessible. Reliability still remained questionable, but rapport was easier to establish compared to previous interactions. Her eye contact was consistent, and her speech was normal in rate, rhythm, tone, and volume. Her thought form was organized, coherent, and goal and future oriented. Despite endorsing current suicidal ideations, she denied having a plan or intent and felt safe to be discharged home. She denied any delusional content, as well. Her mood subjectively was "improving," and her affect was euthymic and reactive. Her cognition was grossly intact, and she denied any auditory hallucinations or visual hallucinations. Her insight and judgment were both deemed as being fair. Thank you for involving us in this patient's care. [**Signature 7**] Dictated By: [**First Name9 (NamePattern2) 8**] [**Last Name (un) 9**] (Res), MD [**Signature 7**] Dictated For: [**First Name4 (NamePattern1) 10**] [**Last Name (NamePattern1) 3**], MD Psychiatry VP/MODL Job #: 459275 Doc #: 35087473 D: 20/03/2018 13:17:37 T: 20/03/2018 15:07:09

BC MENTAL HEALTH CENTRE AND SUBSTANCE ABUSE Patient Loc-Svc: CPE-PM OUTPATIENT PSYCHIATRY CLINIC DISCHARGE SUMMARY Admitted: [**2020-12-29**] (DD/MM/YYYY) Discharged: (DD/MM/YYYY) Date of admission: [**2020-12-29**]. Date of discharge: [**2020-12-30**]. Admission medications: 1. Risperidone 1 mg daily. 2. Fluvoxamine 125 mg daily. 3. Doxycycline 100 mg daily. 4. Feramax 300 mg daily. 5. Melatonin 10 mg nightly. 6. As needed: Benadryl. Discharge medications: No change to any medications except: 1. Risperidone will be slightly increased by 0.125 mg every week for a target dose of 1 mg p.o. b.i.d. 2. Benztropine has been added as a p.r.n. medication in case of any extrapyramidal side effects. 3. Doxycycline, Feramax, Melatonin, and fluvoxamine are unchanged. ADMISSION DIAGNOSIS Autistic spectrum disorder, borderline intellectual disability, aggression in the context of previous. DISCHARGE DIAGNOSIS Autistic spectrum disorder, borderline intellectual disability, aggression in the context of previous. COURSE IN HOSPITAL Please see the excellent consultation note by Dr. [**First Name4 (NamePattern1) 1**] [**Last Name (NamePattern1) 2**] regarding the admission of Noorayne Ladha. I have known Noorayne from previous consultations in the emergency department, and this admission summary was very helpful in catching me up to the things that have recently happened. Noorayne had a very short stay on the CAPE unit which was uneventful from any safety events. Briefly, Noorayne was admitted to hospital for endorsing suicidal ideation in the context of conflict with his family, who had removed equipment that he usually uses for entertainment (Nintendo DS, computer) after he broke a laptop in frustration. During the next day, he became very upset with respect to his loss of privileges, had to be removed from school after getting very upset, and then when he was at home he indicated that he wanted to hurt himself. Mother drove him to hospital. Noorayne spent the evening sleeping, and was very easy to be interviewed on the next day of admission. Meeting with Noorayne, it was clear that he had returned to his baseline. He had perceived some slights with respect to his mom taking away his electronics, but he admitted that he took things too far and felt like he said things that he did not mean. He autistically explained many problems that he has with the world, and on the face of it these are concerning things to be said. For example, he believes that the world would be better without any children. He believes that the world would be better if someone would kill [**First Name4 (NamePattern1) 3**] [**Last Name (NamePattern1) 4**]. He believes that if there were no banks or money, that people would be happier. He also makes misogynistic and racial comments, sharing with me that he wished that there were "no women, and no black people." He says these very matter of factly, and I do not believe his intention is to create any offense, but it is clear that by expressing these things he is going to create significant concern for people around him. I shared that with him, and he admitted that he should not say those things out loud. I believe that in his autistic world, he is very influenced by his online hang outs. He is particularly interested in two Internet web sites, Reddit, and 4 [**Last Name (un) 5**], both places where if one wants to, they can descend into a world of significant misogyny, racism, and hatred. I believe that Noorayne is very influenced by things that he reads online, and is very powerfully captured by funny things such as the means or jokes, even at the expense of misogyny or racism. I shared with Noorayne that he needs to make sure that he is looking at things that are appropriate and remembering that people online can be manipulative. Noorayne superficially accepts this but also believes that he is part of the group and believes that he could lead "a revolution against the world." Noorayne admits that he should not have been aggressive towards his mother and should not have threatened suicide. He is no longer suicidal. He feels like going home is appropriate, and felt like he had no difficulties with being discharged today. He wanted to be a part of any family planning meetings, and was receptive to the idea of me meeting with his parents first. When parents came in for a meeting, they shared that his behavior had declined since March, with a reduction of risperidone from a higher dose which caused significant oculogyric events, down to 1 mg which has not led to any oculogyric events but has been less helpful with respect to containing his aggression. We explored options with respect to treating this and parents selected the treatment plan below, which was our recommended treatment plan. Parents had no concerns in taking Noorayne home and felt that he had returned to baseline. They were appreciative of his short stay on the unit but they do miss him and the unit was active with respect to distress by other patients, so they were worried about the influence of fear on Noorayne. They elected to take him home on discharge. Noorayne was discharged easily with no complications on [**2020-12-30**], at approximately 2 p.m. IMPRESSION If feels like Noorayne was doing better at 2 mg of risperidone but he was having events that were quite convincingly oculogyric crises. These events are dangerous with respect to their connection to other central dystonias, which