Seeking help for a mental health crisis, Lindsay Redding went to Doylestown Hospital earlier this year. In the waiting room, she struck up a conversation with the mother of an adolescent who also was waiting for care.
Redding, who is 37 and lives in Doylestown, said she was shocked when the mother told her that her family had been sleeping on couches in the hospital’s crisis center for a week because there were no beds available in area residential treatment centers for adolescents.
“I just thought it was such a shame,” Redding said.
The coronavirus pandemic has created a mental health crisis as more people need help with anxiety and depression. A survey conducted in September by the National Council for Behavioral Health found that 52% of behavioral health organizations are seeing an increase in demand for services.
Yet the survey also found that 54% of organizations have had to close programs for pandemic-related reasons, while 65% have had to cancel and reschedule appointments or turn away patients. Nearly a quarter surveyed cited financial hardship as a contributing factor.
Crisis centers and emergency departments at hospitals in the Philadelphia area are feeling the crunch as they are often the first stop for people in a mental health crisis. The next step is an inpatient mental health program for additional treatment or discharge if the patients are judged not to pose a danger to themselves or others.
The wait for a bed often took days even before the pandemic, particularly for children and adolescents. COVID-19 requirements and precautions, such as testing and quarantining, have made placements even harder. Plus, having to spend a lot of time in an emergency room can be especially overwhelming for someone in crisis, experts said, making it more difficult to treat the mental health symptoms.
“There have never been enough psychiatric stabilization beds for kids,” said Roy Leitstein, CEO of Legacy Treatment Services, a behavioral health provider with offices in South Jersey. “Not in New Jersey, not in Pennsylvania, not in the nation. The pandemic has created a whole other layer of challenges associated with those residential crisis stabilization services. The whole system has kind of stopped moving, through nobody’s fault.”
‘A cumbersome process’
Mental health providers across the country are grappling with growing waiting lists of patients seeking services. In a poll of nearly 1,800 psychologists conducted by the American Psychological Association published in November, 74% reported seeing more patients with anxiety disorders than before the pandemic, and 60% reported seeing more patients with depression.
At Lenape Valley Foundation, which has managed the crisis center in Doylestown Hospital since the 1970s, the pandemic has made it more difficult for staff to find beds in residential mental health treatment centers or psychiatric wards, particularly for children and adolescents.
“We’re looking outside of the crisis center everywhere for a bed for the person, but we’re working with resources within a very small area,” said CEO Sharon Curran. “When [the patients] are with us in the crisis center, we make them as comfortable as we can. This is a place where people come in and get referred out, and now we have a situation where they have to stay longer than they ever have historically.”
Before the pandemic, the average wait for transfer at the foundation’s crisis center was 16 hours, Curran said. During the pandemic, that time has increased to 24 to 48 hours. For people who require more specialized care, such as those with violent tendencies or autism, placement can now take up to a week.
Abington Hospital-Jefferson Health has also seen wait times grow. According to data shared by the hospital, the average wait for pediatric patients seeking behavioral health care through the emergency room doubled from just under 100 hours last March to nearly 200 hours by the end of the year. They spend that time in a hospital bed, but not in the kind of facility they really need.
New Jersey crisis centers, especially those that work with youth, are facing similar challenges, Leitstein said.
At the beginning of the pandemic, many children and parents avoided going to the emergency room for behavioral health issues for fear of contracting COVID-19. Hospitals were also trying to move as many beds as possible into COVID-19 wards, but the situation has now changed, Leitstein said.
“Now what we see, coming out of that situation, is that our resources are obviously deficient,” he said, noting that there’s been a significant spike in kids and adolescents attempting suicide in the last year in New Jersey. “They weren’t sufficient to begin with.”
Overall, there’s been an increase in the last year in the number of patients going to emergency rooms for psychiatric care, said Kevin Caputo, chair of psychiatry at Crozer Health in Delaware County. And, he said, COVID has created “a more cumbersome process now to get them placed.”
“A kid once spent two months with us, trying facility after facility,” Caputo said. “Adolescent places have been very selective in who they’ll take, so placements are very difficult for certain patients. This problem existed prior to COVID, but it has intensified due to COVID.”
Because every patient has to be tested for COVID-19 before being placed, there’s more lag time. But the emergency room is “probably the worst place for someone with a psychiatric illness” because of all the stimuli, Caputo said.
Patients who test positive for COVID-19 and are symptomatic are trickier to place, Caputo said. Because they can potentially infect entire inpatient units, those patients have to be admitted to a medical floor where they receive care while waiting for a negative COVID-19 test result.
“The difficult part is, what are you doing for 10 days?” he said. “It’s not really true inpatient psychiatric treatment.”
Inpatient treatment can “make a world of difference,” Caputo said. Seeing other people get better and participating in group therapies can help patients learn coping strategies that they can’t get while isolated in one room. And although building new inpatient units is expensive, it is one course of action that would make placing patients easier for hospitals, he said.
The emergency department at Lower Bucks Hospital has also seen an increase in the average time a patient waits for an inpatient program, said April Martin, a nurse who works closely with behavioral health patients. Some inpatient facilities cannot handle patients with more severe symptoms, she said. Currently, adult patients may wait up to a few days for placement, while pediatric patients can wait for weeks.
“We kind of just have to hold them here,” Martin said. “We give them regular medications and try again at more places, but if they can’t go, then they wait here another day.”
COVID-positive patients may wait in a negative pressure room until they test negative. “We’ve had people in that situation for weeks, and even though psychiatrists will come and see them, their mental health is not being treated properly,” she said.
Martin said the hospital is working with local officials to figure out a better plan.
“Everybody here is trying,” she said. “Our main goal is to get the patients the help that they need, but mental health is definitely a broken system. It’s just really sad.”
Making prevention the priority
Nancy DeAngelis, Abington Hospital’s director of behavioral health, said placing children in inpatient facilities has long been a challenge.
“The reasons for this are multi-factorial and include challenging family situations where the legal guardian is unavailable to provide permission to transfer and a shortage of inpatient beds for this patient population,” DeAngelis said in a written statement.
DeAngelis said one solution is legislation that would allow providers, social workers, and managed care organizations to work with patients across county lines. This would expand the number of inpatient beds that hospitals can refer patients on Medicaid to.
“Unless our legislators ... create changes ... the situation will not improve,” she said.
The best approach is to try to reach patients with behavioral health issues before a crisis, DeAngelis said. Primary care physicians, schools, community centers, early intervention teams, outpatient psychiatrists, and other providers can help their patients manage mental health issues, she said.
“In our community, demand for beds on inpatient psychiatric units exceeds supply,” Diane Custer, Abington’s emeritus chair of psychiatry, said in an emailed statement. “Our crisis clinicians search a 600-mile radius over many states and are still not able to find beds for every patient that needs one.”
Curran said she is optimistic about Pennsylvania’s updated regulations and licensing requirements around crisis management. In 2019, Pennsylvania’s Independent Regulatory Review Commission approved new regulations for outpatient psychiatric services that required 50% of psychiatric time to be provided by advanced practice professionals or through telehealth. Curran also pointed out that increasing access to evidence-based treatments for mental health, such as cognitive behavioral therapy, can help people avoid hospitalization.
“We can’t wave a wand and make that happen overnight but can we get there sooner so we don’t get to that place where people are hospitalized?” Curran said. “And is there any other level of care that we can do rather than inpatient? Definitely.”