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

Nonparticipation in Work and Education in Emerging Adulthood and Depressive Symptoms through Early Midlife

More than one-in-eight young adults in the US between the ages of 16 to 24 were not in employment, education, or training (NEET) in 2020 - a level not seen since the Great Recession. This study examines the long-term association between NEET status in emerging adulthood and later depressive symptoms using the National Longitudinal Study of Adolescent to Adult Health (1995-2018). Growth curve models chart the association between NEET status and depressive symptoms over time in the US. The analytic sample includes 9,349 individuals and 28,047 person-wave observations for respondents between ages 18 to 43. In a fully specified model, respondents who reported NEET status in emerging adulthood (ages 18-26), exhibited greater depressive symptoms across emerging adulthood through early midlife (ages 33-43) (b=0.44, 95% CI 0.33, 0.54) compared to those participating in employment, education, or training. Associations persisted even after accounting for early life disadvantage and using propensity score matching to further diminish possible sources of bias. Results indicate that disconnection from school and work during emerging adulthood may constitute a risk factor for depressive symptoms through early midlife.

Impact of COVID-19 and Public Health Measures on Positive Suicide Screens Among Emergency Department Children

OBJECTIVE

The aim of this study was to examine the association between prolonged time in the COVID-19 pandemic and rates of positive routine suicide screens among youth accessing healthcare in the pediatric emergency department.

METHODS

Participants were English- and Spanish-speaking youth aged 10-18 years presenting without an acute mental/behavioral health concern to the emergency department or urgent care of a large hospital system, serving a 7-state region, who completed routine screening for suicide risk. Visits between March 1, 2019 and December 31, 2021 were included. We conducted a quasi-experimental interrupted time series analysis and categorized visits into the prepandemic year, COVID-19 year 1 (Y1), and COVID-19 year 2 (Y2). The primary outcome measure was rate of positive suicide screen.

RESULTS

A total of 33,504 children completed routine suicide screening; 2689 children had a positive screen. The overall rate of positive suicide screens increased throughout the pandemic compared with baseline (7.5% prepandemic, 8.4% Y1, 9.3% Y2; P < 0.01). Rates of positive suicide screens in Y1 increased 0.04% per week and surpassed prepandemic rates, then decreased 0.1% per week throughout Y2 ( P < 0.01), during a time when social distancing mitigation efforts decreased.

CONCLUSIONS

Cumulative time in the COVID-19 pandemic was associated with increased positive suicide screens in children. School reopening and normalization of social routines preceded an observed negative trend in rates of positive suicide screens in Y2 of the pandemic. This study demonstrates fluctuating trends in suicide screen positivity, potentially influenced by social distancing and public health measures. Our study may support that maintaining social connectedness and access to school-based or community resources may be a protective factor for youth suicide risk during a pandemic or other natural occurrence.

Factors Associated With Discharge Against Medical Advice in US Adolescents Hospitalized for Suicidal Ideation or Suicide Attempt

OBJECTIVE

Little is known about factors associated with discharge against medical advice (DAMA) in adolescent acute care hospitalization for suicidal ideation (SI) and suicide attempt (SA). Our study seeks to determine whether certain socioeconomic factors or hospital characteristics are associated with DAMA in this population.

METHOD

This retrospective cross-sectional study used data from the National Inpatient Sample from the 2015 fourth quarter to 2019. We included children 10 to 19 years of age hospitalized with a primary or secondary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of SI or SA. Exposures were patient socio-demographics and hospital characteristics. The outcome was DAMA. Logistic regression generated odds ratios (ORs) with 95% CIs to measure the association between each patient and hospital characteristics and DAMA.

RESULTS

Of 476,755 hospitalizations meeting inclusion criteria, 3,825 (0.8%) were DAMA. After adjusting for socio-demographics and hospital characteristics, predictive factors for DAMA were age 16 to 19 years (OR = 1.41; CI = 1.08-1.82), self-pay status (OR = 1.43; CI = 1.12-1.83), hospital region South and West (OR = 1.55; CI = 1.10-2.20 and OR = 1.79; CI = 1.26-2.54, respectively), and urban non-teaching status of the hospital (OR = 1.90; CI = 1.42-2.55). Hispanic patients were less likely to be DAMA (OR = 0.66; CI = 0.51-0.85).

PLAIN LANGUAGE SUMMARY

This study utilized retrospective data from the National Inpatient Sample (2015 to 2019) to determine predictive factors for discharge against medical advice (DAMA) for youth, aged 10 to 19 years old, hospitalized for suicidal ideation or suicide attempt. Of 476,755 hospitalizations for suicidality, 3,825 (0.8%) were discharged against medical advice. Correlates of discharge against medical advice included age 16 to 19 years, self-pay status, admission to an urban non-teaching hospital, or a hospital located in the South or West Regions of the United States. Hispanic patients were less likely to be discharged against medical advice with no other racial/ ethnic differences observed.

CONCLUSION

Variations in DAMA probabilities by age, insurance status, hospital teaching status, and hospital regions suggest a need for a better understanding of this uncommon outcome.

Integrated care models for youth mental health: A systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of integrated models of mental healthcare in enhancing clinical outcomes, quality of life, satisfaction with care and health service delivery outcomes in young people aged 12-25 years. A secondary objective was to identify common components of integrated mental health interventions.

METHODS

A systematic review and meta-analysis of studies published 2001-2023 that assessed clinical or health service use outcomes of integrated care, relative to treatment as usual, for any mental health condition in 12-25 years old accessing community-based care.

RESULTS

Of 11,444 titles identified, 15 studies met inclusion criteria and 6 studies were entered in the meta-analysis. Pooled effect size found integrated care was associated with a greater reduction in depressive symptoms relative to treatment as usual at 4-6 months (standardised mean difference = -0.260, 95% confidence interval = [-0.39, -0.13], p = 0.001). Of the seven studies reporting access or engagement, all reported higher rates of both in the intervention arm. The most frequent components of integration were use of a multidisciplinary team (13/15 studies), shared treatment planning (11/15) and workforce training in the model (14/15).

CONCLUSIONS

Integrated models of mental healthcare are associated with a small, but significant, increase in effectiveness for depressive symptoms relative to treatment as usual. Given integrated care may increase access and engagement, future research should focus on assessing the impact of integrated care in a wider range of settings and outcomes, including clinical and functional recovery, satisfaction with care and system-level outcomes such as cost-effectiveness.

National Trends in Emergency Department Visits for Suicide Attempts and Intentional Self-Harm

OBJECTIVE

This study estimated national annual trends and characteristics of emergency department visits for suicide attempts and intentional self-harm in the United States from 2011 to 2020.

METHODS

Data were from the National Hospital Ambulatory Medical Care Survey, an annual cross-sectional national sample survey of emergency departments. Visits for suicide attempts and intentional self-harm were identified using discharge diagnosis codes (ICD-9-CM for 2011-2015; ICD-10-CM for 2016-2020) or reason-for-visit codes. The annual proportion of emergency department visits for suicide attempts and intentional self-harm was estimated.

RESULTS

The weighted number of emergency department visits for suicide attempts and intentional self-harm increased from 1.43 million, or 0.6% of total emergency department visits, in 2011-2012 to 5.37 million, or 2.1% of total emergency department visits in 2019-2020 (average annual percent change, 19.5%, 95% CI=16.9, 22.2). Visits per capita increased from 261 to 871 visits per 100,000 persons (average annual percent change, 18.8%, 95% CI=17.6, 20.0). The increase in visits was widely distributed across sociodemographic groups. While suicide attempt and intentional self-harm visits were most common among adolescents, adults age 65 or older demonstrated the largest increase (average annual percent change, 30.2%, 95% CI=28.5, 32.0). Drug-related diagnoses were the most common co-occurring diagnosis among suicide attempt and intentional self-harm visits. Despite the rise in emergency department visits for suicide attempts and intentional self-harm, less than 16% included an evaluation by a mental health professional.

CONCLUSIONS

A significant national increase in emergency department visits for suicide attempts and intentional self-harm occurred from 2011 to 2020, as a proportion of total emergency department visits and as visits per capita. These trends underscore an urgent need to improve the continuum of mental health care for individuals with suicidal symptoms.