can include laryngospasm. For this reason, it is very important to weigh the oculogyric crisis' significant negative with respect to risperidone. At the same time, the risperidone was restarted from a switch from aripiprazole at a high dose and ramped up very quickly, and with his previous good response to risperidone and his lack of any dystonia today, we felt that it was appropriate to try and increase his risperidone gradually. Another option that was considered was to keep his risperidone exactly where it was, but to add clonidine. In the pursuit of not adding too many medications together, he is already on quite a list, we elected to do a cautious re titration of risperidone, watching out for any oculogyric events. With respect to his behavior and language, it will always be shocking and in his autistic world, he is not causing any offence by his statements. He comes across as legitimately a charming person, but when you delve into his thinking it is clear that he is very black and white, and he has been heavily influenced by racial and misogynistic posts online. That all being said, he treats people with respect and says the right thing when he knows he should. Some of his more outlandish statements are very difficult to digest, but I believe that there is no current evidence of any significant violence towards others or his threats that he has mentioned to other people do not seem to have significant weight behind them. I know that he has lost school standing and had to switch schools because of a threat towards principal, and he says some things such as "wanting to kill all children which are obviously unsettled. At the same time, his autistic spectrum disorder is not treatable, and he is well contained and responds very well to a behavioral approach. He holds himself to a very high standard and I believe his greatest risks are when he is frustrated doing self injury or attempting to elope. I do not believe that he is at risk for homicidal acting out, either injuring others or trying to kill others. When it comes to his suicide risk, his autism and borderline IQ are protective factors. That being said, in frustration I could see him hurting himself. For this reason, frustration tolerance is one of our biggest goals, which I hope that the medication changes will accommodate. As well, I have encouraged parents not to try too many behavioral things right now while he is clearly unsteady. For all these reasons, I felt that discharge from hospital was appropriate, there is a chronic risk of hurting himself, and he has previously made threats against others, however I do not believe that these threats or violent parameters will change with any inpatient treatment, and a gradual titration of risperidone is most appropriately done as an outpatient. Watching Noorayne react so negatively to emotion of the unit (another patient became quite distressed) was also quite convincing that the hospitalization was relatively traumatic for Noorayne. With parents being on board with the safety plan, demonstrating excellent judgment with respect to managing Noorayne, and Noorayne's willingness to try to take things a little bit easier and try a new medication, discharge was appropriate. TREATMENT PLAN 1. Increase gradually risperidone by 0.125 mg every week to a target dose of 2 mg (1 mg b.i.d.). 2. Mother will keep look out for any oculogyric events, if they happen, she has benztropine on order to be able to give him. If the benztropine does not work I have instructed her to bring him to the hospital. 3. If risperidone is not able to come back to the full dose at 2 mg total dose daily, going back to 1 mg daily and using clonidine, with an eye to possibly switching to clonidine or guanfacine monotherapy should be the next course of action. 4. We set up appointments with Dr. [**Last Name (STitle) 6**] for followup with respect to dystonia. I will check in for any appointments that Dr. [**Last Name (STitle) 6**] can not make, and mother can set up an appointment with me to check in. We are hopeful that the dystonia checks can happen biweekly, and if there is any challenges with increasing the doses, we can hold at our current dose or consider going to the clonidine. Please note that as of today, at 1 mg of risperidone there was no dystonia or clonus noted. It was a pleasure working with Noorayne and we wish him the very best in the future. [**Signature 7**] Dictated By: [**First Name4 (NamePattern1) 8**] [**Last Name (NamePattern1) 9**], MD Psychiatry TB/MODL Job #: 498284 Doc #: 35329425 D: [**2021-01-28**] 15:56:06 T: 05/04/2018 16:54:53

BC CHILDREN'S HOSPITAL Patient Loc-Svc: T1ED-MH DISCHARGE SUMMARY Admitted: 26/04/2018 (DD/MM/YYYY) Discharged: (DD/MM/YYYY) This report is provided to support continuity of care. Blanks/discrepancies are indictated by [**Signature 1**]. Please contact the dictating author for clarification. If you are the dictating author, please fax any corrections or clarification to: Transcription Services [**Telephone/Fax (2) 2**] WORKING DSM-V DIAGNOSES 1. Borderline personality traits versus disorder, 301.83 (we have discussed that given [**Location (un) 3**] age as well as seeing him during a time of crisis, it is not appropriate to give him a full diagnosis of borderline personality disorder). 2. Unspecified depressive disorder, 311. 3. His unspecified anxiety disorder, 300. 4. Cannabis use disorder, mild, 305.20. 5. Parent-child relational problem, 361.20. 6. Intellectual disability, psychoeducation test conducted in spring of [**2020**] (written language output disorder, arithmetic disorder, and a writing output disorder). MEDICATIONS ON DISCHARGE 1. Fluoxetine 20 mg p.o. q.a.m. Please note that we have changed the dosing to morning dosing, as evening dosing can be quite agitating and may have interrupted in [**Location (un) 3**] sleep pattern. He was given a 1-month supply with no repeats. 2. Lorazepam sublingual 0.5 to 1 mg q.4h p.r.n. to a maximum of 4 mg in 24 hours. We have given him a prescription of 30 tablets with no repeats. The family is aware to use this as part of his safety planning and acute distress episodes, especially in the first month after discharge. 3. Trazodone 25 mg p.o. nightly for initial and mid insomnia. Given for a 1-month supply with no repeats. 