Capturing a Moment: A Reflection on Mental Health and Emergency Medicine

“’Lisa’s’ Story” is a recollection of a patient encounter experienced by Kyra Reed. Kyra is a PGY-2 in the Emergency Medicine/Pediatrics Residency Program at Indiana University and a member of its Advocacy Track.

After a brisk knock on the door, I entered the room of a young female patient who was at the office for her eighth grade physical exam. It was the time of year for school physicals, and the schedule at the underserved, rural clinic in which I was working as a medical student through the Rural Medicine Program at Indiana University, was absolutely filled for the day. Introducing myself to the 12 year-old patient, “Lisa”, she said hello and made eye contact only briefly. As I began the encounter with light-hearted comments about the upcoming school year, Lisa began fidgeting with her rings and massaging her arms in a nervous manner. Lisa reported that she felt dizzy sometimes and that she has nearly passed out on multiple occasions. Cautiously guiding the conversation, I attempted to see if there was something more she wanted to share with me. Noting her thin frame and very low BMI, I said “You know, even though starting a new year at school can be fun, it can also be quite scary – with new classes, teachers, and students. I was always nervous the first week of school. Do you feel the same way?” Lisa contemplated for a moment and then softly replied, “I am really scared.” “Is there anything in particular about school that worries you?” I asked. After a few moments, Lisa began crying and stated, “Yes… I’m fat and everyone knows it.”

Subsequently opening up about her habits, which included restricting food gradually over the past year and exercising five hours daily, Lisa confided that she wanted help. With no insurance, however, the search for resources proved to be challenging. I was eventually able to locate a specialist on a sliding scale fee that was a two-hour drive away. Providing Lisa with a journal, I encouraged her to chronicle her journey through recovery. We have kept in touch since, and now many years later, Lisa is working on being healthy and happy. She has held several student conferences in which she has shared her story and helped other students with similar issues. She aspires to be a pediatric psychiatrist.

It is an encounter such as this that I reflect on often as I continue through training. It is not the typical story of a large scale event, catastrophe, or a shocking incident in the emergency department that one may hear or think of when discussing important moments in their medical career. This story is a relatively subtle one, yet to me was truly striking because of that very aspect. Taking a moment to sit and truly communicate with a patient can provide an opportunity to capture a moment where a seemingly straightforward, everyday school physical exam suddenly becomes a catalyst for a transformative moment in one’s life. Now, Lisa has touched the lives of so many others with her story, creating a wave of positive change. For me, this encounter sparked an interest that will continue throughout my medical career. Physicians in particular see patients at their most vulnerable moments, and these opportunities should not slip through the cracks. How many others can we catch in that moment?

I could not help but wonder…
— Is Lisa’s story just the tip of the iceberg?
— How prevalent are mental health disorders in adolescents (depression, anxiety, eating disorders, etc)?
— Are we missing an opportunity to identify these patients?
— Is there a difference in prevalence between rural and urban settings?
— Does the resource distribution reflect the need in these areas?

What does the data tell us?
Pediatric Mental Health Fast Facts(6):
– Suicide in the U.S. currently ranks as the 4th leading cause of death for 10-14 year-olds and the 3rd leading cause of death for 15-19 year-olds
– This accounts for 11.3% of all deaths in the latter age group in 2006.
– More than half of adolescents 13-19 years of age have suicidal thoughts
– Nearly 250,000 adolescents attempt suicide each year
– Up to 10% of children attempt suicide sometime during their lives.
– 83% of adolescent patients who had attempted suicide were not recognized as suicidal by their primary care physicians

Fourteen million children and adolescents, or approximately greater than 1 in every 5 children suffer from mental health disorders in the United States(1,5). This prevalence suggests the need for a useful detection method of these children and adolescents in order to appropriately identify and treat mental health disorders, including anxiety, depression, and eating disorders. The American Academy of Pediatrics (AAP) recommends regular screening of children and adolescents in the primary care setting(5). However, for adolescents who had attempted suicide, 83% of them had not been identified as having suicidal ideation by their PCP(6). So how can detection improve? Since children and adolescents are seen in larger numbers in the primary care setting during annual school physical examinations, this seems to provide an excellent opportunity to screen for mental health disorders that may have not otherwise been detected. This will be the start of the focus of my project on assessing prevalence of mental health disorders in underserved areas, both urban and rural. The next step will be to assess resource availability in relation to the objective need.

