Simona Bujoreanu

Randomized efficacy trial of two psychotherapies for depression in youth with inflammatory bowel disease.

OBJECTIVE Pediatric inflammatory bowel disease (IBD) is associated with high rates of depression. This study compared the efficacy of cognitive behavioral therapy (CBT) to supportive nondirective therapy (SNDT) in treating youth with comorbid IBD and depression. METHOD Youth (51% female and 49% male; age 9-17 years, mean age 14.3 years) with depression and Crohns disease (n = 161) or ulcerative colitis (n = 56) were randomly assigned to a 3-month course of CBT or SNDT. The primary outcome was comparative reduction in depressive symptom severity; secondary outcomes were depression remission, increase in depression response, and improved health-related adjustment and IBD activity. RESULTS A total of 178 participants (82%) completed the 3-month intervention. Both psychotherapies resulted in significant reductions in total Childrens Depression Rating Scale Revised score (37.3% for CBT and 31.9% for SNDT), but the difference between the 2 treatments was not significant (p = .16). There were large pre-post effect sizes for each treatment (d = 1.31 for CBT and d = 1.30 for SNDT). More than 65% of youth had a complete remission of depression at 3 months, with no difference between CBT and SNDT (67.8% and 63.2%, respectively). Compared to SNDT, CBT was associated with a greater reduction in IBD activity (p = .04) but no greater improvement on the Clinical Global Assessment Scale (p = .06) and health-related quality of life (IMPACT-III scale) (p = .07). CONCLUSION This is the first randomized controlled study to suggest improvements in depression severity, global functioning, quality of life, and disease activity in a physically ill pediatric cohort treated with psychotherapy. Clinical trial registration information-Reducing Depressive Symptoms in Physically Ill Youth; http://clinical trials.gov; NCT00534911.

Depression subtypes in pediatric inflammatory bowel disease.

Objective: The association between inflammatory bowel disease (IBD) and depression provides a unique opportunity to understand the relation between systemic inflammation and depressive symptom profiles. Methods: Youth (n = 226) ages 9 to 17 years with comorbid IBD and depression underwent psychiatric assessment and evaluation of IBD activity. Latent profile analysis (LPA) identified depressive subgroups based on similar responses to the Childrens Depression Rating Scale-Revised. Demographic factors, depression severity, anxiety, IBD activity, inflammatory markers, IBD-related medications, and illness perception were evaluated as predictors of profile membership. Results: Mean age was 14.3 years; 75% had Crohn disease; 31% were taking systemic corticosteroids. Mean depressive severity was moderate, whereas IBD activity, which reflects inflammation, was mild. LPA identified 3 subgroups: Profile-1 (mild, 75%) had diverse low-grade depressive symptoms and highest quality of life; Profile-2 (somatic, 19%) had severe fatigue, appetite change, anhedonia, decreased motor activity, and depressed mood with concurrent high-dose steroid therapy and the highest IBD activity; and Profile-3 (cognitive, 6%) had the highest rates of self-reported depressive symptoms, ostomy placements, and anxiety with IBD symptoms in the relative absence of inflammation. Conclusions: Evidence was found for 3 depression profiles in youth with IBD and depression. Our analyses determined that patients with predominantly somatic or cognitive symptoms of depression comprised 25% of our cohort. These findings may be used to design subgroup-specific interventions for depression in adolescents with IBD and other physical illnesses associated with systemic inflammation.

Approach to psychosomatic illness in adolescents.

Purpose of review Due to the increased prevalence of psychosomatic presentations and the difficulty of managing such patients, this article summarizes the latest findings for identifying individual and family risk factors, and new trends in the evaluation and management of pediatric patients with psychosomatic illness. Recent findings Up to 50% of patients in pediatric care will complain of medically unexplained symptoms with significant functional and emotional impairment. Such patients place heavy burdens on the healthcare system (frequent utilization of health resources and hospitalizations, specialist consultations, unnecessary investigations, and treatments). Somatoform disorders in pediatric care are associated with risks for psychiatric co-morbidity (anxiety and depressive disorders), family conflict, parent-perceived ill health, and school problems/absenteeism. Summary Gaining expertise in addressing pediatric psychosomatic illness can make a great difference in patients’ life and in physicians’ professional satisfaction. Effective treatment approaches involve a multidisciplinary approach to consolidate care and facilitate communication, target the patient/familys understanding of the mind–body relationship and their acceptance of the bio-psycho-social formulation and treatment, and utilize functional rehabilitation and cognitive behavioral therapy for the individual and family and management guidance for schools.

