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.