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By Taylor Knopf
A 9-year-old girl with mental health issues spent at least four months this spring living in a Novant Health emergency room in Wilmington: sleeping, eating, doing school work. During that time, emergency department staff searched for an available mental health facility that could take a child so young.
“I have kids that have been in our hospital for three, four or five months waiting for an appropriate living situation,” said Paula Bird, vice president of behavioral health services at Novant Health, the Winston-Salem-based hospital network that operates Novant Health New Hanover Regional Medical Center.
She explained that many of these long stays occur when a county department of social services is involved. In some cases, overwhelmed parents bring their child to the ER and leave, saying they can’t take the child back home without some kind of treatment.
The Wilmington case, which was described by Bird, is not unique. Hospital officials across the state say there are children in mental health distress living in their emergency departments. Atrium Health has seen a 65 percent increase in emergency department patients needing psychiatric care, according to leaders at the Charlotte-based hospital group. For children in need of psychiatric care, the demand tripled over the course of the pandemic.
“We’ve seen since the beginning of 2022 that our numbers have just stayed high consistently and that’s not typical,” Wayne Sparks, medical director of Atrium Health Behavioral Health Services, said in May. “We’ll have surges, but they typically will be a week or two and then go back down. But this has been sustained now for the last five months.”
Emergency department data from hospitals across North Carolina show an elevated rate of pediatric patient visits throughout most of the pandemic compared to previous years, mirroring national trends. Young people have experienced higher levels of depression, with 44 percent of U.S. high school students in 2021 reporting persistent feelings of sadness or hopelessness.
Kids who harm themselves or express suicidal thoughts often land in the emergency department. From there, it’s common for emergency department staff to initiate an involuntary commitment — a process that calls for sending patients to one of the state’s few psychiatric hospital beds.
Health experts are calling the youth mental health crisis the latest wave of the coronavirus pandemic. Late last year, the U.S. Surgeon General released an urgent advisory calling attention to the dire statistics and solutions.
Health officials, hospital executives and patient advocates agree that a hospital emergency department is not the right place for kids in mental health distress — or any psychiatric patient — to receive treatment. But when community mental health services are inadequate or hard to find, people have nowhere else to go but the ER.
Before the pandemic, North Carolina’s mental health system already relied heavily on emergency services. Now, hospital and state health officials say — and the data show — that the system is buckling under the influx of even more patients in crisis.
A ‘major math problem’
Rising mental health-related emergency room visits, more involuntary commitments and longer wait times for psychiatric hospital beds are symptoms of much larger problems within the state’s mental health system, health experts say.
These crisis services are supposed to be last resort options. But when people can’t find community mental health services, or when the wait time for a therapist is months long, these become the norm.
“We’ve got to get people before they get into crisis,” said Kody Kinsley, secretary of the North Carolina Department of Health and Human Services. “Right now, the provider space is not sufficient.”
Comprehensive mental health services aren’t always covered by private health insurance plans and, if some coverage exists, the out-of-pocket costs are high. Private insurance plans often pay as little as 80 percent of what Medicare — a government program — pays to mental health providers, he said.
Mental health providers cannot sustain practices at that low of a reimbursement rate, Kinsley explained. He said in June that he was looking for a therapist and even he — the state’s top health official — hadn’t been able to find one.
When people can’t find preventive mental health care, such as an outpatient psychiatrist appointment, that’s when they show up at the ER in crisis, Kinsley said.
“And so this just creates a lot of chaos and demand on the system that’s unsustainable,” he said.
“Unsustainable” was a word repeated often by hospital officials statewide as they talked about the record numbers of mental health patients they’re seeing. And they expect the demand for psychiatric services to continue climbing.
North Carolina is the ninth most populous state in the nation and is among the top five states for population growth. North Carolina also ranks 44th nationally in access to mental health care and 45th overall for pediatric mental health care, according to the most recent data from Mental Health America, a Virginia-based nonprofit advocacy group.
