Suicidal thoughts and other mental-health problems drive more youth to emergency rooms

The number of children and young adults visiting the emergency department for psychiatric concerns rose 28 percent over a four-year period, and visits having to do with suicide more than doubled, according to a study published this week in the journal Pediatrics.

The findings amplify concerns that the mental-health care system is failing to meet the country’s needs, forcing people to rely on emergency rooms ill-equipped to deal with psychiatric concerns.

“If it’s a true crisis, the emergency department is really one of the only places we have,” said Luther Kalb, a coauthor of the study and assistant professor at the Kennedy Krieger Institute in Baltimore. “But it’s not the best place to get routine care.”

Researchers examined national data on emergency department (ED) visits between 2011 and 2015.

They found the growth in visits was largely driven by adolescents and youth of color, but they’re not sure why. It could reflect a greater prevalence of mental illness, or it could be the result of greater awareness leading people to seek help, Kalb said.

Researchers also found only 16 percent of patients in the ED for psychiatric concerns saw a mental-health specialist. When the visits were for suicide or self-harm specifically, that number went up to just 37 percent.

“Even in a crisis, you’re not going to get the most qualified care there,” Kalb said.

Many EDs don’t have a psychologist or psychiatrist on staff, and there’s an overall shortage of mental-health providers in the country.

But as rates of suicide increase across the nation, and about one in 10 youth struggle with a serious psychiatric disorder, experts are increasingly turning to the ED as an opportunity to identify people at risk and get them help before they get worse.

A recent federally funded study found nearly a third of children ages 10 to 12 who were asked about suicidal thoughts in the emergency room were identified as at-risk — including 7 percent of those who had gone to the ED for physical complaints only.

The study authors said their results show how important it is to screen kids as young as 10 for suicide risk.

But in many EDs, this type of screening doesn’t happen, meaning youth with psychiatric concerns can go home without mental-health care.

It also means the increase in psychiatric visits seen in recent years is an undercount. “When you actively screen for mental-health problems in the ED, you’re going to get a much higher number,” Kalb said.

By the time individuals visit the ED for mental-health concerns, they’re often in crisis, Kalb said.

People who don’t have insurance or cannot access mental-health professionals turn to the ED as a safety net when situations get particularly bad. The ED is obligated to treat all patients regardless of time of day, insurance status, or financial means.

According to the study, 5 to 7 percent of all pediatric ED visits in the United States are related to mental health or substance abuse.

“It’s become the de facto provider for mental-health crises,” Kalb said. “But it didn’t necessarily ask to take on that role.”

Kalb and his colleagues found more than half of all ED visits for mental health were longer than three hours. As the number of inpatient psychiatric beds has decreased in the last few decades, patients can wait days or even weeks to be admitted.

“They’re not safe to go home, so they’re stuck in this middle ground in the ED,” Kalb said.

Ideally, Kalb said, there should be emergency facilities for mental-health care where patients can see a mental-health professional 24/7, and get fast-tracked to inpatient treatment if needed.

Some behavioral crisis centers provide this type of service, but they’re rare. The cost and complexity of starting such centers are barriers, Kalb said.

Simpler ways to improve care include training more ED doctors in mental-health response, from how to screen to what to do if someone is identified as high risk.

Researchers at the National Institute of Mental Health have developed guidance on how to screen youth for suicide in medical settings. Previous studies have shown universal suicide-risk screening in the ED can lead to a nearly twofold increase in suicide-risk detection.

Another promising effort is the use of telemedicine to have mental=health specialists consult on emergency cases even if they cannot be with the patient in the ED.

“Now that we’re seeing mental health is a major, if not growing, issue in our society, we need to rethink the way we deal with crises,” Kalb said.