Health-related Emergency Department Research Articles

Electronic Health Record Phenotyping of Pediatric Suicide-Related Emergency Department Visits

Suicide is a leading cause of death among young people. Accurate detection of self-injurious thoughts and behaviors (SITB) underpins equity in youth suicide prevention. To compare methods of detecting SITB using structured electronic health information and measure algorithmic performance across demographics. This cross-sectional study used medical records among youths aged 6 to 17 years with at least 1 mental health-related emergency department (ED) visit in 2017 to 2019 to an academic health system in Southern California serving 787 000 unique individuals each year. Analyses were conducted between January and September 2023. Multiexpert electronic health record review ascertained the presence of SITB using the Columbia Classification Algorithm of Suicide Assessment. Random forest classifiers with nested cross-validation were developed using (1) International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for nonfatal suicide attempt and self-harm and chief concern and (2) all available structured data, including diagnoses, medications, and laboratory tests. Detection performance was assessed overall and stratified by age group, sex, and race and ethnicity. The sample comprised 2702 unique youths with an MH-related ED visit (1384 youths who identified as female [51.2%]; 131 Asian [4.8%], 266 Black [9.8%], 719 Hispanic [26.6%], 1319 White [48.8%], and 233 other race [8.6%]; median [IQR] age, 14 [12-16] years), including 898 children and 1804 adolescents. Approximately half of visits were related to SITB (1286 visits [47.6%]). Sensitivity of SITB detection using only codes and chief concern varied by age group and increased until age 15 years (6-9 years: 59.3% [95% CI, 48.5%-69.5%]; 10-12 years: 69.0% [95% CI, 63.8%-73.9%]; 13-15 years: 88.4% [95% CI, 85.1%-91.2%]; 16-17 years: 83.1% [95% CI, 79.1%-86.6%]), while specificity remained constant. The area under the receiver operating characteristic curve (AUROC) was lower among preadolescents (0.841 [95% CI, 0.815-0.867]) and male (0.869 [95% CI, 0.848-0.890]), Black (0.859 [95% CI, 0.813-0.905]), and Hispanic (0.861 [95% CI, 0.831-0.891]) youths compared with adolescents (0.925 [95% CI, 0.912-0.938]), female youths (0.923 [95% CI, 0.909-0.937]), and youths of other races and ethnicities (eg, White: 0.901 [95% CI, 0.884-0.918]). Augmented classification (ie, using all available structured data) outperformed classification with codes and chief concern alone (AUROC, 0.975 [95% CI, 0.968-0.980] vs 0.894 [95% CI, 0.882-0.905]; P < .001). In this study, diagnostic codes and chief concern underestimated SITB prevalence, particularly among minoritized youths. These results suggest that priority on algorithmic fairness in suicide prevention strategies must extend to accurate detection of youths with suicide-related emergencies.

The impact of recreational cannabis legalization on cannabis-related acute care events among adults with schizophrenia.

Patients with schizophrenia have a higher risk of cannabis use disorder and may be uniquely affected by the legalization of recreational cannabis. This study examined whether cannabis legalization led to changes in acute care utilization among patients with schizophrenia. Using linked health administrative data, we included adult patients with schizophrenia in Ontario from October 2015 to May 2021 (n = 121,061). We examined the differences in cannabis, psychosis, and mental health-related emergency department (ED) visits over three periods: pre-legalization, legalization of flowers and herbs (phase 1), and legalization of edibles, extracts, and topicals (phase 2) using interrupted time-series methods. Our study found that phase 1 was associated with decreases in cannabis-related, mental health-related, and cannabis + psychosis-related ED visits among the patients with schizophrenia. Notably, an immediate 25.8% (95% CI 13.8-37.6%) decrease in cannabis-related ED visits was observed in men, and an immediate 18.5% decrease in mental health-related ED visits (95% CI 6.0-31.2%) in women. These decreases were also shown in the comparative ITS models, demonstrating that the changes observed were distinct from trends in the general population. However, phase 2 was not associated with any significant changes. Despite higher baseline rates of acute care utilization among patients with schizophrenia, cannabis legalization was associated with significant reductions, particularly during phase 1. Our findings suggest that regulatory measures accompanying legalization could enhance the quality and safety of cannabis products, potentially leading to fewer adverse health outcomes in vulnerable patient populations. Further research is needed to optimize healthcare responses for this vulnerable population.

