Op-Ed
Two Years Later: Covid-19 and the Untold Effects from Closures of Inpatient Psychiatric Units in Private Healthcare Systems
May 2022

In November of 2021, I sat in the room of the pediatric emergency department and assessed a 16-year-old African-American patient who was brought in twice in one week for suicidal ideations and aggressive behavior towards others. The caregiver from the foster home reported that this happened after the teen was repeatedly asked not to flicker the lights off and on in their residence. The patient clearly in distress, was somewhat talkative on the first night, though their thoughts were disorganized and this teen appeared to be intermittently preoccupied with internal stimuli. Nevertheless, they were willing to describe to me their version of what had transpired earlier that evening. During their second visit, later that week, they were less voluble, with noticeably diminished expressions, and hardly engaged with me.

After both visits, this patient was discharged back to their foster care facility. Scripts for medications were sent to the nearby pharmacy in hopes, but with no guarantee, that someone would help the patient to obtain them and that they would comply with the prescription. Research has shown that race and ethnicity disproportionately affects those diagnosed with schizophrenia or psychotic disorders, the onset is often in their teens. A diagnosis of the like may account for this person's uncontrollable psychomotor behavior. Not to mention, many psychiatric medications can take weeks to months to become effective—the therapeutic relief is not immediate, even when taken as prescribed. Two weeks later, I saw the same patient for a third time. It was during this visit that they were finally admitted by the attending psychiatrist to be transferred to an in-patient psychiatric facility. 

If a patient doesn’t have a known prior psychiatric history history, then hopefully the right medication will stabilize them, and perhaps they are better off at home rather than waiting in a hospital to be transferred to another facility. But I do have to wonder, if the 50-bed psychiatric unit where I worked had reopened, would this 16-year old have been discharged the first night they were brought to our emergency department? Or would they have been admitted for stabilization, observation, and received the additional care and therapeutic support they desperately needed during their first visit, if they only had to travel several flights upstairs to an in-patient psychiatric unit? 

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As we pass two years since the start of Covid-19 we must take seriously the untold effects of the global pandemic on the most vulnerable among us: those in need of acute psychiatric care. While many were already suffering form an untreated serious mental illness, the Covid-19 pandemic itself exacerbated mental illness in the general population as a result of  from grief and loss, to overnight stressors and constrictions of everyday life. Many local psychiatric facilities, closed because of this 2020 global health emergency and services remain curtailed or outright restricted to this day. This continues to have an adverse effect on patients in need of acute psychiatric care and ongoing treatment for a serious mental illness.  

While Covid-19 did not create the systemic flaws inherent to our healthcare systems, it certainly exacerbated them and brought new and urgent attention to them. It also clarified the dire effects of inequitable access to the broken healthcare system. One of the less discussed issues caused by the pandemic, unknown to most save for those in need of acute psychiatric care and those of us working on the frontlines, was the sudden closure of in-patient psychiatric units throughout private hospitals in New York, and the compounded damage this has caused. With the daily decline in Covid-19 hospitalizations and the CDC relaxing Covid guidelines, now is the time to pivot and provide proper in-patient care for those who suffer from serious mental illness.

At the onset of the pandemic, in March 2020, then-Governor Cuomo suspended the regulatory process which requires hospitals to go through lengthy protocols before closing public services, citing the need for Covid Surge Plans. What may have been a warranted emergency measure at the time, however, continues on today. The consequences of not re-opening these units, nearly two years later, has generated another full-blown crisis—not only for patients in need of critical psychiatric care, but those requiring other urgent traumas, critically-ill patients, as well as those in need of emergency medicine. It has also put healthcare workers like me, charged with providing mental health support, in crisis.

I trained in the emergency department at New York-Presbyterian Brooklyn Methodist Hospital on the night-shift, which shuttered its 50-bed psychiatric unit when Covid-19 first hit. As a Clinical Social Worker directly caring for patients in crisis, it is nearly impossible for me to spend time with the population we are there to serve—whether for a psychiatric emergency or any other medical or social determinant—when the bulk of our time is spent searching for beds at facilities where the lights are still on.

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Emergency departments are designed to treat all cases, from sprains and strains to more serious, life-threatening conditions such as sepsis or strokes. For those suffering from a serious mental illness, such as schizophrenia, bipolar disorder, psychoses, and/or major depressive disorders, long-term emergency department boarding—in a setting with bright lights, piercing sounds, and sometimes bellicose fellow patients—is less than ideal. People experiencing a psychiatric emergency would be much better cared for at an in-patient facility that is designed for and staffed specifically to treat this patient population. 

