Scarcity Of Mental Health Care Means Patients - Especially Kids - Land In ER

Tue Nov 1 19:10:24 PDT 2016

October 17, 2016

Scarcity Of Mental Health Care Means Patients - Especially Kids - Land In ER

<http://khn.org/news/scarcity-of-mental-health-care-means-patients-especiall
y-kids-land-in-er/> Kaiser Health News

By Shefali Luthra

On any given day, pediatrician Lindsay Irvin estimates a quarter of her
patients need psychiatric help. She sees teens who say they are suicidal,
and elementary school children who suffer chest pains stemming from bullying
anxiety.

Though she does her best, she doesn't consider herself qualified to treat
them at the level they need at her practice in San Antonio. She doesn't have
the training, she said, to figure which medications are best suited to treat
their various mental health conditions. And she doesn't have time. She's
juggling stomach ailments, vaccinations and ear aches.

As a result, she's seen some of her patients wind up in the emergency room
or going without care. These experiences evidence the degree of unmet need
for mental health treatment.  "I see kids' lives destroyed by not getting
care," she said.

Now, research abstracts presented Monday by the American College of
Emergency Physicians offers insights into how frequently patients with
mental health issues land in the emergency room - often because
opportunities to intervene earlier are missed.

The researchers analyzed data compiled by the National Hospital Ambulatory
Medical Care Survey, which tracked mental health visits to the emergency
department between 2001 and 2011. The data tracks a national sample of
patients who use hospital emergency and outpatient departments.

Compared with patients who have physical illnesses, the researchers found
that people with mental health conditions rely more on the emergency
department, and are more likely to be admitted when they show up. They tend
to stay longer, too. The researchers have not yet described down how the
visits broke out by age. But anecdotally, children and older patients - "the
extremes" - appear particularly affected, said Suzanne Lippert, a clinical
assistant professor in emergency medicine at Stanford University, and lead
author on the abstracts.

These findings underscore two concerns, Lippert said. They highlight
potential consequences when patients can't find good outpatient mental
health care, and that, when psychiatric patients arrive in a crisis, there's
often no good place for them to continue treatment once the immediate issue
has been addressed.

Medical patients can usually be sent home "because we know they'll be
evaluated by [their] doctor in one or two days," Lippert said. But
psychiatric patients don't always have that option because of gaps in the
mental health care system.

Young patients may be affected the most, said Steven Schlozman, an assistant
professor of psychiatry at Harvard Medical School and associate director of
the Clay Center for Young Healthy Minds at Massachusetts General Hospital.
He was not affiliated with the research.

"It's a numbers game. Unless you live in a large urban area, you're very
unlikely to find a child psychiatrist," Schlozman said. The emergency
department, then, often is the only realistic venue for care.

Some numbers: About 6 percent of all emergency department patients - of all
ages - had a psychiatric condition. More than 1 in 5 were admitted, compared
with just over 13 percent of medical patients, and about 11 percent required
transfer to another facility, compared with 1.4 percent. About 23 percent of
mental health patients stayed in emergency care for longer than 6 hours, and
about 1.3 percent for more than 24 hours - compared with 10 percent and half
a percent of medical patients.

The most severely ill mental health patients were far more likely to spend
extended periods of time in the ER. Bipolar disorder, depression, psychosis
and having multiple conditions all tracked with stays longer than 24 hours.

These findings, the researchers write, highlight a "growing crisis."

There is also a national shortage of inpatient psych beds, so patients have
to wait longer in the ER, Lippert said. She's seen them stay for over a
week.

An online poll of emergency physicians released Oct. 17 offers evidence of
how this plays out for young psychiatric patients. Of the 1,700 physicians
responding, more than half (57 percent) reported increased wait times and
boarding for children with mental health issues.

Plus, psychiatric patients can be harmed by long stays in cramped, overused
emergency quarters, said Thomas Chun, an associate professor of emergency
medicine and pediatrics at Brown University.

"We are the wrong site for these patients, and they have very important,
very special needs. Our crazy, chaotic environment is not a good place for
them," said Chun, who was not affiliated with the abstracts.

Meanwhile, the young patients are least likely to get reliable care even
after leaving. Whether they need regular follow-up with a psychiatrist, or a
transfer to specialized facility, the resources often aren't in place. The
American Academy of Child and Adolescent Psychiatry estimates 8,300 such
specialists practice in the country, while more than 15 million young
patients need services.

"They'll land in a pediatrician or family practice," Irvin said. "I'm not
trained to navigate the ins and outs of psychotropic meds," she added,
recalling difficulties she recently had finding a specialist who could
prescribe the necessary medications and continue working with a suicidal
teenage girl, who was one of her patients.

And children in crisis sometimes wait weeks for proper in-patient treatment,
Chun said. That's less common in his home state of Rhode Island which, he
said, is "fairly resource-rich" in terms of psychiatric care - but he hears
it often from colleagues in New York. Doctors will agree a child needs to be
transferred, but no beds are available.

For children, the problem also doesn't fall evenly. The resource squeeze is
especially problematic for families with limited means, noted Alfiee
Breland-Noble, an associate professor of psychiatry at Georgetown University
Medical Center, who was not involved with the research. Cost, coupled with a
stigma toward mental conditions, means low-income families are more likely
to let a child's ailment slide, until it reaches a crisis point.

That tracks with another finding: Emergency psychiatric patients were more
likely to be uninsured than were physical health ones. About 22 percent of
mental health patients lacked coverage, versus 15 percent for physical
conditions - likely, Lippert said, in part because of the particular
challenges the uninsured face in finding affordable psychiatry.

In San Antonio, just one visit to a child therapist can cost hundreds of
dollars out of pocket, Irvin said. For her patients, the choice can be a
week's worth of groceries or seeing the doctor. Often, that means, "a kid
will go neglected."

By the time a child gets treatment, she added the mental condition can have
produced physical ailments, too. It's more expensive to treat, it's bad
medicine, and it's avoidable, she said.

"These kids should never be in the emergency room," she said. "They
shouldn't be waiting for 24 hours in a plastic chair."

Jeff Wells
Deputy Editor, CAL/AAEM News Service

Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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