4. Melatonin 3 to 15 mg p.o. nightly 30 minutes before bedtime over-the-counter. THERAPEUTIC RECOMMENDATIONS UPON DISCHARGE 1. Safety planning: We have gone over explanation of safety planning with both [**Location (un) **] individually as well as with both parents during the discharge meeting today. We have also filled out [**Signature 1**] form which was done in the emergency department, where he rates as low suicide risk. [**Location (un) **] is actually very insightful and displays good judgment and is able to ask for help when he is feeling distraught. Although he had a recent overdose of "20 tablets of ibuprofen" in the context of altercation at band camp in Whistler 48 hours ago, there was very vague evidence of the same. It is important to note that his ongoing suicidal thinking behaviors as well as gestures are very important to take in the context of [**Location (un) 3**] overall level of distress. It should also be noted that he is quite aware that he has "maladaptive coping" and at times may escalate from 0 to 100 without any clear psychosocial stressors or reasoning. We have gone over a behavioral approach with safety planning, and we have also encouraged the family to discuss the safety plan with [**Location (un) **] upon discharge in the next week. This will also give the family language to discuss safety as well as "overwhelming feelings" for [**Location (un) **]. We have given them a handout on behavioral strategies. We have also gone over a few behavioral strategies which would include creating a "safe place" for [**Location (un) **] to go when he is being disrespectful towards his family or self-deprecating towards himself and has urges of self-injurious behaviors. We have also discussed deescalation strategies for the parents to use in order to provide some level of role modeling for [**Location (un) **]. We have discussed that when [**Location (un) **] is feeling overwhelmed that his overall organization of feelings and expression of affect, it is very difficult for him to communicate, given that his "prefrontal cortex is being highjacked." The family clearly understands this and understands that it will require practice on both [**Location (un) **] as well as the family, but they are willing to refine and work through the safety planning as needed. They are also aware that if they are in a moment of crisis, and they have gone through the safety plan as well as using any deescalation techniques, such as lorazepam sublingually, and they are unable to deescalate the situation to present to [**Hospital 4**] [**Hospital 5**] for additional crisis management. At this time, [**Location (un) **] does not meet criteria under the Mental Health Act and is safe for discharge. Please note that he has a history of chronic suicidal ideation and actually does have some coping mechanisms which he can access, including deep breathing, mindfulness techniques, as well as challenging some of his cognitive distortions, which were discussed on this CAPE stay. 2. Biological. We have given him a prescription, as noted above, with discharge medications. The only change that we did make was that his dosing of Prozac should be now in the morning, as nighttime dosing may lead to further agitation and interrupted sleep pattern. We have discontinued the Seroquel 25 mg p.o. at bedtime, as this is not a very safe choice for a young youth, given the potential metabolic side effects (i.e. weight gain, abnormal fasting blood work). Instead, we have gone over trazodone as a good alternative to use to help with sleep; however, we still would encourage overall behavioral approaches, such as sleep hygiene as well as higher doses of melatonin ranging from 12 to 15 mg 30 minutes before bedtime. 3. Psychological interventions: The bulk majority of our time, in terms of formulating [**Location (un) **] as well as during our discharge interview, was around what psychological avenue would best suit [**Location (un) 3**] needs at this time. At this time, he is currently seeing [**Signature 1**] , who is part of the high-risk mental health team in [**Location (un) 4**] for the past 2 months. Although this has been very supportive in nature and quite beneficial for [**Location (un) **] as well as the family to ensure some level of clinical stability, we have discussed that [**Location (un) 3**] needs are likely beyond supportive and insight-oriented therapy. At this time, he is currently positively engaging in group therapy for anxiety disorders, which we encouraged him to continue, as he is able to feel supported by the community team. Our social worker, [**Last Name (un) 6**] [**Last Name (un) 7**], has discussed with [**Female First Name (un) 8**] that moving forward, likely a child and youth mental health team approach would be best beneficial. We have specifically discussed that even though [**Location (un) **] is 13 years of age, that he certainly is displaying maladaptive coping habits or mechanisms in the context of a borderline personality structure. We specifically have advocated for not only one-to-one therapy around important practices around borderline treatment, but we have also encouraged the family to think about family therapy in the future. Although it was a tenuous discharge meeting, the family really did understand how complex the borderline personality structure is and that it requires very specific treatment, such as dialectical behavioral therapy. Although we are not aware of what is available in terms of resources on [**First Name4 (NamePattern1) 4**] [**Last Name (NamePattern1) 9**], we have encouraged the family to continue to advocate around getting services for [**Location (un) **] as well as the family. For example, working with a therapist specifically around mindfulness techniques as well as regulation responses as well as identifying emotions could be a great starting point for one-to-one therapy for [**Location (un) **]. In addition, mobilizing other supports for the family is essential in this treatment plan, as the family needs to further have a deeper understanding of borderline personality but also work around the behavioral coping mechanisms and support that they need moving forward. 