Mental health-related ED visits among kids on the rise in Colorado

One-quarter of Colorado’s mental health-related emergency department visits were for children in 2018, a new report has found.

The share of children’s emergency department visits where mental health was the primary diagnosis grew from 21% in 2016 to 25% in 2018, according to an analysis performed by the Center for Improving Value in Health Care using claims data for commercially insured, Medicaid and Medicare Advantage patients. Those visits for adults dropped from 79% to 75% in that time.

“For a lot of kids it’s the ability to feel comfortable asking for help,” said CIVHC spokeswoman Cari Frank. “That’s one of the concerns. That’s an issue adults face too, the stigma. But kids might not feel comfortable telling their parents they’re sad and they don’t want their parents to worry. But they might not get the help they need.”

CIVHC’s data include nearly 4,300 mental health-related emergency department claims for kids in 2018, compared with about 12,700 for adults. That’s compared with about 4,100 such visits for kids in 2016 and about 15,000 for adults that year.

Overall, mental health emergency department visits comprised 1.5% of the total visits between 2016 and 2018, CIVHC found. That number may be lower than previous analyses because it excludes visits where a mental illness was the secondary diagnosis. It also excluded substance abuse diagnoses. Between 2007 and 2011, about one in eight emergency department visits involved mental health and substance use disorders, according to the Agency for Healthcare Research and Quality.

In 2016, “mental, behavioral and neurodevelopmental disorders” was the primary diagnosis in nearly 4% of emergency department visits, according to the U.S. Centers for Disease Control and Prevention.

A potential bright spot in the report was the fact that Colorado’s total emergency department visits with mental health as a primary diagnosis dropped by 11% between 2016 and 2018. That was sharper than the 5.5% total decline in emergency department visits during that time. Viewed as a rate per 100,000 visits, mental health-related visits declined 6.3% in that time.

That runs contrary to the national trend between 2006 and 2013, when the AHRQ found the number of emergency department visits related to depression, anxiety or stress reactions grew by 55.5% per 100,000 population.

The decline in mental health-related emergency department visits could be because of a statewide crisis system Colorado developed five years ago, said Rick Doucet, CEO of Community Reach Center, a prominent mental health provider in Colorado. One of the goals behind that project was to decrease such visits, he said.

“The ER really doesn’t do anything for people with behavioral health issues,” he said. “If we can get to them before they get to the point of needing an emergency room, we’re doing our job. If they get to the emergency room, we’ve missed something.”

Anxiety disorder was the most common mental health diagnosis in all three years studied, comprising 24% last year, followed by major depressive disorder at 22% last year. Panic disorder came in third at 6% last year. The analysis covered more than 200 mental health diagnoses, not including substance abuse diagnoses.

Among patients under 18, major depressive disorder was the most common diagnosis.

Medicaid paid for nearly 64% of emergency department visits with mental health as the primary diagnosis last year, down from 73% in 2016. Medicaid was also the only payer whose spending on mental health-related emergency department visits declined between 2016 and 2018, from $12.1 million in 2016 to $8.1 million in 2018. Meanwhile, commercial payers spent $12.6 million on such visits in 2016 and $14.6 million in 2018. Medicare Advantage’s spending on the visits grew from $1.9 million to $3 million in that time.

One driver behind the decreased Medicaid visits is the fact that Colorado’s Medicaid program has worked hard to reduce emergency department visits and provide more integrated behavioral health services, Frank said.

“If it’s being driven by one particular thing, it might be the way they’re managed,” she said.

CIVHC’s analysis included roughly 50% of commercial insurance claims in all three years studied, plus all Medicaid and Medicare Advantage claims. It did not include fee-for-service Medicare claims.