Psychiatric Emergency Department Visits After Regional Expansion of Community Health Centers

New York City's Stop, Question, and Frisk Policy and Psychiatric Emergencies among Black Americans

Under the Stop, Question, and Frisk (SQF) policy, New York City (NYC) police stopped Black Americans at more than twice the rate of non-Hispanic whites, after controlling for arrests and precinct differences. We examined whether police stops of Black Americans during SQF correspond positively with psychiatric emergency department (ED) visits among Black residents in NYC. We utilized as the exposure all police stops, stops including frisking, and stops including use of force among Black Americans in NYC between 2006 and 2015 from the New York City Police Department's New York City-Stop, Question, and Frisk database. We examined 938,356 outpatient psychiatric ED visits among Black Americans in NYC between 2006 and 2015 from the Statewide Emergency Department Database (SEDD). We applied Box-Jenkins time-series methods to control for monthly temporal patterns. Results indicate that all stops, frisking, and use of force of Black residents correspond with increased psychiatric ED visits among Black Americans in NYC (all stops-coef = 0.024, 95%CI = 0.006, 0.043; frisking-coef = 0.048, 95%CI = 0.015, 0.080; use of force-coef = 0.109, 95%CI = 0.028, 0.190). Our findings indicate that a one standard deviation increase in police stops equates to a 2.72% increase in psychiatric ED visits among Black residents in NYC. Use of force may have the greatest mental health consequences due to perceived threats of physical violence or bodily harm to other members of the targeted group. Racially biased and unconstitutional police encounters may have acute mental health implications for the broader Black community not directly involved in the encounter itself.

Housing Status as a Predictor for Outpatient Care Following an Emergency or Urgent Care Encounter with a Behavioral Health Diagnosis: A Multivariable Analysis

Individuals without stable housing experience high rates of mental illness and seek behavioral health care in emergency care settings. Little is known about the effect of homelessness on outpatient follow-up after utilizing emergency or urgent care for behavioral health care. Patient encounters with behavioral health diagnoses among 7 emergency department (ED) or urgent care (UC) locations over 4 years were used to determine the correlation between housing status and outpatient follow-up within 90 days. Of 1,160,386 visits by 269,615 unique patients, 55,738 (23%) encounters included a behavioral health diagnosis. Patients with stable housing were twice as likely to follow up with a primary care provider (PCP) and with an outpatient behavioral health provider than patients without housing (aOR 2.60; aOR 2.00, p < 0.0001). Homelessness is associated with difficulty in accessing follow-up behavioral health care. UCs and EDs may use specific interventions to improve outpatient follow-up.

The relationship between outpatient service use and emergency department visits among people treated for mental and substance use disorders: analysis of population-based administrative data in British Columbia, Canada

Background

Research findings on the association between outpatient service use and emergency department (ED) visits for mental and substance use disorders (MSUDs) are mixed and may differ by disorder type.

Methods

We used population-based linked administrative data in British Columbia, Canada to examine associations between outpatient primary care and psychiatry service use and ED visits among people ages 15 and older, comparing across people treated for three disorder categories: common mental disorders (MDs) (depressive, anxiety, and/or post-traumatic stress disorders), serious MDs (schizophrenia spectrum and/or bipolar disorders), and substance use disorders (SUDs) in 2016/7. We used hurdle models to examine the association between outpatient service use and odds of any ED visit for MSUDs as well count of ED visits for MSUDs, stratified by cohort in 2017/8.

Results

Having had one or more MSUD-related primary care visit was associated with lower odds of any ED visit among people treated for common MDs and SUDs but not people treated for serious MDs. Continuity of primary care was associated with slightly lower ED use in all cohorts. One or more outpatient psychiatrist visits was associated with lower odds of ED visits among people treated for serious MDs and SUDs, but not among people with common MDs.

Conclusion

Findings highlight the importance of expanded access to outpatient specialist mental health services, particularly for people with serious MDs and SUDs, and collaborative models that can support primary care providers treating people with MSUDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07759-z.

