Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019

Mary Arakelyan; Seneca Freyleue; Divya Avula; Jennifer L McLaren; A James O’Malley; JoAnna K Leyenaar

doi:10.1001/jama.2023.1992

. 2023 Mar 28;329(12):1000–1011. doi: 10.1001/jama.2023.1992

Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019

Mary Arakelyan ^1,^✉, Seneca Freyleue ², Divya Avula ^2,³, Jennifer L McLaren ^1,^2,⁴, A James O’Malley ^2,⁵, JoAnna K Leyenaar ^1,²

PMCID: PMC10051095 PMID: 36976279

Key Points

Question

How have hospitalizations for pediatric mental health conditions at acute care hospitals changed from 2009 to 2019?

Findings

In this retrospective analysis of a national data set representing an estimated 4 767 840 pediatric hospitalizations, annual hospitalizations for mental health diagnoses increased from 160 499 in 2009 to 201 932 in 2019. Hospitalizations with a diagnosis of attempted suicide or self-injury increased from 49 285 in 2009 to 129 699 in 2019 and comprised 64% of mental health hospitalizations in 2019. Mental health hospitalizations accounted for more than one-quarter of all hospital days and half of all interfacility transfers in children and adolescents aged 3 to 17 years in 2019.

Meaning

Mental health diagnoses, including attempted suicide and self-injury, accounted for an increasing number and proportion of pediatric acute care hospitalizations between 2009 and 2019.

Abstract

Importance

Approximately 1 in 6 youth in the US have a mental health condition, and suicide is a leading cause of death among this population. Recent national statistics describing acute care hospitalizations for mental health conditions are lacking.

Objectives

To describe national trends in pediatric mental health hospitalizations between 2009 and 2019, to compare utilization among mental health and non–mental health hospitalizations, and to characterize variation in utilization across hospitals.

Design, Setting, and Participants

Retrospective analysis of the 2009, 2012, 2016, and 2019 Kids’ Inpatient Database, a nationally representative database of US acute care hospital discharges. Analysis included 4 767 840 weighted hospitalizations among children 3 to 17 years of age.

Exposures

Hospitalizations with primary mental health diagnoses were identified using the Child and Adolescent Mental Health Disorders Classification System, which classified mental health diagnoses into 30 mutually exclusive disorder types.

Main Outcomes and Measures

Measures included number and proportion of hospitalizations with a primary mental health diagnosis and with attempted suicide, suicidal ideation, or self-injury; number and proportion of hospital days and interfacility transfers attributable to mental health hospitalizations; mean lengths of stay (days) and transfer rates among mental health and non–mental health hospitalizations; and variation in these measures across hospitals.

Results

Of 201 932 pediatric mental health hospitalizations in 2019, 123 342 (61.1% [95% CI, 60.3%-61.9%]) were in females, 100 038 (49.5% [95% CI, 48.3%-50.7%]) were in adolescents aged 15 to 17 years, and 103 456 (51.3% [95% CI, 48.6%-53.9%]) were covered by Medicaid. Between 2009 and 2019, the number of pediatric mental health hospitalizations increased by 25.8%, and these hospitalizations accounted for a significantly higher proportion of pediatric hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]). The percentage of mental health hospitalizations with attempted suicide, suicidal ideation, or self-injury diagnoses increased significantly from 30.7% (95% CI, 28.6%-32.8%) in 2009 to 64.2% (95% CI, 62.3%-66.2%) in 2019. Length of stay and interfacility transfer rates varied significantly across hospitals. Across all years, mental health hospitalizations had significantly longer mean lengths of stay and higher transfer rates compared with non–mental health hospitalizations.

Conclusions and Relevance

Between 2009 and 2019, the number and proportion of pediatric acute care hospitalizations due to mental health diagnoses increased significantly. The majority of mental health hospitalizations in 2019 included a diagnosis of attempted suicide, suicidal ideation, or self-injury, underscoring the increasing importance of this concern.

This retrospective analysis of a nationally representative database of US acute care hospital discharges assesses increased mental health diagnoses and hospitalizations among pediatric patients between 2009 and 2019.

Introduction

In 2016, approximately 1 in 6 youth in the US was estimated to have a mental health condition, and less than half reported receiving any mental health services in the preceding year.¹ Despite the relatively high prevalence of pediatric mental health conditions, more than one-third of US counties, including half of rural counties, do not have an outpatient mental health facility that provides treatment for children.²

Reports suggest that the prevalence and severity of mental health conditions among children and adolescents has been increasing and that a growing number are seeking care at acute care hospitals.^3,4,5,6,7 Over the past 2 decades, emergency department visits for mental health conditions have increased significantly, particularly for suicide and/or self-injury.^3,8,9,10,11 According to the 2019 National Youth Risk Behavior Survey: suicide was the second leading cause of death among children and adolescents aged 3 to 17 years; and 18.8% of youth are estimated to have seriously considered attempting suicide in the preceding year.^12,13

Inpatient stays for mental health diagnoses are a marker of illness severity and unmet need in outpatient settings. However, there are few analyses describing national trends in pediatric mental health hospitalizations across structurally diverse acute care hospitals; the most recent national analysis reflects data from 2009, finding that nearly 10% of pediatric acute care hospitalizations had a primary mental health diagnosis.¹⁴ Updated analyses are needed. This study’s aims were to describe (1) changes between 2009 and 2019 in the number and proportion of pediatric acute care hospitalizations with a principal mental health diagnosis and in associated measures of health care utilization; (2) health care utilization among mental health and non–mental health hospitalizations, and (3) variation in health care utilization for mental health diagnoses according to a hospital’s annual volume of mental health hospitalizations.

Methods

Study Design and Data Sources

We conducted a retrospective analysis of the 2009, 2012, 2016, and 2019 Kids’ Inpatient Database (KID), which is part of the Healthcare Cost and Utilization Project (HCUP) and sponsored by the Agency for Healthcare Research and Quality.^15,16 Published approximately every 3 years, the KID is the largest nationally representative database of pediatric acute care hospital discharges in the US, including data from all payers and those who were uninsured.^15,16 It includes inpatient stays and excludes emergency department encounters not resulting in a hospitalization; there is no indicator to denote observation services or boarding-status hospital stays. The KID includes “short-term, non-Federal, general, and specialty hospitals” and excludes short-term rehabilitation hospitals, long-term non–acute care hospitals, psychiatric hospitals, and substance-dependency treatment facilities.^15,16 Each data set contains a full calendar year of data that represents 80% of discharges (excluding newborns) for patients younger than 21 years. The KID includes discharge weights based on the universe of hospitals of the American Hospital Association, which were used to obtain national estimates for this analysis.