Association between preferred language and use of mental health services among home care recipients with schizophrenia spectrum and other psychotic disorders: A retrospective cohort study in Ontario, Canada, 2010 to 2015

Language is an important demographic factor that may impact patients’ interactions with the healthcare system. This may become more apparent for individuals with a mental illness. The objective of this study was to evaluate whether individual language was associated with the use of inpatient and outpatient psychiatric services among home care recipients with schizophrenia spectrum and other psychotic disorders. We conducted a population-based retrospective cohort study using health administrative data. The study population included all individuals aged 18–105 with schizophrenia spectrum and other psychotic disorders, identified via a validated algorithm, who were receiving home care in Ontario, Canada between January 1, 2010 and December 31, 2015. Home care data was used to identify patients’ primary language, categorized as Anglophone, Francophone, or Allophone. Mental health service use was evaluated over a one-year period following their first home care assessment in the study period and included the rate of outpatient psychiatrist visits and mental health-related emergency department (ED) visits and hospitalizations. Multivariable regression evaluated the association between primary language and mental health service use. The cohort consisted of 9,436 patients (85.8% Anglophones, 3.3% Francophones, 11.0% Allophones). Mental health service use was low among all linguistic groups during the one-year study period, with 53.4% with no outpatient psychiatrist visits and 83.3% and 83.0% with no mental health-related hospitalizations or ED visits, respectively. Francophones had a higher rate of mental health-related hospitalizations compared to Anglophones (adjusted relative risk = 1.36, 95% confidence interval 1.02–1.80), with no differences in hospitalization rates between Allophones and Anglophones. Language was not associated with the rate of outpatient psychiatrist visits or mental health-related ED visits. Mental health service use among homecare patients with schizophrenia spectrum and other psychotic disorders was low. While Francophones had a higher hospitalization rate than Anglophones, language was otherwise not associated with mental health service use.

Changes in Service Use After Participation in an Intensive Outpatient Program Among Adults With Posttraumatic Stress Disorder.

Intensive outpatient programs (IOPs) have been shown to reduce posttraumatic stress disorder (PTSD) symptoms in veteran populations. The aim of this study was to examine the association between IOP participation and inpatient psychiatric and mental health-related emergency department (ED) encounters among patients with PTSD. This is a retrospective cohort study among 258 adults with PTSD who participated in the IOP at Kaiser Permanente Oakland Medical Center between January 1, 2017, and December 31, 2018. The authors compared changes in inpatient psychiatric hospitalizations and mental health-related ED encounters from the year before vs after the first IOP engagement. Bivariate analyses comparing ED and inpatient utilization pre- and post-IOP engagement, stratified by sociodemographic variables were conducted using paired t-tests and McNemar's test. Conditional multivariable logistic regression was performed to assess the odds of psychiatric utilization. Participants were more likely to have ≥ 1 inpatient psychiatric encounter (28.7% vs 15.9%; p < 0.01) and ≥ 1 mental health-related ED encounter (24.8% vs 18.2%; p = 0.04) pre-IOP vs post-IOP. The authors' multivariable analysis demonstrated that patients experienced a 56% reduction in the odds of inpatient psychiatric encounters (adjusted odds ratio = 0.42, 95% confidence interval: 0.26-0.68, p < 0.01) and a 35% reduction in mental health-related ED encounters (adjusted odds ratio = 0.63, 95% confidence interval: 0.40-1.00, p = 0.05) post-IOP vs pre-IOP. This study demonstrated a significant reduction in inpatient psychiatric hospitalizations and mental health-related ED visits among patients with PTSD in the year following participation in an IOP. These findings support the use of IOPs for patients with PTSD to reduce the likelihood of intensive service use.

Mental Health Service Use Before First Diagnosis of a Psychotic Disorder.

