Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US

Cultural Adaptation of the teen Mental Health First Aid (tMHFA) Program from Australia to the USA

teen Mental Health First Aid (tMHFA) is an evidence-based program developed in Australia that teaches young people in grades 10-12 how to identify and respond to signs of mental health challenges and crises among peers. Recognizing the growing adolescent mental health crisis in the USA, the National Council for Mental Wellbeing, in partnership with a Johns Hopkins University research team, used a multimethod research approach to adapt the program culturally and contextually from Australia to the USA. The goals of the study were to engage adolescents, MHFA instructors, and content area experts (N = 171) in a process to determine: how to retain the elements of the course that were evidence-based and effective while adapting the program for US students, what topics to add so US students have the essential information and skills teens needed to help a friend experiencing a mental health challenge or crisis, what changes to make to curriculum materials to ensure the style and delivery resonate with US students, and what tools to include so the program is implemented safely and with fidelity in diverse US schools. This paper outlines the adaptation process, including engaging participants, identifying key recommendations for modification, and making changes to the tMHFA program. The findings demonstrate the types of adaptations that may be needed to facilitate implementation and maintenance of program effectiveness when introducing tMHFA to new populations of students in the USA. In addition, the process outlined can be replicated toward this purpose as the program continues to expand both in the USA and in other countries.

Population level administrative data evidence of visits to the emergency department by youth with intellectual/developmental disabilities in BC, Canada

INTRODUCTION

The literature indicates that youth with intellectual/developmental disabilities (IDD) have poor health and that access to health services decreases as they transition from pediatric to adult services. At the same time their use of emergency department services increases. The objective of this study was to compare use of emergency department services by youth with IDD to youth without IDD, with particular emphasis on the transition period from pediatric to adult health care services.

METHODS

This research used a population level administrative health data base for the province of British Columbia Canada for 2010-2019 to examine the use of emergency departments by youth with IDD (N = 20,591) compared to a population group of youth without IDD (N = 1,293,791). Using the ten years of data, odds ratios for visits to the emergency department were calculated adjusting for sex, income and geographical area within the Province. In addition, difference-in-differences analyses were calculated for age matched subsets of the two cohorts.

RESULTS

Over the ten year period, 40.60% of youth with IDD visited an emergency department at least once, compared to 29.10% of youth without IDD. Youth with IDD had an odds ratio of visiting an emergency department 1.697 (1.649, 1.747) times that of youth without IDD. However, when odds were adjusted for a diagnosis of either psychotic illness or anxiety/depression, the odds for youth with IDD visiting emergency compared to youth without IDD were reduced to 1.063 (1.031, 1.096). Use of emergency services increased as youth aged. Type of IDD also affected use of emergency services. Youth with Fetal Alcohol Syndrome had the greatest odds of using emergency services compared to youth with other types of IDD.

DISCUSSION

The findings from this study indicate that youth with IDD have higher odds of using emergency services than youth without IDD although these increased odds appear to be largely driven by mental illness. In addition, use of emergency services increases as the youth age and transition from pediatric to adult health services. Better treatment of mental health issues within this population may reduce their use of emergency services.

The impact of the COVID-19 pandemic on psychiatric emergency consultations in adolescents

BACKGROUND

There is growing evidence that the COVID-19 pandemic, and its associated social distancing measures, affect adolescents' mental health. We wanted to examine whether and how the number and characteristics of adolescents' psychiatric emergency presentations have changed throughout the pandemic.

METHODS

We extracted data from the records of 977 psychiatric emergency consultations of adolescents aged 12- 19 who had been referred to the mobile psychiatric emergency services in Rotterdam, the Netherlands between January 1^st 2018 and January1^st 2022. Demographic, contextual, and clinical characteristics were recorded. Time-series-analyses were performed using quasi-Poisson Generalized Linear Model to examine the effect of the first and second COVID-19 lockdown on the number of psychiatric emergency consultations, and to explore differences between boys and girls and internalizing versus externalizing problems.

RESULTS

The number of psychiatric emergency consultations regarding adolescents increased over time: from about 13 per month in 2018 to about 29 per month in 2021. During the COVID-19 pandemic, the increase was tempered. In the second wave a pronounced increase of psychiatric emergencies among adolescents with internalizing problems but not with externalizing problems was found.

CONCLUSION

Despite the reported increase of mental health problems in adolescents during the COVID-19 pandemic, we did find a smaller increase in psychiatric emergency consultations in this group then would be expected considering the overall trend. Besides changes in help-seeking and access to care, a possible explanation may be that a calmer, more orderly existence, or more parental supervision led to less psychiatric emergency situations in this age group. In the second wave the number of emergency consultations increased especially among girls with internalizing problems. While there has been a particular fall in emergency referrals of adolescents with externalizing problems since the start of the pandemic it is still too early to know whether this is a structural phenomenon. It would be important to elucidate whether the changes in emergency referrals reflect a true change in prevalence of urgent internalizing and externalizing problems in adolescents during the pandemic or a problem related to access to care.

Psychiatric emergencies among urban youth during COVID-19: Volume and acuity in a multi-channel program for the publicly insured

This study sought to characterize changes in the utilization of psychiatric emergency services among children and adolescents during distinct phases of 2020, as compared with prior years. We conducted a retrospective review of electronic health records from January 2018 through December 2020 that included all encounters made by patients under age 21. We then analyzed data for the 15,045 youth psychiatric encounters during the study period. Encounter volume in 2020 was significantly lower than prior years in March through May (IRR, 0.44; 95% CI, 0.40-0.49), May through July (IRR, 0.63; 95% CI, 0.56-0.71), and October through December (IRR, 0.76; 95% CI, 0.70-0.83). Encounters for youth with primary psychotic disorders remained at typical levels throughout 2020. Among older adolescents and youth with anxiety disorders, pervasive developmental disorders, and substance use disorders, encounter volume was significantly lower than prior years only during the initial lockdown period. There were significantly more encounters than normal conducted by mobile crisis units, including via telehealth, in July through October (IRR, 1.31; 95% CI, 1.06-1.62) and October through December (IRR, 1.28; 95% CI, 1.05-1.55) of 2020. Differences in patterns of encounter volume based on sociodemographic and clinical characteristics highlight subgroups of youth who may have been particularly vulnerable to acute mental health problems during periods of social distancing and isolation. Proactive efforts to engage vulnerable youth in outpatient treatment during periods of increased infectivity may help prevent increasing symptoms from reaching the point of crisis.

Safety of a prehospital emergency medical services protocol for an alternative destination for pediatric behavioral emergencies in Alameda County

Background

Pediatric patients with behavioral health emergencies (BHEs) are often transported to an emergency department (ED) by emergency medical services (EMS), despite having no physical medical complaints, to await psychiatric evaluation and treatment. This process leads to significant delays in their care. We examined the safety of directly transporting pediatric patients with BHEs from the field to an alternative destination of a psychiatric emergency service (PES) facility using an EMS protocol.

Methods

A retrospective review from November 1, 2011, to November 1, 2016, was conducted for pediatric EMS encounters using EMS data from Alameda County, California. Our primary outcome was the safety of a prehospital alternative destination protocol. We identified the proportion of patients who required retransport to an ED within 24 h after arriving at PES (defined as a failed diversion). We also describe the mortality of all patients being transported for a BHE.

Results

There were 38,241 total pediatric encounters, with 20.1% for BHEs. A total of 3122 (41%) BHE encounters met protocol criteria and were transported directly to the PES. Only 16 (0.5%) patients had a secondary transport (failed diversion) to an ED within 24 h of arrival. No patients with a BHE transported to the PES died within 30 days of the EMS encounter.

Conclusion

Death and adverse clinical outcomes are extremely rare in pediatric patients using a prehospital alternative destination protocol. This information could significantly improve the care of children with BHEs.

Systematic tracking of mental health acute care visits: A model of care for college students

Objective: College students who receive an acute care visit (ACV) from an emergency or inpatient unit require mental health follow-up (MHF) to improve long-term outcomes. This study describes tracking ACVs and MHF, while identifying characteristics of multiple vs. single ACVs.Participants: 191 students who received an ACV (N = 231) at one public university - enrollment approximately 39,000.Methods: For two academic years (AYs), students were tracked and offered timely MHF. Demographics, clinical information, utilization patterns, and rates of MHF were analyzed.Results: Primary reasons for an ACV were suicidal thinking (60.6%) and psychosis (13.9%). MHF improved between AYs (65.8% to 93.3%, X² = 27.48, p < .01). Multiple vs. single visits were more likely to present with self-injurious behavior and psychosis and received more intensive follow-up yet, had similar rates of MHF.Conclusions: The primary reasons for an ACV - suicidal thinking and psychosis - underscore the importance of campus suicide prevention and psychosis-specific services.

Acute mental health service use in adolescents with suicidal thoughts and behaviours: Impact on outpatient care

INTRODUCTION

Youth with suicidal thoughts and behaviours often present to acute emergency care settings for assessment. Timely outpatient follow up may reduce return acute care visits. The primary aim of our study was to describe clinical and contextual differences between youth who do and do not use acute care once connected to outpatient services.

