NO PLACE TO REST
Santa Fe Reporter - 7/25/2019
The diagnosis sank his heart. Richie Sanchez' 16-year-old son was suffering from first-episode psychosis, a common precursor in adolescents to adult schizophrenia. Overthe course of months, Sanchez' son had isolated himself from friends, become increasingly suspicious of others, and would often wake in the night disoriented by dreams he could not easily distinguish from reality.
Yet, the diagnosis was not altogether surprising, Sanchez tells SFR. It called to mind fearful childhood memories of stories about what befell his grandfather, who was committed to a psychiatric ward in Northern California in the 1950s. Because of his family history, Sanchez wanted to make sure his son received the best possible care, and he felt grateful of such early intervention for an illness that often goes undiagnosed in young adults until symptoms are quite severe.
But at first, finding the right dosage and medication for the condition was a matter of trial and error, and when a change in his medication regime nudged the teen into a period of hopelessness punctuated by erratic behavior, Sanchez began to worry.
As he considered options in case of an emergency, Sanchez was shocked to find that there were no psychiatric inpatient beds for youth in Santa Fe County. As a divorced single parent who worked full-time and lives in a rural area north of Santa Fe, he spent long hours away from home while his son went unsupervised. His concern escalated after an episode where neighbors found the teen sleeping nude under a pile of leaves in their backyard. What if they had called the police?
But if he took his son to a hospital in Albuquerque for inpatient services, Sanchez' schedule would make visiting difficult.
"I want to make sure that either me or someone else in the family has oversight over any hospitalization of my kid," says Sanchez, anxiously stroking a bushy salt-and-pepper beard as he speaks. He pauses, lifts a full mug of black coffee-grown cold in the 30 minutes since he met SFR at a downtown coffee shop-then sets it down again without taking a sip. "The psych ward did pretty bad things to my granddad, and I know times have changed and all, but I wanna be sure he's getting treated right, you know? My kid doesn't trust strangers; I don't want him to feel abandoned."
Considering the potential severity of his diagnosis, Sanchez made the tough decision last year to send his son to California to live with his parents, who are retired and whose home is close to a facility that offers youth inpatient services-just in case. Sanchez says his artistically talented son graduated this spring from an arts-oriented high school and is currently stable, and Sanchez hopes to move to join him on the West Coast by the end of the summer.
The Sanchezes' story is ultimately a tale of success. But for Santa Fe County and youth here who are likely to experience an acute psychological crisis requiring hospitalization each year, it's a story of failure.
Severe to moderate mental illnesses factor into many of these cases, but for children with or without a diagnosed mental illness, the most common cause for hospitalization is contemplated or attempted suicide.
For many advocates, the intersection of mental illness and suicidally is where the system is in most critical need of attention.
Santa Fe County has no safe space for youth to lay down a troubled head at a time when they may be in imminent danger of hurting themselves or someone else, or falling into crisis. Recent trends in behavioral health data indicate that the number of young people in need of such services is increasing. And while this need has been acknowledged by the county, local inpatient psychiatric services for youth are still nowhere in sight.
Growing cause for concern
Across the country, data shows suicide amongyoung people is on the rise. In New Mexico, suicide rates are nearly double the national average for all age groups- for ages 15 to 19, the state leads the nation. In 2017, twice as many New Mexico youth took their own lives as in 2016.
In Santa Fe County between 2009 and 2013, youth suicide rates per 100,000 people were 5% higher than the state as a whole. During those years, the Office of the Medical Investigator recorded 14 youth deaths by suicide in the county, including one who was 12 years old. Since then, and just through April of this year, it's listed as the cause of death for another nine teens here ranging in age from 14 to 19.
In 2017, Santa Fe County analyzed the community's most pressing gaps in health care services. Across the board, a lack of behavioral health services stood out as an urgent need. For youth, high suicide rates and accelerating rates of self-reported depression and hopelessness were leading indicators of a growing behavioral health care problem. Lowering rates in both areas are among the goals of the county's Behavioral Health Strategic Plan, released in the spring.
Those reduction goals reflect two distinct pieces of one troubling puzzle.
Overall, Santa Fe has a problem getting kids the mental health care they need. In the 2017 analysis, the county used national and state data scaled to the county's population size to estimate that roughly 2,300 adolescents in the Santa Fe area experience major, long-lasting depressive episodes in a given year-but only 780 are likely to receive any mental health care service. Additionally, over 1,000 young people in the county have serious thoughts of suicide.
Part of the county's strategy is to adopt a "zero suicide" model based on best practices developed by national suicide prevention and mental health care organizations. The model calls for suicide prevention in the "least restrictive" settings and inpatient hospitalization only as a last resort.
