Why is there a massive mental health crisis in this country?
Perhaps the reason is that so much about the way we treat mental health in this country is just nuts.
The Takeaway
If a given approach is not working–and no one would argue that the current approach to mental health crises in kids or adults is working–it is time to try a new approach.
The US medical system doesn’t fund mental health on so many levels: insurance doesn’t adequately cover it; access to mental health insurance is highly unequal; community resources are underfunded and the help offered to schools is inequitable; and because insurance has increasingly failed to cover mental health, there therefore are not enough mental health providers.
Right now, that translates into too many kids heading to the emergency room to treat preventable mental health crises; eternal emergency room waits; and woeful lack of treatment.
But there are some hopeful solutions on the horizon, none of which is sufficient in and of itself, but all of which help: new ER treatment teams; expanding community and school resources; and promising legislation that will help address both.
An equitable and easily accessible expansion of outpatient and community residential behavioral health crisis programs and school resources represent a better answer to this crisis than relying on emergency rooms that are ill equipped to meet patients’ needs. But since many kids and adults are still heading to the ER in a mental health crisis, we also need to expand treatment in the ER rather than holding patients in limbo until they can be transferred to a hospital bed where therapy can begin.
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Two cases in point: A family member of a patient from Leominster who went into the ER with a mental health crisis wrote to me: “The Leominster ER is not equipped to handle mental health patients. They do not have the staff or the money. All they can do is “warehouse” them until Community Health Link can find them a bed in a treatment center.” A physician recently called me to ask for help: her teenage son had been sitting in a local ER where he had gone to seek treatment for a mental health crisis, but, she said, the boy had been languishing there for almost a week with no treatment. “They aren’t giving him any therapy there,” she said. He has been there for five days–and now he IS going crazy! I am a physician, but I don’t know what to do.”
An article on the health crisis published in the Boston Globe the day after I received this call suggests that these families are not alone. The article described instances of both kids and adults with mental health challenges being kept in some ERs in Massachusetts for up to a month without mental health care.
The Mass Hospital Association confirms that statistic: according to this report, seventy-four kids –and five times as many adults–were sitting in ERs across the state, sometimes for longer than a week, without getting mental health treatment.
Why? I reached out to colleagues for some answers.
Why the wait?
It turns out that this problem long predates the COVID-19 pandemic.
According to this study by Yale researcher Katherine Nash, ER wait times for pediatric mental health increased dramatically in the 10 year period from 2005-2015: ER visits of longer than TWELVE HOURS (!!) increased from 5.3% to 12.7% over that time period.
But COVID exacerbated the problem both due to the psychological angst it engendered and because hospital emergency rooms are filling up with COVID-19 patients who compete with these patients for beds.
Harsh inequalities: waits are far worse for minorities
Dr. Nash’s study also found significant racial disparities in care: Hispanics were three times as likely as white patients to stay longer than 12 hours in the ER. That difference did not correlate with type of insurance (Medicaid vs. other) and was not seen for other medical conditions: the number of hours required to address non–mental health visits did not increase over that time.
Studies show that excess wait times experienced by minorities compound another injustice: the mental health pandemic, like COVID-19 itself, burdens communities of color far more: the suicide rate in black youth is twice that seen in white children–and is highest in black girls.
Solutions: since patients are waiting in the ER–why not treat in the ER?
According to Dr. A., an excellent therapist in the Boston area, “The long ER wait times have been a problem for years. I know that Children’s Hospital often has a hard time finding inpatient beds. I’m sure it’s become even harder during the pandemic. I’ve always thought that hospitals should develop mobile teams within the hospital to do intensive family work from the ER or wherever the kids are being housed while they wait for beds. The kids and families are already there, so why not just start treating them?!”
In the state of New York, there is a team that evaluates patients in the ER–and if a patient doesn’t meet criteria for admission, then outpatient support is orchestrated and the patient is discharged so they can get therapy as outpatients–which may have been helpful in the above cases.
Indeed, Children’s, MGH and Newton Wellesley Hospital have now launched mobile units to treat mental health crises in the ER. Not only that, but a pilot program treating patients in the ER has shown that it helps patients avoid inpatient admission. But I have read of no such program for Leominster.
Which is unfortunate, because being treated right away must be tremendously empowering to the patient: his/her crisis is treated like a crisis and it saves the patient from waiting for weeks in a supercharged, stressful environment that can only add to their angst.
