North Carolina hospitals that were stretched to their limits during the coronavirus pandemic have seen a dramatic decrease in the number of COVID-19 patients this spring.

But now hospitals say they’re struggling with another health crisis, one that predates the pandemic but has been made worse by it, and they’re asking the state’s political leaders for help.

People with behavioral and mental illnesses are increasingly ending up in the emergency rooms of North Carolina’s medical hospitals, which are ill equipped to treat them. In December, 20% of patients discharged from an emergency room in the state were diagnosed with a behavioral health problem, sometimes in addition to a physical injury, up 7.5% from a year earlier, according to data compiled by the N.C. Healthcare Association, which represents the state’s hospitals.

The increase was much higher for children. Nearly 1 in 10 children treated in a hospital emergency department in December were diagnosed with a behavioral health problem, up 70% from a year earlier, according to the association.

Barbara-Ann Bybel, director of psychiatric services at UNC Medical Center in Chapel Hill and UNC WakeBrook in Raleigh, says the trend has continued in 2021. Bybel said patients with mental illnesses can wait days, sometimes weeks, in hospital emergency departments for openings at psychiatric hospitals or other facilities where they can get treatment.

“It’s a second pandemic. We’re referring to it as the mental health tsunami. And this giant wave is coming and it’s continuing to grow and it still hasn’t even made landfall yet,” Bybel said in an interview. “So what are we doing to prepare for it instead of just waiting to get washed away?”

Last week, the hospital association and nearly a dozen other organizations appealed to Gov. Roy Cooper and the Republican leaders of the General Assembly for help. In a letter dated June 14, they said North Carolina is failing to meet the growing demand for mental health services.

“Quite simply, the behavioral health crisis across North Carolina has reached a state of emergency, and we urgently need your leadership and collaboration to address it,” the letter said.

The letter was signed by several medical organizations, including those representing doctors, nurses, psychologists and psychiatrists. But also lending support was the N.C. Chamber, the state’s top business organization, and Blue Cross and Blue Shield of North Carolina, its busiest health insurer.

Gary Salamido, the chamber’s president and CEO, said businesses understand that improving the state’s mental health system is critical to recovering from the COVID-19 pandemic.

“The N.C. Chamber believes in advancing conversations about the significance of mental health to stop the stigma surrounding mental illness and to help more North Carolinians seek and receive treatment,” Salamido said in a written statement. “Mental illnesses are treatable, and North Carolinians must have access to this vital care.”

Blue Cross said the pandemic helped bring attention to the problems.

“The COVID-19 crisis has further highlighted gaps in North Carolina’s behavioral health system and is requiring everyone in the health care community to work together,” the company wrote in a statement. “We have a unique opportunity at this time to bring together the organizations that can make a difference and help determine how behavioral health is provided in this state.”

The groups did not say what they thought the state should do to help with the prevention and treatment of mental illness. Instead, they asked for a meeting with state leaders “to immediately address this crisis.”

Cooper responds with plea for Medicaid expansion

Senate leader Phil Berger and House Speaker Tim Moore have not formally responded to the letter. A spokeswoman for Berger said he is open to meeting with the organizations to discuss their letter and their concerns.

Cooper replied Thursday in a letter that indicates the effort may falter over old disagreements between Democrats and Republicans in the state.

Cooper, a Democrat, wrote that expanding Medicaid, the government insurance program for low-income people, would make treatment available to more people with mental illness and substance abuse problems. He has long pressed for making more uninsured people eligible for the program and this spring proposed adding 600,000 using money from the American Rescue Plan Act passed by Congress in March.

But Republicans have staunchly opposed enrolling more people in what they consider a federal entitlement program the state can’t afford. Earlier this month, Moore and Berger announced that neither the House nor Senate budget proposals would include Medicaid expansion.

Cody Hand, the hospital association’s vice president for government relations, said he was disappointed that the Senate’s proposed budget released this week didn’t include additional funding for mental health programs, even though the state enjoys a surplus fueled in part by federal coronavirus relief money.

“They didn’t include even a mention of the need to reform behavioral health,” Hand said in an interview. “When given the opportunity, with the amount of excess revenue they had, to put some money aside to address the behavioral health program, I really think they missed out on a valuable opportunity.”

The problems predate the COVID-19 pandemic

Hospital emergency rooms are designed to treat urgent medical problems, such as heart attacks, strokes and physical injuries, from lacerated hands to gunshot wounds. They’re busy, sometimes chaotic places that often aren’t equipped to handle people who are suicidal, severely depressed or having a psychotic episode.

But people with behavioral health problems arrive every day, by ambulance, in the backs of police cars or on their own or with a family member, because they don’t know where else to go, Bybel said.

“Think about it: When you call your doctor’s office on a Friday night and the doctor’s office is closed, what do they say on their recording? ‘If this is an emergency, call 911. If this is an emergency, go to your local emergency room,’” she said. “Everyone’s directing them to go to the emergency department. And without more mental health crisis centers, there really is no alternative.”

Many larger hospitals have adjusted by having psychiatric staff on hand and dedicated spaces for mental health patients. Three years ago, Rex Hospital in Raleigh opened a special area for people with behavioral health problems, with eight private rooms adjacent to its emergency department. Rex refers to the $2.5 million facility as a “holding area,” because it’s meant to keep people only until they can be moved to a psychiatric hospital or clinic.

The reliance on hospitals and county jails to hold people with mental illness is not a new problem. But the upheaval of the pandemic and the closing of businesses and schools has made things worse, by causing stress and anxiety and disconnecting people from their normal support, Bybel said.

“A lot of people are just not coping well,” she said. “It’s not just us; it’s a national trend.”

Hand said another factor is that people stopped seeking help with behavioral health problems, either because offices or clinics weren’t seeing patients or they were worried about contracting the coronavirus.

“People were avoiding care, and we’re seeing that bubble up,” he said.

In his letter, Cooper echoed these concerns. He said he has asked Dr. Mandy Cohen, the secretary of the Department of Health and Human Services, and her deputy Kody Kinsley to arrange a meeting with the groups that raised the alarm.

“The historical unmet need in North Carolina’s behavioral health system has only been compounded by the pandemic,” he wrote. “And unfortunately we expect these numbers to continue to worsen as we witness the pandemic’s full impact.”

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Richard Stradling covers transportation for The News & Observer. Planes, trains and automobiles, plus ferries, bicycles, scooters and just plain walking. Also, hospitals during the coronavirus outbreak. He’s been a reporter or editor for 33 years, including the last 21 at The N&O. 919-829-4739, [email protected]