Public Health Reports / January–February 2007 / Volume 122
Trends in Mental Health and Chronic
Condition Visits by Children Presenting for
Care at U.S. Emergency Departments
Jacqueline Grupp-Phelan, MD,
Jeffrey S. Harman, PhDb
Kelly J. Kelleher, MD, MPHc
aDivision of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
bUniversity of Florida, Gainesville, FL
cDivision of Behavioral and Developmental Pediatrics, Columbus Children’s Research Institute, Columbus, OH
Address correspondence to: Jacqueline Grupp-Phelan, Div. of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333
Burnet Ave., Cincinnati, OH 45229; tel. 513-636-3465; fax 513-636-7967; e-mail <email@example.com>.
© 2007 Association of Schools of Public Health
Objective. The purpose of this study was to compare the burden of mental
health disorders to the burden of other chronic care conditions as measured by
emergency department (ED) visits by children with respect to prevalence rates,
time trends, and hospital admission rates.
Methods. Data from the 1995–2001 National Hospital Ambulatory Medical
Care Survey were used to assess the number of visits to emergency depart-
ments by children with a diagnosis of a mental health or chronic condition, a
mental health-related reason for the visit, or a prescription or continuation of
Results. From 1995 to 2001, there was an increase in the proportion of visits
by children with mental health problems. During the same period, the propor-
tion of visits by children with chronic illness appeared stable. Overall, mental
health diagnoses made up approximately 5% of all U.S. emergency department
visits by children, similar to the percentage of total visits for other chronic
conditions (5.2%). Approximately 15% of visits in both the mental health and
chronic condition groups ended in hospital admission compared to less than
5% in the overall group of ED visits by children.
Conclusions. The burden of mental health related visits to U.S. EDs is growing
at a faster rate than visits related to chronic conditions. Visit intensity, hospital
admission, and medication utilization is just as intense as that for chronic condi-
tions. Promoting provider mental health training and restructuring the ED visit
to allow for rapid mental health assessment and immediate onsite or contigu-
ous mental health care may be one way to improve outcomes for families and
to position the ED as part of a larger integrated system of effective mental
Mental Health and Chronic Conditions in Children at U.S. EDs 61
Public Health Reports / January–February 2007 / Volume 122
important. The NHAMCS database represents all
nonmilitary U.S. hospitals, not just tertiary care cen-
ters. EDs across the country—rural, suburban and
urban—are seeing increases in their mental health
related visits. This increase may be related to declines
in the supply of mental health services resulting from
declining public mental health dollars and shortages
of child mental health specialists. It may also be due to
increased demand and growth in child and adolescent
mental disorders, as has been noted in primary care
and educational settings.8,9
Similar to services already offered for chronic condi-
tions, the burden of pediatric mental health services
may require comprehensive planning such as standard-
ized assessments, available specialty evaluations, case
managers, and linkages with outpatient and residential
services. Restructuring the ED visit to allow for rapid
mental health assessment and immediate onsite or
contiguous mental health care may be one way to
improve outcomes for families and to position the
ED as part of a larger integrated system of effective
chronic illness care.
As with any secondary dataset analysis, this study is
limited by the variables available in the dataset. It
would have been interesting to look at severity of ill-
ness and measures of intensity of ED utilization such
as intravenous fluids, laboratory tests, and the need
for monitoring or restraints. In addition, using ICD-9
codes to identify mental illness is underrepresentative
of the true prevalence of mental illness. However, the
authors have increased mental health case finding by
using the mental health visit, which includes visits with
a combination of either a mental health ICD-9 code,
a chief complaint of a mental health problem, and/or
a visit resulting in a psychotropic medication prescrip-
tion, order or continuation.
In summary, the visit, medication, and hospital
admission intensity of mental health disorders in
children presenting to U.S. emergency departments is
as burdensome as that for children with chronic dis-
orders. In the context of a lack of mental health care
capacity in the community, it appears that the demand
for ED-based mental health services will continue to
increase. To respond to this need even while advocat-
ing for increased funding, services, and availability of
traditional services for those with mental health issues,
EDs should (1) re-examine how they respond to this
need, (2) shore up and streamline the internal process
by which they assess and meet the need, and (3) focus
on the physician/nursing educational and training
component to insure that these needs are met.
This project was supported in part by a grant from the National
Institute of Mental Health (5K23MH063716-02).
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