'More ill, more desperate': How hospitals are responding to changing mental health trends

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Increased stress, isolation and burnout among patients and clinicians amid the pandemic shed light on a widespread lack of mental health resources. Many hospitals and health systems quickly pivoted their mental health strategies to meet this growing need.

Becker's interviewed healthcare leaders across the country about what their organization is doing in response to current mental health trends.

Editor's note: Responses were lightly edited for brevity.

Question: What mental healthcare trends is your hospital seeing? How has demand changed since the pandemic started?

Ben Weinstein, MD. Chair of the Department of Psychiatry and Behavioral Health at Houston Methodist: We have seen significant fluctuations in the demand for emergency psychiatric services. During COVID-19 surges, people stayed away from the emergency departments and then flooded the EDs when the COVID-19 peak subsided. Just like in general healthcare, the delay in mental healthcare results in an increase in acuity. Patients are more ill and more desperate. Everyone in the community is impacted, especially healthcare workers.

Jonathan Ripp, MD. Dean of Well-being and Resilience at the Icahn School of Medicine at Mount Sinai and Chief Wellness Officer at Mount Sinai Health System (New York City): We implemented a longitudinal assessment examining the psychological impact of the pandemic on front-line healthcare workers. Symptoms of depression, anxiety and post-traumatic stress affected nearly 2 in 5 workers at the start of the pandemic, but decreased to just over 1 in 5 seven months later. Though these mental health outcomes decreased, burnout remained high, affecting nearly half the workforce throughout. Despite these findings, we saw that more than 75 percent of our sample experienced post-traumatic growth seven months after the first wave at the end of 2020.

Olga Barg, MD. Associate Professor of Clinical Psychiatry at the Perelman School of Medicine at University of Pennsylvania (Philadelphia): Demands for mental health treatment have steadily increased during the pandemic. We are seeing higher-acuity patients in our ambulatory practices, emergency departments and on hospital services. Interruptions in community-based treatment resources early in the pandemic have added to the higher acuity of patients presenting for inpatient care, as well as creating added challenges of coordinating care on discharge. Inpatient psychiatric and addiction treatment units across the region face challenges to meet the growing treatment needs. 

Additionally, admissions and infection protocols for COVID-19 have reduced inpatient psychiatric bed availability, which can create longer boarding times in medical emergency departments and medical hospital settings. The pandemic also created an increased need for mental health support for our employees who had to rapidly adapt to meet our community's healthcare needs.

David Ginsberg, MD. Vice Chair of the Department of Psychiatry at NYU Langone Health (New York City): Over the course of the pandemic, we have identified many contributing factors to an increase in both inpatient and ambulatory mental health needs, including contracting COVID-19; grief over loss of family members, friends or work colleagues; economic stressors; grieving the loss of certain freedoms; decreased exercise and movement; and family care obligations. Specifically, the increase in behavioral healthcare demand was most associated with illnesses such as depression, anxiety, profound grief and post-traumatic stress disorder. What has most changed since the pandemic began is the sheer number of people seeking care and diagnosed with these conditions.

Itai Danovitch, MD. Chair of the Department of Psychiatry and Behavioral Neurosciences at Cedars-Sinai Medical Center (Los Angeles): The trends at Cedars-Sinai mirror national trends. Nationally, there has been an increase in substance use disorders, depression, anxiety, suicidal ideation and other mental health conditions over the course of the pandemic. These issues are likely tied to stress, social isolation, difficulty accessing services, COVID-19 itself and other social determinants that have been exacerbated by the pandemic. 

Bryan King, MD, Vice President of Child Mental Health at UCSF Health, and Dan Becker, MD, Vice President of Adult Mental Health at UCSF Health (San Francisco): The pandemic has had profound mental health effects throughout the population. Numerous stressors have contributed to these effects, including direct impacts on health, economic stress, concerns about job and housing security, and increased child care responsibilities. Children and adolescents, in particular, have missed important social development opportunities. And social isolation has compounded the loneliness experienced by many segments of our society, including senior citizens and those with severe mental illness and substance use disorders. The resulting increase in demand for mental health and substance use services, along with the constraints placed by the pandemic, has transformed how we deliver services. 

For each of the past several years, UCSF Health has seen marked annual increases in demand for mental health services across all hospitals and clinics. The pandemic has directed a spotlight on national challenges with mental healthcare delivery, including a longstanding crisis with respect to child and adolescent care. Access remains a critical issue for our health system despite leveraging telehealth, expanding outpatient access by nearly 30 percent, and more than doubling the number of child and adolescent psychiatrists and psychologists on our staff. 

