Stand in Line

ON ANY NIGHT IN ANY EMERGENCY room in the United States, you might find a young person experiencing chest pains and another in psychological or emotional distress for, say, being the target of online bullying.

The young person with chest pains will get scans, blood work, and other exams deemed necessary. If they need to be admitted, an appropriate room will likely be found; if they’re discharged, they’ll leave with a follow-up appointment or a referral to a specialist and usually a plan for follow-up.

For their peer with psychological or emotional distress, it’s a different story. If their crisis is severe enough — for example, if they have indicated they are considering suicide — and they need to be hospitalized, it’s likely there will be no beds available on the appropriate wards. They will either remain in the emergency department receiving inpatient care for possibly several days or be moved to the medical ward, where they will receive psychiatric treatment. When they’re discharged, they may need to wait months to get an appointment with an outpatient child psychiatrist.

“The mental health problems that kids come into the ER with are as life-threatening as any other illness or injury we might see, perhaps more so,” says Zheala Qayyum, MMSc ’19, an HMS assistant professor of psychiatry and medical director of emergency psychiatric services at Boston Children’s Hospital. Qayyum is right; 2020 data from the U.S. Centers for Disease Control and Prevention show that suicide is the second leading cause of death among young people between the ages of 10 and 24. The U.S. Surgeon General, the National Institutes of Health, and the American Medical Association have issued reports warning that adolescent mental health in the United States is in a state of emergency; in 2016, an article in the AMA Journal of Ethics called for policy changes that would promote more access to mental health care for adolescents through the funding of school-based programs and services.

“Schools and pediatricians are the two major referral sources for us in the emergency room,” says Qayyum. “They’re the places where people have the most contact with the kids. The teachers and doctors can pick up if something is going awry or a kid is in crisis. They’re the ones who pick up on it.”

According to the CDC, between 2009 and 2019, suicidal ideation, suicide attempts, and persistent sadness or hopelessness increased by 40 percent among U.S. high school students. Yet, the CDC estimates that in 2019 less than 20 percent of young people nationwide who sought care for mental health challenges received the care they needed.

“I’ve lived with this crisis for quite some time,” says Qayyum. “Before I began in the emergency department at Children’s, I was running an adolescent and young adult inpatient psychiatric unit. Pre-pandemic, we noticed that boarding times were longer — and we didn’t have enough beds.”

Qayyum adds, “People agree that hospitalizing kids is not the solution.The problem is that we don’t have enough supports in the community to prevent hospitalizations.”

Amid the crisis in adolescent mental well-being that, as Qayyum points out, has been decades in the making, physicians who care for young people are seeking solutions that can help them now. However, despite the acute need, a systemic solution will require long-term societal and policy shifts. Some are underway while many are still aspirational. Others wait to be discovered.

External forces

To explain this increase in mental health conditions and illnesses among young people, experts have cited a long list of social and cultural shifts, including the increasing pressure in all aspects of adolescent life. Discrimination based on race, gender, or sexual orientation and childhood trauma have long been identified as major risk factors for adolescent and adult mental and behavioral health problems. The Robert Wood Johnson Foundation recently added attending a high-performing school to their list of factors that put young people at risk for poor mental health.

A growing body of evidence indicates that some forms of social media may also be harmful for certain young people. An ongoing, crowd-sourced collaborative review of literature related to social media and mental health, overseen by Jonathan Haidt, the Thomas Cooley Professor of Ethical Leadership at the Stern School of Business at NYU, and Jean Twenge, a professor of psychology at San Diego State University, references studies indicating a causal effect between the arrival of social media platforms on college campuses and an increase in anxiety and depression among students on those campuses. Other experiments cited showed that even brief exposure to the idealized, filtered selfies often posted on social media sites was associated with body shame and lowered self-esteem.

Overwhelmed

The damage of such influences accumulates. Some physicians note that young people in mental distress are sicker and younger than those they saw earlier in their careers. And these young people are less likely to find the resources they need to recover their mental health.

“Pediatricians are expected to provide considerably more mental health care than we were when I first started practicing thirty years ago, but support from child psychiatrists is much harder to find and there are not nearly enough child therapists to see all of the children in need,” says Carolyn Sax, MD ’87, an HMS assistant professor of pediatrics, part-time, at Boston Children’s and a pediatrician at Hyde Park Pediatrics, part of Boston Children’s Primary Care Alliance.

“There are more requests from patients and families for behavioral health services. There seems to be an increase in mood and anxiety issues among children and teens and a greater expectation that emotional issues should and can be addressed. We need to provide more mental health interactions with our young patients. Unfortunately, this need also coincides with an absolute famine of availability of mental health providers outside of primary care pediatrics.”

The pediatricians Sax works with take an integrated approach to providing mental health care to their patients by including behavioral health providers in their pediatric primary care medical home. This patient-centered, comprehensive, teambased medical home model provides their young patients with access to mental health assessments and short-term interventions designed to help with psychological, social, emotional, and academic challenges.

