Research

JAMA | Original Investigation

National Trends in Mental Health–Related Emergency Department Visits

Among Youth, 2011-2020
Tanner J. Bommersbach, MD, MPH; Alastair J. McKean, MD; Mark Olfson, MD, MPH; Taeho Greg Rhee, PhD

Editorial page 1453

IMPORTANCE There has been increasing concern about the burden of mental health problems Multimedia
among youth, especially since the COVID-19 pandemic. Trends in mental health–related
emergency department (ED) visits are an important indicator of unmet outpatient mental Supplemental content

health needs.

OBJECTIVE To estimate annual trends in mental health–related ED visits among US children,

adolescents, and young adults between 2011 and 2020.

DESIGN, SETTING, AND PARTICIPANTS Data from 2011 to 2020 in the National Hospital
Ambulatory Medical Care Survey, an annual cross-sectional national probability sample
survey of EDs, was used to examine mental health–related visits for youths aged 6 to 24 years
(unweighted = 49 515).

MAIN OUTCOMES AND MEASURES Mental health–related ED visits included visits associated
with psychiatric or substance use disorders and were identified by International Classification
of Diseases-Ninth Revision, Clinical Modification (ICD-9-CM; 2011-2015) and ICD-10-CM
(2016-2020) discharge diagnosis codes or by reason-for-visit (RFV) codes. We estimated the
annual proportion of mental health–related pediatric ED visits from 2011 to 2020. Subgroup
analyses were performed by demographics and broad psychiatric diagnoses. Author Affiliations: Department
Multivariable-adjusted logistic regression analyses estimated factors independently of Psychiatry and Psychology,
Mayo Clinic, Rochester, Minnesota
associated with mental health–related ED visits controlling for period effects. (Bommersbach, McKean);
Department of Psychiatry, Vagelos
RESULTS From 2011 to 2020, the weighted number of pediatric mental health–related visits
College of Physicians and Surgeons,
increased from 4.8 million (7.7% of all pediatric ED visits) to 7.5 million (13.1% of all ED visits) Columbia University Irving Medical
with an average annual percent change of 8.0% (95% CI, 6.1%-10.1%; P < .001). Significant Center, New York, New York
linearly increasing trends were seen among children, adolescents, and young adults, with the (Olfson); Department of Psychiatry,
Yale University School of Medicine,
greatest increase among adolescents and across sex and race and ethnicity. While all types of New Haven, Connecticut (Rhee);
mental health–related visits significantly increased, suicide-related visits demonstrated the New England Mental Illness, Research
greatest increase from 0.9% to 4.2% of all pediatric ED visits (average annual percent Education, and Clinical Center, VA
Connecticut Healthcare System,
change, 23.1% [95% CI, 19.0%-27.5%]; P < .001).
West Haven, Connecticut (Rhee);
Department of Public Health
CONCLUSIONS AND RELEVANCE Over the last 10 years, the proportion of pediatric ED visits for
Sciences, University of Connecticut
mental health reasons has approximately doubled, including a 5-fold increase in School of Medicine, Farmington
suicide-related visits. These findings underscore an urgent need to improve crisis and (Rhee).
emergency mental health service capacity for young people, especially for children Corresponding Author: Greg
experiencing suicidal symptoms. Rhee, PhD, Department of Public
Health Sciences, University of
Connecticut School of Medicine,
JAMA. 2023;329(17):1469-1477. doi:10.1001/jama.2023.4809 263 Farmington Ave, Farmington, CT
06030 (tgrhee.research@gmail.com).

M
ental health concerns among US children have been
increasing over the last 2 decades, and the COVID-19
pandemic has accelerated these concerns. In 2021,
several pediatric health organizations declared a national state
of emergency in children’s mental health.1,2 From 2009 to 2019,
the percentage of high school students who reported persis-
tent feelings of sadness or hopelessness increased by 40%,3
and national suicide rates among youth aged 10 to 24 years in-
creased by 57%.4 In addition, approximately 1 in 5 US chil-
dren experience mental illness every year,5,6 yet half never re-
ceive appropriate treatment.7
The emergency department (ED) serves as a safety net for
individuals with unmet mental health needs. However, EDs have
limited capacity to provide evidence-based care for psychiat-
ric illness.8 Over the last 2 decades, there has been concern about
increasing rates of pediatric mental health–related ED visits.
From 2007 to 2016, several national studies found that mental
health–related pediatric ED visits increased between 50% and
60%.9-12 Furthermore, preliminary data from early in the
COVID-19 pandemic suggest there was an increase in the pro-
portion of pediatric ED visits for mental health concerns as chil-
dren were disconnected from regular outpatient supports.13-16

