Integrating Mental Health into Pediatric IBD Care

WE Bennett, MD Pfefferkorn. JAMA PediatrPublished online August 19, 2019. doi:10.1001/jamapediatrics.2019.2669

Full Link: Editorial: “Mental Health Screening as the Standard of Care in Pediatric Inflammatory Bowel Disease” Thanks to Ben Gold for this reference.

An excerpt:

Butwicka and colleagues1 have published a fascinating, landmark cohort study in this issue of JAMA Pediatricsassessing the prevalence of psychiatric diagnoses and symptoms among children with inflammatory bowel disease (IBD) in Sweden. The authors used a rigorous design that compared a cohort of more than 6000 pediatric patients with IBD with hundreds of thousands of healthy controls, as well as a separate cohort comprising the patients’ own siblings who did not have IBD. Butwicka et al1 computed hazard ratios for any psychiatric disorder, as well as for multiple specific disorders, and found a hazard ratio of 1.6 for any psychiatric diagnosis when comparing children with IBD with healthy controls. The statistical analysis is stellar and represents the best data we currently have on the intersection of pediatric IBD and mental health. Their study highlights a substantial risk in a vulnerable population and should trigger revision of guidelines and allocation of resources to support widespread screening and treatment for these dangerous conditions.

Related Article:

A Butwicka et al. JAMA Pediatr. Published online August 19, 2019. doi:10.1001/jamapediatrics.2019.2662 

Full Text Link: Association of Childhood-Onset Inflammatory Bowel Disease With Risk of Psychiatric Disorders and Suicide Attempt

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Gun Carrying Adolescents –Why We Are Going to See More School Shootings

A recent cross-sectional study (RMC Kagawa et al. J Pediatr 2019; 209: 198-203) shows a high rate of gun carrying among adolescents in the U.S.

Key findings:

  • Based on a sample of 10,112 adolescent who completed surveys, 2.4% of adolescents reported carrying a gun in the prior 30 days.
  • Carrying a gun was more common among adolescents with a conduct disorder (adjusted prevalence ratio 1.88), drug use disorders (APR 1.91) and patients with specific phobias (APR 1.54)
  • The authors estimate that 1.1% of adolescents with a disorder associated with self- or other-directed violence also carry guns.  This extrapolates to 272,000 adolescents with both risk factors.
  • Nearly two-thirds of adolescents who report gun carrying had a mental health disorder

My take:

  1. Guns are everywhere.  Gun carrying among adolescents, while only a small percentage of all adolescents, represent a grave risk; especially, since the majority who report carrying guns (in this study) have mental health issues.
  2. Safe storage needs to be a requirement of gun ownership.  Gun access and misuse by adolescents is a ‘clear and present danger’ (apologies to Tom Clancy).

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Quitting Smoking Associated with Better Mental Health

Given the amount of information about the negative consequences of smoking that is currently available, some might say that you would have to be mentally-ill to start smoking.  The good news is that stopping smoking has been associated with improvements in mental health (BMJ 2014; 348: g1151 dii 10.1136/bmj.g1151 -thanks to Mike Hart for this reference).  Free full-text BMJ article PDF

From Abstract:

Design Systematic review and meta-analysis of observational studies.

Eligibility criteria for selecting studies Longitudinal studies of adults that assessed mental health before smoking cessation and at least six weeks after cessation or baseline in healthy and clinical populations.

Results 26 studies that assessed mental health with questionnaires designed to measure anxiety, depression, mixed anxiety and depression, psychological quality of life, positive affect, and stress were included…. the standardised mean differences (95% confidence intervals) were anxiety −0.37 (95% confidence interval −0.70 to −0.03); depression −0.25 (−0.37 to −0.12); mixed anxiety and depression −0.31 (−0.47 to −0.14); stress −0.27 (−0.40 to −0.13). Both psychological quality of life and positive affect significantly increased between baseline and follow-up in quitters compared with continuing smokers 0.22 (0.09 to 0.36) and 0.40 (0.09 to 0.71), respectively). There was no evidence that the effect size differed between the general population and populations with physical or psychiatric disorders.

Conclusions Smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. The effect size seems as large for those with psychiatric disorders as those without. The effect sizes are equal or larger than those of antidepressant treatment for mood and anxiety disorders.

Figure 2 shows the relationship of the individual studies and the mental health outcomes.  In every study except one, there was improvement in those who quit smoking, though many of the studies had confidence limits that indicated that the results did not meet statistical significance.

Bottomline: This study indicates that quitting smoking can improve rather than worsen mental health.

The burden of being a physician

The following link comments on a study regarding the high rate of physician burnout:

The Widespread Problem of Doctor Burnout – NYTimes.com

Among my physician friends, the topic of emotional fatigue comes up infrequently.  While there are different difficulties for every type of job, I think if you are not a physician it is hard to understand the emotional toll of the job.  If you care about what you do, it is hard to disassociate from the obvious suffering that some patients endure.  In addition, in many cases the decisions that we help families reach often have unexpected outcomes.

Though some physicians may not struggle with these issues, the link above indicates that this problem is pervasive.

If you have a practical solution, let me know.  Happy New Year.

Related blog (more upbeat):

“It is never boring to be a physician” | gutsandgrowth