State lockdown policies, mental health symptoms, and using substances

Objective

Previous literature finds an increase in depressive symptoms, substance use, and suicidal ideation following the COVID-19 pandemic in the US – suicides do not appear to increase. We examine whether 1) state lockdown policies in the US precede an increase in mental health symptoms; and 2) the extent to which using substances amplifies or attenuates the relation.

Methods

We specified, as our exposure variable, the timing of state-level lockdown orders. We used, as the outcome variable, the 4-item Patient Health Questionnaire (PHQ-4) that measures anxiety and depression symptoms. We utilized the Understanding America Study (UAS), a nationally representative sample of 7,597 adults across 50 states in the US, surveyed biweekly between March 10, 2020 and November 11, 2020. Linear fixed effect analyses controlled for time-invariant individual factors, as well as employment status, household income, and previous mental health diagnosis.

Results

Regression results indicate an increase in PHQ-4 scores of approximately 1.70 during lockdown, relative to no lockdown (p < 0.05). Relative to no lockdown, an increase in alcohol use corresponds with a 0.08 unit decrease in PHQ-4 scores during lockdown (p < 0.05).

Conclusion

State lockdown policies precede greater mental health symptoms. Increases in consuming alcohol attenuates the relation between state lockdown policies and mental health symptoms. Results may portend greater addiction following the pandemic warranting further investigation into utilization of substance use treatment.

Continuity of Mental Health Care at Community Health Centers and Reduced Emergency Department Visits for Suicidal Ideation/Self-Harm

We examined whether county-level increases in continuity of mental health care (i.e., mental health visits per mental health patient) at Community Health Centers (CHCs) correspond with a decline in Emergency Department (ED) visits for suicidal ideation and self-harm (1) overall, and (2) among specific race/ethnicities across 211 counties from 10 US states, from 2006 to 2015 (sample size = 1412 county-years). We used fixed effects linear regression analyses with county-level socioeconomic covariates and year indicators. In the full sample, continuity of mental health care at CHCs varies inversely with ED visits for suicidal ideation/self-harm (coefficient: -0.04, p < 0.1). Race-specific analyses show that a one unit increase in continuity of mental health care at CHCs corresponds with a 5% decline in ED visits for suicidal ideation/self-harm among whites (p < 0.05). Expansion of mental health care services at CHCs may serve as a key point of prevention for suicidal behavior.

Emergency Department visits for depression following police killings of unarmed African Americans

Previous literature on racism and adverse mental health largely focuses on individual-level exposures. We investigate whether and to what extent structural racism, as measured by police killings of unarmed African Americans, affect a severe and acute mental health outcome among African Americans: depression-related Emergency Department (ED) visits. We used police killings of unarmed African Americans as our exposure and depression-related ED visits (per 100,000 population) as our outcome. We examined the relation across 75 counties from five US states between 2013 and 2015 (2700 county-months). Linear fixed effect analyses controlled for time-invariant county-factors as well as the number of hospitals and arrests for violent crimes (per 100,000 population). Police killings of unarmed African Americans correspond with an 11% increase in ED visits per 100,000 population related to depression among African Americans in the concurrent month and three months following the exposure (p < 0.05). Researchers and policymakers may want to consider prevention efforts to reduce racial bias in policing and implement surveillance of fatal police encounters. These encounters, moreover, may worsen mental health and help-seeking in the ED among African Americans not directly connected to the encounter.

Rapid Growth of Mental Health Services at Community Health Centers

Community Health Centers (CHCs) target medically underserved communities and expanded by 70% in the last decade. We know little, however, about mental health services at CHCs. We analyzed data from 2006 to 2015 and determined county-level drivers of these services. Mental health patients at CHCs fall from 2006 to 2007 but then rise consistently from 2007 to 2015. Counties with fewer physicians, greater percent insured and greater percent white population show faster growth in mental health services. Increases in mental health services at CHCs outpace general CHC growth and reflect federal efforts to integrate behavioral health care into primary care.

