Key Points
Question
What are national trends in mental health–related emergency department (ED) visits among children, adolescents, and young adults from 2011 to 2020?
Findings
While the total number of pediatric and young adult ED visits has remained relatively stable from 2011 to 2020, the proportion of visits for mental health reasons has approximately doubled, including a 5-fold increase in the proportion of visits for suicide-related symptoms.
Meaning
These findings suggest an urgent need to expand emergency and crisis services to address pediatric mental health concerns, especially for suicidal symptoms.
Abstract
Importance
There has been increasing concern about the burden of mental health problems among youth, especially since the COVID-19 pandemic. Trends in mental health–related emergency department (ED) visits are an important indicator of unmet outpatient mental health needs.
Objective
To estimate annual trends in mental health–related ED visits among US children, adolescents, and young adults between 2011 and 2020.
Design, Setting, and Participants
Data from 2011 to 2020 in the National Hospital Ambulatory Medical Care Survey, an annual cross-sectional national probability sample survey of EDs, was used to examine mental health–related visits for youths aged 6 to 24 years (unweighted = 49 515).
Main Outcomes and Measures
Mental health–related ED visits included visits associated with psychiatric or substance use disorders and were identified by International Classification of Diseases-Ninth Revision, Clinical Modification (ICD-9-CM; 2011-2015) and ICD-10-CM (2016-2020) discharge diagnosis codes or by reason-for-visit (RFV) codes. We estimated the annual proportion of mental health–related pediatric ED visits from 2011 to 2020. Subgroup analyses were performed by demographics and broad psychiatric diagnoses. Multivariable-adjusted logistic regression analyses estimated factors independently associated with mental health–related ED visits controlling for period effects.
Results
From 2011 to 2020, the weighted number of pediatric mental health–related visits increased from 4.8 million (7.7% of all pediatric ED visits) to 7.5 million (13.1% of all ED visits) with an average annual percent change of 8.0% (95% CI, 6.1%-10.1%; P < .001). Significant linearly increasing trends were seen among children, adolescents, and young adults, with the greatest increase among adolescents and across sex and race and ethnicity. While all types of mental health–related visits significantly increased, suicide-related visits demonstrated the greatest increase from 0.9% to 4.2% of all pediatric ED visits (average annual percent change, 23.1% [95% CI, 19.0%-27.5%]; P < .001).
Conclusions and Relevance
Over the last 10 years, the proportion of pediatric ED visits for mental health reasons has approximately doubled, including a 5-fold increase in suicide-related visits. These findings underscore an urgent need to improve crisis and emergency mental health service capacity for young people, especially for children experiencing suicidal symptoms.
This study uses National Hospital Ambulatory Medical Care Survey data for 2011 to 2020 to evaluate trends in pediatric mental health–related emergency department visits.
Introduction
Mental health concerns among US children have been increasing over the last 2 decades, and the COVID-19 pandemic has accelerated these concerns. In 2021, several pediatric health organizations declared a national state of emergency in children’s mental health.1,2 From 2009 to 2019, the percentage of high school students who reported persistent feelings of sadness or hopelessness increased by 40%,3 and national suicide rates among youth aged 10 to 24 years increased by 57%.4 In addition, approximately 1 in 5 US children experience mental illness every year,5,6 yet half never receive appropriate treatment.7
The emergency department (ED) serves as a safety net for individuals with unmet mental health needs. However, EDs have limited capacity to provide evidence-based care for psychiatric illness.8 Over the last 2 decades, there has been concern about increasing rates of pediatric mental health–related ED visits. From 2007 to 2016, several national studies found that mental health–related pediatric ED visits increased between 50% and 60%.9,10,11,12 Furthermore, preliminary data from early in the COVID-19 pandemic suggest there was an increase in the proportion of pediatric ED visits for mental health concerns as children were disconnected from regular outpatient supports.13,14,15,16
Despite these early data, there have been no updated nationally representative estimates of annual trends in pediatric mental health–related ED visits since 2016,9,10,11,12 including trends stratified by age, race and ethnicity, and psychiatric diagnoses. It is not known whether the increase in pediatric mental health–related ED visits has continued to rise over the last 5 years, and if so, for which subgroups or whether it has plateaued or declined. It is also not known how other indicators of pediatric mental health–related ED visits have changed over the last decade, including the urgency and length of visits. Given the important role of EDs as safety net sources of care, examining national trends in ED visits provides critical opportunities to identify population-wide unmet mental health needs and inform service delivery.
In this study, we use nationally representative data from the 2011-2020 National Hospital Ambulatory Medical Care Survey (NHAMCS)17 to examine recent trends and characteristics of mental health–related ED visits among children, adolescents, and young adults in the US. By addressing the following 4 questions, our goal is to shed light on national unmet mental health needs among youth and inform efforts to reduce the burden of mental illness on young people and their families.
