Advancing Public Mental Health in Canada through a National Suicide Prevention Service: Setting an Agenda for Canadian Standards of Excellence.

The Public Health Agency of Canada is funding a new Canada Suicide Prevention Service (CSPS), timely both in recognition of the need for a public health approach to suicide prevention, and also in the context of the COVID-19 pandemic, which is causing concern about the potential for increases in suicide. This editorial reviews priorities for suicide prevention in Canada, in relation to the evidence for crisis line services, and current international best practices in the implementation of crisis lines; in particular, the CSPS recognizes the importance of being guided by existing evidence as well as the opportunity to contribute to evidence, to lead innovation in suicide prevention, and to involve communities and people with lived experience in suicide prevention efforts.

Screening and Intervention for Suicide Prevention: A Cost-Effectiveness Analysis of the ED-SAFE Interventions.

OBJECTIVE: Suicide screening followed by an intervention may identify suicidal individuals and prevent recurring self-harm, but few cost-effectiveness studies have been conducted. This study sought to determine whether the increased costs of implementing screening and intervention in hospital emergency departments (EDs) are justified by improvements in patient outcomes (decreased attempts and deaths by suicide). METHODS: The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study recruited participants in eight U.S. EDs between August 2010 and November 2013. The eight sites sequentially implemented two interventions: universal screening added to treatment as usual and universal screening plus a telephone-based intervention delivered over 12 months post-ED visit. This study calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves to evaluate screening and suicide outcome measures and costs for the two interventions relative to treatment as usual. Costs were calculated from the provider perspective (e.g., wage and salary data and rental costs for hospital space) per patient and per site. RESULTS: Average per-patient costs to a participating ED of universal screening plus intervention were $1,063 per month, approximately $500 more than universal screening added to treatment as usual. Universal screening plus intervention was more effective in preventing suicides compared with universal screening added to treatment as usual and treatment as usual alone. CONCLUSIONS: Although the choice of universal screening plus intervention depends on the value placed on the outcome by decision makers, results suggest that implementing such suicide prevention measures can lead to significant cost savings.

High Resource Utilization of Psychiatric Emergency Services by Methamphetamine Users.

Methamphetamine use has increased throughout the United States in recent years, and is historically prevalent in Hawai'i. This retrospective study aimed to determine the effect of methamphetamine use on emergency department (ED) resources, by examining visits to an emergency department (ED) in an urban hospital in Hawai'i from 2007 - 2011. The rate of patients who tested positive for amphetamine was measured and broken down by year. Primary outcomes included length of ED stay, the administration of medication or physical restraints for safety, and the rate of psychiatric hospitalization. Overall, 15.1% of drug-screened patients (N = 16,018) tested positive for amphetamines over the study period. Amphetamine-positive patients spent more time per visit on average in the ED, and were more likely to require medication and physical restraints, compared to amphetamine-negative patients. Amphetamine positive patients were admitted to inpatient psychiatry less frequently than negative-testing patients. In summary, there is higher resource utilization per psychiatric emergency service visit by amphetamine-positive patients; however if patients can be stabilized in the ED, the increased ED resources utilized may be offset by the reduced burden on inpatient facilities.

Acute Care Use for Ambulatory Care-Sensitive Conditions in High-Cost Users of Medical Care with Mental Illness and Addictions.

OBJECTIVE: The role of mental illness and addiction in acute care use for chronic medical conditions that are sensitive to ambulatory care management requires focussed attention. This study examines how mental illness or addiction affects risk for repeat hospitalization and/or emergency department use for ambulatory care-sensitive conditions (ACSCs) among high-cost users of medical care. METHOD: A retrospective, population-based cohort study using data from Ontario, Canada. Among the top 10% of medical care users ranked by cost, we determined rates of any and repeat care use (hospitalizations and emergency department [ED] visits) between April 1, 2011, and March 31, 2012, for 14 consensus established ACSCs and compared them between those with and without diagnosed mental illness or addiction during the 2 years prior. Risk ratios were adjusted (aRR) for age, sex, residence, and income quintile. RESULTS: Among 314,936 high-cost users, 35.9% had a mental illness or addiction. Compared to those without, individuals with mental illness or addiction were more likely to have an ED visit or hospitalization for any ACSC (22.8% vs. 19.6%; aRR, 1.21; 95% confidence interval [CI], 1.20-1.23). They were also more likely to have repeat ED visits or hospitalizations for the same ACSC (6.2% vs. 4.4% of those without; aRR, 1.48; 95% CI, 1.44-1.53). These associations were stronger in stratifications by mental illness diagnostic subgroup, particularly for those with a major mental illness. CONCLUSIONS: The presence of mental illness and addiction among high-cost users of medical services may represent an unmet need for quality ambulatory and primary care.