So, how does this impact Emergency Medicine?
It suggests that we have an opportunity to intervene. The data indicates an increasing incidence of pediatric psychiatric emergencies and unrecognized suicidal ideation in adolescents, which is in conjunction with an already underdeveloped outpatient mental health infrastructure in many communities(6). This is particularly true for rural areas. These patients utilize emergency departments, whether they are acutely in crisis, or involved in risky behaviors leading to trauma, substance abuse, or suicide attempts. Rotheram-Borus et al reported that “fewer than 50% of adolescents seen for suicidal behavior in the ED were ever referred for treatment, and, even when they were referred, compliance with treatment was low.”(7) I think we can do better.

What are the barriers in the ED to recognizing and referring these patients?
— Time, time, time. These at-risk patients take time to identify, especially when the visit reason seems unrelated and the department is bustling.
— Education. Paucity of mental health education for medical staff and ancillary support inhibits recognition of these patients. Also, lack of awareness of available resources leads to ineffective referrals for follow-up.
— Resource availability. Lack of access to the necessary resources continues to be an issue, for both inpatient admissions and outpatient referrals. This is especially the case in the rural setting, when the nearest resource may be two hours or more away.
— Patient priorities. Should I pay for mental health services or pay the electric bill? Factors such as being able to afford the gas money and the day off of work in order to follow up in clinics are huge for these patients and their families. The priorities relative to the patient’s situation can ultimately result in a lack of follow-up.

What we can do in the ED:
– Always consider a mental health disorder, even if the chief complaint seems unrelated
– Take the extra minute to ask follow up questions if concerned (SBIRT – Screening, Brief Intervention, and Referral to Treatment)
– Familiarize oneself with the available resources in the community
– Advocate for these patients – increasing education, awareness, and policy changes
– Ask about patient barriers, and involve social work if available
– Reinforce the importance of treatment of mental health issues, keeping in mind the rate of serious outcomes, including suicide
– Consider phone call after discharge if concerned for ability to follow up

A final reflection:
By continuing to keep our eyes open to the needs of others, we can have a valuable impact. Understanding one another on this basic level spans gender, geography, culture, and income. We have an incredible opportunity in medicine to contribute to this cause in a multitude of ways. So, capture your moment – no matter how subtle it may seem. The outcome may be inspiring.
Thanks for reading!

LINKS
IUSM Rural Medicine Program

REFERENCES

1. Behavioral health screening and referral in the pediatric office. Swartz J. King HS. Rider EA.
Pediatric Annals. 40(12):610-6, 2011 Dec.

2. Brief mental health screening questionnaire for children and adolescents in primary care settings.
De la Osa N. Ezpeleta L. Granero R. Domenech JM. International Journal of Adolescent Medicine & Health. 21(1):91-100, 2009 Jan-Mar.

3. Incorporating mental health checkups into adolescent primary care visits. Allen PL. McGuire L. Pediatric Nursing. 37(3):137-40, 2011 May-Jun.

4. Mental health screening of adolescents in pediatric practice. Husky MM. Miller K. McGuire L. Flynn L. Olfson M. Journal of Behavioral Health Services & Research. 38(2):159-69, 2011 Apr.

5. American Academy of Pediatrics. IMPACT Fact Sheet: Improving Mental Health in Primary Care Through Access, Collaboration, and Training (IMPACT). Available at: http://www.aap.org/commpeds/dochs/mentalhealth/docs/IMPACT%20Fact%20Sheet.pdf.

6. Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical
Services System: The Committee on Pediatric Emergency Medicine
Pediatrics 2011;127;e1356; originally published online April 25, 2011; DOI: 10.1542/peds.2011-0522

7. Rotheram-Borus M, Piacentini J, Van Ros- sem R, et al. Enhancing treatment adher- ence with a specialized emergency room program for adolescent suicide attempt- ers. J Am Acad Child Adolesc Psychiatry. 1996;35(5):654 – 663

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