Follow-up After Pediatric Mental Health Emergency Visits

Children in Mental Health Crisis: Pediatric Primary Care Providers' Role in Bridging Treatment Following Higher Levels of Care

The current study examines the role of pediatric PCPs in bridging treatment for youth who have experienced mental health crises and the characteristics of these patients for whom PCPs sought psychiatric consultation and referral support from a child psychiatry access program, Maryland Behavioral Health Integration in Pediatric Primary Care. Psychiatric consultation and referral calls between 2012 and 2021 were included if a) the patient was recently seen in a higher level of care and b) the PCP was bridging treatment following the patient's discharge; 208 calls met criteria. The most common mental health concerns included depressed mood, suicidal thoughts/gestures, and anxiety. Acute concerns of aggression, suicide attempts, and hallucinations were also reported. Over half of the patients had two or more mental health diagnoses. At the time of the call, only one quarter of these patients had outpatient therapy services while about half were receiving medication treatment. Most of these patients were discharged from the higher level of care without a care plan. Pediatric PCPs are managing their patients' complex mental health concerns following receipt of higher levels of care. Improvements in collaboration and care coordination between pediatric PCPs and emergency department providers are needed.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study

BACKGROUND

The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends.

METHODS

We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics.

RESULTS

We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05).

CONCLUSIONS

During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Trends in youth acute care hospital visits for anxiety and depression in Illinois

PURPOSE

This study analyzes the trajectory of youth emergency room or inpatient hospital visits for depression or anxiety in Illinois before and during the COVID-19 pandemic.

METHODS

We analyze emergency department (ED) outpatient visits, direct admissions, and ED admissions by patients ages 5-19 years coded for depression or anxiety disorders from 2016 through June 2023 with data from the Illinois Hospital Association COMPdata database. We analyze changes in visit rates by patient sociodemographic and clinical characteristics, hospital volume and type, and census zip code measures of poverty and social vulnerability. Interrupted times series analysis was used to test the significance of differences in level and trends between 51 pre-pandemic months and 39 during-pandemic months.

RESULTS

There were 250,648 visits to 232 Illinois hospitals. After large immediate pandemic decreases there was an estimated -12.0 per-month (p = 0.003, 95% CI -19.8-4.1) decrease in male visits and a - 13.1 (p = 0.07, 95% CI -27 -1) per-month decrease in female visits in the during-pandemic relative to the pre-pandemic period. The reduction was greatest for outpatient ED visits, for males, for age 5-9 and 15-19 years patients, for smaller community hospitals, and for patients from the poorest and most vulnerable zip code areas.

CONCLUSIONS

llinois youth depression and anxiety hospital visit rates declined significantly after the pandemic shutdown and remained stable into 2023 at levels below 2016-2019 rates. Further progress will require both clinical innovations and effective prevention grounded in a better understanding of the cultural roots of youth mental health.

Impact of COVID-19 on Acute Care Hospitalizations for Suicidality

BACKGROUND AND OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic contributed to the public health crisis for pediatric mental health. We characterized our local patient population presenting with suicidality or suicide attempts before and after the pandemic by examining: 1. frequencies of hospitalizations for suicidality to determine whether they differed by age, legal sex, race and ethnicity, or socioeconomic status; 2. average length of stay and discharge disposition; 3. 7-, 30-, and 365-day reutilization rates; and 4. admission trends during COVID-19 surges.

METHODS

Retrospective data between March 2018 and March 2022 was analyzed, including patients ages 10 to 17 years hospitalized for either suicidality or a suicide attempt at 1 freestanding tertiary care pediatric medical hospital in the Midwest. Encounters were divided into 2 categories on the basis of the COVID-19 pandemic: "Prelockdown" (March 1, 2018-March 12, 2020) and "postlockdown" (March 13, 2020-March 31, 2022). Patients were limited to 1 presentation pre- and postlockdown. We analyzed frequencies using means and SDs, categorical data using χ2 and Fisher's exact tests, and continuous data with t tests.

RESULTS

A total of 1017 encounters were included, stratified into pre- and postlockdown groups for analysis (909 encounters, 889 unique patients). There was a significant difference in 365-day reutilization pre- and postlockdown when analyzing re-presentation to the emergency department (P = .025) and hospital readmission (P = .006). Admissions incrementally increased after the COVID-19 alpha variants in September 2020 and again after the delta variant in August 2021.

CONCLUSIONS

The COVID-19 pandemic further intensified the already critical issue of pediatric mental health, demonstrating increased reutilization in the year after their initial presentation and an increase in admissions after the alpha variant.

Evidence-based brief interventions targeting acute mental health presentations for children and adolescents: systematic review

BACKGROUND

Brief intervention services provide rapid, mobile and flexible short-term delivery of interventions to resolve mental health crises. These interventions may provide an alternative pathway to the emergency department or in-patient psychiatric services for children and young people (CYP), presenting with an acute mental health condition.

AIMS

To synthesise evidence on the effectiveness of brief interventions in improving mental health outcomes for CYP (0-17 years) presenting with an acute mental health condition.

METHOD

A systematic literature search was conducted, and the studies' methodological quality was assessed. Five databases were searched for peer-reviewed articles between January 2000 and September 2022.