Racial Disparities in Pediatric Psychiatric Emergencies: A Health Systems Approach

Less than half of African American youth with severe mental disorders receive psychiatric care. When they do receive care, African American youth use the Emergency Department at higher rates than whites. We examine whether rapid expansion of primary mental health care at Community Health Centers reduces Emergency Department visits for psychiatric care especially among African American youth. Through four studies, we examine (1) the impact of mental health service capacity on the disparity of psychiatric care among African American youth; (2) how Community Health Center mental health visits vary with repeat psychiatric emergency visits; (3) the county-level drivers of the expansion of Community Health Centers; and (4) how Community Health Center expansion affects overall psychiatric emergency care. Results indicate that increased continuity of mental health care at Community Health Centers corresponds with a reduction in racial disparities in youth psychiatric ED visits. In addition, an increase in Community Health Center capacity varies inversely with repeated psychiatric Emergency Department visits and inversely with psychiatric Emergency Department visits overall. And finally, results show an increase in Community Health Center mental health services among counties with greater poverty, lower physician availability, and higher percentage of uninsured. Our studies indicate that expansion of federally-funded primary mental health services affects the overall system of emergency psychiatric care. However, this expansion does not appear to dramatically reduce racial/ethnic disparities in psychiatric emergency department visits.

Psychiatric-related Revisits to the Emergency Department Following Rapid Expansion of Community Mental Health Services

OBJECTIVES

Repeat visits (revisits) to emergency departments (EDs) for psychiatric care reflect poor continuity of care and impose a high financial cost. We test whether rapid expansion of community health centers (CHCs)-which provide regional, low-cost primary care-correspond with fewer repeat psychiatric-related ED visits (PREDVs).

METHODS

We obtained repeated cross-sectional time-series data for 7.8 million PREDVs from the State Emergency Department Database for four populous U.S. states (California, Florida, North Carolina, and New York) from 2006 to 2011. We specified as the outcome variable the count of repeat visits per ED visitor with a psychiatric diagnosis. We retrieved aggregate-level mental health visits at CHCs from the Uniform Data System. Negative binomial regression methods controlled for individual-level confounders, county health system and sociodemographic attributes, year fixed effects, and county fixed effects.

RESULTS

The risk of a repeat PREDV decreased with a county-level increase in mental health patients seen at CHCs (incidence rate ratio = 0.986, 95% confidence interval = 0.98 to 0.99). Conversion of this rate ratio to the number of revisits averted indicated 34,000 fewer repeat PREDVs in these four states statistically associated with a 1% expansion in CHC mental health visits. Exploratory analyses found that revisits decline for relatively mild/moderate illnesses (e.g., mood, anxiety disorders) but not for severe illnesses (e.g., schizophrenia/psychoses).

CONCLUSION

An increase in mental health services at CHCs corresponds with a modest decline in repeat PREDVs. This decline concentrates among those with less severe mental illnesses.

African American/white disparities in psychiatric emergencies among youth following rapid expansion of Federally Qualified Health Centers

OBJECTIVE

To test whether rapid expansion of mental health services in Federally Qualified Health Centers (FQHCs) reduces African American/white disparities in youth psychiatric emergency department (ED) visits.

DATA SOURCES

Secondary ED data for psychiatric care for 3.3 million African American and white youth in nine states, 2006-2011. We used the HCUP SEDD and SID. We obtained FQHC service data from the Uniform Data System.

STUDY DESIGN

The psychiatric ED visit is the dependent variable. Logistic regression methods control for individual risk factors for ED use, as well as county-level health system factors and county and year fixed effects. Key independent variables include indicators of mental health service capacity in FQHCs in a county-year.

DATA EXTRACTION METHODS

We extracted ED psychiatric visits for 3.3 million African American and white youth in nine states, 2006-2011, from the HCUP SEDD and SID, and FQHC data from the Uniform Data System.

PRINCIPAL FINDINGS

Overall mental health visits at FQHCs correlate positively with psychiatric ED visits among African American youth. However, increases in the number of mental health visits per FQHC patient corresponds with fewer outpatient psychiatric ED visits among African American youth, relative to white youth (odds ratio = 0.96; 95% CI = 0.94, 0.98).

CONCLUSIONS

Increases in the intensity of services offered per mental health patient at FQHCs-rather than increases in overall capacity-may reduce African American youth's overreliance on the ED for psychiatric care.