HCUP databases qualify as limited data sets¹⁷; the Dartmouth-Health institutional review board determined this study to be “not human subjects research.” The methods and findings of this study are reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement for observational studies¹⁸ and the HCUP data use agreement requirements.

Identification of Mental Health Hospitalizations and Attempted Suicide or Self-injury

We used the Child and Adolescent Mental Health Disorders Classification System (CAMHD-CS) to identify hospitalizations with a principal mental health diagnosis, hereafter called mental health hospitalizations.¹⁹ All other hospitalizations were considered non–mental health hospitalizations. The CAMHD-CS outlines 30 mental health disorder groups, including attempted suicide, suicidal ideation, or self-injury (hereafter referred to as attempted suicide or self injury), and maps International Classification of Disease 9th Revision (ICD-9) and ICD-10 codes to Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) diagnoses. The study was limited to hospitalizations among children and adolescents aged 3 to 17 years.¹⁹ We excluded 1275 discharges across all years (<0.1%) for missing a primary ICD diagnosis code.

In the ICD-9 system, suicide or self-injury were frequently coded with external cause of injury codes (E-codes), and the transition from ICD-9 to ICD-10 codes in 2015 (when E-codes were discontinued) may have influenced the proportion of hospitalizations classified with a primary mental health diagnosis. To facilitate comparisons across the ICD-9 and ICD-10 periods and avoid undercounting potential hospitalizations for suicide and self-injury in 2009 and 2012 in these 2 data years, we included all hospitalizations with E-codes listed in the CAMHD-CS suicide or self-injury disorder group as mental health hospitalizations, regardless of the principal ICD-9 diagnosis. With survey weighting, this approach resulted in the identification of 11 645 additional hospitalizations in 2009 and 12 513 additional hospitalizations in 2012. Characteristics of hospitalizations are presented using the original CAMHD-CS approach in eTable 1 in Supplement 1.

Suicide or self-injury have historically been considered symptoms of other disorders (eg, major depressive disorder), and the DSM-IV and DSM-5 do not include suicide or self-injury in their diagnostic systems.^20,21,22 Therefore suicide or self-injury hospitalizations were identified as having either a primary CAMHD-CS disorder group of suicide or self-injury (including E-codes) or another primary mental health diagnosis with a CAMHD-CS–defined suicide or self-injury diagnosis in a secondary position. Within each CAMHD-CS disorder group, the proportion of hospitalizations with any diagnosis of suicide or self-injury were examined to capture patterns of co-occurrence.

Cohort Characteristics

For each hospitalization, the KID contains patient data on age at admission (in years), binary sex, race and ethnicity, primary payer, and median household income of each patient’s zip code (in quartiles). Race and ethnicity were reported given established disparities in mental health hospitalizations and suicide^23,24; these data were reported to HCUP by participating partner organizations and collected according to each hospital’s standard operating procedures, which can vary.²⁵ Age at admission was categorized into 3 to 10 years (childhood), 11 to 14 years (early adolescence), and 15 to 17 years (middle adolescence), based on age ranges used in Bright Futures.²⁶ The Complex Chronic Condition classification was applied to identify children with 1 or more complex chronic conditions, and the Children With Disabilities algorithm was used to identify those with disabilities.^27,28 For each hospitalization, the number of unique CAMHD-CS disorder groups among all primary and secondary diagnoses was also counted. Hospital characteristics included geographic region based on US Census regions, ownership, and location/teaching status.

Health Care Utilization Measures

Changes in the number and proportion of hospitalizations for mental health diagnoses and with suicide or self-injury, length of stay (LOS) in days, and interfacility transfers were assessed over time. To identify interfacility transfers, an indicator that the index hospital did not provide the full course of inpatient care (termed definitive care²⁹), hospitalizations with discharge to short-term hospitals, skilled nursing facilities, intermediate-care facilities, or other medical facilities (including psychiatric hospitals) were identified. Costs in 2019 were examined using data from the KID on total charges associated with a hospitalization (total amount billed), which were converted to costs (expenses incurred in the provision of care) using HCUP cost-to-charge ratios.³⁰

Statistical Analysis

After applying the KID survey weights to generate national estimates, we summarized demographic, clinical, and hospital characteristics of mental health hospitalizations within each year of data. For each characteristic, we determined the estimated count and proportion with associated 95% CI; for meaningful changes over time, P values were derived using χ² tests with Rao-Scott corrections.

We determined the proportion of hospitalizations, hospital days, and interfacility transfers attributable to a primary mental health diagnosis in each year and plotted these proportions with associated 95% CIs. We used weighted logistic regressions to assess differences in the proportions of hospitalizations and transfers due to mental health diagnoses in 2019 compared with 2009. For the proportion of total hospital days attributable to mental health hospitalizations, we compared the difference in values between 2009 and 2019 to an empirical null distribution created through parametric bootstrapping based on survey estimates of total days; P values were reported for these comparisons of proportions. We then compared LOS and likelihood of interfacility transfer among hospitalizations with a primary mental health diagnosis to those with a non–mental health primary diagnosis within each year, using Poisson regressions and logistic regressions respectively. Resulting effect sizes were plotted with 95% CIs in forest plots.

To assess variation in health care utilization across hospitals in 2019, all hospitals with at least 1 mental health hospitalization were grouped into modified deciles reflecting hospitals’ mental health hospitalization volumes. The number of mental health hospitalizations per hospital was determined by multiplying the number of hospitalizations at each facility by 1.25, as the KID includes an 80% sample of these discharges.^15,16 Hospitals with less than 11 hospitalizations comprised the first bin and the remaining hospitals were divided into 9 approximately equal-sized groups. We then grouped hospitalizations based on their hospital decile and calculated the geometric mean LOS and proportion with interfacility transfer in each decile, plotting the resulting summary measures in forest plots with 95% CIs. To further demonstrate hospital-level variation, we calculated the median and IQR of hospitals’ geometric mean LOS and interfacility transfer rate.

