Child and Adolescent Mental Health Repeat Visits to the Emergency Department: A Systematic Review

Results

The search identified a total of 176 articles: 21 from PsycINFO, 130 from PubMed, and 25 from CINAHL. Nine studies met all inclusion criteria.^8,14,17–23 Two additional studies also met inclusion criteria and were identified through references and our own work.^13,24 See Fig 1 for the flow diagram. Characteristics of included studies can be found in Table 1. Heterogeneity in reported statistical analyses, determinants explored, and the small number of studies meeting inclusion criteria precluded the use of meta-analyses to pool and interpret study results. Thus, a narrative and graphical synthesis of review findings is presented and grouped by study variables.

• Download figure
• Open in new tab
• Download powerpoint

FIGURE 1

Flow diagram.

Demographic factors examined in the literature were age, biological sex, indicators of socioeconomic status, race/ethnicity, and involvement with child protective services. Nine studies considered age^{8,13,14,17–19,21–23}; however, the use of different age ranges and comparison groups might account for the mixed findings. Nevertheless, there appears to be a trend toward older youth being at higher risk of returning to the ED. Similarly, 10 studies examined the influence of biological sex^{8,13,14,17–23} and found mostly nonsignificant results, although there is some evidence that suggests girls have a higher likelihood of repeating. Seven studies examined various indicators of socioeconomic status; for example, governmental assistance and insurance status.^{8,14,18–21,23} Results suggest that lower socioeconomic status may be a significant predictor of return visits. Six studies also considered race/ethnicity^{14,18–21,23} and 4 of them found that minority status increased return visits, which might be linked to cultural and/or socioeconomic differences in MH-seeking behaviors. Finally, involvement with child protective services was a significant determinant in 3 of 4 studies.^13,18,20

Clinical factors examined in the literature were suicidal ideation, intentional self-harm, psychiatric and developmental diagnoses, symptom severity, and taking psychotropic medications at the time of the index visit. Seven studies considered suicidal ideation, self-harm, and/or suicide attempts and found mixed results.^{8,13,17,18,20–22} There appeared to be a trend toward a higher likelihood of repeating when suicidal ideation and self-harm behaviors were of greater intensity and duration.²² Previous suicide attempt was not a predictor in 1 study,¹⁸ but a suicide attempt at the index visit became a predictor in another when other variables were taken into consideration.²¹ Only 1 study examined homicidal thoughts and found it to be associated with repeat visits.¹⁷ Psychiatric diagnoses included in the analyses varied greatly between studies. A few psychiatric diagnoses were associated with repeat visits: mood and affective disorders,^8,13 psychotic disorders including schizophrenia,^8,24 and behavior or personality disorders.^18,24 There were mixed results when considering presentations related to alcohol and other substance use/abuse, as 1 study found that it increased likelihood,²⁴ another found that it decreased likelihood,⁸ and yet another found no association.¹³ Patients with dual diagnoses (defined by a co-occurrence of a mental disorder and a substance-related disorder) were at an increased likelihood of repeating.²⁴ Two studies looking at triage level found no association with repeat visits for high severity and a decreased likelihood of presenting for low severity.^8,23 Nevertheless, there was a trend toward increased presentations when severity was measured by psychiatric comorbidity.^18,23 On the other hand, having a medical comorbidity appeared to decrease return visits.²³ Finally, 1 study determined that children and adolescents currently taking psychotropic medication were more likely to return to the ED.¹³

The most common MH care access and utilization factors examined were receipt of MH services, disposition at the time of the presentation, previous psychiatric hospitalizations, and hospital characteristics. Results suggest a strong association between past and/or current MH services and repeat visits.^{13,14,18,21,23} Only 1 study found that it reduced repeat visits.¹⁷ One study took a more in-depth look at how patients accessed discharge recommendations and found that having a physician follow-up visit for MH; having more than 1 follow-up visit; seeing a physician other than a general practitioner, pediatrician, or psychiatrist; and seeing a physician in a hospital outpatient clinic increased their likelihood of revisiting the ED.²³ Four studies^13,14,18,21 found that children and adolescents with a history of psychiatric hospitalization were more likely to return to the ED. Three studies observed that living close to the hospital (city residents) compared with those living farther away was significantly associated with repeat visits.^13,14,18 One study determined that those presenting to general hospitals (compared with pediatric hospitals) were more likely to have return visits.⁸ Finally, in terms of time of ED presentation, nighttime visits (5 pm–9 am) were more common in repeat visitors compared with daytime visits (9 am–5 pm).¹⁷

Only 1 study looked at a family-level factor²¹ and determined that previous parental experience seeking MH care for their child was significantly associated with repeat visits.