The Use of Telepsychiatry to Provide Cost-Efficient Care During Pediatric Mental Health Emergencies.

OBJECTIVE: This study evaluated a videoconference-based psychiatric emergency consultation program (telepsychiatry) at geographically dispersed emergency department (ED) sites that are part of the network of care of an academic children's hospital system. The study compared program outcomes with those of usual care involving ambulance transport to the hospital for in-person psychiatric emergency consultation prior to disposition to inpatient care or discharge home. METHODS: This study compared process outcomes in a cross-sectional, pre-post design at five network-of-care sites before and after systemwide implementation of telepsychiatry consultation in 2015. Clinical records on 494 pediatric psychiatric emergencies included ED length of stay, disposition/discharge, and hospital system charges. Satisfaction surveys regarding telepsychiatry consultations were completed by providers and parents or guardians. RESULTS: Compared with children who received usual care, children who received telepsychiatry consultations had significantly shorter median ED lengths of stay (5.5 hours and 8.3 hours, respectively, p<.001) and lower total patient charges ($3,493 and $8,611, p<.001). Providers and patient caregivers reported high satisfaction with overall acceptability, effectiveness, and efficiency of telepsychiatry. No safety concerns were indicated based on readmissions within 72 hours in either treatment condition. CONCLUSIONS: Measured by charges and time, telepsychiatry consultations for pediatric psychiatric emergencies were cost-efficient from a hospital system perspective compared with usual care consisting of ambulance transport for in-person consultation at a children's hospital main campus. Telepsychiatry also improved clinical and operational efficiency and patient and family experience, and it showed promise for increasing access to other specialized health care needs.

Costs of the police service and mental healthcare pathways experienced by individuals with enduring mental health needs.

BACKGROUND: Substantial policy, communication and operational gaps exist between mental health services and the police for individuals with enduring mental health needs. AIMS: To map and cost pathways through mental health and police services, and to model the cost impact of implementing key policy recommendations. METHOD: Within a case-linkage study, we estimated 1-year individual-level healthcare and policing costs. Using decision modelling, we then estimated the potential impact on costs of three recommended service enhancements: street triage, Mental Health Act assessments for all Section 136 detainees and outreach custody link workers. RESULTS: Under current care, average 1-year mental health and police costs were £10 812 and £4552 per individual respectively (n = 55). The cost per police incident was £522. Models suggested that each service enhancement would alter per incident costs by between -8% and +6%. CONCLUSIONS: Recommended enhancements to care pathways only marginally increase individual-level costs.

Improving Quality of Emergency Care Through Integration of Mental Health.

The goal of this study was to better integrate emergency medical and psychiatric care at a large urban public hospital, identify impact on quality improvement metrics, and reduce healthcare cost. A psychiatric fast track service was implemented as a quality improvement initiative. Data on disposition from the emergency department from January 2011 to May 2012 for patients impacted by the pilot were analyzed. 4329 patients from January 2011 to August 2011 (pre-intervention) were compared with 4867 patients from September 2011 to May 2012 (intervention). There was a trend of decline on overall quality metrics of time to triage and time from disposition to discharge. The trend analysis of the psychiatric length of stay and use of restraints showed significant reductions. Integrated emergency care models are evidence-based approach to ensuring that patients with mental health needs receive proper and efficient treatment. Results suggest that this may also improve overall emergency department's throughput.

Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary.

We examined the patient characteristics and hospital charges associated with routine medical clearance laboratory screening tests in 1,082 children younger than age eighteen who were brought to the emergency department (ED) for involuntary mental health holds--that is, each patient was brought to the ED to be evaluated for being a danger to him- or herself or to others, for being gravely disabled (unable to meet his or her basic needs due to a mental disorder), or both--from July 2009 to December 2010. Testing was performed on 871 of the children; all patients also received a clinical examination. The median charge for blood and urine testing together was $1,235, and the most frequent ordering pattern was the full comprehensive panel of tests. Of the patients with a nonconcerning clinical examination, 94.3 percent also had clinically nonsignificant test results. When we extrapolated cost savings to the national level, omitting routine screening laboratory tests in the population of pediatric patients presenting to the ED on an involuntary psychiatric hold with nonconcerning clinical exams could represent up to $90 million in savings annually, without reducing the ability to screen for emergency medical conditions. Provider-initiated diagnostic testing instead of routine screening would lead to significantly lower charges to the ED and the patient.