METHODS

A 24-month retrospective chart review of suicidal youth aged 13-16 (n = 45) presenting for outpatient mental health treatment. Youth who used acute services during the study period (ASU) or did not (non-ASU) were compared on demographic, risk profile, and mental health service use.

RESULTS

The mean age of participants was 14.6 years (73% female). Suicide risk profile at baseline did not differ between groups, but was significantly higher in ASU youth at 24 months. There were more youth in service at the end of the study period in the ASU group compared to the non-ASU group (11% vs 55%).

CONCLUSION

Youth who do continue to access acute services may be at higher risk of suicidality even after outpatient treatment. Although it is unclear whether this is linked to outpatient engagement, it raises further questions about this population and how they respond to community based mental healthcare.

Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019

Importance

Approximately 1 in 6 youth in the US have a mental health condition, and suicide is a leading cause of death among this population. Recent national statistics describing acute care hospitalizations for mental health conditions are lacking.

Objectives

To describe national trends in pediatric mental health hospitalizations between 2009 and 2019, to compare utilization among mental health and non-mental health hospitalizations, and to characterize variation in utilization across hospitals.

Design, Setting, and Participants

Retrospective analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative database of US acute care hospital discharges. Analysis included 4 767 840 weighted hospitalizations among children 3 to 17 years of age.

Exposures

Hospitalizations with primary mental health diagnoses were identified using the Child and Adolescent Mental Health Disorders Classification System, which classified mental health diagnoses into 30 mutually exclusive disorder types.

Main Outcomes and Measures

Measures included number and proportion of hospitalizations with a primary mental health diagnosis and with attempted suicide, suicidal ideation, or self-injury; number and proportion of hospital days and interfacility transfers attributable to mental health hospitalizations; mean lengths of stay (days) and transfer rates among mental health and non-mental health hospitalizations; and variation in these measures across hospitals.

Results

Of 201 932 pediatric mental health hospitalizations in 2019, 123 342 (61.1% [95% CI, 60.3%-61.9%]) were in females, 100 038 (49.5% [95% CI, 48.3%-50.7%]) were in adolescents aged 15 to 17 years, and 103 456 (51.3% [95% CI, 48.6%-53.9%]) were covered by Medicaid. Between 2009 and 2019, the number of pediatric mental health hospitalizations increased by 25.8%, and these hospitalizations accounted for a significantly higher proportion of pediatric hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]). The percentage of mental health hospitalizations with attempted suicide, suicidal ideation, or self-injury diagnoses increased significantly from 30.7% (95% CI, 28.6%-32.8%) in 2009 to 64.2% (95% CI, 62.3%-66.2%) in 2019. Length of stay and interfacility transfer rates varied significantly across hospitals. Across all years, mental health hospitalizations had significantly longer mean lengths of stay and higher transfer rates compared with non-mental health hospitalizations.

Conclusions and Relevance

Between 2009 and 2019, the number and proportion of pediatric acute care hospitalizations due to mental health diagnoses increased significantly. The majority of mental health hospitalizations in 2019 included a diagnosis of attempted suicide, suicidal ideation, or self-injury, underscoring the increasing importance of this concern.

Racial Differences in Emergency Department Visit Characteristics and Management of Preadolescents at Risk of Suicide

OBJECTIVE

Suicide rates and frequency of pediatric emergency department (ED) visits for suicidal thoughts and behaviors have increased among Black preadolescents in the United States in recent years. This study examined whether characteristics of ED visits and treatment management of preadolescents with suicidal thoughts and behaviors differed by race.

METHODS

An electronic medical record query identified patients ages 8-12 (N=504) who visited a pediatric ED with a psychiatric-related chief complaint in 2019. The authors examined suicidal thoughts and behaviors that were reported with the Ask Suicide-Screening Questions tool, ED clinical impression, and ED disposition overall and by race.

RESULTS

Compared with other racial groups, Black preadolescents were less likely to report suicidal thoughts, despite equivalent lifetime histories of suicide attempts, and were more likely to be brought to the ED by police and discharged (instead of being admitted to inpatient psychiatric care).

CONCLUSIONS

Research to better understand racial disparities in suicide risk among preadolescents can inform prevention efforts.

U.S. Emergency Department Telepsychiatry Use in 2019

Introduction: Although many emergency departments (EDs) receive telehealth services for psychiatry, or telepsychiatry, to manage acute psychiatric emergencies, national research on the usage of ED telepsychiatry is limited. To investigate ED telepsychiatry usage in the pre-COVID-19 era, we surveyed a sample of EDs receiving telepsychiatry in 2019, as a follow-up to a survey targeted to similar EDs in 2017. Methods: All U.S. EDs open in 2019 (n = 5,563) were surveyed to characterize emergency care. A more in-depth second survey on telepsychiatry use (2019 ED Telepsychiatry Survey) was then sent to 235 EDs. Of these EDs, 130 were randomly selected from those that reported telepsychiatry receipt in 2019, and 105 were selected based on their participation in a similar survey in 2017 (2017 ED Telepsychiatry Survey). Results: Of the 235 EDs receiving the 2019 Telepsychiatry Survey, 192 (82%) responded and 172 (90% of responding EDs) confirmed 2019 telepsychiatry receipt. Of these, five were excluded for missing data (analytic samplen = 167). Telepsychiatry was the only form of emergency psychiatric services for 92 (55%) EDs. The most common usage of telepsychiatry was for admission or discharge decisions (82%) and transfer coordination (70%). The most commonly reported telepsychiatry mental health consultants were psychiatrists or other physician-level mental health professionals (74%). Discussion: With telepsychiatry as the only form of psychiatric services for most telepsychiatry-receiving EDs, this innovation fills a critical gap in access to emergency psychiatric care. Further research is needed to investigate the impact of the COVID-19 pandemic on usage of ED telepsychiatry.

Trends of repeated emergency department visits among adolescents and young adults for substance use: A repeated cross-sectional study

Emergency Department (ED) visits for substance-related concerns among young people have been increasing in recent years. Understanding the factors related to repeated ED visits (two or more ED visits per year) for substance use concerns among young people is critical to developing a more efficient mental healthcare system that does not overburden ED and that provides efficient care for substance use patients. This study examined trends of substance use-related ED visits and factors related to repeated ED visits (two or more ED visits per year, in comparison to one ED visit per year) among adolescents and young adults (aged 13 to 25 years) in the province of Ontario, Canada. Binary logistic regression models were conducted to examine associations between hospital-related factors (hospital size, urbanicity, triage level, ED wait time) and visit status (2+ vs 1 ED visit/year), controlling for patient characteristics (age/sex). A population-based, repeated cross-sectional data over a 10-year period (2008, 2013, and 2018) was used. The proportion of substance use-related repeated ED visits significantly and consistently increased in the year 2013 and 2018 compared to 2008 (2008 = 12.52%, 2013 = 19.47%, 2018 = 20.19%). Young adult, male, medium-sized hospital, urban location, wait times longer than 6 hours, and symptom severity was associated with increased numbers of repeated ED visits. Furthermore, polysubstance use, opioid use, cocaine use, and stimulant use were strongly associated with repeated ED visits compared with the use of substances such as cannabis, alcohol and sedatives. Current findings suggest that repeated ED visits for substance use concerns could be reduced by policies that reinforce evenly distributed mental health and addiction treatment services across the provinces in rural areas and small hospitals. These services should put special efforts into developing specific (e.g., withdrawal/treatment) programming for substance-related repeated ED patients. The services should target young people using multiple psychoactive substances, stimulants and cocaine.

Augmenting Mental Health Support for Patients Accessing Different Degrees of Formal Psychiatric Care through a Supportive Text Messaging Program: Protocol for a Randomized Controlled Trial

Patients feel more vulnerable when accessing community mental health programs for the first time or after being discharged from psychiatric inpatient units. Long wait times for follow-up appointments, shortage of mental health professionals, lack of service integration, and scarcity of tailored support can weaken their connection to the health care system. As a result, patients can present low adherence, dissatisfaction with treatment, and recurrent hospitalizations. Finding solutions to avoid unnecessary high-cost services and providing tailored and cost-effective mental health interventions may reduce the health system burden and augment patient support. We propose implementing an add-on, supportive text messaging service (Text4Support), developed using cognitive-behavioural therapy (CBT) principles to augment mental health support for patients attending to or being discharged from psychiatric care in Nova Scotia, Canada. This randomized controlled trial aims to investigate the effectiveness of Text4Support in improving mental health outcomes and overall mental well-being compared with usual care. We also will examine the intervention's impact on health services utilization and patient satisfaction. The results from this study will provide evidence on stepped and technology-based mental health care, which will contribute to generating new knowledge about mental health innovations in various clinical contexts, which is not only helpful for the local context but to other jurisdictions in Canada and abroad that are seeking to improve their health care.

