Sociodemographic Differences in Physician-Based Mental Health and Virtual Care Utilization and Uptake of Virtual Care Among Children and Adolescents During the COVID-19 Pandemic in Ontario, Canada: A Population-Based Study.

OBJECTIVE: We sought to evaluate the relationship between social determinants of health and physician-based mental healthcare utilization and virtual care use among children and adolescents in Ontario, Canada, during the COVID-19 pandemic. METHODS: This population-based repeated cross-sectional study of children and adolescents (3-17 years; N = 2.5 million) used linked health and demographic administrative data in Ontario, Canada (2017-2021). Multivariable Poisson regressions with generalized estimating equations compared rates of outpatient physician-based mental healthcare use during the first year of the COVID-19 pandemic with expected rates based on pre-COVID patterns. Analyses were conducted by socioeconomic status (material deprivation quintiles of the Ontario Marginalization index), urban/rural region of residence, and immigration status. RESULTS: Overall, pediatric physician-based mental healthcare visits were 5% lower than expected (rate ratio [RR] = 0.95, 95% confidence interval [CI], 0.92 to 0.98) among those living in the most deprived areas in the first year of the pandemic, compared with the least deprived with 4% higher than expected rates (RR = 1.04, 95% CI, 1.02 to 1.06). There were no differences in overall observed and expected visit rates by region of residence. Immigrants had 14% to 26% higher visit rates compared with expected from July 2020 to February 2021, whereas refugees had similarly observed and expected rates. Virtual care use was approximately 65% among refugees, compared with 70% for all strata. CONCLUSION: During the first year of the pandemic, pediatric physician-based mental healthcare utilization was higher among immigrants and lower than expected among those with lower socioeconomic status. Refugees had the lowest use of virtual care. Further work is needed to understand whether these differences reflect issues in access to care or the need to help inform ongoing pandemic recovery planning.

Building Resilience and Attachment in Vulnerable Adolescents (BRAVA): a brief group intervention for adolescents with mild-to-moderate suicidal ideation and their caregivers.

INTRODUCTION: Suicidal Ideation (SI) is common in adolescents and increases the risk of completed suicide. Few brief interventions have been shown to reduce SI in adolescents. The objective of this study was to evaluate the feasibility of a novel brief group intervention, building resilience and attachment in vulnerable adolescents (BRAVA), designed for adolescents and their caregivers to reduce adolescent SI. METHODS: The study was a pre-post, noncontrolled trial in which 46 adolescents were enrolled in the BRAVA intervention. Adolescents and caregivers completed an intake assessment, six BRAVA group sessions, and an exit assessment 1-week post-BRAVA. RESULTS: Adolescents' SI decreased significantly after completing the BRAVA treatment (pre-post difference = 18.1, 95% CI = 10.01-26.12). Significant improvements in associated symptoms of depression, anxiety, and perceived stress were also observed. Caregivers had reduced perceived stress (pre-post difference = 2.7, 95% CI = 0.30-5.16) and reduction in attachment avoidance (difference = 1.6, 95% CI = 0.29-2.91). Treatment satisfaction was high across the six modules. The rolling entry feature of the intervention allowed participants to begin treatment approximately 2 weeks sooner compared to waiting for the next group cycle. CONCLUSIONS: Study results demonstrate that the BRAVA intervention has the potential to reduce SI among adolescents who present to hospital services in crisis. Further studies are required to establish BRAVA's efficacy in a randomized controlled trial.

The HEADS-ED: Evaluating the Clinical Use of a Brief, Action-Oriented, Pediatric Mental Health Screening Tool.

OBJECTIVES: This effectiveness study aimed to evaluate the clinical use of the HEADS-ED tool for patients presenting to a pediatric emergency department (PED) for mental health (MH) care. METHODS: In this pragmatic trial, PED physicians used the HEADS-ED to guide their assessment and identify areas of MH need in 639 patients (mean [SD], 15.16 [1.40] years; female, 72.6%) who presented to the emergency department with MH concerns between May 2013 and March 2014. RESULTS: The HEADS-ED guided consultation to psychiatry/crisis, with 86% receiving a recommended consult. Those with a HEADS-ED score of greater than or equal to 8 and suicidality of 2 (relative risk, 2.64; confidence interval, 2.28-3.06) had a 164% increased risk of physicians requesting a consult compared with those with a score of less than 8 or greater than or equal to 8 with no suicidality of 2. The HEADS-ED mean score was significantly higher for those who received a consult (M = 6.91) than those who did not (M = 4.70; P = 0.000). Similarly, the mean score for those admitted was significantly higher (M = 7.21) than those discharged (M = 5.28; P = 0.000). Agreement on needs requiring action between PED physicians and crisis intervention workers was obtained for a subset of 140 patients and ranged from 62% to 93%. CONCLUSIONS: Results support the HEADS-ED's use by PED physicians to help guide the assessment and referral process and for discussing the clinical needs of patients among health care providers using a common action-oriented language.