Intersectional trends in child and adolescent suicide-related emergency department encounters in Florida (2016‒2021)

Objectives

Emergency department (ED) visits resulting from suicidal thoughts and behaviors have increased at alarming rates among youth in the United States in recent years. Understanding trends among specific racial, ethnic, gender, and/or age subgroups can provide the foundation for tailored solutions for those with the greatest need for support.

Methods

Using data from the Florida State Emergency Department Database from 2016 to 2021, we calculated annual rates of ED suicide-related diagnoses per 1000 young people aged 8‒21 years. We explored annual trends by age and intersectional race/ethnicity and sex subgroups. Additionally, we examined subgroup-specific stratified percent changes from 2016 to 2019 and 2016 to 2021.

Results

Among 8‒12-year olds, the highest rates of suicide-related ED encounters occurred among Black males and females and this trend was steady over time. Among 13‒21-year-old patients, Black and White females displayed the highest rates of suicide-related ED encounters across 2016‒2021, and all subgroups experienced a slight decline in 2020 and 2021. Rates generally increased between 2016 and 2019, with the largest percent increase (10.6%) occurring among Black females aged 18‒21 years, whereas there was a trend of decreased rates among most subgroups between 2019 and 2021.

Conclusions

Across all years and age groups, Black females showed consistently higher rates of suicide-related ED encounters than almost any other subgroup, supporting previous research that Black adolescent females may be disproportionately suffering from the mental health crisis faced by young people. Furthermore, preteen Black males need additional mental health support, as do adolescent and young adult White females.

Process and Impact of Development of an Adolescent Emergency Psychiatry Unit at a Large Urban Hospital

OBJECTIVES

Boarding of adolescent patients with mental health concerns requiring ongoing observation and treatment is of increasing concern across US emergency departments. The objective was a proof of concept of developing an adolescent psychiatric emergency unit and assessment of the impact of this unit on lengths of stay (LOS).

METHODS

We describe the creation of the unit designed to allow safe assessment and boarding of patients, and appropriate interventions and services, while arranging transfer to inpatient facility or safe discharge home. Using a precreation and postcreation analysis and comparison with a similar facility that did not create such a unit, we utilized linear regression to investigate the primary outcome of total length of stay and secondary outcomes of psychiatric emergency department and pediatric emergency department length of stay for both unit-eligible patients and all patients.

RESULTS

The overall length of stay was not associated with a statistically significant change for unit-eligible patients; however, there was a significant decrease in the pediatric emergency department LOS for unit-eligible patients. This was associated with a decrease in beds lost to boarding in the pediatric emergency department of 544 hours per month.

CONCLUSIONS

Creation of an adolescent psychiatric emergency unit without allotment of significant additional resources is an option to decrease pediatric emergency department boarding times for adolescent patients requiring ongoing emergent therapy for mental health concerns.

Adolescent Health in the Post-Pandemic Era: Evolving Stressors, Interventions, and Prevention Strategies amid Rising Depression and Suicidality

Prior to COVID-19, there were already increasing rates of youth with mental health concerns, including an increase in youth presenting to medical emergency departments (EDs) with mental health chief complaints and limited access to treatment. This trend worsened during the pandemic, and rates of youth presenting to medical EDs with suicidal ideation and self-harm increased 50% from 2019 to 2022. This resulted in a "boarding" crisis, in part, due to a lack of inpatient psychiatric hospitalization beds, and many youth were left without access to adequate treatment. Additional study of innovations in health care delivery will be paramount in meeting this need.

Emergency Department Pediatric Mental and Behavioral Health Patients Transported by Emergency Medical Services and Police: Trends and Interventions

OBJECTIVE

We aimed to understand transport utilization trends, demographics, emergency department (ED) interventions, and outcomes of pediatric mental and behavioral health (MBH) patients transported by emergency medical services (EMS), police, or self-transported.

METHODS

This retrospective cohort study utilized electronic health record data from patients aged 5 to 18 years presenting with acute MBH conditions at 2 affiliated pediatric EDs from January 2012 to December 2020. Data included demographics, ED interventions for aggression/agitation, Brief Rating of Aggression by Children and Adolescents (BRACHA) scores, and ED dispositions. Descriptive statistics and comparative analyses were conducted using chi-square, Wilcoxon rank sum tests, and multivariable logistic regression. Linear regression analyzed trends.

RESULTS

Of 440,302 ED encounters, 70,557 (16%) were for acute MBH concerns, with 14.6% transported by EMS and 5.9% by police. The proportion of MBH visits increased from 9.9% in 2012 to 19.8% in 2020 (95% (confidence interval) CI [0.7, 1.7], P = 0.0009), with a concurrent 0.4% annual increase in those transported by EMS (95% CI [0.2, 0.6], P = 0.006). MBH patients transported by EMS and police had significantly higher odds of requiring restraint in the ED and were more likely to have higher BRACHA scores and to be admitted compared to self-transported patients (all comparisons, P < 0.001).

CONCLUSIONS

Pediatric MBH ED visits and EMS utilization are increasing. MBH patients transported by EMS and police may represent a more aggressive ED population. Given the rising encounters within this high-risk population, our EDs, EMS, and police need support and resources for safe pediatric MBH patient management.

The Declaration of the National Emergency in Child and Adolescent Mental Health: It Takes a Village

Recognition of the high prevalence of children's mental health conditions and challenges to accessing needed care faced by children and their families have been long-standing concerns, emerging well before the onset of the COVID-19 pandemic. Global data examining the prevalence of at least one mental health and/or substance-use disorder for 2516 million people aged 5 to 24 years in 2019 found that at least 293 million people were affected by at least one mental health disorder and 31 million affected by a substance-use disorder.

Psychotropic Medication Administration in Pediatric Emergency Departments

BACKGROUND AND OBJECTIVES

Visits by youth to the emergency department (ED) with mental and behavioral health (MBH) conditions are increasing, yet use of psychotropic medications during visits has not been well described. We aimed to assess changes in psychotropic medication use over time, overall and by medication category, and variation in medication administration across hospitals.

METHODS

We conducted a retrospective cross-sectional study of ED encounters by youth aged 3-21 with MBH diagnoses using the Pediatric Health Information System, 2013-2022. Medication categories included psychotherapeutics, stimulants, anticonvulsants, antihistamines, antihypertensives, and other. We constructed regression models to examine trends in use over time, overall and by medication category, and variation by hospital.

RESULTS

Of 670 911 ED encounters by youth with a MBH diagnosis, 12.3% had psychotropic medication administered. The percentage of MBH encounters with psychotropic medication administered increased from 7.9% to16.3% from 2013-2022 with the odds of administration increasing each year (odds ratio, 1.09; 95% confidence interval, 1.05-1.13). Use of all medication categories except for antianxiety medications increased significantly over time. The proportion of encounters with psychotropic medication administered ranged from 4.2%-23.1% across hospitals (P < .001). The number of psychotropic medications administered significantly varied from 81 to 792 medications per 1000 MBH encounters across hospitals (P < .001).

CONCLUSIONS

Administration of psychotropic medications during MBH ED encounters is increasing over time and varies across hospitals. Inconsistent practice patterns indicate that opportunities are available to standardize ED management of pediatric MBH conditions to enhance quality of care.

Annual Research Review: Sex, gender, and internalizing conditions among adolescents in the 21st century - trends, causes, consequences

Internalizing conditions of psychopathology include depressive and anxiety disorders; they most often onset in adolescence, are relatively common, and contribute to significant population morbidity and mortality. In this research review, we present the evidence that internalizing conditions, including depression and anxiety, as well as psychological distress, suicidal thoughts and self-harm, and fatal suicide, are considerably increasing in adolescent populations across many countries. Evidence indicates that increases are currently greatest in female adolescents. We present an epidemiological framework for evaluating the causes of these increases, and synthesize research on whether several established risk factors (e.g., age of pubertal transition and stressful life events) and novel risk factors (e.g., digital technology and social media) meet conditions necessary to be plausible causes of increases in adolescent internalizing conditions. We conclude that there are a multitude of potential causes of increases in adolescent internalizing conditions, outline evidence gaps including the lack of research on nonbinary and gender nonconforming populations, and recommend necessary prevention and intervention foci from a clinical and public health perspective.