The effect of increased emergency department demand on throughput times and disposition status for pediatric psychiatric patients

OBJECTIVES

Emergency department (ED) crowding has been shown to increase throughput measures of length of stay (LOS), wait time, and boarding time. Psychiatric utilization of the ED has increased, particularly among younger patients. This investigation quantifies the effect of ED demand on throughput times and discharge disposition for pediatric psychiatric patients in the ED.

METHODS

Using electronic medical record data from 1,151,396 ED visits in eight North Carolina EDs from January 1, 2018, through December 31, 2020, we identified 14,092 pediatric psychiatric visits. Measures of ED daily demand rates included overall occupancy as well as daily proportion of non-psychiatric pediatric patients, adult psychiatric patients, and pediatric psychiatric patients. Controlling for patient-level factors such as age, sex, race, insurance, and triage acuity, we used linear regression to predict throughput times and logistic regression to predict disposition status. We estimated effects of ED demand by academic versus community hospital status due to ED and inpatient resource differences.

RESULTS

Most ED demand measures had insignificant or only very small associations with throughput measures for pediatric psychiatric patients. Notable exceptions were that a one percentage point increase in the proportion of non-psychiatric pediatric ED visits increased boarding times at community sites by 1.06 hours (95% CI: 0.20-1.92), while a one percentage point increase in the proportion of pediatric psychiatric ED visits increased LOS by 3.64 hours (95% CI: 2.04-5.23) at the academic site. We found that ED demand had a minimal effect on disposition status, with small increases in demand rates favoring <1 percentage point increases in the likelihood of discharge. Instead, patient-level factors played a much stronger role in predicting discharge disposition.

CONCLUSIONS

ED demand has a meaningful effect on throughput times, but a minimal effect on disposition status. Further research is needed to validate these findings across other state and healthcare systems.

Parenting Practices and Adolescent Internalizing Symptoms in the United States, 1991-2019

PURPOSE

Adolescent internalizing symptoms are increasing in the United States. Changes in parenting practices, including monitoring and communication, have been hypothesized to contribute to these increases. We aimed to estimate trends in parenting practices and understand whether shifts in such practices explain increases in internalizing symptoms.

METHODS

Using 1991-2019 Monitoring the Future data (N = 933,645), we examined trends in five parental practices (i.e., knowledge [three combined indicators], monitoring [four combined indicators], communication, weekend curfew, social permission) with ordinal regressions. We tested associations between parental practices and indicators of being in the top decile of depressive affect, low self-esteem, and self-derogation using survey-weighted logistic regressions, adjusted for gender, race/ethnicity, grade, and parental education.

RESULTS

The prevalences of parental practices have not changed over time, with the exception of increases in parental knowledge, specifically parents knowing where an adolescent is after school (1999-2019 mean increase: 4.34 to 4.61 out of 5) and knowing an adolescent's location (4.16-4.49) and company at night (4.26-4.51). Higher levels of each practice were associated with lower internalizing symptoms (e.g., adjusted odds ratio for a high depressive affect based on a one-unit increase in parental knowledge: 0.89, 95% confidence interval: 0.88, 0.90). Patterns were consistent across internalizing outcomes and decade.

DISCUSSION

Parental knowledge, monitoring, and other practices are stable protective factors for adolescent mental health. These factors are not changing in a manner that would plausibly underlie increases in internalizing symptoms. Future interventions should provide resources that support these parental practices which are tied to adolescent internalizing symptoms.

Prediction of Suicide Attempts and Suicide-Related Events Among Adolescents Seen in Emergency Departments

IMPORTANCE

Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool.

OBJECTIVE

To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata.

DESIGN, SETTING, AND PARTICIPANTS

The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023.

MAIN OUTCOMES AND MEASURES

This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA.

RESULTS

Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively).

CONCLUSIONS AND RELEVANCE

This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.

Long-Term Trends in Psychiatric Emergency Services Delivered by the Boston Emergency Services Team

Rising psychiatric emergency department (ED) presentations pose significant financial and administrative burdens to hospitals. Alternative psychiatric emergency services programs have the potential to alleviate this strain by diverting non-emergent mental health issues from EDs. This study explores one such program, the Boston Emergency Services Team (BEST), a multi-channel psychiatric emergency services provider intended for the publicly insured and uninsured population. BEST provides evaluation and treatment for psychiatric crises through specialized psychiatric EDs, a 24/7 hotline, psychiatric urgent care centers, and mobile crisis units. This retrospective review examines the sociodemographic and clinical characteristics of 225,198 BEST encounters (2005-2016). Of note, the proportion of encounters taking place in ED settings decreased significantly from 70 to 58% across the study period. Findings suggest that multi-focal, psychiatric emergency programs like BEST have the potential to reduce the burden of emergency mental health presentations and improve patient diversion to appropriate psychiatric care.

Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments

OBJECTIVES

Emergency department (ED) utilization by children with mental and behavioral health (MBH) conditions is increasing. During these visits, pharmacologic restraint may be used to manage acute agitation. Factors associated with pharmacologic restraint use are not well described.

METHODS

This was a retrospective cohort study of ED visits from the Pediatric Health Information System database, 2010-2020. We included visits by children 3-21 years with a primary MBH diagnosis and identified visits with pharmacologic restraint. Regression models were used to analyze the association between patient- and hospital-level factors and restraint.

RESULTS

Of 545 800 ED MBH visits over the study period, 22 194 visits (4.1%) involved pharmacologic restraint use. In multivariable analysis, restraint was associated with ages 18-21 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.59-2.22), male sex (OR, 1.25; 95% CI, 1.16-1.34), Black race (OR, 1.22; 95% CI, 1.09-1.35), visits starting overnight (OR, 1.68; 95% CI, 1.45-1.96), or the weekend (OR, 1.26; 95% CI, 1.22-1.30), and repeat ED visits (OR, 1.31; 95% CI, 1.17-1.47). Every 100-visit increase in average annual MBH volume was associated with a 0.09% decrease in restraint (95% CI, -0.15 to -0.04) with no significant association between average annual ED volume and restraint (95% CI, -0.25 to 0.25).

CONCLUSIONS

For children in the ED with MBH conditions, ages 18-21 years, male sex, Black race, visits starting overnight or the weekend, and repeat ED visits were associated with pharmacologic restraint. These results can inform strategies to reduce restraint use and ensure safe and equitable ED care.

The Impact of the COVID-19 Pandemic on Pediatric Mental Health Emergency

OBJECTIVE

The aim of this study was to compare pre/post-coronavirus disease 2019 pandemic changes in mental health-related visits to the pediatric emergency department.

MATERIALS AND METHODS

We conducted a retrospective analysis of all mental health-related pediatric emergency department visits to a tertiary general hospital between June and September 2019, 2020, and 2021. We described pre/post-coronavirus disease 2019 changes in the use of pediatric emergency departments, such as timing of visits, sex discrepancies, diagnostic distribution, discharge planning, and others.

RESULTS

Compared with the corresponding months before the pandemic (n = 187), mental health-related pediatric emergency department visits decreased by 20.8% in June-September 2020 (n = 148) and increased by 12.2% in 2021 (n = 210). The distributions of age, sex, timing of visits, reasons for presentations, hospitalization, and outpatient clinic appointment rates were not statistically significant between the years. Self-harm in females and aggression/violence in males were the most common reasons for presentation to pediatric emergency departments in each year. In the post-pandemic period, ambulance use and patients referred by other hospitals for psychiatric consultation increased, while the completion time of consultations decreased (P < .05). The frequency of attention-deficit hyperactivity disorder and depression decreased, but obsessive-compulsive disorder and anxiety disorders were more common in the post-pandemic period than in the corresponding months before the pandemic (P < .05).

CONCLUSION

Our results suggest that the coronavirus disease 2019 pandemic resulted in a significant change in mental health-related visits to the pediatric emergency department. Those in the groups with reduced visits may be at risk for delayed access to treatment for their mental and behavioral difficulties.

Developing a prototype digital risk mitigation pathway for children and young people admitted to acute paediatric NHS care in mental health crisis: Protocol of the Safety Assessment in Paediatric healthcare Environments (SAPhE) pathway study

Background

Globally, there are increasing numbers of Children and young people (CYPs) experiencing a mental health crisis requiring admission to acute paediatric inpatient care. These CYPs can often experience fluctuating emotional states accompanied by urges to self-harm or attempt to end their life, leading to reduced safety and poorer experiences. Currently, in the UK National Health Service (NHS) there are no standardised, evidence-based interventions in acute paediatric care to mitigate or minimise immediate risk of self-harm and suicide in CYP admitted with mental health crisis.

Objective

To outline the protocol for the SAPhE Pathway study which aims to: 1) identify and prioritise risk mitigation strategies to include in the digital prototype, 2) understand the feasibility of implementing a novel digital risk mitigation pathway in differing NHS contexts, and 3) co-create a prototype digital risk mitigation pathway.

