Mental Health Emergency Department Visits Research Articles

Use of Electronic Health Record-Based Measures to Assess Quality of Care for Pediatric Agitation.

Acute agitation during pediatric mental health emergency department (ED) visits presents safety risks to patients and staff. We previously convened multidisciplinary stakeholders who prioritized 20 proposed quality measures for pediatric acute agitation management. Our objectives were to assess feasibility of evaluating performance on these quality measures using electronic health record (EHR) data and to examine performance variation across 3 EDs. At a children's hospital and 2 nonchildren's hospitals, we assessed feasibility of evaluating quality measures for pediatric acute agitation management using structured EHR data elements. We retrospectively evaluated measure performance during ED visits by children 5 to 17 years old who presented for a mental health condition, received medication for agitation, or received physical restraints from July 2020 to June 2021. Bivariate and multivariable regression were used to examine measure performance by patient characteristics and hospital. We identified 2785 mental health ED visits, 275 visits with medication given for agitation, and 35 visits with physical restraints. Performance was feasible to measure using EHR data for 10 measures. Nine measures varied by patient characteristics, including 4.87 times higher adjusted odds (95% confidence interval 1.28-18.54) of physical restraint use among children with versus without autism spectrum disorder. Four measures varied by hospital, with physical restraint use varying from 0.5% to 3.3% of mental health ED visits across hospitals. Quality of care for pediatric acute agitation management was feasible to evaluate using EHR-derived quality measures. Variation in performance across patient characteristics and hospitals highlights opportunities to improve care quality.

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

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. 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. 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). 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.

Predictors of mental health emergency department visits and psychiatric hospitalizations in children in foster care

BackgroundDespite the promise of safe, nurturing environments, children in foster care are at significantly elevated risk of mental health disorders. ObjectiveTo identify factors associated with increased mental health emergency department (ED) visits and psychiatric hospitalizations for children in foster care. ParticipantsChildren aged 4–18 years in child welfare services custody who presented to a foster care clinic from December 2017 to January 2020 (N = 311). MethodsA descriptive cohort study was conducted to collect semi-structured data on a child’s foster care placement history, trauma history, reported behavioral concerns, academic delay, and demographics after new foster care placement. Mental health ED visits and psychiatric hospitalizations within one year of the foster clinic visit were identified using a health information exchange platform. Simple and multiple logistic regression was used to determine unadjusted and adjusted odds ratios for associations of independent variables with mental health ED visits and psychiatric hospitalizations. ResultsIn the study population, most children (78.5 %) were placed with foster families, followed by group homes (18.3 %) and kinship care (3.2 %). Within one year of the foster clinic visit, 24.1 % and 7.4 % of patients had ≥1 ED visit for mental health concerns or ≥1 psychiatric hospitalization, respectively. While children with increased prior placements and group home placement had increased odds of ≥1 ED visit in univariate analyses, no significant association was seen in multivariable analysis. More than half of the children placed in group homes had at least one mental health ED visit compared to 17.4 % of children placed with foster families. ConclusionsChildren placed into out-of-home care have high rates of mental health ED visits and psychiatric hospitalizations. Understanding predictors of poor mental health and associated service utilization can help guide the allocation of resources for better prevention.

Medicaid Value-Based Payments and Health Care Use for Patients With Mental Illness