“We have a major math problem,” said Samantha Meltzer-Brody, chair of psychiatry at the University of North Carolina at Chapel Hill and director of the UNC Center for Women’s Mood Disorders. “We have underfunded mental health in North Carolina for years. Mental illness has not gone away. In fact, the prevalence of many disorders has only gone up.”
Her team at UNC Medical Center’s main psychiatric clinic saw a 150 percent increase in patients per month from spring 2020 to spring of 2022.
“So if you have increasing prevalence and increasing population growth, and you have not had investment to expand services,” she said, “then what happens is exactly what we’re seeing, which is people can’t access care.”
While the pandemic-fueled mental health crisis has made local and national headlines, some of North Carolina’s data wasn’t readily available to the public until the publication of this article.
Rising involuntary commitments
In North Carolina, anybody can petition a judge to order an involuntary commitment. Involuntary commitment is a legal tool that is supposed to be used as a last resort when a person is deemed to be an immediate danger to themselves or others. These patients temporarily lose the right to make their own decisions while being treated for psychiatric problems or substance use.
The process also usurps the rights of a parent or guardian to make health decisions for their child — a reality that sometimes comes as a surprise to parents who bring their children to the ER.
This practice was already on the rise before the pandemic, with increases in involuntary commitment petitions outpacing state population growth, a phenomenon also taking place in other states. Over the past decade, involuntary commitment petitions have nearly doubled, increasing by at least 97 percent from 2011 to 2021.
The trend accelerated throughout the pandemic, with many counties reporting record numbers of commitment petitions last year.
In most counties, a commitment order triggers a call to the local sheriff’s office to transport the patient to an emergency department for an evaluation or to an available psychiatric bed. Patients and their families describe being traumatized when law enforcement officers show up to move them, which most often comes with handcuffs and added stigma.
Meanwhile, sheriffs say they don’t want to be in the practice of moving patients, arguing that it should be done by mental health workers. Officers often don’t have the training or tools to respond to mental health calls. Their presence alone — with marked vehicles, uniforms and firearms — often escalates a situation.
North Carolina Health News gathered and analyzed county-level data showing how the number of involuntary commitment petitions continued to increase year-over-year in roughly half of the state’s counties throughout the pandemic. The other half reported numbers that reflect pre-pandemic levels, which were already climbing.
There were exceptions. Some counties reported decreases in involuntary commitment petitions in 2020 during the early months of the pandemic while stay-at-home orders were in effect.
Long waits and sicker patients
Hospitals saw a drop in visits for all causes in 2020 as people avoided doctor’s offices and emergency departments for fear of catching COVID-19. Stephanie Greer, director of behavioral health services at Appalachian Regional Healthcare System, based in Boone, said the drop in behavioral health patients in the ER was noticeable and came with consequences.
“Once we started coming out of the throes of the pandemic, the result was that the people who were showing up were much sicker than they had been before,” she said. “The acuity was much, much higher because they had held off trying to avoid exposure … Then we saw spikes and volumes again.”
When people delay getting help for their mental health issues, their symptoms worsen and become harder to treat, explained Lisa McCanna, senior vice president of Atrium Health Behavioral Health Services. That means it takes longer to stabilize these patients during their psychiatric hospitalizations.
“Our length of stay has grown, which just backs up the bottleneck of people who need help,” she said.
There have been longer wait times for patients in emergency departments with referrals to one of the three state-run psychiatric hospitals. In the months prior to the first coronavirus cases, the average wait for a state-run psychiatric bed was about six days. Wait times remained elevated through the pandemic, peaking at an average of more than 16 days in December 2021.
Data from state-run facilities appear to show a decrease in the number of patients waiting for a psychiatric bed during the pandemic. However, the state health department’s chief medical officer for behavioral health, Carrie Brown, says this particular data point doesn’t paint the full picture.
