**This story contains descriptions of self-harm that may not be suitable for all readers**
At some point during a school outdoor activity, 13-year-old Stacy, not her real name, broke away from her classmates and made her way into a wooded area. Her intention was to find an old wooden bridge she had heard wasn’t too far away, stand on the edge, and jump.
Stacy didn’t find the bridge, but upon being alerted to the incident by friends, the counselor at Stacy’s private school called her parents. Stacy’s parents were informed she was a threat to herself and couldn’t be in school without first getting serious help.
This was the final straw that pushed Stacy’s parents, fearful for their daughter’s life as she became ever more depressed and anxious, to take her to the emergency room. Stacy’s father, who we’re calling William, says the family had spent weeks prior trying to get Stacy help.
Stacy had been experiencing ever-increasing levels of anxiety and depression, superficially cutting her arms at times. Her condition was exacerbated by William’s own medical issues that saw him hospitalized for a time. Stacy’s parents had seen the marks on her arm and had taken her to their family physician, who prescribed her a low dose of Zoloft, an anti-anxiety medication, but offered little in the way of referrals to a psychiatrist or therapist.
“We had gone initially to her pediatrician for advice and the pediatrician said what many other people have subsequently told us: Psychology Today has a great website,” William said in an interview. “We looked on the website and they had a list of a lot of providers in Connecticut, but it was ‘not seeing patients,’ ‘not seeing patients,’ waitlist, waitlist, waitlist. So, we put our daughter on a waitlist for one or two providers, never got a call.” While she was on the waitlist, Stacy’s anxiety and depression worsened dramatically.
Stacy had been secretive about her mental health issues, William said. She was a “very Type-A personality,” constantly pushing herself for good grades at school, and not wanting to disappoint her parents in any way.
They had been trying to get her help for “several months,” according to William, but when the school counselor informed them Stacy was no longer safe to be in school they decided the time had come to take the next step to keep her safe. They took her to the emergency room at Connecticut Children’s Medical Center (CCMC) in Hartford in May of 2022, a far drive from their home, but a place they knew had a good reputation for handling children.
Upon learning Stacy was having thoughts of suicide, she, and her father, who was still in his work clothes, were ushered to the behavioral health wing of the emergency department. “There were four or five kids waiting in the hallway where I was with my daughter,” William said. “It was a locked area, security guard at the door.”
“I was the only parent there at the time she was waiting for a room,” William said. “Some of the kids had clearly been in and out, the staff recognized them, and it made me wonder: are they actually getting care, or are they on a merry-go-round where they’re going to be treated, come back in, treated, come back in?”
William waited in the hallway with Stacy for five hours, unable to use his cell phone to update his wife due to hospital safety precautions, until a room in the emergency department finally opened for her.
Behavioral health rooms in emergency departments, and in inpatient behavioral health departments of hospitals, are not like typical hospital rooms. Everything has been stripped down to prevent self-harm or harm to others. There’s nothing in those rooms that patients can use to cut themselves, nothing on which to tie bed sheets or clothing; the television is in the wall and surrounded by protective plexiglass, and patients are monitored 24 hours a day. They sleep with the lights on. “It’s basically a cell block,” William said.
After her evaluation William was informed that Stacy was a “7/10” on the severity scale and had to be admitted to inpatient care, but there were very few facilities in the state accepting children. Stacy would have to wait in the emergency department until a bed at an appropriate facility opened. She waited in the emergency department for five days.
Connecticut Children’s was finally able to secure a bed for Stacy at an inpatient hospital, a roughly 45-minute drive from their family home. While not ideal, William and his wife and his wife were overjoyed that she would finally be getting real help. They signed the paperwork for Stacy’s transfer, but a key detail about the facility was left out of the conversation and William didn’t learn of it until Stacy was already admitted: there was no visitation allowed.
“That we weren’t able to see her absolutely enraged me,” William said. “Our daughter is being taken someplace behind locked doors and we can’t see her. The experience of waiting that long in a cell and then being transported to a facility and not allowed to see her family – what’s that going to do to the mental health of a patient who already has mental health problems?”
