Kristen Soderman had struggled with her mental health for years. This spring, mourning the loss of routine brought on by the COVID pandemic and the death of the grandmother who helped raise her, she found herself in a crisis.
The 16-year-old arrived at Boston Children’s Hospital for psychiatric treatment. And waited.
She spent 31 days at Boston Children’s, first in the emergency department, then on a medical floor, without receiving intensive psychiatric care. She longed to return home to Barre, to feel the sun on her face, to hold her dog.
“I spent a little over a month of my life sitting, doing nothing,” Kristen said.
COVID has spawned a mental health crisis that has brought staggering numbers of children and adults to emergency departments seeking help — only to languish for days or weeks before they receive psychiatric treatment to help them heal. There aren’t enough beds or workers to treat all the patients in need, and the demand is overwhelming the health care system.
Massachusetts hospitals estimate that more than 500 patients across the state who need mental health treatment are stuck in emergency departments and medical units right now — a phenomenon known as “boarding.” Many are reeling from the stress and trauma of a pandemic that has upended normal life and stubbornly will not end.
“I call it our pandemic,” said Dr. Kevin Churchwell, chief executive of Boston Children’s. “The number of children, adolescents, young people that have continued to present with behavioral and mental health issues is just totally off the charts.”
The shortage of psychiatric treatment beds and qualified staff existed well before the days of COVID. But it has grown to alarming levels.
“This is a crisis on top of a crisis,” said Dr. Jacob Venter, chief of child and adolescent psychiatry at Cambridge Health Alliance. “The pandemic has really exacerbated everything, made everything a lot worse.”
There are two to three times as many patients boarding now than in the pre-COVID days, according to hospitals and state health officials. They are coming to the hospital sicker, and they are waiting longer for care.
Governor Charlie Baker’s administration is spending an estimated $40 million on incentives for hospitals that agree to treat more psychiatric patients. Several hospitals across the state have committed to adding a total of more than 300 new beds by the end of the year, 136 of them for children and adolescents. More than 40 percent of these beds have already opened.
But as the pandemic lingers, and with COVID cases rising again, the mental health crisis shows no signs of abating. It is expected to last for years, even after the virus subsides.
“The reality is the ways in which people recover from trauma and loss … often takes months to years,” said Dr. Scott Rauch, president and psychiatrist-in-chief at McLean Hospital. “This is a multi-year trauma.”
National studies show the pandemic’s profound impact on Americans’ mental health. A report from the Centers for Disease Control and Prevention found that 41 percent of adults surveyed in June 2020 reported adverse mental health effects, including anxiety, depression, and post-traumatic stress — and 11 percent said they had seriously considered suicide.
Among adolescents ages 13 to 18, mental health insurance claims doubled as a share of total medical claims during the height of COVID in 2020, compared with the prior year, according to a FAIR Health analysis.
The pandemic has disrupted life for 17 months, an especially long time for children and teens deprived of crucial connections to friends and school support networks.
“With children, that’s a significant part of their lives, and the effect of that is not just going to disappear overnight,” Venter said.
Children and adolescents have been struggling with social isolation and loneliness during the pandemic, said Dr. Patricia Ibeziako, associate chief in the department of psychiatry and behavioral sciences at Boston Children’s. Some are experiencing anxiety about the coronavirus, which may have infected their family and friends.
“The data is clear that teenage girls have been disproportionately emotionally impacted by the pandemic,” Ibeziako said. “We’ve seen an increase in depression, anxiety, eating disorders, and suicide so far.”
Many of the children and adolescents seeking treatment during the pandemic have a previous diagnosis of a mental health disorder, but others are in crisis for the first time.
A mother from Western Massachusetts said her 13-year-old child was happy and active and showed no signs of depression, until last fall. The child began spending more time online, in addition to attending school virtually, and became irritable and withdrawn. Eventually, the child started refusing food and began cutting themselves.
The parents brought the child to Boston Children’s, where they waited 23 days before getting treatment. During that time, the child continued to refuse food, lost weight, and became sicker, according to their mother.
The middle-schooler was “locked in a room for over three weeks — never permitted out, never allowed fresh air or sunlight,” said the mother, who asked not to be named to protect her child’s privacy. “It’s not unlike being in a prison.
“They kept saying how they wished they could jump out the window.”
The trauma in Kristen Soderman’s life had been building for years. In 2015, she lost her uncle and a family friend. The next year, her grandfather. In 2017, when she was 11, she and her mother came home one day to find her mother’s boyfriend badly injured from a motorcycle accident in their driveway. He later died.
Kristen’s grandmother died last October, a loss that stung unlike the others, and her aunt died in April. Meanwhile, the pandemic was muddling her life.
“COVID drove me crazy,” Kristen said. “You go from living a structured life to having nothing to do. Along with mental health, it was horrible. So then I started getting into more and more trouble.”