What are national annual trends in pediatric mental health–related ED visits from 2011-2020, including trends from 2019 to 2020 at the onset of COVID-19?
How do trends vary by age, sex, race and ethnicity, and psychiatric diagnosis?
Among pediatric mental health–related ED visits, how have visit characteristics changed over the study period, including length of visits, urgency, and how often children see a mental health professional?
Which sociodemographic and diagnostic characteristics are most strongly associated with pediatric mental health–related ED visits?
Methods
Data Source and Sample
This study is based on data from the 2011-2020 NHAMCS, a cross-sectional survey of ED visits across the US conducted annually by the National Center for Health Statistics.17 The NHAMCS utilizes a 3-stage probability sampling design and sampling weights that allow for generalization of estimates to all nonfederal, short-stay, and general (medical, surgical, and pediatric) hospital EDs across the US.18,19 Visit information is abstracted from patient medical records by trained staff during a randomly assigned 4-week period to account for seasonal flux.18
For this study, we identified visits for children (6-11 years old), adolescents (12-17 years old), and young adults (18-24 years old) (unweighted = 49 515). Age ranges were based on previous NHAMCS studies.9 Response rates averaged 77.0% (range, 62.6%-87.0%) over the 10-year period and were accounted for by sampling weights.17,18 The NHAMCS was approved by the National Center for Health Statistics research ethics review board.17 The study was covered by the common rule exemption20 and did not require institutional review board review as data are deidentified and publicly available. Additional information regarding descriptions, questionnaires, and sampling methodology is available on the NHAMCS website.17
Measures
Mental health–related ED visits included visits related to psychiatric or substance use disorders and were identified by either 1) International Classification of Diseases-Ninth Revision, Clinical Modification (ICD-9-CM; 2011-2015) or ICD-10-CM (2016-2020) discharge diagnosis codes or by reason-for-visit (RFV) codes. ICD-9-CM and ICD-10-CM discharge diagnosis codes for each visit represent the physician’s final assessment of the patient’s diagnoses.18,21,22 RFV codes, in contrast, are based on a system developed by the National Center for Health Statistics to classify a patient’s primary reasons for seeking care, as stated in their own words.18,23 Mental health–related visits were identified when any of the 5 discharge diagnosis codes or psychiatric RFV codes identified a mental health condition. eTable 1 in Supplement 1 lists the ICD and RFV codes that identified mental health–related visits in our study. Psychiatric RFV codes were based on National Center for Health Statistics criteria9,24 and ICD codes were based on mental health conditions from the Centers for Disease Control and Prevention National Syndromic Surveillance Program.15,25
Based on previous NHAMCS studies,9,26 we categorized mental health diagnoses into 6 categories: (1) mood (eg, depression, anxiety, mania, trauma, and stress-related); (2) behavioral (eg, disruptive, impulse control, attention-deficit/hyperactivity disorder); (3) psychosis; (4) suicide-related (suicide, suicidal ideation, suicidal attempts, and nonsuicidal self-injury); (5) substance use; and (6) other (eg, eating disorders, personality disorders, and parent-child problems). Diagnosis codes for neurodevelopmental disorders, such as autism spectrum disorder, were not included as they are not counted as mental health conditions in the National Syndromic Surveillance Program. This is consistent with prior NHAMCS studies.9,24
Sociodemographic characteristics included age, sex (female or male), US census region, insurance type, and race and ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White, and non-Hispanic other). Non-Hispanic other included Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native individuals, and people of 2 or more races.19
Visit characteristics were selected based on previous NHAMCS studies9,24,27,28 and included whether a mental health professional was seen, urgency of visit, and length of visits (calculated as minutes from ED arrival to discharge).19 Visit urgency was a 5-level item, based on nursing triage rating, that indicated the immediacy with which the patient should be seen. This 5-level item was dichotomized as urgent (emergent, immediate, and urgent) vs nonurgent (semiurgent and not urgent).9
Data Analysis
First, descriptive data were presented on the proportion of mental health–related encounters among all ED visits by children, adolescents, and young adults from 2011-2012 to 2019-2020. We reported an average annual percent change (AAPC) of ED visits from 2011 to 2020 using a modified Poisson model after adjusting for age, sex, and race and ethnicity (Table 1).29,30 When reporting the proportions over time, we combined annual surveys into 2-year groups for presentation purposes, which is recommended by National Center for Health Statistics methods guidance,18 but all trend analyses (eg, average annual percent change) were conducted on an annual basis.