Before the pandemic, in New York there was already a decline in the number of psych beds statewide. Closures to private, in-patient psych units, using Covid-19 justifications, has intensified this pre-existing problem, and has arguably added to the rise in people living with untreated mental-health disorders. It was estimated in 2017 that more than 1.6 million New Yorkers live with serious psychological illnesses or are in mental distress. Hospitalization rates for New Yorkers with serious mental illness, before Covid-19, were higher than the national average. Just as the Covid-19 pandemic exacerbated already existing inequities in New York City, it also exacerbated mental illness in three distinct subpopulations: racial and ethnic minorities, the LGBTQ+ community, and Generation Z populations.

For the most acute psychiatric diagnosis, the length of stay for patients diagnosed with a serious mental illness is much longer on average than other hospital stays. Research shows that New York state only has available 52% of the inpatient beds needed to treat people suffering from acute mental illness in all populations, including people who are incarcerated. In fact, people living with mental illness in New York are more likely to encounter the criminal justice system, resulting in higher arrests and incarcerations in this state. 

The shortage of available psych beds in New York has a cascading effect for other patients, too—many of whom are critically ill and also in need of emergency services. Those who unexpectedly find themselves in the emergency department often wait in close proximity to psychiatric patients and consequently bear witness to unanticipated outbursts or aggressions, all while experiencing their own trauma. Patients who walk-in can wait in the triage area for hours simply because the patient census exceeds the staff permitted to care for a given number of patients and beds aren’t available.

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In December of 2021, during the height of the Omicron surge, I had a patient who was medically cleared for transfer when I began my shift one Monday evening. This patient had tested negative for Covid-19 upon arrival that day. When I came to work two nights later, that same patient remained lying in the hallway. Given the 70+ hour wait time, the accepting facilities will often ask for a repeat Covid test. That Wednesday evening, this patient then tested positive for Covid-19. While awaiting transfer to New York-Presbyterian Westchester Behavioral Health Center, this patient contracted Covid-19 in the emergency department in Brooklyn, which meant they would now have to be removed from the queue where they had already been accepted. Now, this persons was in need of transfer to psychiatric unit for people who are Covid-positive, which given there are significantly fewer overall beds that fit this criteria city-wide, are even harder to source.

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Part of the reason, after more than a decade in another field, I became a Clinical Social Worker was to help people who may not have access to equitable healthcare. Many suffering from an untreated serious mental illness face poverty, housing insecurities, racial injustice, and other oppressive forces; these are often people who have endured hardship for years while mentally deteriorating. If they are able to receive some form of treatment, they often don't have access to follow-up care and can’t afford costly prescriptions once released from an inpatient unit not to mention specialty psychotherapeutic treatment and support therapy. For people experiencing psychiatric emergencies or in need of urgent mental health care—those for whom private-pay or outpatient psychiatric support services are not an option—the emergency department is often their first point of entry, and not always by choice. 

Not all but many diagnosed with a severe mental illness also suffer from co-occurring chronic conditions from other complex-psychological issues, substance-abuse, or psychosocial issues. Even if medication and therapeutic treatments are able to stabilize their mental illness, these patients still face a matrix of obstacles. This is the population of vulnerable New Yorkers who end up back in our emergency department mere days after discharge from a long-term care facility. In the realm of psychiatric care, this has led to patients moving out of institutions and into the community, many of whom are not equipped for community-based care or even self-directed care. 

For those of us charged with providing mental-health support and resources for patients and their loved ones, finding beds remains an ongoing challenge and one that consumes much of our time. Night after night, I try to secure a safer and more comfortable environment for patients to receive the care they need. Yet I face relentless frustration as I’m repeatedly told by colleagues at the accepting facilities, “We don’t have any beds available tonight. Try again in the morning.” These constant dead-ends leave us with no option but to attempt to keep a patient comfortable (which often means medicated) amid a very chaotic setting. 

This also leaves other patients who are in need of our services—crisis intervention, those have been physically or sexually assaulted, patients in need of resources if they are undomiciled, bereavement counseling, suspected child protective service assessments, and others—waiting, as there is immense pressure from hospital administrators to move the psychiatric transfers out of the emergency department as soon as possible. 

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It is widely accepted in healthcare that psychiatric units generate less revenue in comparison to other surgical units. This creates a financial incentive to keep these psychiatric units in community hospitals permanently closed and convert the space into a more lucrative unit. While hospitals make more money, the most vulnerable New Yorkers suffering from severe mental illnesses continue to be quickly discharged without medical stabilization or receiving proper treatment let alone continuing care. The effects on patients, healthcare workers and the community writ large due to sudden closures of psychiatric units cannot be understated. Those of us who are trained to intervene in moments of crisis often cannot, because we’re preoccupied trying to transfer patients who have been at the emergency department for days.

The landscape in the spring of 2022 is entirely different than in early 2020 when Covid-19 first hit New York. Our private hospital systems must reopen their psychiatric units. If now defunct 50-bed psychiatric-units like the one in the hospital where I worked were to re-open overnight, it would not completely solve this full-blown crisis, but it would be a step in the right direction.