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At Rady Children’s Hospital-San Diego, emergency department visits for psychiatric reasons are far higher than ever. Hospitals nationwide are struggling with the behavioral health crisis in young people.
Even though he’s familiar with the numbers, Ben Maxwell speaks with a sense of disbelief when he describes the dramatic surge in young people coming to Rady Children’s Hospital-San Diego for mental health emergencies.
“It’s beyond unprecedented for us at this point,” said Maxwell, the interim director of child and adolescent psychiatry at Rady Children's.
In 2011, Rady Children’s saw less than 200 patients in the emergency department for psychiatric crises. This year, more than 4,700 patients were seen for psychiatric emergencies, Maxwell told Chief Healthcare Executive in an interview.
“We now see in a busy week what we used to see in an entire year,” Maxwell said. “Unprecedented isn't even in the ballpark. It’s a tsunami of patients slipping through the cracks.”
Hospitals across the country are seeing more children and teens showing up in emergency departments because of suicide attempts, overdoses and other behavioral crises, healthcare leaders say. Doctors at children’s hospitals, which are overwhelmed with the number of patients with respiratory viruses and the flu, say their capacity issues have been compounded by the number of patients with mental health needs.
The American Academy of Pediatrics, the Children’s Hospital Association and more than 100 other groups signed a letter in October asking President Biden to declare a national emergency due the youth mental health crisis.
“Emergency department visits for suspected youth suicide attempts have increased dramatically and those for eating disorders have doubled during the pandemic,” the letter states.
U.S. Surgeon General Vivek Murthy issued an advisory about the mental health crisis in youth in December 2021.
Health officials say the crisis worsened in the COVID-19 pandemic, with young people being more isolated, anxious and depressed. From April through October 2020, emergency department visits for mental health reasons rose 31% for those 12-17, and 24% for kids aged 5-11, compared to 2019, according to data from the Centers for Disease Control and Prevention.
Even before the pandemic, health officials were alarmed at the rise in deaths by suicide. The suicide rate among those 10 to 24 rose 57% between 2007 and 2018, according to federal statistics.
At Rady Children’s, the inpatient beds are regularly filled to capacity, leading to longer boarding times in the emergency department. That can be stressful for any patient, but it’s particularly troublesome for patients already struggling with anxiety or other behavioral health issues.
“It’s not the best place for those kids,” Maxwell said of the emergency department.
And it’s problematic since the number of children and teens showing up with behavioral health emergencies continues to rise.
Identifying risk earlier
Rady Children’s is teaming with San Diego County to build a pediatric mental and behavioral health campus. It will double the size of the inpatient behavioral health unit, and expand services for children who need therapy but don’t need to be admitted. But that won’t be built for a few years.
In the meantime, Rady is leading efforts to intervene and get kids help before they show up in the emergency department, Maxwell said. They’re working with doctors to screen young people who are at risk of depression and suicide.
“We’re trying to think through how we prevent kids from getting to that point in the first place,” Maxwell said.
Rady has worked with primary care providers to help them identify warning signs of mental health struggles in young patients. Nearly 200 primary care providers have been given some mental health training.
“We’re trying to identify kids in primary care,” Maxwell said. “We’re fortunate here in our region. Some groups have really taken behavioral health on.”
Healthcare advocacy groups, including the American Medical Association and the American Psychiatric Association, have called for the greater integration of behavioral health and primary care. Since most kids see a primary care physician from time to time, those physicians and practices can be invaluable in spotting kids who may need help.
“There can’t be effective healthcare without mental health care embedded in that system,” Maxwell said.
Rady Children’s also operates an urgent care facility for behavioral health needs in San Diego. The facility offers walk-in hours for clinician to assess patients who are having suicidal thoughts and may be at risk of harming themselves or others. If there’s a need for hospitalization, the patient is transferred to an emergency department or psychiatric hospital.
Doctors and healthcare leaders offer a variety of reasons for the growing number of children and teens showing up in hospitals for mental health emergencies.
In addition to the pandemic, kids are struggling with loneliness and social isolation, Maxwell said. Social media can help young people connect but can also magnify the stresses kids are experiencing.
Reflecting a national trend, Rady is seeing more patients with eating disorders and issues with their body image, Maxwell said.
The surgeon general noted some of those challenges in his advisory on the mental health crisis a year ago.
“Even before the pandemic, an alarming number of young people struggled with feelings of helplessness, depression, and thoughts of suicide — and rates have increased over the past decade,” Murthy said in a statement. “The COVID-19 pandemic further altered their experiences at home, school, and in the community, and the effect on their mental health has been devastating.”
‘No other place to send them’
Other hospitals are working to deal with the influx of young people with behavioral health needs.
Intermountain Healthcare is in the midst of a $600 million campaign to expand its pediatric care, and behavioral health is a key part of that effort. Intermountain has seen a 300% increase in children coming into emergency departments for behavioral health issues over the last several years, said Katy Welkie, Intermountain’s vice president of children’s health and CEO of Intermountain’s Primary Children’s Hospital.
“It's probably the area we get the most questions, the most interest,” Welkie said. “And it's become increasingly a community charge to do more with behavioral health.”
“We are seeing lots of kids with depression and anxiety, and whether that's in the emergency department, which I think is something that we really want to try and avoid. Because emergency departments aren't the best place for kids with behavioral health issues,” she said.
Some general hospitals have closed pediatric units or scaled back services for children, leaving children’s hospitals fewer options to transfer patients, healthcare leaders say.
Moira Szilagyi, president of the American Academy of Pediatrics, pointed to the mental health crisis as a significant factor in the challenges facing children’s hospitals.
“Many emergency department and inpatient beds are occupied by children and adolescents who have mental health needs,” she wrote in an op-ed for CNN. “This is not because these are necessarily the right places for them to receive mental health care. It is because there is literally no other place to send them.”
Szilagyi and other healthcare leaders have called for greater federal investments in children’s hospitals and pediatric care.
Some also point to the need to train more clinicians in mental health for children and teens.
Over half of all U.S. counties are without a single practicing psychiatrist, according to the University of Michigan. Of the nation’s 100,000 clinically trained psychologists, only 4,000 are trained to work with children and teens, according to the American Psychological Association.
“This area of healthcare has been underfunded for so long,” Maxwell said. “Many people who have skills to do this don’t work in the healthsystem, so they can find jobs in other areas.”
Telehealth is going to have to be a component of expanding mental health care, particularly with the shortage of clinicians, Maxwell and other healthcare leaders said.
“There’s a shortage of workers that can do the sort of work that’s needed,” Maxwell said. “Telehealth is a great way to do it.”
While healthcare providers and leaders say they hope there is more attention and money put into addressing the mental health needs of youth, they said they are grateful more people are talking about the issue.
Even as health systems and children’s hospitals are strained by the demand, they say they are glad more people are reaching out for help.
“More kids are struggling with mental health concerns and need this care, and more people are willing to ask for this care,” Maxwell said.
If you’re struggling with thoughts of suicide, call 988 to reach the 988 Suicide and Crisis Hotline.