Challenges for teens with sickle cell disease extend to mental health
As most adults remember, adolescence can be a difficult period of life. As they grow and change physically, adolescents also face challenges regarding independence, body image, mood, peer interactions, and planning for the future. These challengesmay be heightened in adolescents with chronic illnesses, and can lead to serious health consequences. For instance, oral chemotherapynonadherence in teens with acute lymphoblastic leukemia is a major contributor to the higher relapse rate seen in this age group.1 Adolescents and young adults with type I diabetes and depression have poorer glycemic control.2 For youth with sickle cell disease (SCD) the relationships between mood, body image, andmedical outcomes are likely evenmore complex becausemood is intertwinedwith pain, the cardinal symptom of SCD. In this issue of Pediatric Blood and Cancer, Bhatt and colleagues3 report onbody image,mood, andhistory of suicide attempts in a cohort of youth with SCD ages 16 years and older in Jamaica. Using a standardized questionnaire in the outpatient SCD clinic, they found that youth with SCD were more likely than their healthy peers to have body image dissatisfaction and symptoms of depression. Participants with SCD were almost twice as likely to have attempted suicide. Furthermore, they also found that depression symptoms and prior suicide attempts were more prevalent in teens with more severe SCD, as determined by frequency of pain episodes and hospitalizations. This study's strengths include the focus on adolescents with SCD at their baseline state of health, rather than during a hospitalization, and the comparison with a healthy peer group. The relationship between mental health and SCD pain is wellknown. In a prospective study, adultswith SCDwho self report depression symptoms have more frequent, more severe pain of longer duration.4 In a retrospective analysis of children with SCD via a multicenter US hospital discharge database, co diagnosis with a psychiatric disorder was associated with greater hospitalization frequency and longer length of stay,5 but this study was limited by lack of outpatient data and temporal relationships between pain and psychiatric diagnoses. Now, by screening teens at outpatient visits using a standardized questionnaire, Bhatt et al. have provided further evidence that pain and depression symptoms are linked in those with SCD. However, a lingering question from all of these studies is whether pain causes depression symptoms or depression symptoms exacerbate pain. Itmay not be possible to distinguish between cause and effect, since pain and mental health are closely intertwined.While Bhatt and colleagues did not specify the subjects' medical treatments, it is possible that treating pain more effectively in those with SCD will improve mental health. Frustratingly, the best way to treat frequent or chronic pain is unclear. A recent prospective study found that adults with SCD receiving chronic opioid therapy had greater central sensitization to pain and worse chronic "non crisis" pain,6 suggesting that more opioid pain medications are not the solution. Rather, pain prevention may have a greater impact on pain relatedmood disturbances. Not included in the current study was whether physicians were aware of their patients' depression symptoms, body image dissatisfaction, and suicide attempts. Clinicians cannot treat what they do not know about, so identifying mental health needs during medical visits is a critical first step. Unfortunately, no standard recommendations for mental health care exist for SCD, and psychosocial care was not addressed in the 2014 National Heart, Lung, and Blood institute SCD evidence based care guideline.7 While several approaches to mental health care have been reported in the literature, none has been found to be consistently effective. A combined medical and psychosocial approach can be successful, as described by Brandow and colleagues8 in a single center study. They found that teens had significantly fewer hospitalizations after attending a multidisciplinary pain clinic staffed by a hematologist, psychologist, and pain management specialist. Interventions included psychological therapies and nonpharmacological pain management techniques, combined with opioid and nonopioid pain medications and disease modifying therapies. This approach may not be available at all SCD centers, but implementing a self reported mental health screening tool for teens with SCD during their routine outpatient visits might be feasible, with referrals a psychologist or counselor for high risk individuals. Advances in medical treatment of SCD will likely lead to better mental health among adolescents. Since 2014, hydroxyurea has been recommended for all children with Hb SS/S beta zero thalassemia to
Pediatric blood cancer