Demand for mental health services that peaked during the pandemic has remained stubbornly high, increasing waitlists and spilling patients into Maine's hospital emergency rooms.
Prior to COVID-19, Mainers might wait weeks to see a behavioral health specialist. Now waitlists are months long, said Dr. Anthony Ng, medical director for community services at Northern Light Acadia Hospital.
"You could put them on the waiting list but for every moment they wait, weeks and months, their illness could worsen," Ng said.
Maine was losing psychiatrists in the years leading to the pandemic, and the numbers have continued to drop. In 2019, three counties – Franklin, Piscataquis and Sagadahoc – did not have any psychiatrists, according to a statewide report released last month.
Staff shortages during the pandemic forced outpatient programs to reduce services despite rising rates of isolation, depression and anxiety at a time of economic uncertainty and political discontent, said Ng, who is also a Distinguished Fellow of the American Psychiatric Association.
Maine already had high suicide rates before the pandemic: In 2019, the state suicide rate per 100,000 was 19.4 compared to 13.9 nationally.
COVID-19 made the situation worse, and the need for services has not eased despite the easing of pandemic lockdowns that caused widespread isolation, mental health professionals told The Maine Monitor.
Linda Durst, chief medical officer with Maine Behavioral Healthcare, said she has tracked more suicide deaths during the pandemic than in the five years prior. In particular, she's seen an "acceleration in severe suicide attempts in youth." Durst also chairs the department of psychiatry at Maine Medical Center.
The numbers have been higher in the past year, perhaps because as the pandemic has dragged on, "people have gotten less hopeful," Durst said. And delayed care meant that people who sought care had more severe cases.
But there are efforts to address this. Gov. Janet Mills allocated $230 million for behavioral health services this fiscal year, including $15.4 million released in June to help reduce waitlists for community-based services and reduce emergency department use for behavioral health crises. And Maine Medical Center has expanded its psychiatry residency program into rural communities.
Experts say the pandemic is an opportunity to rethink the way they deliver mental health services.
EMERGENCY ROOMS GET BUSIER
When there aren't enough treatment providers, people with more severe mental health challenges may end up in emergency rooms.
Behavioral health visits to emergency rooms in Maine hospitals have remained 25 percent higher than before the pandemic, according to a survey conducted this week by the Maine Hospital Association. The length of stay in the emergency room has increased by 25 percent — and in some cases as much as 35-40 percent.
At one point last year, psychiatric patients took up half the emergency beds in Maine's largest hospital system, the Bangor Daily News reported.
Keeping patients in emergency room beds for extended stays – a practice called boarding – is one of the top problems facing hospitals, said Steven Michaud, president of the Maine Hospital Association. It's a bad situation for everyone because the patient doesn't receive the long-term level of care needed, it puts an extra strain on staff and takes away beds from other patients.
Hospitals have seen rising rates of violence from patients towards staff as a result.
"It doesn't mean that all behavioral health patients are violent. Not at all. But they are disproportionately more so, and to say otherwise is just not facing reality," Michaud said. "So when we have these patients it is more dangerous for our staff in the emergency room."
Workforce shortages are part of the problem, but the lack of an adequate number of treatment centers goes back to the national movement in the 1970s and 1980s to shrink state mental health facilities, Michaud said.
"This is a long-standing problem, which tells you there hasn't been enough services out in the community for years, if not decades," Michaud said. "And by the way, this is a national phenomenon. Everybody like me is pulling their hair out about this across the country.”
In addition to allocating funds to providers, the Mills administration in January opened a close supervision residential facility to provide an alternative to incarceration or hospitalization, opened a crisis center in Portland and expanded crisis support for youth based on a pilot program in Aroostook County, according to a spokesperson.
Increasing funding to providers and increasing the number of beds for in-patient treatment will help, but Michaud said it's important to also start thinking about different methods of providing care.
"There's not enough money in all the government to take care of this so we're going to have to do both: We need more resources ... but we also need different ways of looking at it in terms of models," Michaud said.
Between 2015 and 2020, the number of practicing licensed psychiatrists in Maine dropped by half to 110.
The drop-off is due in large part to a wave of retirements that was hastened by the pandemic, Durst said. The average age of a psychiatrist in Maine is 55.
But Durst added that there seems to be renewed interest in psychiatry and she's seen impressive applicants for training programs.
Maine Medical Center runs the state's only psychiatric residency program, which offers four years of postgraduate training. There are five residents in the standard program and three in child psychiatry. The program was expanded this year to include two residents in a rural track in Rockland.
There's a lot of evidence that people from rural areas, or who are trained in rural areas, are more likely to stay there, said John Gale, a senior research associate at the University of Southern Maine and the former president of the National Rural Health Association .
Experts said it's important to have providers in rural areas because they have local knowledge and understanding of what their patients are experiencing, and are better able to connect and treat them. In addition, it is difficult for people to drive hours from home, spending time and gas money, to receive these services.
Gale said the shortage of workforce professionals and mental health services has existed for his entire 40-year career in the field. There's been some progress but it hasn't solved the problem.
"We're not likely to produce enough psychiatrists and social workers who want to go to rural communities to fill the need, so I think we have to think about it differently than we used to," he said.
Telehealth is one way to improve access but it's a "double edged sword," said Ng, with Acadia Hospital. While it may bridge the gap for people who live in areas without local mental health services, telehealth also means that Maine-based psychiatrists could work remotely in other places. In addition, not everyone has broadband to support telehealth communications.
Experts told The Maine Monitor that one of the most important solutions is to weave mental health services into primary care, school-based programs and community support.
This is a chance to be more proactive and work on stress reduction, rather than wait for problems to get so severe that they need to see a psychiatrist, Ng said.
"This is time for us to look at new ways to work with communities, rather than the old-fashioned way of just putting more people out there to see more patients."
This story was originally published by The Maine Monitor. The Maine Monitor is a local journalism product published by The Maine Center for Public Interest Reporting, a nonpartisan and nonprofit civic news organization.