(026) The Value of a Strong Therapeutic Alliance and the Cost of Breaking It: The Case of a Chronically Medically Ill, Suicidal Young Adult

Abstract:

Background:



Children, adolescents, and young adults with chronic medical illnesses are uniquely susceptible to comorbid mental illness. Research has demonstrated that children afflicted by chronic medical conditions have a higher incidence of anxiety disorders and play a role in the trajectories of patients´ lives leading to psychosocial impairments that may result from bullying, school absenteeism, and social difficulties secondary to being a child with a chronic medical illness. Our case highlights a unique instance where the benefit of involuntary admission to psychiatry did not outweigh the cost of fracturing our chronically ill, medically noncompliant patient’s relationship with her pediatric gastroenterologist.



Methods:



We present a case of a 20-year-old woman with a past psychiatric history of anxiety, depression and past medical history of gastroschisis status post small bowel, liver, stomach, and pancreas transplant at one year of age. The patient was admitted to inpatient pediatric gastroenterology for nutritional rehabilitation after she stopped her tube feeds. The patient acknowledged that this action was a suicide attempt. Our team discussed the benefits of inpatient psychiatry admission with the patient’s pediatric gastroenterologist who believed strongly that involuntary psychiatric admission would be viewed as a breach of trust. The provider speculated that the patient might discontinue her treatment with possible serious medical consequences and the patient’s mother concurred. The decision was made to have the patient remain on the medical floor with a one-to-one patient attendant. The patient attendant was removed after a follow-up evaluation. She was restarted on her home psychotropic regimen of fluoxetine 40mg once a day and initiated on mirtazapine 7.5mg at bedtime. She had established outpatient psychiatric care and did not require connection to services. Before signing off, the consultation-liaison psychiatry team confirmed that she was not suicidal and that she had an outpatient psychiatry appointment scheduled within 7 days of discharge.



Discussion:

The case highlights a young adult patient who had been suffering from a serious, chronic medical illness since the age of one. The case also highlights the challenges of keeping the patient on the medical floor. The medical floor did not provide a therapeutic milieu or staff specially trained to handle psychiatric issues. Her presentation is congruent with the limited research available on the psychiatric sequelae of chronic illnesses in young patients. She developed anxiety, depression, and social difficulties secondary to her illness. After years of living with the threat of her premature mortality, she developed a lack of concern for consequences, likely resulting in her noncompliance with medication.



Conclusions:

In her unique case, fracturing the trust she had in her pediatric gastroenterologist outweighed the value of involuntary inpatient psychiatric care.