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Youth Suicide Series: gaps in a crisis-driven system

Youth Suicide Series: gaps in a crisis-driven system

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Editor’s note: This is the second installment in a special project by the Mid-Valley Newspapers exploring the issue of youth suicide in the mid-valley. The next part in the series is scheduled to appear in early April. To read the previous installment in the series, click here.

A mid-valley teenager had struggled with depression and mental health issues since she was a small child, but last November, she hit crisis level. In the weeks it took for a bed to open in an inpatient treatment facility, she became increasingly suicidal and violent.

Her younger sibling stayed with their grandparents, her father quit his job to be with her every minute of the day and her mother kept the phone close at all times.

On one of their worst days, the mother got a call from a county worker.

“The worker called us right before 5 and told us she’s sorry she didn’t get back to us, but there had been a suicide in the community, and it was a crisis,” the mother recalled in a letter she sent to Oregon Rep. Sara Gelser. “All I could feel was fear for my own child and anger that someone successfully killing themselves is what was finally a crisis.”

Linn and Benton counties lost at least three young people — two high school students and a recent graduate — to suicide between October and December last year. In the past month since Gelser, D-Corvallis, introduced a bill aimed at helping prevent these deaths, youth suicides at Oregon State University, Bend High School and Eugene made the news.

Records for the past decade show that, on average, three to six mid-valley residents between the ages of 10 and 24 take their own lives every year.

The experience of the mid-valley parent who wrote Gelser isn’t unique. Parents face the challenge of navigating a mental health system made up of a patchwork of limited services and treatment options. While public mental health clinicians and community partners work to pool resources and creatively fill the gaps, they admit that the crisis-driven system in place to deal with troubled youths has little capacity for prevention or intervention, even while it struggles to treat the most at-risk youth while they’re in crisis.

‘He gave us a number’

“Trying to get help for her has been so heartbreaking,” the mother wrote in her letter to Gelser.

The mid-valley woman explained that her daughter had attempted to kill herself before and had talked about wanting to die since she was 8 years old. In November, when matters boiled over, her parents took her to the emergency room because they were desperate. It was the only place where they could get immediate help.

Every day, the emergency rooms in Linn and Benton county hospitals become the after-hours point of access for adults and children seeking help during a mental health crisis. The patients may be ridden with anxiety, depressed, combative or at risk of hurting themselves.

The ER at Good Samaritan Regional Medical Center in Corvallis sees two to three adults per day and two to three minors per week who are in mental health crisis, according to Dr. Caroline Fisher, chief of child psychiatry for Samaritan Health Services.

Mid-valley hospitals are too small to staff a 24-hour mental health unit, so the emergency room doctor and nursing staff are tasked with cases they may not be trained to handle. In 2012, emergency rooms in Albany, Corvallis and Lebanon hospitals saw 102 children and adolescents with psychiatric issues.

In cases that appear serious enough, emergency room staff bring in the on-call mental health clinician.

“We took her to the ER, where they threatened to restrain her to the bed,” the mother recalled in the letter. “When the county crisis worker got there two hours after us, she (my daughter) screamed herself to sleep. The worker looked at us and her and said, ‘Things seemed to have calmed down.’ He gave us a number and sent us home.”

Difficult decisions

The emergency room staff and the on-call clinician assess the suicidal child or adolescent, determine the level of danger and come up with a plan to keep everyone safe.

The truth, however, is that they have only one decision to make.

“Ultimately, at the ER, it’s do they need to be at the hospital or not?” said Mitch Anderson, Benton County Health Department director and head of the mental health division.

Patients are hospitalized overnight only if they’re considered an imminent danger to themselves or others, Anderson said. The hospital offers added security and 24-hour monitoring, but no active psychiatric treatment.

Mid-valley hospitals don’t have inpatient psychiatric wards for minors, so potentially dangerous youths are housed in the pediatric ward until a bed at an inpatient facility comes open at the Children’s Farm Home in Corvallis or in other facilities in places such as Portland.

Thirteen of the 102 youth who walked into mid-valley emergency rooms in 2012 with a mental health crisis were placed in inpatient facilities of some sort, Fisher said, while two others had already been staying in residential treatment at the Children’s Farm Home.

The hospital, Fisher said, is far from the ideal place to house suicidal youth.

“The pediatrics ward is not set up to be safe from (sharp objects) and this ward (in Corvallis) is integrated with the maternity ward” with babies and new mothers, Fisher said. “If you get an out-of-control, manic teenager, that screws up everybody on the pediatric ward.”

The Benton County Health Department assesses youth in crisis but for the past couple of decades, the county has held contracts with and referred children to providers such as the Old Mill Center and the Children’s Farm Home for treatment and case management, Anderson said, on the principle that the county shouldn’t compete with private providers.

As a result, Fisher said, a Benton County youth who walks into the ER is more likely to be sent home with a referral and no follow-up.

“They make the decision — in or out — and then it’s over,” she said.