1. At this time, we do not feel that cognitive behavioral therapy, interpersonal therapy, or mobilizing any manualized type of therapy would be beneficial for [**Location (un) **]. He really requires validation of this hospital stay as well as the strife that he is feeling, even though if it feels "behavioral" to the family. The family certainly intellectually understands the complexities now of the borderline pathology, especially in the context of adoption, history of attachment which continues with biological mother. We also feel that the family would benefit from learning more about attachment in the context of having an adopted child and how to manage some of these distressing behaviors, which is clearly affecting not only [**Location (un) **] on an individual basis but the entire family interpersonally. We would certainly advocate for social work to be involved in this multidisciplinary team approach, as the family would require support and education during the treatment journey of this child. 1. Social history: We are in support of him starting his job at McDonald's in the next few months as a way of not only organizing his time but also gaining some level of skills and autonomy. We also encouraged him to continue with his hobbies, which include music, and potentially to pursue perhaps summer camps that would nurture some of his innate talents as well as abilities. We also encourage him to lead a healthy lifestyle, which would include not only good sleep hygiene but also a healthy balanced nutrition and 30 minutes of exercise on a daily basis at least 5 times a week. The social and healthy lifestyle changes can be gradual, and for further information, they can access the [**First Name9 (NamePattern2) 10**] [**Last Name (un) 11**] Mental Health workbook to healthy lifestyles and behaviors. 2. School accommodations: [**Last Name (un) 6**] [**Last Name (un) 7**], our CAPE social worker, will be in touch with the school on Monday. We are aware of the psychoeducation test and some of the learning challenges that [**Location (un) **] is displaying. From our understanding, he does have a solid IEP in place; however, we would like to further advocate for [**Location (un) 3**] needs, which are likely more emotional, and some of the interpersonal conflict that he may have upon return to school. We are very aware that he is a bright individual; however, the school stress is absolutely important in order for us to fully formulate some of [**Location (un) 3**] distress outside of the family unit. In addition, his social abilities and his intense relationship with peers and overall fear of abandonment are very important for the school to understand, as well, moving forward. 3. Community followup: We recommend that [**Location (un) **] follows up with his family doctor in the next 2 weeks just to oversee how the medications are going as well as how the family is responding to the community child youth mental health recommendations. We also have followed up with [**Female First Name (un) 8**], who will coordinate the referral to the Child and Youth Mental Health team in [**Location (un) 4**]. We encouraged the family to contact [**First Name5 (NamePattern1) 6**] [**Last Name (NamePattern1) 7**] in case that there are missing links upon discharge and/or difficulties accessing the child and youth team in [**Location (un) 4**]. 4. Reason for referral in the emergency department: The emergency physician referred [**Name9 (PRE) **] after 20-tablet ingestion of ibuprofen in the context of an altercation at band camp in Whistler. This was in the context of him bringing in alcohol, despite knowing the rules, and him reacting to the "consequences." This was for diagnostic profiling and treatment options. 5. Status while on the Cape unit: [**Location (un) **] was admitted for a 24-hour stay in the context of parent-child conflict and increased suicidal ideation. This was an important admission for not only [**Location (un) **] but as well as the family to clarify the diagnoses that are likely affecting this youth and feeling constantly "invalidated" or dismissed for his mental health concerns. When [**Location (un) **] was assessed in the emergency department, he had an overall feeling of being overwhelmed and wanting to be in the hospital in order for his parents to "understand what I'm going through finally). While he was on the CAPE unit, he was very cooperative as well as asking very good questions when they it to diagnosis and his medication changes. We had given him psychoeducation materials while on the CAPE unit prior to his discharge to look over and to ask us if he requires any additional information around borderline personality disorder. He agrees that he is quite black-and-white and that he can escalate and that sometimes it probably feels like "walking on eggshells for his parents." At the same time, [**Location (un) **] was not in the space to receive a lot of information on this stay. We created it to be a an overall validating experience for him in order to gain some buy in with mental health professionals. [**Location (un) **] admitted that he felt heard, but it was not until his parents came for the discharge meeting that he clearly escalated. During that time, 1 hour before the discharge meeting, he called the parents and quickly relayed to staff that he feels overall that his parents "don't care" and that the reason he is in hospital is all "his fault." We specifically brought this information up during the family meeting to discuss the dissonance of what [**Location (un) **] feels and what he hears or what is communicated to him. The family then understood that focusing more on [**Location (un) 3**] experience versus discussing the details of "what was said and what was not said" is much more important at this time to ensure that [**Location (un) **] feels heard by his family. During our discharge meeting, we not only went over the therapeutic plan, but [**First Name5 (NamePattern1) 6**] [**Last Name (NamePattern1) 7**] also went over many different types of behavioral strategies to help the family navigate this type of complex picture. We also discussed substance use disorders and how although this can be higher in youth that have underlying mental health diagnosis, such as depression, anxiety, or borderline personality, that he has good judgment to know that he is currently using cannabis and alcohol as a means of "maladaptive coping." He has all of the information intellectually from both his family as well as from the community team. He does not feel that he has a "substance use problem" at this time, and with the use that he is discussing with us, we felt that he did not require concurrent disorders referral at this time. In the future, however, if he continues to experiment, or his usage increases in the context of interpersonal stressors, the community team should certainly look at a concurrent disorder referral and potentially use a motivational interviewing modality. At this time, we are aware that we have shifted the diagnosis for community providers to start thinking of this in a more complex personality structure but also that the symptoms of anxiety, panic attacks, and depressive symptoms are certainly still present cross sectionally. Thank you for this complex referral. We hope that the family feels supported and heard upon this discharge; however, we understand that there may be more questions or concerns that come out of this discharge in the next while, and we are happy to either talk to the healthcare professionals as well as the family should they have any immediate concerns. If you have any questions or concerns, please do not hesitate to contact the undersigned. [**Signature 12**] Dictated By: [**Name6 (MD) 13**] [**Name8 (MD) 14**], MD Psychiatry SN/MODL Job #: 559245 Doc #: 35692913 D: 27/04/2018 17:55:06 T: 27/04/2018 19:33:50

