News

Editorial: No beds for teens

A disturbing lack of in-patient mental health services for adolescents

It was a shock to us and many readers to discover that when local teens facing an acute mental health crisis need hospitalization, Stanford University's world-renowned children's hospital must turn them away.

And even more surprising, in the entire county -- the sixth largest in California and the largest north of Los Angeles -- not a single hospital, including the county-funded Valley Medical Center, offers such services.

When local adolescents in crisis are taken by parents, police or paramedics to the Stanford or other emergency departments and they are deemed to need hospitalization, they wait -- often for many hours -- while the emergency-room staff tries to find an available bed at one of the few Bay Area hospitals with adolescent psychiatry units. And an ER staff person must physically stay with them constantly until they are transferred.

When and if a bed is located, policies dictate that the teen must be transported by ambulance, a humiliating and costly practice, often not covered by insurance.

With all the attention teen suicides have received since the first Palo Alto contagion in 2009, the resources that have been poured into programs and services to address adolescent mental health needs, and all the focus on de-stigmatizing mental illness, the common assumption was that acute cases were being gently handled within our local hospitals by physicians familiar with the unique conditions facing Palo Alto youth.

Incredibly, not so.

Thanks to a local family that shared its story with the Weekly, the distressing reality of this inadequate system is now out in the open. With 50 students at Paly and Gunn high schools alone having been hospitalized during this school year, dozens of families have discovered this gap in available resources.

The nearest inpatient facilities are at Mills-Peninsula Hospital in San Mateo, which has only 17 beds, and Fremont Hospital, with 25 beds. St. Mary's Hospital in San Francisco has 20 and Alta Bates in Berkeley has 34.

According to Supervisor Joe Simitian, who is asking county staff to look into the problem, each year more than 600 youth in Santa Clara County are being referred elsewhere for treatment.

And when a bed can be found, the long distances place added strains on families needing to participate in therapy sessions and conform to strict visiting policies and hours.

There are many explanations offered for why acute inpatient psychiatric care for children and adolescents is so sparse, but they all boil down to finances. Most challenging is that hospitalizations of adolescents largely occur during the school year, leaving specialty units with few patients during summer months. Staffing becomes a challenge, and maintaining a secure unit that has empty beds during the summer is costly.

Hospitals make money by keeping their beds filled, and setting aside beds that can only be used by limited types of patients reduces flexibility. Insurance-coverage limitations on mental health inpatient services are another challenge.

Interestingly, the economics support a 15-bed adolescent inpatient eating disorders clinic at El Camino Hospital, operated in partnership with Stanford, but admissions are limited to youth who are medically compromised due to abnormal eating behavior.

In addressing the soaring rates of adolescent mental health needs, Stanford's Division of Child and Adolescent Psychiatry has focused its attention on educational outreach in schools and the broader community and on increasing staffing in its outpatient child and adolescent psychiatry clinic. There are no current plans to develop inpatient services.

Patients come from all over the world to be treated for virtually every physical condition imaginable at Stanford Hospital and Lucile Packard Children's Hospital Stanford. Medical miracles occur almost every day, often at tremendous and uncompensated expense, and our local community is fortunate to have leading experts in most medical specialties at our doorstep.

That makes it particularly hard to understand why neither the children's hospital, which is more than doubling in size and adding 149 beds, nor the adult hospital, which will add more than 350 beds as part of its expansion, are considering these needs.

While preventative mental health programs and outpatient treatment should remain important priorities, we urge health care leaders to address the lack of services for those teens needing acute inpatient care. World-class communities and institutions should not be quietly shipping their most vulnerable off to other places for treatment.

Related content:

Why so few hospital beds for teens?

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

Comments

25 people like this
Posted by Ridiculous
a resident of Palo Alto High School
on May 29, 2015 at 8:28 am

This is an outrage on the part of both Stanford and LPCH for failing to serve their community adequately.

Both hospitals charge excessive rates (2-4 times that of non-teaching hospitals), [portion removed] receive untold millions of dollars in donations-- yet plead poverty when asked why they share an emergency room, why they make excessive [portion removed] use of medical students, and why they underpay their nursing staff ( while overpaying administrators-- the highest paid in the nation).

LPCH is supposed to serve people under 21 years of age, yet has no psychiatric beds. Isn't mental illness a treatable physical problem?

Stanford simply needs to man up and do the decent and ethical thing instead of giving cheesey excuses.

Stanford needs to stop resting on aged laurels and be a proactive member of the Palo Alto community which they are supposed to serve--not further tarnish the image of!


