Children With Complex Medical Illnesses Need Mental Health Care, Too

By Carolyn Crist

July 27, 2020

(Reuters Health) - Children and teens who have chronic illnesses such as cystic fibrosis are at increased risk of anxiety, depression, self-harming behaviors and suicidal thoughts, and they need care that integrates both physical and mental health, two clinicians argue.

Children's hospitals that serve these patients, however, often don't offer psychiatric care, which forces doctors to make difficult choices, the authors point out in a perspective article in the journal Pediatrics.

"Sometimes doctors face the dilemma of addressing psychiatric or medical care, and they shouldn't have to choose one or the other. The system is disjointed, and we need to address this gap," said coauthor Kristin Canavera, a psychologist at St. Jude Children's Research Hospital in Memphis, Tennessee.

Suicide is now the second-leading cause of death in children, adolescents and young adults between ages 10 and 24, according to the Centers for Disease Control and Prevention, and kids with chronic illnesses face an even higher risk.

"We need to shift to a preventive model in children's hospitals, outpatient settings and primary care clinics," Canavera told Reuters Health by phone. "Part of that requires us reducing the stigma around mental health and making it OK to ask for mental health services."

Canavera and colleague Dr. Liza-Marie Johnson, program director of oncology hospitalist medicine at St. Jude's, write about the case of an adolescent girl who went to a local children's hospital for cystic fibrosis complications but was also experiencing suicidal ideation and self-harming behaviors. The hospital didn't offer psychiatric care, so she was transferred to the closest pediatric hospital able to provide both types of care - 250 miles away. The distance and financial constraints prevented her parents from being able to travel to visit her while she was there.

Several factors create this dilemma, the authors write, including health insurance coverage issues, a national shortage of child psychiatrists, limited availability of inpatient beds for mental health services, and the need to "balance managing what is in the best interest of the child from both a psychiatric and medical standpoint," the authors write. Medical units also don't tend to have the credentialed professionals to manage inpatient psychiatric care, suicide, violence prevention and other severe behavioral concerns.

But a few solutions could fill in the gap, Canavera and Dr. Johnson write. Psychology and psychiatry consultation and liaison services, for instance, could be a cost-effective way to assist hospital staff and improve patient care. Likewise, nurses and other staff could be trained in crisis prevention, mental health conditions and behavior de-escalation tactics. Hospitals could also collaborate with local mental health groups that offer "wrap-around" or home-based services to help patients, both at the hospital and after they leave.

"As we face the COVID-19 pandemic, the need for integrated behavioral health services is even greater," said Dr. Naomi Bardach of the University of California, San Francisco, who wasn't involved in the article.

"Some patients needing inpatient psychiatric care also have COVID-19, diagnosed as part of standard admission practices in the emergency department," she told Reuters Health by email. "Inpatient psychiatric facilities will not accept these patients until they are no longer infectious, leading to delays of up to two weeks to accessing psychiatric services if the hospital does not have integrated behavioral health care."

Ultimately, hospital administrators and medical leaders will need to advocate for policy changes and legislation that integrates mental and physical health care, the authors write. The American Academy of Child and Adolescent Psychiatry, for instance, promotes pediatric mental health through research, educational initiatives and policy guidelines such as health insurance reimbursement for mental health services.

"As soon as children are diagnosed with a chronic disease or disability, we should ask about the mental health side as well," said Dr. Donald Greydanus of Western Michigan University, in Kalamazoo. Dr. Greydanus, who wasn't involved with the perspective article, has written about suicide risk among adolescents with a chronic illness.

"Chronic illness makes life more difficult, and kids need someone to ask them how they're feeling and how they're coping," he told Reuters Health by phone. "We need to look at mental health from the beginning so they know they can pick up the phone and call their doctor if they have concerns."

SOURCE: Pediatrics, online July 22, 2020.