“I do not think that this means there’s been any decreased need,” she said. “I think the need absolutely has stayed the same if not increased.”
High demand for state hospitals
The state facility wait time data only includes people in emergency departments waiting to come to state psychiatric hospitals, Brown explained. It doesn’t include patients referred from another inpatient facility or the increasing number of walk-ins to the state-run psychiatric facilities.
She said the state-run psychiatric hospitals should be reserved for patients with the most serious and complex needs. Walk-ins complicate that because they might not be the patients with the most severe issues, but they are physically there, jumping the line.
That also increased wait times in emergency rooms.
Patient counts and wait times were also affected by how hospitals’ staffing and operations were upended during the pandemic. Mental health treatment often takes place in groups, so quarantine units for incoming patients were set up to prevent the spread of COVID-19. Plus, the number of beds state facilities can operate depends on staffing, which Brown explained took a hit during the pandemic, as it did in every health care institution across the country.
In June, the three state-run psychiatric hospitals averaged a 23 percent staff vacancy rate, totaling more than 1,000 empty positions across the facilities.
In other words, even if there are actual beds available, the facilities might not have the staff to operate them.
During fiscal year 2022, which ended June 30, at least 458 patients received treatment at the state’s psychiatric facilities because they were arrested for a crime and were not yet mentally competent to stand trial.
By law, the state is required to admit these patients first.
When state psychiatric hospitals admit more patients who are incapable of proceeding to trial, that means there are fewer patients the state hospitals can admit from emergency departments, Brown said. “It’s a fine balance. That’s just another sort of piece of a puzzle.”
These factors lead to longer wait times for admission to state-run psychiatric facilities.
When that happens, emergency departments will decrease their referrals to the state-run psychiatric hospitals and look for other options, Brown explained. There are outpatient treatments and privately-owned psychiatric hospitals designated to treat patients under an involuntary commitment in North Carolina.
Ultimately, emergency wait times show there’s a high demand for state-run psychiatric resources which are stretched thin.
Mental health professionals who have practiced in North Carolina for decades say the catalyst for this started more than 20 years ago with a good idea that lacked follow through.
A two-decade decline
In 2001, state lawmakers passed sweeping mental health reform legislation. They decided to shut down some North Carolina psychiatric facilities, most notably Raleigh’s Dorothea Dix Hospital and John Umstead Hospital in Butner.
Novant Health’s Paula Bird, who was then Dix Hospital’s director of nursing, said the idea was that many people with mental illness would be better served outside of hospitals in the least restrictive setting possible.
“I think that they envisioned that there would be community wellness centers and there would be day care for adults to be able to go to, but then be able to go back home and be supported,” she said. “And that just simply didn’t happen.”
The General Assembly took the savings from closing the hospitals. Year after year lawmakers — both Democrats and Republicans — didn’t spend the dollars that patient advocates and hospitals say were needed to make the rest of the plan happen. Instead, they focused on other spending priorities.
“The whole deinstitutionalization of mental health was a great idea, but the money didn’t follow the patients,” Bird said. “And so that is where we ended up: with disjointed services and very much a complex bureaucracy.”
Appalachian Regional’s Stephanie Greer was an administrator at the state-run Broughton Hospital when North Carolina privatized mental health care. Gone were the old county-based mental health centers, replaced by state-funded regional behavioral health management companies, known as local management entities or managed care organizations. Instead of providing the care, LME-MCOs were tasked with managing the care delivered to mental health patients by the independent therapists and clinicians.
Patients who had been living in the long-term care areas of psychiatric hospitals for years were discharged to assisted living facilities and residential placements, Greer said.
Most of those placements had little or no mental health services to help these patients.
“What I personally believe happened is that we started trying to reduce inpatient bed capacity without fully having the outpatient infrastructure in place,” Greer said. “And I think that we did a disservice to a lot of patients.”