Health outcomes associated with emergency department visits by adolescents for self-harm: a propensity-matched cohort study.

BACKGROUND: Self-harm is increasing among adolescents, and because of changing behaviours, current data are needed on the consequences of self-harm. We sought to investigate the trends related to hospital presentation, readmission, patient outcome and medical costs in adolescents who presented with self-harm to the emergency department. METHODS: We used administrative data on 403 805 adolescents aged 13-17 years presenting to Ontario emergency departments in 2011-2013. Adolescents with self-harm visits were 1:2 propensity matched to controls with visits without self-harm, using demographic, mental health and other clinical variables. Five years after the index presentation, hospital or emergency department admission rates for self-harm, overall mortality, suicides and conservative cost estimates were compared between the 2 groups. RESULTS: Of 5832 adolescents who visited Ontario emergency departments in 2011-2013 after self-harm (1.4% of visits), 5661 were matched to 10 731 adolescents who presented for reasons other than self-harm. Adolescents who presented with self-harm had a shorter time to a repeat emergency department or hospital admission for self-harm (hazard ratio [HR] 4.84, 95% confidence interval [CI] 4.44-5.27), more suicides (HR 7.96, 95% CI 4.00-15.86), and higher overall mortality (HR 3.23, 95% CI 2.12-4.93; p < 0.001). The positive predictive value of self-harm-related emergency department visits for suicide was 0.7%. Adolescents with self-harm visits had mean 5-year estimates of health care costs of $30 388 compared with $19 055 for controls (p < 0.001). INTERPRETATION: Adolescents with emergency department visits for self-harm have higher rates of mortality, suicide and recurrent self-harm, as well as higher health care costs, than matched controls. Development of algorithms and interventions that can identify and help adolescents at highest risk of recurrent self-harm is warranted.

Changing Rates of Self-Harm and Mental Disorders by Sex in Youths Presenting to Ontario Emergency Departments: Repeated Cross-Sectional Study.

OBJECTIVE: To document the rates of intentional self-harm and mental disorders among youths aged 13 to 17 years visiting Ontario emergency departments (EDs) from 2003-2017. METHODS: This was a repeated cross-sectional observational design. Outcomes were rates of adolescents with (1) at least 1 self-harm ED visit and (2) a visit with a mental disorder code. RESULTS: Rates of youths with self-harm visits fell 32% from 2.6/1000 in 2003 to 1.8 in 2009 but rose 135% to 4.2 by 2017. The slope of the trend in self-harm visits changed from -0.18 youths/1000/year (confidence interval [CI], -0.24 to -0.13) during 2003 to 2009 to 0.31 youths/1000/year (CI, 0.27 to 0.35) during 2009 to 2017 (P < 0.001). Rates of youths with mental health visits rose from 11.7/1000 in 2003 to 13.5 in 2009 (15%) and to 24.1 (78%) by 2017. The slope of mental health visits changed from 0.22 youths/1000/year (CI, 0.02 to 0.42) during 2003 to 2009 to 1.84 youths/1000/year (CI, 1.38 to 2.30) in 2009 to 2017 (P < 0.001). Females were more likely to have self-harm (P < 0.001) and mental health visits (P < 0.001). Rates of increase after 2009 were greater for females for both self-harm (P < 0.001) and mental health (P < 0.001). CONCLUSIONS: Rates of adolescents with self-harm and mental health ED visits have increased since 2009, with greater increases among females. Research is required on the determinants of adolescents' self-harm and mental health ED visits and how they can be addressed in that setting. Sufficient treatment resources must be supplied to address increased demands for services.

A systematic review of management strategies for children's mental health care in the emergency department: update on evidence and recommendations for clinical practice and research.

