Maryland Pao, MD

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Suicide is a global public health crisis and is the 

 In 2018, more than 45,000 adults in the US died by suicide, surpassing the number of homicides by more than 2-fold. Moreover, suicide risk is even higher among individuals with comorbid medical illnesses. Illness such as cancer, diabetes, and asthma have all been shown to increase risk for suicide.

 Given that medical illness is a concerning suicide risk factor, medical settings provide an optimal venue for suicide risk detection and intervention.

Medical settings are well positioned to detect suicide risk. The majority of people who died by suicide visited a health care professional months before their death, placing medical providers on the frontlines of suicide risk detection and suicide prevention.

 However, many patients with suicidal thoughts who present to the health care system with somatic complaints do not disclose suicidal thinking unless asked directly, and most medical settings do not screen for suicide risk.

Notably, suicides in the hospital are one of the top 5 most frequently 

sentinel events to The Joint Commission (TJC).

 Many are surprised to learn that although in-hospital suicides are relatively rare for patients undergoing general medical care, a sizeable portion of them occur on non-behavioral health units, such as intensive care units or emergency departments (EDs). Given these striking statistics and the goal of leveraging hospitals as partners in suicide prevention, TJC revised National Patient Safety Goal 15.01.01 (NPSG 15) in 2019.

 NPSG 15 outlines several elements to optimize patient safety and the reduction of suicide risk in medical settings. In particular, NPSG 

performing environmental safety assessments, removing ligature risks, screening patients with behavioral health issues for suicide risk, and providing further assessment of at-risk individuals who screen positive.

 Although NPSG 15 refers to suicide risk screening of all patients who are being treated or evaluated for a behavioral health condition as their primary reason for care, the TJC issued Sentinel Event Alert 56 in 2016, recommending suicide risk screening for all patients, using brief, evidence-based screening tools.

Following these recommendations, a growing number of health care systems have implemented suicide risk screening programs for all patients, including those presenting with medical complaints. Such a program at 

 (PHHS) is an example of how to successfully implement hospital-wide universal suicide risk screening. Using one of the screening tools recommended by TJC, PHHS screened more than 325,000 patients in the first 6 months of implementing their screening program and detected a positive screen rate of below 4% among patients undergoing medical care.

 It will be important for hospitals to work with frontline clinicians to develop safe and feasible procedures for implementing the safety guidelines outlined in NPSG 15 across diverse rural and urban settings and to be able to articulate their procedures to TJC surveyors when they assess hospitals for safe care delivery.

Several suicide risk screening tools are commonly used, with varying levels of evidence to support their use among these patients. Thom and colleagues

 reviewed several brief suicide risk screening tools and discussed the benefits and limitations of each for use in a hospital setting.

 Their review discusses 6 screening tools, including the Ask Suicide-Screening Questions (ASQ), the Patient Safety Screener (PSS-3), and the Columbia-Suicide Severity Rating Scale (C-SSRS), most of which are also TJC-recommended screening tools.

 The authors highlighted that only 2 of the tools discussed, the ASQ and the PSS-3, were developed and validated specifically for patients undergoing medical care.

Notably, the C-SSRS, a tool used by many hospitals due to its application to both youth and adults, has not been validated specifically for use in medical settings. Although Thom and colleagues highlighted that no suicide risk screening tools have been validated for use among both pediatric and adult patients undergoing medical care, recent data show that the ASQ, originally validated for use among youth, also has excellent psychometric properties among adult medical patients, potentially allowing for the use of 1 screening tool across hospitals.

Some medical settings utilize depression screeners to identify patients at risk for suicide. For example, the Patient Health Questionnaire (PHQ-9), which is an excellent depression screen, is sometimes utilized as a suicide-risk screening tool.

 Although there is a well-documented association between suicide and depression, extant research shows that the 2 are not synonymous. In 1 study, 90% of suicide decedents met criteria for diagnosis of a mental illness; however, only 28% of suicide decedents met the criteria for major depressive disorder.

 Moreover, screening solely for depression in patients undergoing medical care may not adequately detect suicidal ideation.

Question 9 on the PHQ-9, which asks about the frequency of a patient being bothered by “thoughts that you would be better off dead, or of hurting yourself in some way,” contains both an “or” and the word hurting instead of killing. Some studies have used this item to identify large numbers of at-risk patients.

However, specific concerns exist regarding the sensitivity and specificity of item 9

; the awkward wording of the question leading to inaccurate responses

; and that relying solely on item 9 may miss a large portion of patients at risk for suicide.

Using depression screeners such as the PHQ-9 as a proxy for suicide risk screening may be insufficient to detect suicide risk. Additionally, other mental health disorders, such as substance use disorders, schizophrenia, and anxiety disorders are associated with risk of suicide, which would go undetected by screening only for depression.

 Asking directly about suicide risk and using validated tools specific to hospital settings is necessary to accurately screen for suicide risk.

risk screening tools that was created and tested specifically for use among patients undergoing medical care, the ASQ is also part of a 3-tiered suicide risk screening clinical pathway.

 Although this pathway was designed for use among youth, the 3-tiered system can be applied to all such patients, including adults. The proposed pathway starts with the use of a brief screening instrument to rapidly screen all medical patients for suicide risk. For this step, Brahmbhatt and colleagues

 recommended the use of the ASQ due to its brevity and focus on patients undergoing medical care. The PSS-3 is the other screening tool that has been tested on adult patients in the ED and makes an excellent first-line brief screener.