BC MENTAL HEALTH CENTRE AND SUBSTANCE ABUSE Patient Loc-Svc: CPE-MH DISCHARGE SUMMARY Admitted: [**2020-03-07**] (DD/MM/YYYY) Discharged: [**2020-04-06**] (DD/MM/YYYY) This report appears to be incomplete and has been distributed to support continuity of patient care. If you are the dictating author/preceptor, please make the required corrections/clarification and remove this disclaimer prior to signing the report. During this dictation, you requested copies of this report to be sent to recipients who could not be properly identified, are not in the provider dictionary, or are prohibited from receiving reports. While our department will make every effort to distribute copies appropriately, all recipient(s) listed below may not receive a copy. Dr. [**First Name (STitle) 1**] (sp?) DATE OF ADMISSION [**2020-08-02**]. DATE OF DISCHARGE [**08-04**]. 2017. ADMISSION DIAGNOSIS No specific diagnoses is mentioned on the admission note. DISCHARGE DIAGNOSIS 1. Alcohol-related neurocognitive disorder. 2. Rule out FASD. 3. Rule out oppositional defiant disorder. 4. Rule out conduct disorder. 5. Rule out unspecified ADHD. 6. Rule out learning disorders. 7. Parent-child relationship problem. DISCHARGE MEDICATIONS [**Male First Name (un) 2**] was discharged with a prescription for risperidone 0.25 mg p.o. b.i.d. for 30 days. Of note, on admission, he was on Seroquel 12.5 mg p.o. at bedtime which was discontinued during this admission. DISCHARGE FOLLOWUP Disposition: [**Male First Name (un) 2**] was discharged to the care of his adopted parents. During the discharge meeting, we explained in detail that we do not expect that the presentation changed significantly compared to prior to admission although we hope that starting risperidone might help him to better control his behavior. We highlighted the importance of close followup and better diagnostic assessment through time. If it is confirmed that he might have a problem related to conduct disorder or severe ODD, the adequate evidence-based management for those disorders need to be implemented and started. With a diagnosis of alcohol-related neurocognitive disorders or FASD, he is going to receive support from Hollyburn and he has an appointment scheduled for [**08-25**], where he most likely get a behavioral consultant or a behavioral analyst to help him and the family to have a better understanding of the problems and a better handle on them. Meanwhile, we are going to make a referral to child and youth mental health team so he can get counseling and psychiatry under the same roof. Until that happens, he will continue seeing Dr. [**First Name (STitle) 1**]. The parents have stated that cannot afford the private therapy any longer. We are also going to refer him to [**Signature 3**] so that the urgent mental health team at North Vancouver have some records of his history in case things escalate and parents have to bring him to Lions Gate Hospital so they would be prepared with some prior knowledge about him although we hope that none of those become necessary. We are also going to request MCFD support file to be open to help the family, either providing respite or a youth worker or an outreach worker as clearly [**Male First Name (un) 4**] escalating problems have affected every family member. I have strongly suggested and recommended for the parents that until all the services are in place, they should focus on decreasing and minimizing the number of outbursts and volatility in the home. I suggested that they back off from many of their expectations knowing that in the long run it is not a good idea but short-term because the right and adequate supports are not in place, keeping peace and calm would be the sole objective. We reviewed the medications safety profile, provided them with Keltie [**Signature 3**] and resources that they can read more about the medication. I have provided them with the lab requisition to get the basic blood work done so we can establish a baseline in the early days of taking risperidone. I also advised them that if he continues on this medication, he needs to be referred to metabolic clinic at Children's Hospital. Finally, we advised them that we cannot foresee the future. If emergencies arise, they should not hesitate calling 911 or bringing him to emergency room. However, most likely by the time that he is seen by mental health or psychiatry in emergency room, the crisis would be over. If things are not very different than today's presentation, we do not see any benefit in prolonged admission or keeping him longer in the emergency room. PRESENTATION TO HOSPITAL [**Male First Name (un) 2**] is a 14-year-old male with a complex neurodevelopmental profile and multiple significant attachment disruptions for the first 3 years of his life he has been completely neglected and since 6 years ago has been adopted by his current parents. However, he continues to suffer from those early attachment injuries. He has been showing behavioral problems and impulsivity from very young age. He has been assessed by Sunny Hill and diagnosed with alcohol-related neurocognitive disorders/rule out FASD. The behavior problems are getting worse. He steals from his parents and stores, sells stuff in school. They found a Vape in his belongings. The parents described him running a secret life, not being part of the family, getting angry over little things and escalating to the point of causing real safety risks for other people and it seems to be getting only worse. He received Seroquel 