By Katherine Liebesny, MD
Fellowship Training Director
Carilion Clinic
The relationship between social media and mental health is under increasing scrutiny. Communication of suicidal thinking or behavior on social media platforms is an increasingly common reason for the referral of youth to the emergency room for psychiatric evaluation. The burden of detection often falls on peers, but schools also have a significant role in detection and referral.
A recent meta-analysis of social media and self-injurious thoughts and behaviors suggests that cybervictimization and posting about suicide and self-harm on social media are significantly related to suicide risk (Nesi et. al, 2021). Adolescent girls are more likely to be victims of cyberbullying and appear to have more negative mental health impact from their social media behaviors. Unfortunately, the rates of suicide in this demographic are increasing faster compared to any other group. Communications of suicidal thinking or behaviors on social media and cybervictimization must be incorporated into a modern risk assessment for youth.
Schools that receive federal funding for internet and technology are required to have an internet safety policy. Compliance with this is often achieved through software that monitors school provided personal computers, categorizes concerning behavior and alerts designated administrators. The impact of these protocols on detection of kids at risk, referral to the emergency room and use of mental health services remains unclear.
However, up to 1/3 of visits to the pediatric emergency room for psychiatric evaluations are of low acuity and could likely be diverted (Soto et al., 2009). Grudinkoff et. al (2015) studied school referrals to the emergency room for mental health evaluation and found that these referrals made up 44% of the ED consultations that year but only 8% required hospitalization and 47% did not need any specific mental health follow-up. In fact, 53% of children referred by the school for suicidal ideation were discharged without specific mental health follow up. Notably, in school evaluations reduced the proportion of ED referrals that were deemed inappropriate. Pilot programs that offer same day ambulatory access to schools referring children for urgent mental evaluations have successfully diverted these evaluations from the ED and shifted the utilization of the ED to higher acuity patients (Alvarado et. al, 2020). Unfortunately, a lack of parity in reimbursement for psychiatric evaluations in ambulatory vs. emergency room settings has limited the sustainability and growth of these programs.
As most kids presenting to the emergency room for suicidal ideation will not be admitted, we need better screening in schools and resources outside of the emergency department to address urgent evaluations for suicidal youth. Those who are evaluated in the ED require a family based and systems aware approach to disposition effectively and increase the likelihood of follow up for children in crisis.
