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One Child’s Story of Integrated Care

A young boy, Tommy, shuffles his feet into the consult room followed by his mother and grandmother. Fidgety, hesitant, and anxious, he picks at his oversized clothing. The clothes couldn’t hide that this child is overweight.

Taking his History & Physical, the nurse practitioner, Sloane, learns he was recently diagnosed with skeletal sarcoma and had previously been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and Obsessive-Compulsive Disorder (OCD). The nurse practitioner had been called in for a psychiatric consult to evaluate his risk of developing anxiety after the cancer diagnosis.

Rates of depression and other psychological disorders are substantially higher in adolescents and young adults with cancer when compared with older adults.1 Additionally, outcomes for chemotherapy treatment and tolerance of its side effects are influenced by mood. Specifically, depression is associated with decreased amounts of brain-derived neurotrophic factor, which directly impacts the number of tumor cells killed by chemotherapy.2 This growing body of evidence supports treating mood disorders prior to starting chemotherapy in order to maximize effectiveness of treatment and increase chances of survival. This is further supported by the American College of Surgeons Commission on Cancer’s standard of systematic psychosocial distress screening for accredited programs. These findings highlight the relatedness of physical and mental health and the importance of integrated care in all patients. In this case, while the presenting condition was a physical one, evaluating mental health was critical to promoting outcomes and survivorship.

In evaluating this young patient’s medication, the consulting practitioner finds that he is taking Zyprexa as part of his treatment for OCD and for its anti-nausea properties in addition to Adderall which was prescribed for his ADHD. Given that Zyprexa has weight gain side effects and Adderall can aggravate anxiety, the practitioner decides to wean his dosages of Zyprexa and Adderall, start treatment on Prozac, and work with the oncology team to find an alternative medication to address chemotherapy induced nausea.

While medication management is just a small part of providing integrated care, it is a critical component of integrated care, especially when balancing the physical side effects and the psychological side effects of comprehensive treatment.

When working with children, the common hurdle can be parental buy-in to start psychiatric medications. Even though chemotherapy is a rather aggressive treatment, it can be easier for parents to understand the benefits of treatment and accept the side effects. In contrast, there remains a stigma around starting psychiatric medication treatment, indicating the medical community still has some opportunity for growth in driving mental health and physical health parity.

Even though she has a full patient load, Sloane connects well with Tommy. She takes more than the allotted 10 minutes just talking with him. She learns about his preferences – that he likes watching soccer and sometimes playing too, that he’s good at math, but hates sitting still for too long. She gets to know the mother and grandmother. In developing this relationship, she gains the trust of the family and emphasizes the need to look for signs of depression or worsening anxiety with the medication change and new diagnosis. While discussing Tommy’s treatment, Sloane notices some warning signs of verbal and emotional abusive tendencies in the household and therefore made a referral to a social worker for further evaluation and treatment.

Apart from the medication management component, providers who see patients on a more regular basis can develop relationships that support holistic care. In this case, further conversation revealed additional issues with the family which in turn allowed for further psychotherapy services. The importance of psychiatric consult services for conditions likely to aggravate mood disorders is just one way we see acute health systems moving towards integrated care. Whether patients present primarily with a physical diagnosis or psychiatric diagnosis, integrated care demands that we treat an entire patient’s health and recognize how a change in one system can cause downstream change in another.

It is not about mental health or physical health; it is about comprehensive health.

Special thanks to Sloane Sparks, an NP who is a child psychiatric consult for the Hematology Oncology Unit at Vanderbilt University Medical Center in addition to her other work in the community mental health setting.

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