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Mental Health Care – Perspectives from a Trauma Center Anupam Kharbanda, MD, MSc Director of Research Emergency Services Children’s Hospitals and Clinics of Minnesota May 1st, 2015 Children’s disclaimer • You may download, use and copy these materials for educational and noncommercial use only. Content may be subject to copyright or trademark law when so designated; use of such information requires Children’s permission. • Children's makes no representations or warranties about the accuracy, reliability, or completeness of the content. Content is provided "as is" and is for informational use only. It is not a substitute for professional medical advice, diagnosis, or treatment. Children’s disclaims all warranties, express or implied, statutory or otherwise, including, without limitation the implied warranty of merchantability, non-infringement of third parties’ rights, and fitness for a particular purpose. Children’s disclaims any liability for losses or damages arising from or related to any use or misuse of this content. 2 | © 2013 Disclosures • No conflict of Interest • No financial disclosure 3 | © 2013 Asthma MVA ED Fever 4 | © 2013 Abdominal pain Depression Anxiety Mental Health Drug Abuse 5 | © 2013 ADHD ED/Trauma 6 | © 2013 Mental Health Overview • Scope of the problem • Two case examples −ADHD −Self harm behavior • Prevention strategies −Identification −ED Management 7 | © 2013 The Problem • Up to 20% of US Children 9-17 yo have a MH disorder • High levels of unmet need for community-based Mental Health (MH) services • MH issues presenting with increasing prevalence in emergency medicine • ED’s acting as surrogate for routine care 8 | © 2013 Dolan et al, Pediatrics. 127(5) May 2011 The Problem • ED’s often poorly equipped to address these patients − Lack of psychiatric personnel − Lack direct access to inpatient psychiatric beds − Lack direct access to outpatient resources − Longer wait times 9 | © 2013 Dolan et al, Pediatrics. 127(5) May 2011 How Big of a Problem? • MH visits account for 2-5% of all ED visits − Approximately 1.6 million visits/yr for those < age 18 − Suicide is the #3 cause of death among adolescents • Vast majority of of MH visits to ED − Related to Depression and/or Self-Harm − Violent behavior − Anxiety 10 | © 2013 Simon et al, Clinical Pediatrics, pp 1-8, 2014. How Big of a Problem? • Patients with underlying MH conditions − More likely to be involved in high risk behaviors and thus experience an injury. • Majority of MH patients discharged from the ED − However, if MH issue not properly addressed: More likely to return to ED Less likely to follow-up with outpatient follow-up 11 | © 2013 Newton et al, Ann Emerg Med. 56(6) 2010 So what – ED care is quick! • MH patients place significant burden on ED infrastructure − Require more resources − Often require consultation with MH expert − Inpatient options severely restricted • As a consequence: − Average evaluation in excess of 5 hours − 2x longer than visits for non-MH related ED care − Contributes to ED over-crowding 12 | © 2013 Dolan et al, Pediatrics. 127(5) May 2011 ED/Trauma 13 | © 2013 Mental Health Case Example #1: ADHD • ADHD − Affects 5% of children − Constellation of: Hyperactivity Inattention Impulsiveness • As a consequence: − Clinicians have theorized that these patients are at higher risk for trauma 14 | © 2013 Case Example #1: ADHD • Do patients with ADHD have higher rates of injury? − Analysis of the National Trauma data bank (1988-1996) − Examined patients 5-14 years of age who underwent a Trauma Examined charts for prior ADHD diagnosis − Patients with ADHD more likely to: Fights/assault based injuries (2x) Self harm (10x) Bike based injuries (2x) To suffer head injuries as well as multiple injuries • Bottom line: Patients with ADHD have higher rates of injury and are more severely injured 15 | © 2013 DiScala et al, Pediatrics. 102(6) December 1998 Case Example #1: ADHD • Can mitigation of symptoms reduce rates of trauma? − Analysis of electronic health records over a 12 year period − Examined patients 6-19 years old who were on methylphenidate − Primary outcome: incidence of trauma − Main findings Methylphenidate use associated with a reduction in risk of trauma related ED admissions (approx 10%). 16 | © 2013 Man et al, Pediatrics. 135,(1) January 2015 Case Example #1: ADHD • Increased benefit noted in adolescents ( >16 years) − Risk reduction of 32% (95% CI .53 - .86) • Authors conclude: − “Trauma prevention should be considered in the broader clinical assessment of methylphenidate risks and benefits…” • Single center study, results need verification − No current FDA guidance 17 | © 2013 Man et al, Pediatrics. 135,(1) January 2015 Case Example #2: Self Harm • Patients with self-harm behavior are at higher risk for attempting suicide Up to 50% of adolescents have suicidal thoughts • Recent data indicates a rapid rise in self-harm behavior • Average number of ED visits doubled between1993-2008 • These visits were most common among 15-18 year olds • Up to 10% of children/adolescents in USA have attempted suicide 18 | © 2013 Case Example #2: Self Harm • For primary and secondary prevention, need to understand the trends in self-harm behavior • Analysis of the National Trauma Data Bank (NTDB) from 2009-2012 − Largest collection of Trauma patients in USA − Represents 700 trauma centers, 95% of all centers • Examined all cases of self-harm in patients aged 1018 years of age − Examined associations by race, gender, age, comorbid conditions, insurance, and pre-existing mental health diagnoses 19 | © 2013 Cutler et al, Pediatrics. In press Case Example #2: Self Harm • Results − From 2009-2012 286,678 adolescents in the NTDB − 1.3% of these patients presented with self-harm 