In a recently released article in Pediatrics, Dr. Bonnie Zima and colleagues explore “Psychiatric Disorders and Trends in Resource Use in Pediatric Hospitals.” (10.1542/peds.2016-0909) This topic is highly relevant for both hospitalists and pediatricians in primary care, because increased recognition and diagnosis of mental health disorders has changed the landscape of our practice. The authors used the Pediatric Health Information System (best known by its acronym PHIS) to examine discharge and billing data on hospital stays from 2005-2014 for children ages 3-17 years from 33 US hospitals– the database includes about 23% of all hospital stays for this age group, so the cohort is impressively large.
The authors focus on resources used as measured by total hospitalizations, hospital days, and hospital costs, and examine these outcomes by the measures that PHIS provides, including child demographic variables and chronic disease conditions, and in relation to whether the primary diagnosis was medical or psychiatric. The results are not completely intuitive, since I for one expected all costs and all hospital days to simply increase, and they did not. Please read the article itself to get the full story. While there was an overall increase in hospitalizations, hospital days and costs, and an increase in these measures for children hospitalized with combined medical and psychiatric diagnoses the authors found a decrease in hospitalizations, hospital days and costs for those with psychiatric diagnoses only. Depression, anxiety and suicide/self-injury were the most common psychiatric disorders. Yet in 2014, “…almost four of five hospitalizations with a psychiatric disorder were for children with a primary medical diagnosis…” What can or should we do with this information?
I believe there are research, practice and training implications. From the health researcher’s point of view, understanding the interaction between psychiatric diagnosis and medical diagnosis is crucial – which one triggers the admission, which one is simply co-coded, which drives the cost of the hospital stay, and most importantly what is the interaction between the medical and psychiatric conditions? Only by understanding the interaction between mental/emotional health, and physical health, will we be able to help the child or teen, intervene, and prevent not just the hospital admission, but the morbidity that accompanies the co-diagnoses.
From the practicing generalist or subspecialist’s point of view, the message is simple but the task is enormous – children and adolescents with chronic illness or even acute illness have mental health needs that impact and exacerbate their underlying physical illness. We must identify and address these mental health needs, and this is an urgent priority. If a 15 year old with inflammatory bowel disease (IBD) is depressed, he or she will likely become less compliant with medications and diet, less likely to feel and act well, may withdraw from support systems, and spiral downwards. While the presentation may be a worsening of IBD, the cause may be treatable depression. We must find a way to proactively recognize and treat this teen before his or her mental health problem compromises physical health and impairs quality of life in other ways too. And we need to train our students, residents and fellows to empathically recognize mental health disorders, to respect the profound impact such disorders have on their patients’ lives and chronic conditions, to expect to include this discussion in our history, and to advocate for their treatment. It should be as routine for a trainee to ask about symptoms of depression and anxiety as to ask about allergies and medications.
Finally, although this may seem “pie in the sky,” we can take routine pediatric care one step further for children and teens through prevention of mental health disorders by focusing on positive relationships, and on family, community and individual supports. Sometimes huge database studies like this one don’t seem very accessible to the individual provider but I believe this article by Dr. Bonnie Zima and colleagues gives us a host of ways forward.