16 people like this
Posted by Greenacres
a resident of Green Acres
on May 29, 2015 at 10:17 am

"Most challenging is that hospitalizations of adolescents largely occur during the school year, leaving specialty units with few patients during summer months. Staffing becomes a challenge, and maintaining a secure unit that has empty beds during the summer is costly."

Suicidality apparently has a seasonal cycle, regardless, even in adults. The cycle should just be factored into the overall cost of the program. Empty beds will happen in a properly functioning program.

Also, according to Annenberg Public Policy Center, the suicide rate is highest in spring and summer. Perhaps if our system weren't so broken, and as the beds become available and part of the system, the consideration about costly empty summer beds will end up being lifesaving summer beds.
Web Link

Thanks to the Weekly for this excellent coverage. Please consider also examining why it is this problem went on for so, so long, with all the suffering, without our schools having been a mechanism for shedding light on it and changing things to benefit our students? Why not, and what could we change so our schools are more responsive and responsible to the health and wellbeing of our children and families?


15 people like this
Posted by Craig
a resident of Los Altos
on May 29, 2015 at 11:30 am

Comment on "No Beds for Teens":

I have been following this story with great interest. My first job out of college in 1971 was at Friends Hospital, a private psychiatric hospital in Philadelphia. I worked as a nursing aide for two years on their new in-patient adolescent unit. As I recall, there were about 24 beds for young people aged 13-17. The unit was organized as a therapeutic community, a progressive new idea at that time. Working there was an amazing, transformative experience for everyone involved. Fortunately, many of these patients had excellent insurance coverage and could afford to stay on the unit long enough to get the most benefit from this treatment approach.


3 people like this
Posted by Joe
a resident of Another Palo Alto neighborhood
on May 29, 2015 at 12:11 pm

This series on unmet teen mental health needs has managed to generate a lot of smoke—but not much heat, or meaningful information. Almost totally missing is any sense of the cost to provide beds, and support services, to fulfill a demand of about 600 teen patients a year. There has been no information provided about the typical stay in the hospital for such patients, or the actual costs to provide adequate services. And there has been little insight into what benefit being in the hospital provided these patients (and their families).

Hospitals are large, expensive-to-operate institutions that need to provide for the majority of community. Many hospitals run at a loss, which has seen smaller hospitals closing, or merging with larger chains. Expecting these already over-worked hospitals to provide a wing of beds to service teen mental health issues can only increase the costs, and provide little in the way of revenue.
The argument that using medical facilities in San Mateo County is unacceptable—because of travel time begs the question, how long are teen medical health referrals sequestered in a hospital? If the answer is three days, or so, this argument about travel time becomes ridiculous.
> When and if a bed is located, policies dictate that the teen must be
> transported by ambulance, a humiliating and costly practice, often
> not covered by insurance.

If a patient (be that person teen or adult) has become so distraught, uncontrollable, despondent to the point of being suicidal—then being transported to a health facility with paramedics (ie—an ambulance) seems to be well within the realm of reasonable policy. While an ambulance transport can easily cost 1,500 dollars, with hospital beds costing 5,000-10,000 dollars a day, this additional expense seems small by comparison. And claims that an ambulance transport is “humiliating” to a teen begs the question how the Weekly knows this to be true? If someone is close to suicide, does the Weekly really believe that unless that person is taken to the hospital in a BMW that his/her condition will be exacerbated by a fifteen minute ambulance transport?

This series has raised a few issues—including the quality of journalism in this town.


3 people like this
Posted by Barron Park
a resident of Barron Park
on May 29, 2015 at 12:37 pm

[Post removed.]


8 people like this
Posted by Greenacres
a resident of Green Acres
on May 29, 2015 at 2:17 pm

@Joe,
No offense, but this very well-written article was about a specific circumstance locally and specific medical centers locally. What does that have to do with "many hospitals" running at a loss who knows where?

Stanford just came out and bought every last one of those luxury condos going up next to Whole Foods in Los Altos for employee housing. We live in an area with a extraordinarily high concentration of billionaires. Didn't Apple give like almost half a billion dollars to Stanford med not that long ago?

Are you trying to tell us in a roundabout way that somehow Stanford has been trying but can't fill this important local need by pleading poverty? Sorry, I don't think the journalists are who got that wrong.


17 people like this
Posted by Been There
a resident of another community
on May 29, 2015 at 3:35 pm

@Joe,

A 5150 is a 72 hour mandatory hold. Most kids in crisis spend from 10 to 15 days hospitalized. The reason is that the hospital first has to evaluate the situation and make a diagnosis--no lab tests for mental health--have to spend lots of time talking with the child and determining the type of issue-depression, psychosis, anxiety, bipolar, etc. The hospital spends most of the first 2 days making that determination. Then if meds are prescribed ( as they often are) they have to get the child on them and stable. You have to titrate (start with low doses and increase slowly until you get the right response) most kids onto almost all anti depressants. This can take up to a week more. And if you don't get a good result you may have to try a different drug where you have to get them off the first drug slowly and then onto the other one. Oh, and most psychiatric drugs are not approved for children, so it's basically a crap shoot to get it right the first time.

