Youth in crisis need beds now, doc says
It’s 4 a.m. and Joanne is waiting in the emergency department with her grandson. It’s been seven hours.
Nine hours earlier, he was frantic and inconsolable, screaming he didn’t want to live any longer. His rage escalated to a point where she felt she had no choice but to call police. Now she sits in silence beside him – too tired to wait much longer but too afraid to leave. Her heart breaks to see this 12-year-old boy in such anguish and she worries what he will do if he doesn’t get help.
Although this scenario is not based on a specific individual’s experience, it’s an example of what Dr. Marcie Kostenuik sees almost every shift working as an emergency room physician at Royal Victoria Hospital where she says youth in extreme crisis can wait hours before they see a physician and, when they do, there is not much help available for them.
“I had one (patient) who sat in the hallway of the emergency department all night and that’s where our trauma rooms are. Someone came in and had a heart attack and died, and here’s this suicidal boy watching this trauma and death going on in front of him,” Kostenuik says. “This was his experience. So, the next time he’s suicidal, I don’t think he’s going to come. It was a horrendous experience.”
According to the Canadian Mental Health Association, approximately 294 youths die from suicide each year – many more try – and it’s the leading cause of death in the 15-to-24 age group after motor vehicle accidents. Statistics show that females attempt suicide more often but, because males tend to use more dramatic means such as weapons or hanging, more succeed.
It was the devastating news of several suicides by Barrie high school students two years ago that highlighted the need for better mental health care for this high-risk group, and moved Kostenuik and her colleague Dr. Leah Skory to form No Youth Left Behind.
The group represents a collection of medical and mental health professionals from such groups as CMHA, New Path Youth and Family Services, Kinark Child and Family Services, as well as the native mental health community who advocate for an in-patient crisis unit for children and youth. “We’re trying to be a voice for these kids,” says Kostenuik. “I’m in the position to see that the family doctors are sending these kids to emergency and the emergency doctors are sending them to their family doctors. Nobody is dealing with this. There is nowhere to put them; there is no way to deal with this.”
With the arrival of a new children’s psychiatrist at RVH, Kostenuik says the time is right to consider offering these beds. “There’s no question that suicide rates are rising for young people and there is no question that there are young people that become psychotic and absolutely need an admission to the hospital; there’s no question about it,” agrees Nancy Roxborough, executive director of CMHA – Barrie Branch. “We know that from our Early Psychosis Intervention Program (EPIP) where we do take kids under 16 that can have a psychotic episode and be extremely ill, and really not safe to stay at home.”
Roxborough also says there are more community mental health programs than ever for children to prevent them from ever getting to the crisis stage, and points to CMHA’s EPIP that began three years ago through Ministry of Health funding. Although most CMHA programs assist those 16 and older, EPIP will help youth as young as 14. As part of its crisis service, CMHA also has a mobile unit that goes out in Barrie and operates a five-bed crisis unit for people 16 and older who are experiencing a psychotic episode or are expressing suicidal thoughts that are not immediately life-threatening.
In Simcoe County, Mobile Crisis Response Services is available Monday to Friday, from 8:30 a.m. to 8:30 p.m., through Kinark Child and Family Services and New Path Youth and Family Services. The service provides immediate telephone response within 30 minutes of receiving a call from children up to 18 years of age or their family members when they are experiencing a crisis that is not immediately life-threatening but requires urgent intervention. A crisis response worker will meet with the individual once the immediate risk is resolved, to provide further crisis management.
Kostenuik has given the crisis line number to all ER doctors and nurses to use when a youth in crisis comes in. “It’s ridiculous that our emergency department would have to call this crisis line but they will come to our emergency department,” she says. But when the situation is life-threatening, even the crisis units send Barrie youth to the emergency department at RVH where Kostenuik says sometimes they can wait for 10 hours or longer behind people with heart attacks, car accident victims and others with very serious ‘physical’ problems.
The physician who finally sees them will probably admit them either to the adult psychiatric ward or the pediatric ward – whether they need it or not – just to be on the safe side. “Once they’re in the door, we’re afraid to send them out ... The problem with teenagers is they have no coping skills. That’s why they are at such high risk and they just think, ‘I’m going to kill myself.’ They don’t mean it but the emergency doctor doesn’t figure out the whole story and realize they are crying for help and they need help. So, instead of getting help, they get locked up. When they show up at the hospital, they think, ‘Great, somebody is finally going to help me,’ and then they’re locked up and sent home the next day.”
When they are sent back out into the community with instructions to seek help, many do not get the treatment they need in a timely manner due to a shortage of child psychiatrists in the area and extremely long waiting lists for child and youth programs. “We’re trying to find solutions,” Kostenuik says of her group. “We’re trying to organize training for doctors; bring in speakers; we’ve talked about making our own group of family doctors to deal with these cases, if there is nothing else right now... My dream is to have this central intake number so that it would help co-ordinate everything that is needed in the community but we’re certainly not there yet.”
The good news is that the need for a pediatric in-patient psychiatry ward is finally on the radar of the North Simcoe Muskoka Local Health Integration Network (LHIN), which has, until recently, only been looking at improving mental health services for adults. “It’s certainly recognized that this is a gap in the services that are currently available within our LHIN,” notes Jean Trimnell, CEO of the North Simcoe Muskoka LHIN, who has met with Kostenuik. “Looking at what’s the most appropriate solution is clearly something we need to do, and then a recommendation would come forward to the LHIN board, once that background work has been done, to look at what would be required to bring that to action.”
Recently, the LHIN’s Regional Action Group for Addictions and Mental Health – which has been charged with the task of developing a three-year plan for a comprehensive system of care for adults – has expanded its mandate to include looking at improving services for children. “As we go forward and redo our planning for our next version of the Integrated Health Service Plan, we’ve recognized that we need to have a much clearer focus on services for children,” says Trimnell.
But it’s not just Ministry of Health funding that is required. Any planning for children must involve co-ordinating with the Ministry of Children & Youth Services and the Ministry of Community & Social Services. Although the plan is to bring these ministries to the table, so far, LHIN staff has not met with staff from either ministry to discuss the issue.
Brent Stein, clinical director at CMHA – Barrie branch and chairperson of No Youth Left Behind, agrees that more acute care beds for youth would be beneficial but he says there also needs to be a direct relationship with community mental health resources. "What we would like to see are child and youth workers in the emergency department who could better link people with Child and Youth Services. Part of what we’re doing on this committee is trying to bring forward a community of practice where (there is follow through to other resources),” he said. “What we’re envisioning is some sort of system where there is more continuity of care.”
Kim Goggins
15 September 2008