James Potash, MD. Director of the Department of Psychiatry and Behavioral Sciences at Johns Hopkins Hospital (Baltimore): Early on, the pandemic posed great challenges for us, as it did for everyone. There was a reduction in the number of people coming into the psychiatric emergency service, but for those who did come in and needed admission, we had to set up a system to COVID test them. The people who did get admitted tended to be more psychiatrically ill than we were used to. Now the flow of psychiatric patients in the emergency department is back to normal, and the COVID processes are all ironed out. But our inpatient bed capacity remains reduced because of continued cautiousness about COVID transmission. On the outpatient side, the demand certainly continued, and, in fact, more people had issues related to psychosocial concerns like losing their jobs, having trouble with managing their children who couldn't go to school, and coping with racial distress. We also had high levels of distress among health system employees who faced high demands and high anxiety around treating COVID patients, and handling the professional and personal stresses induced by the pandemic.

Leo Pozuelo, MD. Chair of Psychiatry and Psychology at Cleveland Clinic: Like the rest of the country, we are seeing patients who have delayed their medical care, and thus patients are coming in medically sicker. This connotes a higher psychological burden, for both patients and caregivers alike. We have seen an uptick in psychiatric consultations on the medical and surgical floors.

Our census for inpatient psychiatric hospitalizations has been very steady, only experiencing a dip in the second quarter of 2020, with a rebound and sustained full occupancy along adult and child beds. The bottleneck of access and limited supply of community health resources has been an unfortunate theme at the beginning of and post-pandemic.

In the outpatient sector, the demand for psychiatric and psychological services has never been higher. The silver lining of COVID has been a better acceptance of the need for mental wellness. The impact of prolonged social distancing and isolation, and its psychological footprint, will more than likely be larger than the physical footprint of this pandemic.

Finally, there is the continuous strain on our caregivers. The chronic nursing and allied health shortage, coupled with still high levels of burnout among certain services lines, has been in the forefront of our leadership communications.

Terry Schneekloth, MD. Professor and Chair of the Department of Psychiatry and Psychology at Mayo Clinic Arizona (Phoenix): The pandemic has caused many major social stressors, including isolation from friends and family, reduced direct social contacts at work, and disrupted employment and job loss. Common mental health consequences disrupted exercise routines with their associated sense of wellness, heightened anxiety, worsened mood, and excessive use of alcohol, cannabis and other substances of abuse. Consequently, many individuals are seeking care from mental health professionals, an estimated national average of three- to four-times normal, and access to care is very difficult.

Q: What is your hospital doing in response to these trends?

Dr. Weinstein: Houston Methodist is increasing access to care for our patients across the system. We have added therapists to our inpatient services and our primary care clinics. Our clinicians are seeing the most ill COVID-19 patients and reducing their medical acuity by treating anxiety. The Center for Performing Arts and Medicine has developed a hospital-based music therapy service. Hospital leadership champions mindfulness for providers. Houston Methodist has increased access to care for our employees by eliminating copays for mental health, increasing out-of-network benefits, and opening a clinic just for our employees and their dependents. The Emotional Health and Wellbeing program is staffed by the community's best mental health clinicians and provides mental healthcare for our staff and their families free of charge.

Jonathan DePierro, PhD. Assistant Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai and Clinical and Research Director of Mount Sinai's Center for Stress, Resilience, and Personal Growth (New York City): The Mount Sinai Health System opened the Center for Stress, Resilience, and Personal Growth in June 2020 as a resource to support the resilience and psychological well-being of its more than 45,000 faculty, staff and trainees. CSRPG provides workshops focused on factors that support resilience that are increasingly utilized, an app providing mental health screening and resilience-building resources and immediately accessible behavioral healthcare. CSRPG partners with many other stakeholders within the MSHS, including the Office of Well-Being and Resilience, the Department of Psychiatry, human resources and spiritual care to provide robust, multitiered support during and beyond the pandemic.

Dr. Barg: We continue to work tirelessly to accommodate the evolving mental health needs of our community and support our workforce. Early in the pandemic, we developed and implemented protocols to ensure safe patient care delivery in all facets of mental health treatment. Operationalizing telehealth removed significant barriers for individuals needing ambulatory mental health services. We test all patients in need of inpatient mental health treatment for COVID-19 and have protocols to safely co-manage COVID-19 patients with psychiatric needs on our medical units. This allows us to continue to deliver therapeutic group interventions, which are integral for inpatient psychiatric and addiction treatment. Our collaborative care programs — Penn Integrated Care and Mental Health Engagement, Navigation and Delivery — continue to expand access to mental health treatment in primary care and hospital settings, respectively. We also developed Penn Cobalt, a digital platform for access to mental health and wellness resources for our employees, and the COVID-19 ambulatory listening and medication management clinic to support employees. 

