PURPOSE: The aim of this study is to understand pediatric emergency department (PED) directors' perspectives on the COVID-19 pandemic's effect on PED visits for mental health concerns.

METHODS: Semi-structured phone interviews were conducted with a national convenience sample of PED directors. Interviews were recorded, transcribed verbatim, and analyzed using rapid content analysis.

RESULTS: Twenty-one PED directors from 18 states were interviewed. Directors perceived an increased volume of mental health visits and higher patient acuity. Some PEDs innovatively adapted services but were also met with new barriers in providing care due to increased use of personal protective equipment and required COVID-19 testing. Transfer to inpatient psychiatric units was more complicated due to reduced overall bed capacity and the need for a negative COVID test.

DISCUSSION: The COVID-19 pandemic strained an already fragile pediatric emergency mental health system. Building infrastructure for adaptations and mental health service reserve capacity could help ensure proper care for pediatric patients with mental health crises during future public health emergencies.

To understand ED providers' perspective on how to best care for individuals who present to US emergency departments (EDs) following self-injurious behavior, purposive recruitment identified nursing directors, medical directors, and social workers (n = 34) for telephone interviews from 17 EDs. Responses and probes to "What is the single most important thing ED providers and staff can do for patients who present to the ED after self-harm?" were analyzed using directed content analysis approach. Qualitative analyses identified four themes: treat patients with respect and compassion; listen carefully and be willing to ask sensitive personal questions; provide appropriate care during mental health crises; connect patients with mental health care. Participants emphasized treating patients who present to the ED after self-injurious behavior with respect and empathy. Hospitals could incentivize provider mental health training, initiatives promoting patient-provider collaboration, and reimbursement strategies ensuring adequate staffing of providers with time to listen carefully.

<p><strong>STUDY OBJECTIVE: </strong>We explored emergency department clinical leaders' views on providing emergency mental health services to pediatric and geriatric patients with suicidal ideation and suicide attempts.</p>

<p><strong>METHODS: </strong>We conducted semistructured interviews with a total of 34 nursing directors, medical directors, and behavioral health managers at 17 general hospital EDs across the United States, using purposive sampling to ensure variation among hospitals. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using Atlas.ti and a directed content analysis approach.</p>

<p><strong>RESULTS: </strong>Respondents from across a range of ED types expressed concerns regarding the capacity of their EDs to meet mental health needs of children and older adults. They experienced emotional distress over the increasing number of pediatric patients presenting to EDs with suicidal ideation/suicide attempt and described EDs as inappropriate environments for young patients with suicidal ideation/suicide attempt. Similarly, leaders expressed feeling ill-equipped to diagnose and treat geriatric patients with suicidal ideation/suicide attempt, who often had medical comorbidities that complicated treatment planning. Respondents noted that pediatric and geriatric patients frequently boarded in the ED. Some felt compelled to use creative solutions to provide safe spaces for pediatric and geriatric patients. Respondents voiced frustration over the lack of outpatient and inpatient mental health services for these patients.</p>

<p><strong>CONCLUSION: </strong>Clinical leaders in EDs across the nation expressed distress at feeling they were not adequately equipped to meet the needs of pediatric and geriatric patients with suicidal ideation/suicide attempt. Future innovations to provide ED care for children and older adults with suicidal ideation/suicide attempt might include training for ED teams, access to specialist mental health clinicians through telehealth, and adaptations of physical spaces.</p>

<p>Adolescents in the United States are increasingly seeking treatment for mental health crises in emergency departments and general medical hospitals. Medical needs are often addressed quickly, yet youth remain hospitalized because further psychiatric treatment is not immediately available. We sought to better understand the experiences of caregivers whose children are "boarding" in a medical hospital while awaiting inpatient psychiatric treatment. We conducted semi-structured interviews with caregivers who were recruited, enrolled, and interviewed during their child's hospital stay. Interviews were audio-recorded, transcribed verbatim, and thematic analysis was facilitated by NVivo 12. Fourteen caregivers enrolled in the study. Themes that emerged included positive hospital and provider experiences; frustration with the medical and mental health care systems; information needs; fears about inpatient psychiatric units; practical challenges and emotional needs; difficulties with caregiver-child communication; difficulties with clinician-caregiver communication; and need for self-care and support. While many caregivers felt positively about the overall experience at the hospital, they also wished for more information about their child's treatment plan and future, as well as social support, emotional comfort for themselves, and self-care skills and resources. Their experiences illuminate ways in which clinical practice can ameliorate concerns and alleviate stress of caregivers related to their child's mental health crisis.</p>

