Abdominal pain accounts for up to 10% of pediatric cases in the emergency department, which often serves as the initial point of care for these patients. Researchers have long been aware of a link between abdominal pain, one of the most common pediatric conditions, and depression in children.
However, much of the evidence to date came from specialty clinics and focused on patients with chronic, rather than acute, pain diagnoses, according to Dr. Sarah R. Martin, a clinical psychologist and assistant professor of anesthesiology at the UC Irvine Center on Stress & Health and member of the emergency medicine staff at CHOC, part of Rady Children’s Health.
Dr. Martin and her colleagues at CHOC and UC Irvine wanted to examine the association between abdominal pain and depression early on, before pain turned chronic, so they turned to a more conducive setting: the ED.
An optimal study setting
The ED’s status as an entry point to care for youth with abdominal pain made it an ideal location in which to investigate the abdominal pain/depression relationship, especially since research in the emergency setting was lacking.
“We knew that depression rates in youth with chronic abdominal pain are almost double those of the general pediatric population, and that co-occurring depression and high pain-related impairment were common in this population,” Dr. Martin says. “But very little was known about depression in youth presenting to the ED with abdominal pain, even though the ED is a common access point for care and serves a large and diverse population. We wanted to fill this gap by characterizing depression in children with abdominal pain in the ED and identifying those who might be at higher risk.”
Screening for depression
Partnering with the UC Irvine Center on Stress & Health, the CHOC ED research team conducted depression screenings in pediatric patients who presented to the ED with abdominal pain. The screenings took place after ED triage. The researchers excluded patients requiring lifesaving treatment and those with a primary psychiatric complaint, such as suicide concern, identified during triage.
“We included only patients with idiopathic abdominal pain presentations. This included patients whose pain was not attributed to an infectious illness, a systemic or chronic medical condition, or those who required surgical intervention,” Dr. Martin says. “Study participants completed surveys on a tablet before they were seen by the provider, and the providers were notified if the patients recently endorsed self-harm ideation or screened positive for severe depressive symptoms.”
The participants included 169 patients ages 11 to 17 who answered questions about demographics, pain and related impairment, and depression. The researchers used the Patient Health Questionnaire to assess depression, with an overall score of 10 or higher indicating depression and a score of 1 or higher on question 9, which deals with self-harm ideation, indicating thoughts of self-harm.
Illuminating an earlier start for mental health concerns
Nearly 30% of the study participants reported depression, and more than 9% endorsed self-harm ideation, results that surprised the researchers. The study found an association between depression and Latinx identity and impairment from abdominal pain. The findings appeared in the journal Pediatric Research.
“Although the rates of depression and self-harm ideation in our study are similar to what has been reported in chronic abdominal pain samples, most of the children in our study were not experiencing chronic symptoms,” Dr. Martin says. “That tells us significant mental health concerns may be present much earlier than we typically recognize. Without screening, these symptoms may go completely unrecognized during an ED visit focused on acute abdominal pain. This highlights an important opportunity for early identification and intervention.”
Potential explanations for two key associations
Dr. Martin believes the study’s association between depression and abdominal pain-related impairment may be due to the well-known ability of pain and depression to fuel each other. Pain can inhibit daily functioning and lead to stress and social isolation, contributing to depression. Depression can intensify feelings of pain and associated impairment.
Healthcare disparities may help explain why Latinx youth in the study were more likely to report depression.
“Latinx youth are underrepresented in pediatric pain research, but broader pediatric mental health literature suggests they are at increased risk for depression secondary to systemic care inequities,” Dr. Martin says. “Our findings highlight the importance of including diverse populations in future studies so we can better understand and address the mechanisms driving these disparities.”
The researchers plan to continue investigating the relationship between pain and depression by studying other common, pain-related conditions that drive patients to the ED, such as headache. They are also planning longitudinal follow-ups to track patients’ pain, mental health and healthcare usage. According to Dr. Martin, this monitoring will allow the team to understand how patients’ symptoms and use of healthcare resources evolve, potentially revealing risk factors for poor outcomes and overuse of the medical system.
Implications for pediatric depression screening protocols
For Dr. Martin, the study underscores the value and importance of screening young patients with abdominal pain for depression, which the findings demonstrate is feasible in the ED. Using multiple screeners and surveys, she says, may help clinicians better detect mental health concerns, given that some study participants reported self-harm ideation on the PHQ despite no such findings emerging from verbal Ask Suicide-Screening Questions during triage.
“Early screening can reveal depressive symptoms that may otherwise go undetected, and it can guide timely referrals,” Dr. Martin says. “CHOC has taken important steps toward expanding depression and suicide risk screening, and our findings support these efforts. While we all recognize the challenges of limited mental health resources, early detection still matters. It allows families and providers to start the process of seeking care sooner and may ultimately prevent worsening symptoms and improve outcomes for patients.”
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