OBJECTIVE: Children with mental health crises require access to specialised resources and services which are not yet standard in general and paediatric EDs. In 2010, we published a systematic review that provided some evidence to support the use of specialised care models to reduce hospitalisation, return ED visits and length of ED stay. We perform a systematic review to update the evidence base and inform current policy statements. METHODS: Twelve databases and the grey literature were searched up to January 2015. Seven studies were included in the review (four newly identified studies). These studies compared ED-based strategies designed to assess, treat and/or therapeutically support or manage a mental health presentation. The methodological quality of six studies was assessed using the Cochrane Effective Practice and Organization of Care Risk of Bias tool (one interrupted time series study) and a modified Newcastle-Ottawa Scale (three retrospective cohort and two before-after studies). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was applied to rate overall evidence quality (high, moderate, low or very low) for individual outcomes from these six studies. An additional study evaluated the psychometric properties of a clinical instrument and was assessed using criteria developed by the Society of Pediatric Psychology Assessment Task Force (well-established, approaching well-established or promising assessment). RESULTS: There is low to very low overall evidence quality that: (1) use of screening laboratory tests to medically clear mental health patients increases length of ED stay and costs, but does not increase the risk of clinical management or disposition change if not conducted; and (2) specialised models of ED care reduce lengths of ED stay, security man-hours and restraint orders. One mental health assessment tool of promising quality, the home, education, activities and peers, drugs and alcohol, suicidality, emotions and behaviour, discharge resources (HEADS-ED), has had good accuracy in predicting admission to inpatient psychiatry. CONCLUSIONS: Lower-quality data suggest benefits to the use of specialised resources and services for paediatric mental health care in general and paediatric EDs. Experimental evaluation of strategies and the inclusion of patient-reported outcomes will improve confidence in these findings. Additional psychometric studies are needed for the HEADS-ED tool to be considered well established.

Barriers and Facilitators to Implementing the HEADS-ED: A Rapid Screening Tool for Pediatric Patients in Emergency Departments.

OBJECTIVES: This study sought to identify barriers and facilitators to the implementation of the HEADS-ED, a screening tool appropriate for use in the emergency department (ED) that facilitates standardized assessments, discharge planning, charting, and linking pediatric mental health patients to appropriate community resources. METHODS: A qualitative theory-based design was used to identify barriers and facilitators to implementing the HEADS-ED tool. Focus groups were conducted with participants recruited from 6 different ED settings across 2 provinces (Ontario and Nova Scotia). The Theoretical Domains Framework was used as a conceptual framework to guide data collection and to identify themes from focus group discussions. RESULTS: The following themes spanning 12 domains were identified as reflective of participants' beliefs about the barriers and facilitators to implementing the HEADS-ED tool: knowledge, skills, beliefs about capabilities, social professional role and identity, optimism, beliefs about consequences, reinforcement, environmental context and resources, social influences, emotion, behavioral regulation and memory, and attention and decision process. CONCLUSIONS: The HEADS-ED has the potential to address the need for better discharge planning, complete charting, and standardized assessments for the increasing population of pediatric mental health patients who present to EDs. This study has identified potential barriers and facilitators, which should be considered when developing an implementation plan for adopting the HEADS-ED tool into practice within EDs.

The current state of mental health services in Canada's paediatric emergency departments.

OBJECTIVE: To describe emergency mental health services in major paediatric centres across Canada. METHODS: A cross-sectional study of mental health services in emergency departments (EDs) from all 15 Canadian tertiary care paediatric centres was conducted. RESULTS: Fifteen individuals participated and were either a paediatric emergency physician with administrative responsibilities (60%) or an emergency mental health care provider (40%). Four participants reported that their ED used an evidence-based guideline, tool or policy, and one participant reported their ED based its services on published research evidence. Reported ED-based mental health resources included a crisis intervention team (five EDs), a mental health nurse (six EDs) and a social worker (five EDs). Thirteen participants reported on-site consultation with child psychiatry and six reported urgent follow-up as an adjunct service to ED care. CONCLUSIONS: There is a wide variety of mental health care practices in Canadian paediatric EDs. Consideration of which resources are required to ensure evidence-based, effective services are provided to children and youth is necessary.

