Are the Kids Alright? Investigating the Apparent Epidemic in

Pediatric Emergency Mental Health Presentations

David Lovas, MD, FRCPC

Co-Lead of IWK Emergency Mental Health & Addictions

Leslie Anne Campbell, RN, PhD

Sobey Family Chair of Pediatric Mental Health Outcomes

Disclosures

• None

• Natasha is 15

• No PMH/PPH

• Presents to ER with mom

• Mom has just discovered that Natasha has been cutting herself for several months, and when she asked her about it, she said that she thinks about killing herself

• A thorough assessment reveals chronic NSSI, anxiety, no clear mood disorder, but chronic difficulties regulating herself and dealing with stress. She is able to safety plan and is interested in outpatient follow-up which, is offered

• Mom is worried and wants Natasha admitted

Outline

• What’s happening?

• Are pediatric emergency mental health presentations increasing?

– Examining the evidence

• If so, why?

• What can be done?

• What are the challenges?

• Epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area.

• Pandemic refers to an epidemic that has spread over several countries or continents, usually affecting a large number of people.

Center for Disease Control (CDC)

Recent Media Attention

• CIHI Report released spring 2015

*ED visits are for Alberta & Ontario only

Pedi ED MH Presentations Over Time

1990 2000 2010

Sills 2002 (‘93-’99) [US]

Taastrom 2014 (‘01-’10) [Norway]

Pittsenbarger 2014 (‘01-’10) [US]

Mapelli 2015 (‘02-’12) [BC]

What are kids presenting with?

CIHI data

1) Anxiety disorders*

2) Substance-related disorders

3) Mood disorders*

* = biggest increases

What are kids presenting with?

Sills et al, 2002

What are kids presenting with?

Newton et al, 2009

Why are pediatric emergency mental health presentations increasing?

Medicalization of behavioural concerns

Mental illness

Inadequate primary care/MH services or access to care

MH perceived as more

dangerous

Parents, Schools, Police more aware,

but more fearful Biomedical MH promotion

Emergency MH

Presentations Societal Stress / Changes

Mental Illness?

Mental Illness Incidence/Prevalence?

• Lots of evidence for treatment-seeking and treatment rates, including psychotherapy and psychopharmacology (e.g. Olfson et al, 2014)

• Some rates of diagnoses may be related to treatment-seeking, public and physician awareness, broadened diagnostic definitions

• Rates of severe mental illness tend to be stable (e.g. schizophrenia) and don’t tend to vary across countries/cultures/time; other disorders such as conduct disorder & substance use vary by cultural/social factors/changes

Collishaw, 2015 Maughan et al, 2005 Hafner, 1985

Mental Illness Incidence/Prevalence?

• Evidence that current rates of MH diagnoses in high income countries are higher than in the 70s and 80s

• But that the observed increase leveled off or even decreased slightly at the end of the 20th century / beginning of the 21st century

Maughan et al, 2008 Nuffield Foundation Report, 2009

Mental Illness Incidence/Prevalence?

• Other general pediatric MH service use studies have shown rates of use, but not associated with rates of mental illness/distress

• Rather, factors such as rates of disrupted families (single parents, etc) and educational problems were associated with rates of use

• Disorder or loss of function is not as predictive of general MH service use as parental burden, parental/teacher perception

Tick et al, 2008 Wichstrom et al, 2014 Ryan et al, 2015

Inadequate Access to Care?

Inadequate Access to Care?

• US data – 80% of 6-17 year olds do not received needed mental health services (Kataoka et al, AJP, 2002)

• Poorer insurance more frequent ED visits (for both MH and general health)

• Poorer insurance poorer access to primary care (Newacheck et al, NEJM, 1998)

• Adult data – Less regular primary care more non-urgent ED visits (Petersen et al, 1998)

Inadequate Access to Care?

• Poorer, under resourced areas (e.g. Northern Alberta) are associated with fewer GP visits before or after the ED visit, and higher rates of ED visits for teens with mood disorders

• Minority children are less likely to have had a mental health visit before an ED visit than white children (Kataoka et al, AJP, 2002; Snowden et al, 2008)

• [Paste my correlations here from the CIHI data re MH care professional correlations with admission rates by province]

Societal Stress / Changes?

Societal Stress / Changes?

• Are there more pediatric MH crises because society in general is more stressed? Are kids & ERs the Canary in the Coal Mine?

• ¼ workers in Canada describe their day-to-day lives as “highly stressful”

• But these rates/markers of stress in Canada do not appear to be rising over the past 15 years

Stats Can

Societal Stress / Changes?

• Example of adolescent conduct disorders - rates of disorder associated with (Collishaw et al, 2007):

– Single parent & stepparent families

– Income inequality

• In general, these factors, along with parent unemployment, are associated with general pediatric MH service use (Gunther et al, 2003)

Societal Stress / Changes?

• ED Rates Alberta (2002-08) (Newton et al, CMAJ, 2012):

– Rates of visits go for First Nations kids and those on government subsidy

– They have the highest rates of visits, risk of return, and longest post-ED visit wait for psychiatry (First Nations), or general practitioner (government subsidy)

– Most common diagnoses: anxiety & acute stress reactions

– Rates go down for the non-First Nation/Subsidy kids

The Double-Edged Sword of Mental Health Promotion?

The Double-Edged Sword of Mental Health Promotion?

• Meta analysis on trends in public attitudes towards mental illness:

– Improving MH literacy, primarily biological model

– Greater acceptance of treatment

– But…

– Public stigma has not decreased, and if anything may have increased…

Schomerus et al, 2012

The Double-Edged Sword of Mental Health Promotion?

• Biomedical model awareness ‘side effects’: – Increased perceived dangerousness – Increased fear – No change in desire for distance

• Rather individuals with mental disorders are more likely to come to harm, than to harm others – Higher and earlier mortality – Greater risk of experiencing violence

• Biomedical model implicitly/explicitly suggests the use of medical resources – hence the ED / hospital

Kvaale et al, 2013

What can we do?

1) Need to better understand better why families are bringing their kids to the ER – Quantitative epidemiological analysis of our local

data and summarizing the national & international data

– Examine the effect of repeat or high-utilizers (“Super Utilizers” – defined as 4 or more visits/yr; US Medicare/Medicaid)

– Qualitative analyses with families; engaging patients and families to be involved in research so that their views inform the work

What can we do?

2) Need to better understand the needs of families and the perceived gaps in services or inadequacies of emergency care

3) Establishing Emergency Mental Health quality improvement markers based on the identified problems and patient/family based needs

4) Collaborating with stakeholders to identify top priority (highest potential impact) projects, related QI markers

5) Test and measure potential interventions

Challenges

• The problems MH professionals perceive and what to do about them do not always line up with how parents perceive things

• E.g. – the treatment most commonly offered but not wanted by parents?

• Parenting class (46%)

• Followed by medication, tied with parent counseling (44%)

Shanley et al, 2008

Challenges

• Empowering schools and family physicians; decreasing fear and stigma

• Potentially looking at how we conduct mental health promotion

• Looking at the mental health system – is there anything systemically (outside of the ER) that would better meet patient/family needs?

Thanks in advance!

Patient Engagement—Collaborative Grant