RESULTS

We synthesised 30 articles on the effectiveness of brief interventions in the form of (a) crisis intervention, (b) integrated services, (c) group therapies, (d) individualised therapy, (e) parent-child dyadic therapy, (f) general services, (g) pharmacotherapy, (h) assessment services, (i) safety and risk planning and (j) in-hospital treatment, to improve outcomes for CYP with an acute mental health condition. Among included studies, one study was rated as providing a high level of evidence based on the National Health and Medical Research Council levels of evidence hierarchy scale, which was a crisis intervention showing a reduction in length of stay and return emergency department visits. Other studies, of moderate-quality evidence, described multimodal brief interventions that suggested beneficial effects.

CONCLUSIONS

This review provides evidence to substantiate the benefits of brief interventions, in different settings, to reduce the burden of in-patient hospital and readmission rates to the emergency department.

Management of youth with suicidal ideation: Challenges and best practices for emergency departments

Suicide is a leading cause of death among youth, and emergency departments (EDs) play an important role in caring for youth with suicidality. Shortages in outpatient and inpatient mental and behavioral health capacity combined with a surge in ED visits for youth with suicidal ideation (SI) and self-harm challenge many EDs in the United States. This review highlights currently identified best practices that all EDs can implement in suicide screening, assessment of youth with self-harm and SI, care for patients awaiting inpatient psychiatric care, and discharge planning for youth determined not to require inpatient treatment. We will also highlight several controversies and challenges in implementation of these best practices in the ED. An enhanced continuum of care model recommended for youth with mental and behavioral health crises utilizes crisis lines, mobile crisis units, crisis receiving and stabilization units, and also maximizes interventions in home- and community-based settings. However, while local systems work to enhance continuum capacity, EDs remain a critical part of crisis care. Currently, EDs face barriers to providing optimal treatment for youth in crisis due to inadequate resources including the ability to obtain emergent mental health consultations via on-site professionals, telepsychiatry, and ED transfer agreements. To reduce ED utilization and better facilitate safe dispositions from EDs, the expansion of community- and home-based services, pediatric-receiving crisis stabilization units, inpatient psychiatric services, among other innovative solutions, is necessary.

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.

Projecting the Future Pediatric Subspecialty Workforce: Summary and Recommendations

This article summarizes the findings of a Pediatrics supplement addressing the United States workforce for 15 pediatric subspecialties. It includes results from a microsimulation model projecting supply through 2040; growth is forecasted to be uneven across the subspecialties with worsening geographic maldistribution. Although each subspecialty has unique characteristics, commonalities include (1) the changing demographics and healthcare needs of children, including mental health; (2) poor outcomes for children experiencing adverse social drivers of health, including racism; and (3) dependence on other subspecialties. Common healthcare delivery challenges include (1) physician shortages for some subspecialties; (2) misalignment between locations of training programs and subspecialists and areas of projected child population growth; (3) tension between increasing subsubspecialization to address rare diseases and general subspecialty care; (4) the need to expand clinical reach through collaboration with other physicians and advanced practice providers; (5) the lack of parity between Medicare, which funds much of adult care, and Medicaid, which funds over half of pediatric subspecialty care; and (6) low compensation of pediatric subspecialists compared with adult subspecialists. Overall, subspecialists identified the lack of a central authority to monitor and inform child healthcare provided by pediatric subspecialists as a challenge. Future research on the pediatric subspecialty workforce and the children it serves will be necessary to ensure these children's needs are met. Together, these articles provide overarching and subspecialty-specific recommendations to improve training, recruitment, and retention of a diverse workforce, implement innovative models of care, drive policy changes, and advise future research.

Children and Adolescents With Suicidal Ideation and the Emergency Department

This Viewpoint discusses the need for formal training in suicide prevention for frontline emergency clinicians and staff, including standardized screening practices, assessment and targeted interventions, and increased connection to outpatient mental health services after discharge from the emergency department.

Timing of Mental Health Service Use After a Pediatric Firearm Injury

OBJECTIVES

To examine how timing of the first outpatient mental health (MH) visit after a pediatric firearm injury varies by sociodemographic and clinical characteristics.

METHODS

We retrospectively studied children aged 5 to 17 years with a nonfatal firearm injury from 2010 to 2018 using the IBM Watson MarketScan Medicaid database. Logistic regression estimated the odds of MH service use in the 6 months after injury, adjusted for sociodemographic and clinical characteristics. Cox proportional hazard models, stratified by previous MH service use, evaluated variation in timing of the first outpatient MH visit by sociodemographic and clinical characteristics.

RESULTS

After a firearm injury, 958 of 2613 (36.7%) children used MH services within 6 months; of these, 378 of 958 (39.5%) had no previous MH service use. The adjusted odds of MH service use after injury were higher among children with previous MH service use (adjusted odds ratio, 10.41; 95% confidence interval [CI], 8.45-12.82) and among non-Hispanic white compared with non-Hispanic Black children (adjusted odds ratio, 1.29; 95% CI, 1.02-1.63). The first outpatient MH visit after injury occurred sooner among children with previous MH service use (adjusted hazard ratio, 6.32; 95% CI, 5.45-7.32). For children without previous MH service use, the first MH outpatient visit occurred sooner among children with an MH diagnosis made during the injury encounter (adjusted hazard ratio, 2.72; 95% CI, 2.04-3.65).

CONCLUSIONS

More than 3 in 5 children do not receive MH services after firearm injury. Previous engagement with MH services and new detection of MH diagnoses during firearm injury encounters may facilitate timelier connection to MH services after injury.