Characterizing mental health service use trajectories preceding diagnosis of a psychotic disorder may help identify individuals at highest risk and in which settings they are at highest risk. To examine mental health service use and diagnostic trajectories before first diagnosis of psychotic disorder and identify utilization and diagnostic patterns. This population-based, retrospective cohort study used linked provincial health administrative data. The sample included individuals aged 15 to 29 years diagnosed with a psychotic disorder in Ontario, Canada, between April 1, 2012, and March 31, 2018. These individuals were matched to individuals with a diagnosis of a mood disorder. Data were analyzed from November 2018 to November 2019. The main outcomes were rates, timing, and setting of mental health-related service use and associated diagnoses in the 3 years before the index disorder among individuals first diagnosed with a psychotic disorder compared with those first diagnosed with a mood disorder. A total of 10 501 individuals with a first diagnosis of psychotic disorder were identified (mean [SD] age, 21.55 [3.83] years; 72.1% male). A total of 72.2% of individuals had at least 1 mental health service visit during the 3 years before their first psychotic disorder diagnosis, which was significantly more than matched controls with a first mood disorder diagnosis (66.8%) (odds ratio [OR], 1.34; 95% CI, 1.26-1.42). Compared with individuals diagnosed with a mood disorder, individuals diagnosed with a psychotic disorder were significantly more likely to have had mental health-related hospital admissions (OR, 3.98; 95% CI, 3.43-4.62) and emergency department visits (OR, 2.27; 95% CI, 2.12-2.43) in the preceding 3 years. Those with psychotic disorders were more likely to have had prior diagnoses of substance use disorders (OR, 2.57; 95% CI, 2.35-2.81), other disorders (personality disorders, developmental disorders) (OR, 1.75; 95% CI, 1.61-1.90), and self-harm (OR, 1.64; 95% CI, 1.36-1.98) in the past 3 years compared with those diagnosed with mood disorders. This study found that in the 3 years prior to an index diagnosis, individuals with a first diagnosis of psychotic disorder had higher rates of mental health service use, particularly emergency department visits and hospitalizations, compared with individuals with a first diagnosis of a mood disorder. Individuals with psychotic disorders also had a greater number of premorbid diagnoses. Differences in health service utilization patterns between those with a first psychotic disorder diagnosis vs a first mood disorder diagnosis suggest distinct premorbid trajectories that could be useful for next steps in prediction and prevention research.

Almost one in five emergency department presentations are by mental health clients: a secondary data analysis.

Mental health-related emergency department (ED) presentations are steadily increasing, including presentations for both mental health and non-mental health concerns by existing clients of mental health services. The study aim was to examine and compare mental health clients and non-clients' ED presentations, identify data and clinical gaps and make recommendations for improvement. De-identified 2017/2018 ED data were used to describe presentations for current and recent (within last 5 years) clients of specialist public mental health and addiction services, compared to presentations of non-mental health clients. Of 49,170 presentations, 18% were by clients of mental health services. Compared to other ED presenters, mental health clients were often younger, female and Māori, required more urgent care and waited longer. Mental health-related International Classification of Diseases (ICD) codes/referrals were most common for presentations by current mental health clients, whereas pain and trauma were often the reason for prior mental health clients' presentations. Discharge diagnoses rarely included self-harm behaviour, and admissions for these clients were more commonly by ED rather than mental health services. Mental health clients are common in ED. Enhanced mental health data capture and improved systems and processes are needed to ensure that ED staff can better meet their often-complex needs.

Parent SMART: Effects of residential treatment and an adjunctive parenting intervention on behavioral health services utilization