Kristen has bipolar disorder and post-traumatic stress disorder and has been in and out of hospitals for years. She has trouble sitting still, and when she’s anxious, she can be loud and impulsive, said her mother, Tina Soderman.
After an incident in May, police brought Kristen to a hospital near her home. She later moved to Boston Children’s, where her mother hoped she would get help. Instead, she spent her days watching “Friends” and “The Office” and playing board games while she waited for a spot in a psychiatric unit to open up.
One day, frustrated, she left her room and tried to get on an elevator. Hospital staff stopped her.
Doctors and nurses checked on her regularly. But Kristen said those brief encounters were mainly focused on safety — Was she thinking about harming herself? Was she eating and using the bathroom? — and didn’t help her process what she was feeling.
Her mother visited every other day, a three-hour round trip from their home.
In the end, Kristen waited for help that didn’t come. She was discharged home.
Her mother believes no psychiatric unit admitted Kristen because of her history of aggressive behavior and run-ins with police: “They were really good to us,” she said of the hospital staff, but “at the end of the day I was disappointed that I couldn’t get her the help that she really needs.”
Boston Children’s declined to comment on Kristen’s case.
The most complex patients can be the hardest to place, according to doctors, parents, and advocates. Hospitals may decline to take these patients because they don’t have enough staff to keep constant watch, or if they feel a patient is a poor fit for their facility.
Patients receive very limited treatment while boarding. The primary concern for hospital staff is to prevent them from hurting themselves or others.
Children in crisis are crowding emergency departments, but sometimes they also spill into hallways or conference rooms, without a TV to pass the time or walls for privacy.
“Nobody’s set up for this,” said Lisa Lambert, executive director of the Parent/Professional Advocacy League, an advocacy group for Massachusetts children and families who need mental health care.
Some hospitals are working to move patients as quickly as possible from emergency departments, which are busy, loud, and full of wires, tubes, and other equipment that pose a danger for people at risk of suicide.
Tufts Medical Center redesigned one of its medical units for patients who are boarding, with safety upgrades to rooms and bathrooms designed to prevent self-harm. The patients get visits from music therapists and the hospital’s service dog.
Tufts doesn’t have an inpatient psychiatric unit for children, so these patients must wait — for a few days, or more than 40 — until a spot opens in another hospital.
“This crisis has really made us stop and think about the way we can make a safe environment,” said Terry Hudson-Jinks, chief nursing officer at Tufts. “We’ve created a place where they can be safe and they can have hope while they wait for expert care.”
But these medical departments can’t substitute for psychiatric treatment centers. In hospital psychiatric units, patient rooms are not full of medical equipment. Patients are encouraged to walk around and interact with one another, and group therapy, along with individual therapy, are key components of treatment. Throughout the day, staff watch patients closely and note changes in their conditions.
In the early weeks of the pandemic, as the number of patients in a mental health crisis began to rise, psychiatrists across the Mass General Brigham hospital system started talking each morning to keep track of boarding patients and search for empty beds. They knew they didn’t have enough.
McLean, Mass General Brigham’s standalone psychiatric hospital, opened a new 20-bed unit at its Belmont campus in October and four beds in Middleborough in January. It’s planning 68 additional beds in Middleborough.
In October, the Baker administration began offering hospitals one-time payments of up to $150,000 for each new psychiatric bed. The administration also agreed to pay hospitals up to $330 a day more for each MassHealth patient they admit.
Hospitals in Springfield, Holyoke, Devens, Natick, Newburyport, Plymouth, and other communities have opened or promised to open new beds.
Boston Children’s is adding 12 beds at its campus in Waltham. Cambridge Health Alliance is adding 64 psychiatric beds, most of them for youths; a 21-bed unit for adolescents in Somerville began filling as soon as it opened in June.
There are 2,871 psychiatric beds across Massachusetts, 378 of them for children, according to state officials. Since 2018, the state has worked with hospitals and insurers to find beds for patients who are boarding.
But beds are only part of the equation. Hospitals are struggling to recruit and retain enough qualified staff, including mental health workers, social workers, nurses, psychologists, and psychiatrists.
“We have tried to meet that need, but unfortunately the workforce is really not there,” said David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems. “We need more staff. We can’t even fill the beds we have now.”
The Baker administration is allocating $31 million in federal stimulus funds for psychiatric facilities to recruit staff.
Without more beds and a larger workforce, patients in crisis may continue to endure long waits, or fail to get the care they’re seeking.
“We don’t even know how many kids are still developing symptoms due to the stress they’ve been under,” said Venter, the psychiatrist at Cambridge Health Alliance. “I’m afraid this demand will continue to linger for quite some time.”
Priyanka Dayal McCluskey can be reached at firstname.lastname@example.org. Follow her on Twitter @priyanka_dayal.