Psychiatric Emergency Service Use Among Young Adults: Precipitators and Patterns

Purpose: Young adults tend to wait until they are in crisis to access mental health services.   They have lower rates of outpatient service use (Pottick et al, 2007) and higher rates of emergency room use (Lau et al, 2014) than adolescents or other adults. Little is known about the circumstances that bring young adults into contact with psychiatric emergency services (PES) and their histories of services and symptoms prior to this contact.  This study presents an in depth analysis of the narratives of young adults who accessed PES to describe the precipitating circumstances of their visit and the lifetime trajectory of problems and help seeking that preceded it.

Methods: Fifty-five young adults (age 18-25) with a diagnosis of Bipolar (47%), Depression (39%) or Schizophrenia (14%) were interviewed immediately following a psychiatric emergency room visit. Interviews used a structured protocol, then a semi-structured qualitative guide to elicit participants’ experiences with symptoms and services.  Interviews were recorded and transcribed, then reviewed by 3 analysts who used an approach based on grounded theory to diagram and describe precipitating incidents and long term pathways to services.  The sample was gender-balanced and ethnically diverse. 

Results: Young adults entered PES due to escalating symptoms and circumstances.  Many presented from another social service setting  [”I was at the shelter… I told her I didn't want to be alive and she said that she is going to call somebody to drop me off”].  Others were brought by family or brought themselves to treatment following escalating symptoms [“I got on the transit… just walked here and checked myself in”]. Motivations for using PES included getting back on medications, getting their lives together [“I want to get my life back on track”], and pressure from others [“my PO told me I needed to come here, get on my medication”].  Service use patterns fell into four groupings.  Two groups reported prior experiences with treatment in childhood/adolescence (n=35), one with stable treatment (n=8) and the other with intermittent use, often in conjunction with juvenile probation or child welfare (n=27).  A third group reported a long history of symptoms without connection to services until young adulthood (n=10).  These highlighted missed opportunities by educators, child welfare, and family.  A fourth group had a later onset of symptoms (n=10).  Themes across groups included pervasive traumatic events and the use of illegal substances to manage symptoms.

Implications: Young adults presented from diverse settings with diverse histories of service use with implications for interventions prior to crisis. Evidence of successful connections and missed opportunities underscore the importance of screening for mental health problems in other child and adult social service settings.  In young adulthood, mental health symptoms were commonly identified after adverse events such as domestic violence, legal problems or homelessness.  Ready connections to outpatient services in these systems could facilitate engagement in treatment prior to crisis.  Findings also highlight the need for all services to be trauma-informed and to screen for co-morbid substance use problems.