12.5 mg which he felt is helping, but the parents did not notice any benefit, recently, he saw Dr. [**First Name (STitle) 1**] who suggested risperidone, but because he did not do the blood work, parents did not give him the medication. He got admitted due to escalating behavioral problems after a visit to the dentist's office and stealing something from that office which he denies although it was found in his pocket. He was admitted to CAPE and he started risperidone which he is tolerating well. HOSPITAL COURSE During this short hospitalization, he slept well overnight, did not show any behavioral problems. [**Name (NI) 5**] took medication without any side effects. He did not voice any suicidal ideation, self-harming urge, or threat or plan to harm anyone else. During the family meeting/discharge meeting, he sat silent for the most part, said that overall he agrees with his parents' assessment, but could not offer any insight why he is doing or engaging in those problem[**Name (NI) 6**] behaviors. BEHAVIORAL OBSERVATION/MENTAL STATUS EXAM AT DISCHARGE [**Male First Name (un) 2**] appears as stated age, fairly groomed and [**Last Name (un) 7**], in casual clothes. Good eye contact. No psychomotor activation or retardation. Friendly and cooperative. Speech is normal rate, rhythm volume. Mood reports is slightly downcast. Affect full, euthymic, reactive. Thought process linear and organized. Thought content denies any suicidal ideation. No homicidal ideation. No auditory or visual hallucinations. Insight and judgment both poor. DICTATION ENDS HERE [**Signature 8**] Dictated By: [**First Name4 (NamePattern1) 9**] [**Last Name (NamePattern1) 10**], MD Psychiatry AE/MODL Job #: 116760 Doc #: 33100218 D: [**2020-04-06**] 21:48:52 T: 07/11/2017 22:58:28

BC MENTAL HEALTH CENTRE AND SUBSTANCE ABUSE Patient Loc-Svc: CPE-MH DISCHARGE SUMMARY Admitted: 31/12/2017 (DD/MM/YYYY) Discharged: [**2021-05-28**] (DD/MM/YYYY) ADMISSION DIAGNOSIS 1. Medication-induced hypomania. 2. Attention deficit hyperactivity disorder (ADHD), combined type. 3. Adjustment disorder with disturbance in mood secondary to 4 placement changes in the last 4 months. DISCHARGE DIAGNOSIS 1. Probable bipolar disorder, uncovered by fluoxetine. Differential diagnosis is noradrenergic activation, resolved. 2. Attention deficit hyperactivity disorder (ADHD), combined type. 3. Adjustment disorder with anxious and depressed mood secondary to disruptions in placement. 4. Parkinsonian symptoms secondary to low-dose risperidone, resolved. TREATMENT AFTER DISCHARGE 1. Return to the highly supported foster home that she was placed in in late [**08-29**]. Continued follow up with Dr. [**First Name4 (NamePattern1) 1**] [**Last Name (NamePattern1) 2**], and with [**First Name8 (NamePattern2) 3**] [**Last Name (NamePattern1) 4**] of the [**Location (un) 5**] Child and Youth Mental Health team. MEDICATIONS ON DISCHARGE 1. Vyvanse 60 mg po qAM 2. Guanfacine XR 3 mg po qAM 3. Trecira Lo 1 tab daily 4. Melatonin 3 mg po qHS prn insomnia 5. Melatonin CR 5 mg po qHS prn insomnia MEDICATIONS CHANGED/STOPPED IN HOSPITAL 1. Strattera/Atomoxetine was stopped while in hospital but may be restarted 2. Fluoxetine was stopped. This is relatively contraindicated 3. Risperidone 0.5 mg caused Parkinsonian symptoms and is relatively contraindicated IDENTIFICATION AND COURSE ON THE UNIT Please see other records for more details. In brief, Dakota is a 15-year-old girl apprehended at age 8 from mother's care, as mother had drug-induced psychotic symptoms and was unable to parent her or Dakota's 2 younger siblings. She had spent years in a stable foster placement and had notable problems with ADHD, impulsivity, anger troubles and had been managed with a complicated regimen of Vyvanse, Strattera, and clonidine. Dakota is very talkative and uses this as a strength, as she does public speaking to outline issues of children in care and plans to be an advocate for those in care when she grows up. There were a number of changes starting in [**2020-05-28**]. Included in this is that care switched from her previous psychiatrist to Dr. [**Last Name (STitle) 2**], and at the same time, she had had a number of short-term placements as VACFSS were trying to get her into a stable placement while living with her younger siblings with whom she has a loving but very competitive relationship. With all of these changes, Dakota's mood started to drop. She began cutting, and following a very brief hospitalization [**2020-09-05**], Dr. [**First Name (STitle) 6**] suggested starting fluoxetine despite a soft family history of bipolar disorder, as maternal grandmother either has bipolar II disorder or else borderline personality disorder. For the first week at a dose of 10 mg, this dramatically improved Dakota's mood, optimism, sleep, reduced her anxiety, and she managed to stop cutting. With the dosage increased to 20 mg just after going into this new foster home, she began to develop classic manic symptoms with pressured speech, disinhibition, no sleep. For that reason, she was admitted to CAPE. The fluoxetine was stopped, but all of her ADHD medications were stopped at the same time. While in hospital, she was seen as driven and pressured, but that seemed to fit more with ADHD than with bipolar disorder. She had some degree of improvement with restarting Vyvanse, but the fluoxetine slows the metabolism of Strattera. Her manic-like symptoms were conceivably due to noradrenergic overdrive from very high serum levels of Strattera so it was felt best to wait until late [**2020-09-27**] before restarting that. Additionally as a way of settling residual symptoms, risperidone 0.5 mg p.o. nightly was started in hospital but, unfortunately, she developed tongue thrust, drooling, and other EPS symptoms, so this was quickly stopped and Benadryl used to ease these symptoms. In her last week of hospitalization, a number of community staff who know her well took her out on passes and saw that she was nearly back to baseline. There was nothing that resembled manic symptoms. With this in mind and after having successful weekend passes, we planned to discharge on [**2020-10-04**]. At that point, the new foster mother came in, highlighted that despite all of these community passes, Dakota had never gone back to the family home, and she was very worried that Dakota might have residual manic symptoms and would not be safe at home. This was somewhat of a surprise to staff, as we all