Medicaid patients with mental illness comprise one of the most high-need and complex patient populations. Value-based reforms aim to improve care, but their efficacy in the Medicaid program is unclear. To investigate if New York state's Medicaid value-based payment reform was associated with improved utilization patterns for patients with mental illness. This retrospective cohort study used a difference-in-differences analysis to compare changes in utilization between Medicaid beneficiaries whose outpatient practices participated in value-based payment reform and beneficiaries whose practices did not participate from before (July 1, 2013-June 30, 2015) to after reform (July 1, 2015-June 30, 2019). Participants were Medicaid beneficiaries in New York state aged 18 to 64 years with major depression disorder, bipolar disorder, and/or schizophrenia. Data analysis was performed from April 2021 to July 2023. Beneficiaries were exposed to value-based payment reforms if their attributed outpatient practice participated in value-based payment reform at baseline (July 1, 2015). Primary outcomes were the number of outpatient primary care visits and the number of behavioral health visits per year. Secondary outcomes were the number of mental health emergency department visits and hospitalizations per year. The analytic population comprised 306 290 individuals with depression (67.4% female; mean [SD] age, 38.6 [11.9] years), 85 105 patients with bipolar disorder (59.6% female; mean [SD] age, 38.0 [11.6] years), and 71 299 patients with schizophrenia (45.1% female; mean [SD] age, 40.3 [12.2] years). After adjustment, analyses estimated a statistically significant, positive association between value-based payments and behavioral health visits for patients with depression (0.91 visits; 95% CI, 0.51-1.30) and bipolar disorder (1.01 visits; 95% CI, 0.22-1.79). There was no statistically significant changes to primary care visits for patients with depression and bipolar disorder, but value-based payments were associated with reductions in primary care visits for patients with schizophrenia (-1.31 visits; 95% CI, -2.51 to -0.12). In every diagnostic population, value-based payment was associated with significant reductions in mental health emergency department visits (population with depression: -0.01 visits [95% CI, -0.02 to -0.002]; population with bipolar disorder: -0.02 visits [95% CI, -0.05 to -0.001]; population with schizophrenia: -0.04 visits [95% CI, -0.07 to -0.01]). In this cohort study, Medicaid value-based payment reform was statistically significantly associated with an increase in behavioral health visits and a reduction in mental health emergency department visits for patients with mental illness. Medicaid value-based payment may be effective at altering health care utilization in patients with mental illness.

Association of Integrating Mental Health Into Pediatric Primary Care at Federally Qualified Health Centers With Utilization and Follow-up Care

More than 1 in 5 children in low-income families report a mental health (MH) problem, yet most face barriers accessing MH services. Integrating MH services into primary care at pediatric practices such as federally qualified health centers (FQHCs) may address these barriers. To examine the association of a comprehensive MH integration model with health care utilization, psychotropic medication use, and MH follow-up care among Medicaid-enrolled children at FQHCs. This retrospective cohort study used Massachusetts claims data from 2014 to 2017 to conduct difference-in-differences (DID) analyses before vs after implementation of a complete FQHC-based MH integration model. The sample included Medicaid-enrolled children aged 3 to 17 years who received primary care at 3 intervention FQHCs or 6 geographically proximal nonintervention FQHCs in Massachusetts. Data were analyzed in July 2022. Receipt of care at an FQHC implementing the Transforming and Expanding Access to Mental Health Care in Urban Pediatrics (TEAM UP) model, which began fully integrating MH care into pediatrics in mid-2016. Utilization outcomes included primary care visits, MH service visits, emergency department (ED) visits, inpatient admissions, and psychotropic medication use. Follow-up visits within 7 days of a MH-related ED visit or hospitalization were also examined. Among the 20 170 unique children in the study sample, at baseline (2014), their mean (SD) age was 9.0 (4.1) years, and 4876 (51.2%) were female. In contrast to nonintervention FQHCs, TEAM UP was positively associated with primary care visits with MH diagnoses (DID, 4.35 visits per 1000 patients per quarter; 95% CI, 0.02 to 8.67 visits per 1000 patients per quarter) and MH service use (DID, 54.86 visits per 1000 patients per quarter; 95% CI, 1.29 to 108.43 visits per 1000 patients per quarter) and was negatively associated with rates of psychotropic medication use (DID, -0.4%; 95% CI -0.7% to -0.01%) and polypharmacy (DID, -0.3%; 95% CI, -0.4% to -0.1%). TEAM UP was positively associated with ED visits without MH diagnoses (DID, 9.45 visits per 1000 patients per quarter; 95% CI, 1.06 to 17.84 visits per 1000 patients per quarter), but was not significantly associated with ED visits with MH diagnoses. No statistically significant changes were observed in inpatient admissions, follow-up visits after MH ED visits, or follow-up visits after MH hospitalizations. The first 1.5 years of MH integration enhanced access to pediatric MH services while limiting the use of psychotropic medications. Additional implementation time is necessary to determine whether these changes will translate into reductions in avoidable utilization.

