The pandemic has escalated the need for increased access to mental health care among patients of all ages. And mental health nurses are among the providers who are feeling the pressure.
Crisis Declared
In 2020 U.S. hospitals experienced a 24% increase in emergency department (ED) visits among children ages five to 11 years for mental health reasons compared to 2019. Mental health visits to U.S. EDs rose 31% from year to year among teens, according to the Children's Hospital Association. The Children's Hospital Association also notes that hospital admissions and ED visits for suicide attempts doubled from 2008 to 2015.
The COVID-19 pandemic exacerbated the trend, said Laura J. Wood, DNP, RN, NEA-BC, FAAN, Executive Vice President for Patient Care Operations, System CNO, and Sporing Carpenter Chair for Nursing at Boston Children's Hospital.
"For children and adolescents, what began as a pandemic focused on an infectious disease evolved into a mental health crisis of unprecedented proportion," Wood said.
In October 2021, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association declared a national emergency in children's mental health, citing the serious toll of the COVID-19 pandemic on top of existing challenges such as the pre-COVID-19 rise in suicides.
Mental health is part of holistic health, said Lindsey Casey, MSN, RN, NEA-BC, Senior Vice President and CNO at Children's Hospital New Orleans.
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Lindsey Casey, RN[/caption]
"While the pandemic has largely focused on the physical health of our community, we cannot lose sight of the mental health consequences significantly impacting the pediatric population," Casey said. "The statistics are staggering. According to the CDC, comparing 2020 to 2019, suspected suicide attempts were up 51% for girls ages 12 to 17."
Adults are suffering, too. One in three reported symptoms of an anxiety disorder in 2020, compared with one in 12 in 2019, according to the American Hospital Association's Nov. 15, 2021, letter responding to the Senate Finance Committee's request for information on behavioral health care in the U.S.
The upswing in mental health issues should come as no surprise given the pandemic's associated physical isolation, ongoing uncertainty, fear, and grief.
Struggling To Provide Access to Mental Health Care
The pandemic changed traditional models of care for mental health care.
"During the COVID-19 pandemic, community-based support systems such as schools, neighborhood recreational centers, after school programs, and school-based resources such as school nurses rapidly vanished with the onset of mandated stay-at-home declarations," Wood said. "As a result, families with children and adolescents in crisis turned to acute care healthcare settings, including children's hospitals, in unprecedented volumes. The numbers of children and adolescents requiring inpatient care quickly filled child and adolescent mental health facilities and eclipsed the capacity of children's hospitals across the entire country."
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Connie Vogel, RN[/caption]
Inpatient psychiatric settings have been extremely affected by COVID-19 and the need to maintain restrictions related to mask wearing, social distancing, and cleanliness, according to Connie Vogel, PhD, RN, CNE, who is faculty at Capella University, School of Nursing and Health Sciences.
Imagine if a patient becomes aggressive, Vogel said. "Maintaining the safety of that individual, other patients, and staff is difficult in the best of circumstances. Adding the concerns regarding direct contact due to COVID-19, it is extremely difficult to manage disruptive behaviors and to maintain 1-to-1 suicide precautions," Vogel said.
While schools and community mental health resources have reopened for the time being (the impact of the newest COVID-19 Omicron variant remains unknown), there are looming supply and demand issues.
Mental health providers, including mental health nurses, are in short supply and at risk of burnout. Like people in the general population, healthcare providers who take care of patients' mental health needs are succumbing to pandemic-related fear and stress as access to mental health care does not meet the escalating mental health needs of communities.
"For those with ongoing behavioral health and substance abuse issues, one of the most serious effects has been a decrease in direct contact with service providers, counselors, and groups that provided ongoing support and helped individuals maintain their equilibrium," Vogel said.
Adults in the general population also report mental health issues related to high stress. The American Psychological Association's "Stress in America: A National Health Crisis" report suggests 78% of adults reported that their stress and stress responses such as disturbed sleep and anxiety had increased due to the COVID crisis, Vogel said.
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Maria Ingalla, DNP[/caption]
Maria Ingalla, DNP, PMHNPBC, PMHC, who owns and practices at Paperflower Psychiatry in Phoenix, Arizona, and is a nursing mental health professor at Arizona State University, said she has been seeing more patients with acute suicidal ideation since the start of the pandemic.
"The number of young kids with suicidal ideation around school has increased. I think a lot of it is that kids are being forced to go back to school now, after being off for a year," Ingalla said. "That has caused more of an uptick in patients coming in to see us because now there is a massive amount of social anxiety."
America is ill-prepared to respond to the population's mental health needs, due to severe shortages in the behavioral health workforce, according to the American Hospital Association's letter.
"More than 100 million Americans live in areas that have shortages of psychiatrists.... For hospitals and health systems, the pandemic exacerbated existing behavioral health challenges, with many hospitals forced to decrease the size of their behavioral health workforce due to budgetary pressures," according to the American Hospital Association.
Add to that the number of state-funded psychiatric beds per capita has declined by 97% between 1955 and 2016, which has resulted in a sharp increase in the number of ED visits for behavioral healthcare services, according to the American Hospital Association.
Nurses Seek Solutions Through Advocacy Efforts
Nurses have key roles in providing much-needed pediatric access to mental health care and advocating for this population, according to Wood.
"Nurses can help parents validate childhood stress and vulnerabilities and refer children to sources of support sooner," Wood said. "Strong and connected family relationships have a significant ability to mitigate the risk children and adolescents experience during periods of high stress."
Wood said nurses are getting increasingly engaged in public policy advocacy to improve the state of child and adolescent mental health in the U.S. such as:
- Improved reimbursement for screening and primary health care preventative mental health services most often not reimbursed or inadequately reimbursed by commercial and government payers
- More effective training to advanced practice registered nurses (APRNs), pediatricians, and other primary care providers about early mental health risks, identification, and screening
- Educational sessions to engage parents and school personnel regarding appropriate early identification of children at risk, alternatives for getting help, and effective engagement by school personnel
- Greater support of federal initiatives in promoting state and local municipalities in adopting the recommendations from Healthy Students, Promising Futures
Changes Could Be on the Way
In September 2021, Senate Finance Committee Chairman Ron Wyden, D-Ore., and Finance Committee Ranking Member Mike Crapo, R-Idaho, launched an effort to develop bipartisan legislation to address barriers that impede access to mental health care.
As part of the effort, they sent a letter to behavioral healthcare stakeholders and others asking for input to aid in the policy's development.
Wyden and Crapo wrote their goal is to develop legislation addressing many of the behavioral health care challenges currently faced by millions of Americans.
The American Hospital Association's letter makes recommendations for strengthening the mental health workforce, which includes addressing reimbursement issues and strategies to reduce burnout. Also recommended is bolstering student loan forgiveness programs to support training for behavioral health professionals at all levels and promoting efforts to reduce variability of scope-of-practice laws and support further changes.
"The [American Hospital Association] supports streamlining licensing and credentialing for federal programs and promoting interstate licensure compact agreements for physicians and allied health professionals," according to the letter.
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