heard the message that Dakota was being discharged on [**2020-10-04**] and her community staff all confirmed that she was back to her baseline level of functioning and was safe to return to the community. After a long discussion trying to address foster mother's realistic concerns that there may still be untreated manic symptoms, we came up with a modified plan for Dakota to leave with the foster mother on an overnight pass so that there is still support of CAPE unit, with a discharge on the morning of [**2020-10-05**], by telephone. Unfortunately, Dakota woke in the middle of the night, had difficulty getting back to sleep then was irritable and oppositional in the morning of the 9th. Discussions with the foster mother and her longstanding VACFSS worker confirmed that this was her usual irritability probably worsened by her frustration at a prolonged hospital stay, but she was not presenting as manic. Given that Dakota was regressing on the CAPE unit, even though she had run away from this new foster home, we believe she is no longer certifiable and that extending her stay could cause harm but not improve this irritability related to lifelong trauma and insecure attachment, so we proceeded with the discharge. Regarding medication issues, Vyvanse was slowly reintroduced with the first 60 mg dose of Vyvanse to be on [**2020-10-05**]. Dakota remained on guanfacine 3 mg p.o. nightly throughout her stay and the Strattera was very briefly restarted at lower dose before being stopped and can safely be restarted in 1 week. My understanding is that Dr. [**First Name4 (NamePattern1) 7**] [**Last Name (NamePattern1) 8**] has had discussions with Dr. [**Last Name (STitle) 2**] about medication strategies. It appears that the next option would be whether to restart the Strattera that has been used effectively in the community, or else to have a trial of lamotrigine as the next medication step. Both medications need slow titration. My understanding is Dr. [**Last Name (STitle) 2**] is comfortable doing that and is aware that if Dakota is not manageable in the community with community resources, it would be possible to put in a planned admission request to the adolescent psychiatric unit, P2. I have called a discharge prescription into her local pharmacy, Shoppers [**Telephone/Fax (2) 9**]. MENTAL STATUS AT DISCHARGE Dakota presented as a talkative 15-year-old girl, who was well groomed and was clearly angry at being on the CAPE unit and pointing out that she had not received any psychotherapy, as there had not been any consistency of psychiatric care. She felt that she was not getting help and was frustrated that she was now missing school as a result of delays in discharge. Despite this understandable and justifiable anger, her speech was not pressured, she could have give and take in the conversation, and answer a few questions appropriately. There was very little therapeutic rapport with Dakota being angry at all inpatient psychiatrists which limited getting more details. She did not present as manic, agitated, or disinhibited with me nor with staff. FORMULATION Our formulation remains that Dakota is a complex girl with trauma, loss, many attachment issues, who clearly has ADHD and has some degree of risk for bipolar disorder given a soft family loading for this, but also developing manic symptoms on an SSRI that slowed the metabolism of her atomoxetine. With this combination of multiple changes in placement and multiple stressors, she has developed problems with sad mood and anxiety and it was difficult to tease out whether this represented a Major Depressive Disorder or else an understandable reaction to real outside stressors. That being said, Dakota's symptoms dropped dramatically with the use of low-dose fluoxetine so there may be an underlying condition treatable with some medication options. Dakota has strengths in that she has a well-established team to support her who know her well, and her school is very supportive of her return to school. [**Signature 10**] Dictated By: [**First Name11 (Name Pattern1) 11**] [**Initial (NamePattern1) 12**] [**Last Name (NamePattern1) 13**], MD Psychiatry AWF/MODL Job #: 262283 Doc #: 33967898 D: [**2021-04-27**] 18:11:55 T: [**2021-04-27**] 19:23:22

BC MENTAL HEALTH CENTRE AND SUBSTANCE ABUSE Patient Loc-Svc: CPE-MH DISCHARGE SUMMARY Admitted: [**2021-05-01**] (DD/MM/YYYY) Discharged: [**2021-08-01**] (DD/MM/YYYY) LENGTH OF STAY 3 days. ADMISSION MEDICATIONS 1. Fluoxetine 60 mg daily. 2. Wellbutrin XL 150 mg daily. 3. Chlorpromazine p.r.n. (25 mg, 25 mg, 50 mg, t.i.d.). MEDICATIONS ON DISCHARGE We made a number of changes to [**Male First Name (un) 1**] p.r.n. and regular medication schedule, to address the current crisis, while we had a conversation with Dr. [**Last Name (STitle) 2**] about re-exploring previous medication trials once the dust has cleared with respect to discharge changes. 1. Fluoxetine is unchanged at 60 mg daily. 2. Chlorpromazine is being discontinued as a p.r.n. medication, instead, loxapine, which has had significant benefit for [**Male First Name (un) **] in hospital, both in our emergency department and in the CAPE unit, is the preferred p.r.n. medication, at 10 mg dosing q.1h to a maximum of 30 mg daily for significant agitation. 3. Wellbutrin has been discontinued for the time being, and in our discussion with Dr. [**Last Name (STitle) 2**], we have agreed that re-exploring Wellbutrin as a treatment for his underlying struggles might be a more reasonable option in a few weeks, but letting our change below be the focus of the medical changes for the time being. 4. Risperidone 0.25 mg p.o. b.i.d. This medication is likely going to work more immediately than a Wellbutrin addition at this point would, and with the interactions between Wellbutrin, fluoxetine, and risperidone, it was felt that he would be better to start the risperidone first, see how things are looking after he is in placement, and then move towards a reconsideration of Wellbutrin gently in the future. 5. He also takes melatonin and multivitamins daily. PRE-ADMIT DIAGNOSIS [**Male First Name (un) **] was admitted due to increased aggression with a background of autism and anxiety. POST-ADMIT DIAGNOSES 1. Autism. 2. Unspecified anxiety disorder. 3. Developmental coordination disorder. 4. Unspecified impulse control disorder. 