Autistic traits in adolescents in psychiatric inpatient care: Clinical and demographic characteristics and correlates

Background

Rates of psychiatric hospitalization among adolescents in the United States are rising, with many adolescents presenting to these settings with diverse clinical presentations, including autistic traits. To our knowledge, there has been little research identifying clinical characteristics of adolescents with autistic traits admitted to psychiatric inpatient units, which may be leveraged to improve assessment and treatment practices.

Method

In the current study, we examined clinical and demographic characteristics of 195 adolescents admitted to an adolescent psychiatric inpatient unit. Specifically, we investigated the prevalence of adolescents endorsing elevated autistic traits and tested associations between autistic traits, psychiatric symptoms (anxiety, depression, suicidal thoughts), and key demographic variables (age, sex, gender, sexual orientation).

Results

Results show that over half of the adolescents admitted to the psychiatric inpatient unit reported elevated autistic traits on a short screening questionnaire. Higher autistic traits were significantly associated with more severe depressive symptoms, though to a small degree. Autistic traits were not associated with anxiety symptoms, suicidal thoughts, nor social disconnectedness, and did not differ by sex, gender identity, nor sexual orientation.

Conclusions

Findings highlight the challenge of diagnostic overshadowing among adolescents in crisis and the need for more rigorous measures designed for an inpatient setting to improve risk stratification, clinical assessments, intervention approaches, and discharge planning.

Mental Health-Related Outpatient Visits Among Adolescents and Young Adults, 2006-2019

Importance

Concerns over the mental health of young people have been increasing over the past decade, especially with the rise in mental health burden seen during the COVID-19 pandemic. Examining trends in mental health-related outpatient visits provides critical information to elucidate contributing factors, identify vulnerable populations, and inform strategies to address the mental health crisis.

Objective

To examine characteristics and trends in mental health-related outpatient visits and psychotropic medication use among US adolescents and young adults.

Design, Setting, and Participants

A retrospective cross-sectional analysis of nationally representative data from the National Ambulatory Medical Care Survey, an annual probability sample survey, was conducted from January 2006 to December 2019. Participants included adolescents (age 12-17 years) and young adults (age 18-24 years) with office-based outpatient visits in the US. Data were analyzed from March 1, 2023, to September 15, 2023.

Main Outcomes and Measures

Mental health-related outpatient visits were identified based on established sets of diagnostic codes for psychiatric disorders. Temporal trends in the annual proportion of mental health-related outpatient visits were assessed, including visits associated with use of psychotropic medications. Analyses were stratified by age and sex.

Results

From 2006 to 2019, there were an estimated 1.1 billion outpatient visits by adolescents and young adults, of which 145.0 million (13.1%) were associated with a mental health condition (mean [SD] age, 18.4 [3.5] years; 74.0 million females [51.0%]). Mental health-related diagnoses were more prevalent among visits by male (16.8%) compared with female (10.9%) patients (P < .001). This difference was most pronounced among young adults, with 20.1% of visits associated with a psychiatric diagnosis among males vs 10.1% among females (P < .001). The proportion of mental health-related visits nearly doubled, from 8.9% in 2006 to 16.9% in 2019 (P < .001). Among all outpatient visits, 17.2% were associated with the prescription of at least 1 psychotropic medication, with significant increases from 12.8% to 22.4% by 2019 (P < .001).

Conclusions and Relevance

In this cross-sectional study, there were substantial increases in mental health-related outpatient visits and use of psychotropic medications, with greater overall burden among male patients. These findings provide a baseline for understanding post-pandemic shifts and suggest that current treatment and prevention strategies will need to address preexisting psychiatric needs in addition to the effects of the COVID-19 pandemic.

Impact of mental health boarding on clinicians at a children's hospital: A qualitative analysis

BACKGROUND

The child and adolescent mental health boarding crisis (i.e., prolonged stays in acute care hospitals for patients awaiting mental health treatment) continues to challenge acute care hospital staff and resources. We sought to understand clinician's experiences while caring for patients experiencing mental health boarding.

METHODS

We conducted semistructured qualitative interviews with clinicians who care for patients experiencing mental health boarding in an acute care freestanding children's hospital with no inpatient psychiatric unit. We used an inductive approach to determine interview themes and major findings.

RESULTS

The study included 48 clinician participants from diverse specialties, including 13 social workers, 11 nurses, five psychiatric technicians, six pediatric residents, four attending pediatric hospitalists, four attending psychiatrists, one psychologist, and four other mental health specialists. We identified emergent themes in five domains: (1) frustrations with the mental healthcare system, (2) lack of training in mental healthcare skills, (3) feelings of helplessness, (4) ineffectiveness of medical model of care during mental health boarding, and (5) resilience and support factors.

CONCLUSIONS

Caring for patients with mental health boarding has negative effects on clinicians, and health system efforts to prevent boarding could improve workforce retention and reduce burnout.

Characteristics of pediatric behavioral health emergencies in the prehospital setting

OBJECTIVE

Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters.

METHODS

We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use.

RESULTS

Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61).

CONCLUSIONS

Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.

Management of the Agitated Patient

The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions and physical restraints as necessary. Face-to-face examination, monitoring, and documentation by the physician are essential. The emergency physician should be familiar with multiple pharmaceutical options, tailored to the individual patient. Use of ketamine, benzodiazepines and antipsychotics should be considered. Patient autonomy, safety, and medical well-being are paramount.

Pediatric Psychiatric Emergencies

Pediatric psychiatric emergencies account for 15% of emergency department visits and are on the rise. Psychiatric diagnoses in the pediatric population are difficult to make, due to their variable presentation, but early diagnosis and treatment improve clinical outcome. Medical reasons for the patient's presentation should be explored. Both physical and emotional safety must be ensured. A multidisciplinary approach, utilizing local primary care and psychiatric resources, is recommended.

Emergency Department Care of the Patient with Suicidal or Homicidal Symptoms

Patients frequently present to the emergency department (ED) with acute suicidal and homicidal thoughts. These patients require timely evaluation, with determination of disposition by either voluntary or involuntary hospitalization or discharge with appropriate outpatient follow-up. Safety concerns should be prioritized for patients as well as ED staff. Patient dignity and autonomy should be respected throughout the process.

Pharmacologic Restraint Use During Mental Health Admissions to Children's Hospitals

OBJECTIVES

Primary mental health admissions are increasing across US children's hospitals. These patients may experience agitation requiring pharmacologic restraint. This study characterized pharmacologic restraint use in medical inpatient units by primary mental health diagnosis.

METHODS

This retrospective, cross-sectional study used the Pediatric Health Information System database. The study included children aged 5 to 17 years admitted with a primary mental health diagnosis between 2016 and 2021. Rates of pharmacologic restraint use per 1000 patient days were determined for 13 mental health diagnoses and trended over time with Poisson regression.

RESULTS

Of 91 898 hospitalizations across 43 hospitals, 3% of admissions and 1.3% of patient days involved pharmacologic restraint. Trends in the rate of pharmacologic restraint use remained stable (95% confidence interval [CI], 0.7-2.1), whereas the incidence increased by 141%. Diagnoses with the highest rates of pharmacologic restraint days per 1000 patient days included autism (79.4; 95% CI, 56.2-112.3), substance-related disorders (45.0; 95% CI, 35.9-56.4), and disruptive disorders (44.8; 95% CI, 25.1-79.8). The restraint rate significantly increased in disruptive disorders (rate ratio [RR], 1.4; 95% CI, 1.1-1.6), bipolar disorders (RR, 2.0; 95% CI, 1.4-3.0), eating disorders (RR, 2.4; 95% CI, 1.5-3.9), and somatic disorders (RR, 4.2; 95% CI, 1.9-9.1). The rate significantly decreased for autism (RR, 0.8; 95% CI, 0.6-1.0) and anxiety disorders (RR, 0.3; 95% CI, 0.2-0.6).

