There is a concerning lack of follow-up care for young people who experience a mental health crisis, new research suggests.
Results from a large database study showed less than half of youth and young adults hospitalized for a psychiatric event received follow-up care within 7 days. The follow-up rate was less than 30% for those who had visited an emergency department.
The strongest predictor of follow-up was having received both primary and mental health care during the 6 months prior to using the acute service.
Dr Brian Skehan
"For people discharging folks after a psychiatric crisis, whether it be in a hospital or emergency room setting, connecting them with their outpatient provider to ensure the transfer of care and continuity of care is vitally important to reduce risks for this population," co-investigator Brian Skehan, MD, PhD, assistant professor and psychiatrist, University of Massachusetts Chan Medical School, Worcester, said during a press briefing.
If these discharged patients do not have a provider, "make sure they get one," Lisa Dixon, MD, editor-in-chief of Psychiatric Services, added during the same briefing. "That's the gift of life potentially for these young people."
The findings were published online October 12 in Psychiatric Services.
Alarming Trends
The alarming suicide trends among youths were exacerbated by the COVID-19 pandemic, Skehan noted.
He cited a 2021 study that showed more than 44% of high school students experienced persistent sadness or hopelessness over the previous year, 1 in 5 seriously considered suicide, and almost 1 in 10 actually attempted suicide.
"When we look at the number of young adults and adolescents struggling with behavioral health issues, the data trend is disturbing nationwide," Skehan said.
The current study included participants aged 12-27 years who had private insurance. Many youth in this age category are experiencing significant changes, such as moving from high school to college and from pediatric providers to adult providers — and some "get lost in this transition," said Skehan.
He noted many inpatient psychiatric units are not geared to young adults. "They may miss out on some aspects of inpatient care because it's not geared to their developmental stage," he said.
Assessing US patient data in the IBM MarketScan commercial database (2013–2018), the researchers created two study samples: 95,153 inpatients and 108,576 patients who used the ER. All had an acute event stemming from a mental health condition.
The investigators explored the role of "established" outpatient care, defined as having had at least one visit with a provider of primary or mental health care in the 6 months prior to the acute psychiatric event.
Covariates included age at time of service (aged 12-17 years or 18-27 years), gender, healthcare plan type, psychiatric diagnosis, whether the acute event was self-harm or suicide related, and medical complexity.
Low Follow-up Rates
In the inpatient group, the average age was 18.9 years, the most common length of hospital stay was 4-6 days, and 1.5% left against medical advice. The most common primary diagnosis was major depression (53.7%), followed by bipolar disorder (22.3%). The least common disorders were posttraumatic stress disorder (PTSD), comorbid eating disorders, and disruptive disorders.
About one third of participants had used both primary and mental healthcare during the 6 months before hospitalization, whereas 22.8% had no established outpatient care. Established care was most common among those with comorbid eating disorders and least common among those with psychotic disorders.
Results showed 42.7% of the hospitalized patients received follow up within 7 days and 67.4% received follow up within 30 days.
The strongest predictor of mental health follow-up care was established outpatient care. Compared with those who had no such care, those who had received both primary care and mental healthcare before the acute event had the highest odds of receiving follow-up (within 7 days, adjusted odds ratio [AOR], 2.81; 95% CI, 2.68 - 2.94).
Older age and leaving against medical advice were associated with decreased likelihood of follow-up. Female sex, hospitalizations related to self-harm or suicidality, and longer length of stay were associated with increased likelihood of mental health follow-up care.
Compared with those hospitalized for major depression, those hospitalized for schizophrenia, bipolar disorder, PTSD, disruptive disorders, or comorbid substance use disorder were less likely to receive mental health follow-up. For example, only 23.7% of youth with comorbid substance use discharged from the hospital had follow-up within 7 days.
Similar patterns were observed for 30-day follow-up care.
"Accessible and Appealing" Options Needed
In the ER-visit group, the average age was 19.5 years (58% female). Most (70.4%) had no chronic health conditions other than a psychiatric disorder. The primary diagnoses were anxiety disorders or phobias (44.1%) and major depression (23%).
One in four visits included a code for self-harm, suicidal ideation, or suicide attempt. And almost one third lacked established outpatient care before the ER visit.
Results showed 28.6% of the ER group received mental health care follow-up within 7 days and 46.4% received it within 30 days.
Again, the strongest predictor of mental health follow-up was prior outpatient care. For example, compared with participants with no established outpatient care, those with both primary care and mental health care were the most likely to receive follow-up within 7 days (AOR, 4.06; 95% CI, 3.72 - 4.42).
These numbers "are far from the goal of making sure everybody is getting follow-up care within 7 days of an acute psychiatric event," Skehan said.
He stressed the need for "accessible and appealing options for youth." These could include telehealth services, improved communication among health care providers in the ED, and reducing barriers to access follow-up care.
"This probably highlights the need to have more case management and referral services, and maybe make sure patients have a follow-up appointment before they leave the emergency room," said Skehan.
"This doesn't necessarily guarantee they'll get there but hopefully it makes it more likely they will have that access should they need it," he added.
The study was funded by grants from the National Institute of General Medical Sciences and the National Center for Advancing Translational Sciences, from the US National Institutes of Health. The investigators have reported no relevant financial relationships.
Psychiatr Serv. Published online October 12, 2022. Full text
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