After a patient screens positive for suicide risk, the second and essential step is to have a trained clinician (eg, a mental health clinician, nurse practitioner, physician assistant, primary care physicians) conduct a 10- to 15-minute brief suicide safety assessment (BSSA) to determine how to effectively manage the patient’s suicide risk. The secondary safety assessment step was created to avoid a one-size-fits-all planfor anyone who screens positive on a primary screener. All positive screens should not be treated as an 

; in fact, the majority of positive screens will be non-acute positives that do not require full safety precautions, but rather need further assessment.

This second step helps to ensure that mental health resources are used effectively and patients who reveal suicidal thoughts are not treated in a way that may seem punishing. For the BSSA, the clinical pathway published by Brahmbhatt and colleagues suggested the C-SSRS or the ASQ BSSA. Anecdotal evidence from frontline screeners suggests that the C-SSRS, which is a good in-depth suicide risk severity rating scale, is lengthy as a first-line screener and is more appropriate as a secondary suicide safety assessment tool for use among patients who screen positive for suicide risk. The ASQ and the ASQ BSSA are available as part of the ASQ Toolkit.

 The aim of the BSSA is to help a clinician further assess suicide risk in order to determine next steps in the pathway—whether a full mental health evaluation is needed at that particular medical visit, or if it can wait for an outpatient mental health referral.

Following a positive suicide risk screen, an essential component of ensuring patient safety is safety planning and lethal means counseling. Stanley and Brown

 published a safety plan worksheet that can help clinicians assist patients in planning how they will handle a future suicidal crisis. This worksheet consists of 6 steps that includes identifying personal warning signs, internal coping strategies, people and settings that can provide distraction, trusted people who can provide help, contact information for mental health resources, and ways to make the environment safe. The last step refers to the process of lethal means safety counseling, which is a detailed discussion on how to limit access, remove, or safely store dangerous items (eg, pills, firearms, knives, and ropes).

Implementation of suicide risk screening has been a specific challenge for many hospital systems due to difficulty selecting an evidence-based tool across the lifespan and across medical/surgical specialty settings that work in both inpatient and outpatient settings. In addition, guidance around how positive screens should be interpreted have led to systems developing untenable rules, such as “all positive screens require 1-to-1 sitters” and “strict safety precautions.”

In 2018, more than 45,000 adults in the US died by suicide, surpassing the number of homicides by more than two-fold.

Somewhat surprisingly, the rate of positives screen results due to reporting a past suicide attempts is significant. Past suicidal behavior is one of the most predictive risk factors of future behavior, but many reported attempts were in the distant past (eg, more than 10 years earlier). How should these truthful responses be interpreted? Such past behavior may be important clinical history when delivering a poor medical prognosis to a patient. Clearly more implementation research is needed on how to handle past attempt history and how frequently patients should be screened.

Suicide risk screening is especially challenging in the time of a pandemic. Data are not yet available to ascertain how COVID-19 will affect the suicide rate. However, the 3-tiered clinical pathway needed to be revised to accommodate mostly telehealth screening. Due to the urgent need, we revised the suicide risk screening clinical pathways published by Brahmbhatt and colleagues to reflect the need for phone 

Typically, anyone who is in imminent danger requires an urgent psychiatric evaluation in an ED. The pathway needed to be revised to help patients with acute suicide risk avoid exposure to COVID-19 in the ED and to spare the ED from over-crowding during the pandemic crisis. Separate adult and youth versions of this 

were created and are available as part of the ASQ Toolkit (

 However, they have not yet been empirically tested. A critical part of this pathway is for the health care practitioner to provide 

 to the patient and family members or friends to ensure safe storage or removal of potentially dangerous items (eg, pills, firearms, belts, knives).

Detection and management of suicide risk screening in the medical setting is no longer theoretical. There are many hospitals successfully implementing suicide-risk screening programs with validated instruments. Universal suicide risk screening can be successfully implemented without incurring a need for additional resources. Use of the intermediate step of a brief suicide safety assessment provides critical guidance for determining appropriate follow up in a safe and efficient manner. Given the increasing suicide rates in the general population, medical venues offer important opportunities for early detection, assessment, and referral. With evidence-based tools and pathways to guide them, every health care provider can be a partner in suicide prevention.

is the Clinical Director of the National Institute of Mental Health (NIMH) Intramural Research Program at the National Institutes of Health, she is also the Deputy Scientific Director, NIMH; 

is an Intramural Research Training Award Fellow at the NIMH; 

 is a Staff Scientist and Clinical Psychologist at the National Institute of Mental Health Intramural Research Program at the National Institutes of Health, she also serves as a senior attending with a specialty in pediatric psychology on the Psychiatry Consultation Liaison Service in the Hatfield Clinical Research Center at NIH.

Acknowledgement—This research was supported in part by the Intramural Research Program of the NIMH (Annual Report Number ZIAMH002922).

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3. Ahmedani BK, Stewart C, Simon GE, et al. Racial/ethnic differences in health care visits made before suicide attempt across the United States. 

4. Pan YJ, Lee MB, Chiang HC, Liao, SC. The recognition of diagnosable psychiatric disorders in suicide cases’ last medical contacts. 