Mental Health 911: Advocating for the Integration of Behavioral Health Services in Pediatric Hospital Emergency Departments

The coronavirus disease pandemic of 2019 has led to increased concern in mental health needs among pediatric populations. As the number of pediatric mental health emergency department visits have increased, so has the need for integrated behavioral health services in hospitals. This paper describes a standard of mental health care and the benefits of providing mental health services in pediatric hospital settings. The Trauma Mental Health Counseling Program, Hurt-2-Healing (H2H™) was developed and implemented in a Level-1 pediatric hospital and has served a total of 1,523 pediatric trauma patients and their caregivers since 2021. This program established a new hospital-based standard of mental healthcare for pediatric trauma patients and their caregivers. A questionnaire was developed to evaluate the efficacy of the Hurt-2-Healing program within domains such as openness to seeking counseling, psychoeducation, helpfulness of counseling, and ability to cope with the traumatic injury. The majority of (83%) patients/caregivers had no previous counseling experience prior to hospital admittance. Questionnaire responses indicated that after receiving mental health services, caregivers felt more aware of their children’s mental health needs and reported being more open to seeking future mental health counseling services for their child. Further, most respondents were in strong agreement that receiving mental health counseling services during the hospital stay was helpful. These results highlight the need for, and benefit of, providing a standard of care integrating behavioral health services in pediatric hospitals.

Mental Health Revisits at US Pediatric Emergency Departments

Pediatric emergency department (ED) visits for mental health crises are increasing. Patients who frequently use the ED are of particular concern, as pediatric mental health ED visits are commonly repeat visits. Better understanding of trends and factors associated with mental health ED revisits is needed for optimal resource allocation and targeting of prevention efforts. To describe trends in pediatric mental health ED visits and revisits and to determine factors associated with revisits. In this cohort study, data were obtained from 38 US children's hospital EDs in the Pediatric Health Information System between October 1, 2015, and February 29, 2020. The cohort included patients aged 3 to 17 years with a mental health ED visit. Characteristics of patients, encounters, hospitals, and communities. The primary outcome was a mental health ED revisit within 6 months of the index visit. Trends were assessed using cosinor analysis and factors associated with time to revisit using mixed-effects Cox proportional hazards regression. There were 308 264 mental health ED visits from 217 865 unique patients, and 13.2% of patients had a mental health revisit within 6 months. Mental health visits increased by 8.0% annually (95% CI, 4.5%-11.4%), whereas all other ED visits increased by 1.5% annually (95% CI, 0.1%-2.9%). Factors associated with mental health ED revisits included psychiatric comorbidities, chemical restraint use, public insurance, higher area measures of child opportunity, and presence of an inpatient psychiatric unit at the presenting hospital. Patients with psychotic disorders (hazard ratio [HR], 1.42; 95% CI, 1.29-1.57), disruptive or impulse control disorders (HR, 1.36; 95% CI, 1.30-1.42), and neurodevelopmental disorders (HR, 1.22; 95% CI, 1.14-1.30) were more likely to revisit. Patients with substance use disorders (HR, 0.60; 95% CI, 0.55-0.66) were less likely to revisit. Markers of disease severity and health care access were associated with mental health revisits. Directing hospital and community interventions toward identified high-risk patients is needed to help mitigate recurrent mental health ED use and improve mental health care delivery.

Ambient heat and emergency department visits for mental health in Canada: assessing temporal variations by greenspace, urbanicity and socioeconomic status

BACKGROUND AND AIM Although previous research has suggested that greenspace might attenuate health risks associated with ambient heat, there is limited research on mental health disorders. Thus, we evaluated the effect modification of greenspace on heat-related mental health emergency department (ED) visits and whether these effects changed over time. METHODS We conducted a case-crossover study for mental health-related ED visits in Canada between 2004 and 2021 during warm-season months (May to August). ED visits for all Canadians living in 111 health regions were included. Daily average temperature as well as greenspace exposure, estimated by the Normalized Difference Vegetation Index (NDVI), were assigned to individuals at their residential location. Extreme heat was defined as the 95th percentile of the health region-specific warm-season temperature distribution. Conditional logistic regression was used to estimate associations between heat and mental health-related ED visits. RESULTS A total of 10,638,372 ED visits for any mental health condition were included. Days of extreme heat were associated with an increased risk of ED visits for any mental health condition (OR = 1.07; 95% CI: 1.05-1.09). In the earlier part of the study period (2004–2009), the associations between ambient heat and mental health ED visits were stronger among individuals exposed to the lowest quartile of NDVI exposure (OR = 1.20; 95% CI: 1.15-1.25), compared to individuals in the highest quartile of NDVI (OR = 1.01; 95% CI: 0.96-1.07). This difference, however, accentuated in the later part of the study (2016-2021) with the ORs for regions in the lowest quartile of NDVI increasing to 1.29 (95% CI: 1.25-1.34) and remaining stable for regions in the highest quartile. Effects appeared strongest in the most deprived socioeconomic areas. CONCLUSIONS Potential health benefits of greenspaces should be considered in mitigation strategies regarding the impacts of climate change on mental health ED visits.