OBJECTIF: Décrire les services de santé mentale d'urgence dans les principaux centres pédiatriques du Canada. MÉTHODOLOGIE: Les chercheurs ont mené une étude transversale des services de santé mentale offerts aux départements d'urgence (DU) des 15 centres pédiatriques de soins tertiaires du Canada. RÉSULTATS: Quinze personnes ont participé à l'étude. Il s'agissait de pédiatres d'urgence pédiatrique ayant des responsabilités administratives (60 %) ou de dispensateurs de services de santé mentale d'urgence (40 %). Quatre participants ont indiqué que leur DU faisait appel à des lignes directrices, un outil ou une politique probants et un participant a indiqué que les services de son département se fondaient sur des résultats de recherche publiés. Les ressources de santé mentale utilisées au DU incluaient une équipe d'intervention en cas de crise (cinq DU), une infirmière en santé mentale (six DU) et un travailleur social (cinq DU). Treize participants ont déclaré obtenir des consultations en pédopsychiatrie sur place et six, un suivi urgent en services complémentaires aux soins d'urgence. CONCLUSIONS: On constate une grande variété de pratiques de soins de santé mentale dans les départements d'urgence pédiatrique du Canada. Il faut se pencher sur les ressources nécessaires pour garantir des services probants et efficaces aux enfants et aux adolescents.

Meeting the service needs of youth with and without a self-reported mental health diagnosis during COVID-19.

Background: The COVID-19 pandemic catalyzed major changes in how youth mental health (MH) services are delivered. Understanding youth's MH, awareness and use of services since the pandemic, and differences between youth with and without a MH diagnosis, can help us optimize MH services during the pandemic and beyond. Objectives: We investigated youth's MH and service use one year into the pandemic and explored differences between those with and without a self-reported MH diagnosis. Methods: In February 2021, we administered a web-based survey to youth, 12-25 years, in Ontario. Data from 1373 out of 1497 (91.72%) participants were analyzed. We assessed differences in MH and service use between those with (N=623, 45.38%) and without (N=750, 54.62%) a self-reported MH diagnosis. Logistic regressions were used to explore MH diagnosis as a predictor of service use while controlling for confounders. Results: 86.73% of participants reported worse MH since COVID-19, with no between-group differences. Participants with a MH diagnosis had higher rates of MH problems, service awareness and use, compared to those without a diagnosis. MH diagnosis was the strongest predictor of service use. Gender and affordability of basic needs also independently predicted use of distinct services. Conclusion: Various services are required to mitigate the negative effects of the pandemic on youth MH and meet their service needs. Whether youth have a MH diagnosis may be important to understanding what services they are aware of and use. Sustaining pandemic-related service changes require increasing youth's awareness of digital interventions and overcoming other barriers to care.

Contexte: La pandémie de la COVID-19 a catalysé des changements majeurs de la manière dont les services de santé mentale (SM) sont dispensés aux jeunes. Comprendre la SM des jeunes, la connaissance et l'utilisation des services depuis la pandémie, et les différences entre les jeunes avec et sans un diagnostic de SM peut nous aider à optimiser les services de SM durant la pandémie et au-delà. Objectifs: Nous avons investigué la SM et l'utilisation des services des jeunes un an après le début de la pandémie et exploré les différences entre ceux avec et sans un diagnostic de SM auto-rapporté. Méthodes: En février 2021, nous avons administré un sondage en ligne à des jeunes de 12 à 25 ans en Ontario. Les données de 1373 participants sur 1497 (91,72 %) participants ont été analysées. Nous avons évalué les différences de SM et d'utilisation des services entre ceux avec (N = 623, 45,38 %) et sans (N = 750, 54,62 %) un diagnostic de SM auto-rapporté. Les régressions logistiques ont servi à explorer le diagnostic de SM comme prédicteur de l'utilisation de services tout en contrôlant les confusions. Résultats: 86,73 % des participants ont rapporté une SM pire depuis la COVID-19, sans différences entre les groupes. Les participants ayant un diagnostic de SM avaient des taux plus élevés de problèmes de SM, de connaissance et d'utilisation des services comparé à ceux sans diagnostic. Le diagnostic de SM était le prédicteur le plus fort de l'utilisation de services. Le sexe et l'abordabilité des besoins de base prédisaient aussi indépendamment l'utilisation de services distincts. Conclusion: Divers services sont nécessaires pour atténuer les effets négatifs de la pandémie sur la SM des jeunes et répondre à leurs besoins de service. Savoir si les jeunes ont un diagnostic de SM peut être important pour comprendre quels services ils connaissent et utilisent. Soutenir les changements de services liés à la pandémie exige d'accroître la connaissance des jeunes des interventions numériques et de surmonter d'autres obstacles des soins.