5. Frankenfield DL, Keyl PM, Gielen A, et al. Adolescent patients”: healthy or hurting? Missed opportunities to screen for suicide risk in the primary care setting. 

6. The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission. 

https://www.jointcommission.org/assets/1/18/Summary_4Q_2017.pdf

7. The Joint Commission. Hospital National Patient Safety Goals. NPSG.15.01.01. 

https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_hap_jan2020.pdf

8. The Joint Commission. Detecting and treating suicide ideation in all settings. 

9. Roaten K, Johnson C, Genzel R, et al. Development and implementation of a universal suicide risk screening program in a safety-net hospital system. 

10. Thom R, Hogan C, Hazen E. Suicide-risk screening in the hospital setting: A review of brief validated tools. 

11. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. 

12. Boudreaux ED, Jaques ML, Brady KM, et al. The patient safety screener: validation of a brief suicide-risk screener for emergency department settings. 

13. Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. 

14. The Joint Commission. Validated/ Evidence-Based Screening Tools. Suicide Prevention Resources to support Joint Commission Accredited organizations implementation of NPSG 15.01.01. 

https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/suicide-prevention/suicide_prevention_resources_ep2_npsg150101.pdf

15. Horowitz LM, Snyder DJ, Boudreaux ED, et al. Validation of the Ask Suicide-Screening Questions (ASQ) for adult medical inpatients: a brief tool for all ages. 

16. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. 

17. Conwell Y, Duberstein PR, Cox C, et al. Relationships of age and axis I diagnosis in victims of completed suicide: a psychological autopsy study. 

18. Recklitis CJ, Lockwood RA, Rothwell MA, Diller LR. Suicidal ideation and attempts in adult survivors of childhood cancer. 

19. Simon GE, Coleman KJ, Rossom RC, et al. Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice. 

20. Simon GE, Rutter CM, Peterson D, et al. Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? 

21. Uebelacker LA, German NM, Gaudiano BA, Miller IW. Patient health questionnaire depression scale as a suicide screening instrument in depressed primary care patients: a cross-sectional study. 

22. Suarez L, Beach SR, Moore SV, et al. Use of the Patient Health Questionnaire-9 and a detailed suicide evaluation in determining imminent suicidality in distressed patients with cardiac disease. 

23. Razykov I, Hudson M, Baron M, Thombs BD. Utility of the Patient Health Questionnaire?9 to assess suicide risk in patients with systemic sclerosis. 

24. Louzon SA, Bossarte R, McCarthy JF, Katz IR. Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? 

25. Dueweke AR, Marin MS, Sparkman DJ, Bridges AJ. Inadequacy of the PHQ-2 depression screener for identifying suicidal primary care patients. 

26. Brahmbhatt K, Kurtz BP, Afzal KI, et al. Suicide-risk screening in pediatric hospitals: Clinical pathways to address a global health crisis. 

27. National Institute of Mental Health. Ask Suicide-Screening Questions (ASQ) Toolkit, 2017. 

28. Stanley B, Brown GK. Safety Planning Intervention: a brief intervention to mitigate suicide risk. 

Articles

The authors share evidence-based guidance for patient safety that minimizes suicide risk in medical settings.

Implementation Challenges of Universal Suicide Risk Screening in Adult Patients in General Medical and Surgical Settings

A. State you cannot work with him if he discontinues his medication

B. Contact his parents to bring them into the next session to discuss concerns about medication nonadherence

C. Review indications and informed consent for each medication to understand his history of treatment and current ambivalence

D. Agree to discontinue medications if he appears stable and keep close clinical watch while building a therapeutic alliance

It is common for young adults to express a desire to discontinue medications taken since childhood.

To encourage treatment adherence, it is appropriate to redo the informed consent process and review indications for each medication. This will remind the patient of how a medication can help him in functioning and reaching goals.

Because the effects and adverse effects that the patient's parents or guardian agreed to in the past may no longer be acceptable, it is important to present the risks and benefits of each medication.

Closely screen for the patient’s current level of substance use, which may have changed with decreased supervision, for the possible impact on regimen adherence, medication levels, and treatment effectiveness.

Challenges of Transitioning From Pediatric to Adult-Oriented Care

,” by Margaret J. Yoon, MD and Maryland Pao, MD, on which this quiz was based.

Poll

A 19-year-old new patient comes to you wanting to discontinue all his childhood psychiatric medications. What is the best next step?

Mini Quiz: New Patient Consult

Young adult psychiatry addresses the needs of transitional-age youth typically between the ages of 15 and 26 years. The phenomena of transitional age difficulties are a result of cultural and societal changes in which physiologic maturity (as marked by chronological age and biological development) and the acquisition of skills necessary for independent adult life in modern society are not aligned; this may be due to chronic illness in childhood, which is on the rise, or changes in parenting or other psychosocial difficulties. Society is confused about the roles and responsibilities of youth, as noted by Giedd:

Age-of-consent questions are particularly enmeshed in political and social contexts. For example, currently in the United States a person must be at least 15 to 17 years old . . . to drive, at least 18 to vote, buy cigarettes, or be in the military, and at least 21 to drink alcohol. The minimum age for holding political office varies . . . some municipalities allow mayors as young as 16 . . . , governors from 18 to 30. The age of consent to sexual relations varies worldwide from puberty . . . to age 18.

