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More seniors with mental health issues ending up in the ER

June 01, 2011 | Stephanie Bouchard, Associate Editor

HONOLULU – A study presented last month at the annual American Psychiatric Association conference points to a pending crisis in geriatric psychiatry and potential healthcare cost increases as older adults end up in emergency rooms for mental health-related issues.

“Increased Elderly Utilization of Psychiatric Emergency Services in Honolulu: A Reflection of the Mental Health Crisis Facing Our Nation’s Aging Population” looked at the records of 17,004 patients who used the emergency room and were identified as using psychiatric emergency services at the Queen’s Medical Center in Honolulu between 2007 and 2010.

The study found that the number of geriatric patients (age 65 and older) with mental health issues – which include dementia, depression and Alzheimer’s disease – increased nearly 21 percent from 2007 to 2010. That increase seen is one example of a nationwide geriatric mental health crisis.

The crisis is due to a confluence of problems, said Brett Lu, MD, PhD, one of the authors of the study. It's mainly due to a shortage of mental health resources and the large number of Baby Boomers becoming seniors.

“There is about one geriatric psychiatrist for every 10,000 senior citizens right now, and this shortage will worsen to one for every 20,000 by 2030, especially if no significant efforts are made to encourage physician trainees to consider a career in geriatric psychiatry and to improve the current poor Medicare reimbursement,” said Lu.

“While comprising about 12 percent of the U.S. population, older Americans only account for 6 (percent) to 9 percent of outpatient mental health services, and this disparity is likely to worsen with our aging population,” he noted.

A lack of awareness and education about the mental illnesses faced by the elderly, such as dementia, means elderly patients with mental illness often end up in the ER.

“Emergency care is always more expensive,” said Iqbal “Ike” Ahmed, MD, clinical professor of psychiatry and geriatric medicine at the University of Hawaii. “You’re employing the most expensive possible care to these folks. And generally the care for the elderly tends to be more expensive for a couple of different reasons. One, in addition to the fact that it’s an emergency, elderly have more co-morbid medical problems. It’s never purely a psychiatric issue. ... You’re dealing with people with multiple medical problems. ... So they often end up in more hospitalization, nursing home care, ER care. These are probably the most expensive types of care you can provide.”

Ideally, prevention, early intervention, policy change and education are needed to help mitigate the crisis, Ahmed said.

[See also: States, feds slash mental health funding [ http://www.healthcarefinancenews.com/news/states-feds-slash-mental-health-funding ].]

Public education is crucial so that caregivers can recognize the difference between normal aging and dementia and find care before a crisis develops. But, Ahmed said, “there’s no point educating the public if you cannot provide the services. So I think we need to address the service delivery piece of it.”

“People are interested in looking at new models of care as well because geriatric psychiatrists can’t be the only ones taking care of these needs,” he said. There aren’t enough geriatric psychiatrists to go around, he said, so the healthcare system needs to begin addressing mental health issues of the elderly at the level of the primary care physician.

“People are looking at working on collaborative care models, integrated care models, medical home, things of that sort, where they actually might be able to provide mental health services at the level of people coming to the clinic – the primary care – to see their doctor," he said. "And that’s where we see the need to do it.”

©2011 MedTech Media

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ER Visits Persist for Children with Mental Health Problems Despite Regular Outpatient Care

Released: 5/26/2011 12:00 PM EDT
Embargo expired: 6/1/2011 12:00 AM EDT
Source: Johns Hopkins Medicine

Newswise — Johns Hopkins Children’s Center scientists have found that having a regular outpatient mental health provider may not be enough to prevent children and teens with behavioral problems from repeatedly ending up in the emergency room. The study is published in the June 1 issue of the journal Psychiatric Services [ http://psychservices.psychiatryonline.org/cgi/content/abstract/62/6/646 ].

Analyzing more than 2,900 records of pediatric patients, ages 3 to 17, treated at the Hopkins Children’s ER for mental health crises over eight years, the investigators found that 338 of them (12 percent) returned to the ER within six months of their initial visit. The majority of the ER visits stemmed from behavioral problems or minor psychiatric crises, such as disruptive classroom behavior, verbal altercations and running away, the researchers said. Only a few involved severe psychotic episodes (3 percent of the visits) or suicide attempts (10 percent). Most importantly, the researchers found, two-thirds of patients (220) reported having an outpatient mental health provider at both visits, and 288 (85 percent) reported at the second visit that they have a regular mental health provider.

The findings are concerning, the researchers said, because they may signal that patients are not actually getting the care they need on an outpatient basis.

Mental health experts have traditionally emphasized the importance of outpatient care in managing non-emergency cases and have urged connecting such patients to outpatient mental health programs. Most ERs are neither designed nor staffed to deliver effective, coordinated mental health care, the investigators said.

“We think of the ER as a ‘front door to care,’ but our findings suggest otherwise as a significant number of patients repeatedly seek care in the ER despite being connected to an outpatient provider,” said lead author Emily Frosch, M.D., a pediatric psychiatrist at Hopkins Children’s.

The findings, Frosch said, raise more questions than they answer, and researchers have only begun to untangle the complex reasons behind recurrent ER visits for non-emergency psychiatric problems.

“We need to understand why families who are already connected to outpatient providers continue to seek ER care, why providers send patients to the ER and what role, if any, ERs may play in the continuum of care for non-psychotic, non-suicidal patients,” Frosch said. “It is possible that ERs fulfill an important function in that continuum for some patients.”

The researchers said one possible explanation is that patient families face barriers to routine outpatient psychiatric care, including limited office hours. Families who have had a positive experience in the ER in the past may be simply choosing to return there for subsequent problems, the researchers say. Also, some families may also find ER care less stigmatizing than outpatient mental health services. Frosch added that ER visits may be driven by some outpatient providers who may not have sufficient resources for optimal care and instead send patients to the ER.

The Hopkins team said future studies should explore more specifically the link between outpatient care and ER visits.

“Perhaps the most critical questions to ask are ‘When was the child’s latest outpatient visit?’ and ‘What exactly transpired between that visit and their subsequent trip to the ER?’” Frosch said.

Susan dosReis, Ph.D., also of Hopkins, was co-investigator in the study.

Related on the Web:

Emily Frosch profile
http://www.hopkinschildrens.org/Emily-Frosch-MD.aspx

Teens and Depression
http://www.hopkinschildrens.org/one-in-two-depressed-teens-prone-to-recurrence-after-recovery.aspx

Child Psychiatry News and Features
http://www.hopkinschildrens.org/taxonomyNews.aspx?id=508

Founded in 1912 as the children's hospital of the Johns Hopkins Medical Institutions, the Johns Hopkins Children's Center offers one of the most comprehensive pediatric medical programs in the country, with more than 92,000 patient visits and nearly 9,000 admissions each year. Hopkins Children’s is consistently ranked among the top children's hospitals in the nation. Hopkins Children’s is Maryland's largest children’s hospital and the only state-designated Trauma Service and Burn Unit for pediatric patients. It has recognized Centers of Excellence in dozens of pediatric subspecialties, including allergy, cardiology, cystic fibrosis, gastroenterology, nephrology, neurology, neurosurgery, oncology, pulmonary, and transplant. For more information, visit http://www.hopkinschildrens.org.

©2011 Newswise, Inc.

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