CONCLUSIONS

Pharmacologic restraint use among children hospitalized with a primary mental health diagnosis increased in incidence and varied by diagnosis. Characterizing restraint rates and trends by diagnosis may help identify at-risk patients and guide targeted interventions to improve pharmacologic restraint utilization.

Trends in Pediatric Emergency and Inpatient Healthcare Use for Mental and Behavioral Health Among North Carolinians During the Early COVID-19 Pandemic

BACKGROUND

Widespread school closures and health care avoidance during the COVID-19 pandemic led to disruptions in access to pediatric mental health care.

METHODS

We conducted a retrospective study of emergency and inpatient administrative claims from privately insured children aged 6-20 years in North Carolina between January 2019 and December 2020. We compared rates of emergency department (ED) visits (per 100 000 person-days) and risks of hospitalizations (per 100 000 persons) with diagnosis codes in each category (mental/behavioral health; suicidal ideation, suicide attempt, and intentional self-harm [SI/SA/ISH]; and social issues) across 3 time periods (pre-pandemic, lockdown, and reopening). We calculated the proportion and 95% confidence intervals (CI) of total ED visits and total hospitalizations attributable to mental/behavioral health and SI/SA/ISH across the 3 time periods.

RESULTS

Rates of all categories of ED visits decreased from pre-pandemic to the lockdown period; from pre-pandemic to the reopening period, mental/behavioral health visits decreased but rates of SI/SA/ISH visits were unchanged. The proportion of ED visits attributable to mental/behavioral health increased from 3.5% (95% CI 3.2%-3.7%) pre-pandemic to 4.0% (95% CI 3.7%-4.3%) during reopening, and the proportion of SI/SA/ISH diagnoses increased from 1.6% (95% CI 1.4%-1.8%) pre-pandemic to 2.4% (95% CI 2.1%-2.7%) during the reopening period. Emergency care use for social issues and hospital admissions for mental/behavioral health and SI/SA/ISH diagnoses were unchanged across the study periods.

CONCLUSIONS

In the early pandemic, pediatric mental health care and acute suicidal crises accounted for increased proportions of emergency care. During pandemic recovery, understanding the populations most impacted and increasing access to preventative mental health care is critical.

The intersection of race, ethnicity, and gender and the prevalence of suicidal thoughts and behaviors

The prevalence of suicidal thoughts and behaviors across distinct intersections of race/ethnicity and gender among adolescents remains understudied. The current study seeks to address this important gap in suicide scholarship using a statewide representative sample of U.S. Florida middle school and high school adolescents. Data drawn from the 2022 Florida Youth Substance Abuse Survey (FYSAS) (N = 41,764) were analyzed to examine disparities in suicidal thoughts and suicide attempts among 26 racial/ethnic and gender subgroups of middle school and high school aged adolescents. Survey-weighted prevalence estimates for both suicidality outcomes were generated, and binary contrasts were used to assess the statistical significance of the differences in the probabilities between members of each subgroup and youth belonging to all other subgroups. Our results indicate that the prevalence of suicidal thoughts and attempts was highly gendered and varied according to racial/ethnic subgroups. Native American girls reported more suicidal thoughts (49.9%) and attempts (16.5%) in the past 12 months than any race/gender group. Other racial/ethnic and gender groups that reported particularly high rates of suicidal thoughts and attempts were West Indian/Caribbean female adolescents (48.8% and 13.4%, respectively), Puerto Rican female adolescents (48.5% and 14.7%, respectively), and Black/non-Hispanic female adolescents (19.9% and 15.6%, respectively). Because certain gender and race/ethnic subgroups are at an increased risk for suicidality, more research is needed to better understand the risk and protective factors to determine which suicide prevention strategies might best serve each group.

EMS Responses for Pediatric Behavioral Health Emergencies in the United States: A 4-Year Descriptive Evaluation

BACKGROUND

The occurrence of behavioral health emergencies (BHEs) in children is increasing in the United States, with patient presentations to Emergency Medical Services (EMS) behaving similarly. However, detailed evaluations of EMS encounters for pediatric BHEs at the national level have not been reported.

METHODS

This was a secondary analysis of a national convenience sample of EMS electronic patient care records (ePCRs) collected from January 1, 2018 through December 31, 2021. Inclusion criteria were all EMS activations documented as 9-1-1 responses involving patients < 18 years of age with a primary or secondary provider impression of a BHE. Patient demographics, incident characteristics, and clinical variables including administration of sedation medications, use of physical restraint, and transport status were examined overall and by calendar year.

RESULTS

A total of 1,079,406 pediatric EMS encounters were present in the dataset, of which 102,014 (9.5%) had behavioral health provider impressions. Just over one-half of BHEs occurred in females (56.2%), and 68.1% occurred in patients aged 14-17 years. Telecommunicators managing the 9-1-1 calls for these events reported non-BHE patient complaints in 34.7%. Patients were transported by EMS 68.9% of the time, while treatment and/or transport by EMS was refused in 12.5%. Prehospital clinicians administered sedation medications in 1.9% of encounters and applied physical restraints in 1.7%. Naloxone was administered for overdose rescue in 1.5% of encounters.

CONCLUSION

Approximately one in ten pediatric EMS encounters occurring in the United States involve a BHE, and the majority of pediatric BHEs attended by EMS result in transport of the child. Use of sedation medications and physical restraints by prehospital clinicians in these events is rare. National EMS data from a variety of sources should continue to be examined to monitor trends in EMS encounters for BHEs in children.

Reduction of Mental Health-Related Emergency Department Admissions for Youth and Young Adults Following a Remote Intensive Outpatient Program: Quality Improvement Analysis

BACKGROUND

Pediatric mental health emergency department (ED) visits are increasing at 6% to 10% per year, at substantial cost, while 13% of youth with psychiatric hospitalizations are readmitted in the following weeks. Hospitals do not have the resources to meet escalating youth's mental health needs. Intensive outpatient (IOP) programs, which provide multiple hours of care each week, have the power to reduce the number of patients in need of hospitalized care and provide a step-down option for patients discharging from ED's in order to prevent readmissions.

OBJECTIVE

The purpose of this program evaluation was to assess (1) whether youth and young adult ED admission rates decreased following participation in a remote IOP program and (2) whether there were differences in readmission rates between youth and young adults by gender identity, sexual orientation, race, or ethnicity.

METHODS

Data were collected from intake and 3-month postdischarge surveys for 735 clients who attended at least 6 sessions of a remote IOP program for youth and young adults. Patients reported if they had been admitted to an ED within the previous 30 days and the admission reason. Over half (407/707, 57.6%) of clients were adolescents and the rest were young adults (300/707, 42.4%; mean age 18.25, SD 4.94 years). The sample was diverse in gender identity (329/687, 47.9% female; 196/687, 28.5% male; and 65/669, 9.7% nonbinary) and sexual orientation (248/635, 39.1% heterosexual; 137/635, 21.6% bisexual; 80/635, 10.9% pansexual; and 170/635, 26.8% other sexual orientation) and represented several racial (9/481, 1.9% Asian; 48/481, 10% Black; 9/481, 1.9% Indigenous; 380/481, 79% White; and 35/481, 7.2% other) and ethnic identities (112/455, 24.6% Hispanic and 28/455, 6.2% other ethnic identity).

RESULTS

Mental health-related ED admissions significantly decreased between intake and 3 months after discharge, such that 94% (65/69) of clients with a recent history of mental health-related ED admissions at IOP intake reported no mental health-related ED admissions at 3 months after discharge from treatment (χ21=38.8, P<.001). There were no differences in ED admissions at intake or in improvement at 3 months after discharge by age, gender, sexuality, race, or ethnicity.

CONCLUSIONS

This study documents a decrease in ED admissions between intake and 3 months after discharge among both youth and young adults who engage in IOP care following ED visits. The similar outcomes across demographic groups indicate that youth and young adults experience similar decreases after the current tracks of programming. Future research could conduct a full return-on-investment analysis for intensive mental health services for youth and young adults.