Analyses were conducted using R, version 4.3.1 (R Core Team), SAS software version 9.4, and Python 3.8.10. The threshold for statistical significance was .05 and all reported P values were 2-sided. A total of 229 unweighted observations across all years were missing LOS and 1824 were missing discharge status. We proceeded with pairwise deletion and reported all missing data in the tables and figures.

Results

Sociodemographic, Clinical, and Hospital Characteristics

From 2009 to 2019 (data from 2009, 2012, 2016, and 2019), the KID contains unweighted data from 944 284, 891 903, 789 806, and 756 311 acute care hospital discharges among children and adolescents aged 3 to 17 years, representing a weighted total estimate of 4 767 840 hospitalizations. In 2009, an estimated 160 499 hospitalizations at US acute care hospitals had a primary mental health diagnosis, increasing to 171 570 in 2012, 188 549 in 2016, and 201 932 in 2019.

Adolescents aged 11 to 14 years accounted for an increasing proportion of mental health hospitalizations over time, increasing significantly from 33.5% (95% CI, 32.7%-34.2%) in 2009 to 40.4% (95% CI, 39.8%-41.0%) in 2019 (P value <.001). Mental health hospitalizations in children aged 10 years and younger and in children aged 15 years and older had commensurate decreases over this period (Table 1). The proportion of hospitalizations in females also increased significantly over time, from 51.8% (95% CI, 51.1%-52.6%) in 2009 to 61.1% (95% CI, 60.3%-61.9%) in 2019 (P value <.001). Differences across years in race and ethnicity, primary payer, community median income, co-occurring complex chronic conditions, and co-occurring disabilities were relatively small (Table 1). From 2009 to 2019, a significantly higher proportion of hospitalizations occurred at urban teaching and freestanding children’s hospitals with proportional declines in hospitalizations at rural and urban non–teaching centers. Other hospital characteristics were not notably different across years.

Table 1. Sociodemographic, Clinical and Hospital Characteristics of US Pediatric Hospitalizations for Primary Mental Health Diagnoses, 2009-2019, Weighted National Estimates^a.

	2009		2012		2016		2019
	No.	% (95% CI)	No.	% (95% CI)	No.	% (95% CI)	No.	% (95% CI)
Total mental health hospitalizations	160 499		171 570		188 549		201 932
Sociodemographic and clinical characteristics
Age	160 500^b		171 570		188 549		201 932
Childhood (3-10 y)	21 468	13.4 (12.2-14.5)	21 599	12.6 (11.5-13.6)	20 765	11.0 (9.9-12.1)	20 305	10.1 (9.1-11.0)
Early adolescence (11-14 y)	53 715	33.5 (32.7-34.2)	61 995	36.1 (35.5-36.8)	69 577	36.9 (36.4-37.4)	81 589	40.4 (39.8-41.0)
Middle adolescence (15-17 y)	85 317	53.2 (51.6-54.7)	87 976	51.3 (49.9-52.6)	98 207	52.1 (50.7-53.5)	100 038	49.5 (48.3-50.7)
Sex	159 863		171 557		188 528		201 906
Female	82 887	51.8 (51.1-52.6)	94 513	55.1 (54.3-55.9)	115 040	61.0 (60.1-61.9)	123 342	61.1 (60.3-61.9)
Male	76 976	48.2 (47.4-48.9)	77 044	44.9 (44.1-45.7)	73 488	39.0 (38.1-39.9)	78 564	38.9 (38.1-39.7)
Race and ethnicity^c	127 014		150 406		169 861		189 832
Asian or Pacific Islander	1414	1.1 (0.9-1.3)	2124	1.4 (1.1-1.8)	3118	1.8 (1.4-2.3)	3550	1.9 (1.5-2.2)
Black	21 832	17.2 (15.1-19.3)	28 104	18.7 (16.6-20.8)	30 014	17.7 (15.9-19.4)	33 064	17.4 (15.7-19.1)
Hispanic	16 318	12.8 (9.8-15.9)	20 525	13.6 (10.7-16.6)	24 433	14.3 (11.1-17.7)	27 084	14.3 (11.7-16.9)
Native American	1775	1.4 (0.7-2.2)	1546	1.0 (0.5-1.6)	2098	1.2 (0.7-1.8)	2422	1.3 (0.7-1.9)
White	77 936	61.4 (58.0-64.7)	90 203	60.0 (56.8-63.2)	102 782	60.5 (57.4-63.6)	113 711	59.9 (57.1-62.7)
Other	7739	6.1 (4.8-7.4)	7904	5.3 (4.1-6.4)	7416	4.4 (3.6-5.1)	10 001	5.3 (4.4-6.1)
Primary payer	159 746		171 093		188 448		201 722
Medicaid	75 896	47.5 (44.8-50.2)	83 107	48.6 (45.9-51.3)	96 308	51.1 (48.7-53.6)	103 456	51.3 (48.6-53.9)
Private insurance	71 723	44.9 (42.2-47.6)	74 584	43.6 (41.2-46.0)	80 336	42.6 (40.2-45.1)	84 801	42.0 (39.3-44.8)
Other	6876	4.3 (3.5-5.1)	8476	5.0 (4.1-5.8)	7065	3.7 (3.0-4.5)	6806	3.4 (2.8-3.9)
Self-pay	4993	3.1 (2.6-3.6)	4144	2.4 (2.1-2.7)	4014	2.1 (1.8-2.4)	6088	3.0 (2.5-3.5)
Medicare	258	0.2 (0.1-0.3)	782	0.5 (0.1-0.8)	725	0.4 (0.1-0.6)	571	0.3 (0.1-0.5)
Median income at zip code^d	156 476		167 492		186 020		199 713
Quartile 1	46 489	29.7 (26.9-32.6)	48 280	28.8 (26.2-31.4)	53 313	28.7 (26.0-31.3)	56 001	28.0 (25.4-30.7)
Quartile 2	41 132	26.3 (24.5-28.0)	41 887	25.0 (23.2-26.8)	47 344	25.5 (23.8-27.1)	51 315	25.7 (24.0-27.4)
Quartile 3	36 749	23.5 (22.1-24.9)	40 444	24.1 (22.8-25.5)	45 527	24.5 (23.2-25.8)	50 682	25.4 (23.9-26.9)
Quartile 4	32 106	20.5 (18.1 23.0)	36 881	22.1 (19.4-24.6)	39 836	21.4 (18.9-23.9)	41 715	20.9 (18.5-23.3)
>1 Complex chronic condition^e	11 201	7.0 (6.3-7.6)	13 289	7.7 (7.0-8.5)	15 934	8.4 (7.7-9.2)	17 937	8.9 (8.2-9.6)
Co-occurring disability^f	25 882	16.1 (14.9-17.3)	27 266	15.9 (14.7-17.1)	30 430	16.1 (15.0-17.3)	32 228	16.0 (14.7-17.2)
Hospital characteristics
Hospital region	160 499		171 571^b		188 548^b		201 933^b
Midwest	54 186	33.8 (27.4-40.1)	55 771	32.5 (26.2-38.8)	62 919	33.4 (26.5-40.2)	68 134	33.7 (27.2-40.3)
South	53 937	33.6 (27.7-39.5)	60 984	35.5 (29.5-41.6)	68 688	36.4 (30.1-42.8)	76 289	37.8 (31.6-44.0)
Northeast	32 532	20.3 (16.1-24.5)	33 580	19.6 (15.2-23.9)	32 757	17.4 (13.3-21.4)	32 208	15.9 (12.1-19.8)
West	19 844	12.4 (9.0-15.8)	21 236	12.4 (8.9-15.8)	24 184	12.8 (8.9-16.8)	25 302	12.5 (8.7-16.4)
Hospital ownership	149 608		171 570		188 550^b		201 932
Private, not-profit	111 750	74.7 (68.7-80.7)	125 027	72.9 (67.4-78.3)	138 177	73.3 (67.6-79.0)	143 975	71.3 (65.3-77.3)
Government, non-federal	19 987	13.4 (9.0-17.7)	25 068	14.6 (10.7-18.6)	27 974	14.8 (10.4-19.3)	33 350	16.5 (11.4-21.6)
Private, investor-owned	17 871	11.9 (7.0-16.9)	21 475	12.5 (8.0-17.0)	22 399	11.9 (7.5-16.3)	24 607	12.2 (7.9-16.5)
Hospital location/teaching status^g	152 200		171 570		188 550^b		201 933^b
Urban teaching	83 955	55.2 (48.9-61.4)	97 382	56.8 (50.6-63.0)	121 209	64.3 (57.7-70.8)	147 301	72.9 (67.3-78.6)
Urban non–teaching	44 524	29.2 (23.5-35.0)	44 869	26.2 (20.7-31.6)	30 954	16.4 (11.7-21.1)	17 255	8.5 (5.6-11.5)
Freestanding children's	13 613	8.9 (4.4-13.5)	19 450	11.3 (6.2-16.4)	28 291	15.0 (11.7-21.1)	29 460	14.6 (9.4-19.8)
Rural	10 108	6.6 (4.8-8.5)	9869	5.8 (4.0-7.5)	8096	4.3 (2.8-5.8)	7917	3.9 (2.4-5.4)