Another problem: emergency rooms are not the right place to treat mental illness
As important, one psychiatrist I contacted noted: “treating in the ER is not easy.“
“Our staff, our nurses, our physical space — none of it is appropriate for these kids. Some of the Boston hospitals are doing what they can, but what these kids need cannot be delivered in that setting. The issue is that there is nowhere to send them to get appropriate treatment.”
“You can give antibiotics and fluids in an ER, but there’s nothing IV for family dysfunction or bullying, and our medications take 2-4 weeks to even start to help. Some ERs do have larger mental health teams, and we treat as much as we can (for example a kid who needs a medication titrated; we also offer virtual group therapy to kids who are boarding in the ER or in the hospital.. But the treatment they access on an inpatient unit just isn’t replicable in an ER: group therapy, individual therapy, TIME, and “milieu therapy,” i.e. being in a supportive environment and away from their stressors and social media.”
“We actually HAVE put mental health workers into place in some ERs and pediatric floors in order to provide additional therapy, and that’s been really helpful, but it’s still not common that it allows a kid to go home.”
Going Home to Nothing
She adds, “Even if it does, they are often going home to nothing — there are no outpatient providers anywhere. We all get multiple calls every week from colleagues within the hospital (physicians and others) who can’t find care for their Allways insured kids in crisis and we’re just helpless.”
Lack of funding–what’s up with that?
She continues, “The problem at all levels of care (outpatient, intensive outpatient, day programs, residentials, inpatient) is absolutely funding, as well as administrative parity. For example, my social workers spend up to 2 hours on the phone with insurance companies getting “authorization” to admit a suicidal child to inpatient once a bed is identified. Can you imagine needing to get permission to admit a patient with pneumonia?”
“We need funding reform and true healthcare parity; I keep hearing that bundled payments/PMPM (I barely understand what those words mean) will help, but it’s not going to be overnight. Children and folks with mental illness are doubly not a priority for… anyone. “
“The “good” psychiatric hospitals all operate at a loss and child psychiatry at places like MGH and NWH are heavily subsidized by the hospitals/philanthropy.”
Again–we the public are left with so many questions. A lack of beds doesn’t explain why it should take a social worker two hours to get insurance to pay for a bed that IS available.
And why is this problem getting worse? Why is insurance not paying? Why must “philanthropy” cover these services? When you come in with a heart attack, insurance covers that. Not philanthropy!
The therapist above mentioned that her social worker had to spend 2 hours getting a MassHealth patient admitted. But the patient described in the case I presented has insurance–is the child of a physician at one of our top hospitals, no less! And yet that child waited for over a week to be admitted. So insurance cannot be the only obstacle.
Meanwhile, increases in outpatient reimbursement rates are being suggested to induce more providers to take insurance and pediatric behavioral health urgent cares are being set up as an alternative to the ER. But how will years of underfunding this specialty be reversed overnight?
Not enough beds?
Many ascribe the increased wait to a lack of beds.
Several reasons are given for this shortage:
- More people are in crisis due to months’ long waits for outpatient care;
- Few inpatient beds are available due to the lack of home and community based treatment and residential services;
- A lack of staff;
- The gradual loss of beds “over the years”
- Lack of adequate resources in certain areas.
According to a representative from MAMH, the Massachusetts Association for Mental Health, MassHealth has now funded new beds and Cambridge Health Alliance, MGH/McLean, Bay State, and Tara Vista are opening or have opened new beds.
At the same time, she says, insurers are turning to online resources.
These answers–again!– raise so many questions.
Mass health–Massachusetts’ name for Medicaid–”funds” only a certain number of mental health admissions? Does it do that for heart attacks–or other health conditions?
What about insurance companies referring patients to on “online psychiatric resources”? That approach seems a highly untested and a questionable one at a time when kids and adults alike are feeling the loss of connection. Won’t AI exacerbate rather than help the disconnection that patients are experiencing? Aren’t kids spending enough time on their devices already–and isn’t the time spent on devices associated with depression?
Perhaps this technology may provide a temporary stopgap at a moment of systemic failure. I, for one, am deeply sceptical of cheap, technologic solutions to a deep sociologic problem.
More questions: is hospital admission really the best approach? There is a significant increase in suicide risk following mental health discharges. Why is that? Maybe the whole paradigm for treating mental illness is off-track.
And how exactly can we explain this sudden lack of beds, since in fact it is a problem that has been worsening for years? Don’t we first need to answer this question: why have we waited over 15 years to address a lack of beds?