It was another five days before the therapist called William and his wife in for a family meeting. Stacy was being treated by an Advanced Practice Registered Nurse (APRN), who had been increasing the dose of Zoloft. During the family meeting, the providers were all upbeat, William said. They told him Stacy was doing better and thought they had her anxiety under control, but William saw something different.
“She wouldn’t smile at us. The body language she gave in the meeting was withdrawn, no smiles,” William said. “It was not the body language I expected based on how I’d been prepped for the meeting.”
The family meeting took place on a Friday and the providers told William and his wife they should pick Stacy up Monday morning. They were also told they would receive a “safety plan” for Stacy to help them understand how to keep her safe.
That night, Stacy tried to strangle herself with her underwear strap. She was placed under strict one-to-one observation. Despite the suicide attempt, Stacy was discharged on the following Wednesday.
The safety plan William received upon picking up his daughter left much to be desired. It was a “Stanley-Brown Safety Plan,” that listed warning signs for suicidal thoughts, internal coping strategies like water-coloring or reading, and the phone numbers for times of crisis, such as the suicide prevention hotline and Stacy’s outpatient therapy program.
“They hand me a piece of paper that was a generic, boilerplate,” William said. “I’m supposed to have something that tells me how to keep my particular loved one safe. This is all we have. This facility is getting thousands upon thousands of dollars per day from my family alone for my daughter to be there and this is what you come up with for a safety plan for a child who, the Friday before, tried strangling herself with her underwear strap?”
William and his family were happy to have Stacy back home, naturally, and following a short vacation over Memorial Day Weekend, Stacy returned to school. A few days later at school, she attempted to overdose on Ibuprofen, which she had been secretly stockpiling. A therapist at Stacy’s intensive outpatient therapy program identified the overdose during a routine screening and sent her by ambulance to the CCMC emergency room.
Although the safety plan did mention stockpiling of medication – listed as “Step 6: Making the environment safe… No access to weapons or stockpiled meds”– William and his wife felt wholly unprepared for this. They had locked up the family’s medications but hadn’t considered that she would secretly stockpile medication used for headaches one at a time until she could potentially overdose.
William was already unhappy about their previous emergency department experience and especially at the inpatient facility that treated her. Stacy’s stay in the emergency department this time lasted four days before the hospital contacted William and his wife saying Stacy was being transferred back to the same inpatient facility where she had previously attempted suicide.
Angry, William demanded to know who had signed off on the transfer because he had explicitly said he didn’t want her returning to a place that discharged her following a suicide attempt saying she was ready to go home when she clearly wasn’t.
William’s demands for the transfer paperwork at the facility were met with a nursing supervisor advising him he’d have to wait 7-10 days for a medical records request and then being told to leave.
Stacy stayed at the inpatient facility for another 13 days.
“Unfortunately, that family’s experience is all too common,” says Thomas Burr, communications director for the Connecticut chapter of the National Alliance on Mental Illness (NAMI).
Burr would know. Before he went to work for NAMI he was employed in the corporate world and faced similar challenges when his son experienced mental health issues as a youth and into adulthood. “The mental health system was not great before COVID, but COVID took a system that had been stretched to the breaking point and broke it.”
The pandemic had a widely acknowledged negative effect on mental health nationwide for both children and adults. In Connecticut, the effect on children was pronounced enough that the legislature took up and passed a slew of bills during the 2022 session to create more funding and support for youth mental health.
But there are a number of issues at hand: a lack of inpatient psychiatric beds, particularly for youth, the lack of mental health professionals working in the state, and a lack of community resources and systems to intervene before it gets to the point a patient needs hospitalization.
Stacy’s long stay in the emergency department is not uncommon nor unique to that hospital. Wait times for youth psychiatric care have been documented previously in other reporting and the hospital is now undertaking an expansion to add a 12-bed psychiatric unit, a welcome improvement to Connecticut’s mental health system.