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Abbreviations: HCUP, Healthcare Cost and Utilization Project; KID, Kids’ Inpatient Database.

^{^a}

Data are based on retrospective analysis of the 2009, 2012, 2016, and 2019 KID, a nationally representative database of US acute care hospital discharges. Analyses include hospitalizations of patients aged 3 to 17 years and used the KID discharge weights and survey weighting packages within statistical software to obtain national estimates.

^{^b}

All frequencies reported in this table are estimates derived using survey weighting methods and rounded to the nearest whole number.

^{^c}

Data regarding patients’ race and ethnicity were reported to HCUP by participating partner organizations and collected according to each hospital’s standard operating procedures, which can vary.

^{^d}

Quartile ranges for median household income at home zip code vary annually (eg, quartile 1 encompasses median household incomes of <$40 000 in 2009 and <$48 000 in 2019). Details available in the HCUP data dictionaries.¹⁵

^{^e}

Hospitalizations with 1 or more complex chronic conditions based on the pediatric Complex Chronic Condition classification system, which matches International Classification of Diseases diagnostic codes to 12 categories, including technology dependence and transplant.²⁶

^{^f}

Hospitalizations were deemed to have evidence of a co-occurring disability based on the Children with Disabilities Algorithm, a diagnostic code-based algorithm.²⁷

^{^g}

Starting in 2014, more hospitals were categorized as urban, teaching hospitals as there was an increase in facilities with approved residency programs in the American Hospital Association Annual Survey, from which hospital characteristics are derived. The Accreditation Council for Graduate Medical Education became the primary body for residency approval around this time.

Mental Health Diagnoses

Depressive disorders were the most common primary diagnoses in all years, comprising 29.7% of mental health hospitalizations in 2009 (95% CI, 27.9%-31.4%) and increasing significantly to 56.8% in 2019 (95% CI, 54.5%-59.1%) (Table 2). Hospitalizations for eating and feeding disorders also increased significantly over time from an estimated 1850 in 2009 (1.2% [95% CI, 0.8%-1.5%]) to 4262 in 2019 (2.1% [95% CI, 1.6%-2.7%]) (P value =.008), almost doubling the proportion of mental health hospitalizations. Hospitalizations for anxiety disorders showed a similar increase from an estimated 2059 in 2009 (1.3% [95% CI, 1.1%-1.5%]) to 3689 in 2019 (1.8% [95% CI, 1.6%-2.1%]). Concurrently, as shown in Table 2, hospitalizations decreased for bipolar and related disorders, disruptive, impulse control and conduct disorders, attention-deficit/hyperactivity disorder, schizophrenia spectrum, and other psychotic disorders. In 2009, 19.7% (95% CI, 17.7%-21.7%) of mental health hospitalizations were experienced by children with diagnoses in 4 or more unique mental health disorder groups, increasing significantly to 42.4% (95% CI, 40.1%-44.6%) in 2019 (P value <.001).

Table 2. Primary Diagnoses Among Mental Health Hospitalizations and the Co-occurrence of Any Attempted Suicide or Self-injury Diagnosis, 2009-2019, Weighted National Estimates^a.