New and continuing physician-based outpatient mental health care among children and adolescents during the COVID-19 pandemic in Ontario, Canada: a population-based study.

Objective: To assess physician-based mental health care utilization during the COVID-19 pandemic among children and adolescents new to care and those already engaged with mental health services, and to evaluate differences by sociodemographic factors. Study design: We performed a population-based repeated cross-sectional study using linked health and administrative databases in Ontario, Canada among all children and adolescents 3-17 years. We examined outpatient visit rates per 1,000 population for mental health concerns for those new to care (no physician-based mental healthcare for ≥1 year) and those with continuing care needs (any physician-based mental healthcare <1 year) following onset of the pandemic. Results: Among ~2.5 million children and adolescents (48.7% female, mean age 10.1 ± 4.3 years), expected monthly mental health outpatient visits were 1.5/1,000 for those new to mental health care and 5.4/1,000 for those already engaged in care. Following onset of the pandemic, visit rates for both groups were above expected [adjusted rate ratio (aRR) 1.22, 95% CI 1.17, 1.27; aRR 1.10, 95% CI 1.07, 1.12] for new and continuing care, respectively. The greatest increase above expected was among females (new: aRR 1.33, 95% CI 1.25, 1.42; continuing: aRR 1.22 95% CI 1.17, 1.26) and adolescents ages 13-17 years (new: aRR 1.31, 95% CI 1.27, 1.34; continuing: aRR 1.15 95% CI 1.13, 1.17). Mood and anxiety concerns were prominent among those new to care. Conclusion: In the 18 months following onset of the pandemic, outpatient mental health care utilization increased for those with new and continuing care needs, especially among females and adolescents.

Physician management of pediatric mental health patients in the emergency department: assessment, charting, and disposition.

OBJECTIVE: The focus of this study was to describe the clinical data that pediatric emergentologists recorded and how they were used in the mental health (MH) care of patients. METHODS: A structured chart review was conducted for all MH presentations to a pediatric emergency department in 2007. Three research assistants extracted clinical chart data and completed the Child and Adolescent Needs and Strengths Tool. RESULTS: The clinical records of 495 children and youth were reviewed. Emergentologists referred 124 (25.4%) for a psychiatric consult, and 46 (37%) of these patients were admitted to either an inpatient psychiatric or eating-disorders unit. Psychosis, suicide risk, eating disturbance, anxiety, and resistance to treatment predicted admission to the psychiatric inpatient unit or the eating-disorders unit. Of the 365 patients discharged back to the community, the majority (n = 189, 51.8%) were referred back to their family physician. For 117 patients (32%), there was no discharge documentation in the medical chart. Age, parent present, currently on medication, currently receiving counseling, depression, anxiety, and adjustment to trauma predicted provision of charted recommendation. CONCLUSIONS: This study revealed that the pediatric emergentologists' charting of MH patients is inconsistent and incomplete. Although recorded clinical data predicted psychiatric consultation and disposition for these patients, missing data were evident in a significant number of records. The results of the study point to a need to develop a more uniform approach to the collection and recording of clinical data for MH patients.

What's the harm in asking? A systematic review and meta-analysis on the risks of asking about suicide-related behaviors and self-harm with quality appraisal.

Research emphasizes the importance of asking about suicidality. Unfortunately, misperceptions of harm remain which can compromise clinical care, research, and public health surveillance efforts. Our objective was to evaluate the empirical evidence on whether and how asking about suicide related behaviors (SRB), such as suicidal ideation and suicide attempts, and non-suicidal self-injury (NSSI) results in harmful outcomes. We reviewed and rated seventeen studies and conducted a systematic review and random-effects meta-analysis on eight studies comparing those asked vs. not asked on immediate and later SRB, NSSI, and psychological distress (PD). Forest plots demonstrated no statistically significant effects of asking on SRB, NSSI, or PD. Eight RCTs provided the strongest evidence and demonstrated either low or unclear risk of bias, and the remaining cohort studies were of low to moderate quality. With the current available evidence, we found no harmful outcomes of asking, however more RCTs with a low risk of bias are required to firmly conclude that asking through self-report and interview methods does not further exacerbate distress, SRB and NSSI compared to those not asked.

