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A hidden cost of Covid: contraction of mental health services



Over the past six months, New York state hospitals have repurposed or closed hundreds of psychiatric, detox and drug rehabilitation beds to make room for patients with Covid-19, leading to a cascading crisis in mental health care.

Treatment has become harder to find just as the pandemic has driven increased demand for services, according to interviews with behavioral health professionals, patients and patients’ families.

About 400 psychiatric beds remain closed for treatment, more such closures than in the past five years, according to the state mental health office. Likewise, about 150 addiction beds in hospitals are closed, according to the State Office of Addiction Services and Support. The overall number of such beds has increased slightly over the past five years.

Psychiatric beds in New York general hospitals

Beds closed from March to July *

Hospitals have also closed behavioral health beds in other states including Illinois, Massachusetts and Texas, along with Washington, D.C. The closures are pronounced in New York, a state hard hit by the coronavirus.

Healthcare professionals in New York described patients being discharged early to free up space, although many still showed signs of psychosis and mania. Some hospitals that kept the units open were overwhelmed, they said.

Imani Fecu, 24, who suffered from schizoaffective and bipolar disorder, was discharged from Health + Hospitals / Kings County, a public hospital, just days after she was admitted in late March.

Her grandmother, Sandra Lindie, along with her assistants, thought it was too early for Ms. Fecu to stabilize on new antipsychotic and mood medications. “She crashed and there was no safety net for her accident,” Ms. Lindie said.

At one time, Ms. Fecu enrolled at New York University and volunteered to teach JavaScript. He also struggled with heroin and separation from his incarcerated mother. After her discharge, she refused her medications and struggled to find a suitable treatment program, say her aides, who were reluctant to force her to return to the hospital.

On June 25, Ms. Lindie returned to her Brooklyn home with takeaway food and found her dead niece on the floor. He said the police found heroin and a needle in his room. The spokesperson for the city hospital system declined to comment on Ms. Fecu, citing patient privacy, but said all decisions were made using expert clinical judgment.

Some of Imani Fecu’s personal effects.

Sandra Lindie found Mrs. Fecu unconscious in a room she now keeps locked up.

Bed cuts in New York were even higher in the spring and early summer when Covid-19 spread. This represented the sharpest reduction in the number of psychiatric beds in general hospitals in at least a decade: 542 beds in 27 hospitals were repurposed or closed – 10.6 percent of those beds – according to the state mental health office. At least 403 detox and rehabilitation beds in hospitals and community facilities were also off-limits, about 13 percent of all such beds, the state office for addiction services said.

“There are not enough providers, not enough beds and not enough hands on the deck,” said Abby Venzor, a New York therapist whose patient tried unsuccessfully to find treatment in 10 different hospitals.

The state’s mental health care system was already strained, with bed counts dropping when the state closed its psychiatric facilities in favor of community mental health support and general hospitals cut services.

Nationwide closures have forced more patients to turn to critical mental health care – community-based organizations that help people outside of hospitals – but these groups have struggled to keep up. A September survey of more than 300 of these US groups found that 65 percent had canceled, rescheduled, or rejected patients, according to the National Council for Behavioral Health.

Some, including the New York State Association of Nurses, fear hospitals will use the moment to close psychiatric units. Inpatient treatment of psychosis costs patients an average of $ 1,351 per bed per day, while a range of common heart care costs between $ 28,000 and $ 86,000, the group says.

“Behavioral health is the line of service that loses money,” said Harsh Trivedi, a trustee of the American Hospital Association and chief executive of Sheppard Pratt, a private behavioral health hospital in Maryland. He said the steep financial losses linked to Covid have helped spur US hospitals to close their beds.

NewYork-Presbyterian has closed the 30-bed psychiatric unit at its Allen Hospital.

Poor reimbursement from insurers, including Medicaid, helped drive nationwide closures even before the coronavirus pandemic, said a spokesperson for Westchester Medical Center Health Network, a system that closed beds in suburban New York .

Nationwide, no one knows the true number of recent closures mainly because hospitals moved quickly and didn’t need to offer detailed move reports, thanks to federal and state waivers that allow immediate reuse of behavioral-health beds when the pandemic has struck. The Federal Substance Abuse and Mental Health Services Administration and several state public health departments said they did not have complete data.

The New York Mental Health Office said it expected all repurposed beds to come back online eventually. Agency spokesman James Plastiras said the state has “sufficient capacity” despite the changes and has received no reports of people who have been denied admission due to pandemic-related closures.

A city under stress

Interactions with the free New York City mental health support service (messages, calls, app visits and online services) increased in 2020 compared to 2019. Contact with the nonprofit Crisis Text Line also increased.