Mental health disorder group of primary diagnosis	Estimated No. of hospitalizations				% of total mental health hospitalizations (95% CI)				% With any attempted suicide or self-injury diagnosis (95% CI)
Mental health disorder group of primary diagnosis	2009	2012	2016	2019	2009	2012	2016	2019	2009	2012	2016	2019
Total mental health diagnoses	160 499	171 570	188 549	201 932	100	100	100	100	30.7 (28.6-32.8)	41.3 (38.8-43.8)	39.4 (36.5-42.2)	64.2 (62.3-66.2)
Depressive disorders	47 597	58 038	91 241	114 710	29.7 (27.9-31.4)	33.8 (32.0-35.6)	48.4 (46.4-50.3)	56.8 (54.5-59.1)	37.8 (34.3-41.4)	51.9 (47.9-55.8)	40.7 (36.8-44.6)	69.9 (67.5-72.3)
Bipolar and related disorders	24 497	17 897	15 476	10 545	15.3 (13.7-16.9)	10.4 (9.1-11.7)	8.2 (7.0-9.4)	5.2 (4.5-5.9)	24.0 (21.1-27.0)	33.9 (30.4-37.5)	29.5 (25.8-33.3)	56.7 (53.3-60.0)
Miscellaneous	24 094	31 375	13 193	5899	15.0 (13.0-17.0)	18.3 (16.3-20.2)	7.0 (5.7-8.3)	2.9 (2.3-3.6)	21.3 (18.3-24.3)	31.4 (28.3-34.5)	23.6 (19.0-28.3)	52.4 (47.0-57.8)
Disruptive, impulse control, and conduct disorders	12 467	11 569	11 948	9863	7.8 (6.7-8.8)	6.7 (5.6-7.9)	6.3 (5.2-7.5)	4.9 (3.9-5.8)	10.3 (8.6-12.0)	18.4 (15.0-21.7)	17.4 (14.4-20.3)	32.5 (29.7-35.2)
Suicide or self-injury	11 889	12 764	17 617	17 997	7.4 (6.5-8.3)	7.4 (6.5-8.4)	9.3 (8.1-10.6)	8.9 (7.7-10.1)	100	100	100	100
Trauma and stressor-related disorders	9843	9896	11 190	12 921	6.1 (5.2-7.0)	5.8 (4.9-6.7)	5.9 (5.1-6.7)	6.4 (5.4-7.4)	26.5 (22.9-30.0)	36.1 (32.3-39.9)	32.1 (28.0-36.1)	56.1 (52.1-60.2)
Schizophrenia spectrum and other psychotic disorders	7174	6659	5167	4653	4.5 (4.1-4.8)	3.9 (3.6-4.2)	2.7 (2.5-3.0)	2.3 (2.1-2.5)	14.7 (12.4-17.0)	22.0 (18.8-25.3)	17.9 (15.1-20.7)	30.7 (28.2-33.2)
Attention-deficit/hyperactivity disorder	6731	5388	5447	5590	4.2 (3.3-5.1)	3.1 (2.4-3.9)	2.9 (2.3-3.5)	2.8 (2.2-3.4)	9.9 (7.8-11.9)	14.3 (11.4-17.1)	16.8 (13.3-20.3)	38.4 (35.0-41.8)
Substance-related and addictive disorders	3980	3617	2513	2630	2.5 (1.9-3.0)	2.1 (1.6-2.6)	1.3 (1.1-1.5)	1.3 (1.1-1.5)	8.3 (6.4-10.2)	12.2 (9.9-14.6)	13.5 (10.8-16.2)	23.0 (18.2-27.8)
Anxiety disorders	2059	2807	3367	3689	1.3 (1.1-1.5)	1.6 (1.4-1.9)	1.8 (1.6-2.0)	1.8 (1.6-2.1)	17.3 (14.5-20.0)	28.3 (24.6-32.1)	29.7 (25.8-33.7)	53.6 (49.6-57.7)
Autism spectrum disorder	2025	1939	2682	2411	1.3 (1.1-1.4)	1.1 (1.0-1.3)	1.4 (1.2-1.7)	1.2 (1.0-1.4)	8.2 (6.3-10.2)	13.9 (11.3-16.5)	12.7 (10.1-15.4)	26.4 (22.9-29.9)
Feeding and eating disorders	1850	2576	3222	4262	1.2 (0.8-1.5)	1.5 (1.0-2.0)	1.7 (1.2-2.2)	2.1 (1.6-2.7)	5.0 (3.6-6.4)	8.6 (5.7-11.5)	8.4 (6.6-10.2)	12.8 (10.3-15.3)
Somatic symptom and related disorders	1286	1672	1132	1976	0.8 (0.7-0.9)	1.0 (0.8-1.1)	0.6 (0.5-0.7)	1.0 (0.8-1.1)	1.2 (0.5-2.0)	3.0 (2.0-3.9)	2.4 (1.3-3.5)	4.9 (3.8-6.0)
Maternal mental illness or substance abuse^b	1029	878	807	981	0.6 (0.6-0.7)	0.5 (0.5-0.6)	0.4 (0.4-0.5)	0.5 (0.4-0.5)	15.6 (12.7-18.5)	18.3 (14.7-22.0)	15.4 (11.5-19.4)	19.4 (15.5-23.2)
Accidental or undetermined poisoning	968	1184	958	1332	0.6 (0.5-0.7)	0.7 (0.6-0.8)	0.5 (0.4-0.6)	0.7 (0.6-0.8)	37.9 (34.0-41.8)	35.4 (31.8-39.0)	2.6 (1.4-3.8)	3.0 (2.0-4.1)
Obsessive-compulsive and related disorders	380	347	387	410	0.2 (0.2-0.3)	0.2 (0.2-0.2)	0.2 (0.2-0.2)	0.2 (0.2-0.2)	19.0 (14.4-23.6)	23.4 (17.4-29.4)	24.8 (18.7-30.9)	47.6 (41.2-54.0)
Personality disorders	256	294	260	350	0.2 (0.1-0.2)	0.2 (0.1-0.2)	0.1 (0.1-0.2)	0.2 (0.1-0.2)	19.3 (12.8-25.9)	22.3 (14.9-29.6)	31.8 (23.7-40.0)	72.8 (66.3-79.1)
Mental health symptoms	221	330	486	476	0.1 (0.1-0.2)	0.2 (0.2-0.2)	0.3 (0.2-0.3)	0.2 (0.2-0.3)	13.7 (8.2-19.1)	14.9 (9.9-19.9)	13.3 (9.7-16.9)	22.3 (17.6-26.9)
Other^c	2152	2339	1457	1234	1.3 (1.1-1.5)	1.4 (1.2-1.6)	0.8 (0.7-0.9)	0.6 (0.5-0.7)	5.6 (4.2-7.0)	5.0 (3.7-6.2)	4.2 (3.2-5.2)	9.2 (8.0-10.4)
No. of unique mental health disorder groups per hospitalization^d
1	35 257	30 315	24 454	14 897	22.0 (20.2-23.8)	17.7 (16.0-19.3)	13.0 (11.8-14.2)	7.4 (6.6-8.1)	21.1 (18.8-23.4)	23.1 (20.3-25.8)	8.0 (6.5-9.4)	11.4 (9.3-13.6)
2	51 375	50 937	52 171	43 121	32.0 (30.8-33.3)	29.7 (28.4-31.0)	27.7 (26.4-29.0)	21.4 (20.1-22.7)	24.8 (22.9-26.8)	33.5 (31.0-36.0)	28.6 (25.9-31.2)	48.3 (45.6-50.9)
3	42 306	46 630	52 561	58 360	26.4 (25.5-27.2)	27.2 (26.4-27.9)	27.9 (27.3-28.5)	28.9 (28.2-29.6)	32.2 (29.7-34.8)	43.5 (40.8-46.3)	41.8 (38.8-44.8)	65.3 (63.4-67.3)
≥4	31 561	43 689	59 363	85 554	19.7 (17.7-21.7)	25.5 (23.2-27.7)	31.5 (29.3-33.7)	42.4 (40.1-44.6)	45.8 (42.1-49.5)	57.3 (54.6-60.1)	56.5 (53.4-59.6)	76.4 (75.1-77.8)

