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On May 25, Jena Hausmann, chronic diclofenac treatment CEO of Children’s Hospital Colorado, in Aurora, Colorado, declared a state of emergency in youth mental health in response to an astronomical increase in pediatric mental health cases, including suicide, which has overwhelmed the institution.

From April 2019 to April 2021, the demand for pediatric behavioral health treatment at the hospital system increased by 90%. In Colorado, suicide is now the number one cause of death among youth and occurs in children as young as age 10 years.

“Now we are seeing our pediatric emergency departments [EDs] and our inpatient units overrun with kids attempting suicide and suffering from other forms of major mental health illness,” Hausmann said in a press release.

“We had to draw attention to what we’re seeing in our hospital and our community on an everyday basis — an unprecedented number of suicidal children who need acute treatment for behavioral health problems — and when I say ‘unprecedented,’ I’m serious — I’ve been in pediatrics for two decades and have never seen anything like this before,” David Brumbauch, MD, a pediatric gastroenterologist and chief medical officer for Children’s Colorado, told Medscape Medical News.

Christine Crawford, MD, associate medical director of the National Alliance on Mental Illness, told Medscape Medical News that she “commends the CEO of the hospital for making this announcement, because it is outrageous to see what is happening with more and more children with significant psychiatric symptoms who are not getting adequate care.”

Jenna Glover, PhD, child psychologist and director of psychology training at Children’s Hospital, said that during the past decade, there has been a steady increase in depression, anxiety, and suicide among youth in Colorado. Suicide, she added, is now the number one cause of death in youth, “so we were already in a state of crisis.” She added that COVID-19 was “the straw that broke the camel’s back.”

“In January to April of this year, behavioral health ED visits to Children’s Hospital were 72% higher than they were 2 years ago at this time,” she said. “Colorado Springs had a 145% increase for ED behavioral health visits during the first 4 months of 2021, compared to the first 4 months of 2020.”

COVID’s Impact

Other problems that have been “skyrocketing” in youth are self-harm, substance use, and eating disorders. Younger children are experiencing an increase in behavioral problems, including developmental regression, such as tantrums, and problems with sleeping, toileting, and eating, Glover noted.

The youth mental health crisis has mushroomed, although social distancing requirements are now beginning to ease and we are in the “home stretch of the pandemic,” Brumbaugh said.

One possible reason “is that we took kids out of their normal routines, social circles, friendships, etc, for 12 months, and that was the limit of their physiological or mental resistance, and they got to the end of their rope,” he speculated.

Glover said, “Kids are burned out, and although they’re asking to return to their life, they don’t feel they have the resources. They feel so behind; they don’t know how to catch up.”

Brumbaugh said that there are not enough child psychiatrists to provide outpatient services or enough inpatient beds for children in crisis.

“This is an unacceptable situation. We would never allow a child with leukemia or appendicitis to go several weeks without treatment,” he said.

Community donors have come forward, enabling an anticipated 50% increase in Children’s Hospital’s mental health outpatient, inpatient, and day services by March 2022.

“On a hospital level, we are continuing to do things to expand access to care, like opening units that provide different levels of care for patients with psychiatric problems, as well as expanding into areas that are more rural,” Glover said.

However, the “blueprint is not in action yet, and a lot of money still needs to be allocated. A workforce has to be created, because there are not enough clinicians to fill these roles,” she added.

Chronic Underfunding

Brumbaugh said Colorado has always had a “relatively underfunded behavioral health system for kids.” A 2021 report by Mental Health America ranks Colorado among the lowest states in the country in terms of overall pediatric behavioral health funding.

However, Glover noted that Colorado is “not exceptional.” The increased vulnerability to youth mental illness and suicide is characteristic of other mountain states, which have larger rural areas, less access to care, and increased access to guns, she said.

Mass shootings may have amped up stress levels. “For some kids, this is happening in their schools or towns, and they feel traumatized and unsafe,” Glover added.

Crawford, who is an assistant professor of psychiatry at Boston University School of Medicine, Boston, Massachusetts, also pointed out that the mental health crisis in youth is not unique to Colorado.

“Throughout the country, we’ve seen these colliding pandemics — inadequate mental health resources for children and COVID-19, which exacerbated the existing mental health crisis,” she said.

“The pandemic led to an increase in telehealth services, making individual and group psychotherapy available to kids in areas that never had access to these before, which is a ‘silver lining’ of the pandemic,” Glover said.

Crawford is “encouraged that we are having more conversations about pediatric mental health, because the pandemic amplified what was already going on and made it impossible to ignore.”

Screening Is Essential

Screening for mental health problems should be at the top of the mind of pediatricians and other clinicians who work with children, Glover said.

“Pediatricians are in the best place to catch potentially suicidal kids, because they are more likely to see these kids than therapists,” she noted

She suggested using a rapid screen for depression, such as the Patient Health Questionnaire–9 (PHQ-9) modified for adolescents. Parents can also fill out a PHQ-9 for younger children and even for themselves.

“Depression, anxiety, and suicidality affect the whole family, so screening for these conditions in adults will benefit the children too,” she said. Teachers should also “be aware of what depression and anxiety symptoms look like in kids, because sometimes they can manifest more as irritability,” Glover added.

Policymakers and insurers need to prioritize pediatric mental health when determining allocation of healthcare, said Crawford.

“Financial incentives should be provided for hospitals to want to reserve beds for psychiatric patients, and in the outpatient setting, we also need to look at the payment structure of psychiatric visits,” she added.

Many psychiatrists do not want to accept insurance because of the increased bureaucracy and low reimbursement rates of insurance companies, and families cannot afford to pay out of pocket, “so we really need to look at the insurance issue at a policy level,” Crawford said.

Brumbaugh, Glover, and Crawford have disclosed no relevant financial relationships.

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