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 Research Original Investigation
Despite these early data, there have been no updated na-
tionally representative estimates of annual trends in pediat-
ric mental health–related ED visits since 2016,9-12 including
trends stratified by age, race and ethnicity, and psychiatric di-
agnoses. It is not known whether the increase in pediatric men-
tal health–related ED visits has continued to rise over the last
5 years, and if so, for which subgroups or whether it has pla-
teaued or declined. It is also not known how other indicators
of pediatric mental health–related ED visits have changed over
the last decade, including the urgency and length of visits.
Given the important role of EDs as safety net sources of care,
examining national trends in ED visits provides critical oppor-
tunities to identify population-wide unmet mental health
needs and inform service delivery.
In this study, we use nationally representative data from
the 2011-2020 National Hospital Ambulatory Medical Care Sur-
vey (NHAMCS)17 to examine recent trends and characteristics
of mental health–related ED visits among children, adoles-
cents, and young adults in the US. By addressing the follow-
ing 4 questions, our goal is to shed light on national unmet men-
tal health needs among youth and inform efforts to reduce the
burden of mental illness on young people and their families.
What are national annual trends in pediatric mental health–
related ED visits from 2011-2020, including trends from 2019
to 2020 at the onset of COVID-19?
How do trends vary by age, sex, race and ethnicity, and psy-
chiatric diagnosis?
Among pediatric mental health–related ED visits, how have visit
characteristics changed over the study period, including length
of visits, urgency, and how often children see a mental health
professional?
Which sociodemographic and diagnostic characteristics are
most strongly associated with pediatric mental health–
related ED visits?
Methods
Data Source and Sample
This study is based on data from the 2011-2020 NHAMCS, a
cross-sectional survey of ED visits across the US conducted an-
nually by the National Center for Health Statistics.17 The
NHAMCS utilizes a 3-stage probability sampling design and sam-
pling weights that allow for generalization of estimates to all non-
federal, short-stay, and general (medical, surgical, and pediat-
ric) hospital EDs across the US.18,19 Visit information is abstracted
from patient medical records by trained staff during a ran-
domly assigned 4-week period to account for seasonal flux.18
For this study, we identified visits for children (6-11 years
old), adolescents (12-17 years old), and young adults (18-24 years
old) (unweighted = 49 515). Age ranges were based on previ-
ous NHAMCS studies.9 Response rates averaged 77.0% (range,
62.6%-87.0%) over the 10-year period and were accounted for
by sampling weights.17,18 The NHAMCS was approved by the Na-
tional Center for Health Statistics research ethics review board.17
The study was covered by the common rule exemption20 and
did not require institutional review board review as data are
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Mental Health–Related Emergency Department Visits Among Youth
Key Points
Question What are national trends in mental health–related
emergency department (ED) visits among children, adolescents,
and young adults from 2011 to 2020?
Findings While the total number of pediatric and young adult ED
visits has remained relatively stable from 2011 to 2020, the
proportion of visits for mental health reasons has approximately
doubled, including a 5-fold increase in the proportion of visits for
suicide-related symptoms.
Meaning These findings suggest an urgent need to expand
emergency and crisis services to address pediatric mental health
concerns, especially for suicidal symptoms.
deidentified and publicly available. Additional information re-
garding descriptions, questionnaires, and sampling methodol-
ogy is available on the NHAMCS website.17
Measures
Mental health–related ED visits included visits related to psy-
chiatric or substance use disorders and were identified by either
1) International Classification of Diseases-Ninth Revision, Clini-
cal Modification (ICD-9-CM; 2011-2015) or ICD-10-CM (2016-
2020) discharge diagnosis codes or by reason-for-visit (RFV)
codes. ICD-9-CM and ICD-10-CM discharge diagnosis codes for
each visit represent the physician’s final assessment of the pa-
tient’s diagnoses.18,21,22 RFV codes, in contrast, are based on
a system developed by the National Center for Health Statis-
tics to classify a patient’s primary reasons for seeking care, as
stated in their own words.18,23 Mental health–related visits were
identified when any of the 5 discharge diagnosis codes or psy-
chiatric RFV codes identified a mental health condition.
eTable 1 in Supplement 1 lists the ICD and RFV codes that iden-
tified mental health–related visits in our study. Psychiatric RFV
codes were based on National Center for Health Statistics
criteria9,24 and ICD codes were based on mental health con-
ditions from the Centers for Disease Control and Prevention
National Syndromic Surveillance Program.15,25
Based on previous NHAMCS studies,9,26 we categorized
mental health diagnoses into 6 categories: (1) mood (eg, de-
pression, anxiety, mania, trauma, and stress-related); (2) be-
havioral (eg, disruptive, impulse control, attention-deficit/
hyperactivity disorder); (3) psychosis; (4) suicide-related
(suicide, suicidal ideation, suicidal attempts, and nonsui-
cidal self-injury); (5) substance use; and (6) other (eg, eating
disorders, personality disorders, and parent-child problems).
Diagnosis codes for neurodevelopmental disorders, such as au-
tism spectrum disorder, were not included as they are not
counted as mental health conditions in the National Syn-
dromic Surveillance Program. This is consistent with prior
NHAMCS studies.9,24
Sociodemographic characteristics included age, sex (female
or male), US census region, insurance type, and race and eth-
nicity (Hispanic, non-Hispanic Black, non-Hispanic White, and
non-Hispanic other). Non-Hispanic other included Asian,
Native Hawaiian or Other Pacific Islander, American Indian
or Alaska Native individuals, and people of 2 or more races.19
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 Mental Health–Related Emergency Department Visits Among Youth Original Investigation Research