Methods

This is a multi-centre study uses a mixed-methods design. A systematic review and exploratory methods (interviews, surveys, and focus groups) will be used to identify the content and feasibility of implementing a digital risk mitigation pathway. Participants will include healthcare professionals, digital experts and CYP with experience of mental health conditions. Data will be collected between January 2022 and March 2023 and analysed using content and thematic analysis, case study, cross-case analysis for qualitative data and descriptive statistics for quantitative data. Findings will inform the experience-based co-design workshops.

Ethics and Dissemination

The study received full ethical approval from NHS REC [Ref: 22/SC/0237 and 22/WM/0167]. Findings will be made available to all stakeholders using multiple approaches.

National estimates of emergency department visits for medication-related self-harm: United States, 2016-2019

BACKGROUND

Medication poisoning is a common form of self-harm injury, and increases in injuries due to self-harm, including suicide attempts, have been reported over the last two decades.

METHODS

Cross-sectional (2016-2019) data from 60 emergency departments (EDs) participating in an active, nationally representative public health surveillance system were analysed and US national estimates of ED visits for medication-related self-harm injuries were calculated.

RESULTS

Based on 18 074 surveillance cases, there were an estimated 269 198 (95% CI 222 059 to 316 337) ED visits for medication-related self-harm injuries annually in 2016-2019 compared with 1 404 090 visits annually from therapeutic use of medications. Population rates of medication-related self-harm ED visits were highest among persons aged 11-19 years (58.5 (95% CI 45.0 to 72.0) per 10 000) and lowest among those aged ≥65 years (6.6 (95% CI 4.4 to 8.8) per 10 000). Among persons aged 11-19 years, the ED visit rate for females was four times that for males (95.4 (95% CI 74.2 to 116.7) vs 23.0 (95% CI 16.4 to 29.6) per 10 000). Medical or psychiatric admission was required for three-quarters (75.1%; 95% CI 70.0% to 80.2%) of visits. Concurrent use of alcohol or illicit substances was documented in 40.2% (95% CI 36.8% to 43.7%) of visits, and multiple medication products were implicated in 38.6% (95% CI 36.8% to 40.4%). The most frequently implicated medication categories varied by patient age.

CONCLUSIONS

Medication-related self-harm injuries are an important contributor to the overall burden of ED visits and hospitalisations for medication-related harm, with the highest rates among adolescent and young adult females. These findings support continued prevention efforts targeting patients at risk of self-harm.

The politics of depression: Diverging trends in internalizing symptoms among US adolescents by political beliefs

Adolescent internalizing symptoms (e.g. depressive affect) have increased over the past decade in the US, particularly among girls. The reasons for these increases are unclear. We hypothesize that increasing exposure to politicized events has contributed to these trends in adolescent internalizing symptoms, and that effects may be differential by political beliefs and sociodemographic characteristics. We analyzed nationally-representative data from 2005 to 2018 Monitoring the Future annual cross-sectional samples of 12th-grade students (N = 86,138). We examined self-reported political beliefs, sex, and parental education as predictors of four internalizing symptom scales over time, including depressive affect. From 2005 to 2018, 19.8% of students identified as liberal and 18.1% identified as conservative, with little change over time. Depressive affect (DA) scores increased for all adolescents after 2010, but increases were most pronounced for female liberal adolescents (b for interaction = 0.17, 95% CI: 0.01, 0.32), and scores were highest overall for female liberal adolescents with low parental education (Mean DA 2010: 2.02, SD 0.81/2018: 2.75, SD 0.92). Findings were consistent across multiple internalizing symptoms outcomes. Trends in adolescent internalizing symptoms diverged by political beliefs, sex, and parental education over time, with female liberal adolescents experiencing the largest increases in depressive symptoms, especially in the context of demographic risk factors including parental education. These findings indicate a growing mental health disparity between adolescents who identify with certain political beliefs. It is therefore possible that the ideological lenses through which adolescents view the political climate differentially affect their mental wellbeing.

Communication pathways from the emergency department to community mental health services: A systematic review

This systematic review synthesizes existing peer reviewed evidence reporting on evaluated strategies used for enhancing communication pathways for continuity of care between the emergency department and mental health community supports. Following the PRISMA guidelines and the PICO framework, this review was conducted between January and July 2021. Included articles needed to evaluate communication pathway interventions for continuity of care between the emergency department and mental health community services which support service users with mental health and/or suicidal crisis. The seven included studies identified three support coordination interventions, two motivational interviewing interventions, an electronic record enhanced strategy and results from a phone follow-up study. This review demonstrates that support coordination, motivational interviewing, education, or an enhanced electronic record strategy can improve continuity of care, and in some cases, reduce the need for people to re-present to ED when they are experiencing mental health concerns or suicidal crisis. Results of this review reveal that a multipronged approach of communication pathways for continuity of care would enable more effective connections with mental health community supports and enable better outcomes for people requiring services.

Predictors of Parent Behavioral Engagement in Youth Suicide Discharge Recommendations: Implications for Family-Centered Crisis Interventions

The number of youth presenting to Emergency Departments (EDs) with psychiatric chief complaints has almost doubled in the last decade. With pediatric patients, ED brief interventions and discharge recommendations necessitate meaningful parental engagement to optimize youth safety and support. This study examined parent-level factors (stigmatizing attitudes, self-efficacy beliefs, distress symptoms, and illness-related stressors) in relation to parents' behavioral engagement (i.e., participation in and follow-through with best practice discharge recommendations). In this short-term prospective study, participants were 118 parent-youth (aged 11-18) dyads (57% female) recruited from a psychiatric ED. Parents' behavioral engagement was measured with parent- and youth-self report at 2-week follow-up. Parents' self-reported anxious and depressive symptoms, insomnia, stress, and stigmatizing attitudes were not related to engagement 2 weeks later. Higher parental self-efficacy beliefs were significantly associated with greater engagement in standard discharge recommendations. Implications for maximizing parent implementation of clinical recommendations during a youth suicide crisis are discussed.

Use of Acute Mental Health Care in U.S. Children's Hospitals Before and After Statewide COVID-19 School Closure Orders

OBJECTIVE

This study aimed to examine changes in child emergency department (ED) discharges and hospitalizations for primary general medical (GM) and primary psychiatric disorders; prevalence of psychiatric disorders among acute care encounters; and change in acute mental health (MH) care encounters by disorder type and, within these categories, by child sociodemographic characteristics before and after statewide COVID-19–related school closure orders.

METHODS

This retrospective, cross-sectional cohort study used the Pediatric Health Information System database to assess percent changes in ED discharges and hospitalizations (N=2,658,474 total encounters) among children ages 3–17 years in 44 U.S. children’s hospitals in 2020 compared with 2019, by using matched data for 36- and 12-calendar-week intervals.

RESULTS

Decline in MH ED discharges accounted for about half of the decline in ED discharges and hospitalizations for primary GM disorders (−24.8% vs. −49.1%), and MH hospitalizations declined 3.4 times less (−8.0% vs. −26.8%) in 2020. Suicide attempt or self-injury and depressive disorders accounted for &gt;50% of acute MH care encounters before and after the statewide school closures. The increase in both ED discharges and hospitalizations for suicide attempt or self-injury was 5.1 percentage points (p&lt;0.001). By fall 2020, MH hospitalizations for suicide attempt or self-injury rose by 41.7%, with a 43.8% and 49.2% rise among adolescents and girls, respectively.

CONCLUSIONS

Suicide or self-injury and depressive disorders drove acute MH care encounters in 44 U.S. children’s hospitals after COVID-19–related school closures. Research is needed to identify continuing risk indicators (e.g., sociodemographic characteristics, psychiatric disorder types, and social determinants of health) of acute child MH care.

Characteristics of a Pediatric Emergency Psychiatric Telephone Triage Service

OBJECTIVES

Caregivers of youth in psychiatric crisis often seek treatment from hospital emergency departments (EDs) as their first point of entry into the mental health system. Emergency departments have struggled over the last decade with growing numbers and now, because of the pandemic, have experienced a deluge of mental health crises. As one approach to divert unnecessary ED admissions, pediatric emergency psychiatric telephone triage services have been created. This study aimed to define the characteristics and utilization of a pediatric triage service and to examine clinician documentation of calls to identify the assessment of risk and disposition.

METHODS

This study included 517 youth (2-18 years; mean, 12.42 years; SD, 3.40 years) who received triage services in the winter of 2 consecutive years. Triage calls were received from caregivers (>75%), schools (17.0%), and providers (6.6%) regarding concerns, including suicidal ideation (28.6%), school issues (28.6%), and physical aggression (23.4%).

RESULTS

Dispositions were for acute, same-day evaluation (9.7%), direct care service (28.8%), further evaluation (within 48-72 hours, 40.0%), and resource/service update information (21.5%). Findings revealed that most clinical concerns were referred for further evaluation. Both adolescent females and males were referred for emergency evaluations at high rates.

CONCLUSIONS

A dearth of information on pediatric crisis telephone triage services exists; thus, developing an evidence base is an important area for future work. This information assists not only in our understanding of which, why, and how many youths are diverted from the ED but allows us to extrapolate significant costs that have been saved because of the utilization of the triage service.

