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Study finds behavioral-related youth hospitalizations complicated by suicidality

June 14, 2018

A recent study published in American Psychiatric Association's Psychiatric Services journal found previous research on youth hospitalizations associated with behavioral and mental disorders failed to adequately consider children exhibiting suicidality or self-harm. Previous studies assigned behavioral health disorders, such as depression, as the primary diagnosis, while identifying suicidality or self-harm as a secondary diagnosis. By looking closely at the data, the new study found that nearly 24 percent of all behavioral-related admissions are complicated by suicidality or self-harm.

Behavioral disorders affect nearly 20 percent of children in the nation, and are among the top five most costly conditions. "This is a vulnerable population in need of high quality health care," said Lawrence C. Kleinman, MD, MPH, FAAP, the study's principal investigator, and the Frederick C. Robbins Professor of Child and Adolescent Health at Case Western Reserve University School of Medicine and Director of the Center for Child Health and Policy at University Hospitals Rainbow Babies & Children's Hospital. "As self-harm is rarely a principal diagnosis, our approach offers new insights into the extent to which suicidality and self-harm are a part of pediatric hospitalization."

The study analyzed all hospital discharge records of patients age 0-20 with primary or secondary diagnoses classified as a behavioral disorder from the 2012 Kids' Inpatient Database (KID), part of the Agency for Healthcare Research and Quality's (AHRQ's) Healthcare Cost and Utilization (HCUP) project. Depression (34%) and other mood disorders (31%) were the most common primary diagnoses, followed by psychotic disorders (9%) and substance use disorders (7%).

Dr. Kleinman noted almost none of the 24 percent of the children and youth who experienced a suicide attempt or other episode of self-harm were discharged with that as the primary reason for admission (known as the primary diagnosis). While children with suicide attempts may be sent home with a primary diagnosis of their underlying behavioral condition, such as depression, they may also be admitted for the physical consequences of the event, such as poisoning. "Suicide or self-harm is rarely a primary diagnosis," the study concludes, "yet, it is a significant part of all admissions with a behavioral disorder. The primary diagnosis for admitting these children needs to take into consideration not only restoring their physical health, but their mental health as well." The researchers believe these results should stimulate immediate and innovative clinical investigation to better understand how health care services can address the needs of these vulnerable youth.

In a second distinct finding, the rate of behavioral health diagnosis in young women under 21 who deliver babies in the hospital was an order of magnitude higher than in any other group. "The study asks whether this may be a contributor to their becoming pregnant or a consequence of a pregnancy that overwhelms their resilience," said Kleinman."

The study notes public health insurance programs and public hospitals bear a disproportionate share of the mental health admissions. In 2012, behavioral disorders diagnosed in children and adolescents were the primary cause for approximately 250,000 hospitalizations to general and children's hospitals in the United States. Additionally, more than 200,000 hospitalizations for other medical conditions involved the management of a behavioral disorder, adding length of stay and nearly $1.36 billion in cost to those admissions. These costs are disproportionately borne by public insurance programs such as Medicaid and the Child Health Insurance Program. The authors ask if this is in part due to insufficient access for poor children to outpatient mental health services that might have headed off hospitalization. Data suggest children without health insurance do not receive even the hospital services they need.

"In 2012 the health insurance and health care safety net seemed to work for children with public insurance at least regarding hospitalization," said Kleinman. "We believe this suggests such safety net programs should be continued and expanded so all children have access to necessary behavioral health care services."

The researchers hope that these significant findings will lead to enhanced mental health resources and programs for children, teens and young adults.
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The study was funded by the Agency for Health Care Research and Quality and Centers for Medicare and Medicaid services, in part through support for the Collaboration for Advancing Pediatric Quality Measures, a federally funded Center of Excellence in the Pediatric Quality Measures Program. In addition to Kleinman at Case Western Reserve University School of Medicine and UH Rainbow, the multidisciplinary team of co-authors come from Mount Sinai Medical Center and Icahn School of Medicine; and the New York Psychiatric Institute and Columbia University, all in New York City.

Egorova, Natalia N., et al. "Behavioral Health Diagnoses Among Children and Adolescents Hospitalized in the United States: Observations and Implications." Psychiatric Services. DOI: 10.1176/appi.ps.201700389

For more information about Case Western Reserve University School of Medicine, please visit: case.edu/medicine.

For more information about University Hospitals Rainbow Babies & Children's Hospital, please visit rainbow.org.

Case Western Reserve University

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