Parenting during the COVID-19 pandemic: The sociodemographic and mental health factors associated with maternal caregiver strain.

INTRODUCTION: The COVID-19 pandemic has introduced new stressors for parents ("caregivers") that may affect their own and their child's mental health (MH). We explored self-reported levels of caregiver strain (parents' perceived ability to meet parenting demands), and the MH and sociodemographic factors of caregivers to identify predictors of strain that can be used to guide MH service delivery for families. METHODS: We administered a web-based survey to Ontario caregivers with a child between 4 and 25 years old, between April and June 2020. We analyzed information from 570 maternal caregivers on their sociodemographics, youngest (or only) child's MH, their own MH, and the degree of caregiver strain experienced since the pandemic. We used linear regressions (unadjusted and adjusted models) to explore the relationship between caregiver strain and sociodemographics, child MH and caregiver MH. RESULTS: Over 75% of participants reported "moderate-to-high" caregiver strain. More than 25% of caregivers rated their MH as "poor" and 20% reported moderate-to-severe anxiety. Forty-five percent of the variance in caregiver strain was accounted for by child age, caregiver anxiety, and multiple child and caregiver MH variables. Younger child age and higher caregiver anxiety were the greatest predictors of caregiver strain. CONCLUSION: We found a relationship between child age, child and caregiver MH variables, and caregiver strain. Given the interrelatedness of these factors, supporting caregivers' MH and lessening their role strain becomes critical for family well-being. Evidence-based individual, family, and public health strategies are needed to alleviate pandemic-related strain. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Utilization of Physician-Based Mental Health Care Services Among Children and Adolescents Before and During the COVID-19 Pandemic in Ontario, Canada.

IMPORTANCE: Public health measures to reduce the spread of COVID-19 have heightened distress among children and adolescents and contributed to a shift in delivery of mental health care services. OBJECTIVES: To measure and compare physician-based outpatient mental health care utilization before and during the COVID-19 pandemic and quantify the extent of uptake of virtual care delivery. DESIGN, SETTING, AND PARTICIPANTS: Population-based repeated cross-sectional study using linked health and administrative databases in Ontario, Canada. All individuals aged 3 to 17 years residing in Ontario from January 1, 2017, to February 28, 2021. EXPOSURES: Pre-COVID-19 period from January 1, 2017, to February 29, 2020, and post-COVID-19 onset from March 1, 2020, to February 28, 2021. MAIN OUTCOMES AND MEASURES: Physician-based outpatient weekly visit rates per 1000 population for mental health diagnoses overall and stratified by age group, sex, and mental health diagnostic grouping and proportion of virtual visits. Poisson generalized estimating equations were used to model 3-year pre-COVID-19 trends and forecast expected trends post-COVID-19 onset and estimate the change in visit rates before and after the onset of COVID-19. The weekly proportions of virtual visits were calculated. RESULTS: In a population of almost 2.5 million children and adolescents (48.7% female; mean [SD] age, 10.1 [4.3] years), the weekly rate of mental health outpatient visits was 6.9 per 1000 population. Following the pandemic onset, visit rates declined rapidly to below expected (adjusted relative rate [aRR], 0.81; 95% CI, 0.79-0.82) in April 2020 followed by a growth to above expected (aRR, 1.07; 95% CI, 1.04-1.09) by July 2020 and sustained at 10% to 15% above expected as of February 2021. Adolescent female individuals had the greatest increase in visit rates relative to expected by the end of the study (aRR, 1.26; 95% CI, 1.25-1.28). Virtual care accounted for 5.0 visits per 1000 population (72.5%) of mental health visits over the study period, with a peak of 5.3 visits per 1000 population (90.1%) (April 2020) and leveling off to approximately 70% in the latter months. CONCLUSIONS AND RELEVANCE: Physician-based outpatient mental health care in Ontario increased during the pandemic, accompanied by a large, rapid shift to virtual care. There was a disproportionate increase in use of mental health care services among adolescent female individuals. System-level planning to address the increasing capacity needs and to monitor quality of care with such large shifts is warranted.

An Innovative Model of Pediatric Emergency Department Mental Health Care: Protocol for a Multicenter Type 1 Effectiveness-Implementation Cluster Randomized Trial.