The inverse situation is illustrated in the legal entity of emancipated minors, which recognizes certain youth as developmentally or functionally advanced beyond their chronological age of less than 18 years once they demonstrate certain adult competencies (eg, financial self-sufficiency, marriage, caretaking of children, military service).

[[{"type":"media","view_mode":"media_crop","fid":"44425","attributes":{"alt":"Â© Alex Tor/shutterstock.com","class":"media-image media-image-right","id":"media_crop_8283121832594","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4965","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 94px; width: 150px; float: right;","title":"Â© Alex Tor/shutterstock.com","typeof":"foaf:Image"}}]]Young adulthood is a time of increased motivation, opportunity, and risk-taking, but also of increased risk for the onset of multiple, highly prevalent psychiatric disorders. Mood and anxiety disorders typically present during late adolescence and in the early twenties. There is a heightened risk of substance abuse disorders due to incompletely developed impulse control coupled with increased access to drugs. Eating disorders and the first break for early-onset psychosis also peak within this age range.

Disorders from childhood and adolescence, such as ADHD and autism spectrum disorders, continue to affect function, but at a higher degree that cannot be as easily accommodated by families and educational or therapeutic systems. Popular expressions such as “extended adolescence” or “failure to launch” focus concern on the individual’s deficits, but it is important to consider a developmental perspective that recognizes the challenges of the family and the clinical system in transitioning youth as well. So, who is responsible for treating the adolescent and young adult and when and how should transitions in care occur?

When to refer a young patient to an adult psychiatrist

Child and adolescent psychiatrists practice within a moving developmental frame and may work with adolescents and young adults as they enter adulthood for continuity of care. However, pediatric psychiatrists may choose to refer the patient to an adult psychiatrist for several reasons. The volume of emerging young adults would quickly saturate pediatric providers’ patient load. Educational or employment transitions can result in a geographic move that makes access to childhood providers difficult. Child and adolescent psychiatrists may treat multiple members of a family, and referral to another clinician may help separation and foster the patient’s individuation process.

When a patient is reluctant to transition to adult services, pediatric psychiatrists may recognize dynamics that resist change to the treatment configuration, such as avoidance due to anxiety about more independent functioning, leaving an established doctor-patient relationship, unacknowledged dependence on the family support that pediatric treatment providers offer, and reaction to an enactment of parental loss or abandonment. With support, the patient can be guided through the sense of loss and normal grief in such a transition. Thus, planning for the transition, on the part of the child psychiatrist as well as the receiving adult psychiatrist, requires forethought as much as a year before the actual transition if possible.

Issues in accepting transitioning patients

When adult providers begin to work with adolescents and young adults and their families who have transitioned from child psychiatry, reviewing confidentiality and setting treatment boundaries avoid confusion between the treatment models. Pediatric psychiatrists operate with a family-informed developmental model that may incorporate routine communication with parents to direct supportive changes in the home. Families may have the expectation that their child’s treating psychiatrist will freely release information. A review of confidentiality policies at the first meeting should outline how information (that will be more regulated in its release and with the child’s permission) will be exchanged by the adult psychiatrist with the family.

As children negotiate their own space apart from parents, there may be a greater need to establish clear boundaries. Information-gathering meetings with the family should be discussed beforehand with patients to define the level of disclosure and role of the session. Family sessions may also be balanced with separate meetings with significant others and families of choice, as this recognizes the importance of extra-familial relationships and invites other adult perspectives on a patient’s history.

Developmental discontinuity to adult functioning

There are several situations that can hinder a smooth segue to adult functioning. Young adulthood is a period when mood or psychotic disorders may first present, and it may be a difficult, clinically unstable period. For youths who have had periods of severe symptomatology, their caretakers may have provided too much accommodation out of a sense of overprotection, thereby enabling avoidance of challenges during adolescence. Consequently, these youths may not have had opportunities to develop skills to function autonomously, and they may stall from anxiety or regress when adult expectations are placed on them.

Alternately, if an adolescent received inadequate supervision, there may be hidden or minimized development of symptoms that worsened with disengagement from treatment. With the additional loss of parental support at 18, these youths fall off the treatment radar until nonadherence results in relapse. With decreased supervision, young adults may have increased access to settings where recreational drugs are available, just as they have also reached the legal age limit for the purchase of alcohol. Some vulnerable youth may have undertreated substance abuse or be self-treating mood and anxiety symptoms with substances, all of which can undermine appropriate adult coping.

Not every young person has mastered skills of independent functioning by the age of 18, so the transitional age range reflects the discontinuity that can appear between chronological age and developmental maturity. Some families (such as those with high-conflict divorces or another family member with chronic illness) may be dependent on the child’s presence or other benefits they bring to the household, and the family destabilizes when the adolescent attempts to functionally individuate or leave. The young adult experiences himself or herself as the cause of the family’s distress and delays transitioning in order to stabilize the family.

J is a 17-year-old high-performing junior at a competitive high school when she presents for psychiatric care for acute MDD with suicidal ideation and prominent anxiety features, in the context of increasing academic demands, declining grades, new-onset self-injury, and social withdrawal. She requires 2 inpatient hospitalizations for recurrent suicidal ideation of jumping in front of the subway en route to school.