Table 1. National Trends in the Proportion of Mental Health–Related Encounters of All Emergency Department Visits Among Children, Adolescents, and Young Adults, 2011-2020a.
| 2011-2012 | 2013-2014 | 2015-2016 | 2017-2018 | 2019-2020 | Average annual percent change (95% CI)b | P value | |
|---|---|---|---|---|---|---|---|
| Unweighted total ED visits, No. (%) | 13 901 (28.1) | 10 939 (22.1) | 9196 (18.6) | 8041 (16.2) | 7438 (15.0) | ||
| Weighted total ED visits, No. (%) | 62 479 886 (20.3) | 61 688 794 (20.0) | 64 432 890 (20.9) | 59 956 772 (19.5) | 59 238 390 (19.2) | ||
| Any mental health diagnosisc | 7.7 | 8.5 | 12.3 | 12.2 | 13.1 | 8.0 (6.1 to 10.1) | <.001 |
| Mood | 4.0 | 3.9 | 5.9 | 5.5 | 6.0 | 7.0 (4.2 to 9.9) | <.001 |
| Behavioral (nonsuicidal) | 1.0 | 1.3 | 1.8 | 1.9 | 2.2 | 10.0 (5.7 to 14.5) | <.001 |
| Substance use | 2.8 | 3.7 | 5.0 | 4.6 | 3.9 | 6.0 (3.1 to 9.1) | <.001 |
| Psychosis | 0.6 | 0.6 | 0.9 | 0.9 | 1.2 | 11.7 (6.4 to 17.3) | <.001 |
| Suicide-related | 0.9 | 1.1 | 2.5 | 3.5 | 4.2 | 23.1 (19.0 to 27.5) | <.001 |
| Other | 2.2 | 2.3 | 3.8 | 3.9 | 5.1 | 12.0 (8.3 to 15.8) | <.001 |
| 1 Mental health diagnosis | 4.9 | 5.6 | 7.3 | 6.8 | 7.0 | 5.7 (3.5 to 8.0) | <.001 |
| ≥2 Mental health diagnoses | 2.8 | 2.9 | 4.9 | 5.4 | 6.0 | 11.7 (8.5 to 15.0) | <.001 |
| Subgroup analyses | |||||||
| Age group | |||||||
| 6-11 y | 2.0 | 2.7 | 3.9 | 4.2 | 4.7 | 11.0 (6.3 to 16.0) | <.001 |
| 12-17 y | 8.6 | 9.4 | 14.2 | 12.5 | 15.6 | 7.6 (4.4 to 10.8) | <.001 |
| 18-24 y | 9.5 | 10.7 | 15.5 | 16.5 | 15.9 | 7.7 (5.6 to 9.9) | <.001 |
| Male sex | 8.6 | 10.0 | 13.5 | 12.1 | 14.0 | 6.7 (4.4 to 9.2) | <.001 |
| Female sex | 6.9 | 7.3 | 11.3 | 12.2 | 12.3 | 9.2 (6.9 to 11.6) | <.001 |
| Race and ethnicity | |||||||
| Hispanic | 6.2 | 6.9 | 9.7 | 8.7 | 10.9 | 7.7 (4.4 to 11.1) | <.001 |
| Non-Hispanic Black | 5.6 | 6.4 | 11.2 | 8.9 | 12.2 | 9.7 (6.2 to 13.3) | <.001 |
| Non-Hispanic White | 9.2 | 10.2 | 13.5 | 15.2 | 14.4 | 7.4 (5.0 to 9.8) | <.001 |
| Non-Hispanic other | 6.6 | 7.5 | 13.9 | 16.7 | 15.8 | 12.2 (5.9 to 18.8) | <.001 |
| Insurance coverage | |||||||
| Private | 7.2 | 8.3 | 12.1 | 12.4 | 14.0 | 9.2 (6.5 to 11.9) | <.001 |
| Public | 7.5 | 7.9 | 11.4 | 10.6 | 12.8 | 7.5 (4.9 to 10.3) | <.001 |
| Self-pay | 8.6 | 7.9 | 12.8 | 13.0 | 12.8 | 7.6 (2.8 to 12.5) | .002 |
| Other | 9.0 | 13.9 | 11.3 | 17.8 | 7.1 | 1.0 (−5.0 to 7.3) | .75 |
| Geographic region | |||||||
| Northeast | 9.8 | 11.0 | 12.2 | 14.5 | 14.2 | 6.3 (3.0 to 9.8) | <.001 |
| Midwest | 7.9 | 8.1 | 16.0 | 16.5 | 16.4 | 11.8 (7.7 to 16.2) | <.001 |
| South | 6.8 | 7.9 | 10.1 | 8.5 | 11.3 | 6.6 (3.0 to 10.2) | <.001 |
| West | 7.3 | 8.3 | 11.9 | 13.5 | 12.6 | 7.9 (4.7 to 11.1) | <.001 |
Abbreviation: ED, emergency department.
Data are from the National Hospital Ambulatory Medical Care Survey.17,18 Data are reported as percent values unless otherwise specified.