According to the Connecticut Hospital Association in their testimony to the General Assembly’s Public Health Committee, over a 20-day period in February of 2022, there were 38 children below the age of 17 waiting in emergency departments for placement at inpatient psychiatric facilities but there were only 3 beds available on a daily basis. On several days, there were no available beds.
“The need for expanded inpatient psychiatric services for children and adolescents is clear and growing more acute with each passing day,” the hospital association wrote.
But individuals and families also need to understand what inpatient psychiatric care in a hospital setting entails: it’s rarely pleasant, something that William and Stacy learned in their first trip through the mental health system. Inpatient units are designed to keep a patient from harming themselves or others. It’s a last resort in a moment of crisis.
“A lot of people think an inpatient psych stay means you’re going to be in a benevolent place of healing,” said Kathy Flaherty, executive director of the Connecticut Legal Rights Project, an organization that provides legal services to low-income individuals with mental health issues.
Flaherty is no stranger to the inpatient system, either, having been through it as a young woman in law school. “Inpatient psych hospitals are not like that. They’re just not.”
“Having observed the way the system has operated over the last several decades, I think one the things that is most frustrating to me is, how does everybody let things get so bad for a kid that a parent feels they have no choice but to bring their child to an emergency room?” Flaherty said. “It never ever should have gotten to that point, but the workforce isn’t there — the shortage of child and adolescent psychiatrists, psychologists, all of that isn’t available.”
“We’re seeing an upward trend of young people expressing themselves that they’re experiencing thoughts of suicide and having mental health challenges, we’re seeing the rebound effect of the pandemic affecting people’s mental health,” said Valerie Lepoutre, peer recovery program manager for NAMI CT, who works with youth. “One of the good things is that they are expressing that they’re having a difficult time, which is points for being able to access support in health, the problem we’re also seeing is that there’s just not enough help out there to support our youth and we need more of that.”
What everyone seems to agree on is that Connecticut’s youth and adults need more care “upstream” from the inpatient hospital setting to prevent an individual from getting to such a crisis point that there are few options other than admission to a behavioral health unit.
The problem with that – and something William also found when he initially sought treatment for Stacy – is there just aren’t enough mental health professionals in the field. Wait times to see a therapist or psychiatrist can turn into times of crisis – and then more waiting in the emergency department.
“A big part of the problem is lack of providers and that’s not something you can just flip a switch for, because that’s nationwide,” Burr said. “There’s not enough mental health providers available for people.”
Dr. Paul Desan, associate professor of psychiatry at Yale University and director of Yale’s psychiatric consultation service, says that even before COVID, Connecticut “had a disastrous shortage of inpatient resources and outpatient resources for both kids and adults.”
“Someone in crisis being in a medical hospital is just not a therapeutic environment that’s optimal for them, so we desperately need more adult bed capacity in Connecticut and the situation is even worse for adolescents,” Desan said in an interview. “There aren’t enough individual practicing psychiatrists to meet the demand.”
Part of the problem, Desan says, is that the pay for psychiatrists working either for the state or in state-subsidized organizations just doesn’t compare to the rest of the nation, and that can make a big difference when a physician graduates with student debt totaling $300,000.
“Our salaries are not competitive with the Midwest at all,” Desan said. “We don’t pay as well. Psychiatrists graduating from our residency program here at Yale could earn a higher salary by moving out of Connecticut.”
“I’m very familiar with the psychological stresses and career decisions that residents are making,” Desan said. “Many doctors went into the business because they want to serve the community and they get what is essentially a mortgage.”
Although the federal government does offer student loan forgiveness for those who go to work in the public sector or nonprofit sector, there are challenges, Desan said.
For one, the individual has to work in the public or nonprofit sector for ten years in order to earn that forgiveness, and the previous federal administration was slow to act on forgiveness applications. Secondly, there exists the possibility of having to change jobs for any number of reasons, so it can be a balancing act.