Her distress decreases as academic adjustments are discussed, antidepressant medication is initiated, and her parents agree to therapeutic support for her. However, she has difficulty stepping down to a partial hospitalization program as she finds family meetings hard to tolerate because of the high level of tension between her parents, and she is often absent from the program the day after family meetings. She engages in individual outpatient medication management and psychotherapy more easily but is nonverbal or angry during periodic family sessions. This is followed by worsening urges for self-injury and thoughts of self-denigration and punishment.

J is unable to return for her senior year in high school because of exacerbation of symptoms, and she ambivalently receives home instruction. She continues in outpatient treatment, but with no clear progress developmentally or educationally.

After several months, J discloses in therapy that there is longstanding, mutual physical domestic violence between her parents, and she is frequently drawn into the fights in her attempts to stop their conflicts. She is concerned about her mother’s apparent depression and her father’s dissociative reactions after fights.

It is identified that the mother’s strong positive transference to J’s individual therapist has been particularly helpful in opening up the parents to treatment, but this secret has never been revealed outside the home. J realizes her perfectionism and academic excellence had initially served to refocus her parents and reduced the number of fights at home in her early years, and now the onset of her MDD and academic failure serves the same purpose. She states that she is afraid to leave home for fear that without her presence and intervention, her parents could inadvertently disable or kill each other.

After a discussion with the entire family, child protective services is contacted and the report is filed with a concurrent request from the parents for voluntary home-based services. The parents also agree to begin couples’ therapy to address relationship dynamics that existed before J was born, and to start to consider individual treatment. This allows J to release some of the caretaking and sense of responsibility she has toward her parents. J chooses to pursue her senior year of high school at a therapeutic boarding school that offers support for her anxiety and depression symptoms, and she is able to consider applying to local colleges.

As J’s 18th birthday approaches, transition to adult care is discussed with her and her parents. Although J has a strong therapeutic alliance with her adolescent psychiatrist and psychotherapist who have worked with her since her first hospitalization, she expresses a desire to find treatment closer to her boarding school and to separate from those who are working collaboratively with her parents. She feels that her parents will continue to struggle with safety in their relationship; although she restricts communication, her mother continues to leave messages for J’s therapist.

Several options that accept J’s insurance are identified and discussed with her over several months. She chooses an adult mental health center that offers group therapy options and specialized treatment for trauma. She allows communication between her pediatric and new adult teams, but restricts communication with her parents despite their expressed preference. She successfully transitions to living in a dorm at a college within the state but outside of her hometown.

Because adolescents and young adults have experience with pediatric providers who use a range of developmental approaches and may be family focused, transition-age patients are usually more comfortable with a practical, emotionally “real” therapeutic engagement with adult therapists. Changes in continuity of care are always challenging. When providing care to transitional patients, consider selective, therapeutically appropriate emotional disclosure during initial sessions to convey your concern, worry, or interest to foster the patient’s engagement and trust.

Building a quick alliance by joining a rejecting stance toward the family of origin is equivalent to building on sand, because this serves to externalize blame and erodes opportunities for reflection and practicing mature responsibility. This also sets up a framework for the projection of blame onto other responsible adults in the young adult’s life, such as bosses, teachers, and friends, which may later extend to the new therapist.

If families are too easily blamed for mistakes that the young adult makes, it impedes the patient from being motivated to problem-solve and may later emotionally block the patient from reaching out to his family when the family can be a supportive resource. A more balanced stance toward the family as a resource-available but separate from the patient-is less likely to result in scapegoating and emotional isolation. Recognize the practical support that families provide to young adults (financial, educational, access to health care, cultural, interpersonal) rather than discard access to these resources, while balancing appropriate boundaries to allow room for individuation.

Assume that young adult patients have not yet mastered independent living skills or achieved functional autonomy, although they may present themselves as doing so. Ask for examples of functioning, and listen for feedback from peers and family members to assess the actual level of independence. Colluding with a young adult’s self-idealization will create a therapeutic dilemma when the patient must acknowledge that he is in trouble. The patient may instead present with a series of crises or perceived victimizations over time due to repeated losses of jobs, housing, and relationships due to unperceived skills deficits.

Make an opportunity early in treatment to hear concerns from the family, and then openly review these concerns with the patient with therapeutic curiosity in a separate session. Note the specific language that is used by families to describe the patient’s historical roles or symptoms, because these labels and stories will be a window into the patient’s view of himself.

Managing confidential information and records

The ability to control access to confidential medical information comes with legal adult status. Youths may not be aware of how their treatment information was released or managed in the past, so a careful review of this history with parents can avoid unpleasant surprises. Young adults may need to be encouraged to allow transfer of medical files and records from pediatric services, and guided through the decision to release information to work or educational settings for appropriate support. Some patients benefit from receiving a hard copy of their records followed by a review with a clinician; this will enable patients to answer questions about their treatment and learn how to provide a medical and psychiatric history.

Spend some time reviewing who should receive updates on treatment, and ask the patient to sign appropriate release forms in sessions without the presence of parents to minimize pressure on the patient to release information. Proactively addressing the change in communication with the parents will avoid conflicts that can later arise from perceived rejection or estrangement. Review with family members that providers may receive unrestricted information from the outside, but are limited by confidentiality to release information, so that the parents understand that sharing their concerns with providers continues to be a valuable way to support their child.