Intervention to reduce inpatient psychiatric admission in a metropolitan city.

When psychiatric hospitalization is over-used, it represents a financial drain and failure of care. We evaluated implementation and cessation of transporting people medically certified for psychiatric hospitalization to a central psychiatric emergency service for management and re-evaluation of hospitalization need. After implementation, the hospitalization rate declined 89% for 346 transported patients; only four of the nonhospitalized patients presented in crisis again in the next 30 days. Following cessation, the hospitalization rate jumped 59% compared to the preceding year. Costs declined 78.7% per diverted patient. The findings indicate that it is possible to reduce hospitalization and costs, and maintain quality care.

The mood disorders association of british columbia psychiatric urgent care program: a preliminary evaluation of a suggested alternative model of outpatient psychiatric care.

OBJECTIVE: To describe an alternative model of psychiatric outpatient care for patients with mood and anxiety disorders (the Mood Disorders Association of British Columbia Psychiatric Urgent Care Program or the MDA Program) using group medical visits (GMV) and (or) email communications in lieu of individual follow-up appointments. METHOD: Annual costs of the MDA Program were compared with average costs of private psychiatrists offering outpatient care and patients being treated in a mental health centre. In addition, questionnaires as to patient satisfaction with the MDA Program intake, GMV experience, and family physician satisfaction with the MDA Program were administered. RESULTS: The MDA Program model of care is significantly more cost effective than individual psychiatric outpatient care or health authority mental health centre care for patients with moderate or severe illness. Patients and family physicians were very satisfied with the model of care and GMVs offered. CONCLUSIONS: The MDA Program model of care appears to be efficient and cost-effective, and patients and referring physicians appear satisfied with the care offered in this program.

Treating psychiatric emergencies in incarcerated minors in the emergency department: what is the cost and what is their disposition?

BACKGROUND: Although mental health disorders are common among incarcerated minors, psychiatric urgencies and emergencies often cannot be treated in juvenile detention facilities, necessitating emergency department (ED) transfers. The cost of this ED care has not been well studied. OBJECTIVE: This study aimed to provide information on disposition and cost related to ED visits by juvenile hall patients transported for urgent psychiatric evaluation. METHODS: A retrospective cross-sectional descriptive study of patients presenting to 1 ED from juvenile detention centers for consideration of psychiatric holds was conducted. Eligible patients were identified by a search of the International Classification of Diseases, Ninth Revision, discharge diagnosis codes and chart review. We collected information on patient demographics and disposition and calculated costs of ED visits, screening laboratories performed, inpatient stays on a medical ward, sitter and parole officer salaries, and ambulance transfers. RESULTS: One hundred eight patients accounting for 196 visits were transported from juvenile hall for urgent psychiatric evaluation. Of the 196 visits, 131 (67%) resulted in an involuntary psychiatric hold. More than half of the patients on hold (75 patients) were admitted to a medical ward for boarding because of lack of psychiatric inpatient beds. Included charges for the 196 visits during the 18-month period totaled US $1,357,884, with most of the costs due to boarding on the medical ward. CONCLUSIONS: We describe the magnitude and cost associated with addressing psychiatric emergencies in a juvenile correctional system relying on transport of patients to an ED for acute psychiatric evaluation and treatment. Further research is needed to determine if costs could be decreased by increasing psychiatric resources in juvenile detention centers.

Racial/ethnic disparities in children's emergency mental health after economic downturns.

African American children-more than other race/ethnicities-rely on emergency psychiatric care. One hypothesized cause of this overrepresentation involves heightened sensitivity to economic downturns. We test whether the African American/white difference in psychiatric emergency visits increases in months when the regional economy contracts. We applied time-series methods to California Medicaid claims (1999-2008; N = 7.1 million visits). One month following mass layoffs, African American youths use more emergency mental health services than do non-Hispanic whites. Economic downturns may provoke or uncover mental disorder especially among African American youth who by and large do not participate in the labor force.

Evaluation of the Housing First program in patients with severe mental disorders in France: study protocol for a randomized controlled trial.

