PITTSFIELD — In May, Ana was admitted to Berkshire Medical Center with hundreds of cuts across her body and a hole chewed nearly through her cheek.
She was 13 years old, in a mental health crisis and “an imminent danger to herself,” said her mother, Keri.
Ana spent nearly two weeks in the hospital — first in the emergency department, then upstairs in the pediatric unit — as her care providers searched across the state for an inpatient psychiatric program with an empty bed.
“They told me a hundred times, ‘There are so many kids on the waitlist, and only so many beds in Massachusetts to begin with,’ ” Keri said. “They’d already started talking about discharging her.”
On the 12th day, Ana got lucky. They had found her a spot — a two-hour drive away, in Worcester.
Keri and Ana had discovered what families across Massachusetts learned during the coronavirus pandemic: When there are no open beds at inpatient programs geared specifically toward psychiatric care, children can get stuck for days or weeks, often in emergency departments, waiting for that care.
Holding patients in the emergency department during a psychiatric crisis, a practice called "boarding," has been an issue for urban and rural hospitals alike since long before the pandemic, but it escalated when the public health emergency caused the number of available psychiatric beds to plummet.
For Berkshire County young people in crisis and their families, the absence of those beds has meant long waits, hours of driving to programs across the state and the fear and desperation of not being able to get help at their worst moments. The Eagle is using first names in this story to protect the privacy of families.
Across Massachusetts, boarding rates rose from 200 to 400 percent from last summer to January, according to the state.
At Berkshire Health Systems, the number of children boarded for one to four days ticked up slightly during the pandemic, according to the hospital system, though the number of children kept in the ED for more than four days dipped compared with previous years. The hospital system points out that the numbers are small — four kids were boarded long term in 2020 — and therefore can fluctuate significantly.
Some young people, like Ana, were moved out of the emergency department but still experienced long hospital stays while waiting for a bed in a youth psychiatric residential facility.
Those stays came as families grappled with the isolation and stress of the pandemic, and as the hospital saw overall demand for pediatric behavioral health services rise, according to BHS. The Brien Center, which partners with the hospital on those services, also saw a spike in requests for help.
“There has been a long-standing history of inadequate mental health services for children,” said Dr. Brenda Butler, a child psychiatrist with BHS. “Globally, nationally, statewide. So, that’s the baseline we start with, and the pandemic has certainly accelerated challenges we have in finding mental health services for kids.”
And though BHS says it is expanding outpatient and some inpatient services, providers and advocates expect boarding will continue long after the pandemic, as high need and service shortages continue to plague the health care system.
Finding a spot
Like Keri, Meagen was desperate to get her 14-year-old daughter some kind of in-person care during the pandemic — even just a counselor. When she couldn’t find anything to help her child, who just had tried to commit suicide, she was distraught.
“I work in health care, and I’ve been working in person with patients, face-to-face, even before masks were mandated,” she said. “It is what it is. They need to be treated. So, why is it any different for mental health?”
Her daughter, Hannah, had been raped, and she was suffering from that trauma as the whole world closed down. Therapy over Zoom had been a disaster.
“I couldn’t have contacts outside my own home,” Hannah said. “It felt like my own brain was attacking myself.”
Out of options, her mother brought her to the BMC emergency department. It was January, the height of the county’s COVID-19 winter surge.
The staff put Hannah in a windowless crisis room, she says, and sent in physicians to check on her. As a precaution, they took away her phone and kept her from anything sharp. Hannah says they also left her without a pillow, so, she bundled up blankets to rest her head on. She remembers an adult from a neighboring room wandered into hers at one point and began to talk to her.
The staff offered to play games, but she was too anxious to try Jenga or any of the other offerings. Mostly, she says, she felt alone, even with people around her 24/7.
“I sat and watched [television] pretty much the entire time,” she said. “I was out of my head.”
While Hannah waited, Meagen holed up in her car and called every inpatient psychiatric program she could find in the state. Each had a six-month waiting list.
“I didn’t understand,” Meagen said. “They were telling us that the teen suicide rate is so high. I said, ‘I’m doing what I can to prevent this, and no one wants to help her.’ ”
After four full days, Meagen realized they weren't going to get a spot, and they left the ED. To Meagen, it felt like they were going home without a plan, and that she was shouldering the burden alone.