Young adults beginning treatment with new adult providers benefit from a thorough review of their medication. They may have assumed independent management of their medication administration and can benefit from a simplified regimen if possible to maximize adherence. It is common for young adults to express a desire to discontinue medications taken since childhood. This may stem from differing views on pathology, a symbolic pushing away of parental labels, or a desire to distance themselves from their illness history. To avoid nonadherence, it is appropriate to redo the informed consent process and review indications for each medication, which will remind the patient of how the medication can help him in functioning and reaching goals. Risks and benefits of each medication should be presented to the patient, because the effects and adverse effects that his parents agreed to in the past may no longer be acceptable. Closely screen for the patient’s current level of substance use, which may have changed with decreased supervision, for the possible impact on regimen adherence, medication levels, and treatment effectiveness.

Patients who have both psychiatric and medical illnesses, particularly young adults with chronic illness (autism spectrum disorder, HIV infection, diabetes) or severe or terminal illnesses (which may require timely review of end-of-life planning), may require additional supports. Maintenance of health in young adults with chronic illnesses strongly depends on a smooth transition to adult care.

Although experiencing the loss of a caring doctor-patient relationship is difficult, providers reluctant to transfer care after long-term work may need to assess their own countertransference. Consider transitioning in a graduated stepwise manner, or plan a multidisciplinary meeting and structured communication between pediatric and adult services; consider including parents, especially if the parents are divorced and there is considerable animosity. The 

 provides suggestions for making the transition easier.

Young adults who are transitioning out of foster care, state custody, or probation placement must master adult skills without the normal scaffolding of family support and may also require additional meetings with agency providers. The presence of a developmental delay or intellectual or other permanent disabilities presents additional challenges. Services may be divided into separate treatment tunnels (eg, school services, employment support, family treatment, therapeutic services) and require extra communication to transition services.

Dr Yoon is an Assistant Attending Psychiatrist at the New York Presbyterian Hospital and an Assistant Professor of Psychiatry in the Division of Child and Adolescent Psychiatry at Weill Cornell Medical College in New York. Dr Pao is Clinical Professor in the Department of Psychiatry at the Georgetown University School of Medicine and Clinical Director of the National Institute of Mental Health, National Institutes of Health, in Bethesda, MD.

 Giedd J. Adolescent brain maturation. Encyclopedia on Early Childhood Development. November 2010. 

http://www.child-encyclopedia.com/brain/according-experts/adolescent-brain-maturation

 Turkel S, Pao M. Late consequences of pediatric chronic illness. 

• AACAP’s Youth in Transition: Moving into Adulthood Resource Center: 

http://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Home.aspx

• National Alliance on Mental Illness (NAMI) Teens & Young Adults Section 

http://www.nami.org/Find-Support/Teens-and-Young-Adults

• Got Transition by the nonprofit Center for Health Care 

• National Collaborative on Workforce & Disability for Youth (NCWD-Youth) 

Who is responsible for treating the adolescent and young adult with psychiatric issues -- and when and how should transitions in care occur? 

Almost one-fifth of US children younger than 18 years (14.2 million) have a chronic illness that results in the need for special health care. Recent advances in medical and surgical technology, such as chemotherapy and immunotherapy, bone marrow transplant, and implantable devices, have increased survival rates and changed the lives of ill children and their families. Health care providers promote normal physical, motor, language, cognitive, sexual, and emotional development in children with chronic illnesses when possible, and foster coping and adjustment when there are limitations.

In adapting to physical illness, it is clear that a child’s poor adjustment is not directly related to the severity of the medical condition alone and that outcomes vary widely. Approximately 20% of children with chronic medical conditions have behavioral and emotional symptoms-twice the rate seen in the general population. These symptoms are normal responses to illness and hospitalization, but when they become pathological and impair a child’s development, early intervention and perhaps even prevention are needed.

Zach is a 15-year-old with a rare primary immunodeficiency disorder that was diagnosed a year earlier. Before his diagnosis, he had been developing typically; he was doing well in school, was participating in sports, and was socially active. During a protracted hospitalization for a bone marrow transplant, multiple medical complications-including central line infections and renal failure-developed, followed by an embolic stroke with residual right-sided weakness; his speech was not affected. Endocarditis necessitated prolonged antibiotic therapy.

Although usually upbeat, Zach became tearful and withdrawn over the ensuing weeks, and he would not participate in physical therapy. Depression was diagnosed by the pediatric psychiatry consultation liaison team, and a low-dose SSRI was prescribed. Soon after, he began to participate in physical therapy. He was less tearful and his mood improved. Because of concerns about possible adverse effects, however, the SSRI was discontinued. Within a week, Zach lacked motivation for physical therapy. After a multidisciplinary meeting, psychopharmacological therapy with the SSRI was reinstated, and he was discharged.


