Mental Health Presentations Research Articles

Sociodemographic characteristics and clinical outcomes for people presenting to emergency departments with mental health diagnoses

BackgroundHospital emergency departments (EDs) are experiencing a growth in presentations with mental health (MH) diagnoses. AimDescribe and compare sociodemographic characteristics and clinical outcomes for people with MH and non-MH diagnoses. MethodsA retrospective study examined routinely collected data for ED presentations in a health district in western Sydney, Australia from 2016 to 2019. Regression models examined variables according to MH status, overall and by age. ResultsIndividuals with MH diagnoses accounted for 3.4% of 647,787 ED presentations. MH presentations were most commonly female (51.5%), aged 16–39 years (62.5%), arrived after hours (60.3%) and via ambulance (52.8%). MH presentations were more likely to be triaged category 2 (OR = 1.58,95%CI = 1.54–1.63) and not seen on time (OR = 1.20,95%CI = 1.17–1.24). They had higher odds of a longer ED stay (OR = 1.96,95%CI = 1.90–20.1), after which they were less likely to be admitted (OR = 0.56, 95%CI = 0.55–0.58) and more likely to be transferred (OR = 3.81,95%CI = 3.66–3.97) or leave before treatment was completed (OR = 1.83,95%CI = 1.74–1.92). ConclusionCharacteristics and outcomes for people presenting to ED with a MH diagnosis significantly differ from those without a MH diagnosis. Provision of timely care is a particular concern. Identifying causes for delays within and external to the ED, and implementing targeted strategies to ameliorate them are required to optimise care.

Childhood adversity, mental health and suicide (CHASE): a longitudinal case-control linked data study of lifetime inpatient records associated with suicide.

ObjectivesChildhood adversity (CA) carries an increased risk of developing later mental health (MH) problems and suicidal behaviour. This study aimed to summarise lifetime hospital attendances for CA and MH in young people who later died by suicide. ApproachThis study is a retrospective longitudinal case control study. Lifetime Scottish inpatient acute and psychiatric records were linked to death records and summarised for individuals born since 1981 who died by suicide in the period 1991-2017 (cases), and controls (1:10) matched on sex, age, and postcode. Relevant records were coded MH (including self-harm) and/or CA. Descriptive statistics and odds ratios (OR) were computed. ResultsData for 2,477 and 24,777 ‘cases’ and ‘controls’ were extracted, of whom 2,106 cases (85%) and 13,589 controls (55%) had lifespan hospital records. Mean age at death for cases was 23.7 (SD=4.9) and 75.9% were male. Psychiatric records represented 11.6% and 1.4% of records for cases and controls, respectively. For the age range 10-18, Maltreatment & violence-related codes were recorded for 160 (7.6%) cases and 371 (2.7%) controls, corresponding to OR=2.9 (95%CI: 2.4-3.6). This was compared with MH at 458 (21.7%) cases and 560 (4.1%) controls and OR=6.5 (95%CI: 5.7-7.4). The highest adjusted ORs were for self-harm episodes recorded in general hospital with aORmale=6.56 (95%CI: 4.96-8.68) and aORfemale=6.87 (95%CI: 4.99-9.48). ConclusionAll CA and MH presentations in inpatient hospital records were associated with greater risk of subsequent suicide, with the strongest association for self-harm.

Paramedics’ Confidence and Perceived Competence When Attending to Varied Patient Presentations: A Mixed-Method Study

