Johns Hopkins Children's Center scientists have found that having a regular outpatient mental health provider may not be enough to prevent children and teens with behavioral problems from repeatedly ending up in the emergency room. The study is published in the June 1 issue of the journal Psychiatric Services.

Analyzing more than 2,900 records of pediatric patients, ages 3 to 17, treated at the Hopkins Children's ER for mental health crises over eight years, the investigators found that 338 of them (12 percent) returned to the ER within six months of their initial visit. The majority of the ER visits stemmed from behavioral problems or minor psychiatric crises, such as disruptive classroom behavior, verbal altercations and running away, the researchers said. Only a few involved severe psychotic episodes (3 percent of the visits) or suicide attempts (10 percent). Most importantly, the researchers found, two-thirds of patients (220) reported having an outpatient mental health provider at both visits, and 288 (85 percent) reported at the second visit that they have a regular mental health provider.

The findings are concerning, the researchers said, because they may signal that patients are not actually getting the care they need on an outpatient basis.

Mental health experts have traditionally emphasized the importance of outpatient care in managing non-emergency cases and have urged connecting such patients to outpatient mental health programs. Most ERs are neither designed nor staffed to deliver effective, coordinated mental health care, the investigators said.

"We think of the ER as a 'front door to care,' but our findings suggest otherwise as a significant number of patients repeatedly seek care in the ER despite being connected to an outpatient provider," said lead author Emily Frosch, M.D., a pediatric psychiatrist at Hopkins Children's.

The findings, Frosch said, raise more questions than they answer, and researchers have only begun to untangle the complex reasons behind recurrent ER visits for non-emergency psychiatric problems.

"We need to understand why families who are already connected to outpatient providers continue to seek ER care, why providers send patients to the ER and what role, if any, ERs may play in the continuum of care for non-psychotic, non-suicidal patients," Frosch said. "It is possible that ERs fulfill an important function in that continuum for some patients."

The researchers said one possible explanation is that patient families face barriers to routine outpatient psychiatric care, including limited office hours. Families who have had a positive experience in the ER in the past may be simply choosing to return there for subsequent problems, the researchers say. Also, some families may also find ER care less stigmatizing than outpatient mental health services. Frosch added that ER visits may be driven by some outpatient providers who may not have sufficient resources for optimal care and instead send patients to the ER.

The Hopkins team said future studies should explore more specifically the link between outpatient care and ER visits.

"Perhaps the most critical questions to ask are 'When was the child's latest outpatient visit?' and 'What exactly transpired between that visit and their subsequent trip to the ER?'" Frosch said.