by Josephine Machado

Graphic design by Athena Li

Imagine this scenario: It’s 4 a.m. in a Toronto emergency department (ED), and you’re left sitting under the harsh fluorescent lights of an echoing waiting room wondering if you’ve made the right decision dragging your 14-year-old daughter to the ED. Upon triage, she is placed on a Form 1 hold under Ontario’s Mental Health Act and admitted to the psychiatric floor. She is just one of thousands of children whose initial encounter with a mental health professional was not in a clinic or counsellor’s office as you had hoped, but in an ED designed for everything but emotional trauma. 

A recent Canadian-based study evaluating transitions in care for children and youth found that over 50% had used the ED as the first contact for mental health concerns without previously seeking outpatient care.¹ This comes as no surprise given that there are 28 000 Ontario youth and children waiting for mental health services; for some families, this wait is up to 2.5 years long.² This is in addition to an estimated 200 000 children and youth requiring mental health care that do not reach the front door of specialized centres.² Long-term trends in Ontario have shown the impact this unmet need has had on EDs, as mental health-related ED visits doubled from 11.7 per 1000 citizens in 2003 to 24.1 per 1000 citizens by 2017.³  

Youth Mental Health Today

Currently, there is limited information regarding the reasons behind the surge in mental health-related ED visits for Canadian youth; however, the Centre for Addiction and Mental Health (CAMH)’s Ontario Student Drug Use and Health Survey (OSDUHS) indicates significant mental health-related stressors among Ontario youth in its 2023 report. Of the 10 145 grade 7 to 12 students surveyed, 51% of students indicated moderate-to-severe psychological distress, including symptoms of anxiety and depression.⁴ Additionally, one-in-five students reported engaging in intentional self-harm, and one-in-six students reported experiencing some form of suicidal ideation over the past year.⁴ Overall, indicators of psychological stress have significantly increased since monitoring began a decade ago in 2013, when students reporting moderate-to-serious levels were just above 20%.⁴ When investigating overarching trends in youth mental health, Statistics Canada (2023) reports that suicide is the second-leading cause of death among individuals aged 10-24; a pattern underscoring the impact of severe mental health crises across the spectrum of adolescence.⁵

What Do Patients Experience Upon Entry?

The Provincial Council for Maternal and Child Health’s Implementation Toolkit indicates the process for patients reporting mental health concerns upon intake to the ED.⁶ First, staff triage and evaluate whether resuscitation or emergency care is required. Once patients are deemed medically stable, mental health screening is done using survey-based screening tools. Clinical assessment is then done by an ED physician and/or a child and youth mental health clinician. High risk patients can be reviewed for admission with consultation from other members of the healthcare team such as a psychiatrist, pediatrician, or family physician. Outcomes of a mental-health related ED visit can range from immediate referral to a mental health specialist with possible admission, to outpatient referral to the community with clinical follow-up. EDs can also simply recommend that patients follow-up with a primary care provider and provide information on mental health resources that the patient can opt to pursue.⁶

Advocacy and Reform

The rising demand for youth mental health care, in addition to the lack of resources and frequent use of EDs as a first point of contact, creates the perfect storm for disaster. The increasing number of adolescents who access the ED following self-harm or for mental disorders is of significant concern. Additionally, the ED can be an overstimulating setting for delivery of mental health care or for care of adolescents, particularly those who have engaged in self-injury.³ Furthermore, there are a substantial number of individuals who present to the ED who do not require institutional emergency services or hospital admission. They are instead retained in the ED or are admitted due to a lack of available community-based services and support.⁷

