An Emergency Department Intervention for Linking Pediatric Suicidal Patients to Follow-Up Mental Health Treatment

Abstract

Objective Suicide is the third leading cause of death among adolescents. Many suicidal youths treated in Emergency Departments (EDs) do not receive follow-up treatment, as advocated by our National Strategy for Suicide Prevention. We compared two strategies for improving rates of follow-up treatment. Methods Randomized controlled trial in which suicidal youths at two EDs (N=181; aged 10–18) were individually randomized between April 2003 and August 2005 to one of two conditions: an enhanced mental health intervention involving a family-based cognitive-behavior therapy session in the ED designed to increase motivation for follow-up treatment and safety, supplemented by care linkage telephone contacts after discharge; or Usual ED-Care enhanced by provider education. Assessments were conducted at baseline and at about 2-months after ED/hospital discharge. The primary outcome measure was rates of outpatient mental health treatment after discharge. Results Intervention patients were significantly more likely to attend outpatient treatment, as compared to usual ED-Care patients (92% vs 76%, p=.004). The intervention group also had a significantly higher rate of psychotherapy (76% vs 49%; p=.001); combined psychotherapy and medication (58% vs 37%; p=.003); and significantly more psychotherapy visits (mean 5.3 vs 3.1; p=.003). Neither the ED intervention nor community outpatient treatment (in exploratory analyses) was significantly associated with improved clinical/functioning outcomes. Conclusions Results support efficacy of the enhanced ED intervention for improving linkage to outpatient mental health treatment, but underscore the need for improved community outpatient treatment to prevent suicide/suicide attempts and poor clinical/functioning outcomes in the high-risk youths treated in EDs for suicidality.

Emergency Department-Based Care Transitions for Pediatric Patients: A Systematic Review

“…Age varied between 0 and 18 years (one study 34 did not mention the age range but specified the average age as 2.2 [SD, 2.8]). One-half of the selected studies (n = 8) included patients with asthma (or acute asthma) 28, 31, 36-38, 42, 43, 45 ; 2 studies focused on suicide attempts or suicide ideation 24,30 ; and 1 study focused on mental health problems. 29 The remaining studies lacked specificity in the clinical conditions: 3 described minor health concerns 26,27,40 ; 1 studied acute infections 33 ; and 1 did not specify the clinical condition that was considered.…”

“…The interventions could be generally classified into the following categories: educational support (face-to-face, video-based, or telephonic), 24,27,28,31,37,38,42,43 appointment scheduling, 27 -30, 42, 45 telephonic reminders, 27 -30, 42, 45 ED-based discharge instructions, 28,36,40,45 monetary incentives, 37,38 text message reminders, 34 providing PCP information, 40 nurse support line, 33 mailed reminders, 43 therapeutic sessions, 24,29 and case management program 28 ( Table 2). …”

“…Four studies used single-component interventions, 26,31,34,36 whereas the rest (n = 12) used multicomponent interventions. 24 In terms of the care continuity framework, 14 interventions were identified that focused on the quality of information, 24, 27 -31, 33, 35, 37, 38, 40, 42, 43, 45 11 interventions that supported communication, 26, 29 -31, 33, 34, 37, 38, 40, 43, 45 and 10 interventions that promoted coordination of care. 24, 27 -30, 37, 38, 42, 43, 45 Only 6 interventions supported all 3 functions of care continuity.…”

“…26,33,34 In the remaining 10 studies, interventions were administered both during and after the ED visit (ie, involving multicomponent intervention). 24, 29 -31, 37, 38, 40, 42, 43, 45 Finally, 9 studies identified 1 of the following theoretical frameworks as the basis of their intervention design: health belief model and promotion of self-efficacy 36,42,43 ; cognitive behavioral theory 24 ; social cognitive theory 31 ; health promotion model 27 ; and transtheoretical model of behavior change (decisional-balance). 38 …”

“…In most studies, the control group received routine care (n = 13). 26 -29, 31, 33, 34, 36 -38, 40, 43, 45 Three studies included an enhanced usual care: Teach et al 42 (usual care with an asthma educational packet), Asarnow et al 24 (usual care with ED staff trained on linking patients with outpatient care), and Grupp-Phelan et al 30 (usual care with standard referral).…”