The burden of mental and behavioral health visits to the pediatric ED: A 3-year tertiary care center experience

BACKGROUND

The shortage of mental health services across the United States has turned pediatric emergency departments (PEDs) into safety-nets for the increasing population of children with mental and behavioral health (MBH) needs. This study provides a descriptive characterization of MBH-related PED visits, the trends in visit, ED length of stay (EDLOS), and admission rate.

METHODS

We reviewed electronic health records of children ≤18 years with MBH needs, who visited the PED of a large tertiary hospital from January 2017 to December 2019. We performed descriptive statistics, chi-square (χ2 ), and logistic regression analyses to evaluate trend in visit, EDLOS, admission rate, and predictors of prolonged EDLOS and inpatient admission.

RESULTS

Of 10,167 patients, 58.4% were females, median age was 13.8 years, and 86.1% were adolescents. On average, visits increased by 19.7% annually, with a 43.3% increase over 3 years. Common ED diagnoses include, suicidality (56.2%), depression (33.5%), overdose/poisoning, and substance use (18.8%), and agitation/aggression (10.7%). Median EDLOS was 5.3 hr, average admission rate was 26.3%, with 20.7% boarding in the ED for >10 hr. Independent predictors of admission include depression (pOR: 1.5, CI: 1.3-1.7), bipolar disorder (pOR: 3.5, CI: 2.4-5.1), overdose/substance use disorder (pOR: 4.7, CI: 4.0-5.6), psychosis (pOR: 3.3, CI: 1.5-7.3), agitation/aggression (pOR: 1.8, CI: 1.5-2.1), and ADHD (pOR: 2.5, CI: 2.0-3.0). Principal independent driver of prolonged EDLOS was patient admission/transfer status (pOR: 5.3, CI: 4.6-6.1).

CONCLUSIONS

Given the study results, MBH-related PED visits, ED length-of-stay, and admission rates continue to rise even in recent years. PEDs lack the resources and capability to provide high-quality care for the increasing population of children with MBH needs. Novel collaborative approaches and strategies are urgently needed to find lasting solutions.

Age Trends And State Disparities In Firearm-Related Suicide In The US, 1999-2020

Using data from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, we analyzed trends in firearm suicide across the life course, comparing age-related trends over time (2015-20 versus 1999-2014) and stratified by differences in state firearm policy environments. Overall, we found stable trends in firearm suicide rates across the life course, although with higher overall rates across all age groups in 2015-20 versus in 1999-2014. Ages 14-16 was the only age group with an accelerating life-course trend in firearm suicide rates in 2015-20 versus in 1999-2014. The state policy environment was associated with significant differences in firearm suicide, with an average of 4.62 more deaths per 100,000 people per year in states with less- versus more-strict environments. This was in contrast to nonfirearm suicides, for which we observed no consistent differences between states. The largest overall differences in firearm suicide between states occurred in adulthood through middle age. These findings can inform further research on health care-based approaches to reducing firearm suicide, such as health care screening for firearm ownership, screening for suicide risk among firearm owners, and motivational interviewing to promote safe firearm storage.

Pediatric Mental Health Emergencies During 5 COVID-19 Waves in New York City

OBJECTIVES

To describe the proportion of pediatric mental health emergency department (MH-ED) visits across 5 COVID-19 waves in New York City (NYC) and to examine the relationship between MH-ED visits, COVID-19 prevalence, and societal restrictions.

METHODS

We conducted a time-series analysis of MH-ED visits among patients ages 5 to 17 years using the INSIGHT Clinical Research Network, a database from 5 medical centers in NYC from January 1, 2016, to June 12, 2022. We estimated seasonally adjusted changes in MH-ED visit rates during the COVID-19 pandemic, compared with predicted prepandemic levels, specific to each COVID-19 wave and stratified by mental health diagnoses and sociodemographic characteristics. We estimated associations between MH-ED visit rates, COVID-19 prevalence, and societal restrictions measured by the Stringency Index.

RESULTS

Of 686 500 ED visits in the cohort, 27 168 (4.0%) were MH-ED visits. The proportion of MH-ED visits was higher during each COVID-19 wave compared with predicted prepandemic trends. Increased MH-ED visits were seen for eating disorders across all waves; anxiety disorders in all except wave 3; depressive disorders and suicidality/self-harm in wave 2; and substance use disorders in waves 2, 4, and 5. MH-ED visits were increased from expected among female, adolescent, Asian race, high Child Opportunity Index patients. There was no association between MH-ED visits and NYC COVID-19 prevalence or NY State Stringency Index.

CONCLUSIONS

The proportion of pediatric MH-ED visits during the COVID-19 pandemic was higher during each wave compared with the predicted prepandemic period, with varied increases among diagnostic and sociodemographic subgroups. Enhanced pediatric mental health resources are essential to address these findings.

Acceptability of Long Versus Short Firearm Safety Education Videos in the Emergency Department: A Pilot Randomized Controlled Trial

STUDY OBJECTIVE

Safe firearm storage is protective against pediatric firearm injuries. We sought to compare a 3-minute versus 30-second safe firearm storage video in terms of acceptability of video content and use in the pediatric emergency department (PED).

METHODS

We conducted a randomized controlled trial in a large PED (from March to September 2021). Participants were English-speaking caregivers of noncritically ill patients. Participants were surveyed about child safety behaviors (including firearm storage), then shown 1 of 2 videos. Both videos described safe storage principles; the 3-minute video included temporary firearm removal and a survivor testimonial. The primary outcome was acceptability, measured by responses on a 5-point Likert scale (strongly disagree to strongly agree). A survey at 3 months evaluated information recall. Baseline characteristics and outcomes were compared between groups using Pearson chi-squared, Fisher exact, and Wilcoxon Mann Whitney tests as appropriate. Absolute risk difference for categoric variables and mean difference for continuous variables are reported with 95% confidence interval (CI).

RESULTS

Research staff screened 728 caregivers; 705 were eligible and 254 consented to participate (36%); 4 withdrew. Of 250 participants, most indicated acceptability in terms of setting (77.4%) and content (86.6%), and doctors discussing firearm storage (78.6%), with no difference between groups. More caregivers viewing the longer video felt the length appropriate (99.2%) compared with the shorter video (81.1%, difference 18.1%, 95% CI 11.1 to 25.1).

CONCLUSIONS

We show that video-based firearm safety education is acceptable among study participants. This can provide consistent education to caregivers in PEDs and needs further study in other settings.

Exploring Service Use Disparities among Suicidal Black Youth in a Suicide Prevention Care Coordination Intervention

OBJECTIVE

The aim of this study is to examine service utilization disparities among Black youth participating in Linking Individuals Needing Care (LINC), a 90-day research-informed suicide care coordination intervention.

METHODS

An open trial pilot was conducted to examine the effectiveness of LINC in increasing access to and engagement in mental health and non-mental health services among suicidal youth (N = 587). Other variables of interest included service use facilitators and service use barriers. Generalized linear mixed models with binomial distribution and logit link were performed to ascertain if service use facilitators and barriers were associated with service utilization and if disparities in service use and engagement existed between Black and White suicidal youth through a comparative analysis.

RESULTS

Service utilization differences were found between Black and White youth. While Black and White youth were both likely to engage in individual therapy (OR = 1.398, p < .001) and non-mental health services (OR = 1.289, p < .001), utilization rates for mental health and medication management services were lower for Black (55.1% to 60.6%) youth compared to White (66.0% to 71.0%) youth. Specifically, Black youth were significantly less likely than Whites to receive medication management (OR = .466, p = .002). Systemic barriers such long waitlists for care (OR = 1.860, p = .039) and poor relationship with providers (OR = 7.680, p = .028) increased odds of engagement in non-mental health services. Clinical disorders and engagement in suicide-related behaviors increased the likelihood of obtaining care from both medication management and non-mental health services.

CONCLUSION

Care coordination services for suicidal youth can increase access and engagement in mental health and non-mental health services. Culturally adapted models attending to cultural and social assets of Black families are needed to reduce disparities and suicide risk among Black youth.