Pediatric Mental Health Emergency Visits During the COVID-19 Pandemic.

IntroductionPaediatric and adult psychiatric emergency department (ED) visits decreased during the initial COVID-19 outbreak. Long-term consequences of the COVID-19 pandemic will include increases in mental healthcare needs, especially among vulnerable groups such as children and adolescents.AimThis study examined changes in the number of overall and diagnosis-specific mental health ED visits among patients aged <18 years following the onset of the COVID-19 pandemic in Madrid, Spain.MethodsUsing clinical records from all psychiatric ED visits at a major teaching hospital between October 2018 and April 2021, we conducted interrupted time-series analyses and compared trends before and after the day of the first ED COVID-19 case (1st March 2020).ResultsA total of 663 patients were included. In March 2020, there was a marked initial decrease of -12.8 (95% CI -21.9, - 7.9) less monthly mental health ED visits. After April 2020, there was a subsequent increasing trend of 3.4 (95% CI 2.6, 4.2) additional monthly mental health ED visits.ConclusionAfter the onset of the COVID-19 pandemic, there was an increase in paediatric psychiatric ED visits, especially due to suicide-related reasons. These data reinforce the crucial role of the ED in the management of acute mental health problems among youth and highlight the need for renovated efforts to enhance access to care outside of and during acute crises during the pandemic and its aftermath.

Mental Health Emergency Department Visits by Children Before and During the COVID-19 Pandemic.

ObjectivesTo describe pediatric mental health emergency department (ED) visit rates and visit characteristics before and during the COVID-19 pandemic.MethodsWe conducted a cross-sectional study of ED visits by children 5–17 years old with a primary mental health diagnosis from March 2018 to February 2021 at a 10-hospital health system and a children's hospital in the Chicago area. We compared demographic and clinical characteristics of children with mental health ED visits before and during the pandemic. We conducted an interrupted time series analysis to determine changes in visit rates.ResultsWe identified 8,127 pediatric mental health ED visits (58.5% female, 54.3% White, Not Hispanic/Latino and 42.4% age 13–15). During the pandemic, visits for suicide or self-injury increased 6.69% (95% CI 4.73, 8.65), and visits for disruptive, impulse control, conduct disorders increased 1.94% (95% CI 0.85, 3.03). Mental health ED visits by children with existing mental health diagnoses increased 2.29% (95% CI 0.34, 4.25). Mental health ED visits that resulted in medical admission increased 4.32% (95% CI 3.11, 5.53). The proportion of mental health ED visits at community hospitals increased by 5.49% (95% CI 3.31, 7.67). Mental health ED visit rates increased at the onset of the pandemic (adjusted incidence rate ratio [aIRR] 1.27, 95% CI 1.06, 1.50), followed by a monthly increase thereafter (aIRR 1.04, 95% CI 1.02, 1.06).ConclusionMental health ED visit rates by children increased during the COVID-19 pandemic. Changes in mental health ED visit characteristics during the pandemic may inform interventions to improve children's mental health.

Child psychiatric emergency visits during the COVID-19 pandemic

IntroductionPaediatric and adult psychiatric emergency department (ED) visits decreased during the initial COVID-19 pandemic outbreak. Long-term consequences of the pandemic will include increases in mental healthcare needs especially among especially vulnerable groups such as children and adolescents.ObjectivesThis study examined changes in the number of overall and diagnosis-specific mental health ED visits among patients aged &lt;18 years following onset of the COVID-19 pandemic in Madrid, Spain.MethodsWe used electronic health records to extract the monthly numbers of total and diagnosis-specific mental health ED visits among patients aged &lt;18 years, between October 2018 and April 2021, to La Paz University Hospital. We conducted interrupted time-series analyses and compared trends before and after the day of the first ED COVID-19 case (1st March 2020).ResultsIn March 2020, there was a marked initial decrease of -12.8 (95%CI -21.9, -7.9) less monthly mental health ED visits. After April 2020, there was a subsequent increasing trend of 3.4 (95%CI 2.6, 4.2) additional monthly mental health ED visits.ConclusionsAfter onset of the COVID-19 pandemic, there was an increase in paediatric psychiatric ED visits, especially due to suicide-related reasons. These data reinforce the crucial role of the ED in the management of acute mental health problems among youth and highlight the need for renovated efforts to enhance access to care outside of and during acute crises during the pandemic and its aftermath.DisclosureNo significant relationships.