Emergency Department Use by Children and Youth with Mental Health Conditions: A Health Equity Agenda

There are growing concerns regarding the referral of children and youth with mental health conditions to emergency departments (EDs). These focus on upward trends in utilization, uncertainty about benefits and negative effects of ED visits, and inequities surrounding this form of care. A review was conducted to identify and describe available types of data on ED use. The authors' interpretation of the literature is that it offers compelling evidence that children and youth in the U.S. are being sent to EDs for mental health conditions at increasing rates for reasons frequently judged as clinically inappropriate. As a major health inequity, it is infrequent that such children and youth are seen in EDs by a behavioral health professional or receive evidence-based assessment or treatment, even though they are kept in EDs far longer than those seen for reasons unrelated to mental health. The rate of increase in these referrals to EDs appears much greater for African American and Latinx children and youth than White children and is increasing for the publicly insured and uninsured while decreasing for the privately insured. A comprehensive set of strategies are recommended for improving healthcare quality and health equity. A fact sheet is provided for use by advocates in pressing this agenda.

E-Cigarette Use Is Associated with Increased Psychological Distress among Youth: A Pooled Cross-Sectional Analysis of State-Level Data from 2019 and 2021

A crisis of worsening youth mental health in recent years across the United States has created alarm among health professionals. As a result, health professionals have sought to improve methods of identifying youth in need of treatment services. Cigarette, cannabis, and alcohol use each consistently serve as behavioral markers of risk for youth mental health problems. Despite the recent growth of electronic cigarette (e-cigarette) use among youth, few studies have examined whether e-cigarettes follow the same associational pattern with mental health problems in the context of other substance use. Additionally, the COVID-19 pandemic may have altered the associations between youth substance use and mental health problems due to both reduced overall use and increased mental health problems after the onset of the pandemic. The current study examined associations between youth substance use and psychological distress before and after the onset of the COVID-19 pandemic using two state-representative samples of youth in grades 8, 10, and 12 from 2019 (N = 58,689) and 2021 (N = 46,823) from Utah. Pooled cross-sectional linear and negative binomial regression models clustered by grade, stratified by school district, and weighted to represent population characteristics estimated associations between recent e-cigarette, combustible cigarette, cannabis, and heavy alcohol use and two measures of psychological distress-depressive symptoms and mental health treatment needs. After controlling for sociodemographic factors and recent uses of other substances, results indicated that psychological distress increased from 2019 to 2021 and that recent e-cigarette, combustible cigarette, cannabis, and heavy alcohol use were each significantly associated with increased levels on both measures of psychological distress. Compared to other substances, e-cigarette use showed the strongest standardized associations. The association of e-cigarette use with depressive symptoms strengthened significantly from 2019 to 2021. Given the youth mental health crisis paired with the widespread adoption of e-cigarettes, health professionals should consider recent e-cigarette use an increasingly important behavioral marker for risks of mental health problems among youth. Results suggest that future research studies examining the temporal ordering of substance use and mental health among youth should include e-cigarettes.

Impact of COVID-19 Pandemic on Children Visiting Emergency Department for Mental Illness: A Multicenter Database Analysis from Korea

We aimed to identify changes in the proportion of pediatric emergency department (PED) visits due to mental illness during the coronavirus disease 2019 (COVID-19) pandemic. This was a retrospective observational study of visits to the PED at six university hospitals from January 2017 to December 2020. We included children aged 5−17 years who were diagnosed with a mental illness. We used segmented regression analysis to identify the change in the proportion of patients with mental illness. A total of 845 patients were included in the analysis. After the first case of COVID-19 was reported in Korea, the number of PED visits significantly decreased by 560.8 patients per week (95% confidence interval (CI): −665.3 to −456.3, p < 0.001). However, the proportion of patients with mental illness increased significantly, by 0.37% per week (95% CI: 0.04% to 0.70%, p = 0.03), at this time point. Subgroup analyses revealed that emotional disorders significantly increased by 0.06% per month (95% CI: 0.02% to 0.09%, p < 0.001) during the pandemic. Our study revealed that an increased proportion of patients with mental illness visited the PED during the COVID-19 pandemic. Specifically, we identified that the proportion of emotional disorders continues to rise during this pandemic.

National Implementation of Emergency Department-Based Follow-up Program for Suicidal Attempts

BACKGROUND

Death by suicide is a major public health problem. To provide multidisciplinary support to patients who attempted suicide, emergency department (ED)-based psychiatric screening and intervention programs were offered. We traced the long-term survival outcome of patients visiting the ED after suicide attempts using the national death certificate registration database.

METHODS

A retrospective observational study was conducted using a database of patients from "Psychiatric Crisis Response Centers" (PCRC) of 27 EDs between January 2013 and August 2015. Patients who visited the ED after attempting suicide were screened and interviewed by social workers from the PCRC. The database was merged with the national death certificate database to trace the death and cause of death of the patients until December 2018. The characteristics and outcomes were compared based on the patient's compliance with the follow-up case management program.

RESULTS

Of the 12,544 interviewed patients, the data of 9,587 patients were successfully matched with data from the death certificate database. Death by suicide was higher in the noncompliance group (4.5% vs. 12.4%, P < 0.001); however, death caused by factors other than suicide did not differ between groups (4.8% vs. 4.9%, P = 0.906).

CONCLUSION

Suicide resulted in a lower long-term mortality rate among patients who complied with the follow-up case management session in the ED-based brief psychiatric intervention and follow-up program.

Emergency health services use and medically-treated suicidal behaviors following depression screening among adolescents: A longitudinal cohort study

The primary goal of depression screening is to reduce adverse psychiatric outcomes, which may have downstream implications for reducing avoidable health services use. The objective of this study was to examine the association of depression screening with emergency health services use and medically-treated suicidal behaviors among adolescents in the U.S. This longitudinal cohort study used insurance claims data from 57,732 adolescents who had at least one well-visit between 2014 and 2017. Propensity score matching was used to compare adolescents who were screened for depression to similar adolescents who were not screened for depression during the well-visit. Outcomes were examined over two-year follow-up and included emergency department use and inpatient hospitalizations for depression-related reasons, mental health-related reasons, and any reason as well as medically-treated suicidal behaviors. Log-binomial regression models were used to examine associations between depression screening and each outcome in the matched sample. Heterogeneity of associations by sex was examined with interaction terms. Being screened for depression was not consistently associated with emergency department use (depression-related reasons: RR = 1.00, 95% CI = 0.76-1.30; mental health-related reasons: RR = 1.02, 95% CI = 0.80-1.29; any reason: RR = 0.96, 95% CI = 0.83-1.11), inpatient hospitalizations (depression-related reasons: RR = 1.05, 95% CI = 0.84-1.31; mental health-related reasons: RR = 1.16, 95% CI = 1.00-1.33; any reason: RR = 1.05, 95% CI = 0.99-1.12), or medically-treated suicidal behaviors (RR = 0.83, 95% CI = 0.51-1.36). Associations were similar in magnitude among male and female adolescents. The results of this study suggest that depression screening, as it is currently practiced in the U.S., may not deter avoidable health services use among adolescents.

A Brief Text-Messaging Intervention for Suicidal Youths After Emergency Department Discharge

Research has shown that the months after hospital discharge following treatment for suicidal thoughts or behaviors is a high-risk period for suicide. Moreover, the needs of a subset of youths at increased risk for suicide are not being met by community mental health providers, resulting in frequent emergency department (ED) visits. While undertaking a quality improvement effort, the authors' health care system piloted caring text messages to support youths discharged from the hospital after screening positive for suicide risk in the ED. The text-messaging intervention was feasible and acceptable, and youths reported that the messages helped reduce their suicidal thoughts and behaviors postdischarge. The results of this text-messaging intervention prompted the Maryland Department of Health to offer a similar intervention to all Marylanders.

Impact of COVID-19 on Pediatric Mental and Behavioral Health Visits to the Emergency Department

OBJECTIVES

This study aimed to describe changes in pediatric emergency department (ED) mental and behavioral health (MBH) visits before and during the early COVID-19 pandemic.

METHODS

We retrospectively reviewed medical records of patients aged from 5 to 17 years presenting to the pediatric ED of a major tertiary care hospital with MBH-related concerns from March 2017 to September 2020. We evaluated trends in MBH ED visits over the study period, specifically comparing patient demographics, diagnosis categories, and ED disposition between the pre-COVID (2019) and COVID (2020) periods using pairwise Pearson χ 2 analyses with reported odds ratios (ORs) in SAS statistical software version 9.4 (SAS Institute Inc, Cary, NC).

