Why so few hospital beds for teens?

Hospitals weigh competing needs for scarce resources

The absence of adolescent inpatient psychiatric beds in Santa Clara County — described by one Palo Alto child and adolescent psychiatrist as a "hospitalization crisis" — is actually the norm rather than the exception in California.

The number of counties without inpatient beds available for adolescents far outnumbers those who have them, meaning that more often than not, youth in crisis are transferred to hospitals miles away from home. Forty-seven counties, or 81 percent of the state, have no adolescents beds. Eleven counties do, according to the California Hospitals Association (CHA). (Click here to see a map of beds available in the Bay Area.)

The state has for the past several years experienced a dramatic decline in all inpatient psychiatric services, with more than a 30 percent loss in the number of beds available statewide since 1995, according to the CHA.

"It's a tragedy in our medical system," said Maria Daehler, a child, adolescent and adult psychiatrist with a private practice in Palo Alto. "Unfortunately, over the last decade, we have really seen the severe dwindling of all inpatient services for all children."

The lack of beds means longer distances traveled to get emergency inpatient care, which for some teens can compound the trauma of hospitalization. For their families, it means stressful, time-consuming commutes to make the daily visits required during hospitalization.

Adolescent inpatient psychiatric units in the Bay Area run as large as 34 beds (Alta Bates Summit Medical Center in Berkeley) and as small as 17 at Mills-Peninsula Hospital in San Mateo, the closest adolescent inpatient unit to Palo Alto.

Several forces, mostly financial, have disincentivized hospitals throughout the state from maintaining or opening specialty inpatient units for adolescent psychiatric patients, mental health professionals say.

"Hospital beds are relatively scarce and valuable commodity so all hospitals — I'm not just talking about psychiatric (units), but hospitals in general — have to consider carefully, what does a community need?" said Daniel Becker, a child/adolescent psychiatrist and director of adolescent mental health services at Mills-Peninsula. "In the end, we have a commitment to the community to figure out ... what's the best use of our resources to serve the community?"

For most communities, the greatest mental health need is within the adult population rather than for children or adolescents. According to Michael Fitzgerald, director of behavioral services for El Camino Hospital in Mountain View, which has a 25-bed inpatient unit for adults, "Every single day in Santa Clara County there are adults waiting for beds that don't exist."

So the specialized resources and staffing required for an adolescent inpatient unit — or any specialty services, like a transplant or eating-disorders treatment unit — must be weighed against other needs in the community where the demand is greater, Becker and other hospital officials said.

The demand for inpatient psychiatric care for teens is also less constant than for adults, fluctuating with the school year. On average, Mills' 17-bed inpatient unit runs at about 50 percent capacity, Becker said, but can be completely empty or full at different points throughout the year. Mills often closes its unit during the summer but does not repurpose empty adolescent beds, not being able to predict when they might next be needed, Becker said.

"If you're a hospital and you're trying to develop a business model, it's very hard to have a program that functions six to seven months a year and stops during the summer months," said Antonio Hardan, professor and chief of the Division of Child & Adolescent Psychiatry at Stanford Children's Health. "A hospital, in order to survive, has to be a little bit creative to be able to maintain the program year round."

"It's not a financial investment," Daehler said of an inpatient psychiatric unit for adolescents. "No place is going to do it if they're hoping to break even."

A glance at where local hospitals are making their investments illustrates this. A new $2 billion, 824,000-square-foot Stanford Hospital facility set to open in 2018 will house more than 350 new beds, but none so far have been designated for inpatient adolescent psychiatric care, a hospital spokeswoman said.

A few miles south at El Camino Hospital in Mountain View, a new $52 million behavioral health facility, also set to open in 2018, will have a total of 36 beds, including nine set aside for a specialty unit to treat women with conditions like postpartum depression and psychological trauma. Fitzgerald said the hospital is still considering whether or not a sub-section of beds could be given over to adolescent psychiatric care.

"There's an expectation: Why would we not have this right here?" Fitzgerald said. "We're sensitive to that. We have to balance that with all the mental health needs. It's a tough message for us to give."

The shortage of beds runs parallel to what the American Academy of Child and Adolescent Psychiatry (AACAP) calls a "workforce crisis" in child and adolescent psychiatry. A 2013 AACAP study found that there are still too few child and adolescent psychiatrists to treat the number of children in the United States. Mental illness impacts 20 percent of American youth; half of all cases of mental illness begin by age 14 and three-quarters by age 24, according to AACAP.