IntroductionScant research has examined the impact of residential treatment on adolescent behavioral healthcare utilization post-discharge, even though behavioral healthcare utilization is major driver of healthcare costs. In the primary analyses of a pilot randomized trial, Parent SMART – a technology-assisted intervention for parents of adolescents in residential treatment – was found to improve parental monitoring and parent-adolescent communication, reduce adolescent drinking, and reduce adolescent school-related problems, relative to residential treatment as usual (TAU). The goal of this secondary analysis of the pilot randomized trial was to assess the effects of residential treatment and the adjunctive Parent SMART intervention on both the amount and type of subsequent behavioral healthcare utilization. MethodThe study randomized sixty-one parent-adolescent dyads to residential TAU (n = 31) or residential TAU plus Parent SMART (n = 30). Of the 61 dyads, 37 were recruited from a short-term residential facility and 24 were recruited from a long-term facility. Adolescents completed a structured clinical interview and self-reported their behavioral health-related visits to the emergency department, nights in residential/inpatient, and outpatient visits over the past 90 days, at baseline, 12-, and 24-weeks post-discharge. Generalized linear mixed models (GLMMs) examined both linear and non-linear (pre- to post- residential treatment) trends, pooled, and stratified by residential facility to examine behavioral health service utilization. ResultsBoth the linear and pre-post GLMMs revealed that behavioral health-related emergency department visits and residential/inpatient nights decreased across both residential facilities. GLMMs estimating change from the pre- to post period indicated that outpatient visits increased across both facilities. There were no significant effects of the Parent SMART adjunctive intervention in GLMMs, though bivariate tests and the direction of effects signaled that Parent SMART was associated with more nights of residential/inpatient utilization. ConclusionResidential substance use treatment may reduce adolescents' subsequent utilization of costly behavioral healthcare services such as emergency department visits and residential/inpatient nights, while increasing utilization of outpatient services. Parent SMART was not associated with significant changes in behavioral healthcare utilization, but the pattern of results was consistent with prior literature suggesting that stronger parenting skills are associated with greater utilization of non-emergency services.

Evaluation of a community-based brief intervention service for youth in crisis with suicidal ideation or self-harm.

To evaluate the implementation of a mixed virtual and in-person brief intervention for young people, aged 12-25 years, presenting to a large urban mental health service in crisis with suicidal ideation and/or self-harm. A pragmatic, real-world evaluation was conducted on the Youth Brief Intervention Service between June 2021 (inception) and October 2022. Service users were offered four sessions over an approximate one-month period. Sessions focused on distress tolerance, safety plans and support systems. Implementation outcomes related to service uptake, retention, fidelity of the model and service user experience. Effectiveness outcomes were measured pre-post and included mental health-related hospital service utilization (primary outcome), functioning, mental health status, self-harm, suicidal ideation and quality of life. Of the 136 young people referred to the Youth Brief Intervention Service, 99 were accepted with 17 disengaging before the first session. Eighty percent of people who commenced, completed the package of care. Young persons' and parent/carers experience of service was high (97% and 88%, respectively). Mental health-related emergency department presentations and inpatient days decreased from 3 months pre-intake to 3 months post-intake (42 vs. 7 presentations, X2 = 25.3, p < .001; 11 vs. 0 inpatient days, X2 = 9.1, p = .01). There were significant improvements in mental health status, days engaging in self-harm, general health and functioning and quality of life. The Youth Brief Intervention Service is feasible, acceptable, subjectively beneficial and coincided with less mental health-related emergency department presentations and inpatient days, and improved mental health status and behaviour.

Mental health impacts of COVID-19: A retrospective analysis of dynamic modelling projections for Australia

BackgroundIn early 2020, we developed a dynamic model to support policy responses aimed at mitigating the adverse mental health effects of the COVID-19 pandemic in Australia. As the pandemic has progressed, it has become clear that our initial model forecasts overestimated the impacts of infection control measures (lockdowns, physical distancing, etc.) on suicide, intentional self-harm hospitalisation, and mental health-related emergency department (ED) presentation rates. MethodsPotential explanations for the divergence of our model predictions from observed outcomes were assessed by comparing simulation results for a set of progressively more refined models with data on the prevalence of moderate to very high psychological distress and numbers of suicides, intentional self-harm hospitalisations, and mental health-related ED presentations published after our modelling was released in July 2020. ResultsAllowing per capita rates of spontaneous recovery and intentional self-harm to differ between people experiencing moderate to very high psychological distress prior to the pandemic and those developing comparable levels of psychological distress only as a consequence of infection control measures substantially improves the fit of our model to empirical estimates of the prevalence of psychological distress and leads to significantly lower predicted effects of COVID-19 on suicide, intentional self-harm hospitalisation, and mental health-related ED presentation rates. ConclusionAccommodating the influence of prior mental health on the psychological effects of population-wide social and economic disruption is likely to be critical for accurately forecasting the mental health impacts of future public health crises as they inevitably arise.

The impact of COVID-19 on emergency department presentations for mental health disorders in Queensland, Australia: A time series analysis.

