From the Journals

Adolescent psychiatric ED visits more than doubled in 4 years

Publish date: March 19, 2019
By
Tara Haelle

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Multiple approaches needed to relieve psychiatric ED care

Even though the “fast-paced, stimulating environment” of an emergency department is not the ideal setting for children and families to receive care for mental health concerns, it remains a crucial safety net – particularly for lower-income individuals – because so many children lack access to mental health services, Dr. Chun and his associates wrote in an accompanying editorial.

“Some of the factors contributing to deficiencies in ED preparedness include a lack of staff trained in the identification and management of acute mental health problems; safe and quiet spaces within the ED; appropriate milieu for respectful, safe care; policies and procedures for ensuring best practices and consistent care; professional expertise to evaluate children’s mental health problems; and access to appropriate and timely follow-up care.”

Yet rates of youth’s psychiatric visits to the ED continue to climb because of a combination of increasing awareness, decreasing stigma for care seeking, limited mental health services, a shortage of pediatric mental health providers, insufficient specialty services, and true increases in mental health needs.

Solving this problem will require multiple coordinated approaches, but innovative options already are being explored, such as integrating child psychiatry services into EDs and “instituting next-day or other timely mental health evaluations,” they wrote. Other approaches include telepsychiatry; bringing mental health resources into schools and clinics; mental health resource sharing among communities; and mobile crisis units that visit schools, homes, primary care clinics, and low-resourced EDs.

Finally, medical training programs must change to adapt to the increasing need for pediatric mental health needs. “Embracing mental health problems as a routine component of pediatric medicine may be part of the solution to addressing the crisis,” they wrote.

Thomas H. Chun, MD, MPH, and Susan J. Duffy, MD, MPH, are at the Hasbro Children’s Hospital in Providence, R.I., and Jacqueline Grupp-Phelan, MD, MPH, is at the University of California, San Francisco, Benioff Children’s Hospital. These comments are a summary of a commentary accompanying Kalb et al. Pediatrics. 2019 Mar 18. doi: 10.1542/peds.2019-0251. The physicians used no external funding and had no financial disclosures relevant to their commentary.


 

FROM PEDIATRICS

Adolescent psychiatric visits to U.S. emergency departments increased 54% between 2011 and 2015, and suicide-related visits from teens more than doubled, a study found.

emergency department Fuse/thinkstockphotos.com

Visits by African American youth and Latino youth both increased by a significant amount, yet only a minority of all youth (16%) were seen by mental health professionals during their psychiatric ED visits.

“This study unmistakably reveals that adolescents are a population with urgent mental health needs,” Luther G. Kalb, PhD, of the Johns Hopkins Bloomberg School of Public Health and the Kennedy Krieger Institute in Baltimore, and his colleagues reported in Pediatrics. “Not only were their visits the most acute, but their probability of suicidal attempt and/or self-harm increased as well,” a finding that matches recent national increases in suicidal ideation.

The researchers used the 2011-2015 National Hospital Ambulatory Medical Care Survey to analyze data on psychiatric ED visits among U.S. youth aged 6-24 years. A psychiatric visit was identified based on the patient’s reason for visit and the International Classification of Diseases, ninth revision, codes for mood, behavioral, or substance use disorders; psychosis; or other psychiatric reasons. Suicide attempt or intentional self-harm were identified with reason for visit codes.

Psychiatric ED visits among all youth increased 28%, from 31 to 40 visits per 1,000 U.S. youth, in the period from 2011 to 2015, a finding “heavily driven by 2015, in which the largest increase in visits was observed,” the authors noted.

The biggest jump occurred among adolescents, whose visits increased 54%, and among black and Latino patients, whose visits rose 53% and 91%, respectively. Adolescent suicide-related and self-injury ED visits more than doubled from 2011 to 2015, from 5 to 12 visits per 1,000 U.S. youth. They were the only age group to see an increase in odds of a suicide-related visit over time (odds ratio, 1.27, P less than .01)

“Ultimately, it is unclear if the findings represent a change in identification (by providers) or reporting (by patients or family members) of mental health in the ED, a shift in the epidemiology of psychiatric disorders in the United States, or fluctuations in referral patterns or service-seeking behavior,” Dr. Kalb and his associates reported.

Study limitations included “an inability to confirm diagnostic validity” and some missing data for visit acuity and race/ethnicity, they said.

The research was funded by the National Institute of Health, and in part by the National Institute of Mental Health Intramural Research program. The authors reported no relevant financial disclosures.

SOURCE: Kalb LG et al. Pediatrics. 2019 Mar 18. doi: 10.1542/peds.2018-2192.

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