The hospital had switched Hannah onto a new antidepressant before she left, and social workers called every day after to check in. Both measures helped. But, for Hannah, it felt like no one had wanted her at her worst, and that was a gut punch.
“It feels like you don't matter,” she said. “I'm over here. I’m trying my best not to kill myself. And I feel like, because I’m so young, they don’t see it as a serious thing.”
An inpatient unit
Young people in crisis in Berkshire County have long been forced to travel for inpatient psychiatric care.
In the 1990s, families often had to drive out of the county, an hour or more, to get an inpatient psychiatric bed, says Jim Mucia, The Brien Center's division director of child and adolescent services. So, The Brien Center opened a child crisis stabilization unit in Pittsfield, an eight-bed residential program geared toward kids like Ana and Hannah.
Though the program was classified as a step down from an inpatient psychiatric hospital, it offered similar services and activities — from psychiatric treatment to group therapy and general recreation.
But, The Brien Center shut down the unit several years ago, after struggling with low reimbursement rates and underuse. Only half its beds were typically filled, according to Mucia.
“The Brien Center was losing hundreds of thousands of dollars,” Mucia said. “It wasn’t one bad year, it was going on three, four years. We pleaded, and pleaded, and pleaded with the state and insurance companies for help.”
The program’s end meant that children who need inpatient psychiatric care had to get admitted to programs outside the Berkshires, such as Providence Hospital in Holyoke or Brattleboro Retreat in Vermont.
During the pandemic, the picture became even worse.
Providence closed its inpatient psychiatric services in 2020 because of staff shortages and low use, according to its parent company. Meanwhile, many hospitals over state lines shut their doors to out-of-state residents when the crisis began, and those still open in Massachusetts reduced their bed count.
At the height of the pandemic, Stat News found there were no psychiatric beds available to patients younger than 18 in Western Massachusetts — and fewer than 400 in the whole state.
With vaccines widely available, the picture has started to brighten. The state will pour millions into psychiatric care, including money from the American Rescue Plan. Baystate Medical Center has opened a new 12-patient unit for kids, and the owners of Providence Hospital also plan to open beds for young people soon at the newly named MiraVista Behavioral Health Center.
But, activists and families say Berkshire County kids need a local option for inpatient care.
This spring, Marney Schorr, who works with suicidal teens as an art therapist in Pittsfield, spent hours on the phone with parents throughout the pandemic. She heard about how they were trying and struggling to get help for their children, and those conversations broke her heart.
“Teens didn’t have access to in-person therapy, they didn’t have access to hospital care, and the hospitals were sending them home,” Schorr said. “Even after a very serious suicide attempt.”
This spring, Schorr started a petition asking BHS to open an inpatient psychiatric unit. Nearly 5,000 people signed the petition, and the comments began to flood in.
"I am a parent of a child who was unable to get services due to lack of beds [in] 2021,” Cheryl wrote. “Have seen it with other youth and I am a [Berkshire County] social worker, so it’s personal and professional.”
“I am a mother [whose] own child at the age of 10 made suicidal comments and needed help,” Sharon wrote. “There was virtually no one in Berkshire County to help him.”
For Schorr, the overwhelming response was a clear sign that families were struggling.
“I think this is something people have wanted for a long, long time,” she said. “We've been under-resourced for teens for way too long.”
The emergency department
Berkshire Health Systems does not comment on individual cases, but hospital staff say that while they would prefer not to have to board any children, they provide high-quality care to those who do stay in the emergency department.
In the ED, young people see a child psychiatrist, a social worker and an emergency medicine physician every day, according to Dr. Liliana Markovic, chair of the department of psychiatry and behavioral science.
The hospital also meets with the family and holds teleconferences with the child’s other providers to come up with a comprehensive plan, she said, in some cases preventing the need for a longer hospitalization.
“They’re getting pretty much the same care they would get if they were in the inpatient unit,” Markovic said. “The only difference is location.”
Families who spoke with The Eagle said the emergency department was a better option than keeping their children home, and that their kids left more stable than they had arrived.
