Youth who self-harmed were five times more likely to have repeat visits to the emergency department, three times more likely to die from any cause and eight times more likely to die from suicide than youth who did not self-harm and who were matched on sex, age, and psychiatric and medical diagnoses.
“Among adolescents who presented after self-harm, and who later had recurrent admissions for self-harm, serious and complex mental conditions were common, most prominently anxiety and mood disorders, as well as substance abuse issues, and concussion or traumatic brain injury,” writes Dr. William Gardner, CHEO Research Institute and the University of Ottawa, Ottawa, Ontario, with coauthors.
The study included data on 403 805 youth aged 13-17 years who visited emergency departments in Ontario, Canada’s largest province, between 2011 and 2013. Of the total number of youth, 5832 visited the emergency department following self-harm, and 5661 of them were matched with 10 731 control participants who visited the emergency department for other reasons. Youth who presented with self-harm, were older (by about a year) than controls and more likely to be female (79% vs. 48%).
Emergency department visits for self-harm have more than doubled in Ontario over the last 10 years—a worrying trend.
“Over and above an elevated suicide risk, having an emergency department visit related to self-harm is a predictor for recurrent visits to the emergency department and greater use of health services,” write the authors.
Almost one-third of the adolescents with visits for self-harm were either readmitted to hospital or had subsequent emergency department visits, which resulted in higher costs to the system.
The adolescents with self-harm had $11 000 higher health system costs over five years than the matched control patients.
The authors noted that this was a conservative estimate on the cost difference.
“Our results suggest that adolescents who present at the emergency department after self-harm would benefit from assessment for mental health or substance misuse disorders,” write the authors.
Although youth with self-harm were more likely to die by suicide, suicide was nevertheless an uncommon outcome (occurring in less than 1% of adolescents who presented to the emergency department following self-harm).
The authors call for research into better ways to assess mental health in the emergency department and to connect emergency departments with community mental health services.
“If adolescents presenting with self-harm have mental health or substance misuse issues, they should be connected to evidence-based community services for treatment,” the authors conclude.
“Health outcomes associated with emergency department visits by adolescents for self-harm: a propensity-matched cohort study” is published in Canadian Medical Association Journal on November 4, 2019
Self-harm is the deliberate attempt to injure oneself, regardless of intent.1 Adolescents who self-harm are at risk for repeated self-harm or suicide.2–6
Adolescent emergency department (ED) visits with self-harm have been increasing in recent years in many jurisdictions,7–9 including Canada.10
ED visits by adolescents for mental disorders have likewise been increasing in many countries,11–14 including Canada.15,16
The increasing numbers of adolescents who access the ED following self-harm or for mental disorders are of concern because the ED is not an ideal setting for delivery of mental health care or for care of adolescents who have self-harmed.
Studying population trends in visits for self-harm or mental disorders is also important because fluctuations in these trends may reflect significant changes in the social conditions affecting adolescent health and may provide direction for targeted interventions.
Hence, the objectives of this study were to examine temporal trends in rates of youths having self-harm and mental health ED visits in Ontario, a large Canadian province with centralized administrative records of all ED visits. Because sex effects are pronounced in adolescent self-harm17,18 and mental health,19 for both objectives, we fit models that permitted us to identify sex and sex by time effects.
Implications
With these increasing rates of adolescents presenting to the ED for self-harm or mental disorders and the importance of ensuring they receive good care, we need to find better ways to connect adolescents to mental health and social services during or following their visit.42
Possible solutions include integration of psychiatric emergency services into regional EDs43 and/or better integration between ED and community mental health services.44
Unfortunately, many hospitals do not have access to local mental health consultants, particularly in sparsely populated regions.45,46 Therefore, some youths receive limited emergency mental health assessments and/or follow-up outpatient mental health care.47–49
This gap might be addressed by using videoconferencing technology to facilitate assessments in the ED setting by mental health specialists located in other settings.50
Community mental health follow-up after self-harm has been associated with reduced likelihood of repeat self-harm,51 but evidence on whether youths can be successfully connected to mental health services from the ED is mixed.47,52,53 Efforts should be made to increase the supply and accessibility42 of evidence-based treatments54–56 for adolescents who self-harm or have mental health problems and where possible to deliver these services to them before they present to the ED.
The development and implementation of such intervention strategies should be informed by research on the specific care that youths with self-harm or mental health disorders received before, during, and following their presentations to the ED.
Our results suggest that Ontario’s destigmatization campaigns may have succeeded in increasing adolescent ED access for self-harm and mental illness. This is a great accomplishment, but unfortunately, it is not clear that there was an adequate increase in mental health treatment capacities to accommodate the surge in adolescents presenting at EDs with self-harm or mental health disorders.
Finally, the concurrence of the inflection points in both time series with the advent of internet-connected mobile devices should prompt increased research on the psychological impacts of social media.
More information:Canadian Medical Association Journal (2019). www.cmaj.ca/lookup/doi/10.1503/cmaj.190188
Journal information: Canadian Medical Association Journal
Provided by Children’s Hospital of Eastern Ontario Research Institute