Yet even this system recommends "inpatient psychiatric hospitalization, with suicide-specific treatment" as critical to the "spectrum" of care.
Many factors can contribute to a young person's suicide, but depression and other mental illnesses, as well as prolonged feelings of hopelessness, remain among the primary indicators of suicide attempts in adolescents. Though not all kids who attempt suicide demonstrate their feelings or show symptoms of illness, and not all kids who have mental health problems are suicidal, there's a strong link between teen depression and anxiety disorders and suicide.
"When a young person makes a decision to end their life, it's generally not because they want to die. Ifs because they don't have hope," Brenda Steele tells SFR by phone. She's an educator, a mental health advocate and the Northern New Mexico coordinator of Breaking the Silence New Mexico, an organization that teaches mental health-based curriculum and suicide prevention in local schools.
For Steele, the numbers speak a personal truth. When she was 12 years old, Steele was diagnosed with depression after her father, who had been diagnosed with schizophrenia when she was very young, took his own life. At 15 she was re-diagnosed with bipolar disorder, and as a young adult, her condition quickly spiraled out of control into bouts of deep depression and substance abuse punctuated by suicide attempts.
The hopelessness she experienced came, in part, from the isolation, stigma and shame she felt in relation to her diagnosis, and the cyclical regularity of her depressive episodes led her to believe she might never recover. "I thought this meant I would be a failure, that my life would not be good," she says.
The turnaround came as she found the courage to speak openly about her illness, and to her surprise, she found solidarity, empowerment and the tools to plan for and weather the storms other illness.
"My life may not look like everybody else's; it might not look normal. Success for me is not what I expected success should look like. And that's OK," she says. Now, at age 40, she no longer feels trapped by her diagnosis. She's even come to appreciate its hidden strengths-her expansive sense of empathy and sensitivity to the emotions of others, which are hallmarks of bipolar disorder.
But as a teen, Steele exhibited symptoms that cause many young people to give up hope completely.
We need, we need
In its annual Youth Risk and Resiliency Survey, the state Department of Health asks high school and middle school students to answer questions about their mental state and other areas of well-being.
Between 2009 and 2017, the number of high school students who self-reported a suicide attempt in the last year steadily decreased. But among middle school students, who are asked about lifetime behavior rather than recent behavior, the number of students who report attempted suicide has gone up. Both groups showed sharp increases in the number of students who report persistent feelings of sadness and hopelessness.
Those reports are part of why, in July, Christus St. Vincent Regional Medical Center released a 2019 Community Health Needs Assessment that named youth depression and suicide rates as the primary indicators of need for children and adolescents. But behavioral health professionals at the hospital say the focus on acute crisis care in a hospital setting would be a misguided approach to the bigger problem. That's part of the reason beds are not their priority.
Statistically, the need for acute behavioral health services is much greater among adults, says Kathy Armijo-Etre, the hospital's vice president of mission, and the hospital has focused efforts on new behavioral health emergency services for adults in the ER.
"So far the patient response to our needs assessment has not been that we need an adolescent in-hospital unit; what we need is support services in the community," says Jesse Cirolia, manager of community health at Christus, adding that the hospital funds grants to local organizations doing prevention work. "We need counselors in schools; we need more access to behavioral health in the outpatient setting; we need an anti-stigma campaign that allows people to feel more comfortable accessing the care that they need; and parent education in multiple languages about how to identify the risk factors."
In 2013, the hospital partnered with the Sky Center, a nonprofit organization in Santa Fe that offers free family counseling to youth who have attempted or contemplated suicide. Any youth who arrives at the ER with suicidal ideation is immediately referred to the Sky Center, where councilors work with children and their families to create a network of support and prevent future suicide attempts.
However, due to the lack of beds in Santa Fe, children needing hospitalization for acute psychological crisis are sent to Albuquerque, where two hospitals offer inpatient services for youth.
The University of New Mexico Children's Psychiatric Center has its own psychological emergency room and offers services to youth regardless of insurance or ability to pay, a rarity across the state. For kids in the most serious states of emergency, the hospital has a unit of 35 beds.
Dr. Chandra Cullen, vice chair of the Child and Adolescent Psychiatry Division at UNM, tells SFR more than half the children in inpatient care at her hospital come from outside Bernalillo County, where it's located. Most are hospitalized for either suicidal ideation or severe psychosis. The scarcity of psychiatric beds for youth across the state is "a significant problem," says Cullen.
She also points to the need for more intermediate services, including outpatient care, partial-hospitalization services and home-based services.
Cullen says she's become increasingly concerned about the rising number of children coming into the hospital. "Since 2014, pretty much year over year we see a 20 to 25% increase in the number of children coming in for psychiatric emergency services," she says.