Associations between outpatient treatment and the use of intensive psychiatric healthcare services

The current manuscript examines concurrent and longitudinal associations between the utilization of outpatient and intensive psychiatric services among Medicaid-enrolled youth. Using an administrative dataset of Medicaid claims from 2007 to 2017, youth were included if they were between the ages of 10-18 (M = 13.4, SD = 2.6) and had a psychiatric Medicaid claim (N = 33,590). Psychiatric services were coded as outpatient, emergency department (ED), inpatient, or residential based on Medicaid codes. Logistic regression analyses indicated that the receipt of even one outpatient visit significantly reduced the odds of having an ED, inpatient, and residential visit within 60-, 90-, and 120-day windows. Survival analyses indicated most youth did not have any ED, inpatient, or residential visit following their first outpatient visit. For remaining youth, having an outpatient visit significantly increased the risk of having an ED, inpatient, and residential visit following their initial appointment, which may suggest these youth are being triaged to a more appropriate level of care. Classification accuracy analyses indicated a cutoff of 2 outpatient visits yielded maximum accuracy in determining youth with ED, inpatient, and residential visits. Findings highlight use of outpatient-level services in reducing risk of more intensive service utilization.

Racial and ethnic disparities in unmet need for mental health care among children: A nationally representative study

BACKGROUND

There is a dearth of large, nationally representative studies that examine racial/ethnic disparities in self-reported unmet need for mental health care among children and youth.

OBJECTIVE

This study assessed racial/ethnic disparities in unmet need for mental health care, use of psychotropic medication, and reasons for forgone care among children and youth.

METHODS

This nationally representative cross-sectional study analyzed data from the combined 2016-2020 National Survey of Children's Health (n = 151,876). Bivariate statistics and multivariable logistic regression models assessed the association between race/ethnicity, unmet need for mental health care, and use of psychotropic medication. Reasons for forgone care were also examined.

RESULTS

Black non-Hispanic children and youth had approximately twice the odds of unmet mental health care needs (AOR, 1.97; 95% CI 1.53-2.55) as White non-Hispanic children and youth. The likelihood of reporting that it was not possible to see a mental health professional was higher for Black non-Hispanic (AOR, 3.39; 95% CI 1.64-7.01) and Multi-racial/Other non-Hispanic children and youth (AOR, 2.96; 95% CI 1.40-6.25) compared with White non-Hispanic peers. Black non-Hispanic, Hispanic, and Multi-racial/Other non-Hispanic children and youth were also less likely to use psychotropic medication (p < 0.001). Common reasons for forgoing care included cost, problems getting an appointment, and lack of transportation or childcare.

CONCLUSIONS

This study found significant racial/ethnic disparities in unmet mental health care, psychotropic medication use, and barriers in accessing mental health care. Data from this study suggest that eliminating these disparities requires policy interventions that address medical and societal barriers to health care access and quality.

Self-harm among youth during the first 28 months of the COVID-19 pandemic in Ontario, Canada: a population-based study

BACKGROUND

Youth have reported worsening mental health during the COVID-19 pandemic. We sought to evaluate rates of pediatric acute care visits for self-harm during the pandemic according to age, sex and mental health service use.

METHODS

We conducted a population-based, repeated cross-sectional study using linked health administrative data sets to measure monthly rates of emergency department visits and hospital admissions for self-harm among youth aged 10-17 years between Jan. 1, 2017, and June 30, 2022, in Ontario, Canada. We modelled expected rates of acute care visits for self-harm after the pandemic onset based on prepandemic rates. We reported relative differences between observed and expected monthly rates overall and by age group (10-13 yr and 14-17 yr), sex and mental health service use (new and continuing).

RESULTS

In this population of about 1.3 million children and adolescents, rates of acute care visits for self-harm during the pandemic were higher than expected for emergency department visits (0.27/1000 population v. 0.21/1000 population; adjusted rate ratio [RR] 1.29, 95% confidence interval [CI] 1.19-1.39) and hospital admissions (0.74/10 000 population v. 0.43/10 000 population, adjusted RR 1.72, 95% CI 1.46-2.03). This increase was primarily observed among females. Rates of emergency department visits and hospital admissions for self-harm were higher than expected for both those aged 10-13 years and those aged 14-17 years, as well as for both those new to the mental health system and those already engaged in care.

INTERPRETATION

Rates of acute care visits for self-harm among children and adolescents were higher than expected during the first 2 and a half years of the COVID-19 pandemic, particularly among females. These findings support the need for accessible and intensive prevention efforts and mental health supports in this population.

Trends in Acute Care Use for Mental Health Conditions Among Youth During the COVID-19 Pandemic

Importance

Understanding how children's utilization of acute mental health care changed during the COVID-19 pandemic is critical for directing resources.

Objective

To examine youth acute mental health care use (emergency department [ED], boarding, and subsequent inpatient care) during the second year of the COVID-19 pandemic.

Design, Setting, and Participants

This cross-sectional analysis of national, deidentified commercial health insurance claims of youth mental health ED and hospital care took place between March 2019 and February 2022. Among 4.1 million commercial insurance enrollees aged 5 to 17 years, 17 614 and 16 815 youth had at least 1 mental health ED visit in the baseline year (March 2019-February 2020) and pandemic year 2 (March 2021-February 2022), respectively.

Exposure

The COVID-19 pandemic.

Main outcomes and measures

The relative change from baseline to pandemic year 2 was determined in (1) fraction of youth with 1 or more mental health ED visits; (2) percentage of mental health ED visits resulting in inpatient psychiatry admission; (3) mean length of inpatient psychiatric stay following ED visit; and (4) frequency of prolonged boarding (≥2 midnights) in the ED or a medical unit before admission to an inpatient psychiatric unit.

Results

Of 4.1 million enrollees, 51% were males and 41% were aged 13 to 17 years (vs 5-12 years) with 88 665 mental health ED visits. Comparing baseline to pandemic year 2, there was a 6.7% increase in youth with any mental health ED visits (95% CI, 4.7%-8.8%). Among adolescent females, there was a larger increase (22.1%; 95% CI, 19.2%-24.9%). The fraction of ED visits that resulted in a psychiatric admission increased by 8.4% (95% CI, 5.5%-11.2%). Mean length of inpatient psychiatric stay increased 3.8% (95% CI, 1.8%-5.7%). The fraction of episodes with prolonged boarding increased 76.4% (95% CI, 71.0%-81.0%).

Conclusions and relevance

Into the second year of the pandemic, mental health ED visits increased notably among adolescent females, and there was an increase in prolonged boarding of youth awaiting inpatient psychiatric care. Interventions are needed to increase inpatient child psychiatry capacity and reduce strain on the acute mental health care system.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.

Mental health emergency admissions in the paediatric emergency department

AIM

To evaluate the demographic characteristics, diagnoses and length of stay of mental health emergency attendance to the paediatric emergency department (ED), to determine the burdens these patients brought to the paediatric ED and to the national economy by examining hospital costs.

METHODS

This retrospective observational study was conducted in a tertiary hospital's paediatric ED in Turkey. Data were obtained from the electronic medical record system from January 2018 to January 2020.

RESULTS

A total of 142 admissions were included of whom 60% were female. The mean age was 15.2 ± 1.8 years, 50% of cases were suicide attempts and 19% were alcohol intoxications. The majority (85.9%) of patients were discharged from the emergency observation unit. Among the diagnostic groups, the mean age was higher in patients with a history of substance abuse. There was a female predominance among patients who were admitted due to suicide attempts. Among the diagnostic groups, the duration of hospital stay and cost of hospitalization were higher in patients who were followed up with a diagnosis of suicide attempt.

CONCLUSIONS

Mental health problems are frequent in the paediatric ED. We determined that the most common cause of attendance in paediatric emergencies was suicide attempts, and the length of hospital stay and hospital cost were higher in this diagnostic group. Although further research is necessary to determine national trends in paediatric mental health problems in the paediatric ED, screening strategies and early detection and interventions in primary healthcare may allow more effective care for childhood mental health problems.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure; challenges with timely access to a mental health professional; the nature of a busy ED environment; and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affect patient care and ED operations. Strategies to improve care for MBH emergencies, including systems-level coordination of care, are therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Prenatal Exposure to Gestational Diabetes Mellitus is Associated with Mental Health Outcomes and Physical Activity has a Modifying Role

Background

Studies suggest a link between prenatal gestational diabetes mellitus (GDM) exposure and poor mental health outcomes. We examined associations between prenatal GDM exposure and depressive and anxiety symptoms in children and assessed physical activity as a potential modifier of these associations.

