Pediatric Mental Health Visits to ED Soar

Nancy A. Melville

August 17, 2015

Pediatric mental health–related visits to a large British Columbia children's hospital emergency department (ED) rose significantly during the past decade, following similar trends reported in the United States, new research shows.

The trend underscores the increased utilization of the ED as a safety net when mental heath services are not otherwise accessible, as well as shortcomings of EDs in stemming this increase, according to the authors.

"Repeated use of the ED for psychiatric needs points to the failure of EDs in establishing long-lasting and stable mental health services to prevent recurrent crises, particularly in the face of the chronic nature of mental health diseases and their associated lack of absolute and effective treatments," Elisa Mapelli, MD, of the Division of Emergency Medicine, Department of Pediatrics, at BC Children's Hospital, in Vancouver, Canada, and colleagues write.

"On the other hand, the trend in decreasing acuity at triage would suggest decreased resilience in youth and their social support network in the face of present social stressors."

Their findings were published online August 6 in the Journal of Pediatrics.

For the retrospective study, the authors evaluated pediatric ED hospital visits between 2002 and 2012 involving a chief complaint or discharge diagnosis related to mental health.

During the course of the study, the total mental health visits to the pediatric ED increased by 47%, compared with an increase of 9% in total visits during the same period.

Overall, 1.9% of the total of 431,797 pediatric ED visits were mental health visits. The proportion of mental health visits increased from 1.56% in 2002 to 2.26% in 2012. The mean age at presentation was 13.2, and 52% of patients were girls.

About one third of mental health visits (31% to 37% yearly) were return visits, with approximately 12% occurring within 30 days of the index visit.

Although the proportion of mental health visits that were triaged to a high-acuity level decreased, the proportion triaged to mid-acuity level increased.

The absolute number of mental health visits resulting in admissions from the pediatric ED increased by 53.7% during the study period; however, the proportion decreased from 42.9% in 2002 to 35.5% in 2012 when accounting for the increase in total mental health presentations (P = .001).

"This is consistent with the trends observed in reduced acuity of mental health visits as defined by the triaging score," the authors write.

The mean length of stay, available for the years 2003 through 2012, was significantly longer for psychiatric patients compared with non–mental health stays (279 minutes vs 183 minutes; P < .001)

Other notable changes during the decade included a shift in the distribution of mental health diagnoses. In the earlier years, the most common mental health diagnosis was substance-related disorder, accounting for approximately one fifth of mental health visits. By 2012, the top two mental health diagnoses were mood and anxiety disorders and suicidal ideation.

"Our findings are in keeping with previously reported trends in North America indicating an increasing frequency of visits to the ED for mental health–related complaints and their consistently longer length of stay than overall ED length of stay," the authors write, citing several studies.

They note that although the numbers continue to rise, EDs still fall short in being able to adequately address many cases, for various reasons.

"Despite increases in the number of beds available over the last decade, this has not favorably affected our pediatric ED overall length of stay," they write.

Factors shown in surveys to consistently challenge ED management of mental health patients include insufficient psychiatric expertise and resources, long wait times for specialized psychiatric consults, and inadequate access to community resources.

The challenges are only exacerbated by the increase in nonemergent mental health visits, the authors conclude.

"Overall, mental health–related visits represent a significant and growing burden on the ED at our tertiary care pediatric center," they say.

"This is primarily related to a dramatic increase in the volume of non-emergent presentations. Future research is needed to address the reasons for these trends as well as to evaluate novel approaches to streamline the management of mental health–related ED visits."

The authors report no relevant financial relationships.

J Pediatr. Published online August 6, 2015. Abstract

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