A visual summary of contributing factors can be found in the provided forest plots. Adjusted odds ratios (ORs), hazard ratios (HRs), and relative risk (RRs) of repeat visits are found in Figs 2-4. Unadjusted ORs, unadjusted HRs, and χ²s converted into ORs (calculated ORs) are available in Supplemental Figs 5-7. It should be noted that many studies did not report nonsignificant statistics, particularly in the adjusted and RR/HR models. Furthermore, a very limited number of statistics were not adequate for plotting and are solely described in the narrative synthesis.

• Download figure
• Open in new tab
• Download powerpoint

FIGURE 2

Demographic factors: forest plot of adjusted ORs, HRs, and RRs of repeat visits.

• Download figure
• Open in new tab
• Download powerpoint

FIGURE 3

Clinical factors: forest plot of adjusted ORs, HRs, and RRs of repeat visits.

• Download figure
• Open in new tab
• Download powerpoint

FIGURE 4

MH access and utilization: forest plot of adjusted ORs, HRs, and RRs of repeat visits.

Risk of Bias Assessment. Two reviewers rated the quality of included studies based on a modified version of the Newcastle Ottawa Scale for Cohort Studies criteria: (1) Design. All studies relied on medical chart reviews or administrative databases. This introduces methodological limitations because charting has been demonstrated to be less reliable for MH information.^12,25 Only 1 study relied on both chart review and data collected prospectively.²¹ (2) Generalizability across EDs. Samples were somewhat representative, as current results reflect 7 geographical regions. Four were US urban centers, including Baltimore (John Hopkins Hospital, Maryland),^14,18 Washington, DC (Children’s National Medical Center),²⁰ Cincinnati (Cincinnati Children’s Hospital Medical Center, Ohio),²¹ and Ann Arbor (University of Michigan Hospital, Michigan).²² Two regions were represented in Canada: the greater Ottawa area (Children’s Hospital of Eastern Ontario, Ontario),^13,17 and the province of Alberta.^8,19,23 One region was represented in France (Hôpitaux de Marseille, Bouches-du-Rhône).²⁴ Most studies included patients accessing 1 or 2 medical centers,^{13,14,17,18,21,22,24} whereas 3 studies included a provincial registry database of 96 to 104 medical centers.^8,19,23 Research integrating data from multiple ED sites provides stronger evidence, as families might have accessed other EDs. However, we noted an overlap in the participant samples of the 3 studies that used registries from the province of Alberta^8,19,23 and an overlap in the samples of the 2 studies from Baltimore city,^14,18 limiting generalizability as findings might be inflated by sample specific variation. Finally, 2 studies examined samples composed of specific MH presentations (suicidal behaviors,²¹ anxiety and stress-related disorders²³), making the predictors in these studies less relevant for predicting return visits for other MH presentations. (3) Breadth of predictors. All included studies explored demographic and clinical factors. All but 1 study²⁴ examined MH care access and utilization predictors. Family predictors were considered in 1 study only.²¹ (4) Measure of effect sizes. For articles using χ² statistics, the strength of association was not reported.^{14,17,18,21,22} (5) Additional outcomes. Four studies examined recency,^8,13,19,23 whereas only 1 study looked at both recency and frequency of repeat visits.¹³ (6) Interaction terms. Three studies explored how factors might interact in their analyses.^8,18,23 (7) Confounding variables. Four studies controlled for other variables in their models^.8,13,18,23 Two used a washout period to ascertain the index visit.^13,18 Based on a sensitivity analysis, a third study reported minimal impact on the results whether a washout period was used or not.⁸ Three of the studies with longer follow-up periods controlled for time-to-repeat in their analyses.^8,13,19 This is important for decreasing the risk of bias, as some participants might have either turned 18 during the study period or had less time to repeat if their index visit was near the end of the study period. (8) Clear definition of repeat visits. None of the studies clearly defined what was meant by a repeat visit. In fact, repeat visit windows ranged from 2 months to 6 years, which limits our ability to draw firm conclusions from between-study differences.