Over the past decade, visits to American and Canadian emergency departments (EDs) for child and youth mental health care have increased substantially.1,2 Acute mental health crises can occur as a result of a variety of concerns, including those that are life threatening (eg, suicide attempts), pose safety concerns (eg, suicidal intentions, aggressive behaviors, alcohol and other drug use), and are physically distressing to the child or youth (eg, panic attacks). ED health care providers play a vital role in assessing the safety and well-being of the child or youth and referring them to services for ongoing care.3,4 During the ED visit, assessment and care should pinpoint risks, inform treatment, and consider family needs and preferences as part of a patient-centered approach. Yet, this approach to care is not widely adopted in EDs. Most EDs do not require the use of pediatric-specific mental health tools to guide assessments or have patient-centered procedures in place to guide the care of patients with mental health emergencies.5-7 Our team believes these limitations have led to the provision of acute mental health care that can lack sufficient quality and efficiency. This study protocol describes a trial designed to evaluate if a novel mental health care bundle that was co-designed with parents and youth results in greater improvements in the well-being of children and youth 30 days after seeking ED care for mental health and/or substance misuse concerns compared with existing care protocols. We hypothesize that the bundle will positively impact child and youth well-being, while also providing cost-effective health care system benefits.

"We suffer from being lost": formulating policies to reclaim youth in mental health transitions.

The greatest financial and institutional weaknesses in mental health services affect individuals between the ages of 16 and 25. The current project sought to identify bodies of evidence supporting effective transitional pathways and to engage policy leaders in a discussion of youth mental health transitions to highlight stakeholder perspectives. Three efficacious pathways from youth health service environments to adult health service structures were identified in the literature: the Protocol/Reciprocal Agreement Structure, the Transition Program Model and the Shared Management Framework. Evidence was presented to a panel of policy officials occupying various roles, up to the position of assistant deputy minister, from the provincial ministries of health, education, child and youth services and training, colleges and universities in Ontario. The panel was then engaged in a discussion regarding youth mental health transitions, and thematic analysis was used to identify policy- and practice-level considerations. The Shared Management Framework was recommended as the preferred transitional model from a policy perspective; however, continued research is required to determine the appropriateness of this approach for all stakeholders involved in youth mental health transitions.

The primary care physician role in cancer genetics: a qualitative study of patient experience.

BACKGROUND: Increased availability of genetic testing is changing the primary care role in cancer genetics. The perspective of primary care physicians (PCPs) regarding their role in support of genetic testing has been explored, but little is known about the expectations of patients or the PCP role once genetic test results are received. METHODS: Two sets of open-ended semi-structured interviews were completed with patients (N=25) in a cancer genetic programme in Ontario, Canada, within 4 months of receiving genetic test results and 1 year later; written reports of test results were collected. RESULTS: Patients expected PCPs to play a role in referral for genetic testing; they hoped that PCPs would have sufficient knowledge to appreciate familial risk and supportive attitudes towards genetic testing. Patients had more difficulty in identifying a PCP role following receipt of genetic test results; cancer patients in particular emphasized this as a role for cancer specialists. Still, some patients anticipated an ongoing PCP role comprising risk-appropriate surveillance or reassurance, especially as specialist care diminished. These expectations were complicated by occasional confusion regarding the ongoing care appropriate to genetic test results. CONCLUSIONS: The potential PCP role in cancer genetics is quite broad. Patients expect PCPs to play a role in risk identification and genetics referral. In addition, some patients anticipated an ongoing role for their PCPs after receiving genetic test results. Sustained efforts will be needed to support PCPs in this expansive role if best use is to be made of investments in cancer genetic services.

A psychometric evaluation of the Hospital Anxiety and Depression Scale in cardiac patients: addressing factor structure and gender invariance.

OBJECTIVES: The present study examined the factor structure of the Hospital Anxiety and Depression Scale (HADS) and tested measurement invariance between genders in a representative sample of cardiac patients across 2 years. DESIGN: Confirmatory factor analysis and structural equational modelling were used to assess the factor structure, measurement, and structural invariance of the HADS. METHODS: Eight hundred and one cardiac patients completed the HADS at baseline, 6, 12, and 24 months. RESULTS: Confirmatory factor analysis consistently supported a three-factor structure of the HADS, with the best fitting model comprised of negative affect, autonomic anxiety, and depression. Structural equation modelling showed that the HADS was invariant by gender among cardiac patients. CONCLUSIONS: The HADS can be appropriately used with both male and female cardiac patients to assess three domains of psychological distress. Future investigations should consider the predictive validity and relevance of the HADS subscales with respect to diagnostic distinctions and clinical outcomes among cardiac patients and other clinical populations.

