Late last year, the California Department of Health Care Services (DHCS) awarded a $33.7 million grant to the San Francisco Department of Public Health (SFDPH) to renovate space at The Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center (ZSFGH) for new inpatient and outpatient psychiatric care facilities catering to pediatric patients up to 24 years of age.
After DHCS invited funding requests the Department “seized the opportunity given the urgent need in the City for more behavioral health treatment facilities for youth, and particularly for youth who are uninsured or on Medi-Cal,” said Dr. Farah Farahmand, PhD., Director, Children, Youth & Families System of Care at SFDPH “This unit will be really critical for kids who are on public insurance, or uninsured, or system involved because we are finding that there are very limited resources for those youth to be able to have mental health services.”
United States Center for Disease Control (CDC) statistics indicate that adolescent mental health has worsened over the past two decades, a trend that accelerated since onset of the COVID-19 pandemic in 2020.
A 2018 Journal of the American Medical Association article found that Black children between the ages of five and 12 were nearly twice as likely to commit suicide as their white peers. In a 2021 CDC survey, three in five girls reported that they felt persistently sad and hopeless; more than one in four seriously considered suicide. Nearly a quarter of teenagers who identify as lesbian, gay, bisexual, or questioning (LGBQ+) had attempted self-destruction.
Deteriorating mental health statistics coincides with the rise of social media. In 2020 Johns Hopkins University researchers found a positive association between the frequency of social media use and depression however, causality remains unclear.
While the role of social media may be unclear, the impact of the pandemic is not. A systematic review of survey studies completed in 2022 by Olaf University and the Mayo Clinic researchers concluded that “mental health issues among children and adolescents are closely related to the COVID-19 pandemic, as well as to various mitigating strategies,” such as social distancing, quarantine, and school closure.”
Dr Fortuna postulates that the pandemic was “…sort of a perfect storm, where we were already seeing these increases and then the world got even more stressful, and kids got even more isolated, and kids got even more loss in their social supports and systems and healthy things for them to do to help kids thrive.”
Declining mental health is manifesting with an increased need for hospital treatment. CDC nationwide data from March to October 2020 showed an uptick in emergency room visits for children ages five to 11, and 11 to 17, of 24 percent and 31 percent, respectively, over the same period in 2019.
Rising demand falls on a fragmented psychiatric care system that’s long been overburdened. The American Association of Medical Colleges (AAMC) projects a nationwide shortfall of 3,400 psychiatrists by 2032 due to increasing needs and aging professionals. According to AAMC, 60 percent of psychiatrists are more than 60 years old. In California, the American Academy of Child and Adolescent Psychiatry (AACAP) estimates that there are just 15 child and adolescent psychiatrists for every 100,000 children and that as many as one out of five children experience mental, emotional, or behavioral disorders.
One outcome is a significant delay between the onset of mental health symptoms and treatment. Research by Philip Wang, Harvard Medical School professor, estimates an average postponement of five to 11 years between the start of a mental disorder and psychiatric care.
“At that point you are looking at specialty services when it could have been intermittent prevention.” said Dr Fortuna.
AACAP estimates that half of mental illnesses start by the age of 14; 75 percent by the age of 24. Adequate care is essential to prevent hardship on patients and their families, and to mitigate social impacts. Homelessness and incarceration are direct consequences of inadequate care for mental illness.
Psychiatric patients are now commonly boarded at hospital Emergency Departments (ED) while they wait to be admitted into inpatient care. Stays can range from a few hours to several days. ED environments are often loud, chaotic, and poorly suited for those in acute mental distress.
Currently, the McAuley Institute at St Mary’s Medical Center on Hayes Street adjacent to Golden Gate Park is the only San Francisco hospital that provides inpatient psychiatric care for pediatric patients. It offers an inpatient Behavioral Health Unit (BHU) for adolescent patients, as well as an intensive outpatient Counseling Enriched Educational Program (CEEP) for 11- to 18-year-old students that’s administered in partnership with the San Francisco Unified School District (SFUSD) and SFDPH.
According to Lanea T. Jueco, RN, MSN, and Director of Nursing at the BHU and the CEEP units, both programs are highly utilized. The 12 bed BHU cared for 669 patients in 2022, with from two to 48 hours wait times. The CEEP attends to an average of 25 students a month, who make their way to the facility through SFUSD and SFDPH referrals. Staff availability is a limiting factor for inpatient and outpatient services; UCSF psychiatry faculty sometimes assist.
BHU accepts Medi-Cal and uninsured patients. Once it reaches capacity, psychiatric patients need to find services outside the county. Private hospitals, such as St. Mary’s, can also reject patients, which more frequently occurs for children within the juvenile justice or foster care systems.
“Those kids are particularly hard to place, because they are often in very complicated psychosocial situations with mental health needs that a lot of units do not feel comfortable with, especially if they are under-staffed,” Dr Fortuna explained.
The ZSFGH units are being built with this underserved population in mind. SFDPH estimates that the new 12-bed inpatient bed facility will care for up to 450 adolescents annually, with an expanded outpatient program able to serve as many as 900 clients a year.
As a public hospital, ZSFGH will care for San Franciscans covered by Medi-Cal and without insurance. SFDPH was unable to provide the View with a timeline for when the new facilities will open; funding to support operations is still being worked out.
Under the California Welfare and Institution Code, minors undergoing mental health crises who are deemed at risk to themselves or others may be held for up to 72 hours under a “5585 hold.” The inpatient psychiatric hospital will care for these adolescents. Safety protocols are one reason why psychiatric hospitals have traditionally been at separate facilities or sectioned-off from other medical care services.
Outpatient services will include a partial hospital program and intensive outpatient care, oriented towards those released from inpatient care who still have significant mental health care needs, or those experiencing a mental health crises but who don’t meet inpatient admittance criteria.
“The intensive outpatient program would provide a higher level of care seen in a typical outpatient program,” Dr. Farahmand explained. “For example, instead of attending therapy once a week for an hour, a patient in an intensive program may attend therapy more frequently and in varying settings, but never for a full day. Alternatively, the partial hospital program would be structured as a five-day-a-week program that is short term and intensive in nature. These programs serve as a bridge between intensive services and inpatient level of care.”
“The need is so tremendous and to be able to have those levels of care is critical right now because otherwise kids do not have a chance in San Francisco to receive these services adequately, and often were having to go to other parts of the state and elsewhere where often they are disconnected from their social supports and families, which is not helpful,” said Dr. Fortuna.