Implementing Integrated Mental Health Care in a Juvenile Myositis Clinic: A One-Year Review

Luana Flores Pereira¹, Louise Boulard², Kayla M. Baker³, Audrey Bell-Peter⁴, Vanessa Carbone³, Brian Feldman⁵, Jayne MacMahon⁶, Valerio Maniscalco⁷, Jo-Anne Marcuz⁸, Tanya Slater⁴, Kristi Whitney⁴, Y. Ingrid Goh³ and Andrea Knight⁹, ¹Neurosciences and Mental Health Program, SickKids Research Institute, Toronto, ON, Canada, ²Neurosciences and Mental Health Program, SickKids Research Institute; The Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada, ³Division of Rheumatology, The Hospital for Sick Children; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada, ⁴Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada, ⁵Division of Rheumatology, The Hospital for Sick Children; Departments of Pediatrics and Medicine, Faculty of Medicine; The Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ⁶Division of Rheumatology, The Hospital for Sick Children; Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada, ⁷Rheumatology Unit, ERN-ReCONNET Center, Meyer Children Hospital IRCCS; Department of Pediatrics, Santo Stefano Hospital, Florence, Italy, ⁸Division on Rheumatology, The Hospital for Sick Children; Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, ON, Canada, ⁹Division of Rheumatology, The Hospital for Sick Children; Neurosciences and Mental Health, SickKids Research Institute; Department of Paediatrics, University of Toronto, Toronto, ON, Canada

Meeting: ACR Convergence 2024

Keywords: mental health, Myositis, Patient reported outcomes, Pediatric rheumatology

Session Information

Date: Sunday, November 17, 2024

Title: Pediatric Rheumatology – Clinical Poster II

Session Type: Poster Session B

Session Time: 10:30AM-12:30PM

Background/Purpose: Juvenile myositis (JM) patients experience a high burden of emotional distress, yet mental health (MH) care is not typically integrated into standard clinical practices. Unaddressed MH issues can adversely affect patients’ quality of life and disease outcomes. As part of a quality improvement initiative to implement MH screening and integrated, onsite social work (SW) within the SickKids JM clinic, this study aimed to 1) investigate the relationship between patient/parent and physician global assessments (PPGA and PGA) and patients’ MH screens, and 2) describe the outcomes of integrated SW support for JM patients.

Methods: We screened JM patients at clinic visits from January 2023-2024 using parent proxy Pediatric Symptom Checklist-17 (PSC-17) for ages 5-11 years, and the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) for ages 12-18 years. Patients with positive screens, total score above established cutoffs, were offered a real-time SW referral, including same-day introduction and an initial SW session scheduled within a week. PPGA and PGA scores were routinely collected during visits. The relationship between global scores and baseline MH screening scores was analyzed using Mann-Whitney U test. We used descriptive statistics to tabulate screening data and qualitatively characterized SW activities including MH issues addressed and interventions provided.

Results: MH screens were completed for 67 patients, with 46 females (69%) and a mean age of 12.4 years (SD=3.3). Seventeen patients (25%) screened positive at baseline (Figure 1), including three reporting passive suicidal ideation. Higher PPGA was significantly associated with positive PHQ-9 screens (U=65.0 p=0.016). No significant associations were observed between any positive MH screens and PGA (Table 1). Of the 17 patients with positive screens, 6 (35%) accepted SW referrals. Comparing those accepting to those declining referrals, the median age was 15.6 (IQR=3.2) vs 13.5 (IQR=2.7) years, and symptom severity was similar with 33% vs 27% having moderate/severe scores (Figure 1). Over the one year, 24 1-hour sessions were conducted amongst the 6 referred patients. Patients reported their MH being affected by disease-related issues and other external stressors (Figure 2). Psychoeducation and counseling interventions tailored to patients’ needs were provided during sessions. Over the one-year period, patients successfully implemented learned skills and all but one concluded their sessions due to improved MH.

Conclusion: We successfully implemented and sustained a MH screening program with integrated SW intervention in the SickKids JM clinic. While PPGA may help identify prevalent MH symptoms, PGA alone may not reflect concerns, underscoring the need for routine MH screening in the JM population. Although only a small number of patients accepted referrals to integrated SW, sessions allowed patients to access appropriate interventions, and for the majority, improved their MH. The limited acceptance rate, predominantly by younger patients, highlights the need for enhanced psychoeducation to fully integrate MH care into routine clinic practices.

Figure 1. Flow chart of screening JM patients for mental health and referring patients to a social worker at baseline as applicable.
Patients seen in JM clinic included 58 patients with juvenile myositis, 6 patients with scleroderma, and 3 patients with overlap syndromes. On the PHQ-9 and GAD-7, screens were positive if scores were higher than 4; on the PSC_17, screens were positive if scores were higher than 15. On the PHQ-9, positive scores were interpreted as follows: 5-9 (mild), 10_14 (moderate), 15_19 (moderately severe) and 20_27 (severe). On the GAD-7, positive scores were interpreted as follows: 5-9 (mild), 10_14 (moderate) and 15_21 (severe). One patient with a mild score was not offered a referral by clinicians who determined the need for a referral to be assessed at follow-up.

Figure 2. Mental health issues and corresponding outcomes identified during social work sessions.

Table 1. Mann-Whitney U test examining PPGA and PGA scores by positive MH screen status.

Disclosures: L. Flores Pereira: None; L. Boulard: None; K. Baker: None; A. Bell-Peter: None; V. Carbone: None; B. Feldman: None; J. MacMahon: None; V. Maniscalco: None; J. Marcuz: None; T. Slater: None; K. Whitney: None; Y. Goh: Pfizer, 5; A. Knight: Pfizer, 6.

To cite this abstract in AMA style:

Flores Pereira L, Boulard L, Baker K, Bell-Peter A, Carbone V, Feldman B, MacMahon J, Maniscalco V, Marcuz J, Slater T, Whitney K, Goh Y, Knight A. Implementing Integrated Mental Health Care in a Juvenile Myositis Clinic: A One-Year Review [abstract]. Arthritis Rheumatol. 2024; 76 (suppl 9). https://acrabstracts.org/abstract/implementing-integrated-mental-health-care-in-a-juvenile-myositis-clinic-a-one-year-review/. Accessed .

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