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Abbreviations: CAMHD-CS, Child and Adolescent Mental Health Disorders Classification System.

^{^a}

See footnote a in Table 1 for details regarding basis of data. Analyses include hospitalizations of patients aged 3-17 with a primary mental health diagnosis. A diagnostic-code based algorithm (CAMHD-CS)¹⁹ was used to match primary diagnosis codes to a mental health disorder group. The proportion of hospitalizations within each disorder group with a secondary diagnosis code of suicide or self-injury is included.

^{^b}

Shortened from Maternal Mental Illness or Substance Abuse During Pregnancy, Delivery or Post-Partum.

^{^c}

Includes the following CAMHD-CS disorder groups, combined due to small cell sizes: motor, neurocognitive, elimination, sexuality and gender identity, intellectual disability, communication, sleep-wake, developmental delay or unspecified neurodevelopmental, specific learning, fetal or newborn damage related to maternal substance abuse, dissociative, substance abuse–related medical illness.

^{^d}

Counts are the number of CAMHD-CS disorder groups that all primary and secondary diagnostic codes associated with a hospitalization match. Each hospitalization in the mental health cohort has at least 1, and in theory, the count could range to 30 (total No. of CAMHD-CS groups and the maximum No. of diagnostic codes on an inpatient record).

From 2009 to 2019, both the absolute number and the proportion of mental health hospitalizations with an attempted suicide or self-injury diagnosis increased significantly, rising from 49 285 in 2009 (30.7% [95% CI, 28.6%-32.8%] of mental health hospitalizations) to 129 699 in 2019 (64.2% [95% CI, 62.3%-66.2%] of mental health hospitalizations; Figure 1). This represents a relative increase of 163.2% (95% CI, 115.5%-210.8%) in the number of mental health hospitalizations with an attempted suicide or self-injury diagnosis. Mental health hospitalizations with an attempted suicide or self-injury comprised a 4-fold greater proportion of all hospitalizations among children aged 3 to 17 years in 2019 vs 2009 (3.5% [95% CI, 3.2%-3.9%] to 12.7% [95% CI, 11.1%-13.9%])—an additional 9.2% percentage points (95% CI, 7.7%-10.6%; P < .001). The proportion of hospitalizations with an attempted suicide or self-injury diagnosis by primary mental health disorder group is shown in Table 2. In 2019, 69.9% (95% CI, 67.5%-72.3%) of hospitalizations with a primary diagnosis of depressive disorders had a secondary diagnosis for an attempted suicide or self-injury. The highest rate of co-occurrence was observed among the small group of hospitalizations for personality disorders in 2019 with 72.8% (95% CI, 66.3%-79.1%) having a secondary diagnosis of an attempted suicide or self-injury. Among those with diagnoses in 4 or more mental health disorder groups, 76.4% (95% CI, 75.1%-77.8%) had an attempted suicide or self-harm diagnosis in 2019.

Figure 1. — Data are based on retrospective analysis of the 2009, 2012, 2016, and 2019 Kids’ Inpatient Database (KID), a nationally representative database of US acute care hospital discharges. Whiskers indicate the 95% CIs. Analyses include hospitalizations in children aged 3 to 17 years with hospitalizations for primary mental health diagnoses determined by the Child and Adolescent Mental Health Disorders Classification System (CAMHD-CS), a diagnostic code–based algorithm.¹⁹ The KID discharge weights and survey weighting packages within statistical software were used to obtain national estimates. Attempted suicide, suicidal ideation, or self-injury was defined as an *International Classification of Diseases, Ninth Revision* (*ICD-9*) diagnosis code or external cause of injury code (E-code) or an *ICD-10* diagnosis code for suicide or self-injury using the CAMHD-CS.¹⁹

^aThe proportion of all hospitalizations with attempted suicide or self-injury was calculated as the number of mental health hospitalizations with a primary or secondary suicide or self-injury diagnosis divided by the total number of hospitalizations among patients aged 3 to 17 years for any condition.

Trends in Health Care Utilization

Between 2009 and 2019, mental health hospitalizations accounted for an increasing proportion of hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]; P < .001), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]; P = .02), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]; P < .001, Figure 2). Mental health hospitalizations increased from an estimated 160 499 to 201 932 between 2009 and 2019, an increase of 41 433 hospitalizations, or 25.8% (95% CI, 3.8%-47.8%). Concurrently, the total estimated number of pediatric hospitalizations decreased significantly, from 1 395 986 in 2009 to 1 020 268 in 2019. Compared to 2009, in 2019 there were 4257 additional mental health hospitalizations that resulted in inter-facility transfer. Compared to 2009, absolute and relative increases in the number of mental health hospital days were not statistically significant. In 2019, the estimated total cost for all mental health hospitalizations was $1.37 billion, of which depressive disorders accounted for 49.1% (eTable 2 in Supplement 1). The estimated mean cost per hospitalization was US $6791.