However, there are alternatives, some state-based. In Massachusetts, for example, the state offers $50,000 in loan forgiveness for health professionals working in underserved communities for 2 years. The National Health Service Corp offers loan forgiveness of up to $100,000 for healthcare professionals who work between two and four years in designated areas.
“Our area of really great need is getting qualified psychiatrists in Connecticut to stay in Connecticut rather than move to a midwestern state where they can feel more financially secure,” Desan said.
But aside from salaries, there are other, more systemic challenges facing the mental health system, not just in Connecticut, but nationally as well.
Upon Stacy’s second inpatient admission, William took it upon himself to do more research into the medications and treatment for adolescents experiencing anxiety and depression. To him, the Zoloft initially prescribed by his family’s Primary Care Physician (PCP) and continued by the inpatient team, wasn’t doing the trick.
He found that Prozac was considered the best treatment, and William made a phone call to the psychiatrist now assigned to his daughter. The doctor said she could switch Stacy to Prozac. William was happy to be more engaged with the treatment team but it seemed that, essentially, he was directing her care.
“My wife and I are educated people, been to college numerous times, advanced degrees, not everybody has that,” William said. “The point is not every parent is going to be positioned to ask the questions to get the care, to really be the quarterback their kid needs. Even being quarterback, she was discharged days after a suicide attempt and I was cool with that, just thinking the provider said it was okay.”
But that is also indicative of a larger problem, according to both Thomas Burr and Dr. Desan.
“Too much of the mental health system is very siloed and it’s not connected,” Burr said. “So, it’s not easy for someone who, by definition, has a brain disorder which is affecting their ability to think logically and clearly and manage their emotions that drive behaviors. Expecting them to navigate this piece-meal, siloed system is just unrealistic.”
Burr compares the mental health situation to that of, say, a cancer patient where the PCP is in constant contact with the oncologists, who are also in contact with a support team “and they’re all working and playing nice and communicating with each other. That doesn’t happen in mental health.”
“To some extent that’s true of the whole medical system,” Dr. Desan said. “But primary care doctors tell us all the time they’re frustrated with how to refer people for mental health care.”
“If a family out in the community is having trouble finding care and physicians who should be very sophisticated need help finding care, how is that family ever going to find appropriate help?” Desan continued.
Again, it comes back to catching problems and having treatment options upstream of crisis situations. It would prevent the long waits in emergency departments and offer more support to adults and children who are first experiencing mental health issues.
“When you’re talking about inpatient resources, in some cases it’s crystal clear, and this is for both adults and teenagers, many of these people if they had gotten appropriate care in the community they could have been stabilized and never would have taken an overdose or otherwise needed inpatient psychiatric care. It all works together,” Desan said.
“I think our state doesn’t necessarily know what to do with people who are in crisis,” Lapoutre said. “So, the first decision made when a child expresses thoughts of suicide is to send them to the hospital, but if we can work with our stakeholders on creating better systems, we can make it a little easier for young people to access help and not necessarily be in that situation.”
Recounting his own experience, William wonders how the current system and lack of mental health resources may affect other children, particularly those in low-income communities. “How many kids out there don’t have parents breathing down the necks of the nurse supervisor?” he asked. “Mental health issues are rampant in lower-income communities; it may be the cause of lower income for many families because they can’t hold a job with untreated mental illness. So, what kind of resources are those communities getting?”
Some of those community resources and support groups are precisely what NAMI offers, although being a nonprofit, advertising their services can take a back seat to actually providing the services. Peer groups run by individuals who have been through the mental health system, as well as resources for families struggling to care for a loved one with mental illness are all part of what they do, and they do it for free.
Connecticut has a couple of dirty little secrets, according to all those interviewed.
For one, Connecticut’s mental health system was not always broken. In fact, Connecticut used to have the highest-rated public mental health system in the country, according to Burr.
In 2006 and 2009, the national NAMI organization graded all 50 states based on their mental healthcare systems. In both years, Connecticut received a B, which was the highest grade awarded. In fact, Connecticut’s rankings for its mental health system aren’t even poor now.