Method

Seventy children (AgeM(SD): 12(2.0), 56% GDM, 59% female) and their parents completed surveys: Center for Epidemiological Studies Depression Scale for Children (CES-DC), State-Trait Anxiety Inventory for Children (STAIC), Child Behavior Checklist (CBCL), and 3-day physical activity recall (3DPAR). Associations between mental health measures with GDM exposure and interactions between GDM exposure and child moderate-to-vigorous physical activity (MVPA) were assessed using regression.

Results

GDM-exposed children had higher anxiety (p = 0.03) and internalizing symptoms (CBCL) (p = 0.04) than unexposed children. There was an interaction between GDM exposure and child MVPA on anxiety (p = 0.02), internalizing (p = 0.04) and externalizing symptoms (p = 0.004). In the low MVPA group, GDM exposed children had more depressive (p = 0.03), anxiety (p = 0.003), and internalizing symptoms (p = 0.03) than unexposed children. In the high MVPA group, there were no group differences except with externalizing symptoms (p = 0.04).

Conclusion

Prenatal GDM is associated with higher anxiety and internalizing symptoms in children. Child MVPA modified the relationship between GDM exposure and mental health outcomes suggesting that physical activity during childhood could mitigate the negative mental health outcomes associated with prenatal GDM exposure.

Pediatric Primary-Care Integrated Behavioral Health: A Framework for Reducing Inequities in Behavioral Health Care and Outcomes for Children

Nearly half of US children and adolescents will suffer a behavioral health (BH) disorder, with substantially higher rates among more disadvantaged children such as racial/ethnic minorities, LGBTQ + youth, and poor children. The current specialty pediatric BH workforce is inadequate to meet the need and the uneven distribution of specialists as well as other barriers to care, such as insurance coverage and systemic racism/bias, further exacerbate disparities in BH care and outcomes. Integrating BH care into the pediatric primary care medical home has the potential to expand access to BH care and reduce the disparities inherent in the current system.

Psychotropic Medication Use in United States Pediatric Emergency Department Visits

OBJECTIVE AND BACKGROUND

Little is known about pediatric psychotropic medication use in the emergency department (ED), despite a rise in mental and behavioral health visits. This study describes psychotropic medication use in a nationally representative sample of pediatric mental and behavioral health ED visits over a 14-year period.

METHODS

We conducted a cross-sectional analysis of pediatric (6-17 years) mental and behavioral health ED visits using the National Hospital Ambulatory Medical Care Survey, 2006-2019. We describe administration of psychotropic medications by medication type, diagnosis, and over time. Using multivariable survey-weighted logistic regression, we examine associations between medication administration and sociodemographics.

RESULTS

A psychotropic medication was administered in 11.4% of the estimated 11,792,860 pediatric mental and behavioral health ED visits in our sample. Benzodiazepines were administered most frequently (4.9% of visits). Visits with anxiety disorders had the highest frequency of psychotropic medication use (26.7%). Visits by Black non-Hispanic patients had a 60% decreased odds of medication administration compared to visits for White non-Hispanic patients. Visits with public compared to private insurance had a 3.5 times increased odds of psychotropic polypharmacy. The proportion of visits in which a psychotropic medication was administered did not change statistically over time.

CONCLUSIONS

A psychotropic medication was administered in 1 in 10 pediatric mental and behavioral health ED visits. Use differed by sociodemographics but did not change over time. As more youth seek mental and behavioral health care in the ED, we must better understand appropriate medication use to ensure quality and equitable care.

Peer victimization and developmental psychopathology in childhood and adolescence Italian psychiatric emergency unit. A single center retrospective observational study

Peer victimization is a public health concern that affects a significant proportion of children and adolescents. The study evaluated the prevalence of peer victimization among 440 subjects referred to Emergency Department for a psychiatric consultation and analyzed the association with psychopathological symptoms. Sample was divided into two categories (6-13 and 14-18 years old). Logistics regression analysis was performed. Peer victimized were reported in 16.3% of subjects; 27.7% were younger than13 years old and 72.3% were between 14-18 years old, representing the main targets for peer victimization.A significant association was found between being peer victimized and depressive disorder (OR=4.57) in subjects younger than 13 years old and, with post-traumatic stress disorder (PTSD)(OR=6.52) in subjects older than 13 years old. Furthermore, linkage between being peer victimized and obsessive-compulsive disorder (OCD)(OR=4.45) was noted. Increased frequency of repeated hospitalizations was also documented.This is the first Italian study about children and adolescent peer victimization in psychiatric setting, showing a significant higher risk for depressive disorder in subjects younger than 13 years old and PTSD and OCD in subjects older than 13 years old. Investigating experiences of peer victimization provides an early diagnosis and a more efficient treatment plans, guaranteeing an improved clinical outcome.

Peer Connectedness and Social Technology Use During COVID-19 Lockdown

During the COVID-19 pandemic lockdown, adolescents relied on social technology for social connection. Although some research suggests small, negative effects for quantity of social technology use on adolescent mental health, the quality of the interaction may be more important. We conducted a daily diary study in a risk-enriched sample of girls under COVID-19 lockdown to investigate associations between daily social technology use, peer closeness, and emotional health. For 10 days, 93 girls (ages 12-17) completed an online daily diary (88% compliance) assessing positive affect, symptoms of anxiety and depression, peer closeness, and daily time texting, video-chatting and using social media. Multilevel fixed effects models with Bayesian estimation were conducted. At the within-person level, more daily time texting or video-chatting with peers was associated with feeling closer to peers that day, which was associated with more positive affect and fewer depressive and anxiety symptoms that day. At the between-person level, more time video-chatting with peers across the 10 days was indirectly associated with higher average positive affect during lockdown and less depression seven-months later, via higher mean closeness with peers. Social media use was not associated with emotional health at the within- or between-person levels. Messaging and video-chatting technologies are important tools for maintaining peer connectedness during social isolation, with beneficial effects on emotional health.

The aftermath of the COVID-19 pandemic on pediatric mental health: A pediatric emergency department's perspective

BACKGROUND

Pediatric mental health visits in the United States has become a public health crisis. Pediatric emergency departments (PED) encounter these patients during mental health emergencies. The COVID-19 pandemic disrupted the social environment of pediatric patients which potentially lead to new and worsening mental health issues. This study examined the proportion of mental health visits to PED around the first wave of the COVID-19 pandemic.

METHODS

This retrospective cohort study assessed the proportion of mental health visits at a urban, PED between September 2019 to February 2022. Inclusion criteria were subjects aged 6 to 18 years with a holding order assigned, and one of identified mental health International Classification of Disease, Tenth Division (ICD-10) codes: F01-F99, T14.19, R45, R46.89. Proportion of mental health visits were compared in 6-month periods with the first 6-months representing the pre-COVID-19 period. Secondary analysis compared demographic information and ICD-10 codes.

RESULTS

A total of 1036 charts were studied: 126 charts from 2019 to 2020, 512 from 2020 to 2021, and 398 from 2021 to 2022. The proportion of mental health visits from September 2019 to February 2020 was 1.4%, and for the following 6-month periods, the proportion of mental health visits was 1.2%, 7.5%, 4.9%, and 5.7%. There was a statistically significant difference (p < 0.001) demonstrating a higher proportion of mental health visits after the start of the COVID-19 pandemic. Secondary analysis demonstrated statistically significant difference in both median age (p < 0.001) and median length of hospitalization (p < 0.001).

CONCLUSION

This study demonstrated a significant increase in pediatric mental health visits following the start of the COVID-19 pandemic. We believe further investigation into the needs and management during acute surges will improve the care we provide to this vulnerable population.

Changes in Depression and Anxiety Among Children and Adolescents From Before to During the COVID-19 Pandemic: A Systematic Review and Meta-analysis

Importance

There is a growing body of high-quality cohort-based research that has examined changes in child and adolescent mental health during the COVID-19 pandemic vs before the pandemic. Some studies have found that child and adolescent depression and anxiety symptoms have increased, while others have found these symptoms to have remained stable or decreased.

