Failure of psychiatric referrals from the pediatric emergency department

<p>Abstract</p> <p>Background</p> <p>Recognition of mental illness in the pediatric emergency department (PED) followed by brief, problem oriented interventions may improve health-care seeking behavior and quality of life. The objective of this study was to compare the frequency of mental health follow up after an enhanced referral compared to a simple referral in children presenting to the PED with unrecognized mental health problems.</p> <p>Methods</p> <p>A prospective randomized control trial comparing an enhanced referral vs. simple referral in 56 families of children who were screened for mental health symptoms was performed in a large tertiary care PED. Children presenting to the PED with stable medical problems were approached every fourth evening for enrollment. After consent/assent was obtained, children were screened for a mental health problem using both child and parent reports of the DISC Predictive Scales. Those meeting cutoffs for a mental health problem by either parent or child report were randomized to 1) simple referral (phone number for mental health evaluation by study psychiatrist) or 2) enhanced referral (short informational interview, appointment made for child, reminder 2 days before and day of interview for an evaluation by study psychiatrist). Data analysis included descriptive statistics and Chi-Square test to calculate the proportion of children with mental health problems who completed mental health follow-up with and without the enhanced referral.</p> <p>Results</p> <p>A total of 69 families were enrolled. Overall 56 (81%) children screened positive for a mental health problem as reported by either the child (self report) or mother (maternal report of child mental health problem). Of these, 33 children were randomized into the enhanced referral arm and 23 into the simple referral arm. Overall, only 6 families with children screening positive for a mental health problem completed the psychiatric follow up evaluation, 2 in the enhanced referral arm and 4 in the simple referral arm (p = .13).</p> <p>Conclusion</p> <p>Children screened in the ED for unrecognized mental health problems are very unlikely to follow-up for a mental health evaluation with or without an enhanced referral. Understanding the role of ED based mental health screening and the timing of an intervention is key in developing ED based mental health interventions.</p

Adolescentsâ Engagement with Crisis Hotline Riskâ management Services: A Report from the Emergency Department Screen for Teen Suicide Risk (EDâ STARS) Study

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154403/1/sltb12558.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154403/2/sltb12558_am.pd

Effect of a Motivational Interviewing–Based Intervention on Initiation of Mental Health Treatment and Mental Health After an Emergency Department Visit Among Suicidal Adolescents

Abstract IMPORTANCE Emergency department (ED) visits present opportunities to identify and refer suicidal youth for outpatient mental health care, although this practice is not routine. OBJECTIVE To examine whether a motivational interviewing–based intervention increases linkage of adolescents to outpatient mental health services and reduces depression symptoms and suicidal ideation in adolescents seeking emergency care for non–mental health–related concerns who screen positive for suicide risk. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, adolescents aged 12 to 17 years who screened positive on the Ask Suicide Screening Questions (ASQ) during a nonpsychiatric ED visit at 2 academic pediatric EDs in Ohio were recruited from April 2013 to July 2015. Intention-totreat analyses were performed from September 2018 to October 2019. INTERVENTIONS The Suicidal Teens Accessing Treatment After an Emergency Department Visit (STAT-ED) intervention included motivational interviewing to target family engagement, problem solving, referral assistance, and limited case management. The enhanced usual care (EUC) intervention consisted of brief mental health care consultation and referral. MAIN OUTCOMES AND MEASURES Primary outcomes were mental health treatment initiation and attendance within 2 months of ED discharge and suicidal ideation (assessed by the Suicidal Ideation Questionnaire JR) and depression symptoms (assessed by the Center for Epidemiologic Studies– Depression scale) at 2 and 6 months. Exploratory outcomes included treatment initiation and attendance and suicide attempts at 6 months. RESULTS A total of 168 participants were randomized and 159 included in the intention-to-treat analyses (mean [SD] age, 15.0 [1.5] years; 126 [79.2%] female; and 80 [50.3%] white). Seventy-nine participants were randomized to receive the STAT-ED intervention and 80 to receive EUC. At 2 months, youth in the STAT-ED group had similar rates of mental health treatment initiation compared with youth in the EUC group as assessed by parent report (29 [50.9%] vs 22 [34.9%]; adjusted odds ratio [OR], 2.08; 95% CI, 0.97-4.45) and administrative data from mental health care agencies (19 [29.7%] vs 11 [19.3%]; adjusted OR, 1.77; 95% CI, 0.76-4.15). At 2 months, youth in the STAT-ED group and the EUC group had similar rates of treatment attendance (1 appointment: 6 [9.7%] vs 2 [3.6%]; adjusted OR, 2.97; 95% CI, 0.56-15.73; 2 appointments: 10 [16.1%] vs 7 [12.7%]; adjusted OR, 1.43; 95% CI, 0.50-4.11). There were no significant group × time differences in suicidal ideation (F = 0.28; P = .72) and depression symptoms (F = 0.49; P = .60) during the 6-month follow-up period. In exploratory analyses, at 6 months, STAT-ED participants had significantly higher rates of agencyreported mental health treatment initiation (adjusted OR, 2.48; 95% CI, 1.16-5.28) and more completed appointments (t99.7 = 2.58; P = .01). CONCLUSIONS AND RELEVANCE This study’s findings indicate that no differences were found on any primary outcome by study condition. However, STAT-ED was more efficacious than EUC at increasing mental health treatment initiation and attendance at 6 months. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01779414 JAMA Network Open. 2019;2(12):e1917941. doi:10.1001/jamanetworkopen.2019.1794