Total conversations with Crisis Text Line, March 1st-July 17th

NYC Ben monthly contacts with total response *

Main topics discussed, 1st March-17th July

NYC Ben total monthly web sessions

Total conversations with Crisis Text Line, March 1st-July 17th

NYC Ben monthly contacts with total response *

Main topics discussed, 1st March-17th July

NYC Ben total monthly web sessions

NYC Ben monthly contacts with total response *

Total conversations with Crisis Text Line, March 1st-July 17th

Main topics discussed, 1st March-17th July

NYC Ben total monthly web sessions

NYC Ben monthly contacts with total response *

NYC Ben total monthly web sessions

Total conversations with Crisis Text Line, March 1st-July 17th

Main topics discussed, 1st March-17th July

Several hospitals say behavioral health beds are closed to comply with Governor Andrew Cuomo’s order that hospitals have a plan to ramp up in the event of a second wave of Covid-19. Cuomo administration officials said the order does not require that a certain number or type of beds remain closed for treatment, only that hospitals have a plan in place.

Hospitals say behavioral health admissions have slowed overall, by up to 40% from March to June in the Northwell case, partly due to fears of catching Covid-19 within hospitals.

With the loosening of lockdowns, hospitalizations have come back and are now at pre-pandemic levels, according to the state mental health office. Northwell Behavioral Health admissions rose 26% in June compared to May; grew 23% over the same period across the entire New York City public health system known as NYC Health + Hospitals.

Nurses and psychiatrists say the number of psychiatric and overdose patients has steadily increased in the summer and early fall. They include essential workers such as bus drivers and doctors suffering from post-traumatic stress disorder, as well as recovering patients with Covid-19 who do not have a history of psychotic crisis.

A spokesperson for Health + Hospitals said the network did not reach or exceed the capacity of the psychiatric bed. Northwell executives said the system had no problem accommodating patients and that most offline beds would be closed for the foreseeable future.

Based on the number of psychiatric beds closed in New York since March and the average length of patients’ stay, the Nonprofit Treatment Advocacy Center estimated that 14,000 psychiatric hospitalizations were lost, people who may need hospital care but not they were able to get it. “People don’t stop getting sick just because there’s nowhere to treat them,” said John Snook, the group’s executive director.

Closed for treatment

In a rush to convert beds for critically ill Covid-19 patients, NewYork-Presbyterian Brooklyn Methodist Hospital closed its two 25-bed psychiatric units in late March. Several patients who were still psychotic were discharged rather than transferred for ongoing care, several health care professionals said.

Emergency medical technician Goldy Landau was called in to help transport patients. One woman suffered from schizoaffective disorder, post-traumatic stress disorder, drug addiction, and a history of personal assault. The nurses told Ms. Landau that the woman, who had been sedated and held for the trip, was not ready to go to her group’s home.

When the woman woke up during the transport and Ms. Landau explained why she was leaving, she said the woman asked, “Will all the crazy people walk down the street?”

In Manhattan, NewYork-Presbyterian also closed the 30-bed psychiatric unit of its Allen Hospital, which serves mostly diverse and low-income Medicaid patients, according to nurse Alana Ribowsky.

Nurses say they have seen former patients who could not receive treatment now act erratically on the streets. Irving Campbell, a nurse with the Brooklyn Methodist of NewYork-Presbyterian, said he saw a patient who “at best is a working former engineer,” appearing disheveled and picking cigarette butts off the floor.

Irving Campbell is among nurses who claim to have seen former patients who could not receive treatment acting erratically in public.


Photo:

Dave Sanders / New York State Association of Nurses

The units, which typically see around 1,500 people a year, remain closed. Closures by private hospitals such as hospitals with tight safety nets in New York-Presbyterian such as Nassau University Medical Center on Long Island and those in the Health + Hospitals network such as Covid-19 increased in the spring.

NUMC discharged 80 psychiatric patients in 10 days, then moved to reuse 56 percent of its beds for behavioral health, said Constantine Ioannou, NUMC’s president of psychiatry. Health + hospitals rushed to deliver 382 behavioral health beds for Covid patients.

NewYork-Presbyterian said its “commitment to behavioral health is unwavering” and that it “is working with regulatory agencies on a plan to reopen behavioral health beds in Brooklyn and northern Manhattan” while remaining prepared for a another wave of coronavirus.


‘This place is not safe.’


– Nurse Jeri Wessberg, who worked in a facility managed by the Westchester Medical Center Health Network.

A similar dynamic was occurring in suburban counties north of New York City, where the Westchester Medical Center Health Network of 10 hospitals serves several counties.

In the spring, the system closed its Kingston 60-bed psychiatric and drug recovery units. Nurses said patients have started backing up in the windowless psychiatric emergency room, forcing some to wait up to four days for a transfer.

Ulster County Executive Patrick Ryan said he feared the Kingston closures were endangering the community, citing an increase in opioid overdose deaths. Overall, substance-related deaths increased 114 percent through August, and suicides doubled in the county since March, compared to the same periods in 2019.