The average annual percent change was controlled for age, sex, and race and ethnicity.
Disorders included within the 6 mental health diagnoses categories were as follows for mood (depression, anxiety, mania, trauma, and stress-related), behavioral (disruptive, impulse control, attention-deficit/hyperactivity disorder), psychosis (no disorders included with this diagnosis category), suicide-related (suicide, suicidal ideation, suicidal attempts, and nonsuicidal self-injury), substance use (no disorders included with this diagnosis category), and other (eating disorders, personality disorders, and parent-child problems).
Second, we repeated the aforementioned analyses per 1000 youths.31 Denominators were derived from the US Census Bureau based on predefined age groups (ie, 5-9, 10-14, 15-19, and 20-24 years).31 As a result, different age groups had to be used for this per-capita analysis. An interaction term was added to assess whether trends in ED visits significantly differed across the age groups (Table 2).
Table 2. National Trends of Mental Health–Related Emergency Department Visits Among Children, Adolescents, and Young Adults (per 1000 Capita) by Age Group, 2011-2020a.
| 2011-2012 | 2013-2014 | 2015-2016 | 2017-2018 | 2019-2020 | Average annual percent change (95% CI) | P value | P value for interactionb | |
|---|---|---|---|---|---|---|---|---|
| Any psychiatric diagnosis | ||||||||
| 5-9 y | 4.8 | 5.4 | 12.5 | 12.2 | 11.8 | 12.2 (4.0 to 20.7) | .002 | .04 |
| 10-14 y | 11.9 | 15.8 | 29.5 | 27.3 | 36.5 | 12.9 (7.9 to 18.2) | <.001 | |
| 15-19 y | 42.6 | 43.3 | 58.9 | 55.1 | 63.3 | 4.9 (1.8 to 8.1) | .002 | |
| 20-24 y | 54.0 | 58.5 | 85.7 | 77.5 | 72.7 | 4.9 (2.2 to 7.6) | <.001 | |
| Mood-related c | ||||||||
| 5-9 y | 3.0 | 1.7 | 3.5 | 3.9 | 2.4 | 3.3 (−8.9 to 17.3) | .61 | .55 |
| 10-14 y | 7.5 | 8.9 | 14.5 | 10.9 | 17.5 | 9.3 (2.5 to 16.5) | .006 | |
| 15-19 y | 22.7 | 21.0 | 33.5 | 31.0 | 32.3 | 4.9 (0.7 to 9.3) | .02 | |
| 20-24 y | 26.0 | 24.1 | 37.4 | 32.6 | 32.4 | 4.5 (0.5 to 8.7) | .03 | |
| Behavioral (nonsuicidal) c | ||||||||
| 5-9 y | 1.5 | 3.0 | 4.8 | 3.6 | 2.4 | 5.6 (−6.7 to 19.6) | .39 | .70 |
| 10-14 y | 4.2 | 5.6 | 9.0 | 9.3 | 12.7 | 13.5 (4.9 to 22.7) | .002 | |
| 15-19 y | 4.8 | 6.1 | 7.5 | 10.8 | 10.2 | 9.7 (1.4 to 18.7) | .02 | |
| 20-24 y | 4.4 | 4.2 | 6.3 | 4.1 | 5.9 | 3.1 (−6.3 to 13.6) | .53 | |
| Substance use c | ||||||||
| 5-9 y | 0.17 | 0.16 | 0.18 | 0.58 | 0.97 | 24.9 (−14.2 to 82.1) | .25 | .74 |
| 10-14 y | 1.4 | 2.8 | 3.0 | 3.0 | 3.2 | 7.4 (−6.1 to 22.8) | .30 | |
| 15-19 y | 13.9 | 17.4 | 20.1 | 16.5 | 18.3 | 2.2 (−3.0 to 7.7) | .41 | |
| 20-24 y | 25.0 | 32.3 | 50.5 | 43.0 | 31.8 | 4.0 (0.4 to 7.8) | .03 | |
| Psychosis c | ||||||||
| 5-9 y | 0.4 | 0.3 | 0.5 | 1.2 | 2.1 | 33.7 (1.6 to 75.9) | .04 | .18 |
| 10-14 y | 0.9 | 1.2 | 1.2 | 2.7 | 3.6 | 21.6 (2.4 to 44.4) | .03 | |
| 15-19 y | 2.5 | 3.0 | 2.9 | 3.1 | 5.6 | 9.4 (−2.9 to 23.2) | .14 | |
| 20-24 y | 4.4 | 4.3 | 9.3 | 6.3 | 6.4 | 5.8 (−3.0 to 15.5) | .20 | |
| Suicide-related c | ||||||||
| 5-9 y | 0.1 | 0.3 | 2.3 | 4.0 | 3.5 | 32.9 (10.8 to 59.3) | .002 | .70 |
| 10-14 y | 2.3 | 3.1 | 9.9 | 9.7 | 13.2 | 21.3 (11.3 to 32.1) | <.001 | |
| 15-19 y | 5.8 | 8.6 | 15.3 | 18.6 | 24.5 | 18.5 (11.5 to 25.9) | <.001 | |
| 20-24 y | 5.2 | 3.6 | 11.1 | 17.5 | 18.6 | 22.3 (14.0 to 31.1) | <.001 | |
| Other c | ||||||||
| 5-9 y | 1.4 | 2.0 | 4.5 | 4.8 | 4.7 | 14.3 (1.3 to 28.9) | .03 | .38 |
| 10-14 y | 5.1 | 6.4 | 15.0 | 13.6 | 18.1 | 14.6 (7.3 to 22.5) | <.001 | |
| 15-19 y | 14.9 | 13.6 | 21.1 | 21.4 | 26.5 | 14.6 (7.3 to 22.5) | <.001 | |
| 20-24 y | 11.7 | 11.9 | 18.1 | 16.1 | 22.9 | 9.5 (3.7 to 15.6) | .001 | |
Data are from the National Hospital Ambulatory Medical Care Survey17,18 and the US Census Bureau.31 Data are reported as percent values unless otherwise specified. Age groups used in the per-capita analysis were predefined based on US Census data.