But, they felt that the experience had been taxing and that their children desperately needed a higher level of care, including more engagement with staff and other young people, more hours of therapy and even the group activities that most inpatient programs offer.
For Mucia, those services are the crucial difference between an emergency department and a specialized inpatient unit.
“Hospitalization and residential care, it’s a 24-hour therapy program,” Mucia said. “They do groups. They do activities, all therapeutically based. Even meals are a therapeutic event. You’re sitting around a table with kids, problems come up, you deal with them.”
In the ED, Ana was physically safe, which was a relief to Keri. But, it was "no place for a child," Keri said. From her room, Ana could hear her neighbors, including one woman who screamed about hanging herself or drinking herself to death, Keri recalls.
Kathleen Kerrigan, president of the Massachusetts College of Emergency Physicians, says EDs at many hospitals can be stressful environments — part of the reason that boarding can be harmful for kids.
“It’s noisy,” she said. “There are six people around you who may or may not be behaving. It’s not conducive to a calm, quiet, collected place.”
As she saw other kids stuck in the emergency department, Keri pushed to have her daughter moved to a room in the pediatric unit. But, even after the move, the family and the hospital kept up the bed search for a residential treatment program. Keri says hospital staff explicitly told her: “This isn’t a treatment center.”
“[Staff] come in, ask the kid how they’re feeling for the day and go about their business,” Keri said.
The hospital system told The Eagle its focus is on increasing availability of care at all levels, including more outpatient services that could prevent the need for hospitalization.
But, offering behavioral health services always has been a challenge, in part because of chronic staffing shortages across the country: The American Academy of Child and Adolescent Psychiatry estimates that the country needs four times as many child psychiatrists as it now has to meet demand. Some hospitals, Markovic said, set up inpatient psychiatric beds but leave them empty because of staff shortages.
Even large Massachusetts hospitals tend to have small psychiatric inpatient units for children, if they offer those services at all: Boston Children’s Hospital has just 16 such spots, out of 400 total pediatric beds.
Berkshire Health Systems says there would not be enough local need to fill an inpatient psychiatric unit for children and teenagers, since it sees an average of about one kid boarded each month.
The hospital uses one or two available beds in its pediatric unit to admit behavioral health cases, such as with Ana.
“When you’re the family member in crisis, desperate for help for your child, it’s hard to have the full perspective,” Butler said. “Not only do the numbers don’t necessarily justify it, historically … maintaining inpatient services for children and adolescents has been very challenging. It’s very hard to staff it.”
The hospital recently hired a second child psychiatrist, after years of trying and failing to recruit one amid the shortages — a hire that local providers call a big victory. It also has received a renewed youth suicide grant to keep on social workers, who run community groups and work with families.
And Butler says the hospital is “in conversation” about starting an intensive outpatient curriculum, in which children could come two to three times each week and work with the social workers and the new psychiatrist.
‘Sleep in shifts’
For some kids, the hospital can become a revolving door for behavioral health crises. Ana’s stay in May marked her second visit to BMC. She first had been admitted in March, and she and her mom had waited a week, again splitting time between the ED and the pediatric unit.
Her mother spent the whole time trying, and failing, to find an inpatient spot in a psychiatric program.
“After so many days, it became a battle of insurance and the hospital,” Keri said. They had to go home, Keri says, and hope that Ana would be OK.
“There was a point when our therapist was so concerned, they said, ‘You and your husband might want to sleep in shifts,’ ” Keri recalled.
Two months later, Ana was in worse shape and had to be admitted again. During that May visit, Keri went in hopeless, almost certain that they never would find a residential program to take Ana to.
When they found the bed in Worcester, Ana and her parents were nervous to be so far from each other.
“She’s two hours from home,” Keri said. “We work. We have another child. It’s not easy to see her.”
But, they felt lucky to even get the spot. At least she had a car she could drive to Worcester — and Ana had a shot at recovery. Some of Keri’s friends had kids that were in similar shape and hadn’t been able to secure any placement.
As the mental health impact of the pandemic lingers, Keri worries about the young people who need care that the state's health system cannot provide.
"The crisis is far from over for many of these kids," she said. "They deserve a chance. They deserve to have somewhere to go to get the help they need."