Innovative community solutions
If the ER isn’t a suitable environment–is there another part of the hospital or even dedicated places in the community that could be dedicated to mental health treatment that would be more conducive to successful care?
Other states, like Oregon and Illinois, have recognized that an ER is not a good setting to treat a patient with mental illness. They have created a less busy and chaotic setting, called “the living room,” that has been shown to decrease patient anxiety.
These community crisis centers offer people experiencing a mental health crisis an alternative to hospitalization. They are open 24/7 — and people receive care immediately. Clearly there are conditions that cannot be treated there–like drug overdoses–but for many mental crises like panic attacks, depression and anxiety, the more calm setting may be more conducive to treatment success.
The stigma of mental illness
Is the stigma of mental illness playing a role here?
Fred Hutchins, the family member of a mental health patient who waited for many days to be triaged at his local ER, thinks it is: “These attitudes are pervasive and deadly,” he wrote to me in an email.
He notes, “There is massive failure to treat which includes denial, lack of response and a fundamental misunderstanding of the nature of mental illness. One of the best Olympic gymnasts in the world was forced to scale back her Olympic participation for mental health reasons. She was faced with ridicule and failure to understand the nature of mental illness.”
He continues, “Not being able to have a conversation about mental illness makes it very difficult for our family members to get the treatment they need. This needs to change because of the great cost to society when people do not get the treatment that they need.”
The stigma surrounding mental illness is clear in the criminalization that surrounds it: many jails and prisons have de facto replaced the psychiatric hospitals that were abruptly phased out in the 1990s, leaving many patients with psychiatric illness on the street–or worse, classified as criminals and locked up. The recent adoption of a pilot program in Boston that will direct 911 mental crisis calls to a 988 crisis team instead is a step in the right direction, a step towards recognition and treatment of mental illness instead of criminalization of it.
Hutchins continues, “We must work to prevent the criminalization of a mental health issue. When you call 911 and the police respond it becomes a criminal matter, rather than a case of a patient in need of treatment. This is unavoidable when the police are involved. Criminalization of a medical condition causes a medical matter to be treated like a criminal matter. They need to be separate. Mental illness, and criminal behavior are not one and the same. “
More is needed: ideas for better community supports
David Cohen wrote the following cogent response to a Boston Globe article on the mental health crisis:
“A first step in managing this crisis is to establish partnerships between schools and community-based mental health agencies so that youth have easy access to therapeutic supports and at no cost. Long term, we need a more centralized system that triages cases to the appropriate levels of care and provides adequate funding for community-based crisis support alternatives over emergency department visits and hospitalizations.”
This is spot on. It’s called prevention–treating mental health issues before they reach crisis level and offering places to treat them other than the emergency room.
Why is there limited access to outpatient treatments?
And why do new government programs in Massachusetts put the onus on schools to apply for these funds–why don’t they have a centralized program like the one suggested above by Mr. Cohen, to allocate funds and take the burden off schools to compete and apply for these funds? The schools that are the most in need are those least able to take the time to fill out cumbersome paperwork, which could result in those districts that most need funding for mental health being shortchanged.
Policy Change: Legislation. H. 1061’s Behavioral Health Investment Trust Fund
In Massachusetts, Representative Marjorie Decker has proposed promising legislation to establish better community programs, which should include partnerships between schools and community-based mental health agencies so that kids have access to meaningful mental health support.
It also proposes funding more hospital beds as well as community-based crisis support alternatives over emergency department visits and hospitalizations.
This is spot on. Both improved treatment options and most of all, prevention–treating mental health issues before they get going, and offering places to treat them other than the emergency room–will offer hope to those who head to emergency rooms suffering from despair–only to encounter more of the same when they arrive.
The root of the problem
What is the root of the problem? Why are so many kids and adults pouring into the ERs in mental health crises? If we don’t address that question, we won’t fix the crisis.
The spike in ER mental health crises is widely blamed on delays in seeking care during the height of the COVID pandemic and on the lack of beds.
But perhaps it is not so much a problem with delays as with abysmal mismanagement of a pandemic that left huge swaths of society feeling disempowered, ignored, and undervalued–from teachers to students to women to minorities. We showed how little we prioritized teachers in Massachusetts by outsourcing teaching to some flimsy online company for many Massachusetts school systems, instead of relying on their own teachers–who could have helped the students weather the storm; we prioritized large companies and dog groomers returning to work rather than school children returning to in-person classrooms. We failed to prioritize adequate ventilation, testing and small classroom size in Boston, choosing to keep those classrooms remote rather than innovate systems used by private schools to keep children in school; and we utterly failed, through lack of funding for the safe schooling needs of our children, to prioritize women returning to work.