Figure 2. — Data are based on retrospective analysis of the 2009, 2012, 2016, and 2019 Kids’ Inpatient Database (KID), a nationally representative database of US acute care hospital discharges. Whiskers indicate 95% CIs. Analyses include hospitalizations in children aged 3 to 17 years with hospitalizations for primary mental health diagnoses determined by the Child and Adolescent Mental Health Disorders Classification System (CAMHD-CS), a diagnostic code–based algorithm.¹⁹ The KID discharge weights and survey weighting packages within statistical software were used to obtain national estimates.

^aInterfacility transfer was defined as discharge status to short-term hospitals, skilled nursing facilities, intermediate-care facilities, or other medical facilities, including psychiatric hospitals. Interfacility transfer reflects transfers following acute care hospitalization and does not include transfers from the emergency department that do not result in hospitalization at the index hospital. A total of 1824 were missing discharge/transfer status. These comprise less than 0.1% of data and were addressed with pairwise deletion in analyses involving interfacility transfer.

^bLength of stay represents number of days at an acute care hospital prior to discharge or transfer. A total of 229 unweighted observations across all years were missing length of stay. These comprise less than 0.1% of data and were addressed with pairwise deletion in analyses involving length of stay.

Health Care Utilization in Mental Health and Non–Mental Health Hospitalizations

In 2019, the estimated geometric mean LOS for mental health hospitalizations was 4.7 days (95% CI, 4.6-4.9 days), compared with 2.6 days (95% CI, 2.5-2.7 days) for non–mental health hospitalizations, representing a difference of 2.1 days (95% CI, 1.8-2.3 days) and an incidence rate ratio of 1.6 (95% CI, 1.5-1.8). Similar patterns were observed across all data years (eFigure in Supplement 1). Relative to hospitalizations for non–mental health diagnoses, those with mental health diagnoses also had consistently higher rates of interfacility transfer; the transfer rate was 10.9% (95% CI, 9.4%-12.4%) for mental health hospitalizations and 2.8% (95% CI, 2.6%-2.9%) for non–mental health hospitalizations, reflecting an odds ratio of 4.3 in 2019 (95% CI, 3.6-5.2).

Variation Across Hospitals

A total of 2213 hospitals in 2009, 1936 in 2012, 1631 in 2016, and 1427 in 2019 admitted children and adolescents with mental health conditions (eTable 3 in Supplement 1). In 2009, 72.7% (n = 1608) of these had less than 11 mental health hospitalizations, decreasing to 62.0% (n = 885) in 2019.

Figure 3 depicts the 2019 geometric mean LOS and proportion of hospitalizations resulting in interfacility transfer grouped by hospital mental health hospitalization volume. Hospitals in the top 3 deciles (n = 184) were the place of care for 81.1% (95% CI, 77.8%-84.5%) of mental health hospitalizations, with the remaining hospitalizations spread across 1243 hospitals. Hospitalizations at high-volume centers had longer LOS on average and a lower likelihood of interfacility transfer; among hospitals in the highest-volume decile, 7.0% (95% CI, 4.5%-9.4%) of hospitalizations resulted in interfacility transfer and their geometric mean LOS was 4.6 (95% CI, 4.2-5.1) days. The opposite was observed for lower-volume hospitals; at hospitals with less than 11 hospitalizations per year, 42.3% (95% CI, 39.6%-45.1%) resulted in interfacility transfer with a geometric mean LOS of 2.0 (95% CI, 1.9-2.1) days. Across all hospitals, the median hospital-level LOS was 2.1 (IQR, 1.6-3.6) days, and the median hospital-level transfer rate was 21.4% (IQR, 0%-60.0%) in 2019.

Discussion

The annual number of pediatric hospitalizations for mental health diagnoses increased by more than 25% between 2009 and 2019, and hospitalizations with a diagnosis of suicide or self-injury increased more than 1.6-fold during this time period. In 2019, more than one-quarter of all hospital days among children and adolescents and almost one-half of interfacility transfers were due to mental health diagnoses. Altogether, these hospitalizations accounted for 1.36 million hospital days and $1.37 billion in hospital costs in 2019.

Our findings illustrate that the proportion of pediatric acute care hospitalizations due to mental health diagnoses has almost doubled since a prior analysis using 2009 data, with mental health hospitalizations representing 19.8% of pediatric hospital stays in 2019.¹⁴ There are several potential reasons for this increase. First, the prevalence of mental health disorders among children and adolescents has been increasing for the last 2 decades.^4,6,7,31 Second, outpatient psychiatric resources for youth have not kept pace with this increasing need and inequities in access remain.^2,32,33,34 Third, a shortage of dedicated facilities for pediatric inpatient psychiatric care exists, which may result in patients staying longer than anticipated in acute care hospitals prior to transfer.^35,36,37 Fourth, hospitalizations for non–mental health diagnoses decreased significantly during the study period, so increases in the number of mental health stays represent a relatively large proportion of total pediatric hospitalizations. This proportional increase is important because it reflects the changing epidemiology of pediatric hospitalizations at acute care hospitals and a corresponding need for resources and medical education to be responsive to these changes.

From 2009 to 2019, the proportion of mental health hospitalizations with a diagnosis of suicide or self-injury more than doubled, increasing from 30.7% to 64.2%. This large increase mirrors findings from studies conducted in outpatient settings, emergency departments, and children’s hospitals, and parallels increasing suicide mortality rates in adolescents and young adults.^{3,6,10,12,38,39,40} Factors contributing to the increase in the number and proportion of hospitalizations with suicide or self-injury are likely multifaceted, and may include social instability, peer and family conflict, increasing prevalence of mental health conditions, and shortages of mental health professionals.^{41,42,43,44,45,46,47}

More than half of all mental health hospitalizations in 2019 had a primary diagnosis of anxiety or depression, consistent with the increasing prevalence of these disorders.^4,48,49,50 Other observed changes may reflect changes in diagnostic definitions or coding practices. For example, we observed fewer hospitalizations for bipolar and related disorders in 2019 than in 2009, possibly due to the addition of a new depressive disorder—disruptive mood dysregulation disorder in the DSM-5—and use of this diagnosis in place of bipolar affective disorder.^51,52 The increase in eating disorder diagnoses observed in this study may be due to increasing prevalence as well as broadening of the DSM-5 criteria for these conditions.^{53,54,55,56,57} Our observation of an increasing proportion of children and adolescents with 4 or more unique mental health diagnoses may reflect an overall increase in mental health comorbidities and could also be affected by more intensive coding practices over time.^58,59

The US has a national shortage of pediatric psychiatric beds, and a growing number of youth with mental health conditions who are cared for at acute care hospitals experience boarding, defined by the Joint Commission as “the practice of holding patients in the emergency department or another temporary location after the decision to admit or transfer has been made.”^35,36,60 Although the KID does not provide the necessary data to determine the fraction of youth who experienced boarding, the shorter mean LOS for mental health conditions at low-volume hospitals coupled with high interfacility transfer rates raises questions about boarding frequency and duration. At a minimum, the wide variation in interfacility transfer rates across hospitals and transfer rates exceeding 60% at one-quarter of hospitals in 2019 suggest insufficient resources to provide definitive mental health care at many acute care hospitals.