Interaction terms were tests to assess whether trends in mental health–related emergency department visits significantly differed across the age groups.
Disorders included within the 6 mental health diagnoses categories were as follows for mood (depression, anxiety, mania, trauma, and stress-related), behavioral (disruptive, impulse control, attention-deficit/hyperactivity disorder), psychosis (no disorders included with this diagnosis category), suicide-related (suicide, suicidal ideation, suicidal attempts, and nonsuicidal self-injury), substance use (no disorders included with this diagnosis category), and other (eating disorders, personality disorders, and parent-child problems).
Third, we descriptively presented visit characteristics of mental health–related ED visits (eFigure in Supplement 1). Next, we conducted multivariable-adjusted logistic regression analyses to identify factors associated with any mental health–related ED visits by age group and included all relevant sociodemographic and clinical factors available in our data set (eTable 2 in Supplement 1). Due to the increase in suicide-related visits, we reported national trends of suicide-related ED visits separately (Table 3).
Table 3. National Trends of Suicide-Related Emergency Department Visits Among Children, Adolescents, and Young Adults, 2011-2020a.
| 2011-2012 | 2013-2014 | 2015-2016 | 2017-2018 | 2019-2020 | Average annual percent change (95% CI)b | P value | |
|---|---|---|---|---|---|---|---|
| Unweighted total ED visits, No. (%) | 13 901 (28.1) | 10 939 (22.1) | 9196 (18.6) | 8041 (16.2) | 7438 (15.0) | ||
| Weighted total ED visits, No. (%) | 62 479 886 (20.3) | 61 688 794 (20.0) | 64 432 890 (20.9) | 59 956 772 (19.5) | 59 238 390 (19.2) | ||
| All | 0.9 | 1.1 | 2.5 | 3.5 | 4.2 | 23.1 (19.0 to 27.5) | <.001 |
| Age group | |||||||
| 6-11 y | 0.1 | 0.2 | 0.7 | 1.7 | 1.3 | 29.8 (21.1 to 39.2) | <.001 |
| 12-17 y | 1.4 | 2.5 | 5.0 | 4.4 | 6.6 | 18.6 (13.5 to 23.9) | <.001 |
| 18-24 y | 1.0 | 0.8 | 2.1 | 4.0 | 4.4 | 25.2 (19.0 to 31.8) | <.001 |
| Male sex | 0.8 | 1.1 | 2.7 | 3.3 | 4.2 | 23.6 (17.4 to 30.0) | <.001 |
| Female sex | 1.0 | 1.1 | 2.4 | 3.7 | 4.3 | 22.7 (17.5 to 28.1) | <.001 |
| Race and ethnicity | |||||||
| Hispanic | 0.6 | 1.0 | 2.4 | 2.0 | 3.3 | 20.1 (13.3 to 27.4) | <.001 |
| Non-Hispanic Black | 0.8 | 0.4 | 1.8 | 3.2 | 3.1 | 23.2 (15.2 to 31.7) | <.001 |
| Non-Hispanic White | 1.1 | 1.4 | 2.7 | 4.4 | 5.2 | 24.2 (18.6 to 30.0) | <.001 |
| Non-Hispanic other | 1.2 | 0.9 | 5.8 | 2.0 | 5.6 | 18.8 (4.7 to 34.9) | .008 |
| Insurance coverage | |||||||
| Private | 0.9 | 1.1 | 2.7 | 3.9 | 6.1 | 30.0 (22.4 to 38.1) | <.001 |
| Public | 0.9 | 1.1 | 2.4 | 3.2 | 3.8 | 21.3 (15.1 to 27.8) | <.001 |
| Self-pay | 1.0 | 0.8 | 2.5 | 3.2 | 3.4 | 20.3 (10.6 to 30.8) | <.001 |
| Other | 1.1 | 2.2 | 2.2 | 6.1 | 2.6 | 14.5 (1.7 to 28.9) | .03 |
| Geographic region | |||||||
| Northeast | 1.4 | 1.4 | 1.8 | 3.0 | 3.6 | 16.7 (6.8 to 27.6) | .001 |
| Midwest | 1.1 | 1.0 | 3.2 | 5.1 | 5.5 | 26.5 (17.2 to 36.5) | <.001 |
| South | 0.8 | 0.8 | 1.8 | 3.0 | 3.7 | 25.2 (18.8 to 32.0) | <.001 |
| West | 0.6 | 1.4 | 3.5 | 3.2 | 4.6 | 21.8 (13.8 to 30.3) | <.001 |
In separate analyses (eTable 3 in Supplement 1), we compared the proportion of individuals with ED visits from 2019 to 2020 alone to identify potential changes associated with COVID-19. We also examined whether mental health–related ED visits per capita have changed from 2019 to 2020 by age group and mental health condition (eTable 4 in Supplement 1).
