In the year leading up to April 2021, Doriane’s 16-year-old daughter went to the emergency room six times.
“Everything started with suicidal ideation,” said Doriane, who asked that her last name not be used for privacy reasons. “And then we did end up having two suicide attempts. It took a while to get a proper diagnosis and to really know what was going on.”
To get her daughter immediate care, the emergency room was the only option for the Holliston residents. But for a child in mental distress, a busy emergency room full of sick and injured patients was especially troubling.
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“To see other patients like that who are suffering in distress, it was just — it was further traumatic,” Doriane said.
The problem of behavioral health patients being stuck in emergency departments isn't a new one. But it’s been exacerbated by a confluence of challenges, including the mental and emotional strain caused by the pandemic and a shortage of trained behavioral health staff. Experts, families and those in Massachusetts hospitals told GBH News that the backup hurts everyone, delaying care for other medical emergencies that come into the emergency room and forcing patients in mental health crises to stay in a stressful environment for an extended period of time as they wait for crucially needed care.
“We are seeing significantly increased amounts of boarding in emergency departments, and also patients that are staying longer once they are in those emergency departments,” said Leigh Simons Youmans, senior director of healthcare policy at the Massachusetts Health and Hospital Association. “And as this mental health crisis and the pandemic progress, it is becoming increasingly problematic with the amount of volume that the emergency departments are seeing.”
The pandemic has been hard on mental health for many people, but teenage girls have been among the most impacted. The CDC reports ER visits for suspected suicide attempts among girls aged 12 to 17 increased nearly 51% nationally between 2019 and 2021.
Ideally, Doriane's daughter would have had a psychological examination in the emergency room and then immediately been moved to an inpatient behavioral health facility that specializes in treating patients like her. But in each visit, there were no beds available right away. So she stayed in the ER.
On her most recent visit last April, the 16-year-old was kept in the ER for two weeks before a suitable inpatient bed was found.
“She did not want to stay there [in the ER]. She would beg me to take her home,” Doriane said. “It was awful. And it’s just, it’s heartbreaking because you don’t want your child to suffer any more than she already has. But, you know as a parent that we needed help. We just needed to get her more support and more help. We knew if she came back [home], I was just afraid that she’d end up dying.”
As of last Tuesday, 559 behavioral health patients were being boarded in the emergency departments or medical/surgical units of 50 reporting hospitals in Massachusetts, according to the Massachusetts Health and Hospital Association. That’s nearly a fifth of all staffed ER and medical/surgical beds at those 50 hospitals. And the number hasn’t dipped below 500 patients in the 15 weeks that the association has been tracking that data.
The state Department of Mental Health is alerted when a behavioral health patient has been in the emergency room for more than two and a half days. In the most recent state data available, from August, the average length of an ER stay for those patients was more than five days.
The problem is even more severe for kids.
“The people who are staying the longest with us in the emergency department, unfortunately are children and adolescents,” said Dr. Suzanne Bird, a psychiatrist at Massachusetts General Hospital who leads the hospital’s acute psychiatry service, which serves patients in the emergency department.
For the children who the state tracked because they were in the ER longer than two and a half days, the average length of stay was closer to a week.
Bird says the problem takes its toll on the ER staff.
“It’s a constant source of tremendous frustration and demoralization and helplessness,” Bird said. “People feel overwhelmed by the constant lack of capacity, the lengthy stays, the inability to provide the care that we know these patients need. We’re doing our best, but we know it’s not where they really need to be. And coming in day after day after day and seeing the same person in the same situation in the same bed is not a good feeling.”
Last spring, MGH tried to adapt to the influx by opening a calmer area of the emergency department, devoted exclusively to behavioral health patients, where patients have their own rooms, away from the loud and chaotic scenes that routinely play out in the ER. Bird says it worked.
“It’s much better, both in terms of decompressing the general emergency department, who need to continue to be available to treat trauma patients and acute medical patients, and also to take these patients with behavioral health emergencies out of the bright, loud, overstimulating, crowded environment, which none of us, honestly, would be able to feel better in,” Bird said.
When the new psychiatric area opened with 20 rooms, she said, they believed that would be sufficient to meet the demand. But the demand recently has gone as high as 50 patients, she said.
The root of the “boarding” problem, experts say, is that there aren’t enough inpatient psychiatric beds available for the patients who need them. That’s largely because of staffing issues, said Joy Rosen, vice president for behavioral health for the Mass General Brigham system. Mass General Brigham has about 600 inpatient psychiatric beds across its system, she said. More than 100 of them are currently unusable because of a lack of staff.
“Staff are either out due to infection or because of the workforce shortage,” Rosen said.
Just like in many other healthcare fields, many behavioral health staff have burned out over the course of the pandemic and chosen to leave the field.
That behavioral health staffing crisis hasn’t escaped the notice of state officials. A spokesperson for the state Executive Office of Health and Human Services told GBH News that the state “has been working to expand and stabilize inpatient psychiatric capacity as well as emergency room diversionary interventions.”
"We knew if she came back [home], I was just afraid that she'd end up dying."Doriane from Holliston, on her 16-year-old daughter
In July, the Baker administration announced a plan to use $31 million in federal relief funds for temporary supplemental payments to recruit new behavioral health staff. The state also provided financial incentives to help add an additional 248 psychiatric beds over the last year, although many of those beds can’t be used due to staffing shortages.
The state is also attempting to expand the behavioral health workforce in the long term by investing $122 million of federal relief funds to help repay student loans for those training to enter the field.
“That’s going to make a significant difference,” said state Sen. Julian Cyr. “We’re going to have an additional 2,000 people in our behavioral health workforce because of this program. But it’s going to take some time to ramp up and to get that loan-repayment program in place. The tricky thing with workforce is that it’s just not quick and easy to solve overnight.”
Cyr authored legislation aimed at bolstering Massachusetts’ behavioral health services across the board. The so-called “Mental Health ABC Act 2.0,” which passed the state Senate for the second time in November and is now before the House, would require, for one, all hospital emergency departments to have a qualified behavioral health clinician available around the clock.
One key part of the bill is already underway. It would direct the state Executive Office of Health and Human Services to create an online portal that would help emergency departments match patients with currently available and appropriate beds. Cyr said the portal is being developed now with federal funding.
Although the legislation has failed to pass the House in the past, Cyr said he’s optimistic it will become law this time.
“All of us, I think, have a newfound appreciation that mental health care is absolutely essential, ... that access to mental health care when people need it is actually an essential part of what people need to lead healthy, fulfilling lives,” he said. “That’s what’s really changed here and what gives me quite a bit of optimism going into the the last seven months of the session.”
For Doriane’s daughter, an accurate diagnosis came after her sixth hospitalization. The teen was diagnosed with bipolar disorder, and Doriane said the medication she was prescribed is helping.
“She’s doing great,” Doriane said. “I mean, she is really happy to be back in school full time. You know, she’s working towards her future. She’s doing really well.”
And she said that’s thanks to excellent inpatient care her daughter received, once a spot opened up and she was finally released from the ER.
If you or someone you know may be struggling with suicidal thoughts, call the National Suicide Prevention Lifeline at 800-273-8255.