How do I know this? My 12 year old son was a 5150 patient who spent 10 days at John Muir hospital in Pleasant Hill--the closest bed at that time. He was taken alone in the ambulance from Stanford hospital at night for a 55 minute ride strapped to a bed with strangers. We were not allowed to see him for 2 days while he was being evaluated. So it can be a burden on the family and traumatic for the kid! I hope no one has to go through our nightmare.


6 people like this
Posted by Wondering
a resident of Midtown
on May 29, 2015 at 4:36 pm

This comment is a bit of a tangent, but bears on the cyclical nature of suicide risk - thus one of the impediments for having sufficient beds available. With respect to physical illnesses we know that if we feed our children too much sugar and starch they are at risk for diabetes and heart disease. These physical ailments in children are born of our poor choices. Why is it not possible that when children are subjected to unreasonable demands at school we cannot see a link between those demands and the mental health issue? Empty psych beds in the summer months seem to make an eloquent argument for the school pressure being the unhealthy force- like too much junk food leading to metabolic diseases.


4 people like this
Posted by Greenacres
a resident of Green Acres
on May 29, 2015 at 4:45 pm

@Wondering,
Since we don't have any of those beds here in town, and the article only surmises about empty beds during summer without establishing the basis for the statement (when research shows suicide spikes in spring and summer), and since -- in case you missed the flood of soul searching about school pressure -- most of the surrounding communities are making all the same "poor choices" you lambast but without the suicide problem, how about we keep the judgmental speculation to a minimum? Addressing school stress is important, and it's happening. You can help. (Judgmental speculation is not it.)


8 people like this
Posted by Gunn Mum
a resident of Greater Miranda
on May 29, 2015 at 4:48 pm

Thank you for bringing this to light. Although we probably can never know, it would be interesting how many times Palo Alto adolescents were unable to access inpatient care. This may be a much more telling statistic than participation in zero period.

Anecdotally, I have heard of kids being placed on 5150 by PAPD with very little substantive evidence of need and no interview of the parent. Kids can say stupid things but our hyper vigilance of any possible hint of suicide has resulted in unnecessary admissions where any control is then taken from both the parent and child. I do think this shows the concern of our society but we do need balance and common sense.


5 people like this
Posted by Paly Mom
a resident of Midtown
on May 29, 2015 at 5:20 pm

I agree with Gunn Mom and would like to know just how many kids are hospitalized and then released as being perfectly healthy. Kids do say stupid things, and then when the system kicks in, they are locked into a 5150 hold as nobody is willing to make the call that the kid is OK just in case they are wrong.

Anecdotally, I have heard of this happening. Yes we do have kids who have mental health problems and desperately need better treatment options. With the high numbers of kids that have been deemed at risk, I would like to know how often caution proves to be just that.


12 people like this
Posted by Wondering
a resident of Palo Alto High School
on May 29, 2015 at 7:28 pm

I wonder if we could get the schools to stop pressuring kids to the point of hospitalization?


Sure we need the service locally, ( and oddly this has been an issue for a while) , but wouldn't it be better to reduce the demand?

- implement homework policy
- stop criminalizing ADHD
- offer real supports for anxiety in the classrooms ( we don't currently. If you have anxiety, many teachers exasperate this with their normal habits)
- support kids with mental illness rather than wear them down


How about making this place humane in the treatment of kids who are at risk?

Is that such a foreign idea?

Why?


21 people like this
Posted by Sarah1000
a resident of Los Altos
on May 29, 2015 at 10:59 pm

