Study finds disparities in boarding rates for children with severe mental illness

A new study conducted by researchers from McLean Hospital and Harvard Medical School, in collaboration with researchers from Massachusetts General Hospital and Cambridge Health Alliance, finds worrying disparities in emergency department admission rates for children and adolescents with severe mental illness symptoms.

After studying more than 4,900 hospitalizations of youth under the age of 17 in Massachusetts over an 18-month period, the researchers found numerous racial and gender disparities. Black youth are less likely to be hospitalized for psychiatric care than white youth. Additionally, transgender and nonbinary youth spend longer in emergency departments and have lower rates of admission to inpatient units compared to cisgender women. Nearly half of hospitalizations did not result in hospitalization.

According to the authors, young people who must be admitted to emergency departments for days or weeks at a time rather than transitioning to inpatient care typically receive less mental health care than they would have received in an inpatient setting, and as a result are at risk for poorer outcomes.

“Our study found that several non-clinical factors appear to influence admission decisions, including statewide demand for inpatient care, and racial and gender disparities permeate the process. Admission is the culmination of problems and lack of access across the entire mental health care system, not just inpatient care. Solving this will require resources and interventions at many levels.”

Nicole M. Benson, MD, MBI, Senior study author, Associate Chief Medical Information Officer at McLean Hospital; Assistant Professor of Psychiatry at Harvard Medical School

Benson and lead study author Lindsay Oberhage, BA, an MD-PhD student and researcher in the Department of Health Policy at Harvard Medical School, led a review of data collected across Massachusetts on all youth ages 5 to 17 who were admitted to an emergency department for more than three hours overnight while waiting for inpatient treatment between May 2020 and June 2022. The researchers used a comprehensive dataset from the Massachusetts-maintained Emergency Psychiatric Admissions Database.

The study found that despite having similar clinical symptoms and psychiatric treatment needs to their white counterparts, Black youth were more than 4 percentage points less likely to receive inpatient care. Transgender and non-binary youth were more than 9 percentage points less likely to be hospitalized than cisgender women, and their emergency department stays were nearly two days longer on average.

Secondary analyses found that statewide demand was strongly correlated with individual outcomes, which may influence hospitalization decisions: for every 100 additional youth hospitalizations across Massachusetts on a day when a child or adolescent was diagnosed with a psychiatric emergency, the proportion of youth hospitalized fell by more than 19 percentage points and hospital length of stay increased by an average of 3 days.

The study authors call for policy reform and targeted interventions to address the root causes of disparities in youth access to psychiatric care. They note that efforts are underway in Massachusetts to implement a roadmap of behavioral health reform focused on crisis intervention teams, strengthening community supports, and improving access to psychiatric beds.

“The hospitalization experience — being confined to an emergency room for days or weeks with 24-hour, one-on-one monitoring, with little to no reliable psychiatric treatment, and no idea how long they’ll be there — is detrimental to children’s health,” Oberhage says. “In fields outside of psychiatry, the sickest patients in the emergency room are the first to be admitted for inpatient treatment. But many inpatient units feel ill-equipped to deal with the kids with the most severe psychiatric symptoms, and inevitably these kids end up suffering in the emergency room.”