The COVID-19 pandemic has been associated with detrimental effects on mental health and psychological well-being. Although multiple studies have shown decreases in mental health-related Emergency Department (ED) presentations early in the COVID-19 pandemic, the medium-term effects on mental health-related ED presentations have remained less clear. This study aimed to evaluate the effect of the pandemic on mental health ED presentations by comparing observed presentation numbers to predictions from pre-pandemic data. This retrospective cohort study tallied weekly ED presentations associated with mental health disorders from a state-wide minimum dataset. Three time periods were identified: Pre-Pandemic (January 1, 2018-March 8, 2020), Statewide Lockdown (March 9, 2020-June 28, 2020), and Restrictions Easing (June 29, 2020-June 27, 2021). Time series analysis was used to generate weekly presentation forecasts using pre-pandemic data. Observed presentation numbers were compared to these forecasts. Weekly presentation numbers were lower than predicted in 11 out of 16 weeks in the Statewide Lockdown period and 52 out of 52 weeks in the Restrictions Easing period. The largest decrease was seen for anxiety disorders (Statewide Lockdown: 76.8% of forecast; Restrictions Easing: 36.4% of forecast), while an increase was seen in presentations for eating disorders (Statewide Lockdown: 139.5% of forecast; Restrictions Easing: 194.4% of forecast). Overall weekly mental health-related presentations across Queensland public EDs were lower than expected for the first 16 months of the COVID-19 pandemic. These findings underline the limitations of emergency department provision of mental health care and the importance of alternate care modalities in the pandemic context.

Cost-effectiveness of system-level mental health strategies for young people in the Australian Capital Territory: a dynamic simulation modelling study

Regional mental health planning is a key challenge for decision makers because mental health care is a complex, dynamic system. Economic evaluation using a system dynamics modelling approach presents an opportunity for more sophisticated planning and important evidence on the value of alternative investments. We aimed to investigate the cost-effectiveness of eight systems-based interventions targeted at improving the mental health and wellbeing of children, adolescents, and young adults in the Australian Capital Territory (ACT). We assessed eight interventions for children and young people (aged ≤25 years) with low, moderate, and high-to-very-high psychological distress: technology-enabled integrated care, emergency department-based suicide prevention, crisis response service, family education programme, online parenting programme, school-based suicide prevention programme, trauma service for youths, and multicultural-informed care. We developed a system dynamics model for the ACT through a participatory process and calibrated the model with historical data, including population demographics, the prevalence of psychological distress, and mental health services provision. We calculated incremental cost-effectiveness ratios compared with business as usual for cost (AU$) per: quality-adjusted life-year (QALY), suicide death avoided, self-harm related hospital admissions avoided, and mental health-related emergency department presentation, using a 10-year time horizon for health-care and societal perspectives. We investigated uncertainty through probabilistic sensitivity analysis and deterministic sensitivity analysis, including using a 30-year timeframe. From a societal perspective, increased investment in technology-enabled integrated care, family education, an online parenting programme, and multicultural-informed care were expected to improve health outcomes (incremental QALYs 4517 [95% UI -3135 to 14 507] for technology-enabled integrated care; 339 [91 to 661] for family education; 724 [114 to 1149] for the online parenting programme; and 137 [88 to 194] for multicultural-informed care) and reduce costs ($-91·4 million [-382·7 to 100·7]; $-12·8 million [-21·0 to -6·6]; $-3·6 million [-6·3 to 0·2]; and $-3·1 million [-4·5 to -1·8], respectively) compared with business as usual using a 10-year time horizon. The incremental net monetary benefit for the societal perspective for these four interventions was $452 million (-351 to 1555), $40 million (14 to 74), $61 million (9 to 98), and $14 million (9 to 20), respectively, compared with business as usual, when QALYs were monetised using a willingness to pay of $79 930 per QALY. Synergistic effects are anticipated if these interventions were to be implemented concurrently. The univariate and probabilistic sensitivity analyses indicated a high level of certainty in the results. Although emergency department-based suicide prevention and school-based suicide prevention were not cost effective in the base case (41 QALYs [0 to 48], incremental cost $4·1 million [1·2 to 8·2] for emergency department-based suicide prevention; -234 QALYs [-764 to 12], incremental cost $90·3 million [72·2 to 111·0] for school-based suicide prevention) compared with business as usual, there were scenarios for which these interventions could be considered cost effective. A dedicated trauma service for young people (9 QALYs gained [4 to 16], incremental cost $8·3 million [6·8 to 10·0]) and a crisis response service (-11 QALYs gained [-12 to -10], incremental cost $7·8 million [5·1 to 11·0]) were unlikely to be cost effective in terms of QALYs. Synergistic effects were identified, supporting the combined implementation of technology-enabled integrated care, family education, an online parenting programme, and multicultural-informed care. Synergistic effects, emergent outcomes in the form of unintended consequences, the capability to account for service capacity constraints, and ease of use by stakeholders are unique attributes of a system dynamics modelling approach to economic evaluation. BHP Foundation.