Table 1. National Trends in the Proportion of Mental Health–Related Encounters of All Emergency Department Visits Among Children, Adolescents,
and Young Adults, 2011-2020a
Average annual
percent change
2011-2012 2013-2014 2015-2016 2017-2018 2019-2020 (95% CI)b P value
Unweighted total ED visits, 13 901 10 939 9196 8041 7438
No. (%) (28.1) (22.1) (18.6) (16.2) (15.0)
Weighted total ED visits, 62 479 886 61 688 794 64 432 890 59 956 772 59 238 390
No. (%) (20.3) (20.0) (20.9) (19.5) (19.2)
Any mental health diagnosisc 7.7 8.5 12.3 12.2 13.1 8.0 (6.1 to 10.1) <.001
Mood 4.0 3.9 5.9 5.5 6.0 7.0 (4.2 to 9.9) <.001
Behavioral (nonsuicidal) 1.0 1.3 1.8 1.9 2.2 10.0 (5.7 to 14.5) <.001
Substance use 2.8 3.7 5.0 4.6 3.9 6.0 (3.1 to 9.1) <.001
Psychosis 0.6 0.6 0.9 0.9 1.2 11.7 (6.4 to 17.3) <.001
Suicide-related 0.9 1.1 2.5 3.5 4.2 23.1 (19.0 to 27.5) <.001
Other 2.2 2.3 3.8 3.9 5.1 12.0 (8.3 to 15.8) <.001
1 Mental health diagnosis 4.9 5.6 7.3 6.8 7.0 5.7 (3.5 to 8.0) <.001
≥2 Mental health diagnoses 2.8 2.9 4.9 5.4 6.0 11.7 (8.5 to 15.0) <.001
Subgroup analyses
Age group
6-11 y 2.0 2.7 3.9 4.2 4.7 11.0 (6.3 to 16.0) <.001
12-17 y 8.6 9.4 14.2 12.5 15.6 7.6 (4.4 to 10.8) <.001
18-24 y 9.5 10.7 15.5 16.5 15.9 7.7 (5.6 to 9.9) <.001
Male sex 8.6 10.0 13.5 12.1 14.0 6.7 (4.4 to 9.2) <.001
Female sex 6.9 7.3 11.3 12.2 12.3 9.2 (6.9 to 11.6) <.001
Race and ethnicity
Hispanic 6.2 6.9 9.7 8.7 10.9 7.7 (4.4 to 11.1) <.001
Non-Hispanic Black 5.6 6.4 11.2 8.9 12.2 9.7 (6.2 to 13.3) <.001
Non-Hispanic White 9.2 10.2 13.5 15.2 14.4 7.4 (5.0 to 9.8) <.001
Non-Hispanic other 6.6 7.5 13.9 16.7 15.8 12.2 (5.9 to 18.8) <.001
Insurance coverage
Private 7.2 8.3 12.1 12.4 14.0 9.2 (6.5 to 11.9) <.001
Public 7.5 7.9 11.4 10.6 12.8 7.5 (4.9 to 10.3) <.001
Self-pay 8.6 7.9 12.8 13.0 12.8 7.6 (2.8 to 12.5) .002
Other 9.0 13.9 11.3 17.8 7.1 1.0 (−5.0 to 7.3) .75
Geographic region
Northeast 9.8 11.0 12.2 14.5 14.2 6.3 (3.0 to 9.8) <.001
Midwest 7.9 8.1 16.0 16.5 16.4 11.8 (7.7 to 16.2) <.001
South 6.8 7.9 10.1 8.5 11.3 6.6 (3.0 to 10.2) <.001
West 7.3 8.3 11.9 13.5 12.6 7.9 (4.7 to 11.1) <.001
Abbreviation: ED, emergency department. follows for mood (depression, anxiety, mania, trauma, and stress-related),
a
Data are from the National Hospital Ambulatory Medical Care Survey.17,18 Data behavioral (disruptive, impulse control, attention-deficit/hyperactivity
are reported as percent values unless otherwise specified. disorder), psychosis (no disorders included with this diagnosis category),
b
suicide-related (suicide, suicidal ideation, suicidal attempts, and nonsuicidal
The average annual percent change was controlled for age, sex, and race
self-injury), substance use (no disorders included with this diagnosis category),
and ethnicity.
and other (eating disorders, personality disorders, and parent-child problems).
c
Disorders included within the 6 mental health diagnoses categories were as