72% were male < 5% had a previous diagnosis of a mental health condition 20 | © 2013 Cutler et al, Pediatrics. In press 21 | © 2013 Case Example #2: Self Harm • In our statistical models − Odds of death highest among Males Older adolescents White race − Adolescents who presented with self-harm 13x higher odds of death as compared to those with other reasons for trauma 22 | © 2013 Cutler et al, Pediatrics. In press Case Example #2: Self Harm • Summary of findings: − Patients with self-harm often present with cutting/piercing behavior − Low rates of previous mental health diagnosis − Co-morbid conditions (obesity/alcoholism) increased risk of self-harm behavior − Patients without insurance with increased odds of death as compared to those with insurance 23 | © 2013 Cutler et al, Pediatrics. In press Prevention Strategies • Education − Asking the appropriate questions (screening tools) − Appropriate community/outpatient options − Appropriate discharge instructions • Management − Consider where to send patients acutely? Children’s hospital vs General facility − Standardized care management plan 24 | © 2013 Prevention Strategies • ED may be the only point of contact for some children with undiagnosed MH complaints • Suicidal behavior is often undetected − Up to 83% adolescents who attempted suicide had no “red flags” during PCP visit • Risk assessment is critical, in multiple domains of care − Given lack of screening tools, researchers have attempted to develop tools that: High sensitivity Can be rapidly administered 25 | © 2013 Horowitz et al. Pediatrics 2001; 107(5) Prevention Strategies • 4 question survey − Are you here because you tried to hurt yourself? − Was it an attempt to kill yourself? − Were you using alcohol or drugs (during the attempt)? − In the past week, have you been having thoughts about hurting yourself? 26 | © 2013 Horowitz et al. Pediatrics 2001; 107(5) Prevention Strategies • 4 part survey identified 98% of patients at risk for suicide − Took 2 minutes to administer − Was conducted by non-mental health clinicians • Purpose of survey is to be asked at ED triage − To identify high risk patients earlier in their ED visit − To facilitate calling of social worker/MH personal − Ensure timely examination by a clinician 27 | © 2013 Horowitz et al. Pediatrics 2001; 107(5) Prevention Strategies • Not enough to simply screen for MH conditions − Access to MH professionals − Plan for outpatient management • ED specific intervention − Family Intervention for Suicide Prevention (FISP) − Goal of intervention is to increase adherence with outpatient MH services − Information provided in structured format by MH personal Brief therapy session in ED Outpatient telephone contact 28 | © 2013 Asarnow et al. Psychiatric Services. 62(11), November 2011 Prevention Strategies: FISP • Four main components − Address the risks of suicidal behavior − Improve family coping skills − Restricting access to lethal means − Education and linkage to outpatient services • Investigators conducted a RCT in two LA ED’s − FISP patients more likely to linked to outpatients services (92% vs 76%) − Increased outpatient treatment visits − Increased number of psychotherapy sessions 29 | © 2013 Asarnow et al. Psychiatric Services. 62(11), November 2011 Management • What should be the role of the ED? − Rapid response to ensure safety and reduce stress Engagement of family Respect for privacy − Assessment and management of acute medical conditions − Screening for suicidal risk − Engage a MH team (composition?) Response time should be established − Linkage with outpatient resources 30 | © 2013 Dolan et al, Pediatrics. 127(5) May 2011 Management • Where should these children receive care? • Important as: − Most children (77%-89%) are not treated at pediatric centers − 20% of US population does not have access to a Pediatric Level 1 Center within 60 minutes • Do outcome vary by center type? − Acute management − What resources are available? − MH evaluation available? 31 | © 2013 Segui-Gomez M (2003) J Pediatric Surg 38(8):1162-1169. Outcomes by Center Type 17.4 million children (~20%) currently have no access to a pediatric verified trauma center within 60 minutes1 Population served by pediatric verified trauma centers within 60 minutes Available at: http://www.traumamaps.org/Trauma.aspx 32 | © 2013 Carr BG (2010) Curr Opin Pediatr 22(3): 326-331 . Outcomes by Center Type Does the type of Trauma Center impact mortality, complications, and diagnostic imaging utilization for patients who experience a trauma? 33 | © 2013 Dreyfus et al, Unpublished data 34 | © 2013 Dreyfus et al, Unpublished Dreyfus et al, Unpublished data 35 | © 2013 Dreyfus et al, Unpublished Dreyfus et al, Unpublished data Outcome by Center Type • After adjusting for patient demographic and injury severity characteristics, pediatric patients treated at free-standing pediatric Level I centers experience: − Lower mortality rates − Fewer complications (pneumonia, DVT) − Less utilization of CT vs. combined centers 36 | © 2013 Dreyfus et al, Unpublished data Conclusions • Mental Health issues seen at high frequency within Emergency Medicine • Specific Mental Health conditions increase the risk for injury and death • Emergency Departments − Are at frontline of recognition and screening − A standardized care management plan and Mental Health team are critical − Pediatric Centers have better outcomes 37 | © 2013 Thank you! 38 | © 2013 Children’s Physician Access 24/7 assistance: referrals, consultations, admissions 612-343-2121 866-755-2121 .................................................... childrensMN.org/healthprofessionals 39 | © 2013 Easy online access to: • Remote EMR • Ask a Children’s specialist • Grand rounds/CME • Conference registration • Patient education materials • Latest news