Mental Health America also issues a ranking of states based on mental health care access. In their latest 2020 report, Connecticut was ranked 10th in the country for adult mental health and 13th for youth mental health, based on prevalence of mental illness and access to care. Overall, Connecticut was ranked 8th for mental health care access.
The earliest report by Mental Health America that could be found online dates back to 2017, but the report combined figures from 2009, 2010, and 2011 to give more historical information. It showed Connecticut in the top five, if not the top position overall in a number of areas in 2011 and 2014.
But the backward slide, even if Connecticut remains better than most states, has certainly triggered the alarm in Connecticut post-COVID. Burr says what really changed the system was the 2008 recession when Connecticut endured nearly a decade of budget deficits.
“Connecticut’s public mental health system was arguably in the middle to late 2000s was the premier public mental health system in the country but suffered ten years of underfunding and outright cuts due to the economic collapse in 2008 and 2009,” Burr said. “They had trimmed at least 17 percent of the DMHAS budget during that time frame and with holdbacks probably close to 20 percent and, again, if you take a decade’s worth of inflation at an annualized rate of 3 percent per year, that’s another 30 percent, so the effective funding for DMHAS was cut in half.”
Dr. Desan, who was president of the Connecticut Psychiatric Society in 2009 and 2010, says that after 2008, their ability to ask the states for more mental health funding was severely diminished.
“After 2008 and the budget crunch, our ability to advocate for the mentally ill was obviously decreased,” Desan said. “The idea that you could ask for more funding for something, it just wasn’t going to happen. I’m hoping that maybe now Connecticut’s budget will have more surplus and there will be more funding for inpatient psychiatric care.”
According to Connecticut’s biennial budget for 2007 to 2009, DMHAS was appropriated $545.7 million. By the 2018, 2019 budget, funding was $612.5 million. Had the funding kept up with general inflation, the figure would have been $636.4 million.
However, according to the Kaiser Family Foundation, healthcare cost increases have outpaced consumer price increases, rising 109.2 percent between 2000 and 2022, compared to 68.8 percent for all consumer goods.
But another little secret, one that applies across the country, has to do with the insurance industry, and something Burr has personal experience with: patients on Medicaid have better access to mental health care than those on private insurance.
“The dirty little secret in Connecticut is that there isn’t true mental health parity – that’s not unique to Connecticut, that’s pretty much everywhere in the U.S. even though the law is that there is mental health parity,” Burr said. “Connecticut, again, we’re not the best anymore but still our public mental health system overall is typically much better than someone who’s got private health insurance will get. It’s like night and day.”
Burr recounts his experience with his own son, saying he was terrified when his son turned 21 and could no longer be on Burr’s insurance plan at the time and was placed on HUSKY coverage and into a state mental health facility.
“It was the best care he ever got. I was completely floored. They did things the private health insurance would never pay for, and the private health insurance hospitals wouldn’t offer. In fact, there are definite services you can only get if you’re on Medicaid in this state because the private health insurance wouldn’t pay for it,” Burr said.
Under the 2008 Mental Health Parity and Addiction Equity Act, group insurance plans that offer mental health and addiction care are prevented from “imposing less favorable benefits limitations on those benefits than on medical/surgical benefits,” according to the Center for Medicare and Medicaid Services. The law was updated under the Affordable Care Act to include individual health insurance coverage as well.
However, according to critics like NAMI, the parity has been slow coming, if at all. According to a report in Psychiatric Times, one of the problems is a lack of oversight and enforcement.
Parity Track found massive disparities in Connecticut’s mental health parity compared to the national average. Twenty-six percent of people reported unmet counseling or therapy needs, based on a 2019 report by Milliman.
Connecticut was a bit ahead of the game in this instance, signing into law a mental health parity law in 2000. In 2019, the General Assembly passed another law requiring insurance companies to submit yearly reports beginning in 2021 regarding their coverage, according to CT Mirror.