Effect of 2 Psychotherapies on Depression and Disease Activity in Pediatric Crohn's Disease

Background:Crohns disease (CD) is associated with depression. It is unclear if psychosocial interventions offer benefit for depressive symptoms during active CD. In this secondary analysis of a larger study of treating depression in pediatric inflammatory bowel disease, we assessed whether cognitive behavioral therapy (CBT) would differentiate from supportive nondirective therapy in treating depression and disease activity in youth with CD. We also explored whether somatic depressive symptoms showed a different pattern of response in the overall sample and the subset with active inflammatory bowel disease. Methods:Youth with depression and CD (n = 161) were randomized to 3 months of CBT (teaching coping skills) or supportive nondirective therapy (supportive listening). Depressive severity was measured using the Childrens Depression Rating Scale-Revised (CDRS-R) with the somatic depressive subtype consisting of those CDRS-R items, which significantly correlated with CD activity. Disease activity was measured by the Pediatric Crohns disease Activity Index. Given the potential confound of higher dose steroids, subanalyses excluded subjects on >20 mg/d prednisone equivalent (n = 34). Results:Total CDRS-R scores in the overall sample significantly decreased over time after both treatments (P < 0.0001). Treatment with CBT was associated with a significantly greater improvement in the Pediatric Crohns disease Activity Index (P = 0.05) and somatic depressive subtype (P = 0.03) in those with active inflammatory bowel disease (n = 95) compared with supportive nondirective therapy. After excluding those on steroids (n = 34), there was a significant improvement in total CDRS-R (P = 0.03) and in Pediatric Crohns disease Activity Index (P = 0.03) after CBT. Conclusions:Psychotherapy may be a useful adjunct to treat depression in the context of CD-related inflammation in youth who are not concurrently on higher dose steroids.

Effect of timing of psychiatry consultation on length of pediatric hospitalization and hospital charges.

OBJECTIVES The purpose of this study was to evaluate the impact of timing of a psychiatry consultation during pediatric hospitalization on length of hospital stay and total hospitalization charges. METHODS The charts of 279 pediatric patients (totaling 308 consultations) referred to the psychiatry consultation liaison service at a freestanding tertiary pediatric hospital between January 1, 2010, and June 30, 2010 were retrospectively analyzed. The variables analyzed included the following: patient demographic characteristics; dates of admission, psychiatric consultation, and discharge; psychiatric diagnoses based on the psychiatric diagnostic evaluation; psychiatric treatment disposition; and illness severity and total charges associated with the medical stay. RESULTS Earlier psychiatry consultation was associated with shorter length of stay and lower hospitalization charges after adjusting for psychiatric functioning, physical illness severity, and psychiatric disposition. Poorer psychiatric functioning and milder physical illness were associated with shorter referral time. CONCLUSIONS Timely involvement of psychiatry consultation services during a medical or surgical hospitalization was associated with reductions in length of stay and total hospital charges in pediatric settings. These findings have important effects on quality of care via decreasing burden on the patient and family and on the medical system resources. Educating pediatric health care providers about the importance of early psychiatry consultation regardless of physical illness severity or psychiatric acuity will likely improve resource management for patients and hospitals.

Effect of Psychotherapy on Health Care Utilization in Children With Inflammatory Bowel Disease and Depression.