In 2012, the latest year for which the data are available, there were between 50 and 100 practicing child and adolescent psychiatrists in Santa Clara County. (Comparatively, there were between 20 and 50 in San Mateo and San Francisco counties, more than 200 in Los Angeles County and zero in more than 10 other counties. Click here to see a breakdown of child and adolescent psychiatrists in California by county.)

Going into child and adolescent psychiatry requires extra years of training (which can mean more student debt) for a field that is notoriously underfunded and offers low pay. Insurance carriers also determine private practice rates based on all mental health professionals who serve children, so a marriage and family counselor with a required two years of training might charge the same rates as Daehler, who has 10 years of postgraduate training, she said. The shortage can lead to teens seeing professionals who might not have extensive training with more serious mental illnesses — with adolescents who are actively suicidal, for example.

Throughout this year, many Palo Alto families have reported long wait times and difficulty getting in to see quality mental health professionals close to home. It took Manon Piernot, a junior at Gunn High School, a month to find a psychiatrist who was close to home, covered by her family's insurance and didn't have an impossibly long wait list. She said many psychiatrists in Palo Alto were not accepting new patients. She ended up seeing one in Burlingame who did not have a wait list.

This process can also be complicated by the need to find a psychiatrist with whom the patient feels truly comfortable.

Mental health professionals themselves say the local network is unequipped to meet the current high demand.

"In spite of having a number of therapists in the community, we don't have an organized mental health system that is designed to fit the need that we have," Stanford child and adolescent psychiatrist Shashank Joshi told the Weekly in April. "We are doing this right now more by default than by design."

Adolescent Counseling Services, the Palo Alto nonprofit that provides on-site counseling for Palo Alto and Gunn high schools, saw 100 more students at least once from August through November of this school year than the same time period last year, according to ACS On-Campus Program Director Roni Gillenson. And in March, with a sense of urgency following the fourth teen death by suicide just weeks before, the school board approved $250,000 in district funds to hire two full-time licensed mental health therapists, one for each high school, as soon as possible.

During what Stanford child and adolescent psychiatrist Victor Carrion calls an "upsurge" at the Stanford Health Care Emergency Department — a spike in visits following a suicide in the community — adolescent visits typically double from one every other day to one per day. One of every three to four emergency psychiatric evaluations results in the need for hospitalization, Carrion said.

In the two weeks following one of this school year's suicides, Stanford clinicians added to their regular workloads 31 extra appointment slots for urgent cases, said Antonio Hardan, director of the Division of Child and Adolescent Psychiatry. These appointments were dedicated to urgent evaluations for adolescents experiencing acute symptoms.

In the past year, Stanford has brought on nine new clinicians in its child- and adolescent-psychiatry outpatient clinic to meet the growing need, Hardan said. There will be four more added within the next six months.

Yet even a teen with acute symptoms might have to wait up to two weeks to be seen in the clinic, he said. A patient coming into the clinic on a referral from an outside provider would face a longer wait.

Stanford's outpatient adolescent-psychiatry clinic is sought after because it accepts insurance for psychiatric services, which not all do.

"There are many private practice psychiatrists and psychologists in Palo Alto and Menlo Park and surrounding communities, but the private-pay model is limiting for families," Hardan said. "Even if they are being seen by a local doctor, families will often want to try and get into our clinic due to insurance coverage."

Those patients who can't be accommodated at the Stanford clinic are referred to providers in Palo Alto or neighboring communities, Hardan said.

"Can child psychiatrists and psychologists take care of the vast number of children that need mental health (services)?" Carrion asked. "The answer very clearly right now is 'no.'"


There is help

Any person who is feeling depressed, troubled or suicidal is urged to call 1-800-784-2433 to speak with a crisis counselor. People in Santa Clara County can also call 1-855-278-4204.

For more resources, go to Resources: How to help those in crisis.