Purpose: Paramedics are routinely called to patients presenting with mental health concerns. Previous literature suggests paramedics find this patient group challenging. However, no study has investigated whether paramedics find mental health presentations (MHP) more challenging relative to other patient presentations, or whether certain paramedic variables relate to their perceived ability to manage MHP. This study investigates differences in paramedics’ perceived ability to attend to MHP compared to other patient presentations, and whether their perceived ability is related to their level of experience or location of work (metropolitan or rural). The study also explores paramedic’s experiences and perspectives of MHP. Method: Operational paramedics in Australia (n = 138) completed a survey assessing their perceived ability to respond to mental health, cardiac, respiratory, and trauma-related presentations. A repeated measures ANOVA tested differences in perceived ability between these patient presentations. T-tests and Pearson’s correlations were conducted to determine whether years of experience or location of work related to their perceived ability for MHP. Nine paramedics were also interviewed, and a thematic analysis conducted to gain insight into paramedic’s experiences and perspectives of MHP. Results: Paramedics reported a significantly lower perceived ability to respond to MHP relative to each other patient presentation measured. No relationships were found between a paramedic’s perceived ability to respond to MHP and their length of work experience or location of work. Interviews with paramedics revealed four superordinate themes: 1) inconsistent conceptualization of their role, 2) feelings of helplessness and frustration, 3) stigmatized views of patients with a mental illness, and 4) inconsistent views of knowledge and learning relating to MHP. Conclusions: Paramedics believe they have a significantly poorer ability to respond to MHP relative to other patient presentations. Education and training focused on defining a paramedic’s role for MHP as well as reducing stigmatized views of patients with a mental illness may improve paramedic’s care of this cohort of patients.

Emergency mental health presentations in children with autism spectrum disorder and attention deficit hyperactivity disorder.

To characterise the key features and management of young people presenting to the emergency department (ED) with a mental health (MH) complaint and a known diagnosis of autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD). Retrospective review of all ED MH presentations in children aged 7-17 years, presenting over a 12-month period from the 1st of January 2018 to the 31st of December 2018, to the Royal Children's Hospital in Melbourne, Australia. Univariate analyses were carried out to examine the relationship between an underlying diagnosis of ASD and/or ADHD and a number of key presentation variables. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated for ED management outcomes. There were 374 presentations in this cohort, representing 28% of the total MH presentations in 2018. The most common reason for presentation was acute severe behavioural disturbance. Young people with ASD and ADHD were at increased risk of having an acute crisis team response activated (ASD RR 2.3, CI 1.6-3.3, ADHD RR 2.2, CI 1.2-4.1). Compared to those without either diagnosis, young people with ASD were more likely to be physically restrained (RR 2.8, CI 1.7-4.6), managed in seclusion (RR 3.3, CI 1.7-6.4) and to receive medication to assist with behavioural de-escalation (RR 2.8, CI 1.6-4.9). Children with ASD and/or ADHD represent one-quarter of all children presenting to the ED with MH complaints. They experience high rates of acute severe behavioural disturbance. Future research is needed to co-design, implement and evaluate better approaches for their management.

Months of May: Mental health presentations and the impact of a psychiatric emergency care centre on an inner-city emergency department.

The impact of psychiatric emergency care centres (PECCs) on ED mental health (MH) presentations has not been presented. We aim to compare demographics, diagnosis and admission frequency of patients presenting to an inner-city ED with MH complaints, before and for several years after the opening of a PECC. We collected ED patient data for the first 200 'mental health' presentations during the month of May in 2005-2007, and 2015-2017. Data included demographics, diagnosis, post-ED disposition, length of stay in ED, use of the Mental Health Act, and the presence of expressed suicidality and psychotic disorders. The days to reach 200 MH presentations decreased from 43 days in 2005 to 17 days in 2017. The mean length of ED stay approximately halved with PECC's introduction, with 20% of patients being admitted to PECC. Prior to PECC, 75% of suicidal patients were discharged from ED; after the opening of PECC, 84% of patients expressing suicidality were admitted to PECC; and 73% of patients admitted with psychotic symptoms went to the acute psychiatric ward. Between 2005 and 2017, MH presentations to ED became significantly more frequent. The opening of PECC reduced length of stay in ED and provided an admission trajectory for patients expressing suicidality, while retaining the pathway to the acute psychiatric ward for those patients presenting with psychosis.

Mental health presentations to the paediatric emergency department: A retrospective study.