RESULTS

Of 8093 MBH-related visits, 58.5% were females, 85.4% were adolescents, and 62.7% self-identified as non-Hispanic. The proportion of MBH-related ED visits increased from 3.8% to 7.5% over the study period ( P < 0.0001). Although total MBH visits decreased by 17.3% from 2019 to 2020, there was a proportionate increase in MBH-to-total-ED visits, representing a 42.8% increase through 2019. Compared with 2019, there was a proportionate increase in MBH-related ED visits by females (10.6%, P < 0.0001), older adolescents (18.2%, P < 0.0001), and non-Hispanic patients (6.1%, P = 0.017) in 2020. The MBH visits in 2020 were more likely related to suicidality/self-harm (OR, 1.2; confidence interval [CI], 1.1-1.4) or substance use (OR, 1.4; CI, 1.1-1.9). Compared with 2019, there were significantly higher odds of admission (OR, 1.6; CI, 1.3-2.1) or transfer for inpatient psychiatric care (OR, 1.8; CI, 1.6-2.1) in 2020.

CONCLUSIONS

Our data suggest that the early COVID-19 pandemic had a significant impact on MBH-related ED visits. Compared with 2019, we observed a significant increase in the proportion of MBH-to-total-ED visits primarily affecting older adolescent, non-Hispanic girls with suicidality/self-harm and substance-related disorders in 2020, despite an overall decrease in the number of MBH visits during this period. There was also an increase in the proportion of visits resulting in admission or transfer for inpatient psychiatric care in 2020.

United States of America Child and Adolescent Psychiatrists' Career Satisfaction by Career Stage

OBJECTIVE

This study sought to examine career satisfaction among United States of America child and adolescent psychiatrists (CAPs) across career stages, identifying predictive factors for their career satisfaction.

METHODS

A total of 526 CAPs responded to a national career satisfaction survey. Satisfaction was assessed via responses to statements about their career on a Likert scale. Career satisfaction was defined as the sum of the scores for satisfaction with their choice of career, career advancement, and career recognition. Responses were disaggregated by the number of years post child and adolescent psychiatry residency training (early career: 0-10 years; midcareer: 11-20 years; and late career: 21 + years post-training). Stepwise linear regression analyses identified predictive factors of career satisfaction.

RESULTS

CAPs' career satisfaction was high (3.95) and increased with career stage. It was most positively correlated with advancement opportunities, job enjoyment, and control of assigned tasks, and most negatively correlated with workload. Job enjoyment was the leading predictive factor of career satisfaction for early career and late career CAPs, with midcareer CAPs identifying task assignment control as the leading contributor to their career satisfaction (all p = .000).

CONCLUSIONS

Career satisfaction in Child and Adolescent Psychiatry is high, increases with career stage, and is most predicted by advancement opportunities. Further study of the predictive factors of CAPs' career satisfaction is warranted as we focus on increasing the workforce in child and adolescent psychiatry.

Evaluating Provider Documentation of Suicide Risk Factors Among Youth Screening Positive for Suicide Risk in a Pediatric Emergency Department

OBJECTIVE

Screening for suicidal ideation in the pediatric emergency department (ED) enhances recognition of suicidality among patients presenting with a nonmental health complaint. Little is known about the assessment of suicide risk factors and disposition among these patients. This study aimed to evaluate pediatric ED providers' documentation of suicide risk factors in this population.

METHODS

We performed a retrospective cohort study of patients screening at risk for suicide on the Ask Suicide-Screening Questions tool. Demographic variables and risk factors for youth suicide were extracted from the electronic health record for eligible patients each month from January 1, 2019, to December 31, 2019. We compared risk factors using χ2 or Fisher exact test.

RESULTS

In 2019, of the 7484 patients screened for suicide, 524 (7%) had a positive screen. Of 220 patient charts reviewed, no suicide risk factors were documented in 53.6% of encounters, and only 1 risk factor was documented in 18.2% of encounters. Substance use was the most frequently discussed risk factor, documented in 33.6% of encounters. History of nonsuicidal self-injury was documented in 11.8% of visits. Other risk factors were documented in fewer than 10% of at-risk patients.

CONCLUSION

Pediatric ED providers do not routinely document risk factors for suicide in medical patients screening at risk. Although the Ask Suicide-Screening Questions is an important initial screen, a standardized secondary risk factor assessment is necessary for a more complete risk stratification for patients with suicidal ideation.

Five-Year Trends in Pediatric Mental Health Emergency Department Visits in Massachusetts: A Population-Based Cohort Study

OBJECTIVES

To evaluate temporal changes in pediatric emergency department (ED) visits for mental health problems in Massachusetts based on diagnoses and patient characteristics and to assess trends in all-cause pediatric ED visits.

STUDY DESIGN

This statewide population-based retrospective cohort study used the Massachusetts All-Payer Claims Database, which includes almost all Massachusetts residents. The study sample consisted of residents aged <21 years who were enrolled in a health plan between 2013 and 2017. Using multivariate regression, we examined temporal trends in mental health-related and all-cause ED visits in 2013-2017, with person-quarter as the unit of analysis; we also estimated differential trends by sociodemographic and diagnostic subgroups. The outcomes were number of mental health-related (any diagnosis, plus 14 individual diagnoses) and all-cause ED visits/1000 patients/quarter.

RESULTS

Of the 967 590 Massachusetts residents in our study (representing 14.8 million person-quarters), the mean age was 8.1 years, 48% were female, and 57% had Medicaid coverage. For this population, mental health-related (any) and all-cause ED visits decreased from 2013 to 2017 (P < .001). Persons aged 18-21 years experienced the largest declines in mental health-related (63.0% decrease) and all-cause (60.9% decrease) ED visits. Although mental health-related ED visits declined across most diagnostic subgroups, ED visits related to autism spectrum disorder-related and suicide-related diagnoses increased by 108% and 44%, respectively.

CONCLUSIONS

Overall rates of pediatric ED visits with mental health diagnoses in Massachusetts declined from 2013 to 2017, although ED visits with autism- and suicide-related diagnoses increased. Massachusetts' policies and care delivery models aimed at pediatric mental health may hold promise, although there are important opportunities for improvement.

Patient characteristics prior to suicide attempts among Hispanics compared to non-Hispanic whites in the United States

BACKGROUND

Suicide rates among Hispanics in the United States are much lower than rates among Whites. The reasons for this difference are uncertain, therefore we compared patient characteristics between Hispanic and White patients with a suicide attempt.

METHODS

Patients with a suicide attempt (n = 8641) between 2012 and 2018 were identified by ICD-9 and ICD-10 codes in a nationally distributed electronic health record data base. Patient demographics, geographic region, health services use, depression treatment, psychiatric and physical comorbidities were measured in the 2 years prior to a suicide attempt.

RESULTS

Most patients with a suicide attempt were White (78.6%) and 6.2% were Hispanic, a majority were 36-64 years of age and 57.3% were female. Younger age and lack of health insurance were significantly (p < .0001) more common among Hispanic compared to White patients with a suicide attempt. Depression treatment was significantly (p < .0001) less common among Hispanic vs. White patients. Sleep disorder and all psychiatric and substance use disorders, except for drug use disorder, were significantly (p-value range: 0.026-<0.0001) more prevalent in the two years before suicide attempt in White patients.

CONCLUSIONS

Diagnosed psychopathology is more common among White vs. Hispanic patients who attempt suicide. Lack of insurance and low depression treatment rates may be associated with suicide attempt among Hispanics. Additional research is needed to determine the mix of factors that predict suicide attempt among Whites, Hispanics, and other minorities.

An Initiative to Improve Efficiency of Emergency Department Adolescent Behavioral Health Visits

ABSTRACT

Pediatric mental illnesses are quite prevalent in the United States and worldwide. Prevalence has been increasing, and it is estimated that 13% to 20% of US children have a mental illness that costs an estimated $247 billion per year and affects children's social, emotional, and cognitive development (Perou et al. MMWR Suppl. 2013;62:1-35). Pediatric behavioral health visits to the emergency department (ED) have been on an exponential rise constituting 5% to 7% of ED visits (Kalb et al. Pediatrics. 2019;143(4):e20182192). This requires pediatric emergency physicians to frequently manage pediatric mental health illnesses and interact with pediatric psychiatrists to create an integrated system.There is no universally accepted protocol for medical clearance of psychiatric patients (Corl et al. Med Health R I. 2008 91(11):339-341). Our medical clearance protocol comprised complete blood counts, complete metabolic panel, thyroid panel, urine toxicology screen, blood alcohol, urine human chorionic gonadotropin for females, and electrocardiogram for patients 16 years and older. These tests are obtained and have to result in pediatric ED before admission to the adolescent psychiatry unit, therefore occupying space and contributing to pediatric ED overcrowding. In an attempt to decrease our length of stay (LOS), we worked with multiple stakeholders to modify this protocol.Based on results of the data extrapolated from adult psychiatry studies (Olshaker et al. Acad Emerg Med. 1997;4(2), 124-128; Parmar et al. West J Emerg Med. 2012;13(5), 388-393; Janiak and Atteberry. J Emerg Med. 2012;43(5), 866-870). The medical clearance process was adjusted, and laboratory tests, electrocardiogram, and other ancillary studies were waived. The new protocol indicates testing based on a detailed history, physical examination, and clinical judgment. The new medical clearance protocol was initiated in December 2018. The median ED LOS for patients seen in the ED and admitted to our inpatient unit from January to November 2018 was 290 minutes in comparison with median LOS for December 2018 to December 2019 period, which was 204 minutes, showing a median reduction of 86 minutes with no adverse outcomes.The median number of encounters requiring admission in both these periods was comparable. A downstream effect of this process was also cost savings. The estimated cost savings ranged from $37.45 to $47.5 per patient, not including labor and other indirect costs. The medical clearance process is a daunting process for both patients and their families and emerging data questioning its use. Goal-directed medical clearance may be an efficient and cost-saving medical clearance for patients requiring emergent psychiatric evaluation.