The situation is somewhat different in Linn County: Because the Linn County Health Department has its own child mental health program, the on-call clinicians can schedule a next-day appointment at the county office and follow through with case management.

Long waits

Kids in crisis make it to the front of the line at the cost of other at-risk youths, who wait at least two weeks to get an initial assessment from a mental health professional.

If more next-day appointments were available in the mid-valley — through private or county providers – it would likely cut down on emergency room visits, said Dr. Cindy Smith, a child and adolescent psychiatrist. Smith is medical director of the Children’s Farm Home in Corvallis, which provides inpatient treatment for up to 64 youths.

“I think a lot of parents could wait a few days if they knew it was just a few days, but usually when they call around to counselors, they hear they’ll have to wait at least a week,” she said.

Seeing a psychiatrist, who can offer medication management and therapy, will take even longer. The wait is at least three months, Fisher said, and it doesn’t matter whether families are on the Oregon Health Plan, privately insured or paying out of pocket.

“I have people coming in six months later,” Fisher said. “If they are in crisis, it can be a long wait before they can see a psychiatrist.”

Locally and nationwide, there just aren’t enough providers, she said.

And without quick interventions, small problems snowball into bigger ones, Smith said. A teenager’s inner turmoil may begin spilling outward in ways that affect schoolwork and involve the juvenile justice system.

“We don’t have adequate intervention services for children who are not yet suicidal, but they’re depressed and heading that way,” Smith said.

Some programs, like Linn County’s Youth Services Teams, aim to intervene when trouble is on the horizon by bringing together agencies, schools, service providers and the families of troubled youth in one room to offer support and solve problems. Last school year, the county’s five teams served 96 families of at-risk — but not necessarily suicidal — adolescents.

But the Youth Services Teams are limited to serving those most at risk. Frank Moore, the Linn County Health Department administrator and mental health director, admits the teams could benefit a lot more kids.

“We are not reaching as far down in acuity as we’d like,” he said.

Other services

Depressed or suicidal children and adolescents have many points of access to get help — private providers, school districts, the juvenile justice system, Boys & Girls Clubs, county mental health programs and so on. Each supplies different services funded in different ways. The result is a fractured and difficult-to-navigate system that treats symptoms differently.

“Depending on who you talk to, you may get the Cadillac treatment plan or you may get a basic treatment plan and it may have nothing to do with the severity or your insurance,” Fisher said. “It’s much more determined by where you came into the system.”

Mental health professionals agree that, when possible, it’s best to treat children and adolescents in their own environments, using the natural supports of their families, friends and schools to teach them how to cope with everyday stressors and build resilience.

But the pressure, depending on the advocate or point of access, sometimes leads officials to send individuals to inpatient treatment even when they don’t need that intense level of care, said Smith, from the Children’s Farm Home.

“I don’t think we have a very uniform agreement of what needs to happen when a child says they’re feeling suicidal,” she said. “A lot of children who are having suicidal thoughts are treated quite effectively in outpatient programs. I think there’s sometimes an idea that every child having suicidal thoughts should be hospitalized, and that’s seldom the case.”

Stigma lingers

On top of the myriad resource and infrastructure-related hurdles in getting care for the kids who need it, another barrier often stops kids and families from seeking help in the first place: the stigma of mental illness.

The shame is so strong, Smith said, that it leads kids to stay quiet when their friends confide that they’re suicidal. It sometimes causes parents to ignore warning signs. It means that society still tends to not take mental health issues as seriously as physical health, even though the two are intrinsically linked.

“There has been a lot of shame, either for the teen or their families, recognizing that there is a mental health problem and something is really wrong,” Smith said.

By the time an adolescent is actually considering suicide, he or she has been

on that path — planning and thinking about it — for months or years. Signs get ignored for a long time, Smith said.

“I think stigma is a huge barrier to people getting help before it becomes an emergency,” she said, adding, “One of their biggest worries (for kids) at the Farm Home is what will people think of them when they go back to school.”

A brighter future

Health care reform is moving toward emphasizing prevention and integrating mental health treatment into primary care.

It’s a hopeful move, Fisher said. Soon, she believes, screenings for depression will be as common in preventive care as testing for diabetes and hypertension.

“We now have, in the Samaritan system, six or eight behavioral health psychologists embedded in primary care offices,” Fisher said.

In fact, she added, “My son just got a depression screening today with height, weight and blood pressure screening.”

Increasing support for mental health support in primary care offices, in theory, will improve the diagnosis and early treatment of mental illness so that patients can be treated more effectively.

Treating mental health issues like any other physical illness may have another welcome result: It could reduce the stigma attached to getting help for mental health issues.

That’s a development Gelser would welcome.

After the first article in this series was published last month, Gelser heard from other parents whose kids are struggling or have thought about suicide. They weren’t strangers, but rather people she knew through her network of friends and family.

“It struck me — how many people are holding this in and how common this must be, given that response? That was heartbreaking to me,” she said. “It made me think, gosh, I wish we could talk about these things because it’s easier when you know you’re not alone.”


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