Objectives: Pediatric patients with inflammatory bowel disease (IBD) are at an increased risk of developing depression compared with community controls. Depression often negatively influences illness behaviors such as resource utilization. We sought to investigate the effects of treating depression on utilization of medical resources in depressed pediatric patients with IBD by comparing rates of health care utilization 1 year before and after psychotherapy. Method: Two hundred seventeen subjects ages 9 to 17 years with IBD and depression received 3 months of psychotherapy for depression as part of a multicenter randomized controlled trial. Of these 217 subjects, 70 had utilization data available 1 year prior and 1 year after receiving 3 months of psychotherapy. Primary outcomes included frequency of hospitalizations, inpatient hospital days, outpatient gastrointestinal visits, and number of emergency room visits, radiological examinations, and endoscopies. Within subject analyses were completed comparing health care utilization 12 months before psychotherapy compared with the 12 months after the conclusion of psychotherapy. Results: Fifty-one and 19 patients had CD and UC, respectively. A total of 55.7% of patients had major depression and 44.3% had minor depression. Overall, all study measures of health care utilization were significantly reduced after psychotherapy (P < 0.01)—including gastrointestinal-related (mean values) hospitalization frequency, inpatient days, outpatient visit, emergency room visits, radiological examinations, and endoscopies. Conclusions: Psychotherapy for comorbid depression in pediatric patients with IBD is associated with decreased GI-related health care utilization. The present study highlights the importance of screening for depression in a pediatric population with IBD, and that psychotherapy may be a reasonable adjunctive treatment for pediatric patients with IBD and comorbid depression.

Bullying Victimization in Medically Hospitalized Patients With Somatic Symptom and Related Disorders: Prevalence and Associated Factors.

OBJECTIVES The purpose of this study is to describe the prevalence of bullying victimization among medically admitted patients with somatic symptom and related disorders (SSDs) and to compare demographic, diagnostic, and psychosocial characteristics of bullied versus nonbullied patients. METHODS Medically admitted patients at a tertiary pediatric facility referred to the Psychiatry Consultation Service with somatic concerns were assessed via a quality improvement (QI) initiative, the SSD Standardized Clinical Assessment and Management Plan (SSD-SCAMP). Retrospective chart and QI data on adolescent and young adult patients assessed via SSD-SCAMP from May 2012 - December 2014 were reviewed. RESULTS Medical records of 282 patients (aged 12-22 years) diagnosed with SSDs were reviewed. Approximately 37% had a history of bullying victimization. Compared with nonbullied patients, bullied patients had higher somatization scores, more functional neurologic symptoms, and longer admissions. Bullied patients also had higher rates of comorbid anxiety, suicidal histories, and family psychiatric histories. Furthermore, bullied patients also had higher rates of learning disabilities and school accommodations and endorsed more significant life events within the year before hospitalization. CONCLUSIONS This study describes the unique health and psychosocial challenges experienced by medically hospitalized bullied adolescents and young adults with SSDs. The findings highlight the importance of a multidisciplinary approach to assessment and management. By implementing QI initiatives such as the SSD-SCAMP, providers can bridge the gap between the clinical needs and long-term management of patients with SSDs.

Irritable Bowel Syndrome and Abdominal Pain in Childhood

Chronic or recurrent abdominal pain in childhood and adolescence that is disabling, but not associated with structural or biochemical abnormalities, is considered a functional gastrointestinal disorder (FGID). Irritable bowel syndrome (IBS) is one of the most commonly diagnosed FGIDs in youth. This article provides current definitions, prevalence, etiology, associated impairments, emotional implications, and treatment of IBS and other FGIDs (functional dyspepsia, abdominal migraine, cyclic vomiting, etc.). A biopsychosocial model and a multidisciplinary rehabilitative treatment approach including that may include pharmacologic, dietary, and psychosocial interventions can help support youth and families in coping with symptoms, preventing disability, and maintaining normal, age-appropriate activities.

Wellness Promotion in Children with Chronic Physical Illness

A large number of US children live with chronic illness. This chapter describes, from an ecological perspective, research on several factors that can improve quality of life and overall wellness among children with chronic physical illness. Effective and healthy coping for patients and their families requires support from multiple levels (individual, family, institutional, and community levels) in order to minimize the impact on typical development. This chapter underlines the importance of patient- and family-centered psychoeducation and care, comprehensive interdisciplinary biopsychosocial formulations, effective training for providers on risk and protective factors, mental health and wellness support, as well as systemic factors such as integrated care and health advocacy. Patients, parents, providers, educators, communities, and policy makers can work together to support physically ill children by promoting illness-prevention and health-promotion while honoring individual strengths and cultural values.