How Pediatric Hospitals Must Adapt to the Adolescent Mental Health Crisis

In March 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19) a global pandemic.¹  Over the ensuing year, while adult hospitals filled with patients with severe acute respiratory syndrome coronavirus 2, a different epidemic drove hospitalizations in pediatric hospitals in the United States. This epidemic had been growing for years, although without the attention or resources needed to properly address it. When schools closed because of COVID-19 and millions of adolescents were forced into virtual learning, it disrupted one of the most important components of mental health for this population, namely, socialization with peers. Additional factors, such as family-member illness, altered family dynamics, lost parental wages, and stress and fear around the pandemic, compounded this problem. The resulting increase in depression and anxiety among adolescents has led to a spike in emergency department (ED) visits and hospitalizations for mental health crises, suicidal ideation, and suicide attempts.^2–4  Indeed, in 1 study, researchers found a 50% increase in ED visits for suicide attempts among teenaged girls from February 2020 to February 2021.²  An already strained mental health system has become even more strained. Adolescents have languished for longer and longer periods of time in EDs and on inpatient medical wards while waiting for beds to open up at psychiatric hospitals. Appointments for outpatient mental health providers have booked farther and farther out. For pediatric hospitalists, the winter practice has transitioned, if briefly, from managing bronchiolitis to managing adolescent despair. Yet, even as the adolescent mental health crisis has worsened, opportunities for addressing it from an inpatient perspective have arisen.

When a child is admitted to the hospital with a medical condition, the management is centered around correcting the pathologic process. For example, when a child is admitted with pneumonia, a cascade of treatment modalities is put into action. Antibiotics are started, oxygen is given, and vital signs are monitored. Many hospitals have treatment protocols that are intended to make the process run smoothly and predictably.⁵  The interventions are meant to relieve the suffering of the child (eg, antipyretics, supplemental oxygen, and child life specialists) and cure the disease (eg, antibiotics). When the disease process has resolved to an adequate degree, the child is discharged from the hospital. Some hospitals have also developed protocols for adolescents admitted with suicidal ideation or suicide attempts.⁶  However, these protocols focus primarily on keeping adolescents safe from harming themselves and often fail to address the underlying cause of their symptoms.⁷  Although these patients may be seen by psychologists, psychiatrists, and social workers, the environment of the hospital and the staffing for these services are often lacking. Hence, these hospitalizations often focus more on triage than treatment. Does the adolescent require transfer to an inpatient psychiatric unit, or can they be managed outpatient? If outpatient, is their home environment safe? Who will serve as their outpatient providers? These are essential questions but often leave the child in a treatment middle ground as they await transfer or discharge to where they will receive definitive treatment. This is analogous to admitting a child with pneumonia, monitoring vital signs, giving fluids and supplemental oxygen, but waiting to start antibiotics until after discharge. Clearly, we can do better, and with pediatric inpatient psychiatric unit wait times extending to weeks or months, we must do better. Here are some ways we can.

First, the hospital needs to feel more like a healing environment and less like a prison. Many hospitals restrict adolescents with mental health crises to their rooms, with limited opportunity to leave the room, go outside, or interact with other youth. These restrictions, designed to ensure safety, often result in youth feeling trapped and punished and contribute to worsening mental health symptoms. But, as demonstrated by many mental health treatment facilities, there are ways to keep environments safe while still promoting healing and modeling effective coping strategies. For example, studies have revealed the healing power of nature⁸  and, conversely, the negative effects of being deprived of it.⁹  Providing access to a natural space for adolescents who are suffering from depression and anxiety during a hospital stay would help create a more healing environment. In addition, isolation may worsen an adolescent’s mental health symptoms. Psychiatric hospitals are designed to allow youth to interact with one another and engage in therapeutic activities. Medical hospitals should consider adding or redesigning space to allow for some social interaction, with appropriate infection-control safeguards given the medical setting. The proliferation of virtual technology during the COVID-19 pandemic may provide virtual group therapy options to achieve some of these therapeutic aims. These 2 basic changes, enhancing the physical and social environments, although significant departures from the usual medical inpatient model of care, could be implemented in varying degrees at pediatric hospitals and may have an immediate impact on improving patient care for this population.

Second, adolescent mental health crises should be treated more like pneumonia and the many other biological diseases admitted to the hospital on a daily basis. Assessing and treating the underlying causes of the adolescent’s symptoms should begin the moment the patient is able to participate, and the temptation to leave the adolescent in a holding pattern until they can be treated somewhere else by someone else must be avoided. This will require multimodal interventions: psychopharmacology, psychoeducation, short-term individual psychotherapy (eg, cognitive behavioral therapy), family therapy, and engaging the youth in activities that teach and promote healthy coping skills. These activities could include yoga or other exercise, art, and music. Child life specialists, which many pediatric hospitals employ, are involved in providing many of these activities currently and would be key in planning and expanding such services. Through recently enhanced telehealth services, rural hospitals that lack pediatric mental health providers and child life specialists could still provide these and other therapeutic services through virtual visits, thus potentially avoiding transfers to centers far removed from a patient’s home and support system.

This approach will require more availability of inpatient mental health professionals at pediatric hospitals, as well as enhanced training of pediatric nurses and physicians. But the investment required by hospital systems could have significant benefits as well. Lengths of stay would likely remain about the same, or even decrease, because patients with mild presentations could be stabilized and discharged to outpatient management sooner, whereas those with moderate presentations (not expected to require >10 days inpatient management) could be treated entirely within the children’s hospital and avoid transfer. The benefits of beginning treatments sooner, and avoiding transfers between hospitals, could have considerable positive impacts, not only on the patient but also on overall resource use for the medical system. Pediatric psychiatric units could then be used for the most severe cases, whereas the majority of cases could be managed on the inpatient pediatric unit or outpatient. This approach would require broad resource allocation and buy-in at all or most hospitals in a region to avoid overwhelming the 1 or 2 hospitals to offer such services for patients with mild to moderate mental health problems. In a system in which a few hospitals elected to take on this patient population, cost sharing between hospitals would be necessary because reimbursement for mental health admissions are much lower than for other diagnoses.¹⁰  Such changes may also have positive impacts on the mental health of health care providers who care for these patients because the focus and resources would be directed toward the more meaningful goal of healing the adolescent rather than just keeping them safe from harm.

Finally, because admissions for adolescent mental health crises tend to be lengthy, hospitals can use this opportunity to provide preventive medical services to this population, who has historically underutilized such services.¹¹  Among others, the raft of potential preventive services could include immunizations, contraception, and oral health. Providing holistic care for all patients admitted to the hospital, but especially adolescents admitted with mental health crises, would help to decrease the disparity in health care use for this population and could prevent future admissions or ED visits.

When the COVID-19 pandemic ends, the adolescent mental health crisis will remain. Addressing this crisis with a more proactive therapeutic approach will benefit not only the adolescents afflicted by mental illness but also health care providers who care for them and the health care system that shelters them.