Visit characteristics were selected based on previous
NHAMCS studies9,24,27,28 and included whether a mental health
professional was seen, urgency of visit, and length of visits (cal-
culated as minutes from ED arrival to discharge).19 Visit ur-
gency was a 5-level item, based on nursing triage rating, that in-
dicated the immediacy with which the patient should be seen.
This 5-level item was dichotomized as urgent (emergent, im-
mediate, and urgent) vs nonurgent (semiurgent and not urgent).9
Data Analysis
First, descriptive data were presented on the proportion of
mental health–related encounters among all ED visits by chil-
dren, adolescents, and young adults from 2011-2012 to 2019-
2020. We reported an average annual percent change (AAPC)
of ED visits from 2011 to 2020 using a modified Poisson model
after adjusting for age, sex, and race and ethnicity (Table 1).29,30
When reporting the proportions over time, we combined an-
nual surveys into 2-year groups for presentation purposes,
which is recommended by National Center for Health Statis-
tics methods guidance,18 but all trend analyses (eg, average an-
nual percent change) were conducted on an annual basis.
Second, we repeated the aforementioned analyses per
1000 youths.31 Denominators were derived from the US Census
Bureau based on predefined age groups (ie, 5-9, 10-14, 15-19,

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 Research Original Investigation Mental Health–Related Emergency Department Visits Among Youth

Table 2. National Trends of Mental Health–Related Emergency Department Visits Among Children, Adolescents, and Young Adults (per 1000 Capita)
by Age Group, 2011-2020a
Average annual
percent change P value
2011-2012 2013-2014 2015-2016 2017-2018 2019-2020 (95% CI) P value for interactionb
Any psychiatric diagnosis
5-9 y 4.8 5.4 12.5 12.2 11.8 12.2 (4.0 to 20.7) .002
10-14 y 11.9 15.8 29.5 27.3 36.5 12.9 (7.9 to 18.2) <.001
.04
15-19 y 42.6 43.3 58.9 55.1 63.3 4.9 (1.8 to 8.1) .002
20-24 y 54.0 58.5 85.7 77.5 72.7 4.9 (2.2 to 7.6) <.001
Mood-relatedc
5-9 y 3.0 1.7 3.5 3.9 2.4 3.3 (−8.9 to 17.3) .61
10-14 y 7.5 8.9 14.5 10.9 17.5 9.3 (2.5 to 16.5) .006
.55
15-19 y 22.7 21.0 33.5 31.0 32.3 4.9 (0.7 to 9.3) .02
20-24 y 26.0 24.1 37.4 32.6 32.4 4.5 (0.5 to 8.7) .03
Behavioral (nonsuicidal)c
5-9 y 1.5 3.0 4.8 3.6 2.4 5.6 (−6.7 to 19.6) .39
10-14 y 4.2 5.6 9.0 9.3 12.7 13.5 (4.9 to 22.7) .002
.70
15-19 y 4.8 6.1 7.5 10.8 10.2 9.7 (1.4 to 18.7) .02
20-24 y 4.4 4.2 6.3 4.1 5.9 3.1 (−6.3 to 13.6) .53
Substance usec
5-9 y 0.17 0.16 0.18 0.58 0.97 24.9 (−14.2 to 82.1) .25
10-14 y 1.4 2.8 3.0 3.0 3.2 7.4 (−6.1 to 22.8) .30
.74
15-19 y 13.9 17.4 20.1 16.5 18.3 2.2 (−3.0 to 7.7) .41
20-24 y 25.0 32.3 50.5 43.0 31.8 4.0 (0.4 to 7.8) .03
Psychosisc
5-9 y 0.4 0.3 0.5 1.2 2.1 33.7 (1.6 to 75.9) .04
10-14 y 0.9 1.2 1.2 2.7 3.6 21.6 (2.4 to 44.4) .03
.18
15-19 y 2.5 3.0 2.9 3.1 5.6 9.4 (−2.9 to 23.2) .14
20-24 y 4.4 4.3 9.3 6.3 6.4 5.8 (−3.0 to 15.5) .20
Suicide-relatedc
5-9 y 0.1 0.3 2.3 4.0 3.5 32.9 (10.8 to 59.3) .002
10-14 y 2.3 3.1 9.9 9.7 13.2 21.3 (11.3 to 32.1) <.001
.70
15-19 y 5.8 8.6 15.3 18.6 24.5 18.5 (11.5 to 25.9) <.001
20-24 y 5.2 3.6 11.1 17.5 18.6 22.3 (14.0 to 31.1) <.001
Otherc
5-9 y 1.4 2.0 4.5 4.8 4.7 14.3 (1.3 to 28.9) .03
10-14 y 5.1 6.4 15.0 13.6 18.1 14.6 (7.3 to 22.5) <.001
.38
15-19 y 14.9 13.6 21.1 21.4 26.5 14.6 (7.3 to 22.5) <.001
20-24 y 11.7 11.9 18.1 16.1 22.9 9.5 (3.7 to 15.6) .001
a 17,18 c
Data are from the National Hospital Ambulatory Medical Care Survey and Disorders included within the 6 mental health diagnoses categories were as
the US Census Bureau.31 Data are reported as percent values unless otherwise follows for mood (depression, anxiety, mania, trauma, and stress-related),
specified. Age groups used in the per-capita analysis were predefined based behavioral (disruptive, impulse control, attention-deficit/hyperactivity
on US Census data. disorder), psychosis (no disorders included with this diagnosis category),
b
Interaction terms were tests to assess whether trends in mental suicide-related (suicide, suicidal ideation, suicidal attempts, and nonsuicidal
health–related emergency department visits significantly differed across the self-injury), substance use (no disorders included with this diagnosis category),
age groups. and other (eating disorders, personality disorders, and parent-child problems).