Related content:

Beyond the 5150: When a teen is in a mental health crisis, what's working -- and what isn't

Simitian: 'Significant' need for psych beds for teens

Storify: Palo Alto community urges support for teen wellbeing

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55 people like this
Posted by Stanford
a resident of College Terrace
on May 22, 2015 at 12:30 pm

The Stanford child and adolescent psych clinic has a 2-3 month wait, and your child will almost certainly be paired with a fellow (advanced trainee) rather than an experienced attending physician. Each year, the fellow graduates, and your child will be paired with a new one. This provides excellent training for Stanford psych fellows, but is not optimal for the young patients. The complete absence of inpatient child and adolescent psych services (outside of the eating disorders treatment/research program) is perhaps understandable from a financial perspective, but not from a community service one.

7 people like this
Posted by $$ is the problem
a resident of Crescent Park
on May 22, 2015 at 7:18 pm

The lack of beds and lack of affordable, experienced therapy for teens is because of $$. While I can't speak to the cost of hospital beds, I can give some info about the cost of experienced therapists (not the inexperienced, although well meaning ACS interns and Stanford interns...) people who have year of experience helping adolescents charge typically $175-200 an hour. Many/most of the therapists in our area do NOT take insurance because the insurance reimbursement rate is about $100 an hour less than their billable rate. (Our Blue Shield insurance gives a therapist the $25 co-pay and $60 an hour or $85 compared to his billable rate of $185.)

Using those numbers, the $250K PAUSD allocated toward therapist for the high schools would allow them to see 32 students per week per school during the school year, not bad, but is it enough?

5 people like this
Posted by RE: $$
a resident of College Terrace
on May 22, 2015 at 10:04 pm

Unfortunately, the $250K PAUSD just allocated towards HS therapists will NOT be used to allow any students to see outside therapists. Instead, it will go to hire 2 new therapists to process the back-log of ERMHS (Educationally-Related Mental Health Services) paperwork.

50 people like this
Posted by Sarah1000
a resident of Los Altos
on May 23, 2015 at 6:48 am

Hospitals deal with fluctuating patient numbers for influenza and maternity cases. The fact that they use fluctuating need as justification for providing ZERO adolescent psychiatric beds in the richest (in per capita income) county in California is shameful and embarrassing.

40 people like this
Posted by mixed unit?
a resident of Crescent Park
on May 23, 2015 at 7:01 pm

One thing Stanford may want to consider would be to make their inpatient psychiatric unit open to both adults and adolescents, with the adolescents grouped together in the unit and overseen by a specialized staff. This would make inpatient adolescent psychiatric treatment more financially viable. This is a model used by some well-known private psychiatric hospitals on the East Coast.

1 person likes this
Posted by Hard to keep up
a resident of Old Palo Alto
on May 24, 2015 at 8:59 am

@ RE:$$ - you said, "Unfortunately, the $250K PAUSD just allocated towards HS therapists will NOT be used to allow any students to see outside therapists. Instead, it will go to hire 2 new therapists to process the back-log of ERMHS (Educationally-Related Mental Health Services) paperwork."

That is news to me and possibly many other parents. I never assumed the $$ would be used to see outside therapists - but... I DID think the purpose of the emergency funding of a dedicated therapist at each school was to have these therapists actually have a caseload of students or possibly case-manage (oversee, coordinate) the students-in-need identified at their school.

The Board discussion that prompted this emergency funding decision had to do with increased numbers of students in distress and an overwhelm of current on campus support programs. Paperwork backlogs for ERMHS (meaning special ed-related only - correct?)was not what I expected out of this.

Can you point to documentation or quotes from PAUSD leaders that support your post - that these therapists will be working on paperwork backlogs and ERMHS-only? No actual students seen? Thank you. Wow.

3 people like this
Posted by sped parent
a resident of Another Palo Alto neighborhood
on May 24, 2015 at 3:39 pm

@hard to keep up,

I too would like an answer to your question. The longer we have been in the special ed system, the greater the web of lies spun on the district end. So they're caught having to re-examine everything to remember what they lied about before, it must be incredibly taxing. In addition, they have a practice of creating paperwork for families (especially through lots of inaccurate/outright false documentation - there's such a consistent pattern with many families, this must come from the district legal as a strategy) so the families are kept off kilter. That also requires a lot of administrative resource. The most vulnerable are just so easy to compromise and maybe even make move away, which seems to be the goal. Someone on another thread said a child who had depression because of the cancer death of a sister was dropped from his private school after they found out he had been in a psychiatric hold. Our schools can't do that overtly, they apply pressure by "encouraging" the most vulnerable to leave by applying stress and even retaliation in the special ed arena.