 Pediatric psychosomatic medicine services (also known as pediatric psychiatric consultation liaison services) bridge the gap between psychiatric and pediatric training to improve the emotional health and quality of life of children and adolescents with chronic illness. Psychiatrists who specialize in psychosomatic medicine provide collaborative care in general medical hospitals, on medical psychiatry inpatient units, and in primary care and other outpatient settings. The psychosomatic medicine consultant helps medical teams determine whether:

• Patients have an underlying or preexisting psychiatric disorder

• Patients have a psychiatric disorder that is the direct consequence of a primary medical condition (eg, brain tumor, Cushing syndrome, stroke sequela) or medical treatment (eg, interferon, high-dose corticosteroids, efavirenz)

• Patients have a somatoform disorder (ie, physical symptoms that seem out of proportion to medi-cal findings, or psychological factors that affect a general medical condition)

Untangling the differential diagnosis is daunting and requires expertise. Now that the health care field includes numerous subspecialists and hospitalists, integrated multidisciplinary care in medicine is more important than ever.

Consideration of pediatric psychopharmacology in the context of medical illness begins with a careful review of all current medications, including over-the-counter drugs as well as herbal, complementary, and alternative preparations. An evaluation of the recommended medication’s route of administration is needed because it may be affected by hepatic, GI, renal, and cardiac diseases. Adverse-effect profiles are also considered (eg, drowsiness may be helpful in a child who is agitated or has insomnia).

There is limited research on the pharmacokinetics and pharmacodynamics of medications across developmental stages, but most psychosomatic medicine specialists follow the principle: “Go low and go slow.” Choose medications with a short half-life, avoid introducing more than one medication at a time, and monitor and document target symptoms closely.

There is limited research on pharmacokinetics and pharmacodynamics of drugs across developmental stages . . . most psychosomatic medicine specialists . . . “go low and go slow.”

In pediatric psychosomatic medicine services, delirium, depression, and anxiety commonly precipitate consultation and psychopharmacological medication. However, there are no FDA-approved indications for psychopharmacological medications in medically ill children with delirium, depression, or anxiety.

The child’s family needs to be fully informed of the reason to use psychotropic medications and of their indications, therapeutic alternatives, and anticipated benefits. Each time a psychotropic medication is used, the risks to benefits ratio needs to be considered. It is essential to keep up-to-date about all FDA black box warnings.

Because of the lack of approved indications for psychotropics in children with medical illness, use is generally extrapolated from literature on medically ill adults or use in physically healthy children with psychiatric conditions. See the 

 for commonly prescribed psychotropic medications in medically ill children.

In children, delirium is an acute mental status change characterized by sleep-wake disturbance, fluctuating symptoms, impaired attention, irritability, agitation, affective lability, and confusion caused by an underlying medical illness. Adults have waxing and waning consciousness accompanied more noticeably by impaired memory, depressed mood, speech disturbance, delusions, and paranoia. Both adults and children have similar rates of impaired alertness, apathy, anxiety, disorientation, and hallucinations.

In medically ill pediatric patients, delirium is frequently caused by seizures; CNS tumors or infections; exposure to toxins; metabolic irregularities; drug-drug interactions; drug withdrawals; inadequate pain management; fever; or treatment with corticosteroids, interferon, chemotherapy, radiation, narcotics, or anticholinergic agents.

Treatment of the underlying medical condition is the most effective means of resolving symptoms of delirium. Environmental and pharmacological interventions can offer relief while medical evaluation takes place. Environmental interventions include frequent reorientation to time, place, and person; an environment that is neither overstimulating nor understimulating; and information for the patient and family on the relationship between altered mental status and physiological mechanisms.

 suggest treating hyperactive delirium with haloperidol or another typical antipsychotic medication. Risperidone or another atypical antipsychotic medication can improve hypoactive/mixed delirium symptoms. Schieveld and colleagues

 used typical and atypical antipsychotics to treat delirium symptoms in 40 ICU pediatric patients. Munzig and colleagues

 also reported success with atypical antipsychotics in patients (aged 1 to 18 years) who had delirium.

Symptoms of depression and anxiety, such as insomnia, loss of appetite, and fatigue, are common in chronically ill patients and can be overlooked or undertreated. Depressive symptoms add to the burden of illness and have been associated with poorer medical outcomes, treatment nonadherence, repeated hospitalizations, and disease-related complications in medically ill patients.

The prevalence of major depressive disorder and depressive symptoms has been found to be as high as 68% in pediatric patients with serious medical illness.

 Most studies use self-rating scales or semi-structured interviews. In evaluating a child or adolescent with depressive symptoms, it is important to distinguish whether the symptoms are attributable to the medical condition and to the effects of treatment or to an underlying psychiatric disorder.

Causes of depression include immune system and cytokine dysfunction, medication complications, endocrine abnormalities or deficien-cies, nutrition-related neurological or medical conditions, and CNS metastases.

 A full medical workup needs to be done to rule out underlying physiological mechanisms before the treatment decision is made.

Focus on the cognitive symptoms of depression, such as poor concentration, low self-esteem, feelings of guilt or of being a burden to others, and any suicidal thoughts (passive or active). Evidence suggests that asking patients, even young children, directly about their suicidal thoughts is the best method to assess suicide risk.

 Medical patients are a vulnerable population at higher risk for suicidal thoughts and behaviors-suicide risk varies by diagnosis, severity of disease, physical functioning, pain management, and prognosis.

When symptoms are attributed to an underlying mood disorder or are causing moderate to severe functional impairment, target antidepressants to specific symptoms. While psychotropic medications have not been studied in medically ill patients in a large-scale systematic manner, one small (N = 15) open-label trial demonstrated that fluvoxamine was well tolerated and significantly improved symptoms of anxiety and depression in pediatric cancer patients.