and 20-24 years).31 As a result, different age groups had to be
used for this per-capita analysis. An interaction term was added
to assess whether trends in ED visits significantly differed
across the age groups (Table 2).
Third, we descriptively presented visit characteristics of
mental health–related ED visits (eFigure in Supplement 1). Next,
we conducted multivariable-adjusted logistic regression analy-
ses to identify factors associated with any mental health–
related ED visits by age group and included all relevant socio-
demographic and clinical factors available in our data set
(eTable 2 in Supplement 1). Due to the increase in suicide-
related visits, we reported national trends of suicide-related
ED visits separately (Table 3).
In separate analyses (eTable 3 in Supplement 1), we
compared the proportion of individuals with ED visits from
2019 to 2020 alone to identify potential changes associated
with COVID-19. We also examined whether mental health–
related ED visits per capita have changed from 2019 to 2020

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 Mental Health–Related Emergency Department Visits Among Youth Original Investigation Research

Table 3. National Trends of Suicide-Related Emergency Department Visits Among Children, Adolescents, and Young Adults, 2011-2020a
Average annual
percent change
2011-2012 2013-2014 2015-2016 2017-2018 2019-2020 (95% CI)b P value
Unweighted total ED visits, 13 901 10 939 9196 8041 7438
No. (%) (28.1) (22.1) (18.6) (16.2) (15.0)
Weighted total ED visits, 62 479 886 61 688 794 64 432 890 59 956 772 59 238 390
No. (%) (20.3) (20.0) (20.9) (19.5) (19.2)
All 0.9 1.1 2.5 3.5 4.2 23.1 (19.0 to 27.5) <.001
Age group
6-11 y 0.1 0.2 0.7 1.7 1.3 29.8 (21.1 to 39.2) <.001
12-17 y 1.4 2.5 5.0 4.4 6.6 18.6 (13.5 to 23.9) <.001
18-24 y 1.0 0.8 2.1 4.0 4.4 25.2 (19.0 to 31.8) <.001
Male sex 0.8 1.1 2.7 3.3 4.2 23.6 (17.4 to 30.0) <.001
Female sex 1.0 1.1 2.4 3.7 4.3 22.7 (17.5 to 28.1) <.001
Race and ethnicity
Hispanic 0.6 1.0 2.4 2.0 3.3 20.1 (13.3 to 27.4) <.001
Non-Hispanic Black 0.8 0.4 1.8 3.2 3.1 23.2 (15.2 to 31.7) <.001
Non-Hispanic White 1.1 1.4 2.7 4.4 5.2 24.2 (18.6 to 30.0) <.001
Non-Hispanic other 1.2 0.9 5.8 2.0 5.6 18.8 (4.7 to 34.9) .008
Insurance coverage
Private 0.9 1.1 2.7 3.9 6.1 30.0 (22.4 to 38.1) <.001
Public 0.9 1.1 2.4 3.2 3.8 21.3 (15.1 to 27.8) <.001
Self-pay 1.0 0.8 2.5 3.2 3.4 20.3 (10.6 to 30.8) <.001
Other 1.1 2.2 2.2 6.1 2.6 14.5 (1.7 to 28.9) .03
Geographic region
Northeast 1.4 1.4 1.8 3.0 3.6 16.7 (6.8 to 27.6) .001
Midwest 1.1 1.0 3.2 5.1 5.5 26.5 (17.2 to 36.5) <.001
South 0.8 0.8 1.8 3.0 3.7 25.2 (18.8 to 32.0) <.001
West 0.6 1.4 3.5 3.2 4.6 21.8 (13.8 to 30.3) <.001
a 17,18 b
Data are from the National Hospital Ambulatory Medical Care Survey. Data Average annual percent change was controlled for age, sex, and race and
are reported as percent values unless otherwise specified. ethnicity.