To describe a cohort of patients aged 7-17 years presenting with mental health (MH) problems to an Australian tertiary paediatric emergency department (ED), in order to identify: (i) predictors of admission; and (ii) prolonged length of stay (LOS); (iii) reasons for ED presentation based on diagnosis and (iv) differences between major diagnostic groups. Data for all presentations from 1 January 2018 to 31 December 2018 were extracted and analysed from the hospital's electronic medical record system. MH presentations were identified though rule-based coding and manual file review. In this 12-month period, 1071 children had 1690 emergency MH presentations constituting 6.7% of all ED presentations for children aged 7-17 years. Collectively, the leading cause for presentations was suicidal ideation, self-harm or drug overdose (55%). Compared to discharged patients, admitted patients were more likely to be female (odds ratio (OR) 1.82, confidence interval (CI) 1.41-2.35), aged over 14-years (OR 2.50, CI 1.98-3.15), triaged with high acuity (OR 2.70, CI 2.00-3.65) and arrive by ambulance or police (OR 1.31, CI 1.04-1.64). The highest risk diagnosis associated with admission was eating disorders (OR 9.19, CI 5.48-15.40). Patients with a prolonged LOS (>8 h) were more likely to need admission (OR 5.38, CI 3.81-7.61) and be diagnosed with drug overdose (OR 2.39, CI 1.51-3.80) or acute behavioural disturbance (OR 1.61, CI 1.09-2.39). Mental health presentations constitute a large proportion of ED presentations. Suicidal behaviour and self-harm account for half of them. We have identified patients at increased risk of admission and prolonged ED LOS.

Innovative pathway for managing children and adolescents with mental health concerns in the emergency department: An intervention feasibility study.

To investigate if an innovative clinical pathway for managing child and adolescent mental health (MH) ED presentations reduces average length of stay (LOS) and improves carer satisfaction. An intervention feasibility study at an ED. Participants were 5-17 years olds presenting with MH problems and their carers. ED medical officer (MO) led Kids Assessment Liaison for Mental Health (KALM) clinical pathway was implemented as an intervention and it was compared to Care as Usual pathway which involved ED MO and MH clinicians. Data were collected via the ED clinical data system and a carer survey. Data were analysed by using SAS v9.4 (SAS, Cary, NC, USA). Survey was compared using Fisher's exact test and LOS was compared using median quantile regression. Fifty (23%) patients used the KALM pathway and 169 (77%) the Care as Usual pathway. The median (min, max) LOS in hours for those on the KALM pathway was 4.13 (0.46, 11.55) compared to 5.09 (0.21, 19.12) for Care as Usual pathway (P = 0.1407). Fewer patients breached the National Emergency Access Target (NEAT) when the KALM pathway was used (56%, n = 28 vs 64%, n = 108, P = 0.252). There were no significant differences in the carer survey between the two care pathways. This study provides valuable information about the benefits of the KALM pathway in managing child and adolescent MH presentations to ED. This new pathway reduces the LOS in ED and improves carer experience compared to the usual care pathway.

Psychotropic medication use for paediatric mental health patients in an emergency department.

There is paucity of evidence for psychotropic medication use in children and adolescents presenting with mental health (MH) problems to the ED. We set out to describe paediatric psychotropic medication use in the ED. We conducted a retrospective electronic medical record review of ED patients with MH discharge codes at a tertiary paediatric ED in 2018. We assessed the epidemiology and management of patients who received a psychotropic medication. We calculated the odds ratios (ORs with 95% confidence intervals [CIs]) of key demographic factors of medicated versus non-medicated MH patients. During 2018 there were 1695 MH-related presentations to the ED. Of these, 280 presentations resulted in the patient receiving a psychotropic medication (16.5%). Medicated children with MH illness were more likely to be male (OR 1.50, 95% CI 1.16-1.96), have a more acute triage category (OR 3.37, 95% CI 2.28-4.98), have an ED length of stay greater than 12 h (OR 3.96, 95% CI 2.56-6.13) and present after hours (OR 1.51, 95% CI 1.16-1.96). Most had a diagnosis of acute behavioural disturbance or suicidal ideation. A variety of treatment regimens were used but children primarily received a single oral agent (diazepam or olanzapine). Parenteral medications were given in 8.6%. No adverse events were recorded. A minority of children with MH presentations to the ED were medicated. It will require multicentre research to determine the most effective and safe acute psychotropic agents for oral and parenteral use in children in the ED.