Limitations

The current findings should be interpreted considering several limitations. Although the KID is the largest nationally representative data set of pediatric inpatient stays, psychiatric hospitals are excluded, so our findings do not represent all hospitalizations for mental health conditions nationally. Additionally, the KID does not include emergency department encounters that do not result in an inpatient stay. During the 11-year period from which these data are drawn, the transitions from ICD-9 to ICD-10 and from DSM-IV to DSM-5 may have influenced our results. However, the methods used a broad definition of mental health hospitalization during the ICD-9 period to enhance the comparability of analyses over this time period and still found that the annual numbers of mental health hospitalizations have increased over time. While changing billing and coding practices may have influenced this trend, literature shows similar patterns within the ICD-9 period alone.^3,61 The Affordable Care Act also passed during this time period, with some studies showing improved access to mental health services; however, this analysis cannot directly evaluate the effect of these changes.^62,63,64 The KID does not provide patient identifiers, and we were unable to determine the number of unique children hospitalized each year or track subsequent admissions across patients. Finally, the KID is released every 3 years and 2019 is the most recently available data set. Further increases in pediatric mental health hospitalizations since the COVID-19 pandemic warrant additional study.

Conclusions

Mental health diagnoses comprise an increasing number and proportion of acute care hospitalizations among children and adolescents in the US. In 2019, almost two-thirds of pediatric mental health hospitalizations had a diagnosis of suicide or self-injury, and mental health hospitalizations accounted for more than one-quarter of hospital days and almost half of interfacility transfers among children and adolescents. These findings underscore the growing effect of mental health diagnoses on the well-being of children in the US.

Supplement 1.

eTable 1. Weighted Sociodemographic, Clinical, and Hospital Characteristics of Pediatric Hospitalizations for Primary Mental Health Diagnoses Applying the Child and Adolescent Mental Health Disorders Classification System Algorithm in its Original Form, 2009, 2012

eTable 2. Weighted Estimates of Aggregate and Mean Costs of Acute Care Hospitalizations With Primary Mental Health Diagnoses Among Children and Adolescents Aged 3-17 Years: 2009 – 2019

eTable 3. Characteristics of Hospitals Admitting Children and Adolescents for Primary Mental Health Diagnoses, 2009-2019

eFigure. Comparison of Length of Stay (A) and Likelihood of Interfacility Transfer (B) Among Pediatric Acute Care Hospitalizations for Primary Mental Health vs Other Medical or Surgical Diagnoses in 2009 to 2019, Weighted National Estimates

Click here for additional data file.^{(285.6KB, pdf)}

Supplement 2.

Data Sharing Statement

Click here for additional data file.^{(11.1KB, pdf)}

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eTable 2. Weighted Estimates of Aggregate and Mean Costs of Acute Care Hospitalizations With Primary Mental Health Diagnoses Among Children and Adolescents Aged 3-17 Years: 2009 – 2019

eTable 3. Characteristics of Hospitals Admitting Children and Adolescents for Primary Mental Health Diagnoses, 2009-2019

Click here for additional data file.^{(285.6KB, pdf)}

Supplement 2.

Data Sharing Statement

Click here for additional data file.^{(11.1KB, pdf)}

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PERMALINK

Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019

Mary Arakelyan, MPH

Seneca Freyleue, MS

Divya Avula, MPH

Jennifer L McLaren, MD

A James O’Malley, PhD

JoAnna K Leyenaar, MD, PhD, MPH

Key Points

Question

Findings

Meaning

Abstract

Importance

Objectives

Design, Setting, and Participants

Exposures

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Study Design and Data Sources

Identification of Mental Health Hospitalizations and Attempted Suicide or Self-injury

Cohort Characteristics

Health Care Utilization Measures

Statistical Analysis

Results

Sociodemographic, Clinical, and Hospital Characteristics

Table 1. Sociodemographic, Clinical and Hospital Characteristics of US Pediatric Hospitalizations for Primary Mental Health Diagnoses, 2009-2019, Weighted National Estimatesa.

Mental Health Diagnoses

Table 2. Primary Diagnoses Among Mental Health Hospitalizations and the Co-occurrence of Any Attempted Suicide or Self-injury Diagnosis, 2009-2019, Weighted National Estimatesa.

Figure 1. Proportion of Youth With an Attempted Suicide or Self-injury Diagnosis Among Mental Health Hospitalizations and All Hospitalizations in Children and Adolescents Aged 3 to 17 Years, 2009 to 2019, Weighted National Estimates.

Trends in Health Care Utilization

Figure 2. Proportion of All Pediatric Hospitalizations, Hospital Days, and Interfacility Transfers Attributable to Mental Health Diagnoses Among Children and Adolescents Aged 3 to 17 Years, 2009 to 2019, Weighted National Estimates.

Health Care Utilization in Mental Health and Non–Mental Health Hospitalizations

Variation Across Hospitals

Figure 3. Interfacility Transfer Rates and Geometric Mean Lengths of Stay Among Children and Adolescents Aged 3 to 17 Years With a Primary Mental Health Diagnosis, Stratified Based on Hospital Volume of Mental Health Hospitalizations, 2019.

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases

Table 1. Sociodemographic, Clinical and Hospital Characteristics of US Pediatric Hospitalizations for Primary Mental Health Diagnoses, 2009-2019, Weighted National Estimates^a.

Table 2. Primary Diagnoses Among Mental Health Hospitalizations and the Co-occurrence of Any Attempted Suicide or Self-injury Diagnosis, 2009-2019, Weighted National Estimates^a.