by age group and mental health condition (eTable 4 in
Supplement 1).
We used Stata version 17.1 MP/4-Core for all analyses. Fol-
lowing the NHAMCS estimation procedures, 32,33 we ac-
counted for complex survey design using svy commands to ac-
count for multistage complex survey sampling techniques
(ie, unequal probability of selection, clustering, and stratifi-
cation) used in the data collection to produce national esti-
mates. We set a P value of less than .05 as the test of statisti-
cal significance.
Results
Overall Trends in the Total Study Sample
From 2011-2012 to 2019-2020, the weighted total national
number of ED visits among individuals aged 6 to 24 years de-
clined from 62.5 million to 59.2 million. The number of men-
tal health–related visits increased from 4.8 million (7.7% of total
pediatric ED visits) to 7.5 million (13.1% of total ED visits), in-
dicating an average annual percent change of 8.0% (95% CI,
6.1%-10.1%) (Table 1). Compared with non–mental health–
related visits, mental health–related visits were more likely
among young adults and less likely among children, the pa-
tients were more likely to be White and less likely to be Hispanic
or non-Hispanic Black, cases were more likely to be catego-
rized as urgent, and visits were more likely to take 6 hours or
longer (eTable 5 in Supplement 1).
Over the study period, the proportion of all types of men-
tal health–related visits increased significantly, including mood,
behavioral, psychosis, and substance use–related visits
(P < .001), but suicide-related visits demonstrated the largest
increase (average annual percent change, 23.1% [95% CI, 19.0%-
27.5%]). In addition, the proportion of visits for mental health–
related reasons increased significantly in all sociodemo-
graphic categories, including by age, sex, race and ethnicity,
insurance type, and geographic region (P < .05 for each). Vis-
its to the ED in which 2 or more mental health diagnoses were
documented increased from 2.8% in 2011-2012 to 6.0% in 2019-
2020 (average annual percent change, 11.7% [95% CI, 8.5%-
15.0%]) (Table 1).
In regards to possible COVID-19 pandemic–related trends
from 2019 to 2020, the weighted total number of ED visits de-
clined from 32.7 million to 26.6 million (eTable 3 in Supple-
ment 1). This is consistent with an earlier study,34 although
there was no significant change in the proportion of visits for
mental health–related reasons including those by age, sex, race
and ethnicity, and insurance type, and no significant change