Pediatric mental health concerns in the emergency department: caregiver and youth perceptions and expectations.

OBJECTIVES: The main purpose of this research was to identify the perceived mental health (MH) concerns of caregivers and youths who present to the emergency department (ED) for MH services. The concordance between caregiver and youth perceptions and clinician ratings of MH concerns were evaluated. Expectations for the visit and perceived stressors that triggered the event are described. METHODS: This study consisted of 241 youths accompanied by caregivers presenting to the ED for MH concerns requiring crisis intervention services. The Caregiver Perception Survey and Youth Perception Survey were completed. These surveys were designed to identify the caregivers' and youths' main concerns and perceived stressors, as well as their expectations in coming to the pediatric ED. A chi analysis was conducted to determine the percentage of agreement of reported MH concerns between groups (youth, caregiver, and clinician), and kappa statistics are reported. RESULTS: Caregivers' and youths' top 5 concerns were suicide ideation, depression or mood, suicidal attempt, anxiety, and self-injury. The top 3 stresses identified by both youths and their caregivers were school, issues with parents, and problems with friends/peers. The top 3 expectations that were noted by caregivers were help/guidance for child, assessment/ evaluation/diagnosis, and health care professional resources. Concordance rates between caregivers and youths for the top 5 concerns ranged from 39.4% to 80.6%. Concordance rates between clinician rating of concerns (as requiring some or immediate action) and caregiver concerns ranged from 18.4% to 45.2%. Concordance rates between clinician and youth ranged from 11.1% to 59.4%. CONCLUSIONS: The top 5 caregivers and youths' main concerns for coming to the ED were similar. However, concordance between perceived concern and clinician assessment is low. Caregivers' expectations for coming to the ED highlight their lack of knowledge of referral procedures and MH services.

A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research.

OBJECTIVE: In this systematic review, we evaluated the effectiveness of emergency department (ED)-based management interventions for mental health presentations with an aim to provide recommendations for pediatric care. METHODS: A search of electronic databases, references, key journals, and conference proceedings was conducted, and primary authors were contacted. Experimental and observational studies that evaluated ED crisis care with pediatric and adult patients were included. Adult-based studies were evaluated for potential translation to pediatric investigation. Pharmacological-based studies were excluded. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data, and a second checked for completeness and accuracy. Presentation of study outcomes included odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CI). Meta-analysis was deferred due to clinical heterogeneity in intervention, patient population, and outcome. RESULTS: Twelve observational studies were included in the review with pediatric (n = 3), and adult or unknown (n = 9) aged participants. Pediatric studies supported the use of specialized care models to reduce hospitalization (OR, 0.45; 95% CI, 0.33-0.60), return ED visits (OR, 0.60; 95% CI, 0.28-1.25), and length of ED stay (MD, -43.1 minutes; 95% CI, -63.088 to -23.11 minutes). In an adult study, reduced hospitalization was reported in a comparison of a crisis intervention team to standard care (OR, 0.59; 95% CI, 0.43-0.82). Five adult-based studies assessed triage scales; however, little overlap in the scales investigated, and the outcomes measured limited comparability and generalizability for pediatrics. In a comparison of a mental health scale to a national standard, a study demonstrated reduced ED wait (MD, -7.7 minutes; 95% CI, -12.82 to -2.58 minutes) and transit (MD, -17.5 minutes; 95% CI, -33.00 to -1.20 minutes) times. Several studies reported a shift in triage scores of psychiatric patients dependent on the scale or nurse training (psychiatric vs emergency), but linkage to system- or patient-based outcomes was not made, limiting clinical interpretation. CONCLUSIONS: Pediatric studies have demonstrated that the use of specialized care models for mental health care can reduce hospitalization, return ED visits, and length of ED stay. Evaluation of these models using more rigorous study designs and the inclusion of patient-based outcomes will improve this evidence base. Adult-based studies provided recommendations for pediatric research including a focus on triage and restraint use.