Police-reported family violence victimisation or perpetration and mental health-related emergency department presentations: an Australian data-linkage study

BackgroundFamily violence is a leading social determinant of mental ill-health but its link to mental health-related emergency department presentations is poorly understood. Existing research has largely used retrospective designs with a focus on victimisation, typically among women. We examined whether police-reported family violence victimisation and perpetration were prospectively associated with mental health emergency department presentations in women and men. We also identified family violence risk and vulnerability characteristics associated with such presentations.MethodsDemographics, prior police involvement, and individual and relationship vulnerabilities were provided by Victoria Police for 1520 affected family members (i.e., primary victims) and 1470 respondents (i.e., persons alleged to have perpetrated family violence) from family violence reports in 2016–17. Emergency mental health presentations 22–30 months post-family-violence report were determined through linkage with the Victorian Emergency Minimum Dataset and compared to statewide presentations.ResultsEmergency mental health presentations during follow-up were identified in 14.3% of the family violence sample, with 1.9% presenting for self-harm. Mental health presentation rates per 1,000 people were markedly higher among affected family members and respondents of both sexes and all ages than in the general population, except for male affected family members aged 45 + . Adjusting for age and sex, the mental health presentation rate was 6 and 11 times higher among affected family members and respondents, respectively, than in the general population. Individual vulnerabilities were more closely related to risk of emergency mental health presentations than relationship characteristics.ConclusionsPolice-recorded family violence is associated with increased mental health-related emergency department presentations over the short-to-medium term. Strengthened cross-sector collaboration is needed to identify, address, and refer individuals with overlapping family violence and mental health needs and to improve victims’ and perpetrators’ access to community mental health and related services. This should help prevent individuals from reaching a crisis point in their mental health.

A Retrospective Cohort Analysis of Mental Health-Related Emergency Department Visits Among Veterans and Non-Veterans Residing in Ontario, Canada: Une analyse de cohorte rétrospective des visites au service d'urgence liées à la santé mentale parmi les vétérans et non-vétérans résidant en Ontario, Canada.

Emergency departments (EDs) are a vital part of healthcare systems, at times acting as a gateway to community-based mental health (MH) services. This may be particularly true for veterans of the Royal Canadian Mounted Police who were released prior to 2013 and the Canadian Armed Forces, as these individuals transition from federal to provincial healthcare coverage on release and may use EDs because of delays in obtaining a primary care provider. We aimed to estimate the hazard ratio (HR) of MH-related ED visits between veterans and non-veterans residing in Ontario, Canada: (1) overall; and by (2) sex; and (3) length of service. This retrospective cohort study used administrative healthcare data from 18,837 veterans and 75,348 age-, sex-, geography-, and income-matched non-veterans residing in Ontario, Canada between April 1, 2002, and March 31, 2020. Anderson-Gill regression models were used to estimate the HR of recurrent MH-related ED visits during the period of follow-up. Sex and length of service were used as stratification variables in the models. Veterans had a higher adjusted HR (aHR) of MH-related ED visits than non-veterans (aHR, 1.97, 95% CI, 1.70 to 2.29). A stronger effect was observed among females (aHR, 3.29; 95% CI, 1.96 to 5.53) than males (aHR, 1.78; 95% CI, 1.57 to 2.01). Veterans who served for 5-9 years had a higher rate of use than non-veterans (aHR, 3.76; 95% CI, 2.34 to 6.02) while veterans who served for 30+ years had a lower rate compared to non-veterans (aHR, 0.60; 95% CI, 0.42 à 0.84). Rates of MH-related ED visits are higher among veterans overall compared to members of the Ontario general population, but usage is influenced by sex and length of service. These findings indicate that certain subpopulations of veterans, including females and those with fewer years of service, may have greater acute mental healthcare needs and/or reduced access to primary mental healthcare.