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 Research Original Investigation
in visit urgency, length of visits, or percent that included evalu-
ation by a mental health professional. Similarly, there was a
general decline in pediatric mental health–related ED visits per
capita from 2019 to 2020, but this change was not found to
be statistically significant (eTable 4 in Supplement 1).
Trends in Characteristics of Visits
As shown in the eFigure in Supplement 1, there were no sig-
nificant changes in visit characteristics in the total sample or
by age group. Less than 20% of overall mental health–related
ED visits included evaluation by a mental health profes-
sional, with no significant change from 2011 to 2020 (panel A
in the eFigure in Supplement 1). Between 70% and 75% of over-
all mental health–related ED visits were urgent (panel B in the
eFigure in Supplement 1), and approximately 20% lasted for
at least 6 hours (panel C in the eFigure in Supplement 1).
Trends by Age Group and Mental Health Condition
As shown in Table 2, mental health–related ED visits per 1000
youth increased significantly across all age groups, but in-
creased the most among 10- to 14-year olds (P value for inter-
action = .04). Aside from increases in suicide-related visits in
all age groups, there were few significant age group trends by
psychiatric diagnoses.
Factors Associated With Mental Health–Related ED Visits
Next, multivariable-adjusted analyses examined factors as-
sociated with mental health–related ED visits (eTable 2 in
Supplement 1). In the total sample, mental health–related ED
visits were significantly more likely among young adults and
adolescents, males, non-Hispanic White individuals, and those
with public insurance. Among children, mental health–
related ED visits were significantly more likely among males.
Among adolescents, mental health–related ED visits were more
likely among females. Among young adults, mental health–
related visits were significantly more likely among males and
those with public insurance and less likely among Hispanic and
non-Hispanic Black individuals.
Trends in Suicide-Related ED Visits
As shown in Table 3, suicide-related visits were most com-
mon among adolescents, accounting for 6.6% of all ED visits
in 2019-2020, and suicide-related visits increased signifi-
cantly in all age groups, across sex, race and ethnicity, insur-
ance type, and geographic region. Sociodemographic and visit
factors independently associated with suicide-related visits are
shown in eTable 6 in Supplement 1.
Discussion
Nationally representative data from the NHAMCS demon-
strates that while the total number of pediatric ED visits has
remained relatively stable from 2011 to 2020, the proportion
of visits for mental health–related reasons has approximately
doubled. Linearly increasing trends were observed for all age
groups, across sexes, and for all race and ethnicity groups.
Of particular concern, suicide-related visits increased 5-fold
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Mental Health–Related Emergency Department Visits Among Youth
and now encompass nearly 5% of all pediatric ED visits. De-
spite the precipitous increase in mental health–related visits,
there has been no change in characteristics of mental health–
related visits, including the percent of visits with evaluation
by a mental health professional (<20% of all pediatric mental
health–related visits), urgency, or length of visits.
Our study presents the first updated nationally represen-
tative estimates of pediatric mental health–related ED visits
since 2016. These findings extend prior studies that have docu-
mented increasing rates of pediatric mental health–related vis-
its over the last 2 decades.9-12,35 While it is difficult to directly
compare estimates across studies due to different age ranges
and definitions of a mental health–related visit, our per-
capita and proportional estimates are consistent with prior
NHAMCS studies.9,11,24 Our study finds that the largest in-
crease in visits occurred in 2015-2016 (which is consistent with
previous studies),9,10 although we demonstrate that rates have
continued to increase since this time. While all age groups have
shown a significant increase in visits, youths aged 10 to 14 years
demonstrate a greater increase than all other age groups. There
are a number of potential explanations for the increase in pe-
diatric mental health–related ED visits including increased
prevalence of mental health concerns among youth in the gen-
eral population,36,37 improved identification of mental health
concerns and treatment referral, increase in help seeking
among youth and families, and reduced access to outpatient
mental health care amid overwhelmed community-based sys-
tems. It is likely that several of these explanations are contrib-
uting to the trends observed.
The substantial increase in pediatric suicide-related visits
over the last decade is of particular public health concern.
These estimates exceed those reported from a national
sample of EDs, which demonstrated that pediatric visits for
deliberate self-harm increased 329% from 2007 to 2016.10
The present findings are consistent with national data dem-
onstrating population-wide increases in suicidal ideation,38
attempts,39,40 and suicide deaths4 among youth over the last
decade, especially among Black adolescents.41,42 This trend
underscores the importance of improving the capacity of EDs
to deliver high-quality care for youth experiencing suicidal
symptoms and improving access to community-based ser-
vices. Some ED interventions for youth have been reported to
reduce suicidal behavior and improve engagement in
follow-up treatment.43-47 These interventions have focused
on comprehensive screening, safety planning, linkage to
follow-up care, and postdischarge contact.
Despite the large increase in pediatric mental health–
related ED visits, it is noteworthy that there has not been a sig-
nificant change in the characteristics of visits, including ur-
gency or length of visits. The observation that only 20% of
pediatric mental health–related visits included evaluation by
a mental health professional underscores widespread short-
ages in the availability of specialty ED mental health services.
Additionally, while some studies have suggested that the in-
crease in pediatric mental health–related ED visits may be due
to an increase in inappropriate or less urgent mental health–
related ED visits,48-50 our study demonstrates the urgency of
visits has not changed.
jama.com
 Mental Health–Related Emergency Department Visits Among Youth Original Investigation Research