5. Sensory over responsiveness. TREATMENT/COURSE IN HOSPITAL [**Male First Name (un) **] was admitted under circumstances that are well described in the admission note dated [**2021-02-01**]. Briefly, after an argument about acquiring a video game, he became very distressed and used a barbecue implement at home to break a number of windows, threatened and hit his mother, and required Emergency Health Services to intervene as well as Police in order to deescalate the situation. He was threatening to kill himself and kill his parents and was admitted to hospital after having significant difficulty settling down in the emergency department. At the time of admission, the parents had determined that they needed to have a voluntary care agreement, and a home had been found within the Ministry; however, in the delay in waiting for the pickup to go home to the Ministry home, he became again dysregulated and required admission to the CAPE unit. On the unit, he has had a number of disruptive moments when he was being told news that he did not want. His typical pattern is to get very overwhelmed when he hears new news or if a conversation is about something that he is not interested in. He expresses his frustration by stomping his feet or putting his hands on his head or screaming and yelling. Examples of triggers for such behavior would be if he said something like "I want to go home," and someone would stay begin "we want you to go home, too, but...," and his immediate reaction to that but would be significant distress. He had 2 major incidents requiring intervention on the unit of seclusion, both being when he was being delivered news about first having to stay at Surrey Hospital, and second being told that he had to go and live somewhere that was not his home. Fortunately, these events also demonstrated his ability to receive sufficient sedation with loxapine and again demonstrated that he was under behavioral control, even in these moments of difficulty. When he would be quickly plicated with something that he wanted, such as video games, his distress would almost completely melt away. When he was able to sleep after receiving loxapine, he would wake up generally in a better mood. Observing [**Male First Name (un) **] significantly handle his distressing news better after the risperidone was started was impressive. Initial start of 0.25 mg b.i.d. seemed to create a significant lesser level of distress in [**Male First Name (un) **]. Examples of this would be when he was told later in the day that he would be going to the group home tat had been found, and he would not be going home, he took it very nonchalantly. Today, on the day of discharge, when a new person came to pick him up, he was able to keep himself well contained. I observed [**Male First Name (un) **], as well, on the grounds with his mother, where he was very upset, but he was able to keep his hands to himself and express his upset to his mom and was rightly soothed by a trip to Starbucks. It seems like the temporizing measure of risperidone was a positive step forward and reassuring with respect to continuing the plan to discharge. [**Male First Name (un) **] was able to be placed in emergency placement that had previously been arranged in the emergency department. A worker named [**Name (NI) 3**] came to pick him up and take him to the new home, and he was discharged without incident. RISK ASSESSMENT Obviously, he has increased risk for harming others and harming himself. Despite his autistic diagnosis, his extreme volatile anger and his use of implements in destruction increase his risk of harming others significantly. This is a chronic risk that is likely part behavioral and in a small part biological, the biological factor being his inability to reason and his difficulties with impulse control; however, for the most part, he uses violence as a way to achieve goals. This is obviously going to be a more and more powerful tool for him as he gets older and larger, and our hope is that behavioral interventions, care team that can be responsive, and as well have breaks and rest as a staffed environment permits, and an ongoing connection to his loving parents who really struggled with this decision to place him in a voluntary care agreement, will be beneficial for [**Male First Name (un) **] going forward. We are very hopeful that [**Male First Name (un) **] is able to maintain safety; however, we expect a number of safety events in the near future. He uses aggression as a way to achieve things that he wants, and I suspect that as things do not meet his needs. We will see more incidents of aggression which can be responded through via external controls, such as 911 calls, Police interventions, etc., external sedation such as using risperidone and trying to find a dose that has him sedated without being too sleepy or less aggressive without being too sedated, and potentially consideration of forensic charges as he gets older. External limitations are likely going to be very necessary for [**Male First Name (un) **] as he navigates his very difficult temper control. As it pertains to the diagnoses, parents and Dr. [**Last Name (STitle) 2**] have long been working with anxiety as the root cause of a lot of his explosiveness, which given his presentation, makes a lot of sense, and we would certainly agree with that assessment. Anxiety medication strategies in all their forms will obviously be helpful for [**Male First Name (un) **], but there is a degree to which his participation is lessened by his black-and-white approach due to his autism. There is very little collaboration that works with [**Male First Name (un) **] in the moment; however, my experience with [**Male First Name (un) **] is that with significant open-ended help-seeking collaboration in which he is the primary driver of treatment direction, I have observed [**Male First Name (un) **] many times offer things well within the realms of possibility after receiving significant encouragement. It may be that behavioral approaches to his anxiety are going to be more helpful than medication approaches, given the situational nature of his anxiety and the likely underlying autism that fuels a lot of his immediate reactions to new environments and situations. It was a pleasure seeing [**Male First Name (un) **] here on the CAPE unit, and we wish him the very best going forward. [**Signature 4**] Dictated By: [**First Name4 (NamePattern1) 5**] [**Last Name (NamePattern1) 6**], MD Psychiatry TB/MODL Job #: 596816 Doc #: 35920511 D: [**2021-08-01**] 20:24:45 T: 11/05/2018 20:55:37