Equity in Emergency Mental Health Care

Over the past 2 decades, young people have increasingly sought acute mental health care in emergency departments (EDs).^1,2 In this issue of Pediatrics, Nash et al³ examine ED length of stay for children with mental health conditions. They draw on 10 years of data from the National Hospital Ambulatory Medical Care Survey (2005–2015) to compare length of stay for visits with and without a mental health diagnosis. In their sample, 4.9% of pediatric ED visits had an associated mental health diagnosis, and mental health visits had 3.3-fold increased odds of a length of stay of ≥6 hours compared with non–mental health visits. Length of stay increased over the 10-year study period to nearly a quarter of visits lasting ≥6 hours. This increase in length of stay over time was driven primarily by visits with a mental health diagnosis only (ie, no accompanying physical health diagnoses). The study’s findings point to increasing friction in the process of accessing emergency mental health care for young people and highlight the importance of improving access to mental health services in an equitable way.

Hispanic patients were nearly 3 times more likely to experience an ED stay >12 hours, compared with non-Hispanic white patients. Although the secondary data analysis in Nash et al³ was not positioned to explain this difference, racism, preferred language, and illness severity might play important roles. Hispanic youth are known to receive less mental health care and lower-quality mental health care than their non-Hispanic white peers.⁴ Hispanic youth are also underrepresented in clinical trials of mental health treatments, and there are disproportionately few mental health professionals of Hispanic ethnicity,⁵ which may further reduce the efficacy of available mental health treatments for this population. Nash et al³ suggest that individual institutions examine local data to ensure that children of all races and ethnicities, particularly Hispanic children, have equitable access to mental health services.

Institutions may benefit from several interventions to improve the quality of mental health services. As a first step, they may audit how race, ethnicity, and preferred language are captured to ensure that the medical record accurately reflects a patient’s self-identity and sheds light on the disparities that prevent families from receiving language-concordant, high-quality mental health care. To further improve quality of care, institutions might seek feedback from Hispanic and Black families and develop interventions that address inequities in care, such as reducing delays to accessing interpreter services and/or mental health evaluations. Some barriers may be difficult to resolve in the ED setting alone and will require a systems-level approach. For example, ED leaders might participate in regional partnerships to work toward ensuring that expedient and language-concordant services are available not just in the ED but also in inpatient psychiatric units and community mental health services.

The coronavirus disease 2019 pandemic has introduced new challenges to pediatric mental health care. Increases in frequency and severity of mental illness⁶ are compounded by disruptions in nonessential health care access and increased risks associated with being in a crowded ED or an inpatient psychiatric unit. Black and Hispanic families have borne an undue burden of grief,⁷ financial instability,⁸ and educational disruption⁹ because of the pandemic and may suffer worse mental health outcomes as well.¹⁰

Policies to mitigate delays in accessing high-quality mental health services can help to alleviate these negative effects. The American Rescue Plan Act, a federal stimulus package approved by Congress on March 10, 2021,¹¹ offers federal funding to states to develop and sustain robust state crisis response systems. Such funding may help broaden the network of mental health crisis services beyond EDs and serve as a streamlined access point for care, regardless of ability to pay. However, even if additional crisis services become available, some youth will require stabilization in an ED. For these patients, the highest-quality ED mental health services would expand beyond triage, assessment, and safety observation. Billing and reimbursement strategies that incentivize the provision of mental health care by ED providers, including safety planning,¹² lethal-means reduction,¹³ and postdischarge mental health outreach,¹⁴ would enable more children to receive evidence-based mental health treatments more quickly.

As health care leaders plan for the future of mental health care in the wake of the coronavirus disease 2019 pandemic, the findings in Nash et al³ can help guide their decisions. Strengthening pediatric community mental health resources, including crisis response services, would facilitate access to high-quality mental health care outside of the ED. In addition, engaging members of marginalized communities in health care services planning will help ensure equitable access to mental health care for all children.

Glossary

ED

emergency department