Children and adolescents with severe acute behavioural disturbance in the emergency department.

Mental health (MH) presentations to ED are increasing in children and adolescents. Little is known about patients with severe acute behavioural disturbance (ABD). We set out to describe patients with ABD severe enough to trigger an acute crisis team response in ED (termed 'Code Grey') and how they differ from other MH patients. Retrospective electronic medical record review of all ED patients with MH discharge codes at a tertiary children's hospital. We assessed the epidemiology and management of patients who triggered acute crisis team interventions (Code Grey) as proxy for severe ABD. We calculated the odds ratios (ORs with 95% confidence intervals) of key demographic factors compared to other MH patients. During 2018, there were 85 347 ED presentations of which 1695 (2.0%) were related to MH diagnoses; 84 MH patients had 141 MH presentations triggering 204 Code Greys (26 patients triggered 59% of Code Greys). These patients had higher triage acuity (OR 12.6 [8.3-19.0]), stayed longer in ED (>12 h OR 8.2 [5.1-13.1]) and were more likely to be admitted (OR 2.0 [1.4-3.0]) compared with non-Code Grey MH presentations. Patients were physically (19.2%), mechanically (31.9%) or chemically restrained (37.6%). Eight different medication approaches were used as either a single agent or a combination of oral and/or intramuscular agents. Children and adolescents with severe ABD differ from other MH presentations and often require physical or chemical restraint. Anticipatory management plans may be valuable for repeat presenters.

Emergency department care for patients with mental health problems, a longitudinal registry study and a before and after intervention study

ObjectiveTo describe the numbers and length of stay (LOS) of patients with mental health (MH) problems at a Dutch emergency department (ED) and the effect of a psychiatric intervention team (PIT) on patient flow. MethodsA longitudinal design was used to assess number of MH presentations and LOS during a 3-year period (2014–2016). In 2017, we introduced a PIT during ED peak hours, to reduce LOS for patients with MH problems. We evaluate the effects of the PIT on patients’ LOS with an 18-month before and after intervention study (2017–2018). ResultsTotal number of ED presentations increased with 4%. Total number of MH presentations increased with 23% from 2014 to 2016. LOS increased by 28 min (95 min vs. 123 min) for all presentations, while not changing for MH presentations (2014: 195 min, interquartile range (IQR) 120–293 and 2016: 190 min, IQR 116–296). In the before and after intervention study, number of MH presentations increased with 36% while LOS decreased with 46 min (p < 0.001). ConclusionsThe number of MH presentations increased over the three years while LOS remained similar. In the before and after intervention study, number of presentations increased even more while LOS decreased significantly. Specialist psychiatric input reduces ED LOS.

Emergency Department Telepsychiatry Service Model for a Rural Regional Health System: The First Steps.

Emergency departments (EDs) have recognized an increasing number of patients presenting with mental health (MH) concerns. This trend imposes greater demands upon EDs already operating at capacity. Many ED providers do not feel they are optimally prepared to provide the necessary MH care. One consideration in response to this dilemma is to use advanced telemedicine technology for psychiatric consultation. We examined a rural- and community-based health system operating 21 EDs, none of which has direct access to psychiatric consultation. Dedicated beds to MH range from zero (in EDs with only 3 beds) to 6 (in an ED with 38 beds). We conducted a needs assessment of this health system. This included a survey of emergency room providers with a 67% response rate and site visits to directly observe patient flow and communication with ED staff. A visioning workshop provided input from ED staff. Data were also obtained, which reflected ED admissions for the year 2015. The data provide a summary of provider concerns, a summary of MH presentations and diagnosis, and age groupings. The data also provide a time when most MH concerns present to the ED. Based upon these results, a proposed model for delivering comprehensive regional emergency telepsychiatry and behavioral health services is proposed. Emergency telepsychiatry services may be a tenable solution for addressing the shortage of psychiatric consultation to EDs in light of increasing demand for MH treatment in the ED.

