Mental health and substance use-related emergency department visits are increasingly common among youth (ages 12–24 years); however, there are no standards or guidelines for providing quality care and referral to appropriate services. Based on existing evidence and insights from a technical committee of 14 Canadian experts (youth, caregivers, service providers and decision-makers), we outline four key priority areas for improving care in emergency department settings and recommendations for implementation. This includes improving the care environment; appropriate and timely mental health and substance use assessment; treatment based on youths' goals, needs, preferences and circumstances; and referral to appropriate services.

Introduction

In Canada, emergency department visits for mental health and substance use care among youth have increased significantly, with notable rises in substance use, mood disorders and anxiety disorders (CIHI 2025). In Ontario, the number of mental health and substance use-related visits among youth (ages 0–24 years) increased from 46,130 to 87,538 between 2006 and 2017 (Chiu et al. 2020). This is largely attributed to the limited availability of publicly funded community services to support youth and a lack of coordination across services (CMHA 2018). Youth seeking emergency care for such concerns often face long wait times for assessment and are frequently discharged without a care plan, often returning to the emergency department for the same concerns (Glowacki et al. 2022; Voineskos et al. 2018). For instance, in 2022, 52% of emergency department visits related to opioid use disorders among youth (ages 5–29 years) were repeated visits (CIHI 2025). Despite this trend, there are no standards or guidelines to ensure that youth receive quality mental health and substance use care in emergency departments and are connected to appropriate services.

In this commentary, we advocate for a quality standard for youth (ages 12–24 years) mental health and substance use care in emergency departments across Canada (Barbic et al. 2025). These recommendations build on existing evidence, including a rapid evidence review aimed at identifying how youth are assessed, treated and referred to community services when accessing emergency departments for mental health and substance use in Canada and the US (Providence Health Care Society, Foundry 2021), prior research aimed at understanding pathways between emergency departments and integrated youth services (Glowacki et al. 2022) and insights from a technical committee of Canadian experts.

Approach

The project team, comprising two health services researchers (authors Roxanne Turuba and Skye Barbic), summarized the existing evidence and derived an initial list of priority areas to improve mental health and substance care for youth in emergency department settings in Canada. The priority areas were reviewed with a technical committee of 14 experts, spanning three stakeholder groups with experience accessing or delivering mental health and substance use care in the emergency department (three youth, three caregivers/family, eight service providers/decision-makers). We held three to four meetings with each group between March and August 2024 to acquire their input and recommendations, with additional e-mail communication and individual feedback sessions. Separate engagement sessions were held to promote a safe and comfortable environment to share experiences and ideas, which resulted in four priority areas of attention, along with a series of recommendations (Table 1, available online here). While youth and caregivers/family shared numerous suggestions to improve their care experiences (e.g., therapeutic strategies) and continuity of care (e.g., warm hand-offs), service providers and decision-makers expressed concerns about the feasibility of such improvements (e.g., changes to hospital policies, staff capacity) and whether these aligned with the emergency department's scope of practice. To reconcile the system-level barriers (e.g., lack of community services, narrow service hours, navigational challenges) (CMHA 2018; Glowacki et al. 2022; Voineskos et al. 2018) and ease the strain on emergency departments, experts agreed there was a need to integrate specialized care teams and providers (e.g., community care teams, multidisciplinary care teams, peer support workers, patient navigators, outreach workers, case managers, social workers) to better support youth and emergency department staff across all priority areas, including transitions to developmentally appropriate services. The following section outlines the key priority areas for improving care in emergency department settings and recommendations for implementation.

Priority 1: Improving the care environment

All technical committee members described emergency departments as suboptimal environments to manage most mental health and substance use concerns. Service providers and decision-makers expressed numerous challenges providing quality mental health and substance use care in emergency care settings, which was corroborated by youth and caregivers/family who shared negative experiences, including experiences of discrimination (e.g., racism, ageism, ableism) and traumatization. While experts stressed the need to increase youth-specific community service capacity (e.g., extending service hours) and rapid access clinics, they also highlighted the need for more culturally safe and trauma-informed care in emergency department settings. This involves using non-stigmatizing and strength-based language; providing youth and caregivers/family with clear information about the emergency department process, as well as their diagnosis, prognosis and treatment options; involving youth in care decision-making; treating youth with respect, compassion, empathy and humility; and implementing therapeutic strategies that truly support de-escalation.

Experts corroborated previous research (Glowacki et al. 2022; Providence Health Care Society, Foundry 2021) recommending comfort carts (e.g., blankets, crafts, earplugs) and separate spaces for mental health patients (e.g., sensory rooms, separate emergency departments), which is consistent with provincial standards and guidelines for secure rooms and least restraint in emergency care settings (BC Ministry of Health 2024; Child Health BC 2022). Furthermore, youth and caregivers/family stressed the need for lasting chart alerts with the youth's safety plan, which appear when opening a youth's medical chart; providing youth access to a support person (e.g., caregiver/family member, friend, Elder, peer supporter, service provider with whom youth already have established a relationship); embedding more counsellors, social workers and peer supporters; and hiring relational security officers who are trained in mental health and substance use, trauma-informed care and cultural safety.

