In crisis, must travel

When Chico pediatrician Craig Corp saw a newly released study on psychiatric hospitalizations for children and teens, he was surprised by the results—namely that nearly 1 in 10 patients under age 18 are admitted for a mental-health condition.

“I find it a bit hard to believe,” he said. “That certainly is not the case locally.”

Technically, the local number is zero, because Butte County has no inpatient facility for pediatric psychiatry. Enloe Medical Center and Butte County Behavioral Health have wards for adults only. When kids or adolescents need hospitalization, they are forced to go elsewhere—usually to Sacramento or the Bay Area.

But that’s not what Corp meant. While the need for psychiatric care is great, the local incidence of hospitalization may not be as high as the study’s national statistic.

“About 25 percent of children have psychiatric disorders, about the same as in adults. Fortunately, inpatient-stay needs are not terribly common,” Corp said. “I think each pediatrician, in Chico at least, refers only a couple of cases a year for inpatient treatment, usually after a significant suicide attempt. For a significant crisis of one sort or another, [a pediatrician will see] maybe five or six a year.”

As one of just three pediatric psychiatrists in Butte County, Dr. Welby Nielsen sees more. His estimate is between two and six patients in crisis per month, “but it might be in a three-day period I get four of those.”

For inpatient care, Nielsen needs to refer families to a big-city hospital, where staff psychiatrists will treat the patient.

“It’s a fairly significant issue,” Nielsen said. “Parents have a harder time sending their kids a fair distance out of the area; having your 12-year-old or 15-year-old who’s in crisis that far away is a big challenge.

“The other issue that comes up is part of the work that you do [as a psychiatrist] is get families involved in the process. It’s that much more challenging if you want to have a family meeting every day, but mom and dad have to travel four hours round trip in order to be in a meeting for an hour. That’s a significant chunk of time for families that work.”

Another challenge is finding a hospital willing and able to admit young patients. Scott Kennelly, assistant director of clinical services for Butte County Behavioral Health, said local families may travel as far as Southern California, particularly if their child is under 10 years old.

“If a patient is bad off, but not acutely suicidal,” Corp said, “it can take a month or more before they can be admitted for inpatient treatment.”

Local options for kids in crisis consist of the county’s crisis stabilization unit (CSU)—which can hold a patient for only 23 hours before having to transfer him or her—and intensive outpatient treatment from Butte County Behavioral Health or an acute-care psychiatric practice.

Behavioral Health, which operates the CSU, sees far more youth in crisis: an average of more than 60 a month (1,131 between July 2012 and December 2013). Around eight a month (93 from July 2012 through June 2013) need to travel out of the county for inpatient treatment.

Considering the benefits, offering inpatient care close to home would seem like a no-brainer.

“Frankly, there are not enough pediatric admissions for a facility just for them,” Corp said. “If the teens could be admitted to an adult facility that certainly would help.”

The problem there, Kennelly said, apart from state regulations and licensing, is safety.

“The concern you have when you mix youth and adults is the issue of victimization as well as presentation [of symptoms],” he said. “A depressed adult is very different than a depressed youth … and you run into issues of a youth potentially being preyed upon sexually or physically.”

Inpatient pediatric psychiatry requires more intensive staffing than inpatient adult psychiatry, which means a greater expense. Butte County has discussed a regional facility with nearby counties, Kennelly said, but no specific plans are in place.

For the study on psychiatric hospitalization, published in the April issue of the medical journal Pediatrics, researchers at UC San Francisco analyzed information from two national databases. Of the juvenile patients with mental-health conditions, 44.1 percent get hospitalized for depression, accounting for $1.3 billion in hospital charges each year.

The second most common diagnosis is bipolar disorder, at 18.1 percent, costing $702 million annually. Third is psychosis, at 12.1 percent, costing $540 million. Anxiety and depression are common conditions locally, while psychosis is more rare.

With inpatient facilities so removed from the North State, Kennelly said Behavioral Health is working with primary care providers to diagnose conditions earlier. In addition, thanks to grant funding from the state, the county is placing mental-health clinicians in hospitals to help emergency-room staff delineate between physical and psychiatric symptoms.

“No one wants to send kids out of the county,” Kennelly said. “Our emphasis, knowing we don’t have inpatient units around here, is prevention—trying to keep them from having to go out of county.”

Independent reporting for this story was made possible through a grant from HealthyCal.org.