Blog: Crisis Interventions for Pediatric Mental Health Presentations in the Emergency Department

May 25, 2015 - This week's post is also available from the Cochrane Child Health blog.

Children’s Mental Health by the Numbers

Every year in Canada, 1.2 million children and youth experience mental health problems and illnesses [1]. Fewer than 20% of them receive appropriate treatment [2]. And from 2006-2007 to 2013-2014, the national rates of visits to the emergency department (ED) for mental disorders among children and youth between the ages of 5 and 24 increased by 45% [3]. 

Beyond the numbers, these statistics describe kids who are battling conditions like depression, harmful and hazardous substance use, and anxiety disorders. Kids who can present to the ED in acute crisis. Kids who often have nowhere else to go.

While ideally, children and youth with mental health needs would receive early intervention and community-based management, this doesn’t always align with service availability or the nature of the treatment need. Sometimes, a crisis can’t be avoided. In all these circumstances, the ED plays an important role in providing care. 

Emergency Department-Based Management Interventions for Mental Health Presentations

A systematic review published in 2010 evaluated the effectiveness of different ED-based management strategies used when children and youth presented with mental health complaints [4]. There were only three studies that focused on pediatric (≤18 years) populations, so nine additional studies in adult populations, or in populations where the age was unknown, were also included. In all cases, patients with a range of mental health conditions were represented.

The authors identified three main categories of interventions: specialized models of pediatric care, patient triage scales, and other ED mental health care.

Specialized Models of Pediatric Care: These interventions included referrals to a specialized psychiatric team, made up of at least a child psychiatrist, and possibly also other psychiatric professionals like a nurse specialist or social worker. In three studies, referrals to these teams were associated with reduced hospital admissions, length of stay in the ED, and a modest cost savings in the ED.

Patient Triage Scales: Five studies evaluated four different triage scales as they were applied to mental health presentations. The outcomes measured across studies were variable, limiting the conclusions that can be made.

Other ED Mental Health Care: While none were evaluated in pediatric populations, three other strategies were described in the systematic review. Changes in legislation allowing psychologists to recommend involuntary patient hospitalization did not lead to significant differences in disposition decisions made by psychologists, or between psychiatrists and psychologists. The use of crisis teams had no impact on patient distress in one study, but reduced hospitalization in another. A computerized reminder system for restraints reduced the time to renewal of restraint orders, as well as time spent in restraints.

Limited evidence on the best strategies to treat children and youth with mental health conditions was available, but this review did find some support for the use of specialized psychiatric teams, and identified gaps in the child health evidence where the adult literature may provide some direction, namely the use of triage scales and developing guidance for restraint.

Dr. Amanda Newton, the senior author of the review, commented “Recent statistics reinforce that addressing emergency mental health care is critical. What is clear from this review is that the pediatric evidence base requires development. Studies that evaluate the quality of care provided and patient reported outcomes are important. Evidence exists outside of this review for specialized care, such as care for intentional self-harm, but a focus on the quality of general emergency mental health care is also important as this is standard care provided in emergency departments.”  

Please join the authors of the systematic review for a live discussion on Twitter this Wednesday May 17 @ 2 pm MT. Check out the journal club announcement here.

References:

1. Mental Health Commission of Canada. (2013). School-based mental health and substance abuse project.

2. Mental Health Commission of Canada. (2015). Topics: Child and Youth.

3. Canadian Institute for Health Information. (2015). Care for Children and Youth with Mental Disorders.

4. Hamm, M. P., Osmond, M., Curran, J., Scott, S., Ali, S., Hartling, L., . . . Newton, A. S. (2010). A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research. Pediatr Emerg Care, 26(12), 952-962. doi: 10.1097/PEC.0b013e3181fe9211