Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study

Am J Emerg Med. 2020 Apr;38(4):702-708. doi: 10.1016/j.ajem.2019.06.002. Epub 2019 Jun 3.


Background: Involuntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients.

Methods: Retrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival.

Results: Child and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7-5.9, p < 0.001).

Conclusions: Child and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.

Keywords: Behavioral health; Mental health; Pediatric; Psychiatry.

MeSH terms

  • Adolescent
  • California
  • Child
  • Female
  • Humans
  • Involuntary Commitment / standards*
  • Male
  • Mental Disorders / psychology
  • Mental Disorders / therapy
  • Psychiatry / classification*
  • Psychiatry / methods
  • Retrospective Studies