An adolescent girl requiring admission for complications of cystic fibrosis was concurrently experiencing suicidal ideation and engaging in self-harming behavior. Because the local children’s hospital did not offer inpatient psychiatric care, she was transferred to the closest pediatric hospital able to provide both concurrent medical and inpatient psychiatric care. Although the patient presented at a large urban medical center, the “nearby” facility was 250 miles away. Unfortunately, because of limited household resources, her parents were unable to visit and directly participate in her medical or psychiatric treatments.
Illustrated in this case is a situation that it is not uncommon for health providers at children’s hospitals: how to manage acute mental health crises in medically complex youth given a lack of available inpatient pediatric psychiatric units within many medical centers. Her providers were faced with the challenge of balancing what was in her best interest, treatment of her pneumonia, cutting behaviors, and suicidal ideation, with the reality that in their community no facility could provide standard of care for both medical and mental health concurrently. How then to minimize harms in attempting to meet both her psychiatric and medical needs?
A burgeoning literature indicates that depression is increasing in children and adolescents, and suicide is now the second leading cause of death in children, adolescents, and young adults (ages 10–24).1 Youth with chronic illness are at an increased risk for depression and suicidal ideation.2 Pediatric emergency department encounters for suicidal ideation and self-harm have doubled for children ages 5 to 17 years, and more than half of these encounters resulted in inpatient hospital admissions.3 Primary mental health diagnoses account for ∼10% of overall pediatric hospitalizations and 3% of hospitalizations at freestanding children’s hospitals.4 These staggering rates underscore that mental health crises seem to be increasing, yet children with mental health disorders often do not receive necessary care, particularly inpatient psychiatric care to address mental health emergencies and safety concerns, because of a lack of available psychiatric services.5
Limited access to mental health care is a well-known public health concern for a variety of reasons, including deficient insurance coverage, a severe shortage of child psychiatrists nationally, and limited availability of inpatient beds.5 “Boarding” psychiatric patients in medical units or emergency rooms because of lack of inpatient psychiatric beds is increasingly problematic. If not admitted to a medical unit, children and adolescents are sometimes transferred to distant facilities, as illustrated in the case above, thereby limiting support and participation from families during the therapeutic process. Although empirical data are limited,4 providers treating youth with medically complex conditions often observe additional barriers when attempting to refer this underserved population for inpatient mental health and concurrent medical care. Freestanding children’s hospitals typically focus on the medical needs of medically complex children, may not be licensed for inpatient psychiatry care, and may have less availability of mental health services compared with general hospitals.4 Meeting both the medical and psychiatric needs of medically complex children often leads to dilemmas for providers in determining the most optimal treatment course.
Many stand-alone psychiatric hospitals refuse to accept medically complex patients given their own lack of available resources to meet patients’ medical needs. Providers must balance managing what is in the best interest of the child from both a psychiatric and medical standpoint, but considering limited available psychiatric resources, appropriate inpatient psychiatric care is often forgone. Mental health services are a limited resource that are even harder to access for medically complex children, which may compromise their chronic health conditions, negatively impact functioning and overall quality of life, or exacerbate their mental health problems.
Although children’s hospitals may admit children on medical units when inpatient psychiatric care is not available, this practice can result in unintended negative consequences. Medical units are often ill-equipped or not credentialed to manage inpatient psychiatric care, suicide or violence prevention, or more severe behavioral concerns, and they do not provide intensive counseling and family-based therapy.6 Many nurses on medical units do not have training in crisis prevention, psychiatry, or behavior management, such as those required of psychiatric providers. Patients, therefore, do not receive adequate care that would otherwise be provided at an inpatient psychiatric facility, and suboptimal management of their psychiatric needs compromises several domains of their quality of life, safety, and care delivery. As such, children and adolescents are likely to continue to experience functional impairment and distress from untreated or undertreated mental health conditions.
To address gaps in access to psychiatric treatment in children’s hospitals, particularly for those who are medically complex, solutions are urgently needed to better manage this complex situation, ensure patient safety, and allow for an improved focus on medical and psychological health. We believe consultation and liaison services for both psychology and psychiatry are a first step in bridging this gap. Evidence suggest that consultation and liaison psychiatry services have been associated with decreased length of stay, cost-effectiveness, and improved patient care quality and staff satisfaction.7,8 Models for consultation and liaison services vary widely, depending on specific needs and resources of the institution, and there is no evidence to suggest an optimal service model.8 Providers may cover general services for the whole hospital or may be embedded into specific areas or clinics. Although telehealth consults are an emerging model, we believe face-to-face services remain the gold standard for delivery of quality longitudinal mental health care. Further research examining best practices for liaison services is needed.
Several other models are available to improve mental health services on inpatient units, such as training providers how to manage behavioral health concerns and strategic investment in psychosocial positions.9 We propose training inpatient nurses in crisis prevention and behavior de-escalation and, more generally, about mental health conditions and treatments. Likewise, all staff should be trained and comfortable in using and understanding the implementation of suicide precautions and the new guidelines put forth by the Joint Commission10 to minimize environmental risks. Finally, we propose collaboration with local mental health organizations that offer wrap-around or in-home services as another possible means to ensure more intensive services. Discussions with these service providers on adapting their traditional in-home services to be available to children beginning in the hospital are encouraged.
These solutions may help alleviate the lack of comprehensive inpatient mental health services to some extent, but ultimately, advocacy on behalf of providers and hospital administration and leadership for broader issues of accessing inpatient psychiatric care and mental health services is warranted. As health care providers, we must improve our advocacy efforts to promote policy change that integrates mental health care alongside medical care. Providers and hospitals serving pediatric populations are encouraged to familiarize themselves with local, regional, or national legislative efforts through organizations with advocacy priorities, such as the American Academy of Child and Adolescent Psychiatry, an organization that promotes pediatric mental health through advocacy, policy guidelines, educational initiatives, and research.11 Advocacy and lobbying to increase insurance reimbursement and coverage for mental health will be critical, particularly for inpatient psychiatric care. Hospital administrators should familiarize themselves with the burgeoning body of literature demonstrating increasing mental health needs among pediatric populations, analyze data from their hospital or catchment areas, and partner with their current providers to develop institutional strategic plans that prioritize funding for inpatient mental health programs to meet this growing need.12 Organizations should benchmark their services against leading national programs already delivering comprehensive services. Strategic planning prioritizing mental health may include expansion or creation of inpatient psychiatric units, leveraging for additional training for staff on managing behavioral and psychiatric needs of youth, and expanding positions for mental health providers.
Our health care system continues to fall short of ensuring that mental health services are available to our youth, particularly those who are medically complex and require inpatient psychiatric care. Until mental health services are available concurrently with medical services, in one medical home, mental health care will continue to be inferior and suboptimal. We must recognize that both mental and physical health are critical for children’s well-being and optimal functioning; segmenting care contributes to stigma around services in mental health. At the core of this problem is the disjointed nature of mental and physical health and the climate of grossly underfunded mental health. To reduce urgent mental health admissions, we must incorporate mental health care into our outpatient medical clinics with the aim of preventing clinical decompensation. To comprehensively address this health crisis, we must prioritize mental health care at children’s hospitals, train additional pediatric providers to deliver this care, and increase availability of mental health services through inpatient psychiatric care and consultation-liaison services. As pediatric providers, we must advocate for these changes and decrease the culture of stigma surrounding mental health.
Dr Canavera drafted the initial manuscript; and both authors conceptualized the manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.