Improving Outcomes for Youth Visiting the Emergency Department With Mental Health Issues

Background/Significance The number of youth visiting the ED with MH issues has risen dramatically in the last decade.1 EDs have become a safety net for a strained mental health system that is under resourced and lacks adequate services to meet demands at the impatient and outpatient level.2 EDs bear a high burden of caring for children and adolescents with acute psychiatric illness, and pediatric patients with MH-related visits require substantial ED resources.2,3 Visits to the ED for MH are longer, more likely to be triaged to urgent evaluation and result in more admissions or transfers compared to visits for other reasons.4,5 ED revisits are also are also common in pediatric MH patients, with a recent study finding return rates of 6-9% within 72 hours, and return rates around 30% over a 4-year study period.6 ED visits for children and adolescents with MH concerns are resource intensive, and further research will be crucial for improving the management of these patients.2,3

Information lacking on resources needed by MH diagnostic subgroup:

MH issues encountered by ED physicians cover a broad range of diagnoses. Bardach et al. examined MH hospitalizations and identified the following as the most common diagnostic subgroups: depression, bipolar disorder, psychosis, externalizing disorder, anxiety disorder, ADHD, eating disorder, substance abuse, reaction disorder and autism.7 ED visits for MH concerns are often thought to mainly involve suicide attempts, self-harm behavior or psychosis, but a recent study of a large urban pediatric ED found that almost half of the visits were for behavioral problems.8 Preliminary data has described that almost half of the behavioral assessments done at CH in 2013 were on individuals with developmental disorders (i.e. autism spectrum disorders). The number of MH ED visits for behavioral issues is growing, but there is limited information regarding this population.8 Overall, the ED experience has not been well documented based upon diagnostic subgroup, but there are critical differences in MH patients depending on their primary concern, specifically connection to outpatient resources and risk of ED revisit.8,9 In order to more efficiently help MH youth it is crucial to obtain information regarding services, and how this differs by diagnostic subgroup.8

Text-messaging to improve MH referral follow-up:

The ED represents a suboptimal care setting for MH youth but does provide an important opportunity to identify children and adolescents in crisis and connect them with external resources.8 Unfortunately, successful follow-up with MH resources by ED patients has been shown to be low, with some studies finding follow-up rates below 30%.10,11 A recent study found that 66% of patients visiting the ED with suicidal behaviors successfully followed up with a mental health provider, a more positive number, but one that still shows a large need for improvement.12 Strategies are needed to improve successful follow-up with MH outpatient referrals as failure to comply with ED discharge guidelines could result in worsening of symptoms and return visits to the ED. While ED providers have a unique opportunity to identify MH youth and provide referrals, they also have limited time and resources. If an intervention is to be incorporated into usual care in the ED, it must be simple, efficient, and easy to replicate. Automated text messaging reminders have been shown to increase attendance to healthcare appointments.13 Over 90% of Americans reported owning a cell phone in 2013, and 81% report using their cell phone to send or receive text messages.14 In addition, the cost and personnel requirements needed to implement an automated text message based system are low, making this a unique intervention technique that could be easily incorporated into usual care in any ED.15 A recent study found that automated text message appointment reminders improved follow-up attendance to primary or specialty care in adult ED patients.15 Additional research is needed to examine the potential of a text message strategy to increase attendance to follow-up appointments in a diverse population of youth visiting the ED the MH concerns.