With so many kids in vulnerable mental health circumstances, this is a veritable powder keg unless McGee steps in and overtly cleans up the problem, apologizes, and lets the public know what the standards will be and where to seek help if they aren't met. Not just for employee behavior, but also their childrens medical/education records, etc. Given what I have seen in this district, I find the idea that we are hiring new people to double down on the paperwork rather than counsel them downright threatening, not supportive of our kids.

1 person likes this
Posted by RE: $$
a resident of College Terrace
on May 24, 2015 at 10:40 pm

I heard from both my HS student's case manager and therapist that the newly-hired HS therapists will focus on determining ERMHS eligibility since there was a big back-log of students requesting such services. They may well meet with students and/or other mental health care providers, but their focus will be on assessment, not treatment.

4 people like this
Posted by Sarah1000
a resident of Los Altos
on May 25, 2015 at 6:38 am

But the fact that the District will have two more therapists is a good thing, regardless of whether or not they face the task of completing a backlog of assessments. (Some students with mental health issues qualify for special education services under the "emotionally disturbed" category. The assessments are necessary to get them these services.) I am sure that emergency referrals will get top priority and those students will be seen. MVLA has six full-time therapists and will have seven next year, two of whom are paid for by El Camino Hospital. Any student (not just special-ed) can see a therapist. Support your Board, Superindent, schools in these hirings and demand more therapists. Does Stanford cover the costs for therapists in your schools? (I'm not talking about a Stanford psych fellow who reviews existing diagnoses or a psychiatrist who is a community liaison but actual $ for therapists.)

21 people like this
Posted by Shame on Stanford
a resident of Community Center
on May 25, 2015 at 10:35 am

Stanford should be ashamed of their lack of support for student mental health services. It's nice to have Professor Joshi as a resource, but how about following the example of El Camino hospital and funding some counselors in the schools? And then how about opening an inpatient facility? I for one pledge that I will give no more financial support to Stanford Hospital or LPCH until they open an inpatient adolescent psychiatric unit. And as long as PAUSD continues smeared in the national press, we should make an effort to be sure that Stanford gets smeared along with it for letting this happen in their backyard without providing any real support to treat these kids.

On top of this, where is all of that mental health "millionaire tax" going? There are plenty of people in this community paying that tax. It would be nice if there were actually some benefits to the community from it.

6 people like this
Posted by concerned parent
a resident of Greenmeadow
on May 25, 2015 at 10:24 pm

I agree with poster, "Stanford", that Stanford Child and Adolescent Psychiatry Dept is woefully lacking basic services including availability of clinical psychologists that have completed their training (that is, are hired on as staff, or what's call "attendings" not postdocs). The postdocs only see your kid for one year on a Sept-Aug calendar, and then your kid must switch to a new one (so if your kid starts after Sept, they see the post doc even less time before needing to change psychologists). This lack of trained staff and continuity of services really hurts and makes our community more vulnerable. The system at Stanford is set up to train PhD psychologists at the expense of our children. Also, continuity with a psychiatrists there is hard to find, as they have tremendous staff turnover. Dr. Joshi Shashank, their celebrity doctor has been pretty much unavailable to new patients for years (except maybe those with some kind of connections). Nor do they have basic family therapy either; bad set up all around.

5 people like this
Posted by Correct
a resident of Barron Park
on May 26, 2015 at 11:05 am

Shame onStanford is absolutely right. It is criminal the way they overcharge, put false charges on hospital bills, double bill, expand, overpay administrators, and expand again.

Their inpatient care is often negligent, med students are under supervised and given too much liberty, attending docs disappear. Packard has NO pediatric E/R, leaving
Children stranded for hours in an adult E/R. There should be pediatric/adolescent mental health services there and plenty of beds for such.

With all their wealth from excessively high rates and billionaire alumni donations, a school and hospital that promotes itself as a world class facility has NO no no excuse for claiming poverty and turning a cold shoulder of irresponsibility.

13 people like this
Posted by Thank you
a resident of College Terrace
on May 26, 2015 at 8:45 pm

Sarah and Mamon, thank you so much for bravely speaking out about your experiences and the inexcusable absence of appropriate adolescent in-patient psychiatric facilities in our community. There are many more of us who have had similar experiences but are too fearful to speak up.

Sorry, but further commenting on this topic has been closed.

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