Download Case Example #2: Self Harm

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
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2 | © 2013
Disclosures
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No conflict of Interest
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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
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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
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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
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