Many patients are transferred from Kingston to Westchester facilities between 20 and 90 miles away, including Mid-Hudson Regional Hospital in Poughkeepsie. Former Kingston patients and nurses reassigned there say discharge was rushed.

Detox Nurse Jeri Wessberg has filed improper care complaints with the state. He wrote that staff members were once required to use Narcan, an overdose antidote, to resuscitate a patient after administering doctor-ordered doses of drugs. “This place is not safe,” said Ms. Wessberg, who said she decided to take unpaid leave in September rather than continue working in Mid-Hudson.

Jeri Wessberg, a detox nurse, filed complaints for improper care at a hospital in Poughkeepsie, New York, on the Westchester Medical Center Health Network.

The system had closed behavioral health beds in Kingston, N.Y., where a sign was posted in support of their reopening.

The inadequate supply of basic products, such as bathrooms and telephones, in the new 15-bed psychiatric overflow unit has led to fights between patients, according to more than a dozen former patients and nurses. They said the shortage of psychiatric staff means that inexperienced technicians often care for patients. Nurses say this has led to excessive “Code Grays” when security and staff are called to treat or detain a non-compliant patient.

Westchester Medical’s health system said in a statement provided by spokesman Andrew LaGuardia that patients received high-quality care and were safely discharged. He added that hospitals with behavioral health services are “experiencing a severe staff shortage.”

Westchester said it was discussing solutions “to maintain, not reduce, current behavioral health bed counts and expand outpatient behavioral health services.” He said he did not experience excessive “Code Grays”, longer waiting times in the emergency room or shortages of supplies.

System already tense

Most of New York’s behavioral bed closures happen in New York City, where Covid-19 has hit its worst.

Hospital systems say the closures did not result in less care due to the lower overall hospitalizations. But patients, families and healthcare workers say the Covid-19 closures have made matters worse with a system already under pressure.

“We are listening to people who, in times of need, are removed from hospitals, discharged prematurely, or forced to stay in facilities away from their homes,” said Matt Kudish, executive director of the New York branch of the National Alliance for Mental Health. which he has heard from many families.

Mental health workers at the city’s Rikers Island prison complex say some inmates released during the pandemic have returned after committing crimes. “They can’t get services when they go out and they’re sick,” said Alicia Butler, a psychiatric nurse at Rikers.

Robert Memory, a former community health worker who sought help in the emergency room at Montefiore Medical Center in the Bronx in July, said he was discharged too early and tried to overdose on pills and alcohol two days later. “I was in a deep dark place with the pandemic and no support,” except a cat, said Mr. Memory.

When he sought assistance in Montefiore, he was transferred to Long Island’s Brunswick Hospital Center. He said the ambulance operator told him there were no other beds in New York City.

Robert Memory says he was discharged too soon from a Bronx hospital.

A spokesperson for Montefiore declined to comment on Mr. Memory’s account, citing the patient’s privacy.

Long Island’s Nassau University Medical Center was among hospitals during the spring surge that, under new federal and state rules, could quickly rotate behavioral health beds for coronavirus patients.

One of the patients who discharged in the summer was Nurys Caceres’ 22-year-old son, released after 10 days, he said, “in full mania.”

She said the springtime of isolation was “the kiss of death” for her son, a former Stony Brook University student diagnosed with bipolar disorder and depression.

A closer look at the pandemic

In late July, Ms. Caceres called the police after her son crashed out of the house, saying he intended to jump in front of a train. He was taken to the NUMC. He was discharged 12 hours later, but Ms. Caceres said the hospital hadn’t told him.

Police found him four days later in Harlem. They took him to Health + Hospitals / Harlem, which moved him to Brunswick on Long Island, Ms. Caceres said. That hospital discharged him in 10 days, unstable and refusing the lithium they had prescribed, his mother said.

“Patients walking through doors are 100% more extreme and acute than they have ever been before,” said Mike Devery, quality manager at Brunswick, who declined to comment on individual patients. He said the hospital has not felt the pressure to discharge early and many patients have had positive outcomes.

Within weeks, Ms. Caceres said, her son took all of her lithium pills in an attempt to kill himself and returned to the NUMC.

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Dr. Ioannou, the president of NUMC psychiatry, said the hospital began reopening its beds in late July, but with slightly less capacity due to coronavirus-related precautions.

He declined to comment on the patients’ cases, but said coronavirus restrictions had strained communications with families and that discharge was difficult for them because “outpatient programs are still more or less closed.”

He said the hospital often kept patients longer than others and was proud to help those without resources. “You will have maybe a little worse results and you will have complicated cases,” he said. “There’s nothing worse than watching a child suffer.”

Westchester Medical Center has closed 60 psychiatric and drug addiction beds at a site in Kingston, N.Y.

Write to Shalini Ramachandran at shalini.ramachandran@wsj.com

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