Predictors of Repeated Visits to a Pediatric Emergency Department Crisis Intervention Program.

Despite documented increases in emergency department (ED) mental health (MH) presentations, there are inconsistent findings on the characteristics of patients with repeat presentations to pediatric EDs (PEDs) for MH concerns. Our study sought to explore the characteristics of MH patients with repeat PED visits and determine predictors of return visits, of earlier repeat visits, and of more frequent repeat visits. We examined data collected prospectively in a clinical database looking at MH presentations to a crisis intervention program housed within a PED from October 2006 to December 2011. Predictive models based on demographic and clinical variables were constructed using logistic, Cox, and negative binomial regression. A total of 4,080 presentations to the PED were made by the 2,900 children and youth. Repeat visits accounted for almost half (45.8%) of all presentations. Multivariable analysis identified five variables that independently predicted greater odds of having repeat presentations, greater risk of earlier repeat presentations, and greater risk of frequent repeat presentations. The five variables were: female, living in the metropolitan community close to the PED, being in the care of child protective services, taking psychotropic medications, and presenting with an actionable need in the area of mood disturbances. Repeat visits account for a large portion of all MH presentations to the PED. Furthermore, several patient characteristics are significant predictors of repeat PED use and of repeating use sooner and more frequently. Further research is needed to examine interventions targeting this patient group to ensure appropriate MH patient management.

Management of mental health patients in Victorian emergency departments: A 10 year follow-up study.

Despite efforts to restructure mental health (MH) services across Victoria, the social and economic burden of MH illness continues to grow. This study compares MH presentations to EDs with a study undertaken 10 years earlier. The article is a retrospective observational study of MH presentations to four Victorian EDs between May and October 2013. Subjects were included if the presentation was MH related as determined by an International Classification of Diseases (version 10) discharge diagnosis, they were referred to an emergency crisis assessment team or had a documented presenting psychiatric complaint. Variables were extracted from electronic medical records and compared with 2004 data from a previous published study. There were 5659 MH presentations over the 5 months compared with 2788 in 2004. The median ED length of stay decreased from 4:18 h in 2004 to 3:20 h in 2013 (P < 0.001), with a significant reduction in length of stay >4 h from 52.5% to 35.4% (P < 0.001). There was a 22-fold increase in short stay units as discharge destination from 0.9% to 20.2% (P < 0.001). Patients presenting with concurrent methamphetamine exposure doubled from 2.2% of presentations to 4.3% (P < 0.001). Despite increasing MH-related presentations, changes in ED practice have allowed improvements in delivery of care through a shortened ED length of stay and the virtual elimination of very long stays over 24 h. However, there continues to be significant variability in management and performance across hospital sites. Identifying which interventions lead to standout site performance, and subsequent application more broadly, may improve future ED delivery of care.

Knowledge and experience of ED Triage nurses in management of patients with mental health needs: The Triage Model of Lazio (TML)

Background In recent years, Emergency Departments (ED) have reported a growing number of patients with mental health (MH) related presentations: often this condition is not recognized or not properly treated. Triage nurses are pivotal to the early detection and management of MH problems. The rapid assessment of MH presentations at triage requires skill, knowledge, experience and confidence. One of the more complex aspects of triage is suicide risk assessment. This study provides an overview of the …

Media Coverage of Youth Suicides and Its Impact on Paediatric Mental Health Emergency Department Presentations

To examine mental health (MH) presentations to the emergency department (ED) of a paediatric hospital following two highly publicized local teen suicides. Youths aged 12-18 years with a MH chief complaint and/or diagnosis were included. Differences in frequencies were analyzed using chi-square tests, and relative risks were evaluated using generalized linear modelling. Significant increases in the number of ED presentations were found within the months of the publicized suicides compared to the same months of previous years. No differences were found in symptom acuity, suicidal status and psychiatric hospitalization rates. Significant increases were found in relative risk of presenting to the ED 28 and 90 days post both publicized suicides. RESULTS suggest there was an association between highly publicized suicides and an increase in the number of MH presentations to the local paediatric ED. Considerations of media's potentially positive role in MH awareness are needed.