The findings of this study have a number of potential im-
plications. First, there is an urgent need to increase capacity to
address pediatric mental health concerns in EDs. Several prom-
ising models exist to improve this capacity, including
telemedicine,51,52 telephone consultation services,53 adoption
of pediatric mental health clinical care pathways,54,55 and greater
psychiatric education for ED clinicians.56 In addition, EDs are
critical mental health access points for children who face struc-
tural barriers, including racial and ethnic minorities and chil-
dren who are undocumented or uninsured.50,57,58 Our analy-
sis reveals that having public insurance is independently
associated with mental health–related ED visits. Ensuring that
all children discharging from EDs have appropriate follow-up
is an important health equity goal and may help prevent need
for emergency care. The trends also underscore the impor-
tance of increasing investments in evidence-based preventive
interventions, including social-emotional learning programs for
at-risk preschool children,59 that have demonstrated benefits
in reducing externalizing problems, adolescent conduct prob-
lems, and adolescent emotional symptoms.60
This study presents some of the first nationally represen-
tative estimates of pediatric mental health–related ED visits at
the beginning of the COVID-19 pandemic. Consistent with data
from Centers for Disease Control and Prevention National Syn-
dromic Surveillance Program,13-15 we find that the proportion
of pediatric ED visits for mental health reasons remained rela-
tively stable amid declines in the total number of pediatric men-
tal health and non–mental health–related ED visits. As data
from 2021 and 2022 become available, it will be important to
continue to examine how the COVID-19 pandemic has poten-
tially impacted these trends.16
Limitations
This study has several limitations. First, there are multiple ways
to identify a mental health–related visit using NHAMCS. We
chose to use both ICD and RFV codes, which is the approach
taken by most other studies.9,24 Some studies have used more
narrow definitions by using only ICD codes.11,35 Other studies
have used broader definitions, including visits at which psy-
chotropic medications were prescribed and refilled61 or a larger
number of ICD diagnoses, specifically, codes for neurodevel-
opmental disorders.62 We chose not to use psychotropic medi-
cations because we were concerned that these medications
could have been prescribed and refilled for a patient who was
not presenting with a mental health concern. We also chose
not to include neurodevelopmental disorders because they are
not included as mental health conditions in the National Syn-
dromic Surveillance Program, and there was concern about
identifying a patient having a mental health–related visit solely
by having a diagnosis of a neurodevelopmental condition. Due
to these exclusions, it is possible that our definition of mental
health–related visits may have underestimated the true num-
ber of mental health–related visits.
Second, NHAMCS samples at the visit rather than at the
patient level. Therefore, the effects of repeated ED visits within
the sampling period cannot be assessed.
Third, NHAMCS does not sample psychiatric institutions
with crisis or urgent care centers so our findings may under-
estimate the number of mental health–related visits. In addi-
tion, because NHAMCS does not indicate whether sampling
occurred in general or pediatric EDs, it was not possible to de-
termine where in the emergency services sector the burden of
increasing pediatric mental health–related visits is most acute.
This is an important focus of future studies.
Fourth, because differences between ICD-9-CM and ICD-
10-CM codes are substantial, caution is advised when di-
rectly comparing estimates from before and after 2016. It is pos-
sible that suicide-related visits were overestimated with the
switch to ICD-10-CM given that the code for suicidal ideation
also included nonspecific and infrequently used codes for other
mental health symptoms (ie, low self-esteem, worries, exces-
sive crying). However, given the linearly increasing trends in
visits annually and across diagnoses, the estimates captured
by our methods, which are consistent with other NHAMCS
studies,9,11,24 appear robust and clinically relevant.
Conclusions
Our nationally representative analysis demonstrates a precipi-
tous increase in mental health–related ED visits, especially
suicide-related visits among children, adolescents, and young
adults over the last 10 years. These results underscore a criti-
cal need to expand nonhospital alternatives to mental health
care for young people. This includes expanding the crisis
continuum of care,63 intensive outpatient programs, school-
based and integrated care models, and outpatient services, in-
cluding psychiatric urgent care and clinics with weekend and
evening availability. With the recent increase in demand for
emergency mental health services by young people and lack
of growth in outpatient mental health services,64 a dedicated
national commitment will be needed to address gaps and de-
ficiencies in mental health outpatient and crisis services for
children, adolescents, and young adults.

ARTICLE INFORMATION
Accepted for Publication: March 13, 2023.
Author Contributions: Dr Rhee had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Concept and design: Bommersbach, Olfson, Rhee.
Acquisition, analysis, or interpretation of data:
Bommersbach, McKean, Rhee.
Drafting of the manuscript: Bommersbach, Rhee.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Rhee.
Administrative, technical, or material support:
Bommersbach, McKean, Rhee.
Supervision: Rhee.
Conflict of Interest Disclosures: Dr Rhee reports
support, in part, by the National Institute on Aging
(NIA) through Yale School of Medicine
(T32AG019134) in the past 3 years; being funded by
the NIA (R21AG070666), National Institute of
Mental Health (R21MH117438), and the Institute for
Collaboration on Health, Intervention, and Policy of
the University of Connecticut; serving as a review
committee member for the Patient-Centered
Outcomes Research Institute (PCORI) and the
Substance Abuse and Mental Health Services
Administration (SAMHSA); receiving honoraria from
PCORI and SAMHSA; serving as a stakeholder/
consultant for PCORI; receipt of consulting fees
from PCORI; serving as an advisory committee
member for the International Alliance of Mental
Health Research Funders; and currently serving as

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© 2023 American Medical Association. All rights reserved.

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 Research Original Investigation
co–editor-in-chief of Mental Health Science and
receiving honorarium payments annually from the
publisher, John Wiley & Sons. No other disclosures
were reported.
Data Sharing Statement: See Supplement 2.
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