Changes in community and hospital-based health care use during the COVID-19 pandemic for adults with and without intellectual and developmental disabilities.

BackgroundDue to the functional, cognitive and communication impairments associated with intellectual and/or developmental disabilities (IDD), adaptations to service delivery during the COVID‐19 pandemic may impact people with IDD differently than others. For community and hospital‐based services, this study describes the proportion of adults with and without IDD who used health care in the year pre‐COVID‐19 and the first year of the pandemic.MethodsThis retrospective cohort study used linked health administrative databases to identify adults aged 18–105 years with and without IDD using unique encoded identifiers. Counts and proportions of adults who used health care services were reported for the pre‐COVID‐19 year (16 March 2019 to 14 March 2020) and the first COVID‐19 year (15 March 2020 to 15 March 2021).ResultsAcross services, the proportion of adults who used services was lower during the first COVID‐19 year compared with the year prior, except for virtual physician visits that increased markedly for people with and without IDD. While the proportion of adults who used services was higher for those with IDD compared with those without IDD for both years, differences were greatest for mental health emergency visits and hospitalisations; adults with IDD were 6.3 to 10.9 times more likely to use these services than others with no IDD during the pandemic.ConclusionsDuring the first COVID‐19 year in Ontario, Canada, service use decreased for all service types, except for virtual physician visits. In both years, adults with IDD remained more likely to use services than other adults, with the largest differences in use of mental health hospitalisations and mental health emergency department visits.

Pediatric Mental Health Emergency Department Visits and Access to Inpatient Care: A Crisis Worsened by the COVID-19 Pandemic.

Pediatric Mental Health Emergency Department Visits and Access to Inpatient Care: A Crisis Worsened by the COVID-19 Pandemic.

Five-Year Trends in Pediatric Mental Health Emergency Department Visits in Massachusetts: A Population-Based Cohort Study

To evaluate temporal changes in pediatric emergency department (ED) visits for mental health problems in Massachusetts based on diagnoses and patient characteristics and to assess trends in all-cause pediatric ED visits. This statewide population-based retrospective cohort study used the Massachusetts All-Payer Claims Database, which includes almost all Massachusetts residents. The study sample consisted of residents aged <21years who were enrolled in a health plan between 2013 and 2017. Using multivariate regression, we examined temporal trends in mental health-related and all-cause ED visits in 2013-2017, with person-quarter as the unit of analysis; we also estimated differential trends by sociodemographic and diagnostic subgroups. The outcomes were number of mental health-related (any diagnosis, plus 14 individual diagnoses) and all-cause ED visits/1000 patients/quarter. Of the 967 590 Massachusetts residents in our study (representing 14.8 million person-quarters), the mean age was 8.1years, 48% were female, and 57% had Medicaid coverage. For this population, mental health-related (any) and all-cause ED visits decreased from 2013 to 2017 (P<.001). Persons aged 18-21years experienced the largest declines in mental health-related (63.0% decrease) and all-cause (60.9% decrease) ED visits. Although mental health-related ED visits declined across most diagnostic subgroups, ED visits related to autism spectrum disorder-related and suicide-related diagnoses increased by 108% and 44%, respectively. Overall rates of pediatric ED visits with mental health diagnoses in Massachusetts declined from 2013 to 2017, although ED visits with autism- and suicide-related diagnoses increased. Massachusetts' policies and care delivery models aimed at pediatric mental health may hold promise, although there are important opportunities for improvement.

Seasonality of Pediatric Mental Health Emergency Department Visits, School, and COVID-19.

The aim of this study was to explore how the academic calendar, and by extension school-year stressors, contributes to the seasonality of pediatric mental health emergency department (ED) visits. The authors reviewed all pediatric mental health ED visits at a large urban medical center from 2014 to 2019. Patients who were younger than 18 years at time of presentation, were Durham residents, and had a primary payer of Medicaid were included in the sample population, and the dates of ED visits of the sample population were compared against dates of academic semesters and summer/winter breaks of a relevant school calendar. Of patients with multiple ED visits, only the first ED presentation was included, and descriptive statistics and a rate ratio were used to describe the study group and identify the rate of ED visits during semesters compared with breaks. Among the sample population from 2014 to 2019, there were 1004 first pediatric mental health ED visits. Of these ED visits, the average number of visits per week during summer/winter breaks was 2.2, and the average number of visits per week during academic semester dates was 3.4. The rate of ED visits was significantly greater during academic semesters compared with breaks (Rate Ratio, 1.6; 95% confidence interval, 1.4-2.0; P < 0.001). Children may be at greater risk of behavioral health crises or having increased mental needs when school is in session. As many children's mental health has worsened during the COVID-19 (coronavirus disease 2019) pandemic, these findings highlight the need for increased mental health services in the school setting as children return to in-person learning. In addition, it may benefit health systems to plan behavioral health staffing around academic calendars.