BACKGROUND: Recent studies in North American contexts have suggested that the Housing First model is a promising strategy for providing effective services to homeless people with mental illness. In the context of the highly generous French national health and social care system, which is easily accessible and does not require out-of-pocket payment, the French Health Ministry insists on rigorous techniques, including randomized protocols, to evaluate the impact of Housing First approaches in France. METHOD AND DESIGN: A prospective randomized trial was designed to assess the impact of a Housing First intervention on health outcomes and costs over a period of 24 months on homeless people with severe mental illness, compared to Treatment-As-Usual. The study is being conducted in four cities in France: Lille, Marseille, Paris and Toulouse. The inclusion criteria are as follows: over 18 years of age, absolutely homeless or in precarious housing, and possessing a 'high' level of need: diagnosis of schizophrenia or bipolar disorder and moderate to severe disability according to the Multnomah Community Ability Scale (score ≤ 62) and at least one of the following three criteria: 1) having been hospitalized for mental illness two or more times in any one year during the preceding five years; 2) co-morbid alcohol or substance use; and 3) having been recently arrested or incarcerated. Participants will be randomized to receiving the Housing First intervention or Treatment-As-Usual. The Housing First intervention provides immediate access to independent housing and community care. The primary outcome criterion is the use of high-cost health services (that is,, number of hospital admissions and number of emergency department visits) during the 24-month follow-up period. Secondary outcome measures include health outcomes, social functioning, housing stability and contact with police services. An evaluation of the cost-effectiveness and cost-utility of Housing First will also be conducted. A total of 300 individuals per group will be included. DISCUSSION: This is the first study to examine the impact of a Housing First intervention compared to Treatment-As-Usual in France. It should provide key information to policymakers concerning the cost-effectiveness and health outcomes of the Housing First model in the French context. TRIAL REGISTRATION: The current clinical trial number is NCT01570712.

Making activity-based funding work for mental health.

The implementation of activity-based funding (ABF) in mental health from 1 July 2013 has significant risks and benefits. It is critical that the process of implementation is consistent with Australia's cherished goal of establishing a genuine and effective model of community-based mental health care. The infrastructure to support the application of ABF to mental health is currently weak and requires considerable development. States and territories are struggling to meet existing demand for largely hospital-based acute mental health care. There is a risk that valuable ABF-driven Commonwealth growth funds may be used to prop up these systems rather than drive the emergence of new models of community-based care. Some of these new models exist now and this article provides a short description. The aim is to help the Independent Hospital Pricing Authority better understand the landscape of mental health into which it now seeks to deploy ABF.

The distribution of mental health service costs for depression in the Alberta population.

OBJECTIVES: In Canada, most mental health services are embedded in the public health care system. Little is known of the cost distribution within the mental health population. Our study aims to estimate the depression care costs of patients with a depression diagnosis, ranking them by the increasing total depression health care costs. METHODS: For fiscal year 2007/08, we extracted administrative health care records from across the continuum, including physicians, outpatient services, and hospitals. Using a unique patient identifier, all service costs were merged for each person. Costs were summed by service categories and then divided by the served population into 10 equal-size groups. Further, we divided costs in the top decile into 10 percentile groups. RESULTS: There were 208 167 people (5.9% of Albertans) who had at least 1 health care visit for depression. The total cost for depression treatment services was $114.5 million, an average $550 per treated person. In the first 9 deciles, most costs were for general practitioners. By the ninth decile, cost per person was about $400. Within the tenth decile, costs increased regularly, and in the top 1 percentile (1% of patients) there was an increase of cost per patient to $25 826 from $5792 in the previous percentile. CONCLUSION: Per person costs were highly skewed. Until the ninth decile, the cost increased slowly, consisting of mainly physician costs. In the last decile, costs increased substantially, mainly because of hospitalizations. Thus both primary care and specialist care play key roles.

Crisis resolution and home treatment: structure, process, and outcome - a literature review.