She said people with severe and persistent mental illness really struggle, falling into a revolving door pattern: their symptoms worsen, so they’re admitted to a psychiatric facility where they’re stabilized and discharged without follow-up care. Then the cycle repeats.
Meanwhile, mental health patients with private insurance become disadvantaged by the new LME-MCO system which is designed to serve low-income patients with Medicaid.
“On the outpatient side — and to me, this is a travesty — it’s almost more challenging if you have insurance to get an appointment in a rural setting on an outpatient basis than if you’re indigent,” Greer said.
In the rural western North Carolina counties her system serves, there is at least a 10- to 12-week wait for an outpatient therapy appointment and about a nine-week wait for a psychiatric medication management appointment.
Greer described a pattern of funding in North Carolina’s mental health system of continually shifting the money and resources between inpatient psychiatric care and outpatient services.
The ultimate solution would be fully funding both, she said.
When the state cut funding for inpatient care in psychiatric hospitals without boosting funds for community-based services, more crisis situations emerged, according to hospital officials.
Now there’s a push yet again to build more inpatient beds. Appalachian Regional opened a behavioral health hospital last year in Avery County. ECU Health announced plans to build a 144-bed behavioral health hospital in Greenville. Executives at Davis Regional Medical Center in Statesville recently announced they’re converting all beds to psychiatric care. WakeMed is trying to build 100 mental health inpatient beds as well.
“We’ve got to provide services across the entire continuum of care,” Greer said, “because without one piece of it, all of the others have undue strain.”
Tomorrow: What hospital and state health leaders say would help fix North Carolina’s mental health crisis.
About the data
In the North Carolina court system, involuntary commitment petitions are filed as confidential special proceedings cases or SPCs. Each county clerk of court office submits this data monthly to the North Carolina Administrative Office of the Courts. Several county clerks of court confirmed that SPCs are largely reserved for involuntary commitment petitions. At the state level, these data are lumped together with the larger group of special proceedings cases, which include name changes, guardianships, estates, wills and several other procedures.
The NC Administrative Office of the Courts provided NC Health News with county-reported SPC data through December 2021.
There were some gaps in the data during the coronavirus pandemic. Over several months and many follow-up phone calls, NC Health News filled in most of the missing totals by calling county clerks of court offices in many counties. Five counties are missing at least one year of data between 2019 and 2021 in our graphic displaying statewide involuntary commitment petition totals.
When querying counties for missing data, we received mixed responses. For example, staff from the Durham County Clerk of Court called back to share data within days of our first outreach. Some county clerk offices, however, were unsure if they could share data with a “confidential” label, including a staff person in the Northampton County Clerk of Court office. Eventually, he got permission from his superiors to share the data and followed up with us.
We had the opposite response from a staff person in Moore County who doubled down on her stance that the data was confidential and would not share it. When we heard back from Wake County — which had the most SPC cases in the state in 2021 — Clerk of Court Blair Williams said that given significant courthouse staffing shortages “our SPC numbers are extremely important in my continued arguments for more resources.”
The entire involuntary commitment process is convoluted and the data limited. A petition is the initial request for an involuntary commitment, but it doesn’t tell us what ultimately happened to the patient. A patient is evaluated by two different clinicians at different points before being treated at a psychiatric hospital under involuntary commitment.
North Carolina didn’t have complete data on how many patients proceeded through the process until 2020 when the large majority of psychiatric inpatient facilities started reporting those numbers to the state Department of Health and Human Services, which is required by state law. In 2020, there were at least 39,776 admissions for treatment at psychiatric hospitals, with 72 to 97 percent of facilities reporting data on a given month to the department. In 2021, there were at least 42,586 admissions to psychiatric hospitals, with 96 to 100 percent of hospitals reporting data on any given month.
We don’t know any demographic data, data on the length of stay or the true number of patients, as the numbers don’t account for people who may have been admitted more than once. In the past, proposals to collect more data on patients who go through the involuntary commitment process in North Carolina have been unsuccessful.