Dr. Ginsberg: We took several steps to address the growing demand for mental health services. Most significantly, we have expanded our telehealth capabilities and significantly increased our number of virtual office visits. This has led to profound shifts in the delivery of psychiatric care — one that has had a positive impact going forward. Additionally, we transformed our Consultation-Liaison Psychiatry service to a virtual platform for a subset of our patients at our Manhattan campus site. Lastly, we developed and enhanced our network of behavioral health services to meet the growing healthcare demands of our workforce of 45,000+ employees.

From an operational standpoint, the move to virtual care has allowed us to hire more psychologists and psychiatrists to meet these growing demands, as we are not as constrained by the availability and costs of office space since most of our providers work virtually from their homes.

During COVID-19, across the NYC metro area, there was a contraction of inpatient and outpatient behavioral healthcare services available. This has contributed to an increase in the number of people seeking psychiatric care in our emergency rooms — nearly double from a few years ago.

Dr. Danovitch: Cedars-Sinai is on the leading edge of recognizing that mental health and physical health are inextricably linked. We screen every patient for mental health conditions and, when indicated, we have a hospital-based psychiatry service that sees hospitalized patients, starts them on appropriate treatments, and refers them for continued care in the community after discharge. 

As an academic medical center, Cedars-Sinai is also studying the impact of delivering addiction services to hospitalized patients with substance use disorders. Though published results from these studies are still pending, emerging data shows that patients are very receptive to these interventions, internists and surgeons seek psychiatric consultation, and delivery of mental health services in the hospital is both feasible and effective. 

Cedars-Sinai is looking at several innovative strategies to improve mental health and reduce reliance on opioids in the management of pain. One innovative program, funded by the NIH, involves the use of virtual reality in pain management. Our work in this space is breaking new ground in the effort to offer VR as an alternative pain management tool for patients.

Drs. King and Becker: While our care model shifted nearly exclusively to remotely delivered video service for both adults and children, we also launched and dramatically expanded a child psychiatry access portal to support primary care pediatricians both inside and outside of our health system to better identify and treat common mental health conditions in the community. We were able to distribute more than 250 cell phones to severely mentally ill patients to keep them connected to intensive case management services. 

We invested in mental health supports for our own staff, faculty and students through the creation of a dedicated portal to expedite access to a range of direct clinical services. And we have produced, curated and disseminated a wide range of online wellness and coping resources for our employees as well as the public. Recognizing that we have yet to get through a likely winter viral surge, we will continue to deliver the majority of mental health services remotely into the new year.   

Dr. Potash: We kept our inpatient units functioning, though we converted all of our double-bed rooms to single-bed rooms. On the outpatient side, we continued to see our outpatients, converting most of them to telemedicine. That has proven quite popular, and though we see more people in person than we did a year ago, we have retained about two-thirds of our outpatients as telemedicine visits because of the high level of convenience for patients. This has also reduced our no-show rate. Our most extraordinary accomplishment was the establishment of a COVID-positive psychiatry inpatient unit at Howard County [Md.], in April 2020. It stayed open through July 2021, and took care of five to 10 patients at a time. It became the focal point in our Johns Hopkins Health System for psychiatrically ill patients who were COVID-positive, but not COVID-symptomatic. On the employee front, we created a MESH (mental, emotional, and spiritual help) group to assist clinicians on the front lines, with support, and, if needed, with psychological and psychiatric care.

Dr. Pozuelo: We are expanding our psychiatry consultation liaison service to provide telemedicine consultation to our inpatient medical and surgical floors. We continue to work with our community health partners and facilitate point-of-care handoffs at time of discharge to secure follow-up and continuity of care.

We are committed to delivering outpatient psychiatric service to our employees (our own employee health plan of nearly 60,000 covered lives), ACO, primary care and specialty-attributable patients. This has prompted an aggressive hiring of 45 mental health providers over the next five years. Still not enough to meet all demands, but a good augmentation of current behavioral health services. 

Finally, the enterprise at the Cleveland Clinic has continued to raise the awareness of mental health. From the CEO on down, mental health awareness for patients and our caregivers is constantly in the forefront. Over the 25 years I have been at this institution, never have I seen such needed attention and resources being allocated to emotional wellness. Working with diverse stakeholders at the Cleveland Clinic (Office of Caregiver Experience, Office of Patient Experience, wellness and preventive medicine, human resources, employee assistance program, and the Department of Psychiatry and Psychology), a team approach is needed to make sure we recruit and retain our most important asset, which is our caregivers.

Dr. Schneekloth: Mayo Clinic Arizona has sought to proactively address mental health needs of patients and employees throughout the pandemic. Over the past year, leadership has authorized significant expansion of clinical staff (psychiatrists, psychologists and social work therapists) in the hospital practice, across outpatient specialty groups, and in primary care. The Mayo Clinic demonstrates its commitment to wellness among staff through affirmation of team efforts, resource support for staff wellness initiatives, and peer outreach programs to struggling staff.

 

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