We used Stata version 17.1 MP/4-Core for all analyses. Following the NHAMCS estimation procedures,32,33 we accounted for complex survey design using svy commands to account for multistage complex survey sampling techniques (ie, unequal probability of selection, clustering, and stratification) used in the data collection to produce national estimates. We set a P value of less than .05 as the test of statistical significance.
Results
Overall Trends in the Total Study Sample
From 2011-2012 to 2019-2020, the weighted total national number of ED visits among individuals aged 6 to 24 years declined from 62.5 million to 59.2 million. The number of mental health–related visits increased from 4.8 million (7.7% of total pediatric ED visits) to 7.5 million (13.1% of total ED visits), indicating an average annual percent change of 8.0% (95% CI, 6.1%-10.1%) (Table 1). Compared with non–mental health–related visits, mental health–related visits were more likely among young adults and less likely among children, the patients were more likely to be White and less likely to be Hispanic or non-Hispanic Black, cases were more likely to be categorized as urgent, and visits were more likely to take 6 hours or longer (eTable 5 in Supplement 1).
Over the study period, the proportion of all types of mental health–related visits increased significantly, including mood, behavioral, psychosis, and substance use–related visits (P < .001), but suicide-related visits demonstrated the largest increase (average annual percent change, 23.1% [95% CI, 19.0%-27.5%]). In addition, the proportion of visits for mental health–related reasons increased significantly in all sociodemographic categories, including by age, sex, race and ethnicity, insurance type, and geographic region (P < .05 for each). Visits to the ED in which 2 or more mental health diagnoses were documented increased from 2.8% in 2011-2012 to 6.0% in 2019-2020 (average annual percent change, 11.7% [95% CI, 8.5%-15.0%]) (Table 1).
In regards to possible COVID-19 pandemic–related trends from 2019 to 2020, the weighted total number of ED visits declined from 32.7 million to 26.6 million (eTable 3 in Supplement 1). This is consistent with an earlier study,34 although there was no significant change in the proportion of visits for mental health–related reasons including those by age, sex, race and ethnicity, and insurance type, and no significant change in visit urgency, length of visits, or percent that included evaluation by a mental health professional. Similarly, there was a general decline in pediatric mental health–related ED visits per capita from 2019 to 2020, but this change was not found to be statistically significant (eTable 4 in Supplement 1).
Trends in Characteristics of Visits
As shown in the eFigure in Supplement 1, there were no significant changes in visit characteristics in the total sample or by age group. Less than 20% of overall mental health–related ED visits included evaluation by a mental health professional, with no significant change from 2011 to 2020 (panel A in the eFigure in Supplement 1). Between 70% and 75% of overall mental health–related ED visits were urgent (panel B in the eFigure in Supplement 1), and approximately 20% lasted for at least 6 hours (panel C in the eFigure in Supplement 1).
Trends by Age Group and Mental Health Condition
As shown in Table 2, mental health–related ED visits per 1000 youth increased significantly across all age groups, but increased the most among 10- to 14-year olds (P value for interaction = .04). Aside from increases in suicide-related visits in all age groups, there were few significant age group trends by psychiatric diagnoses.
