The vital role Australian emergency departments play in frontline mental health care

Mental health conditions such as depression and anxiety can start at an early age. Because the development of common mental health conditions can occur in adolescence to the mid-20s, early intervention is critical to help create a brighter future for young people.

Almost one in 10 young people aged 12 to 15 years old report ever having self-harmed and the leading cause of death in Australia for young people aged 15 to 24 years old is suicide.

Re-presentations common among young women

An important health care setting for young people with mental health concerns is the emergency department (ED). Researchers at UNSW Sydney conducted one of the first comprehensive analyses of ED mental health re-presentations using state-wide registry data in Australia and their findings have been published in the BMJ Open.

Lead author of the study, Dr. Patricia Cullen from the School of Population Health at UNSW Medicine & Health says the study revealed one in four young people who have presented to the ED will return within one year with another mental health presentation, and this is most likely to occur within the first 30 to 60 days of their initial presentation. 

Dr. Cullen says young people who initially presented to the ED with self-harm or suicidal ideation or behavior were more likely to re-present than people with other mental health difficulties. Re-presentations were also more common among young women and people younger than 15 years old.

"Re-presentations are more likely among young people who typically face inequitable access to health care, including Aboriginal and Torres Strait Islander young people and people living outside major cities.  We also noted there were higher re-presentations among people who left without completing treatment or were in the ED for longer periods of time," explains Dr. Cullen.

The researchers said it was essential that EDs, as well as community mental and primary health care services, are aware of those young people at highest risk of re-presentation and work together to strengthen navigation pathways out of the ED to provide follow up mental health care that is more appropriate than recurrent visits to the ED.

Despite the pandemic, this is not a new issue

"We know young people are experiencing high rates of mental health difficulties and distress, and there can be long wait times to access care in the community. While this has been exacerbated during the pandemic, our study demonstrates this is not a new issue. For many young people, access to care is also limited by lack of services where they live, particularly specialized mental health and primary care services that are trauma-informed, culturally safe and youth-friendly."

The study highlights the vital role EDs play in frontline mental health care for young people, as well as the importance of providing youth-friendly mental health care, both in the ED and through referral pathways into community-based services that can provide ongoing care.

"The study emphasizes that we need to ensure equitable access to care so that all young people can receive support in community-based primary and/or mental health care services. We also need to make sure that EDs are well equipped to provide youth-friendly mental health care with appropriate referral and follow-up for young people," says Dr. Cullen.

One finding that surprised the researchers was the number of young people returning to the ED for care and how quickly this occurred—within the first 30 to 60 days from their first presentation.

"This is a stark indicator that the mental health care needs of many young people are not being met by our health system, and these gaps in care disproportionately impact young people who likely face other barriers to accessing care in both our community and hospital settings," explains Dr. Cullen.

The researchers indicate that EDs could help provide timely, high-quality care that is youth-friendly and culturally safe, with appropriate referral pathways into community-based primary and mental health care services.

Dr. Cullen says in recent years, several promising interventions have been implemented in Australian EDs that specifically seek to support young people at highest risk of re-presentation by providing specialized mental health care and aiming to reduce recurrent visits to the ED.

"These programs typically provide assertive outreach, delivered by an ED mental health clinician, who works with the young person following the initial presentation. These clinicians navigate referral pathways to community-based services and provide follow up mental health care."

The researchers acknowledge not including intentional poisoning was a limitation of the study, however, future studies focused specifically on self-harm and suicide may consider including intentional poisoning as a diagnosis.