A second bill pushed by Sen. Matthew Lesser, D-Middletown, in 2022 would have required the state’s insurance commissioner to report on the effectiveness of the state’s parity law. While the bill never received a vote, a similar provision was included in a massive mental health bill requiring the Office of Health Strategy to study whether parity exists between providers of mental health services in the private insurance market and those in the HUSKY Health program.
Testimony submitted in favor of Lesser’s 2022 bill, however, indicated that reports received under Connecticut’s 2019 mental health parity reporting law were “deemed incomprehensible,” according to Suzi Craig, chief strategy officer for Mental Health Connecticut.
But the issue of mental health parity has also been tied up in court after the Ninth District Court of Appeals panel determined it was not unreasonable for insurers to determine coverage inconsistently, according to the CT Parity Coalition. Several Attorneys General, including Connecticut Attorney General William Tong, have filed amicus briefs in the case, Wit v. United Behavioral Health.
“I know the frustration I see for people, especially in the privately insured world, is that what drives somebody’s admission to an inpatient psychiatric unit and the length of their stay on that unit is what their insurance will pay for,” Flaherty said. “If insurance won’t pay, there will be times when the facility fights to keep somebody in longer, but they only have so much time in the day to devote to that and at a certain point the whole facility is going to say we just have to discharge you.”
“Sometimes people have told me kids who are on Medicaid have more access to service than kids covered by commercial insurance,” Flaherty said. “There have been times when I know of parents who have given up custody of their kids to access services, and we should never have a system that is set up like that, it is beyond ridiculous.”
“From a public policy perspective, it really sucks,” Burr said. “Because the private health insurance industry won’t pay for a lot of this stuff, what happens? Once these people’s children turn eighteen, they dump them off their health insurance, they go on the state plan and the state picks up the tab. So, it’s a huge cost shift here in Connecticut but desperate people will do desperate things.”
Stacy’s second inpatient stay, which lasted 13 days, went much better. The change in medication appeared to help. William and his wife felt much more involved in the overall treatment process and her new providers were more responsive.
“We sat down with the doctor and the social worker and said we don’t want to be on this merry-go-round anymore, we’ve only been here twice but that’s two more times than our daughter wants to be here, that’s two more times than anybody wants to be here,” William said. “This time around they felt they were more attuned to Stacy and her needs. My wife and I felt more assured by that conversation. She was released the second time. She came home on my wife’s birthday.”
William says Stacy has been doing much better since her return home. They’ve developed their own safety plan and she’s attending outpatient treatment. Although William says the experience was “eye-opening” and at times and “enraging,” he doesn’t fault the providers personally, but is rather more concerned about the system under which they operate.
“I believe they have the best of intentions,” William said. “This is their chosen field. I believe the system in which they work is screwed up and the administrators make really bad decisions regarding patient care.”
And there is also hope on the horizon for Connecticut’s mental health access and funding overall. In response to the COVID pandemic and its associated mental health issues, the Connecticut legislature passed several new bills during the 2022 session designed to increase care, access, and oversight, both in the hospitals, community, and at schools.
“It was unprecedented,” Burr said. “I’ve been doing advocacy work in one form or fashion for this organization for 15 years and I’ve never seen anything like that, in fact, the last ten years it’s just been cut after cut, and it was awful. This past session they tried to make it right.”
Recovery from mental illness can take time, maintenance, and consistency. It’s harder than resetting a broken arm. Thomas Burr says his son is doing quite well and, naturally, William hopes for the same outcome for his daughter as she navigates her teen years.
“She’s better adjusted now,” William said. “We are better informed, and we’ve been able to implement the provider team’s recommendations. We’re more experienced in what to look out for.”
As many of the professionals said, the COVID pandemic took what was already a strained system and pushed it to the breaking point.
But with every crisis comes an opportunity for learning, change, and reinvention. Connecticut may have taken its first steps toward that change, but, like mental health itself, it will take time, maintenance, and consistency.