ACCESSIBLE SUMMARY: • During the last ten years there has been a major change in developing mental health services generally, and crisis resolution and home treatment (CRHT) services especially. Many Western countries have made a shift in perspective from in-hospital care to home treatment. The new approach is based on treating people who experience mental health crises in their homes instead of through hospitalization. • Most of the published articles on CRHT focus on structural issues pertaining to the development of home treatment services, and on macro-level outcomes such as cost-effectiveness and admission rates. These have political, economic, and practical implications. Few articles describe clinical intervention methods used in home treatment. • This paper explores how home treatment is described as an essential intervention method in crisis resolution at home in relation to three key characteristics of CRHT, which are being mobile, working in the service user's home, and working together with the person's family and network. • There remains a need for further research describing specific characteristics of home treatment, different clinical interventions that are used by CRHT teams, and the directions with which clinical interventions need to be developed further. It is critical to investigate what makes the interventions of the CRHT teams different from the hospital care, and how this affects the service users, the family and the networks, and the professionals. ABSTRACT: The objective of this paper is to explore and systematize the existing knowledge regarding the structure, process, and outcome of crisis resolution and home treatment (CRHT) as a form of community mental health service. Data sources are published peer-reviewed articles. Our study selection is systematic search for peer-reviewed articles written in English and Norwegian published between January 2000 and December 2008. Data are extracted from review of published articles on the subject of CRHT team and home treatment. We identified 35 articles including 6 reviews, consisting of quantitative and qualitative studies. The knowledge regarding CRHT focuses on three areas: (1) structure in terms of the standards, organization, and development; (2) process in terms of clinical interventions; and (3) outcome in relation to cost-effectiveness and admission rates. While the structural issues were presented and discussed a great deal, there is a paucity of articles on clinical intervention methods in home treatment as well as a limited attention on outcomes at the micro-level. There is a need for further studies regarding the clinical work of CRHT teams from the home treatment perspective.

Costs associated with attempted suicide among individuals with bipolar disorder.

BACKGROUND: Bipolar disorder is a chronic mood disorder associated with a high risk for suicide attempts, which carry personal, societal, and economical consequences. No information is available on the economic costs associated with suicide attempts among patients with bipolar disorder or the change in economic costs from before to following the suicide attempt. AIMS OF THE STUDY: The primary objective of this study was to estimate the total health care costs and cost components (inpatient, outpatient, emergency services, and medication) incurred by patients diagnosed with bipolar disorder who attempt suicide. Cost data included psychiatric and non-psychiatric costs. A secondary objective was to compare patients with and without attempted suicide on demographic and clinical characteristics. METHODS: Data for this retrospective study were obtained from the PharMetrics Integrated Outcomes Database (1995-2005). Patients diagnosed with bipolar disorder with (N = 352) and without (N = 15,102) a suicide attempt were identified and compared on demographics and psychiatric and medical comorbidities. T-tests and chi-square tests were used for group comparisons of patient characteristics. Among patients who attempted suicide and were continuously enrolled in the year before and following the suicide attempt (N = 352), Wilcoxon signed-rank tests were used to compare health care costs between the year prior and the year following the first suicide attempt. RESULTS: The average total health care cost for the year following the suicide attempt (N = 352) was $25,012, which was more than 2 times higher than the $11,476 incurred in the prior 1-year period (p. < 001). The total health care cost in the first month following the suicide attempt accounted for 28.9% of the total annual cost. The cost distribution over time showed a large spike for inpatient and emergency services costs in the month following the attempt with sustained increases in medication and outpatient costs. Patients with suicide attempt (N = 1,147) were significantly more likely than patients without (N = 15,102) to be younger, female, and to have comorbid psychiatric and medical diagnoses, especially depressive and substance use disorders. DISCUSSION: The substantial economic costs incurred by patients with bipolar disorder who attempt suicide are marked by an increase in costs of crisis services during the first month following the suicide attempt, along with sustained increases in medication and outpatient costs during the year following the suicide attempt. Limitations of the study include reliance on claims data and potential lack of generalizability beyond private payer data. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Interventions designed to reduce the risk of suicide attempts among patients diagnosed with bipolar disorder may help decrease the related high economic costs, in addition to helping decrease adverse personal and societal consequences. IMPLICATIONS FOR HEALTH POLICIES: Cost-benefit analyses of treatment methods for bipolar disorder need to include the considerable expenses associated with suicide attempts. Current findings may also be of value for modeling the cost-effectiveness of treatment for bipolar disorder and of interest to payers and other health care decision makers, especially those involved in developing Medicare capitation models for patients with chronic conditions such as bipolar disorder. IMPLICATIONS FOR FURTHER RESEARCH: Additional research is needed on the cost of attempted suicide in the treatment of patients with bipolar disorder, especially studies that capture societal costs.