Factors Associated With Mental Health–Related ED Visits
Next, multivariable-adjusted analyses examined factors associated with mental health–related ED visits (eTable 2 in Supplement 1). In the total sample, mental health–related ED visits were significantly more likely among young adults and adolescents, males, non-Hispanic White individuals, and those with public insurance. Among children, mental health–related ED visits were significantly more likely among males. Among adolescents, mental health–related ED visits were more likely among females. Among young adults, mental health–related visits were significantly more likely among males and those with public insurance and less likely among Hispanic and non-Hispanic Black individuals.
Trends in Suicide-Related ED Visits
As shown in Table 3, suicide-related visits were most common among adolescents, accounting for 6.6% of all ED visits in 2019-2020, and suicide-related visits increased significantly in all age groups, across sex, race and ethnicity, insurance type, and geographic region. Sociodemographic and visit factors independently associated with suicide-related visits are shown in eTable 6 in Supplement 1.
Discussion
Nationally representative data from the NHAMCS demonstrates that while the total number of pediatric ED visits has remained relatively stable from 2011 to 2020, the proportion of visits for mental health–related reasons has approximately doubled. Linearly increasing trends were observed for all age groups, across sexes, and for all race and ethnicity groups. Of particular concern, suicide-related visits increased 5-fold and now encompass nearly 5% of all pediatric ED visits. Despite the precipitous increase in mental health–related visits, there has been no change in characteristics of mental health–related visits, including the percent of visits with evaluation by a mental health professional (<20% of all pediatric mental health–related visits), urgency, or length of visits.
Our study presents the first updated nationally representative estimates of pediatric mental health–related ED visits since 2016. These findings extend prior studies that have documented increasing rates of pediatric mental health–related visits over the last 2 decades.9,10,11,12,35 While it is difficult to directly compare estimates across studies due to different age ranges and definitions of a mental health–related visit, our per-capita and proportional estimates are consistent with prior NHAMCS studies.9,11,24 Our study finds that the largest increase in visits occurred in 2015-2016 (which is consistent with previous studies),9,10 although we demonstrate that rates have continued to increase since this time. While all age groups have shown a significant increase in visits, youths aged 10 to 14 years demonstrate a greater increase than all other age groups. There are a number of potential explanations for the increase in pediatric mental health–related ED visits including increased prevalence of mental health concerns among youth in the general population,36,37 improved identification of mental health concerns and treatment referral, increase in help seeking among youth and families, and reduced access to outpatient mental health care amid overwhelmed community-based systems. It is likely that several of these explanations are contributing to the trends observed.
The substantial increase in pediatric suicide-related visits over the last decade is of particular public health concern. These estimates exceed those reported from a national sample of EDs, which demonstrated that pediatric visits for deliberate self-harm increased 329% from 2007 to 2016.10 The present findings are consistent with national data demonstrating population-wide increases in suicidal ideation,38 attempts,39,40 and suicide deaths4 among youth over the last decade, especially among Black adolescents.41,42 This trend underscores the importance of improving the capacity of EDs to deliver high-quality care for youth experiencing suicidal symptoms and improving access to community-based services. Some ED interventions for youth have been reported to reduce suicidal behavior and improve engagement in follow-up treatment.43,44,45,46,47 These interventions have focused on comprehensive screening, safety planning, linkage to follow-up care, and postdischarge contact.
Despite the large increase in pediatric mental health–related ED visits, it is noteworthy that there has not been a significant change in the characteristics of visits, including urgency or length of visits. The observation that only 20% of pediatric mental health–related visits included evaluation by a mental health professional underscores widespread shortages in the availability of specialty ED mental health services. Additionally, while some studies have suggested that the increase in pediatric mental health–related ED visits may be due to an increase in inappropriate or less urgent mental health–related ED visits,48,49,50 our study demonstrates the urgency of visits has not changed.
The findings of this study have a number of potential implications. First, there is an urgent need to increase capacity to address pediatric mental health concerns in EDs. Several promising models exist to improve this capacity, including telemedicine,51,52 telephone consultation services,53 adoption of pediatric mental health clinical care pathways,54,55 and greater psychiatric education for ED clinicians.56 In addition, EDs are critical mental health access points for children who face structural barriers, including racial and ethnic minorities and children who are undocumented or uninsured.50,57,58 Our analysis reveals that having public insurance is independently associated with mental health–related ED visits. Ensuring that all children discharging from EDs have appropriate follow-up is an important health equity goal and may help prevent need for emergency care. The trends also underscore the importance of increasing investments in evidence-based preventive interventions, including social-emotional learning programs for at-risk preschool children,59 that have demonstrated benefits in reducing externalizing problems, adolescent conduct problems, and adolescent emotional symptoms.60
This study presents some of the first nationally representative estimates of pediatric mental health–related ED visits at the beginning of the COVID-19 pandemic. Consistent with data from Centers for Disease Control and Prevention National Syndromic Surveillance Program,13,14,15 we find that the proportion of pediatric ED visits for mental health reasons remained relatively stable amid declines in the total number of pediatric mental health and non–mental health–related ED visits. As data from 2021 and 2022 become available, it will be important to continue to examine how the COVID-19 pandemic has potentially impacted these trends.16
Limitations
This study has several limitations. First, there are multiple ways to identify a mental health–related visit using NHAMCS. We chose to use both ICD and RFV codes, which is the approach taken by most other studies.9,24 Some studies have used more narrow definitions by using only ICD codes.11,35 Other studies have used broader definitions, including visits at which psychotropic medications were prescribed and refilled61 or a larger number of ICD diagnoses, specifically, codes for neurodevelopmental disorders.62 We chose not to use psychotropic medications because we were concerned that these medications could have been prescribed and refilled for a patient who was not presenting with a mental health concern. We also chose not to include neurodevelopmental disorders because they are not included as mental health conditions in the National Syndromic Surveillance Program, and there was concern about identifying a patient having a mental health–related visit solely by having a diagnosis of a neurodevelopmental condition. Due to these exclusions, it is possible that our definition of mental health–related visits may have underestimated the true number of mental health–related visits.
