Psychiatric Boarding Trends Among Publicly Insured Youths During the COVID-19 Pandemic—The Other Pandemic

Abstract

Psychiatric boarding is a crucial clinical and mental health systems challenge deserving attention and discussion. In the JAMA Network Open article, Herrera et al 1 studied psychiatric boarding among publicly insured youths, ages 4 to 20 years (mean age, 13.6 years), who had been evaluated by a mobile crisis team (MCT) in Massachusetts. They compared boarding rates, boarding length of stay, disposition after boarding, and re-presentation within 30 days before and during the COVID-19 pandemic. They found that during the first 18 months of the pandemic, the odds of an MCT encounter resulting in boarding for publicly insured youths doubled, while simultaneously boarding encounters were significantly less likely to end with admission to inpatient or residential care. In addition, publicly insured youths who experienced boarding had significantly more readmissions within 30 days. This report paints a stark picture of psychiatric emergency services for publicly insured youths during the pandemic. The study population of publicly insured youths represents a vulnerable group experiencing a psychiatric crisis so severe that either inpatient or residential care is initially required, 80% of whom were youths of color. While boarding, these youths were supervised, kept in a safe environment, and may have had pharmacotherapy, but no additional treatment was available.Compared with their prepandemic counterparts, a larger percentage of these youths never received the higher level of care they required; they were eventually discharged home, and a portion of them received no additional services.Herein lies the importance of these findings. Although increases in boarding during the pandemic are well-established, 2 the Herrera et al 1 article is the first to demonstrate that compared with prepandemic, during the pandemic, publicly insured youths evaluated by a MCT who were boarding for a higher level of care were less likely ever to receive the treatment for which they were waiting. Perhaps even more importantly, while youths were stable at the time of discharge, for some, this stability was short-lived; they subsequently had more readmissions within 30-days after discharge and more repeat encounters overall. For these youths, boarding was a temporizing measure, not a definitive treatment.The failure of our mental health care system to adequately address the psychiatric needs of our children must serve as a warning that the entire system is in danger of collapse. A system that cannot care for the most vulnerable populations, those most in need of immediate treatment and those who may develop life-long psychiatric illness without treatment, is not performing its most basic and crucial role-preventing long-term disability, morbidity, and mortality. While the mental health care system had inadequate capacity long before the COVID-19 pandemic, it triggered increased psychiatric symptoms in youths and exacerbated the treatment shortages at all levels, creating a mental health care crisis that must be addressed.The problems with the men...