Journal Article Annotations
2022, 3rd Quarter
Annotations by Scott A. Simpson MD MPH
The increasing frequency and acuity of adolescent presentations for behavioral health crises have posed myriad difficulties for emergency psychiatrists and mental health systems. In this narrative synthesis of a systemic literature review, the authors described the benefits of emergency psychiatric models for reducing hospitalization and readmissions among 22 studies with a total of 39,346 patients ages 8-25 across the United States, Canada, and Australia. The variety of studies precluded a meta-analysis, but an overarching theme is apparent: more robust behavioral health services in emergency departments (EDs) reduce hospitalization and representation rates among youth and young adults. Large effect sizes were seen for such diverse modalities as acute crisis units, multidisciplinary consultation teams, telepsychiatry, and enhanced follow-up services. Fewer data were available on adverse event rates.
Strength and weaknesses:
The literature review robustly captured English language literature from multiple countries. Quality assessments were included for reviewed articles, although many studies used a pre-post design, and publication bias appears likely. The authors cannot discern how these interventions reduce hospitalization—whether by systemic improvement in care, dedicated of experienced staff, or altered expectations around potential disposition for at-risk patients.
Youth presenting to ED for behavioral health care are at risk of adverse psychiatric and medical encounters. While providers and health systems often feel under-equipped to manage these presentations, in fact, a range of crisis interventions can help these patients access care without hospitalization. Indeed it seems likely that the effect size for these interventions is larger than for adults. In an era where reducing pediatric ED boarding has an urgent priority, C-L psychiatrists can advocate for more inpatient capacity but must also support development of ED-based services to reduce the demand for higher levels of care.
ED boarding of psychiatric patients remains a persistent challenge for the accessibility, quality, and safety of acute mental health care. This brief commentary presents a familiar example of a psychotic patient who develops iatrogenic agitation in the ED while awaiting disposition to inpatient psychiatry. The authors use this brief case to imagine how to improve patients’ psychiatric care while boarding in the ED. The benefits of rapid consultation and medication management, dedicated crisis units, and virtual teletherapy (including groups) are particularly highlighted. This brief commentary nicely juxtaposes the challenges of boarding psychiatric patients alongside relatively straightforward prescriptions for improving these patients’ care.