Shortchanging mental health for America’s kids
The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the U.S. surgeon general and the National Children’s Hospital Association have all declared a pediatric mental health crisis. I see this up close every day in the vast mental health system I oversee. Rates of anxiety, depression, eating disorders and suicidal behavior have skyrocketed. Young people are sitting for days to weeks in emergency rooms or in general pediatric beds, desperately waiting for admission to an inpatient psychiatric unit.
For kids lucky enough to find an inpatient psychiatric bed, clinics tell us when we try to discharge that they cannot provide a high enough level of outpatient care for that youth. And besides, waitlists of up to six months are the norm for routine outpatient psychiatric care.
Why has the state of mental health among our young people become such an incredible problem? The reasons are many. There have been steady increases in youth depression and suicidal behavior over the last 15 years. The CDC’s Youth Risk Behavior Survey reflects a 10% increase in depressive symptoms and a 5% increase in thoughts of and plans for suicide from 2009 to 2019. Access to care has not kept up with the growth in need, particularly for kids who need more intensive services. Tragically, suicide is now the second leading cause of death among people from 10 to 24 years of age, and will end the lives of more young people than any other health condition.
On top of the baseline trends, COVID has placed incredible stress on kids and families, doubling the need for youth mental health services. Our hobbled mental health service system for children is collapsing under the weight of the demand. Decades of disinvestment and shrinking reimbursements by both public and commercial payers have left us completely unprepared for any kind of increase in need.
Despite the many challenges, we have learned so much about children’s mental illness over the last 20 years and have developed many effective treatments that have proven to work across the developmental life span. We know reaching kids as early as possible in the course of illness is associated with the best health and well-being. Why are we waiting until kids get really sick before we help them? What do we need to do to get these effective services out to kids and their families in a timely manner?
First, we need to address the entrenched drivers underlying our inadequate care system — and those drivers are largely financial. The steady reduction in child and adolescent inpatient psychiatric and residential treatment beds over the last two decades is directly related to shrinking reimbursement rates for inpatient and residential care. Outpatient mental health services, which should be the backbone of our care system, suffer from the same shortfall. Both Medicaid and commercial insurance reimbursement simply do not cover the cost of quality or evidence-based mental health care.
Specifically, on the commercial side, insurance companies reimburse at such low rates that mental health providers cannot afford to provide care to these patients. Finding an in-network provider presents a huge challenge to families, especially if the young person needs to see a child and adolescent psychiatrist, who are in particularly short supply. Families are forced to go out of network to find providers, where their commercial insurance will only cover a small percentage of the real cost of care — if they can even find a mental health provider.
For lower-income families, Medicaid often provides better access, but insufficient reimbursement rates are reflected in low salaries and high workload demands, often provided by the least experienced clinicians. Here, we have an underpaid and demoralized workforce that is leaving public service as soon as they can. They easily can make more income in the private sector, in private practice or in a different field altogether.
The promise of intensive, community-based services — one of the justifications for decreases in inpatient psychiatric and residential treatment capacity — that can keep kids safe at home and in their communities has not materialized. This leads to agonizing stress and pain for families trying to take care of sick kids at home. These services will not become available until we figure out how to sustainably pay for them.
We spent millions and millions of dollars at the beginning of the COVID response to keep people alive. ICU beds sprouted up all over city hospitals in a matter of days. Ventilators were shipped across the country as the surge shifted. The National Guard was mobilized to help. So I ask: where is our mental health emergency response to all the enormous suffering that children and families are experiencing? How do we fix our mental health system so a breakdown like this never happens again? Why don’t we have a realistic rescue plan?
Havens is the Arnold Simon Professor and chair of the department of child and adolescent psychiatry at NYU Grossman School of Medicine.