Psychiatric Emergencies in Minors: The Impact of Sex and Age

OBJECTIVE

Little information is available on young children (age 4-12 years) with mental health problems who are seen by the psychiatric emergency services. We therefore described this population to identify (1) variables that differentiated children from those aged 13 to 18 years who had been referred for psychiatric emergency consultation; and (2) to describe sex differences.

METHOD

We extracted data for a 9-year period from the records of the mobile psychiatric emergency services in 2 urban areas in the Netherlands. In this period, 79 children aged 4 to 12 years (37.2% girls) and 1695 children aged 12 to 18 years (62.2% girls) had been referred for psychiatric emergency consultation. Demographic and process factors were recorded. Clinical characteristics included diagnostic and statistical manual of mental disorders, 4th edition classifications and the Severity of Psychiatric Illness scale. Logistic regression analyses were used to examine differences between the girls and boys in the 2 age groups.

RESULTS

Young children aged 4 to 12 years had been involved in 4.5% of all consultations of minors. In contrast with adolescents, a higher percentage of young children seen for emergency consultation were boys, and a lower percentage was admitted to a psychiatric hospital (7.7%). In boys and girls alike, a DSM classification of behavioral disorder was associated with younger age.

CONCLUSIONS

The young group of children referred for psychiatric emergency consultation comprised relatively more children with behavioral disorders. Decisions to refer them for urgent psychiatric consultation seemed to be influenced by the suspicion of psychotic symptoms or of danger to themselves or others.

Structural Racism and Suicide Prevention for Ethnoracially Minoritized Youth: A Conceptual Framework and Illustration Across Systems

Suicide rates among ethnoracially minoritized youth (i.e., youth of color) peak before the age of 30, and striking disparities in access to mental health services have been identified in this age group. However, suicide prevention strategies have yet to fully address structural racism as a mechanism in producing disparities in risk, protective factors, and access to quality effective intervention for youth of color. Such an approach is critical to provide more culturally responsive mental health care. Through an adapted socio-ecological model, the authors propose the Structural Racism and Suicide Prevention Systems Framework and illustrate pathways through which structural racism impacts suicide prevention and intervention for youth of color in the United States. The authors contextualize the impact of structural racism in three key settings where youth suicide prevention occurs: mental health services, schools, and the interface between crisis care and law enforcement. The authors posit that critical attention must be paid to the intersection of mutually reinforcing, interdependent systems rather than to systems in isolation. The authors then propose recommendations to address structural racism in suicide prevention, including macro-level interventions to improve societal conditions, research strategies to inform structural solutions, training approaches to address institutional racism, and clinical approaches to address the impact of racism and racial trauma on youths and families.

Emergency mental health care for chi̇ldren and adolescents outside of regular working hours: 7 years outcomes from a tertiary hospital

OBJECTIVE

This study aims to define the clinical characteristics and management strategies of children and adolescents presenting with psychiatric crises to the emergency department (ED) of a tertiary health care facility outside of working hours, and to identify predictors of multiple ED visits among them.

METHODS

From January 2012 to December 2018, retrospective records of patients presenting with psychiatric symptoms to the ED and examined by a child psychiatrist after 5 p.m. on weekdays and for 24 h on weekends and public holidays were analyzed.

RESULTS

Our sample consisted of 1576 visits and 1364 patient (Female:Male=1.8:1, mean age=14.86 ± 2.72). The most common reason for visits was self-injurious thought or behaviors (SITB), and the most common diagnosis was depression. While depression was statistically more common in girls, attention deficit hyperactivity disorder, autism and/or intellectual disability (ASD/ID), psychotic disorders, and bipolar disorder were more common in boys. The forensic evaluation was the most common reason for visits among children younger than 6 years old. Of visits, 23% transferred to hospitalization. A history of mental health contact was the lowest in depression (37.5%), psychosis (34.1%), and substance use disorders (33%). Of patients, 10.8% had multiple visits. A history of mental health contacts, conduct disorder, ASD/ID, bipolar disorder, psychotic disorder, and dissociative disorder were predictors of multiple visits to ED with psychiatric reasons.

CONCLUSION

Emergency mental health care outside of regular working hours can be a critical step in the diagnosis and treatment of serious psychiatric disorders in children and adolescents.

Returning to the emergency department: a retrospective analysis of mental health re-presentations among young people in New South Wales, Australia

OBJECTIVES

This study aimed to describe mental health emergency department (ED) presentations among young people aged 8-26 years in New South Wales, Australia, and to identify key characteristics associated with higher risk of ED mental health re-presentation.

DESIGN, SETTING AND PARTICIPANTS

Retrospective analysis of linked ED data records for mental health presentations between 1 January 2015 and 30 June 2018.

MAIN OUTCOME MEASURES

The main outcome was the total number of mental health ED re-presentations within 1 year, following initial presentation. Count regression models were fitted to estimate factors associated with higher likelihood of re-presentations.

RESULTS

Forty thousand two hundred and ninety patients were included in the analyses, and 9713 (~25%) re-presented during the following year; 1831 (20%) presented at least three times. On average, patients re-presented 0.61 times per 365 person-days, with average time until first re-presentation of ~92 days but greatest risk of re-presentation within first 30-60 days. Young people with self-harm or suicidal diagnoses at initial presentation were more likely to re-present. Re-presentations were highest among young people <15 years (IRR 1.18 vs ≥20 years old), female (IRR=1.13 vs male), young people residing outside of major cities (IRR 1.08 vs major cities) and Aboriginal and Torres Strait Islander young people (IRR 1.27 vs non-Indigenous).

CONCLUSIONS

ED mental health re-presentation is high among young people. We demonstrate factors associated with re-presentation that EDs could target for timely, high-quality care that is youth friendly and culturally safe, with appropriate referral pathways into community-based primary and mental healthcare services.

Trends in mental health presentations in a south Australian tertiary emergency department

AIM

Limited recent interstate evidence suggests an increase in paediatric mental health presentations to emergency departments in Australia. We set out to confirm this and whether any specific diagnosis was responsible for this increase.

METHODS

We identified all patients with mental health presentations aged 6-18 years who attended our tertiary emergency department from January 2006 to June 2019 using our emergency department patient record system. Patients were determined to have a mental health presentation if they had a discharge diagnosis or presenting complaint code that corresponded to a mental health disorder or were referred to the mental health team. For analysis, we divided the 13.5-year duration of our study into three periods of 4.5 years.

RESULTS

Comparing the first and last time periods, there was a 156% increase in mental health presentations over 9 years. This was out of proportion to the increase in combined general and mental health presentations of 11.9%. There was an increase in the proportion of patients who were diagnosed with an adjustment disorder (14-26.6%) or a childhood emotional disorder (8.5-20.8%). Additionally, there was an increase in median wait time and a reduction in the proportion of patients seen within their recommended triage time.

CONCLUSION

There is a large increase in the number of paediatric mental health presentations to our emergency department. Further resources may need to be allocated to mental health services in the community and in the emergency department.

Factors associated with a change in disposition for mental health patients boarding in an urban Paediatric emergency department

AIM

Paediatric emergency departments (ED) nationwide experience a shared burden of boarding mental health patients. Whilst boarding, some patients have a change in disposition from hospitalization to discharge home. This phenomenon raises concern because EDs often have scarce resources for mental health patients. We sought to understand which patient and clinical factors are associated with a change in disposition outcome.

METHODS

A nested age-sex-race frequency-matched case-control study was conducted including paediatric patients who presented to an urban PED for mental healthcare over a 36-month period. Control patients included patients admitted to an inpatient psychiatric facility, whilst case patients were those discharged home. Descriptive statistics and multivariable logistic regression analyses were performed to compare groups.

RESULTS

Case patients were more likely to receive intramuscular Haloperidol (OR 2.2 [CI 1.1-4.4]) for agitation and a psychiatric consult (OR 2.3 [1.4-3.9]) whilst boarding. Case patients were also more likely to present with behavioural concerns (OR 1.8 [CI 1.1-3.1]) and have additional complexities such as medical comorbidities (OR 1.8 [CI 1.1-2.9]) or suicidal ideation/attempt (OR 2.6 [CI 1.1-6.1]). Amongst the most common themes for disposition change was improved patient status (58.8%).

CONCLUSION

These findings suggest that boarding mental health patients have different disposition outcomes and thus may benefit from patient-specific treatment interventions. Given that patients' statuses may change during the boarding period prompting discharge to home, more focus should be directed to developing brief evidence-based practises that may be implemented in the ED and effectively bridge the gap to outpatient mental health services.