Second, NHAMCS samples at the visit rather than at the patient level. Therefore, the effects of repeated ED visits within the sampling period cannot be assessed.
Third, NHAMCS does not sample psychiatric institutions with crisis or urgent care centers so our findings may underestimate the number of mental health–related visits. In addition, because NHAMCS does not indicate whether sampling occurred in general or pediatric EDs, it was not possible to determine where in the emergency services sector the burden of increasing pediatric mental health–related visits is most acute. This is an important focus of future studies.
Fourth, because differences between ICD-9-CM and ICD-10-CM codes are substantial, caution is advised when directly comparing estimates from before and after 2016. It is possible that suicide-related visits were overestimated with the switch to ICD-10-CM given that the code for suicidal ideation also included nonspecific and infrequently used codes for other mental health symptoms (ie, low self-esteem, worries, excessive crying). However, given the linearly increasing trends in visits annually and across diagnoses, the estimates captured by our methods, which are consistent with other NHAMCS studies,9,11,24 appear robust and clinically relevant.
Conclusions
Our nationally representative analysis demonstrates a precipitous increase in mental health–related ED visits, especially suicide-related visits among children, adolescents, and young adults over the last 10 years. These results underscore a critical need to expand nonhospital alternatives to mental health care for young people. This includes expanding the crisis continuum of care,63 intensive outpatient programs, school-based and integrated care models, and outpatient services, including psychiatric urgent care and clinics with weekend and evening availability. With the recent increase in demand for emergency mental health services by young people and lack of growth in outpatient mental health services,64 a dedicated national commitment will be needed to address gaps and deficiencies in mental health outpatient and crisis services for children, adolescents, and young adults.
eTable 1. Reason for Visit (RFV) and ICD Codes for Mental Health–Related Emergency Department (ED) Visits
eFigure. National Trends in Visit Characteristics of Mental Health Emergency Department Visits by Age Group and Year, 2011-2020
eTable 2. Multivariable-Adjusted Factors Associated With Any Mental Health–Related Emergency Department (ED) Visits, 2011-2020
eTable 3. Selected Characteristics (Weighted Column %) of Emergency Department (ED) Visits by Pre- and Post-COVID-19 Year
eTable 4. National Trends of Mental Health–Related Emergency Department (ED) Visits Among Children, Adolescents, and Young Adults (per 1,000 Capita) by Pre- and Post-COVID-19 Year
eTable 5. Selected Characteristics (Weighted Column %) of Emergency Department (ED) Visits by Psychiatric Diagnosis, 2011-2020
eTable 6. Multivariable-Adjusted Factors Associated With Suicide-Related Emergency Department (ED) Visits, 2011-2020
eReferences.
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Reason for Visit (RFV) and ICD Codes for Mental Health–Related Emergency Department (ED) Visits
eFigure. National Trends in Visit Characteristics of Mental Health Emergency Department Visits by Age Group and Year, 2011-2020
eTable 2. Multivariable-Adjusted Factors Associated With Any Mental Health–Related Emergency Department (ED) Visits, 2011-2020
eTable 3. Selected Characteristics (Weighted Column %) of Emergency Department (ED) Visits by Pre- and Post-COVID-19 Year
eTable 4. National Trends of Mental Health–Related Emergency Department (ED) Visits Among Children, Adolescents, and Young Adults (per 1,000 Capita) by Pre- and Post-COVID-19 Year
eTable 5. Selected Characteristics (Weighted Column %) of Emergency Department (ED) Visits by Psychiatric Diagnosis, 2011-2020
eTable 6. Multivariable-Adjusted Factors Associated With Suicide-Related Emergency Department (ED) Visits, 2011-2020
eReferences.
Data Sharing Statement