The mental health crisis among children and youth is on the rise, as is glaringly evident in gridlocked emergency rooms around the country. Schools, communities, and clinics have also seen an influx of youth with mental health conditions such as depression, anxiety, ADHD, and behavioral disruption, along with higher suicide rates during the Covid-19 pandemic.
Following a 2021 declaration of a national emergency in child and adolescent mental health, last month the American Academy of Pediatrics (AAP) released a joint policy statement with the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA). It is a necessary call to action for bolstering preventative and treatment resources for children and youth with mental or behavioral health conditions, including the acute need to enhance emergency department (ED) capacity to accommodate children in crisis.
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The statement focused on telehealth as a vital conduit to mental healthcare across settings and as a link to care for underserved communities. In my clinical experiences providing psychiatric crisis care, telehealth is the cornerstone of a strategy for responsible, efficient, and equitable mental healthcare.
Hospitals are overcrowded with individuals with mental health symptoms
In the policy brief, the authors cited that ED visits due to mental health concerns increased during a near-decade period before the pandemic: by 120% at children’s hospitals and by 55% at general hospitals.
The pandemic worsened this crisis and exacerbated existing inequities. For example, in 2021 at Children’s Hospital Colorado, suicide attempts were the primary reason children sought care in the emergency department. Meanwhile, earlier this year at Rady’s Children Hospital in San Diego, the number of children seeking psychiatric emergency services jumped from approximately 30 a month in recent years to 30 a day during the pandemic.
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Even when ED teams can adequately stabilize a child in crisis, outpatient follow-up care is in short supply. A study of more than 28,000 children found that fewer than one-third received an outpatient mental health visit within seven days of being discharged. Slightly more than half (55%) had a follow-up within 30 days.
ED patients face unnecessarily long wait times and stays
Historically, patients with mental health concerns are likely to wait up to 3.2 times longer for care than ED patients presenting without these concerns. Persons with mental health issues are six times more likely to be transferred to facilities with longer inpatient stays. Lack of specialized behavioral health care services worsens this situation: 54% of over 2,000 hospitals nationwide said they did not have a psychiatrist on staff or available for medical ED and inpatient consultation. This problem of lack of timely care can be exacerbated for children and youth presenting to EDs. Children in crisis often must wait in the ED for hours—or even days—to see a psychiatrist.
Unfortunately, I have seen firsthand the consequences of this. Without access to a psychiatrist on an intensive outpatient treatment team, an adolescent experienced a lapse in appropriate pharmacologic treatment to regulate suicidal and homicidal ideations. This led to several hospital readmissions and weeks of inpatient boarding in a medical unit. The adolescent was unable to follow up with a prescriber to make medication adjustments that may have prevented readmissions.
Another adolescent patient was admitted to an inpatient medical unit of a hospital for over four months pending transfer to a residential facility. The patient’s behaviors escalated to violence and were a significant source of distress for many direct care staff—requiring consistent nursing supervision, a two-to-one staff-to-patient ratio, and a consistent security presence.
Similar situations are happening daily across the nation, demonstrating how inadequate behavioral health support can prolong stays, increase isolation, and worsen mental health conditions.
Tackling disparities through innovative solutions
Access to effective, culturally sensitive care is urgently needed in an environment influenced by the impacts on mental health of events such as the pandemic (with its associated disruption on academic and social life), highly publicized instances of racialized violence and the struggle for social justice, social media exposures, and bullying. The ignorance of biases among providers can impact all aspects of the mental health continuum, creating barriers to effective treatment with particularly disparate effects in racialized and other minoritized populations.
Special populations, including those from racialized ethnic groups, individuals identifying as LGBTQ, and immigrant populations, are contending with these challenges in areas lacking specialists or resources. As of 2018, half of U.S. counties lacked access to a psychiatrist. When a specialist is present within a community, wait times for psychiatric care are long, typically exceeding those for all other specialties at an average of more than 10 weeks.
Tackling disparities through technology and digital equity will reduce overall morbidity and mortality, including for patients in the ED not experiencing symptoms of a mental health condition. Along the continuum of mental health care, initiating or enhancing telehealth services in community outpatient clinics can facilitate early intervention to prevent ED visits and critical follow-up to prevent rehospitalization.
A telehealth partner can provide support for staff to address medication management and effective strategies for behavioral care concerns through access to regular therapy or counseling. Telehealth provides an indispensable link to a psychiatry-led solution for the children’s mental health crisis and brings behavioral care within reach—from overwhelmed urban centers to under resourced community clinics and remote rural areas.
Telepsychiatry is a key component to better care for all
Hospitals, at the center of the ongoing mental health crisis, need a behavioral health road map that’s clinician-led and telehealth-enabled. Having a telepsychiatrist as the focal point for behavioral care streamlines ED evaluation, disposition decisions, and treatment for youth with specific psychiatric conditions—helping hospitals cut back on unnecessarily long wait times, strain on ED teams, and inpatient length of stays. Consider these four ways telepsychiatry can reduce psychiatric boarding, improve bed availability across the ED, and provide improved continuity of care:
- Overworked and inundated in-person hospital staff can rely on telepsychiatrists for mental health status exams, peer-to-peer consultations, and patient triaging—ensuring an optimal use of all hospital staff and clinicians’ time.
- Telepsychiatrists can prescribe medication (if needed) and initiate stabilizing treatments more rapidly while patients wait for an inpatient bed.
- Patients waiting for an inpatient placement could be virtually reassessed daily to determine the least restrictive means for treatment, with possible pathways to discharge to outpatient services.
- Remote access to psychiatric and community mental health expertise enhances safety-net planning, bridging patients to community resources to help avoid hospital readmissions.
Furthermore, staff burnout and fatigue are setting in as primary and emergency care physicians are being called upon to treat mental health issues with limited training. More patients in the ED can mean worsened care for all, increasing the likelihood of errors by overwhelmed emergency care staff.
A “mental health moonshot”
Traditional methods of care delivery cannot fully equip our hospitals or clinicians to overcome the mental health crisis. Even when hospitals ramp up to hire more mental health staff and add more inpatient beds, there is often not enough capacity to meet the need. This can also mean resources being diverted away from other hospital uses or forms of inpatient care.
Echoing expert-led bodies on pediatrics and emergency care, telehealth is not just an optional enhancement but a strategic requirement to increasing behavioral care resources, training, and patient access. It is evident: Telehealth can provide a runway for the giant leap we must take to protect our children’s well-being and better meet escalating demand for mental healthcare.
A “mental health moonshot” is needed to address the community-based and systemic barriers affecting children’s mental wellness, including increasing access to telehealth services, in-school resources, expanded insurance and Medicaid coverage, and clinician diversity and bias training for specialists. All combined, these escalated efforts can help our children heal.
Photo: SolStock, Getty Images
Jamie Evans, MD, MPH, (she/her), Medical Director of OnDemand Care and Clinician Engagement with Array is triple boarded in Psychiatry, Family Medicine and Obesity Medicine. Dr. Evans received her medical degree from the University of Pittsburgh and completed her residency at the University of Cincinnati Academic Medical Center. She also holds a master’s degree in public health with a concentration in health behavior and health education. She currently serves as a Medical Director for OnDemand care and a co-chair of the Diversity, Equity, and Inclusion Committee at Array Behavioral Care, a virtual behavioral healthcare practice providing a range of acute and non-acute care services nationally. She previously worked as an outpatient family physician in rural North Carolina for nearly five years prior to joining Array. She continues PRN work in urgent care clinics and has a passion for mentoring students interested in pursuing healthcare careers.