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

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. 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. 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). 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. 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.

Incident mental health episodes after initiation of gabapentinoids vs. dopamine agonists for early-onset idiopathic restless legs syndrome

Limited long-term safety information exists for gabapentinoid treatment of idiopathic restless legs syndrome (RLS). We estimated incident mental health-related emergency department visits and hospitalizations with a primary mental health diagnosis (primary outcome) among early-onset idiopathic RLS patients following first-line treatment initiation and examined outcome risk with gabapentinoids compared with dopamine agonists (DAs). A retrospective cohort study was conducted using administrative claims data from 2012 to 2019. Adults with early-onset (18–44 years) idiopathic RLS initiating either gabapentinoids or DAs within 60 days of new diagnosis were followed up to two years. Incidence rates were calculated and a log-binomial regression model with propensity score weighting estimated relative risk of the outcome and of substance use disorders (SUDs) as a secondary analysis with gabapentinoids. Among a cohort of 6,672 patients, 4,986 (74.7%) initiated DAs and 1,686 (25.3%) gabapentinoids. Incidence of the primary outcome (49.8 [95% CI 40.8–69.3] per 1,000 person-years) and SUDs (49.5 [95% CI 40.6–59.9] per 1,000 person-years) were higher in the gabapentinoid group compared with the DA group. A statistically significant risk of mental health diagnoses with gabapentinoids was not detected, but SUD risk was significant after covariate adjustment. High-risk mental health comorbidities (i.e., SUDs) should be considered when initiating RLS treatments.

Dynamic modelling of the impact of community-based acute mental health services for children and adolescents.

To evaluate the potential impact of the recently announced 'Safeguards' initiative on mental health-related emergency department presentation rates for children and adolescents (0-17 years). This state-funded initiative aims to establish 25 Child and Adolescent Acute Response Teams across New South Wales. We estimated the effects of the 'Safeguards' initiative using a state-level dynamic model of child and adolescent acute mental health care. Potential reductions in total numbers of mental health-related emergency department presentations and re-presentations (i.e. presentations within 3 months of an initial presentation) were assessed via a series of simulation experiments in which we systematically varied the total number of Child and Adolescent Acute Response Teams and the mean duration of care per patient. Assuming a mean treatment duration of 6 weeks per patient, 25 Child and Adolescent Acute Response Teams are projected to reduce total numbers of mental health-related emergency department presentations and re-presentations over the period 2022-2031 by 15.0% (95% interval, 12.0-18.2%) and 31.7% (26.2-37.8%), respectively. Increasing the total number of Child and Adolescent Acute Response Teams above 25 has minimal additional impact on projected reductions in numbers of emergency department presentations and re-presentations, provided the mean duration of care is no more than 8 weeks. However, where the mean duration of care is greater than 4 weeks, a decrease in the number of Child and Adolescent Acute Response Teams below 25 reduces the potential effectiveness of the 'Safeguards' initiative significantly. Our simulation results indicate that full and timely implementation will be critical if the potentially substantial impact of the 'Safeguards' initiative on demand for hospital-based emergency mental health care is to be realised.

Patients languishing in emergency departments: A descriptive analysis of mental health-related emergency department presentations in Australia between 2016-17 and 2020-21.

In the context of concerns regarding hospital access block, this paper provides a descriptive longitudinal analysis of mental health-related ED episodes in Australian public hospitals between 2016-17 and 2020-21. We descriptively analysed Australian Institute of Health and Welfare data for mental health-related ED presentations, outcomes and 5-year trends for Australian public hospitals. There were more than 300,000 Australian mental health-related ED presentations in 2020-21. Presentations increased by an average annual rate of 2.8% between 2016-17 and 2020-21, commonly involving first responder (police, paramedic) attendance. From 2016-17 to 2020-21, the average annual rate of mental health-related ED presentations receiving a triage category of resuscitation increased by 13.7%, emergency by 9.4% and urgent by 4.7%. 90% of MH-related ED presentations were completed within 14h, which was longer than the 90th percentile for all ED presentations (up to 8h). Current mental health policies have not stemmed the rising tide of ED presentations. Mental health-related ED presentations are increasing in number and severity, likely due to health systemic and societal factors. Psychiatry patients stay longer in EDs than other patients. Healthcare reforms should be targeted to provide the best outcome based on principles of equity of access.