Suicide Risk Among Adults With Mental Health Emergency Department Visits With and Without Suicidal Symptoms.

Objective: To describe risk factors and suicide rates during the year following discharge from mental health emergency department (ED) visits by adults with suicide attempts, suicidal ideation, or neither.Methods: National cohorts of patients with mental health ED visits for suicide attempts or self-harm (n = 55,323), suicidal ideation (n = 435,464), or other mental health visits (n = 9,144,807) from 2008 to 2012 Medicaid data were followed for suicide for 1 year after discharge. Suicide rates per 100,000 person-years were determined from National Death Index data. Poisson regression models, adjusted for age, sex, and race/ethnicity, estimated suicide rate ratios (RRs). Suicide standardized mortality ratios (SMRs) were estimated from National Vital Statistics System data.Results: Suicide rates per 100,000 person-years were 325.4 for suicide attempt or self-harm visits (RR = 5.51, 95% CI, 4.64-6.55), 156.6 for suicidal ideation visits (RR = 2.59, 95% CI, 2.34-2.87), and 57.0 for the other mental health ED visits (1.0, reference). Compared to expected suicide general population rates, SMRs were 18.2 (95% CI, 13.0-23.4) for suicide attempt or self-harm patients, 10.6 (95% CI, 9.0-12.2) for suicidal ideation patients, and 3.2 (95% CI, 3.1-3.4) for other ED mental health patients. Among patients with suicide attempt ED visits in the 180 days before their index mental health ED visit, suicide rates per 100,000 person-years were 687.2 (95% CI, 396.5-978.0) for attempt or self-harm visits, 397.4 (95% CI, 230.6-564.3) for ideation visits, and 328.4 (95% CI, 241.5-415.4) for other mental health visits.Conclusions: In the year following discharge, emergency department patients with suicide attempts or self-harm, especially repeated attempts, have a high risk of suicide.

The 2011 and 2016 iterations of the Ontario Marginalization Index: updates, consistency and a cross-sectional study of health outcome associations.

The Ontario Marginalization Index (ON-Marg) is an area-based measure used widely to measure health inequalities in Ontario. Recently, the index was updated for 2011 and 2016. The loss of the 2011 long-form census required the use of alternative data sources for the 2011 version. This paper describes the update of ON-Marg, assesses consistency in the indices across census years using Dissemination Areas, and examines associations between ON-Marg 2016 and four health and social outcomes to demonstrate its potential to measure health inequalities. ON-Marg was created using factor analysis. Differences in quintile assignment was compared over time to assess whether the use of taxfiler, immigration, property assessment, and health card address data in 2011 affected consistency in measurement of marginalization. Inequalities in rates of overall mortality, gonorrhea incidence, mental health emergency department visits, and alcohol retail locations across quintiles of ON-Marg 2016 were quantified using the Relative Index of Inequality. Depending on the dimension, between 81% and 96% of DAs showed limited or no changes in quintiles of marginalization between 2006, 2011 and 2016. Of the 45-64% of DAs that did not change quintile between 2006 and 2016, 1.8% to 8.8% of DAs in 2011 differed by two or more quintiles. Findings showed significant differences in rates of health and social outcomes across quintiles of ON-Marg 2016, with strength and directionality varying by dimension of ON-Marg. Alternative data sources did not substantially affect the consistency of the 2011 version of ON-Marg. The updated ON-Marg is a comprehensive tool that can be used to study health inequalities in Ontario.