It is imperative that we continue to advocate for improvements in the realm of youth mental health aimed at bettering the ED experience and reducing the load of patients requiring emergency care. In 2008, the Canadian Mental Health Association presented a policy submission addressing ED wait times and enabling access to community mental health and addictions services.⁷ The submission was prepared by a partnership inclusive of six mental health organizations representing patients and service-providers. Primary recommendations point to the development and investment in 24-hour crisis response systems in communities, so patients have places to go outside of the ED. Other suggestions include expanding peer-run phone/text support, peer-support worker involvement in discharge planning, and the strengthening of community-mental health services that are directly linked to hospitals to help divert people out of the ED when possible. Successful solutions require shifting investments from EDs to community-based systems that can respond before crises escalate. A promising model to execute this reform is the Integrated Youth Services Approach (IYS), which brings together mental health, substance use, primary care, and peer, family and social supports under one roof. A CAMH-led study explored the model between 2016-2020 and showed that youth in the IYS model accessed services nearly three times faster and required fewer hospital-based psychiatry resources than those in traditional care or a hospital outpatient program.⁸

Improving ED staff training and implementing dedicated emergency mental health teams should also be prioritized. A systematic review of 18 studies conducted between 2013-2023 had found that installing collaborative care models (CCMs) resulted in a 20% reduction in the percentage of patients requiring readmission within 30 days of release.⁹  Moreover, telepsychiatry has drastically improved patient outcomes in rural and underserved areas by providing timely psychiatric consultations, resulting in reduced ED overcrowding and improved patient satisfaction.⁹ Other approaches can include pushing for school-based mental health programs. Children spend a significant amount of time at school, thus educational institutions are well-positioned for working towards mental health promotion, early identification, and suicide prevention. Finally, we must prioritize funding reform, Canadian provinces and territories spend just 6.3% of overall healthcare budgets on mental health; this remains below what many peer countries are spending and is also well short of the recommended 12%.⁷

Despite the concerning trends, there is power in in the possibility for change of how youth mental health is addressed in the ED. Structural changes are necessary to provide care for youth mental health crises and support high patient loads. These changes must be precipitated by an increase in available resources and the initiation of significantly more research to better understand key factors underlying trends in youth mental health. Youth turning to emergency departments for mental-health care is a clear sign of a chronic shortage of accessible services that cannot be ignored.

References

1.  Tucci A, Cloutier P, Polihronis C, et al. Improving transitions in care for children and youth with mental health concerns: implementation and evaluation of an emergency department mental health clinical pathway. BMC Health Serv Res. 2025; 25(1): 475. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-025-12524-z

2.  Children’s mental health ontario. Children’s Mental Health Ontario – CMHO. [cited 2025 Nov 9]. https://cmho.org/

3.  Gardner W, Pajer K, Cloutier P, et al. Changing rates of self-harm and mental disorders by sex in youths presenting to ontario emergency departments: repeated cross-sectional study. Can J Psychiatry. 2019; 64(11):789–97.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882075/

4.  The ontario student drug use and mental health survey(Osduhs).CAMH. [cited 2025 Nov 9]. https://www.camh.ca/en/science-and-research/institutes-and-centres/institute-for-mental-health-policy-research/ontario-student-drug-use-and-health-survey—osduhs

5.  Government of Canada SC. Leading causes of death, total population, by age group [Internet]. 2023 [cited 2025 Nov 9. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310039401

6.  Emergency department clinical pathway for children and youth with mental health conditions – pcmch. [cited 2025 Nov 9]. https://www.pcmch.on.ca/emergency-department-clinical-pathway-for-children-and-youth-with-mental-health-conditions/

7.  In Canada, mental health is a privilege. It should be a right. CMHA National. [cited 2025 Nov 9].https://cmha.ca/what-we-do/state-of-mental-health-in-canada/

8.  New study shows integrated collaborative care helps youth access mental health and substance use supports faster. CAMH. [cited 2025 Nov 9]. https://www.camh.ca/en/camh-news-and-stories/new-study-shows-integrated-collaborative-care-helps-youth-access-supports-faster

9.  Katiki C, Ponnapalli VJS, Desai KJ, et al. NYA. Enhancing emergency room mental health crisis response: a systematic review of integrated models. Cureus. 2024. https://www.cureus.com/articles/312677-enhancing-emergency-room-mental-health-crisis-response-a-systematic-review-of-integrated-models