The portion of U.S. hospital beds occupied by children with suicidal or self-harming behavior has soared over the course of a decade, a large study of admissions to acute care hospitals shows.
An analysis of 4,767,840 pediatric hospitalizations by researchers at Dartmouth College, published Tuesday in the medical journal JAMA, found that between 2009 and 2019, mental health hospitalizations increased 25.8% and cost $1.37 billion.
The study did not include psychiatric hospitals or reflect the years of the coronavirus pandemic, suggesting that it is a considerable undercount.
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Especially striking was the rise in suicidal behavior as a cause: The portion of pediatric mental health hospitalizations involving suicidal or self-harming behavior rose to 64.2% in 2019, from 30.7% in 2009. As a proportion of overall pediatric hospitalizations, suicidal behavior rose to 12.7% in 2019 from 3.5% in 2009.
Although the rise in suicidal behavior among American youths is well-established, the study underlines the gaping inadequacies in the U.S. health system, said Dr. Gabrielle Carlson, director of child and adolescent psychiatry at Stony Brook University medical school, who was not involved in the new study.
“You have got a whole system failure here that is registering itself in suicidal kids,” Carlson said. Parents seeking care for children, she said, encounter a series of frustrations: clinicians who don’t take insurance or aren’t taking new patients; crisis interventions staffed by low-paid, poorly trained workers; insurers that don’t reimburse well.
“The hospital ends up being the place you go when all else fails,” Carlson said. “Could you have nipped it in the bud earlier? That is a systems-of-care problem.” She added, “This is playing itself out in an attention-grabbing way.”
The study analyzed the Kids’ Inpatient Database, the largest nationally representative database of pediatric acute care discharges, which includes patients younger than 21.
Mental health hospitalizations rose significantly in children between ages 11 and 14 but declined in younger and older age groups during the same 11-year period. Girls became a larger portion of mental health hospitalizations, rising to 61.1% in 2019 from 51.8% in 2009. Hospitalizations for suicidal behavior rose to 129,699 in 2019 from 49,285 in 2009.
The study did not examine what caused the trends, but Dr. JoAnna Leyenaar, one of the paper’s co-authors, pointed to “a growing, growing use of social media among children and adolescents and in particular, growing use among younger adolescents,” which she said had been shown to increase symptoms of depression.
Whatever the reason, she added, “we don’t have the magic formula to figure out how to dial this back and make things better.”
Leyenaar said the research was informed by her personal experience as a hospital pediatrician: Although her training included no formal mental health experience beyond a six-week rotation in medical school, children hospitalized after a suicide attempt or self-injury are now a central focus of her working life.
“Five years ago, my care for these patients didn’t look very different from my care for children with respiratory illnesses,” said Leyenaar, an associate professor of pediatrics at Dartmouth’s Geisel School of Medicine. Her team has added trainings on safety planning and cognitive behavioral therapy, in the hope that younger doctors “leave residency better equipped to care for youth with mental health conditions than we did.”
The findings should spur policymakers to place more mental health care services in school and community settings, which “may well result in decreased hospitalizations,” said Mary Arakelyan, a research project manager at Dartmouth Health Children’s and another co-author. Meanwhile, she said, hospitals should confront their increasingly central role as mental health providers.
“For so long, the culture has been, in the hospital, that medical emergencies are the true emergencies,” said Dr. Christine Crawford, a child and adolescent psychiatrist at Boston Medical Center, who was not involved in the study.
Mental health training, she said, should be given throughout the hospital, “kind of like how everyone in the medical staff is trained on how to do CPR.” And, she said, hospitals need to be incentivized to add inpatient psychiatric units, which, because of reimbursement rates, “hemorrhage money.”
The study traced a major shift in the kinds of mental health problems being treated in hospitals, with depressive disorders rising to 56.8% in 2019 from 29.7% in 2009. Hospitalizations for bipolar disorders, conduct disorders and psychotic disorders like schizophrenia decreased, which could reflect better outcomes due to early intervention programs and more wraparound care.
Rates of suicidal behavior are a “marker of distress” among children who lack coping skills to manage stress and “big emotions,” said Crawford, who is also an assistant professor at Boston University School of Medicine.
“When you actually talk to kids who engage in self-harm, who impulsively ingest the Tylenol, they oftentimes talk about an argument that they had with a peer, or a disagreement that they had with an adult,” she said.
In most cases, she said, these children have suffered from diagnosable depression for “many, many months” without being treated. “The kids we’re seeing in the emergency room are doing this rather impulsively in the context of some argument,” she said.
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