Finally, all experts expressed a lack of awareness about specialized care teams and providers available in the emergency department and the availability of community services. As such, they recommended having this information readily updated and available in the emergency department in the form of pamphlets, posters and QR codes directing youth to virtual services, as well as patient navigators to guide youth to services and support a warm hand-off.

Priority 2: Appropriate and timely mental health and substance use assessment

Service providers expressed challenges discharging youth without proper psychiatric evaluation, given the potential risks associated (i.e., harming themselves or others) and the limited availability of specialized staff who are able to properly assess youth, particularly outside of regular business hours. Youth and caregivers/family corroborated this, as they often experienced long wait times in the emergency department waiting for assessment, which often led to increased feelings of distress given the ill-suited environment (see Priority 1). Strategies to ensure timely assessment and care for youth included consulting previous assessments and treatments to inform care and expedite the intake process; taking a holistic approach when assessing symptom severity (e.g., using psychosocial assessments, like HEARTSMAP) (Emergency Care BC 2018; Doan and Koopmans 2018); utilizing resources such as telehealth and 24/7 consultation helplines, particularly in poorly resourced communities (e.g., rural and remote); and embedding specialized providers and care teams who can gather more historical context from youth to properly assess and support youth and caregivers/family with service navigation (see Priority 4).

Priority 3: Treatment based on youths' goals, needs, preferences and circumstances

While service providers noted that most mental health and substance use concerns often need long-term care beyond the scope of emergency department settings, youth and caregivers/families argued that emergency departments are often their only option at the time of need. While addressing barriers to community services is essential, providing emergency care for this population remains important. As such, experts recommended making treatment decisions collaboratively with youth and caregivers/family based on the youths' goals, needs, preferences and circumstances. Special considerations were underscored for youth at high risk of substance use-related harms (e.g., experience of overdose, repeated emergency department visits), such as discussing harm reduction services and treatment options, including opioid agonist treatment. To alleviate the pressures placed on emergency department staff, recommendations included embedding care teams and providers who are trained in youth mental health and substance use care and service navigation to ensure that youth receive timely and appropriate treatment.

Priority 4: Referral to appropriate services

The last priority focused on service providers working collaboratively with youth and caregivers/family to co-develop a clear, written discharge plan that they can understand and comply with and being referred to appropriate in-patient or community services based on the youths' goals, needs, preferences and circumstances. Service providers cited their limited capacity to assist youth and caregivers/family with service navigation and stay informed about the wide range of rapidly changing services available in their communities. Youth and caregivers/family validated this, describing often being discharged with minimal guidance, treatment plans or support in connecting to community services, and later returning to the emergency department for the same concerns. As such, experts recommended increased access to rapid access clinics that extend to youth under the age of 19 for specialist support; transitional discharge models to ensure continued support from the hospital staff after discharge; and integration of multidisciplinary care teams and service providers within the emergency department that can support youth and caregivers/family with service navigation and reduce their reliance on emergency departments. Furthermore, youth and caregivers/family highlighted the need to offer youth direct referrals (i.e., sending a referral form, contacting services, arranging an appointment on the youths' behalf) and providing necessary support to help youth access community services (e.g., transportation assistance). Finally, experts described a need to develop stronger functional relationships between emergency departments and local community services, including schools, primary care and integrated youth services.

Suggested Next Steps

To advance the implementation of the identified priority areas and recommendations, a multi-pronged strategy should be pursued. This includes pilot testing selected interventions in emergency department settings, in partnership with community organizations and health authorities, to assess feasibility, impact and scalability. Continued co-design with youth, caregivers/family and service providers will be essential to ensure that the recommendations remain responsive to diverse needs and local contexts. Developing a clear implementation framework (including defined roles, timelines and evaluation metrics) can support accountability and guide consistent practice changes. Engaging Accreditation Canada and the Canadian Institute for Health Information in this process may help embed these recommendations within national standards, accreditation processes and performance indicators. This will reinforce person- and community-centred quality improvement and ensure that emergency departments across Canada are equipped to meet youth mental health and substance use care needs. Finally, coordinated knowledge translation efforts (e.g., toolkits, policy briefs, training modules) and sustainable funding mechanisms will be key to fostering intersectoral collaboration and ensuring long-term system change.

Conclusions

Our review and expert consultations identified key priorities and recommendations to improve mental health and substance use care for youth and caregivers/family within emergency departments and broader communities. Central to these improvements is the integration of trained providers and care teams to provide timely and appropriate assessment, treatment and service navigation.

Author Contributions

Skye Barbic and Steve Mathias conceptualized the project. All authors took part in the development of the quality standard. Roxanne Turuba took the lead in writing the first draft of the commentary. All authors revised the commentary and approved the final version.

Conflicts of Interest

The authors have no conflicts of interest to declare.

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