Black Youth Suicide Crisis: Prevalence Rates, Review of Risk and Protective Factors, and Current Evidence-Based Practices

Suicide is the second leading cause of death among adolescents and young adults. Historically, Black youths have experienced lower rates of suicide; however, recent data point to significant racial disparities. In this article, the authors review current suicide rates, including alarming new data suggesting that suicide rates are two times higher among Black children ages 5-12 compared with White children in that age range. A clinically focused summary of socioecological risk and protective factors associated with suicide among Black youths, with particular attention on structural drivers and culturally relevant factors, is provided. Current evidence-based reviews suggest that dialectical behavior therapy is the only well-established treatment against self-harm and suicide among youths. However, it is unknown whether current established treatments work for Black youths, because Black youths are rarely included in randomized controlled trials. The authors conclude by reviewing emerging treatments developed and tested specifically for Black youths.

Specification curve analysis shows that social media use is linked to poor mental health, especially among girls

An important 2019 paper applied a novel analytic technique called Specification Curve Analysis (SCA) to data from three large-scale community samples to investigate the association between adolescent technology use and mental health/well-being. The paper concluded that an association exists but is tiny, with median betas between -0.01 and -0.04. This association was reported to be smaller than links between mental health and various innocuous variables in the datasets such as eating potatoes, and therefore to be of no practical significance. The current paper re-ran SCA on the same datasets while applying alternative analytic constraints on the model specification space, including: 1) examining specific digital media activities (e.g., social media) separately rather than lumping all "screen time" including TV together; 2) examining boys and girls separately, rather than examining them together; 3) excluding potential mediators from the list of controls; and 4) treating scales equally (rather than allowing one scale with many subscales to dominate all others). We were able to reproduce the original results with the original configurations. When we used the revised constraints, we found several much larger relationships than previously reported. In particular: among girls, there is a consistent and substantial association between mental health and social media use (median betas from -0.11 to -0.24). These associations were stronger than links between mental health and binge drinking, sexual assault, obesity, and hard drug use, suggesting that these associations may have substantial practical significance as many countries are experiencing rising rates of depression, anxiety, and suicide among teenagers and young adults.

Clinical Outcomes in Routine Evaluation Measures for Patients Discharged from Acute Psychiatric Care: Four-Arm Peer and Text Messaging Support Controlled Observational Study

Background: Peer support workers (PSW) and text messaging services (TxM) are supportive health services that are frequently examined in the field of mental health. Both interventions have positive outcomes, with TxM demonstrating clinical and economic effectiveness and PSW showing its utility within the recovery-oriented model. Objective: To evaluate the effectiveness of PSW and TxM in reducing psychological distress of recently discharged patients receiving psychiatric care. Methods: This is a prospective, rater-blinded, pilot-controlled observational study consisting of 181 patients discharged from acute psychiatric care. Patients were randomized into one of four conditions: daily supportive text messages only, peer support only, peer support plus daily text messages, or treatment as usual. Clinical Outcomes in Routine Evaluation—Outcome Measure (CORE-OM), a standardized measure of mental distress, was administered at four time points: baseline, six weeks, three months, and six months. MANCOVA was used to assess the impact of the interventions on participants’ scores on four CORE-OM subscales across the three follow-up time points. Recovery, clinical change, and reliable change in CORE-OM all-item analysis were examined across the four groups, and the prevalence of risk symptoms was measured. Results: A total of 63 patients completed assessments at each time point. The interaction between PSW and TxM was predictive of differences in scores on the CORE-OM functioning subscale with a medium effect size (F1,63 = 4.19; p = 0.045; ηp2 = 0.07). The PSW + TxM group consistently achieved higher rates of recovery and clinical and reliable improvement compared to the other study groups. Additionally, the text message group and the PSW + TxM group significantly reduced the prevalence of risk of self/other harm symptoms after six months of intervention, with 27.59% (χ2(1) = 4.42, p = 0.04) and 50% (χ2(1) = 9.03, p < 0.01) prevalence reduction, respectively. Conclusions: The combination of peer support and supportive text messaging is an impactful intervention with positive clinical outcomes for acute care patients. Adding the two interventions into routine psychiatric care for patients after discharge is highly recommended.

Identifying pediatric emergency department visits for aggression using administrative claims data

OBJECTIVE

Violence and aggressive behaviors among youth are a leading cause of Emergency Department (ED) mental health (MH) encounters. A consistent method is needed for public health research, to identify ED encounters associated with aggression. The aim of this study was to develop such a screening procedure.

DATA SOURCES

Electronic records and administrative claims data related to MH related ED encounters at one of Pediatric Health Information System (PHIS) Children's Hospitals in the United States from January 1, 2019 to December 31, 2019.

STUDY DESIGN

The authors selected a combination of ICD-10 codes to screen MH ED encounters for aggression; and then conducted a chart review to compare characteristics of groups that screened positive vs. screened negative, and groups with confirmed vs. without confirmed aggression.

DATA EXTRACTION METHOD

Unique ED encounters associated with a MH related ICD-10 code from a one-year period at the study institution were extracted (n = 3092 MH ED encounters). Encounters with any aggression-associated codes were identified as "screen-positive" (N = 349). From the remaining "screen-negative" encounters, 352 unique encounters were randomly selected as a comparison group. Both groups were chart reviewed to investigate the accuracy of the screening method.

MAIN FINDING

Chart review confirmed aggression in 287 of 349 screen-positive and 48 of 352 select screen-negative, chart-reviewed encounters. Additional codes were added, with a goal of finding the combination of codes with the highest accuracy. The resulting screen had sensitivity, specificity, positive and negative predictive values of 0.901, 0.817, 0.818, and 0.864, respectively.

PRINCIPAL CONCLUSIONS

This paper presents a screening method for identifying ED encounters related to aggression. A replication study will be necessary to validate the method prior to applying to large claims data. If validated, it will support future research on this important population.

Characteristics of children and adolescents presenting to the emergency department with self-inflicted injury: Retrospective analysis of two teaching hospitals

BACKGROUND

Data on Taiwanese adolescents with self-inflicted injuries are limited. We describe the epidemiology of children and adolescents visiting the emergency department for self-inflicted injuries in two geographically distinct teaching hospitals.

METHODS

Medical records of children 0-18 years old who visited the emergency department of Taipei Tzu Chi Hospital and Chi Mei Medical Center, Tainan between 2016 and 2019 coded with relevant diagnoses were reviewed. Visits with documented self-inflicted injury were included.

RESULTS

During the 4-year period, 62 children made 74 emergency visits for self-inflicted injury. A total of 88% of visits were made by children with a psychiatric diagnosis, with depressive disorders being the most common (57%). Interpersonal relationship issue was cited as a trigger for self-harm in 49% of visits. Adjusted for annual visit volumes, self-harm visits per 10,000 pediatric emergency visits increased nearly 5 fold between 2016 and 2019, with the most prominent increase in the final year. Poisoning was the most common mechanism of injury and was frequently used by females, as compared to males who tended to jump from heights. Up to 96% of adolescents with previous self-harm seen at the emergency department had sought psychiatric help in the past year. Urban-rural inequity in mental health resource utilization was observed.

CONCLUSIONS

Visits to the emergency department for self-inflicted injuries among children and adolescents increased, most remarkably in 2019, for both hospitals. Intentional poisoning with prescription and over-the-counter medications was the most common method. There was a high prevalence of psychiatric disorders in our study population. As the emergency department is likely the first point of medical contact for such visits, emergency personnel should be trained appropriately on managing such patients.

The Impact of Universal Mental Health Screening on Pediatric Emergency Department Flow

OBJECTIVE AND HYPOTHESIS

Assess the impact of universal mental health screening with MyHEARTSMAP on emergency department (ED) flow, an important aspect of feasibility. We hypothesized that the difference in departmental level ED length of stay (LOS) for screening and matched nonscreening days is less than 30 minutes.

METHODS

We conducted a 2-center, retrospective cohort study between December 2017 and June 2019. At each center, random mental health screening days were assigned over the course of 15 consecutive months. We matched each 24-hour screening day to a unique nonscreening day based on: location (Center 1 or Center 2); day type (weekday: Monday-Thursday or weekend: Friday-Sunday); date (±28 days); and 24-hour volume (±15 patients). We collected retrospective patient flow data, including LOS, across all ED visits to determine the difference in departmental level median LOS between matched screening and nonscreening days.

RESULTS

There was not a statistically significant difference in departmental LOS between screening and nonscreening days. Overall, the difference in departmental LOS was -4.0 minutes (95% confidence interval, -9.8, 1.8) for screening days compared to nonscreening days, with a difference of -2.0 minutes (-9.0, 4.9) at Center 1 and -6.0 minutes (-15.4, 3.4) at Center 2.

CONCLUSIONS

Our findings show that universal mental health screening with MyHEARTSMAP can be implemented without a significant impact of ED LOS.