Mental Health Care – Perspectives from a Trauma

Center

Anupam Kharbanda, MD, MScDirector of ResearchEmergency Services

Children’s Hospitals and Clinics of MinnesotaMay 1st, 2015

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Children’s disclaimer

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• No conflict of Interest

• No financial disclosure

Disclosures

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ED/Trauma Mental Health

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• Scope of the problem

• Two case examples−ADHD−Self harm behavior

• Prevention strategies −Identification−ED Management

Overview

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• 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

The Problem

Dolan et al, Pediatrics. 127(5) May 2011

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• 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

The Problem

Dolan et al, Pediatrics. 127(5) May 2011

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• 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

How Big of a Problem?

Simon et al, Clinical Pediatrics, pp 1-8, 2014.

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• 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

How Big of a Problem?

Newton et al, Ann Emerg Med. 56(6) 2010

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• 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

So what – ED care is quick!

Dolan et al, Pediatrics. 127(5) May 2011

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ED/Trauma Mental Health

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• 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

Case Example #1: ADHD

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• 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

Case Example #1: ADHD

DiScala et al, Pediatrics. 102(6) December 1998

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• 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%).

Case Example #1: ADHD

Man et al, Pediatrics. 135,(1) January 2015

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• 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

Case Example #1: ADHD

Man et al, Pediatrics. 135,(1) January 2015

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• Patients with self-harm behavior are at higher risk for attempting suicideUp 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

Case Example #2: Self Harm

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• 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 10-18 years of age−Examined associations by race, gender, age, co-

morbid conditions, insurance, and pre-existing mental health diagnoses

Case Example #2: Self Harm

Cutler et al, Pediatrics. In press

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• 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

Case Example #2: Self Harm

Cutler et al, Pediatrics. In press

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• 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

Case Example #2: Self Harm

Cutler et al, Pediatrics. In press

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• 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

Case Example #2: Self Harm

Cutler et al, Pediatrics. In press

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• 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

Prevention Strategies

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• 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

Prevention Strategies

Horowitz et al. Pediatrics 2001; 107(5)

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• 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?

Prevention Strategies

Horowitz et al. Pediatrics 2001; 107(5)

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• 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

Prevention Strategies

Horowitz et al. Pediatrics 2001; 107(5)

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• 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

Prevention Strategies

Asarnow et al. Psychiatric Services. 62(11), November 2011

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• 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

Prevention Strategies: FISP

Asarnow et al. Psychiatric Services. 62(11), November 2011

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• 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

Management

Dolan et al, Pediatrics. 127(5) May 2011

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• 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?

Management

Segui-Gomez M (2003) J Pediatric Surg 38(8):1162-1169.

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Outcomes by Center Type

Population served by pediatric verified trauma centers within 60 minutes

Available at: http://www.traumamaps.org/Trauma.aspx

Carr BG (2010) Curr Opin Pediatr 22(3): 326-331.

17.4 million children (~20%) currently have no access to a pediatric verified trauma center within 60 minutes1

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Does the type of Trauma Center impact mortality, complications, and diagnostic imaging utilization for patients who experience a trauma?

Outcomes by Center Type

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

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• 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

Outcome by Center Type

Dreyfus et al, Unpublished data

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• 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

Conclusions

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Thank you!

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Children’s Physician Access 24/7 assistance: referrals, consultations, admissions

612-343-2121 866-755-2121....................................................childrensMN.org/healthprofessionals

Easy online access to:• Remote EMR• Ask a Children’s specialist• Grand rounds/CME • Conference registration• Patient education materials• Latest news