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Making the most out of crisis: child and adolescent mental health in the emergency department
Editorial
Mental illness continues to be one of the greatest challenges facing practitioners and health systems around the world. Because mental illness often presents during adolescence and young adulthood, it can have profound implications for a person’s wellbeing across their lifespan. In a striking example, estimates from the Global Burden of Disease Study 2013 (GBD 2013) reveal that the second most common cause of death for young people aged 10–24 years is self-harm (males 7·8%; females 7·4%). It is a poignant reminder that, unchecked, the volatility of mental illness is a powerful, life-shortening threat. Although self-harm is not in and of itself defined as a mental illness, it is a symptom associated with significant emotional distress, poor coping mechanisms, and with psychopathology. Not only are deliberate self-induced injuries on the rise among adolescents overall, but selfharm is often a predictor of subsequent suicide attempt, in particular in the period directly after a self-harming incident. Fortunately, the majority of self-induced injuries are not fatal, thus providing a window where paediatric patients who self-harm and are at elevated risk can potentially be identified and monitored. Given the gravity of self-harm, it is exceedingly important to determine the contexts in which young people receive care as well as the best practices for intervention in those settings. In the USA, care during acute mental health crises commonly falls to emergency departments (EDs). Adolescent ED visits precipitated by psychiatric circumstances have dramatically increased in the past two decades, with nearly a quarter of young patients being seen in EDs and primary care settings meeting criteria for a diagnosable mental health disorder. Use of EDs for mental health crises is not only increasing because of higher demand, but also because, for many, EDs serve as the only point of medical contact that young people have—often in lieu of primary care or other non-emergency psychiatric services. For most EDs, this is not, however, an ideal substitution because of the lack of both resources and specially trained providers equipped to care for children and adolescents in crisis. Accordingly, ED and paediatrics communities have taken note of the rising burden placed on the ED. In two clinical reports published together in Pediatrics in August 2016, the American Academy of Pediatrics has outlined www.thelancet.com Vol 388 September 3, 2016
various issues that should be considered when treating a child or adolescent in the ED who has a chief psychiatric complaint or emergency or alternatively when a mental health condition may be a secondary factor. For example, one of the critical evaluations that ED physicians must make is whether a patient qualifies for medical clearance or should be treated for an underlying medical condition—a task that is considerably more difficult in children where routine tests such as urine toxicology for drug screening are unlikely to yield helpful results. Thus, obtaining a detailed patient history and communication with psychiatric providers becomes increasingly valuable. The reports lay out some especially useful advice for the evaluation and determination of level of care for paediatric patients with suicidal ideation or attempt. Often seemingly obvious precautions such as putting a patient in a room without access to medical equipment or being supervised can easily be overlooked in the ED setting. When the risk for self-harm is greatest and restraint is necessary, there is also hierarchical guidance for strategies from verbal de-escalation, to the selection of medications to reduce agitation, to the appropriate application and complications of physical restraint. In addition to providing a distillation of the various approaches for comprehensively evaluating a child or adolescent in the ED during an acute mental health crisis, the reports impart some timely and valuable insights for the larger conversation of how EDs are used in the USA. Although children and adolescents are a distinct group that need special consideration, they are clearly not the only ones who rely on ED services. While it is an open debate as to whether the ED is the best first-line option to treat psychiatric patients in crisis, it certainly is being used as such, which could be an overlooked positive given more investment in training and expanding capacity. As the report notes, underserved populations such as homeless people or those with substance abuse disorders, who are already disproportionately reliant on EDs for care, might actually benefit from rapid ED-based screening and coordination of care. As demand increases and ED use, especially for psychiatric crises, grows, perhaps it is time to rethink what an ED can and should be. The Lancet
Vectorarts/iStock
Making the most out of crisis: child and adolescent mental health in the emergency department
For the Global Burden of Disease Study 2013 on young people’s health see http://www.thelancet. com/journals/lancet/article/ PIIS0140-6736(16)00648-6/ fulltext For the two reports in Pediatrics see http://pediatrics. aappublications.org/content/ early/2016/08/18/ peds.2016-1570 and http:// pediatrics.aappublications.org/ content/early/2016/08/18/ peds.2016-1573
