This article is from the National Association of State Mental Health Program Directors Weekly Update – February 21. NASMHPD consistently does great work for State Mental Health Program Directors. Learn more about NASMHPD here.

Study Finds One-Half of Children and Adolescents with a Mental Health Complaint Boarded in an Urban Emergency Department At Least 24 Hours Did Not Receive a Formal Psychiatric Evaluation or Treatment Recommendations

Slightly more than one-half (51.5 percent) of the 573 pediatric psychiatric patients with a mental health complaint or suicidal ideation who boarded for 24 hours or more at a tertiary care urban pediatric hospital in Baltimore from September 2015 to August 2018 left without receiving a formal psychiatric evaluation from a psychiatrist or treatment recommendations.

The retrospective cohort study by Erin P. O’Donnell, M.D. of the Division of Pediatric Emergency Medicine at Johns Hopkins University School of Medicine and her colleagues, reported February 17 in a research letter published on-line in JAMA Pediatrics, included children and adolescents 3- to 18-years-of- age presenting at the Johns Hopkins Pediatric E.D. who were evaluated initially for a mental health chief complaint. Patients had a mean boarding time of 54 hours. Boarding commonly occurred during school months (520 [90.8 percent]), and 97 patients (16.9 percent) for whom hospitalization was initially recommended were discharged home.

The most common chief complaints among the pediatric patients in the study cohort included suicidal ideation or suicidal attempt and behavior disorder (e.g., disruptive disorder). Many patients had a comorbid psychiatric history, with only 74 (12.9 percent) having no previous psychiatric diagnosis. Prior and subsequent ED encounters for mental health concerns were experienced by only 254 patients (46.2 percent) and 143 patients (25.0 percent), respectively.

The most common psychiatric diagnoses among the cohort included depressive disorder (276 [48.3 percent]) and attention- deficit/hyperactivity disorder (259 [45.3 percent]). Answers to Ask Suicide-Screening Questions were positive for 378 patients (66 percent).

Demographic and clinical data were abstracted from medical records. Community socioeconomic status was assessed using data from the US Census Bureau pertaining to income and poverty by census tract or community statistical areas based on the patient’s home address. Of the 573 patients in the cohort, 306 (53.4 percent) were female, and the mean age was 14 years. Most patients were African American (349 [60.9 percent]), resided within the Baltimore city limits (322 [56.2 percent]), and had no long-term medical conditions (354 [61.8 percent]). More than half of the patients lived in communities with a lower median household income and higher poverty rate than the national average.

Among the patients with aggressive behavior, one-quarter (156 [27.2 percent]) required additional medications, and 45 patients (7.9 percent) required physical restraints.

The authors of the study say that the fact that almost half of the patients in the cohort had prior mental health-related ED visits, together with previous studies revealing that patients fail to receive care from mental health clinicians prior to ED presentation, underscores the importance of improving access to outpatient services.

The 2018 NASMHPD Beyond Beds paper, Making the Case for a Comprehensive Children’s Crisis Continuum of Care , by Elizabeth Manley, L.S.W., et al. suggests a way to address this need. That paper posits that a crisis continuum of care designed specifically to meet the needs of children, youth, and young adults, and their parents/caregivers is essential to deescalate and ameliorate a mental health crisis before more restrictive and costly interventions become necessary, and to ensure connection to necessary services and supports.

Ms. Manley and her associates contend that a high-quality child and youth crisis continuum should be available 24/7 for all children, regardless of who the payer might be. The comprehensive crisis continuum the contemplate would feature screening and assessment, using a validated screening tool; mobile crisis response; crisis stabilization services and residential crisis services, where necessary; psychiatric consultation; referrals and warm hand-offs to home- and community-based services; and ongoing care coordination.

Within such a crisis continuum, mobile response and stabilization services (MRSS) would serve to effectively deescalate, stabilize, and improve treatment outcomes, interceding before urgent behavioral situations become unmanageable emergencies. Such services could be instrumental in averting unnecessary emergency department visits, out-of-home placements and placement disruptions, and in reducing overall system costs.

The authors of the paper acknowledge, as the Hopkins study has found, that a significant percentage of persons seen by MRSS providers have not previously received behavioral health treatment and that a first experience in receiving crisis services can be daunting. That makes engaging families in a culturally and linguistically competent crisis response is essential to reducing risk and preventing future crises, but also for developing the type of trust that ensures a family will choose to seek services in the future.