Adherence to antipsychotic laboratory monitoring guidelines in children and youth: a population-based study.

In 2011, the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) published guidelines for the metabolic monitoring of antipsychotic-treated children and youth. Population-based studies examining adherence to these guidelines are needed to ensure the safe use of antipsychotics in children and youth. We conducted a population-based study of all Ontario residents aged 0 to 24 who were newly dispensed an antipsychotic between April 1, 2018, and March 31, 2019. We estimated prevalence ratios (PRs) and 95% confidence intervals (CI) associating sociodemographic characteristics with the receipt of baseline and follow-up (3- and 6-month) laboratory testing using log-Poisson regression models. Overall, 6,505 of 27,718 (23.5%) children and youth newly dispensed an antipsychotic received at least one guideline-recommended baseline test. Monitoring was more prevalent among individuals aged 10 to 14 years (PR 1.20; 95% CI 1.04 to 1.38), 15 to 19 years (PR 1.60; 95% CI 1.41 to 1.82), and 20 to 24 years (PR 1.71; 95% CI 1.50 to 1.94) compared to children under the age of 10. Baseline monitoring was associated with mental health-related hospitalizations or emergency department visits in the year preceding therapy (PR 1.76; 95% CI 1.65 to 1.87), a prior diagnosis of schizophrenia (PR 1.20; 95% CI 1.14 to 1.26) or diabetes (PR 1.35; 95% CI 1.19 to 1.54), benzodiazepine use (PR 1.13; 95% CI 1.04 to 1.24), and receipt of a prescription from a child and adolescent psychiatrist or developmental pediatrician versus a family physician (PR 1.41; 95% CI 1.34 to 1.48). Conversely, monitoring was less frequent in individuals co-prescribed stimulants (PR 0.83; 95% CI 0.75 to 0.91). The prevalence of any 3- and 6-month follow-up monitoring among children and youth receiving continuous antipsychotic therapy at these time points was 13.0% (1,179 of 9,080) and 11.4% (597 of 5,261), respectively. Correlates of follow-up testing were similar to those of baseline monitoring. Most children initiating antipsychotic therapy do not receive guideline-recommended metabolic laboratory monitoring. Further research is needed to understand reasons for poor guideline adherence and the role of clinician training and collaborative service models in promoting best monitoring practices.

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

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

COVID-19 and Pediatric Mental Health Hospitalizations

To analyze Australian national data to examine the impact of the coronavirus disease 2019 (COVID-19) pandemic on mental health-related hospital presentations among children and adolescents during the pandemic period with restrictions, and the period after the restrictions eased. We analyzed the monthly mental health-related inpatient admissions and emergency department (ED) attendances data from 6 large pediatric hospitals across Australia, using the Bayesian structural time series models. The COVID-19 restriction period was from March 2020 to December 2021 and the COVID-19 restriction-eased period from January to June 2022. A total of 130 801 mental health-related hospital admissions (54 907) and ED attendances (75 894) were analyzed. During the COVID-19 restriction period, there was a significant increase in inpatient admissions related to deliberate self-harm behaviors (82%, 95% credible interval [CrI], 7%-160%) and ED attendances related to overall mental health disorders (15%, 95% CrI, 1.1%-30%) and eating disorders (76%, 95% CrI, 36%-115%). The increase was higher among females and those living in the least socioeconomically disadvantaged areas, suggesting a widening gap between mental health-related presentations by sex and socioeconomic status. After the restrictions eased, there were slight declines in mental health-related hospital presentations; however, the numbers remained higher than the pre-COVID-19 levels. The increase in mental health-related hospital presentations during the COVID-19 period calls for additional support for pediatric mental health care, particularly for eating disorders and deliberate self-harm among female adolescents. It is important to monitor pediatric mental health service use as we enter "COVID-19 normal" period.