But she can't say whether there's been an increase in the number of young people who need inpatient care, because the hospital doesn't keep track of how many must wait indefinitely in ERs across the state for placement or who get turned away when the available beds are full.
If there's no room for youth at hospitals in Albuquerque, they are referred to Las Cruces, where 41 acute inpatient beds and 16 long-term residential beds are available.
Hospital leaders' responses point to a disjointed, oftentimes inadequate behavioral health care system for kids.
Steele, the educator, says addressing rising suicide rates and the underlying causes "is an effort that takes a village. ... We need to look beyond the hospital to create a culture of trust and support and take responsibility and accountability as a community for how we address mental illness and its link to suicide."
People also need to hold institutions accountable for providing the services that are needed when acute crisis cannot be avoided, she says.
"There's no question that having inpatient care in a local community is the best option for children. Isolating them in a clinical setting far away from friends or family could cause added trauma," Steele says.
The roadblock to inpatient youth treatment beds in Santa Fe is money, the common refrain goes. Santa Fe County raised the gross receipts tax by one eighth of a percent in June 2017 for behavioral health care, but its plans so far will focus on adults. Christus St. Vincent is "not currently considering taking this on due to costs involved," according to the county's report.
"It's an expensive thing to be in the hospital, but hospitalization is part of the system of care, and there are just a lot of issues around trying to prevent that, that we are not addressing as well as we could," says Rachel O'Connor, director of Health and Human Services at the county. "We have a lot of things that we didn't used to have.... We are going to have a crisis center, we are going to have a mobile crisis response team, but we still have that final niche that needs to be addressed."
Figuring out how to do so, she says, is coming next.
Beds alone won't solve this problem
Hanging heavy over the debate is the unspoken fact that the greatest predictive indicator of future suicide attempts is a previous one, and research shows patients are at greatest risk in the time directly following release from a hospital, whether it be a quick ERvisitora longer inpatient stay. Without adequate follow-up care, many patients return to the chaos of their lives and lapse immediately back into a lethal state of suicidally
But studies also point to two factors that can dramatically decrease the post-hospitalization risk of suicide and of psychiatric readmission for chronic mental illness: a smooth transition from the hospital setting to integrated community-based and outpatient services, and parental and family involvement and education, during a hospital stay and afterwards.
This is precisely why many mental health advocates worry sending a child far from home in the midst of crisis could compound the risks youth face afterwards.
For Desiree Woodland, founder and board president of Breaking the Silence, hospitalization close to home was not enough.
In the years leading up to her son's suicide, Woodland, then a sixth-grade teacher in Albuquerque, says she couldn't recognize his early symptoms of mental illness because the topic was taboo in her own upbringing and went undiscussed in her professional training.
"Now, after all of these many years, I can look back and see the signs," Woodland tells SFR. "But at the time I didn't even recognize it in my own son because honestly I didn't believe that mental illness was real.... And I know there are other teachers and parents out there who, like me, think, 'Oh, this stuff happens in troubled families, but certainly not my family.'"
By his early 20s, her son was in fullblown psychosis. Mention of a suicide plan led to the ER, a diagnosis of schizophrenia and admission to an inpatient psychiatric unit, but he was released after four days due to lack of insurance.
"It was a very painful time because this mental illness piece was just so foreign to all of us," says Woodland. "I don't think the emergency services kept him long enough ... to get used to his diagnosis or establish strategies for how he was going to live with it."
A few short months later, Woodland's son took his own life. He died on May 1, 2006, a month before his 25th birthday.
When youth are sent from Christus St. Vincent Regional Medical Center in Santa Fe to Albuquerque or Las Cruces for inpatient care, St. Vincent makes sure the Sky Center is involved with the family from the moment they leave the ER to the moment they come home to mitigate post-hospital-ization risks.
Such prevention programs can have a remarkable impact.
In coordination with the Sky Center, Gerard's House in Santa Fe runs a post-hospitalization support group for suicidal youth. The group, called Semicolon, has served 45 young people in the last six months alone. Facilitator Katrina Koehler says since it began, not a single youth has attempted suicide during the time of their participation.
And at one school in Santa Fe County, Breaking the Silence's course on mental illness and suicide prevention prompted students to disclose a suicide pact to school administrators. Steele says this outcome is not unusual.
"When kids are suicidal, they often feel like they are bad, crazy or sinful. There's just so much stigma," says Koehler. "In group, we try to re-frame suicidality and create a new narrative around it. Because the truth is that so many of these kids are incredibly passionate and have very nuanced perspectives on the world, but they don't know how to make a difference and don't feel like they know how to create change in their own lives or in the wider world. That's why we always talk about passion and purpose alongside talking about what hurts."