Colorado for decades has struggled with a shortage of mental health treatment options, but care for one age group in particular is most dire: teenagers.
The adolescent mental health epidemic is escalating — suicide is now the leading cause of death for Colorado teens — and the state’s emergency departments are inundated with young patients experiencing mental health crises.
Parents struggle to find treatment that is somewhere on the scale between weekly visits to a therapist and full-time hospitalization. Families looking for intensive, round-the-clock therapy often send their kids to out-of-state treatment centers because they can’t find the right treatment in Colorado.
So it’s not surprising that the for-profit company Insight Behavioral Health saw a market in Denver, recently announcing the opening of a mental health treatment complex in the Lowry neighborhood. Insight has started seeing adult patients and in January will take adolescents ages 12-17.
Mental health experts in Colorado are welcoming the new facility as a much-needed resource for teens but lament that it is a for-profit center geared toward families with commercial insurance. Insight, which is affiliated with The Eating Recovery Center for patients with anorexia, bulimia and other eating disorders, does not accept Medicaid, the state’s insurance program for needy Coloradans.
The facility will have three levels of care for kids and teens: an intensive out-patient program in which patients receive therapy for three to four hours per day, a partial-hospitalization program in which kids check in for the day but go home at night, and a round-the-clock residential treatment center that can take up to 24 children.
Insight joins several other residential treatment centers that take commercial insurance and a few dozen others that serve patients who have Medicaid or who are receiving services because they are in the child welfare or juvenile justice systems.
The state Office of Behavioral Health — which works with 16 agencies providing residential treatment for adolescents — said Colorado has adequate treatment beds for kids, but often not the right types of speciality treatment openings at the time a child needs it. Another complication: it can take months to assess a child’s needs and find the right type of services covered by Medicaid and other government programs.
“It’s challenging to get a kiddo placed,” said Camille Harding, the state’s Community Behavioral Health division director. “The state works hard to exhaust all the funding streams that are allocated to different state agencies. It can take a few months to work through.”
The department is in the midst of a statewide assessment of mental health services, checking county by county on the services available from talk therapy to residential treatment to recovery programs. It is also setting up a one-stop referral point — as required by Senate Bill 195 last year — that families, teachers and physicians can call to find mental health treatment.
An “equal-opportunity problem”
A big push in mental health care in the last several years has been to establish a “continuum of care,” a system that would allow patients to gradually step down their treatment as needed and one that would offer the right treatment early on, before mental illness escalates to the point of requiring hospitalization.
In Colorado, people in mental health crisis are walking into emergency rooms, where they might stay for several hours or a couple of days. The state needs more intensive, out-patient options to help those patients when they leave, mental health experts said.
Patients in mental health crisis who end up in an urgent care unit typically stay for two to four days, and often return to the same emergency room or acute care center the next time they are in crisis. “We’re trying to interrupt that cycle of emergency room visits,” said Dr. Elizabeth Easton, regional clinical director for child and adolescent services for the new Insight treatment facility.
The adolescent intensive out-patient program is designed for teens who need more than a weekly conversation with a therapist. It’s a program to help them with a “gradual building of resiliency to get back into life,” Easton said. It teaches teens how to manage the stressors of peer pressure, academics and other expectations that are causing their illness to escalate.
About 90% of patients pay through private insurance. Insight, which has 11 centers in five states, declined to say how much the treatment costs. The company seeks grants, which totaled $750,000 the last two years, to help families afford out-of-pocket costs not covered by insurance. About 4% of funding comes directly from patients.
The facility does not take Medicaid or the low-cost public insurance called Child Health Plan Plus. Combined, the two programs insure about 500,000 children in Colorado.
Mental Health Colorado president Vincent Atchity said “it’s a shame” the new hospital is for-profit, but noted that mental health access is an “equal-opportunity problem.”
While low-income families can have a difficult time navigating the system to find out what treatment is available through Medicaid and other government-funded programs, “even well-resourced individuals with what they think is good coverage have a hard time finding care,” he said.
Children with private insurance are 10 times more likely to have to go out-of-network for mental health care compared with medical visits to their primary care doctor, according to a nationwide report released last month from the actuarial firm Milliman. That’s double the disparity for adults.
In Colorado, patients went out-of-network up to seven times more often for mental health care compared with medical or surgical care, the report said. This is despite the fact that mental health equality in insurance is required under federal and state law.
Meanwhile, many of the Medicaid-covered adolescent psychiatric beds in Colorado are used by youths who are in the criminal justice system, leaving others in need of treatment without options, Atchity said.
For adolescents, the shortage of services is so acute that parents sometimes say they hope their child is arrested so they will get access to mental health care, he said. “Families may experience an initial moment of relief when their kid is taken away in handcuffs,” Atchity said. “The relief doesn’t last long — now what we’ve got is an adolescent with criminal charges.”
Identifying mental health issues in the emergency room
At Denver Health Medical Center, which cares for patients with Medicaid as well as those with no insurance, doctors have come up with a new plan to deal with the increasing numbers of adolescents coming to the psychiatric emergency department.
The first floor of the main hospital building near downtown Denver contains the adult emergency, pediatric emergency and psychiatric emergency departments. Data revealed that many patients visiting the psychiatric emergency department keep coming back, which made physicians there wonder if there was a better way to get them linked to mental health care outside the emergency department.
So the hospital added a psychology resident — a student in training to become a licensed psychologist — to the pediatric emergency department. The resident, Shaza Karam, reviews patients’ charts, looking for any history of behavioral health issues. She talks to patients in a way many doctors aren’t trained to do — asking direct questions about “thoughts of wanting to die” or depression that is interfering with their daily lives.
The questions she asks and the way she asks them are important because most people who take their own lives denied that they were suicidal at their last medical visit, perhaps because their doctor didn’t ask the right questions, said Dr. Scott Simpson, medical director for Denver Health’s psychiatric emergency services.
Up to 30% of patients in the emergency room have a behavioral health issue along with a medical problem, he said. The hospital has 21 adolescent psychiatric beds, but the goal is to help kids before they need them, he said.
When the emergency department identifies children who are in need of mental health care, they offer family therapy, mindfulness techniques, breathing and relaxation exercises and other, more intensive therapies. Ongoing data analysis will show whether the emergency department is helping kids connect with out-patient services and residential treatment centers, Simpson said.
So far, the department has seen a slight reduction in 60-day return rates of adolescents to the emergency department.
A lack of in-patient psychiatric treatment for kids is an issue, but the larger gap is a shortage of out-patient, intensive programs, Simpson said. For now, emergency departments are picking up that slack.
“We have to be that backstop,” he said.