National Study Shows Majority of Self-Harming Adolescents Don't Receive a Mental Health Assessment During Emergency Room Visit

A national study of Medicaid data shows most young people who present to emergency departments with deliberate self-harm are discharged to the community, without receiving an emergency mental health assessment. Even more, a roughly comparable proportion of these patients receive no outpatient mental health care in the following month. These are the findings from a study conducted by researchers at Nationwide Children’s Hospital that appears in the Journal of the American Academy of Child & Adolescent Psychiatry.

Deliberate self-harm is one of the most common reasons for an emergency department visit by young people in the United States. Eighty to 90 percent of young people who deliberately harm themselves meet criteria for at least one psychiatric disorder, most commonly mood disorders. The National Institute for Clinical Excellence has advised that all patients presenting to emergency departments with an episode of deliberate self-harm should receive a mental health evaluation before discharge.  

“Emergency department personnel can play a unique role in suicide prevention by assessing the mental health of patients after deliberate self-harm and providing potentially life-saving referrals for outpatient mental health care,” said Jeff Bridge, PhD, principal investigator in the Center for Innovation in Pediatric Practice of The Research Institute at Nationwide Children’s Hospital and lead study author.  “However, the coordination between emergency services for patients who deliberately harm themselves and linkage with outpatient mental health treatment is often inadequate.”

In an effort to examine the quality of the emergency mental health management of young people who are discharged to the community after an act of deliberate self-harm, Dr. Bridge and colleagues examined Medicaid Extract files throughout the country for children ages 10 to 19.

They found that in this Medicaid population, most young people who presented to the emergency departments with deliberate self-harm were discharged to the community as opposed to inpatient care. Only 39 percent of all patients who are discharged to the community received a mental health assessment while in the emergency department.

Dr. Bridge says without more detailed information on whether the deliberate self-harm occurred with or without a suicidal intent it is impossible to exclude the possibility that some discharged patients are at relatively low risk, although deliberate self-harm is the main risk factor for completed suicide. The greatest risk of suicide occurs in the period immediately after an episode of deliberate self-harm.

“Our findings suggest that the decision to provide emergency mental health assessment is dictated less by the clinical characteristics of individual patients and more by staffing patterns or established emergency department evaluation protocols,” said Dr. Bridge. “This study highlights the need for strategies to promote emergency department mental health assessments, strengthening the training of physicians in pediatric mental health and adolescent suicide prevention and timely transitions to outpatient mental health care.”

Consistent with previous research of adult patients on Medicaid who present to emergency departments after self-harm, recent mental health treatment emerged as the most powerful predictor of follow-up outpatient mental health care. Nonetheless, only about one half of patients who had visited the emergency department for a mental-health-related reason up to 60 days before, received a mental health assessment during their self-harm incident visit. “This association and the lack of an association between emergency mental health assessment and follow up care suggest that a portion of the follow up mental health visits simply represent ongoing mental health care rather than new emergency-department-driven referrals,” said Dr. Bridge.

Co-authors of the study include Steven C. Marcus, PhD, from the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania; and Mark Olfson, MD, MPH, from the New York State Psychiatric Institute and the College of Physicians and Surgeons of Columbia University.