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More resources needed for pediatric mental health emergencies

There are increasing pediatric mental health visits to hospital emergency departments. Unfortunately, most EDs are unprepared and unsupported to meet this demand.

In my last post, I discussed a recent study from Canada which found increasing pediatric mental health visits to hospital emergency departments. The situation is similar for hospitals in the United States as well.

In the Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical Services System report published in Pediatrics in May 2011, several studies were cited which documented an increase of visits for psychiatric illness EDs in the United States. Mental health illness now accounts for up to 5 percent of pediatric ED visits.Twenty-one per cent of U.S. children aged 9 to 17 years have a diagnosable mental or addictive disorder based on the 1999 Surgeon General's Report on mental health. Ten percent of children in the U.S .currently suffer from mental illness, and more than 30 million children require mental health or substance abuse services, according to a National Institute of Mental Health report.

By the year 2020, the World Health Organization estimated that neuropsychiatric disorders will become one of the five most common causes of morbidity mortality, and disability for children. According to the Institute of Medicine report, not only is ED use for psychiatric illness increasing, but younger patients are being seen. Depression, bipolar disorder, and anxiety are now being identified in children of elementary school age,

An article published in Child and Adolescent Psychiatric Clinics of North America earlier this year, cites suicide and homicide or aggression as the two most common pediatric mental health emergencies. Suicide accounts for more than 4,000 deaths per year, and is the third leading cause of death among persons aged 10 to 24 years. Among teenagers, approximately 16 percent report having seriously considered suicide in the past year, 12.8 percent report having planned a suicide attempt, and 7.8 percent report having attempted suicide in the past year.

All the perpetrators in the Columbine High school shooting in 1999, the Virginia Tech shooting in 2007, and the Newtown Sandy Hook Elementary School shooting in 2012 suffered from mental illness. Events similar to these have led to increased awareness of the disastrous consequences of untreated depression, suicidality, and aggression among adolescents and young adults.

As a result, there has been a dramatic increase in youth presenting to the ED for psychiatric care. Because of a lack of psychiatric specialists and inpatient and outpatient facilities, schools, primary care physicians, and mental health therapists, who cannot admit patients directly from their offices, funnel these patients to the ED.

All EDs in Medicare participating hospitals are mandated to care for all patients who present, after the Emergency Medical Treatment and Active Labor Act (EMTALA) enacted in 1985 which was meant to protect the rights of indigent patients seeking emergency care. EDs have therefore become the safety net for diagnosing and managing psychiatric illness in children. Unfortunately, most EDs which carry this burden are unprepared and unsupported to meet this demand.

EDs can be crowded, noisy, have long wait times, and have little to no private and quiet space available for emergency psychiatric care. This environment can be deleterious for traumatized, paranoid, agitated, or autistic youth. Agitated or aggressive patients sometimes require physical restraints or medications. Restraining patients is labor intensive, and further stretches the already tight resources in busy EDs. ED providers such as physicians, mid-level providers, nurses, and emergency technicians, lack training in the diagnosis and treatment of children and adolescents with psychiatric complaints. They also have limited access to experts in the field.

In a statewide survey in California, less than 50 percent of the EDs could get assistance from a social worker, less than 35 percent had availability of a general psychiatrist, and only 10 percent had availability of a child psychiatrist for consultation. The number of adult and pediatric beds in US state mental health facilities decreased by 32 percent between 1992 and 1998. This number has since dropped significantly below 60,000, and fewer than half are allocated for acute care. The combination of fewer inpatient psychiatric beds and insufficient outpatient services leaves EDs with no choice but to hold or board pediatric psychiatric patients, or admit them to the pediatric ward. These admissions often do not get reimbursed.

All stakeholders for children's mental health wellness need to come together and advocate for potential solutions to this crisis in pediatric mental health care:

  1. Standards of care for the emergency evaluation and treatment of children with psychiatric illness have to be developed.

  2. Primary care physicians who care for children, and pediatric emergency medical providers, need increased training in the identification and treatment of pediatric mental health illness as well as de-escalation and crisis management.

  3. Emergency providers and child psychiatrists require greater collaboration in the management of high risk cases. Telepsychiatry programs, and mobile psychiatric evaluation teams utilized in some parts of the country, have shown promise.

  4. High-quality inpatient and acute care outpatient services for youth in crisis have to be more accessible and available.

  5. Research and development of programs to identify the most effective and cost-effective models of pediatric psychiatric crisis care, both in the ED, and the community, have to be coordinated and funded.

  6. Reimbursement for mental health services for children and adolescents at all levels, have to improve.

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