Characteristics and process outcomes of patients presenting to an Australian emergency department for mental health and non-mental health diagnoses

ObjectivesTo describe and compare characteristics and process outcomes of patient presentations made to a public hospital emergency department (ED) for mental health (MH) and non-mental health (NMH) diagnoses. MethodsThis was a descriptive, retrospective cross-sectional study of patients who presented to an Australian hospital ED between September 2011 and September 2012. Demographic, clinical and outcomes data were extracted from the ED information system. MH presentations were compared to NMH presentations. ResultsNearly 5% of the 66,678 ED presentations were classified as MH. Compared to the NMH group, a lower proportion in the MH group were seen by a physician within the recommended time frame (39.1% vs. 42.1%, p<0.001); had a higher admission rate (36.6% vs. 20.1%, p<0.001); shorter ED Length of Stay (LoS) if admitted (369 vs. 490min, p<0.001) and longer ED LoS if not admitted (241 vs. 187min, p<0.001). ConclusionTime constraints in the busy ED environment are a potential barrier to the delivery of care for all patients who have the right to timely access to health care. Targeted improvements at the front end of the ED system and output processes between ED, community and inpatient admission are recommended for this site.

Physician Management of Pediatric Mental Health Patients in the Emergency Department

The focus of this study was to describe the clinical data that pediatric emergentologists recorded and how they were used in the mental health (MH) care of patients. A structured chart review was conducted for all MH presentations to a pediatric emergency department in 2007. Three research assistants extracted clinical chart data and completed the Child and Adolescent Needs and Strengths Tool. The clinical records of 495 children and youth were reviewed. Emergentologists referred 124 (25.4%) for a psychiatric consult, and 46 (37%) of these patients were admitted to either an inpatient psychiatric or eating-disorders unit. Psychosis, suicide risk, eating disturbance, anxiety, and resistance to treatment predicted admission to the psychiatric inpatient unit or the eating-disorders unit. Of the 365 patients discharged back to the community, the majority (n = 189, 51.8%) were referred back to their family physician. For 117 patients (32%), there was no discharge documentation in the medical chart. Age, parent present, currently on medication, currently receiving counseling, depression, anxiety, and adjustment to trauma predicted provision of charted recommendation. This study revealed that the pediatric emergentologists' charting of MH patients is inconsistent and incomplete. Although recorded clinical data predicted psychiatric consultation and disposition for these patients, missing data were evident in a significant number of records. The results of the study point to a need to develop a more uniform approach to the collection and recording of clinical data for MH patients.

Increasing impact of mental health presentations on New South Wales public hospital emergency departments 1999–2006

The percentage of mental health (MH) presentations to New South Wales (NSW) EDs in recent years has not been described at the statewide level. Evidence from other states suggests this burden might be increasing. The present study aims to evaluate recent trends in MH presentations to NSW EDs, including geographic variations and the spectrum of MH disorders encountered. Data were sourced from the NSW Emergency Department Data Collection, which collates information from routine reporting undertaken in all NSW EDs. The database employs ICD-9 diagnostic descriptors. The present study retrospectively analyses presentations from 1999 to 2006 for patients who received an MH primary discharge diagnosis, as defined by ICD-9. In addition, rates of presentation for poisoning are considered. The percentage of MH presentations to the three largest hospital categories--principal referral, major metropolitan and rural base (i.e. major non-metropolitan)--is examined. During 1999 and 2006, there were 9,013,357 ED presentations at the study sites. Of these, 3.22% received an MH primary discharge diagnosis. An additional 0.93% received a diagnosis of poisoning. In 2006, there were 15,262 more MH presentations than in 1999, a 49.78% increase. Over this period, total annual ED presentations increased by 201,763 (19.30%). General population growth was 6.31%. Across the state, 32.0% of MH presentations were for psychotic conditions and 68.0% for neurotic illnesses. Mental health presentations to NSW EDs are increasing. There is a need to review emergency services to accommodate these changes. The reasons for this growth remain unclear and require formal prospective evaluation.