<p><strong>INTRODUCTION: </strong>Every year, approximately 500 000 patients in the United States present to emergency departments for treatment after an episode of self-harm. Evidence-based practices such as designing safer ED environments, safety planning, and discharge planning are effective for improving the care of these patients but are not always implemented with fidelity because of resource constraints. The aim of this study was to provide insight into how ED staff innovate processes of care and services by leveraging what is available on-site or in their communities.</p>

<p><strong>METHODS: </strong>A total of 34 semi-structured qualitative phone interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 emergency departments. Respondents comprised a purposive stratified sample recruited from a large national survey in the US. Interview transcripts were coded and analyzed using a directed content analysis approach to identify categories of strategies used by ED staff to care for patients being treated after self-harm.</p>

<p><strong>RESULTS: </strong>Although respondents characterized the emergency department as an environment that was not well-suited to meet patient mental health needs, they nevertheless described 4 categories of strategies to improve the care of patients seen in the emergency department after an episode of self-harm. These included: adapting the ED environment, improving efficiencies to provide mental health care, supporting the staff who provide direct care for patients, and leveraging community resources to improve access to mental health resources postdischarge.</p>

<p><strong>DISCUSSION: </strong>Despite significant challenges in meeting the mental health needs of patients treated in the emergency department after self-harm, the staff identified opportunities to provide mental health care and services within the emergency department and leverage community resources to support patients after discharge.</p>

<p><strong>Importance: </strong>To prevent suicide deaths, acute care settings need tools to ensure individuals at risk of suicide access mental health care and remain safe until they do so.</p>

<p><strong>Objective: </strong>To examine the association of brief acute care suicide prevention interventions with patients' subsequent suicide attempts, linkage to follow-up care, and depression symptoms at follow-up.</p>

<p><strong>Data Sources: </strong>Ovid MEDLINE, Scopus, CINAHL, PsychINFO, Embase, and references of included studies using concepts of suicide, prevention, and clinical trial to identify relevant articles published January 2000 to May 2019.</p>

<p><strong>Study Selection: </strong>Studies describing clinical trials of single-encounter suicide prevention interventions were included. Two reviewers independently reviewed all articles to determine eligibility for study inclusion.</p>

<p><strong>Data Extraction and Synthesis: </strong>Two reviewers independently abstracted data according to PRISMA guidelines and assessed studies' risk of bias using the Cochrane Risk of Bias tool. Data were pooled for each outcome using random-effects models. Small study effects including publication bias were assessed using Peter and Egger regression tests.</p>

<p><strong>Main Outcomes and Measures: </strong>Three primary outcomes were examined: subsequent suicide attempts, linkage to follow-up care, and depression symptoms at follow-up. Suicide attempts and linkage to follow-up care were measured using validated patient self-report measures and medical record review; odds ratios and Hedges g standardized mean differences were pooled to estimate effect sizes. Depression symptoms were measured 2 to 3 months after the encounter using validated self-report measures, and pooled Hedges g standardized mean differences were used to estimate effect sizes.</p>

<p><strong>Results: </strong>A total of 14 studies, representing outcomes for 4270 patients, were included. Pooled-effect estimates showed that brief suicide prevention interventions were associated with reduced subsequent suicide attempts (pooled odds ratio, 0.69; 95% CI, 0.53-0.89), increased linkage to follow-up (pooled odds ratio, 3.04; 95% CI, 1.79-5.17) but were not associated with reduced depression symptoms (Hedges g = 0.28 [95% CI, -0.02 to 0.59).</p>

<p><strong>Conclusions and Relevance: </strong>In this meta-analysis, breif suicide prevention interventions were associated with reduced subsequent suicide attempts. Suicide prevention interventions delivered in a single in-person encounter may be effective at reducing subsequent suicide attempts and ensuring that patients engage in follow-up mental health care.</p>