Interestingly, countries that did an excellent job prioritizing women and children and their swift return to school and work by effectively handling the COVID pandemic, not only saved lives–but also the mental health of their communities: suicides in those countries were recently shown to decrease during the first months of the pandemic in such countries, and have been stable thereafter. According to recent studies in the US, the mental health crisis has been catastrophic, and suicide rates have skyrocketed.
In sum:
My sense is that the root of the problem has to do with misplaced priorities.
A response that prioritizes prevention and an outpatient/school or community residential behavioral health crisis system is a better answer to this crisis compared to going to an emergency room that is ill equipped to meet patients’ needs. But since many kids and their families are still going to the ER (and this goes for adults as well) better mental health treatment is needed in the ER–and not just at MGH or Children’s, but across the state. Holding patients in limbo in the ER until they can be transferred to a hospital bed where therapy can begin is not acceptable.
If a given approach is not working–and no one would argue that the current approach to mental health crises in kids or adults is working–it is time to try a new approach.
Fred Hutchins agrees: “I think these issues are very important. This problem in our area is both urgent and critical.”
Resources
Dial 988, not 911: a new emergency number for mental health crises
Boston and other areas are trying a new approach to mental health crises that don’t involve calling 911. 988
A bipartisan 2020 law designated the three-digit phone number 9-8-8 as the new number for the National Suicide Prevention Lifeline, a 24/7 crisis hotline that will connect callers with immediate counseling or referrals for local mental health services.
The new number is set to take effect on July 16, 2022, but advocates want to build crisis care infrastructure and add resources before then, including funds for specialized services for high-risk populations.
Promising legislation:
Marjorie Decker’s bill, H. 1061’s Behavioral Health Investment Trust
“There shall be a Behavioral Health Investment Trust Fund, in this section called the fund. The fund shall be administered by the secretary of the executive office of health and human services. The purpose of the fund shall be to support investments in the behavioral health infrastructure in the commonwealth, including but not limited to: (i) establishing additional inpatient psychiatric beds and providing supplemental payments, as needed, for said beds; (ii) expanding outpatient and partial hospitalization treatment settings, intensive community based acute treatment programs, community based acute treatment programs, substance use treatment programs, crisis stabilization units and community mental health centers; (iii) supporting increased rates of payment for behavioral health providers; (iv) establishing a behavioral health home hospital pilot program; (v) supporting an expanded and culturally and linguistically-competent behavioral health workforce in the commonwealth, including but not limited to psychiatrists, psychologists, nurses, social workers, mental health workers, sitters, certified nursing assistants, licensed mental health counselors, recovery coaches and peer specialists via programs including, but not limited to, psychiatric Graduate Medical Education payments and loan forgiveness programs to increase access to behavioral healthcare equitably across the commonwealth.”
NAMI, the National Alliance on Mental Illness, has helpful resources on recognizing the signs and symptoms of a mental health crisis and more broadly, about the decriminalization of mental illness.
National Suicide Prevention Lifeline: 1-800-273-8255 The National Suicide Prevention Lifeline is a network of local crisis centers that are available 24/7 to provide support for youth and adults who are in any kind of emotional crisis.
The Trevor Project – 1-866-488-7386 The Trevor Project is a 24/7 crisis intervention and suicide prevention hotline for LGBTQ youth.
SafeLink: 1-877-785-2020 SafeLink is for anyone who is being affected by domestic violence or dating violence.
National Runaway Safeline:1-800-786-2929 The National Runaway Safeline helps youth who have run away, are thinking about running away, or who already ran away but are ready to come home.
Disclaimer: None of my sources, except for one family member of a patient in a mental health crisis, wished to be quoted for this piece, so they are quoted anonymously. Sources included: psychiatrists, psychologists, non-profit heads in mental health, family members of affected patients. Was this reluctance due to the stigma around mental health? One therapist said that she was so overworked, she had no room in her practice. In any event–that is why my sources are quoted anonymously.
Medical Disclaimer:
The suggestions given here are not intended as a substitute for the medical advice of your physician, psychiatrist or psychologist. The reader should regularly consult a physician in matters relating to his/her health and particularly with respect to any symptoms that may require diagnosis or medical attention. For additional questions, please call your healthcare provider for reliable, up-to-date information on testing and symptom management of all medical concerns.
