COVID-19 has cast a spotlight on the shortages of mental health resources, especially for children and adolescents, but problems of accessing care have been increasing for years.

A new study, published this month in the journal Pediatrics, found children who visited emergency departments for mental health crises in 2015 were more likely to experience prolonged wait times for care than they were in the previous decade.

Researchers analyzed the length of stay for 36,125 patients ages 6 to 17 visiting a pediatric emergency department between 2005 and 2015 using the National Hospital Ambulatory Medical Care Survey. Researchers categorized visits into wait-time increments — more than six hours, more than 12 hours, or more than 24 hours. The length of stay for mental health visits were then compared with non-mental health emergency department visits.

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In the last decade, they found that the rate of mental health visits that lasted for more than six hours increased from 16% to 25%, compared with non-mental health visits, which remained stable.

“I think that the delay for children waiting in the emergency department to be discharged to a psychiatric facility or home to the community represents our mental health system coming to a head, a boiling point,” said Katherine Nash, lead author of the study and a fellow in the National Clinicians Scholars Program at the Yale School of Medicine. “It’s a proxy indicator of poor access.”

Nash said an emergency department can be “traumatic” for a child going through a mental health crisis because there is a lot of noise and chaos, especially in emergency rooms tailored for adults.

“It’s the opposite of therapeutic,” she said. “There is also a lack of consistency in the providers and nurses caring for you, and every hour you spend waiting there takes away from care.”

The issue is compounded by a rise in pediatric mental health emergency department visits, especially during the pandemic, as well as a shortage in child psychiatrists in most hospitals located in high-demand urban areas, said Hasan Memon, a child psychiatrist in private practice in Princeton, N.J., who was not involved with the study.

In the Philadelphia area, hospitals have struggled to place children and adolescents into psychiatric wards during the pandemic because of a shortage of beds. At Abington Hospital-Jefferson Health, the average wait for pediatric patients seeking mental health care through the emergency department doubled from just under 100 hours last March to nearly 200 hours by the end of the year.

“In urban areas, there’s an under allocation of resources,” Memon said. “Oftentimes there’s no child psychiatrist available in the ER. Not every hospital’s mental health department has a child psychiatrist. There’s underinvestment in mental health when it comes to kids, so the ER winds up being kind of a catch-all.”

In the new study, researchers found that mental health visits had higher rates of extended length of stays than non-mental health visits — 21.2% of mental health visits lasted longer than six hours, compared with 4.8% of non-mental health visits, and 7.7% of mental health visits lasted longer than 12 hours, compared with 1.2% of non-mental health visits.

Often an adolescent patient visiting the emergency department for mental health reasons will have stable vital signs, so they’re not prioritized by the triage scale, Memon said.

“It doesn’t look like anything is going to happen to them, even if they’re having a panic attack, which feels like having a heart attack,” he said. “People with mental health conditions usually get taken care of last because of that.”

Researchers also found that Latino children are nearly three times more likely to experience delays in care than white children. It’s not yet clear why that disparity exists, but Nash suspects it’s because language barriers can make evaluations in the emergency department a longer process. Placements into a facility with appropriate background services can be more challenging as well, since there is a dearth of Spanish-speaking pediatric psychiatric facilities, she said.

“In the emergency room, if we had better translated assessment tools and a standardized form in Spanish, combined with telemedicine, we could address concerns in a more effective way,” Memon said.

Nash said she was surprised by the study’s findings, especially since the issue of extended waits for mental health care has drawn national attention in recent years from the National Association for Healthcare Quality and researchers.

“I was hoping that we had improved in the last two decades, but the take-home message is that it’s getting worse,” she said. “We need to get more creative about how we provide mental health care in the community. We don’t just need more mental health providers, but we need people with diversity in training, language and background. It’s on us to make a system of care to address patients who are not English-proficient.”

Memon said that addressing underinvestment in pediatric mental health is crucial to improving access. Increasing funding for school preventative programs and parenting classes could decrease the burden on the current mental health system, he said.

“We know the solutions,” he said. “We basically just need to address them. We need to invest in these kids’ futures and in them.”

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