Effect of Allergic Rhinitis on the Use and Cost of Health Services by Children with Asthma

Purpose: Allergic rhinitis (AR) is common among children with asthma and exacerbates asthma symptoms. To assess the incremental utilization and cost of asthma-related health services due to concomitant AR among asthmatic children. Materials and Methods: Asthma-related claims were extracted from the Korean National Health Insurance (NHI) claims database, which covers 97 % of the population. Per-capita utilization and costs of asthma-related services were determined from the societal perspective. Results: Of 319,714 children (1- 14 years old) with chronic asthma in 2003, 195,026 had concomitant AR (prevalence 610 per 1,000 asthmatic children). Children with AR had 1.14 times more outpatient visits, 1.30 times more emergency department (ED) visits, and 1.49 times more hospitalizations than children without AR. More children with AR used general hospitals (7.17%) than children without AR (3.23%). The ratios of unit pharmaceutical costs per outpatient visit, ED visit, and admission between children with and without AR were 1.27, 1.20, and 1.14. Total annual expenditure combining direct health care, transportation, and caregivers &apos; costs, were $273 and$217 for children with and without AR, respectively. Conclusion: Health service utilization and costs for asthma were greater for asthmatic children with AR. More frequent ED visits and admissions among asthmatic children with AR suggest poorer control and more frequent exacerbations. Higher unit cost of pharmaceuticals during visits, tendency to receive asthma care from a higher-level facility, and greater risk of ED visit or admission all contributed to the additional economic burden of AR

UGT1A1 sequence variants and bilirubin levels in early postnatal life: a quantitative approach

<p>Abstract</p> <p>Background</p> <p>Fundamental to definitively identifying neonates at risk of developing significant hyperbilirubinemia is a better understanding of the genetic factors associated with early bilirubin rise. Previous genetic studies have focused on the UGT1A1 gene, associating common variation in the coding or promoter regions with qualitative assessments of bilirubin (i.e. significantly elevated or not). These studies have had conflicting results and limited success. We chose to approach the problem by focusing on the quantitative (absolute) change in bilirubin levels early in post-natal life. We apply this approach to the UGT1A1 gene - exploring the contribution of both rare and common variants to early bilirubin changes.</p> <p>Methods</p> <p>We sequenced the exons, PBREM, 5'-, and 3'- regions of the UGT1A1 gene in 80 otherwise healthy term neonates who had repeat bilirubin levels measured within the first five days of life.</p> <p>Results</p> <p>Three novel coding variants were observed, but there was no clear relationship between rare coding variants and bilirubin rise. Adjusted linear regression models fit to evaluate the relationship between changing bilirubin levels and common UGT1A1variants found that among 39 neonates whose bilirubin was resampled within 33 hours, individuals homozygous for the mutant allele of a 3'UTR SNP had significantly smaller changes in bilirubin (P = 0.003) than individuals carrying the wild-type allele.</p> <p>Conclusions</p> <p>Collectively, rare UGT1A1 coding variants do not appear to play a prominent role in determining early bilirubin levels; however common variants in the 3' UTR of UGT1A1 may modulate the early bilirubin rise. A quantitative approach to evaluating early bilirubin kinetics provides a more robust framework in which to better understand the genetics of neonatal hyperbilirubinemia.</p