Children Present Major MH Challenge for Emergency Departments
Abstract
Just because children show up in the emergency department with a psychiatric complaint doesn't mean that they are having a psychiatric emergency.
"Many times, they have an appointment with an outpatient provider, but they have to be seen sooner," said L. Charolette Lippolis, D.O., M.P.H., a child psychiatrist in the psychiatric emergency service at the Children's Hospital of Colorado in Denver, in an interview.
At her hospital, Lippolis sees an overall increased use of the emergency department (ED), which she attributed to a mixture of circumstances. Many EDs in the area have closed, even as the number of inpatient psychiatric beds has declined. Lengths of stay are shorter, and patients aren't always fully stabilized before they are discharged, leading to rehospitalization, she said. "There is also a huge gap in outpatient services, leading to long waits."
A study published in 2002 based on the National Hospital Ambulatory Medical Care Survey reported that pediatric mental health visits to emergency departments rose from 305,000 in 1993 (43.3 per 10,000) to 459,000 in 1999 (61.0 per 10,000).
A more recent survey by another group of researchers, as yet unpublished, says that the percentage of psychiatric diagnoses of the 279 million pediatric emergency visits from 1999 to 2007 rose from 2.4 percent to 3 percent.
Recent research is contributing some insights into this rise.
"There's an increase in presentations with general behavioral dysfunction but not always with clear psychiatric emergencies," said Emily Frosch, M.D., an assistant professor of psychiatry and behavioral sciences and director of education and training in the Division of Child and Adolescent Psychiatry at Johns Hopkins School of Medicine.
In a study of 338 youths who had two visits within six months to the Hopkins Pediatric Emergency Department, Frosch and two colleagues found that 82 percent of the sample had prior contact with the mental health care system. The study appeared in the June Psychiatric Services.
Fewer than 10 percent had made a suicide attempt, and 3 percent had psychotic symptoms at both visits.
Historically, the mental health system pushed for diversion from the ED, said Frosch.
"The thinking was that if you only connected children with care, they wouldn't have to use the emergency department," she said. "But this study finds that most of these children already had an outpatient provider, so accessing care isn't the rate-limiting factor."
One explanation for this apparent discrepancy may reflect a conflict in how different participants view the system, she suggested.
The ED may look to patients, families, and some outpatient providers as the logical place for care despite the current systems' view promoting diversion from the ED in all but the most acute cases.
In some ways it's not surprising that many repeat visitors to the ED are already connected to the mental health system, said Dorothy Stubbe, M.D., an associate professor and director of residency training at the Yale Child Study Center, in an interview.
"You have to adopt a chronic disease model with these children, like those with diabetes," said Stubbe. "Even if they have outpatient treaters, these are the sickest children, so they may need more services. They may need a place to be stabilized, be safe, and then return to their treater."
Understanding the reasons why children appear in psychiatric emergency settings might better inform both policy and clinical practice, Frosch noted.
The need is there, according to a 2007 Institute of Medicine report. "Children with mental health problems represent a real challenge to emergency care providers," said the report. "Some children present to the ED with highly disruptive behaviors, antagonizing health workers and showing signs of rage, [yet] ED providers often lack the training, skills, and resources to deal effectively with mentally ill patients."
The study received no outside funding.
An abstract of "Connections to Outpatient Mental Health Care of Youths With Repeat Emergency Department Visits for Psychiatric Crises" is posted at <http://ps.psychiatryonline.org/cgi/content/abstract/62/6/646>.