 Another case report describes citalopram as being well tolerated and effective in treating depression in 4 children with cancer.

Fluoxetine is an FDA-approved SSRI for depression in children older than 6 years. Fluoxetine, with its active metabolite norfluoxetine, and fluvoxamine are potent inhibitors of cytochrome P-450 (CYP) 3A3 and CYP3A4 and are best avoided, when possible, in combination with macrolide antibiotics, azole antifungal agents, and several other commonly used medications.

Citalopram has been widely used in medical settings because of its short half-life and low tendency to interact with other drugs.

However, the recent FDA warning that dosages greater than 40 mg/d can cause QTc prolongation may curb this practice.

 Escitalopram is approved for depression in 12- to 17-year-olds, and amitriptyline is approved for depression in patients aged 12 years or older.

Although difficult to tolerate in high doses because of anticholinergic symptoms and tachycardia, tricyclic antidepressants are often used in low doses to treat insomnia, weight loss, anxiety, and some pain syndromes. Other antidepressants, such as bupropion and duloxetine, have been found to have clinical utility under careful monitoring.

SSRIs and selective noradrenergic reuptake inhibitors are used with caution since the FDA black box warnings about increased risk of suicidal behavior in children and adolescents using these medications. This underscores the need for careful, weekly monitoring of all children treated with antidepressants. In general, it is unusual for medically ill patients to be suicidal without premorbid depression or with adequate pain management.

Pediatric patients with a history of multiple hospitalizations commonly experience anxiety (particularly separation anxiety), procedural anxiety, and adjustment disorders with anxious mood. A number of factors can contribute to the presence of anxiety symptoms: illness-related biological mechanisms, a response to diagnosis or being in the hospital, genetic and psychosocial causes, or a combination of all of these.

Behavioral and cognitive approaches are recommended as first-line treatment for anxiety symptoms. Medical play therapy, cognitive-behavioral therapy, prizes and incentives for procedures, and distraction techniques such as virtual reality and video game interventions, have demonstrated efficacy in ameliorating anxiety symptoms.

For symptoms that persist or become clinically significant, psychopharmacological treatments can be an important adjunct. Benzodiazepines, such as lorazepam, used in low doses in conjunction with nonpharmacological distraction techniques may be appropriate for procedures that provoke significant anxiety in children. Clonazepam, a longer-acting benzodiazepine, may be helpful with more pervasive and prolonged anxiety symptoms.

Benzodiazepines can cause sedation, confusion, and behavioral disinhibition, so their use should be carefully monitored, especially in those with CNS dysfunction. Benzodiazepine withdrawal precipitated by abrupt discontinuation often occurs on transfer out of intensive care settings, so special care should be taken not to discontinue benzodiazepines too abruptly.

In addition, antihistamines are frequently used to sedate anxious children. While diphenhydramine may be helpful for occasional insomnia, antihistamines are not helpful for persistent anxiety, and their anticholinergic properties can precipitate or worsen delirium.

Escitalopram (approved in healthy children older than 12 for depression) and citalopram are used to treat anxiety as well and may lead to fewer drug-drug interactions in medically ill patients.

Psychopharmacology may supplement psychotherapies such as cognitive-behavioral therapy, behavior work, and family therapy in reducing symptoms of anxiety, depression, and delirium in pediatric medically ill patients-particularly when the disorders are causing significant functional impairment. Left untreated, psychiatric disorders can negatively affect quality of life, symptom management, treatment adherence, medical outcome, and somatic complaints, and they can impede com-pliance with medical procedures. Targeted psychopharmacological treatment, in conjunction with environmental or behavioral interventions, can lessen the severity of mood, sleep, and appetite problems; help medically ill children develop better coping skills surrounding diagnosis, treatment, and procedures; and improve quality of life and functioning in multiple domains.

 Kurtz BP, Abrams AN. Psychiatric aspects of pediatric cancer. 

 Martini DR, Pao M. Psychiatric emergencies. In: Wiener LS, Pao M, Kazak AE, et al, eds. 

Quick Reference for Pediatric Oncology Clinicians: The Psychiatric and Psychological Dimensions of Pediatric Cancer Symptom Management

. Charlottesville, VA: IPOS Press; 2009:121-129.


 Apter A, Farbstein I, Yaniv I. Psychiatric aspects of pediatric cancer. 

 Karnik NS, Joshi SV, Paterno C, Shaw R. Subtypes of pediatric delirium: a treatment algorithm. 

 Schieveld JN, Leroy PL, van Os J, et al. Pediatric delirium in critical illness: phenomenology, clinical correlates and treatment response in 40 cases in the pediatric intensive care unit. 

 Munzig E, Turkel S, Jacobson J, et al. Diagnosis and treatment of pediatric delirium. Poster presented at: Academy of Psychosomatic Medicine; November 20, 2008; Miami.


 de Jonge PD, Hadj FB, Boffa D, et al. Prevention of major depression in complex medically ill patients: preliminary results from a randomized, controlled trial. 

 Koopmans GT, Donker MC, Rutten FH. Length of hospital stay and health service use of medical inpatients with comorbid noncognitive mental disorders: a review of the literature. 

Understanding pediatric psychopharmacology in the context of medical illness.

Maryland Pao, MD

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