Rise in psychiatric cases forces hospital to explore alternatives

Emergency rooms report influx of patients as COVID-19 crisis lingers
Credit: newbridgehealth.org
Bergen New Bridge Medical Center

Hospitals and urgent-care clinics around New Jersey are caring for a growing number of patients experiencing acute anxiety, drug overdoses, suicidal thoughts and other psychiatric crises, a trend experts believe is driven largely by the ongoing COVID-19 pandemic. Many of the patients are children.

Bergen New Bridge Medical Center, which has the state’s largest inpatient psychiatric program, is busier than it has been in more than a decade, officials said. The hospital’s 17-bed pediatric program is also packed most weeks.

“Over the last few months that unit has been filled to capacity more often than not,” Deb Visconi, New Bridge’s president and CEO, told NJ Spotlight News. “And it’s not surprising, when you think about what’s happened in our society over the last year and a half — especially to the children.”

COVID-19 has killed more than 27,000 New Jerseyans and left more than 90,000 hospitalized since it first emerged in March 2020. The result: significant grief and trauma — especially among Black and Hispanic residents, for whom the death rate was at least twice that of whites. It also led to widespread economic loss, with the state processing more than 2 million unemployment claims so far, plus anxiety and isolation as schools, businesses and public spaces were closed for months to reduce the viral spread.

Public health and the pandemic

“I’m concerned about the public health aftermath of the pandemic,” said Dr. Shereef Elnahal, president and CEO of University Hospital in Newark, a city that was hard-hit by the coronavirus. His worries include “long COVID” — a medical condition with symptoms ranging from brain fog to serious organ damage — and the racial disparities in health outcomes, which greatly impact a majority-minority city like Newark.

Though behavioral health cases remain a small number of the overall emergency visits, the increase is causing concern

“I am also very concerned about the mental and behavioral health morbidity that’s going to come — that’s already here,” said Elnahal, a former state health commissioner. Among Newark residents, the need has grown significantly over the past year, he said last week, speaking during a panel discussionon COVID-19 and health care hosted by New Jersey Policy Perspective.

University Hospital’s behavioral health unit is often at capacity and the ER frequently sees patients who have suicidal thoughts or are a danger to others, Elnahal said, situations that requires additional security and specialized treatment, including inpatient care. To help address this need, University formalized an agreement with New Bridge to make it easier for the Bergen County hospital to accept psychiatric patients from the emergency room in Newark.

“It will help them offload (emergency room psychiatric patients with serious needs) and really situate these patients in really the best place, where they will get the best care,” Visconi said. New Bridge has informal agreements with other hospitals to accept psychiatric patients that are beyond the scope of their facility’s care, she said, but the formal deal with University will further ease the transfer process.

Dealing with urgent cases

While the behavioral health units at New Bridge are busy, Visconi said the Bergen County-owned facility — the largest acute care hospital in New Jersey, with more than 1,000 beds and dozens of programs to treat diseases throughout the body — continues to have capacity. New Bridge is affiliated with Rutgers New Jersey Medical School, which shares a Newark campus with University Hospital, and some of the state’s most respected behavioral healthcare systems, making it best equipped clinically to deal with these urgent cases, Elnahal said.

The need is not limited to New Jersey, of course. Research by the nonprofit Kaiser Family Foundation found that more than 30% of adults nationwide reported experiencing anxiety or depression during the pandemic, nearly three times the rate reported in 2019. In New Jersey, nearly 28% of adults said they had suffered with these issues this spring, versus 16.4% pre-pandemic, KFF found.

OD deaths ticking upward

State data indicates New Jersey has also seen a record number of overdose deaths during the first half of 2021 and could see 6% more fatalities than in 2020, if the current trend continues. It comes after the number of fatal overdoses declined for the first time from 2018 to 2019, the first dip after nearly a decade of steady rise.

For some people in crisis, the emergency room is the best option. An analysis of emergency room diagnoses conducted by the New Jersey Hospital Association found that while ER visits declined overall during the last nine months of 2020 — when the pandemic was in full swing — the proportion of anxiety diagnoses rose 19% and diagnoses of substance-use disorder rose nearly 30%, when compared to all other diagnoses. The proportional increase was even greater among children, the NJHA found.

The problem appears to be getting worse as the pandemic drags on this year, something Visconi and Elnahal said they’ve witnessed at their facilities. Emergency room visits involving behavioral health diagnoses — as either a primary or secondary concern — increased nearly one-third from the second quarter of 2020 compared with the same time this year, according to additional data analysis by the NJHA, and inpatient admissions of behavioral health patients rose 21%

“Our hospitals and outpatient providers continue to face the demands of increased volume in behavioral health cases, as well as the increased acuity levels of patients — individuals need more intensive services, have more complex conditions and often require medical interventions,” Mary Ditri, the NJHA’s vice president of community health, said in an email. “Flexibility in the system is important to meet these dynamic needs.”

Most of the behavioral health services in New Jersey, and nationwide, are provided by community-based programs and outpatient services, something experts said is generally more appropriate. But as more psychiatric patients show up at emergency rooms, some hospital leaders believe it is time to expand inpatient capacity — a big change in a decades-long trend toward de-institutionalization.

“Before this pandemic I would have been the last person to argue that we need more inpatient mental health and behavioral health capacity. The name of the game was to move more of that care into the community, as a best practice,” Elnahal said. “But we’re seeing so many people in acute crisis now,” he said, people “that require inpatient hospitalization and we’re running up against real limitations in the inpatient capacity to treat this very severe acute mental illness.”

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The state operates four residential psychiatric hospitals, housing roughly 1,300 people, with other behavioral health beds available at county-run and private facilities.  New Bridge, where the average behavioral health stay is eight to 10 days, has more than 300 beds on the psychiatric unit and an additional 50-plus in a medical detox unit.

The state Department of Health, which licenses hospitals, did not respond to questions about New Jersey’s total psychiatric bed count, current capacity and plans for expansion.  Former Gov. Chris Christie, who focused on expanding addiction services at the end of his second term, prompted the DOH to issue a “call” for hospitals to create another 900 psychiatric beds, a request that was later reduced to 864. The DOH also declined to provide an update on this process.

“It will require a panoply of policy solutions,” Elnahal said, including additional investment in community-based services and better integration with other medical care. “But most notably an expansion of inpatient capacity in the short term,” he continued. “But we also need to plan as a region and as a state for the actual acute mental and psychiatric needs that we’re about to see go further and further in the wrong direction.”

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