Mental Health Crises in Children, Youth: New Data

Pam Harrison

June 02, 2017

More than half of children and youth who present to the emergency department (ED) with a mental health problem have not received any previous mental health treatment by a specialist or primary care clinician, new research shows.

"Emergency services are important for managing acute mental health crises, but for most mental health disorders, primary care would be the most appropriate venue for treatment and referral to specialized services," Astrid Guttmann, MD, senior author on the study and chief science officer at the Institute for Clinical Evaluative Sciences in Toronto, Canada, said in a statement.

"But some of the barriers to accessing that care may be attributed to family issues, and so there are definitely two layers to this. It's not simply an access issue," Dr Guttmann, who is also senior associate scientist at the Hospital for Sick Children, told Medscape Medical News.

The study was published in the June issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

No Primary Care Provider

The study included 118,851 youth living in Ontario, Canada, who had visited the ED for the first time for a mental health problem between 2010 and 2014.

All mental health diagnoses were included in the analysis, and a range of hospitals within a universal access healthcare system was involved.

Of first-time children and youth visiting the ED for mental health problems, 14% were hospitalized, and 40 died in the ED, the investigators state.

The most common reason for the ED visit was related to substance abuse, at 26.6% of all visits, followed by anxiety, at 20.4%; mood or affective disorders, at 18.2%; and acute stress disorder, at 14.4% of visits.

Few children and youth were hospitalized for either substance abuse or anxiety, the researchers note.

In contrast, more than 70% of youth who had symptoms of schizophrenia, delusional disorders, or psychotic disorders were admitted following their visit to the ED.

"In the 2 years preceding first contact, youth had an average of 4.2 primary care visits compared to 10.4 visits in those with prior MH [mental health] care," investigators write.

Indeed, almost 31% of youth who had previously consulted a physician about mental health problems had paid one or more visits to a psychiatrist, they add.

Further analyses revealed identifiable risk factors that made first-contact ED visits for mental health disorders more likely.

Specifically, immigrants and refugees, those living in poor neighborhoods, and those living in rural regions were less likely to receive outpatient care before making their first visit to the ED for mental health care.

The strongest predictor of children and youth having first contact with an ED for mental health disorders was not having a usual provider of primary care (UPC), which upped that risk by 76% and 78%, depending on the age group, compared to children and youth who had a general or family practitioner.

In contrast, youth whose primary care physician saw more patients with mental health problems and who was not part of the fee-for-service system were less likely to make first contact with an ED for a mental health problem, because capitation-based primary care models require such practices to have after-hours access to primary care.

Table. Adjusted Risk Ratios of No Prior Outpatient Care for Mental Health ED Visits

  Age 10 - 17 Years Age 18 - 24 Years
Rural residence 1.15 1.17
Neighborhood income (relative to those with the highest income) 1.03 1.06
Immigration status (relative to nonimmigrant),
nonrefugee immigrant/refugee immigrant
1.16/1.28 1.08/1.13
UPC (relative to GP/FP model),
GP/FP fee-for-service
1.19 1.08
No GP/FP 1.78 1.76

No Access

More than 75% of visits to the ED made by children and youth occurred after 4:00 pm on weekends or holidays, a finding that suggests that a lack of access to primary care may contribute to the frequency with which children and youth pay their first visit to an ED for treatment of mental health problems.

However, it is not only access to primary care but also the timeliness of that access that is probably contributing to the problem. "We know that the majority of Ontarians have a primary care provider — over 96% of the population does — but having a provider and being able to get in in a timely way are two different things," Dr Guttmann explained.

Among countries in the Organisation for Economic Co-operation and Development, Canada in general compares well on measures such as rapid access to a medical appointment, she added.

The fact that the majority of these first-contact visits happened after normal office hours testifies to the fact that acute crises often arise after office hours and need to be dealt with in EDs, which are open at all hours.

The other issue is that accessing the ED for the first time for mental health problems may be related to the stigma surrounding mental health problems.

"Some of the families or patients themselves may be unwilling to seek medical care for mental health problems, so they wait until the problem gets so bad that they land up in the ED," Dr Guttmann said.

"So practices based in neighborhoods where there are higher socioeconomic risks need to ensure that they are more attuned to the various barriers people have to seeking care for mental health problems," she indicated.

Whatever the main drivers are behind the high proportion of children and youth with a mental health problem who present in the ED for the first time, it is clear that ED physicians need to devote more time to follow-up care for these patients on discharge.

"That's not easy, because many of these patients are showing up after hours, when you can't call their physician and make sure that they will be following the patient up," Dr Guttmann admitted.

"But I do think that the follow-up piece is really important," she added.

"And in addition, ED physicians need to explore why it is that these patients are waiting until they are so sick that they have to visit an ED for an acute visit, and if it's not that acute, why it is that patients didn't seek care in a venue that is more appropriate for some of these problems," she said.

EDs Best for Acute Problems

Commenting on the findings for Medscape Medical News, Tom Sugarman, MD, past president of the California chapter of the American College of Emergency Physicians and currently senior director of government affairs for CEP America, Emeryville, California, said that EDs are best suited for treating acute, unexpected problems.

"We are specialists in diagnosing, stabilizing, and arranging follow-up for acute medical conditions. If the patient or the family recognizes or suspects a developing mental health problem, then they are best serviced by a mental health professional in a quiet, less stimulating environment, where there is less time pressure and adequate resources to develop a long-term plan of care, than in an ED," he said.

On the other hand, Dr Sugarman believes that in cases in which an acute psychiatric emergency is suspected, the ED is the ideal place for evaluation, because emergency physicians can rule out any underlying medical cause of the crisis, stabilize the patient, and refer for further care.

"The challenge in most US EDs is the last step: referral," Dr Sugarman acknowledged.

"Finding appropriate and timely referrals for mental health conditions can take days — occasionally weeks — especially for children, and this leads to boarding the ED," he observed.

"The constant activity, lights, movement, and alarms that exist in EDs are simply the wrong environment for a mental health patient in crisis," he added.

"To the extent that early and ongoing continuing care by a mental health professional can prevent emergencies from developing, better access to mental health care will decrease the number of patients requiring emergency psychiatric care. An ounce of prevention is better than a pound of cure."

Dr Guttmann and Dr Sugarman have disclosed no relevant financial relationships.

J Am Acad Child Adolesc Psychiatry. 2017;56:475-482. Full text

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