Objective

To synthesize the available longitudinal cohort-based research evidence to estimate the direction and magnitude of changes in depression and anxiety symptoms in children and adolescents assessed before and during the pandemic.

Data Sources

Medline, Embase, and PsycInfo were searched for studies published between January 1, 2020, and May 17, 2022.

Study Selection

Included studies reported on depression and/or anxiety symptoms, had cohort data comparing prepandemic to pandemic estimates, included a sample of children and/or adolescents younger than 19 years, and were published in English in a peer-reviewed journal.

Data Extraction and Synthesis

In total, 53 longitudinal cohort studies from 12 countries with 87 study estimates representing 40 807 children and adolescents were included.

Main Outcomes and Measures

Standardized mean changes (SMC) in depression and anxiety symptoms from before to during the pandemic.

Results

The analysis included 40 807 children and adolescents represented in pre-COVID-19 studies and 33 682 represented in during-COVID-19 studies. There was good evidence of an increase in depression symptoms (SMC, 0.26; 95% CI, 0.19 to 0.33). Changes in depression symptoms were most conclusive for study estimates among female individuals (SMC, 0.32; 95% CI, 0.21 to 0.42), study estimates with mid to high income (SMC, 0.35; 95% CI, 0.07 to 0.63), and study estimates sourced from North America (SMC, 0.25; 95% CI, 0.15 to 0.36) and Europe (SMC, 0.35; 95% CI, 0.17 to 0.53). There was strong evidence that anxiety symptoms increased slightly during the pandemic (SMC, 0.10; 95% CI, 0.04 to 0.16), and there was some evidence of an increase in study estimates with mid to high income.

Conclusions

This systematic review and meta-analysis of longitudinal studies including children and adolescents found an increase in depression symptoms during the COVID-19 pandemic, particularly among female individuals and those from relatively higher-income backgrounds.

Redefining the Role of Public Health Professionals Serving Black Youths Seeking Mental Health Care: Implications for Training and Mentoring

Attrition rates for Black youths in mental health treatment settings are high, and the extant literature suggests this may be because treatment is not meeting their unique needs. Public health professionals, defined here as all individuals who work to increase the well-being of youths, can play a major role in changing these outcomes. The purpose of this article is to suggest a broader scope of practice, or a redefined role, for public health professionals who work with Black youths seeking outpatient mental health care and to explicate ways in which training and mentoring can help accomplish this goal. Bolstered by a socioecological conceptual model, we suggest 3 standards of practice that we believe must be satisfied to meet the requirement for this redefined public health professional role: using a sociocultural framework, exercising flexibility in one's assigned role, and understanding and incorporating culturally specific strengths and protective factors into care. (Am J Public Health. 2023;113(S2):S140-S148. https://doi.org/10.2105/AJPH.2022.307194).

Bringing Covid to College: Incoming First-Year College Students' Making Meaning of the Pandemic

As time passes from the start of the COVID-19 pandemic in 2020, new cohorts of emerging adults transition to college, carrying with them experiences and effects of the pandemic on their lives and development. This study uses semi-structured interviews and reflexive thematic analysis to investigate how a cohort of 36 young people made narrative meaning of the pandemic in relation to their identities. Data were collected at the beginning of their first year at college and focused on their experiences of the pandemic, its impact on their lives, and the lessons they took away from it. Findings demonstrate that even amid deep and varied challenges, young people coped in nuanced ways and some built narratives of personal growth, development, new social identities, and maturing values. The study contributes to greater depth in understanding the impacts of the pandemic on young people as they develop into emerging adults.

Mixed Signals in Child and Adolescent Mental Health and Well-Being Indicators in the United States: A Call for Improvements to Population Health Monitoring

Policy Points Social indicators of young peoples' conditions and circumstances, such as high school graduation, food insecurity, and smoking, are improving even as subjective indicators of mental health and well-being have been worsening. This divergence suggests policies targeting the social indicators may not have improved overall mental health and well-being. There are several plausible reasons for this seeming contradiction. Available data suggest the culpability of one or several common exposures poorly captured by existing social indicators. Resolving this disconnect requires significant investments in population-level data systems to support a more holistic, child-centric, and up-to-date understanding of young people's lives.

National Trends in Mental Health-Related Emergency Department Visits Among Youth, 2011-2020

Importance

There has been increasing concern about the burden of mental health problems among youth, especially since the COVID-19 pandemic. Trends in mental health-related emergency department (ED) visits are an important indicator of unmet outpatient mental health needs.

Objective

To estimate annual trends in mental health-related ED visits among US children, adolescents, and young adults between 2011 and 2020.

Design, Setting, and Participants

Data from 2011 to 2020 in the National Hospital Ambulatory Medical Care Survey, an annual cross-sectional national probability sample survey of EDs, was used to examine mental health-related visits for youths aged 6 to 24 years (unweighted = 49 515).

Main Outcomes and Measures

Mental health-related ED visits included visits associated with psychiatric or substance use disorders and were identified by International Classification of Diseases-Ninth Revision, Clinical Modification (ICD-9-CM; 2011-2015) and ICD-10-CM (2016-2020) discharge diagnosis codes or by reason-for-visit (RFV) codes. We estimated the annual proportion of mental health-related pediatric ED visits from 2011 to 2020. Subgroup analyses were performed by demographics and broad psychiatric diagnoses. Multivariable-adjusted logistic regression analyses estimated factors independently associated with mental health-related ED visits controlling for period effects.

Results

From 2011 to 2020, the weighted number of pediatric mental health-related visits increased from 4.8 million (7.7% of all pediatric ED visits) to 7.5 million (13.1% of all ED visits) with an average annual percent change of 8.0% (95% CI, 6.1%-10.1%; P < .001). Significant linearly increasing trends were seen among children, adolescents, and young adults, with the greatest increase among adolescents and across sex and race and ethnicity. While all types of mental health-related visits significantly increased, suicide-related visits demonstrated the greatest increase from 0.9% to 4.2% of all pediatric ED visits (average annual percent change, 23.1% [95% CI, 19.0%-27.5%]; P < .001).

Conclusions and Relevance

Over the last 10 years, the proportion of pediatric ED visits for mental health reasons has approximately doubled, including a 5-fold increase in suicide-related visits. These findings underscore an urgent need to improve crisis and emergency mental health service capacity for young people, especially for children experiencing suicidal symptoms.

Premature mortality in young people accessing early intervention youth mental healthcare: data-linkage cohort study

BACKGROUND

Understanding premature mortality risk from suicide and other causes in youth mental health cohorts is essential for delivering effective clinical interventions and secondary prevention strategies.

AIMS

To establish premature mortality risk in young people accessing early intervention mental health services and identify predictors of mortality.

METHOD

State-wide data registers of emergency departments, hospital admissions and mortality were linked to the Brain and Mind Research Register, a longitudinal cohort of 7081 young people accessing early intervention care, between 2008 and 2020. Outcomes were mortality rates and age-standardised mortality ratios (SMR). Cox regression was used to identify predictors of all-cause mortality and deaths due to suicide or accident.

RESULTS

There were 60 deaths (male 63.3%) during the study period, 25 (42%) due to suicide, 19 (32%) from accident or injury and eight (13.3%) where cause was under investigation. All-cause SMR was 2.0 (95% CI 1.6-2.6) but higher for males (5.3, 95% CI 3.8-7.0). The mortality rate from suicide and accidental deaths was 101.56 per 100 000 person-years. Poisoning, whether intentional or accidental, was the single greatest primary cause of death (26.7%). Prior emergency department presentation for poisoning (hazard ratio (HR) 4.40, 95% CI 2.13-9.09) and psychiatric admission (HR 4.01, 95% CI 1.81-8.88) were the strongest predictors of mortality.

CONCLUSION

Premature mortality in young people accessing early intervention mental health services is greatly increased relative to population. Prior health service use and method of self-harm are useful predictors of future mortality. Enhanced care pathways following emergency department presentations should not be limited to those reporting suicidal ideation or intent.