Hi. I am the mom from the 5150 article. I can share a little more of our personal experience to, hopefully, bring some clarity. We view hospitalization as a last-resort. My son became increasingly depressed last summer despite being under good psychiatric care and on medication. His doctor tried increasing the dosage of his medication and the frequency of his therapeutic visits but my son's suicidial thoughts escalated. We made our home as safe as possible but we all, including my son, recognized that if there's the will, then there's a way. To save his life, my son's psychiatrist recommended that my son be hospitalized while the evaluation and medication change described by Been There was made. My son was hospitalized for ten days at Mills. I can only speak to my son's experience but he was hospitalized prior to the start of school, in the "summer", and there were several other teens at Mills at that time. The humiliation of the ambulance ride is not in the actual ride itself but in the fact of being "sent away" for care. As I mentioned in the news article, I have another child who was diagnosed with a serious and rare neuromuscular disease as a teen. I never experienced an ER visit with that child where she was placed in a bed for six hours, untreated, and was, then, sent by ambulance out of the county. Yet, that was what happened with my son though he was suffering from a much more common disease and was, in my opinion, closer to death when we arrived at the ER.
There is a significant issue regarding the cost of mental health care. As it's been explained to me, the law now requires "parity" in coverage for physical health services and mental health services but only by private insurance companies (like ours who covered most of my son's stay). However, the hospitals lose money for patients who are serviced through public insurance such as Medi-Cal because the "parity" requirement does not apply to this type of insurance. So, clearly, some laws need to be changed. However, our children should not be paying the price for our lack of legal clarity. As Nelson Mandela said, "There can be no keener revelation of a society's soul than the way in which it treats its children." And, I find it unacceptable that Stanford can spend $2 billion on an expansion and still not provide a single bed for a suicidial child.


8 people like this
Posted by a parent
a resident of JLS Middle School
on May 30, 2015 at 12:39 am

"Anecdotally, I have heard of kids being placed on 5150 by PAPD with very little substantive evidence of need and no interview of the parent."

My experience of some of the district personnel - it wouldn't surprise me if they did that out of spite or revenge in some cases. They were the CAUSE of our greatest stress. Very little accountability. My kid would never tell them anything, frankly, out of concern for any vulnerability being used against him or our family. Everything we endured, we kept to ourselves.


1 person likes this
Posted by resources
a resident of Palo Alto High School
on May 30, 2015 at 9:22 am

Stanford does provide very expensive care, and perhaps that's an indicator that they may not be in the best position to provide this service to our community. I'd also rather it be provided by a hospital that is excited about taking on this service, rather than one that grudgingly capitulates to community pressure. There is also something to be said for larger programs that will have adequate resources appropriate for adolescents (e.g., recreational facilities and staff who are used to and like working with teens, including occupational therapists, recreational therapists, nurses, counselors, and psychiatrists). There is generally a shortage of inpatient psychiatric beds, so probably more of any kind would be helpful. However, the anecdata in these articles haven't really suggested that there's an actual shortage of adolescent beds in this region. That is, teens are waiting a couple hours, not days. Being a 50 miles away is a drag, but may be a better option.

If the committee finds that there is in fact a need for more beds, then it would be great if a local hospital wanted to invest in that service. In the meantime, it sounds like these regional hospitals with adolescent psych units could improve the family-friendliness of their office hours. Perhaps also Palo Alto crisis teams responding to calls regarding suicidal teens could start the inpatient bed search before moving them at all, and take them directly to the inpatient unit rather than to the Stanford ER.


7 people like this
Posted by Mara
a resident of another community
on May 30, 2015 at 4:39 pm

Stanford Hospital has a bed for a mother to give birth to her child but not to save her child's life if he or she is suicidal. This has to change. Hospitals should always be available to save a child and not send a child away. I would have never known this even happens if this hadn't directly affected my own family.


1 person likes this
Posted by Jean Doten
a resident of Barron Park
on May 31, 2015 at 6:47 am

Certainaly there is a serious problem in the lack of facilities for teenagers who are experiencing a mental health crisis, sometimes with tragic results. On the other hand, some of the problems brought up in the recent article "Beyond the 5150" also apply to adults who are in the system. It is normal for anyone sho goes into an emergency room for a mental health crisis to wait at least 5-6 hours before a hospital bed is located. During that time there is usually no attempt at "treatment" and the patient is under the surveillance of a security officer. El CAmino Hospital is an exception; they provide a CNA to keep an eye on you and keep you company. Adults are also likely to be transfered miles away from home in the same demeaning manner as the teens. Another misconception is that police place a 5150--it is the hospital that makes that call, and it can be reviewed at the patient's request. The police will not necessarily take to you the hospital of your choice, and they may take you out in handcuffs, depending on who comes and gets you. In the interests of longterm mental health, in my opinion the skills of cognative behavior therapy should be taught as a required part of high school curriculum--much much more important than PE.


8 people like this
Posted by Shelah
a resident of Midtown
on May 31, 2015 at 7:35 am

It is interesting to me that over the past five years there has been a lot of discussion regarding the teen suicides plaguing our community yet little to no attention has been focused on actual services and de-stigmatizing the entire process. It is shameful that our local hospitals do not provide these important services and it is also shameful the manner in which these patients are treated. If your teen was in a car accident and the emergency service personnel told you that you could not ride in the ambulance with your child nor see them right away what would the reaction be?


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

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