Unfortunately, Sax notes, the practice does not have the capacity to offer fullservice psychotherapy, so the practitioners try to offer referrals for community-based outpatient care. It can, however, be difficult to find a provider who accepts MassHealth or even private insurance.

“If a child comes in with a severe mood disorder, I feel like I’m on my own,” Sax says. “The system is just broken.”

Woven throughout

As part of an effort to recognize the importance of mental health care and to integrate a recognition of mental health in wellness and illness, HMS is developing a core curriculum that will more thoroughly integrate mental health into MD education. The goal is to create a greater awareness and understanding among medical students of the mental health challenges faced by patients from the populations they might encounter during their careers, no matter which specialty they pursue. High up on the list of skills to be developed and honed are the basic ones useful in any clinical context: listening to and talking with patients.

“Our aim is to teach future physicians the basics of how to assess, when to refer, and how to follow up when they refer,” says Todd Griswold, an HMS assistant professor of psychiatry at Cambridge Health Alliance. Griswold, who has deep roots as a medical educator and a clinician in adult psychiatry and community-focused health care, is part of the team that is developing the curriculum. In addition to Qayyum at Boston Children’s, the team includes Brittany Jordan-Arthur, an HMS instructor in psychology and a staff psychologist with McLean Hospital’s school consultation service, and Sandra DeJong, an HMS associate professor of psychiatry, parttime, and a senior consultant to the child and adolescent psychiatry training program at Cambridge Health Alliance.

The HMS curricular initiative is one facet of a multiyear project funded by the Manton

Foundation. The overall goal of the project is to develop education and training programs aimed at making mental health care more widely available to children and adolescents. The curriculum will also emphasize the importance of understanding the effects that social factors and trauma have on mental health.

The idea is to look at each patient as a whole person, to understand how their mind and body work together and how relationships to their doctor, family, and community affect wellness. Moreover, medical students need to remember that a patient is far more than a collection of organ systems, symptoms, and diagnoses.

“We don’t want to train people to practice humpty-dumpty medicine, where each specialty takes a piece and there’s no one owning putting things back together,” says Qayyum, who is also the training director for the Boston Children’s child psychiatry residency program.

Power tools

Efforts to supply practicing pediatricians and other clinicians with material or training to bolster their knowledge of adolescent mental health issues have been on the rise. In 2021, the American Academy of Pediatrics developed several mental health toolkits to aid clinicians when they work with young patients and their families. In February 2021, the organization released the second edition of Addressing Mental Health Concerns in Pediatrics: A Practical Resource Toolkit for Clinicians and, in March of this year, it released a six-unit online course addressing trauma-informed care and resilience promotion. Each is designed to help practitioners refine skills and procedures for the integrated delivery of mental health care.

Individual hospitals, such as Boston Children’s and Massachusetts General Hospital, have also been developing tools to help pediatricians in the clinic and are building integrated care structures into many hospital-based specialties. For instance, a pediatric psychiatric collaborative care model developed at Mass General embeds mental health care within specialty medical practices such as the Pediatric Cystic Fibrosis Center and the Food Allergy Center, both at Mass General for Children. By integrating mental health care into other specialty centers, pediatricians hope to help patients and families deal with the mental health stresses often associated with chronic illness and other complex or long-term medical care.

A focused, assistive tool being developed by clinicians at Boston Children’s is taking crisis intervention techniques originally developed for the emergency department and adapting them for use in pediatric and primary care settings. This training tool will be available to clinicians through OPENPediatrics, an open-access online community of health professionals.

Strong bonds

Vikram Patel, The Pershing Square Professor of Global Health in the Department of Global Health and Social Medicine in the Blavatnik Institute at HMS, has been advocating for better mental health care globally for years — and has been innovating to achieve just that. Together with collaborators, Patel has found ways to deliver novel, highly effective mental health interventions that don’t rely on specialists or dedicated mental health clinics. Much of his early work was done in India with the community health organization Sangath.

Now Patel is working on projects that will apply those techniques in the United States, including one that will train middle school and high school counselors to deliver evidence-based talk therapy interventions to help young people get unstuck from negative thought cycles. Like the curricular design initiative underway at HMS, this effort is funded by the Manton Foundation.

According to Patel, data from the program indicate that individuals taking part in talk therapy interventions show progress; after only a dozen such sessions, he says, symptoms were alleviated in 60 percent of the participants, potentially preventing them from developing a more enduring mental illness. A similar study, published in 2018 in Behavioural and Cognitive Psychotherapy , assessed a small group of young people. This observational study indicated that after brief behavioral treatments, 65 percent of the participants needed no further intervention.

These techniques promise individual success and may also help reduce the demand for mental health care over time, as fewer people become seriously ill. An added advantage to this type of approach is that it builds and strengthens existing community relationships with school counselors and community health workers.

This bond-building is essential, says Qayyum. “We have to build a sense of connectedness, so young people don’t feel like they’re navigating this crisis on their own.”