Ambient Heat and Risk of Emergency Department Visits for Mental Health among Adults in the United States

BACKGROUND AND AIM: Ambient temperature has long been thought to play a role in the exacerbation of symptoms for many mental and behavioral disorders. However, the impacts of elevated temperature on specific mental health outcomes remain poorly documented. Accordingly, we sought to quantify the association between heat and mental health-related emergency department (ED) visits in the conterminous US among adults aged 18 years and older with commercial health insurance. METHODS: We analyzed de-identified data from ~3.5 million ED visits involving a psychiatric diagnosis during the warm seasons from 2010 and 2019 among adults aged 18 years and older with commercial health insurance living in 2,987 US counties using the OptumLabs® Data Warehouse. We estimated daily population-weighted county average maximum ambient temperature (May to September), and evaluated the association between warm-season ambient temperature and specific mental health diagnoses, as well as any diagnosis among those examined, using a case-crossover study design with a distributed lag nonlinear model. RESULTS:We found monotonic increases in the odds ratio (OR) of ED visits associated with any mental health diagnosis. A 10°C increase in temperature was associated with an OR for any mental health ED visits of 1.042 (95% confidence interval [CI]: 1.036, 1.047). Associations with a 10°C increase in temperature were also pronounced for ED visits due to specific illness, including anxiety and stress disorders (OR: 1.039; 95% CI: 1.030, 1.049), mood disorders (OR: 1.033; 95% CI: 1.024, 1.042), substance abuse disorders (OR: 1.049; 95% CI: 1.041, 1.058), and schizophrenia (OR: 1.049; 95% CI: 1.025, 1.074). CONCLUSIONS:We found that in this large population of insured adults in the US, elevated temperature exposures are associated with increased mental health-related emergency department (ED) visits. Future work should aim to further characterize the relationship between sustained periods of extreme temperature (i.e., heat waves) and mental health. KEYWORDS: Temperature, Climate, Epidemiology, Mental Health

Pharmacologic Restraint Use During Mental Health Visits in Pediatric Emergency Departments

To evaluate the trends and hospital variation in the use of pharmacologic restraint among pediatric mental health visits in the emergency department (ED). We examined ED visits with a mental health diagnosis in patients aged 3-21years at children's hospital EDs from 2009 to 2019. We calculated the frequency of pharmacologic restraint use and determined visit characteristics associated with restraint use. We calculated cumulative percent change for visits with restraints and for all mental health visits. We used logistic regression to test trends over time and evaluate hospital variation in the frequency of restraint use. We identified 389 885 mental health ED visits (54.9% female, median age 14.3years) and 13 643 (3.5%) visits with pharmacologic restraint use. Characteristics associated with pharmacologic restraint use were late adolescent age (18-21years), male sex, Black race, non-Latino ethnicity, public insurance, and admission to the hospital (P<.001). During the study period, both mental health ED visits increased by 268% and mental health ED visits with pharmacologic restraint use increased by 370%. The rate of pharmacologic restraint in this patient population remained constant. Hospital use of pharmacologic restraint for mental health visits varied significantly across hospitals (1.6%-11.8%, P<.001). Pediatric mental health ED visits with and without pharmacologic restraint are increasing over time. In addition, the overall number of pharmacologic restraint use has increased threefold. Significant hospital variation in pharmacologic restraint use signifies an opportunity for standardization of care and restraint reduction.

Children's Mental Health Emergency Department Visits: 2007-2016.

Emergency department (ED) visits for children seeking mental health care have increased. Few studies have examined national patterns and characteristics of EDs that these children present to. In data from the National Pediatric Readiness Project, it is reported that less than half of EDs are prepared to treat children. Our objective is to describe the trends in pediatric mental health visits to US EDs, with a focus on low-volume, nonmetropolitan EDs, which have been shown to be less prepared to provide pediatric emergency care. Using 2007 to 2016 Nationwide Emergency Department Sample databases, we assessed the number of ED visits made by children (5-17 years) with a mental health disorder using descriptive statistics. ED characteristics included pediatric volume, children's ED classification, and location. Pediatric ED visits have been stable; however, visits for deliberate self-harm increased 329%, and visits for all mental health disorders rose 60%. Visits for children with a substance use disorder rose 159%, whereas alcohol-related disorders fell 39%. These increased visits occurred among EDs of all pediatric volumes, regardless of children's ED classification. Visits to low-pediatric-volume and nonmetropolitan areas rose 53% and 41%, respectively. Although the total number of pediatric ED visits has remained stable, visits among children with mental health disorders have risen, particularly among youth presenting for deliberate self-harm and substance abuse. The majority of these visits occur at nonchildren's EDs in both metropolitan and nonurban settings, which have been shown to be less prepared to provide higher-level pediatric emergency care.