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Mental illness continues to be one of the greatest challenges facing practitioners and health systems around the world. Because mental illness often presents during adolescence and young adulthood, it can have profound implications for a person’s wellbeing across their lifespan. In a striking example, estimates from the Global Burden of Disease Study 2013 (GBD 2013) reveal that the second most common cause of death for young people aged 10–24 years is self-harm (males 7·8%; females 7·4%). It is a poignant reminder that, unchecked, the volatility of mental illness is a powerful, life-shortening threat. Although self-harm is not in and of itself defined as a mental illness, it is a symptom associated with significant emotional distress, poor coping mechanisms, and with psychopathology. Not only are deliberate self-induced injuries on the rise among adolescents overall, but selfharm is often a predictor of subsequent suicide attempt, in particular in the period directly after a self-harming incident. Fortunately, the majority of self-induced injuries are not fatal, thus providing a window where paediatric patients who self-harm and are at elevated risk can potentially be identified and monitored. Given the gravity of self-harm, it is exceedingly important to determine the contexts in which young people receive care as well as the best practices for intervention in those settings. In the USA, care during acute mental health crises commonly falls to emergency departments (EDs). Adolescent ED visits precipitated by psychiatric circumstances have dramatically increased in the past two decades, with nearly a quarter of young patients being seen in EDs and primary care settings meeting criteria for a diagnosable mental health disorder. Use of EDs for mental health crises is not only increasing because of higher demand, but also because, for many, EDs serve as the only point of medical contact that young people have—often in lieu of primary care or other non-emergency psychiatric services. For most EDs, this is not, however, an ideal substitution because of the lack of both resources and specially trained providers equipped to care for children and adolescents in crisis. Accordingly, ED and paediatrics communities have taken note of the rising burden placed on the ED. In two clinical reports published together in Pediatrics in August 2016, the American Academy of Pediatrics has outlined www.thelancet.com Vol 388 September 3, 2016
various issues that should be considered when treating a child or adolescent in the ED who has a chief psychiatric complaint or emergency or alternatively when a mental health condition may be a secondary factor. For example, one of the critical evaluations that ED physicians must make is whether a patient qualifies for medical clearance or should be treated for an underlying medical condition—a task that is considerably more difficult in children where routine tests such as urine toxicology for drug screening are unlikely to yield helpful results. Thus, obtaining a detailed patient history and communication with psychiatric providers becomes increasingly valuable. The reports lay out some especially useful advice for the evaluation and determination of level of care for paediatric patients with suicidal ideation or attempt. Often seemingly obvious precautions such as putting a patient in a room without access to medical equipment or being supervised can easily be overlooked in the ED setting. When the risk for self-harm is greatest and restraint is necessary, there is also hierarchical guidance for strategies from verbal de-escalation, to the selection of medications to reduce agitation, to the appropriate application and complications of physical restraint. In addition to providing a distillation of the various approaches for comprehensively evaluating a child or adolescent in the ED during an acute mental health crisis, the reports impart some timely and valuable insights for the larger conversation of how EDs are used in the USA. Although children and adolescents are a distinct group that need special consideration, they are clearly not the only ones who rely on ED services. While it is an open debate as to whether the ED is the best first-line option to treat psychiatric patients in crisis, it certainly is being used as such, which could be an overlooked positive given more investment in training and expanding capacity. As the report notes, underserved populations such as homeless people or those with substance abuse disorders, who are already disproportionately reliant on EDs for care, might actually benefit from rapid ED-based screening and coordination of care. As demand increases and ED use, especially for psychiatric crises, grows, perhaps it is time to rethink what an ED can and should be. The Lancet
Vectorarts/iStock
Making the most out of crisis: child and adolescent mental health in the emergency department
For the Global Burden of Disease Study 2013 on young people’s health see http://www.thelancet. com/journals/lancet/article/ PIIS0140-6736(16)00648-6/ fulltext For the two reports in Pediatrics see http://pediatrics. aappublications.org/content/ early/2016/08/18/ peds.2016-1570 and http:// pediatrics.aappublications.org/ content/early/2016/08/18/ peds.2016-1573
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