One morning in the fall of 2017, Renae Smith, a high school freshman on Long Island, N.Y., could not get out of bed, overwhelmed at the prospect of going to school. In the following days, her anxiety mounted into despair.“I should have been happy,” she later wrote. “But I cried, screamed and begged the universe or whatever godly power to take away the pain of a thousand men that was trapped inside my head.”Intervention for her depression and anxiety came not from the divine but from the pharmaceutical industry. The following spring, a psychiatrist prescribed Prozac. The medication offered a reprieve from her suffering, but the effect dissipated, so she was prescribed an additional antidepressant, Effexor.A medication cascade had begun. During 2021, the year she graduated, she was prescribed seven drugs. These included one for seizures and migraines — she experienced neither, but the drug can be also used to stabilize mood — and another to dull the side effects of the other medications, although it is used mainly for schizophrenia. She felt better some days but deeply sad on others.Her senior yearbook photo shows her smiling broadly, “but I felt terrible that day,” said Ms. Smith, who is now 19 and attends a local community college. “I’ve gotten good at wearing a mask.”She had come to exemplify a medical practice common among her generation: the simultaneous use of multiple heavy-duty psychiatric drugs.Psychiatrists and other clinicians emphasize that psychiatric drugs, properly prescribed, can be vital in stabilizing adolescents and saving the lives of suicidal teens. But, these experts caution, such medications are too readily doled out, often as an easy alternative to therapy that families cannot afford or find, or aren’t interested in.These drugs, generally intended for short-term use, are sometimes prescribed for years, even though they can have severe side effects — including psychotic episodes, suicidal behavior, weight gain and interference with reproductive development, according to a recent study published in Frontiers in Psychiatry.Moreover, many psychiatric drugs commonly prescribed to adolescents are not approved for people under 18. And they are being prescribed in combinations that have not been studied for safety or for their long-term impact on the developing brain.A Medication CascadeRenae Smith’s psychiatric records mention varying doses of at least 10 medications, some of which are not approved for treating depression in adolescents.

GLASGOW, Ky. — One crisp Monday morning in January, Dr. Melissa Dennison sat in a small, windowless exam room with a 14-year-old girl and her mother. Omicron was ripping through Kentucky, and the girl was among three dozen young patients — two of them positive for the coronavirus — that the pediatrician would see that day.But this girl was part of a different epidemic, one that has gripped the community and nation since long before Covid: She and her mother had come to discuss the girl’s declining mental health.The girl had dark hair and wore jeans and a T-shirt bearing the words “Purple Rain.” She was depressed, she told Dr. Dennison, and had been cutting her arm to relieve her emotional pain. Dr. Dennison suggested therapy, but the girl said she would not go.After the exam, Dr. Dennison stood in the hallway and described the case. “You need to get off the phone and the computer,” she had told the girl. “When it’s pretty outside like this, put on a bunch of clothes and go for a walk.”Dr. Dennison prescribed the antidepressant Zoloft, although she wasn’t sure the girl was clinically depressed.“I’d rather they see a psychiatrist,” she said. “But if I’ve got this child and they’re cutting and saying they’re going to kill themselves, I’ll say, ‘Well, I’ll see them today.’ If I call a child psychiatrist, they say, ‘I’ll see them in a month.’”Over the last three decades, the major health risks facing U.S. adolescents have shifted drastically: Teen pregnancy and alcohol, cigarette and drug use have fallen while anxiety, depression, suicide and self-harm have soared. In 2019, the American Academy of Pediatrics issued a report noting that “mental health disorders have surpassed physical conditions” as the most common issues causing “impairment and limitation” among adolescents. In December, the U.S. Surgeon General, in a rare public advisory, warned of a “devastating” mental health crisis among American teens.But the medical system has failed to keep up, and the transformation has increasingly put emergency rooms and pediatricians at the forefront of mental health care. Community doctors now routinely deal with complex psychiatric issues, making tough diagnoses after brief visits and prescribing powerful psychiatric medications for lack of better alternatives. “Pediatricians need to take on a larger role in addressing mental health problems,” the 2019 A.A.P. report concluded. “Yet, the majority of pediatricians do not feel prepared to do so.”Dr. Cori M. Green, a co-author of that report and a pediatrician at Weill Cornell Medicine, said medical training lagged behind. “We need to overhaul the whole system,” she said. “We need to see mental health through a prevention lens and stop seeing physical health as different than mental health.”Dr. Dennison in an examination room, wheeling a laptop from patient to patient. Twenty years ago, 1 percent of her cases related to mental and behavioral health, she estimates; now at least 50 percent do.In Glasgow, Ky., as elsewhere, there are counselors in the schools and therapists in town, including four at Dr. Dennison’s clinic. But they are often booked months out. Psychiatrists are scarce, here and nationwide. Seventy percent of counties in the United States lack a psychiatrist specializing in children or adolescents — and the psychiatrists who can be found are concentrated in wealthier areas, with many accepting only private payments.“There’s a need and nowhere else to go,” Dr. David Lohr, a child and adolescent psychiatrist at the University of Louisville, said of the growing role of primary-care doctors in mental health.Dr. Dennison, 62, has adapted. Two decades ago, she routinely prescribed antibiotics and saw patients with “strep throat, earaches and wheezing,” she said. “And no one heard of A.D.H.D.,” she said, referring to attention deficit hyperactivity disorder. She estimated that, back then, 1 percent of her cases related to mental and behavioral health; now at least 50 percent do.The causes of this crisis are not fully understood. Experts point to many possible factors. Lifestyle changes have led to declines in sleep, physical activity and other healthful activities among adolescents. This generation professes to feeling particularly lonely, a major factor in depression and suicide. Social media is often blamed for these changes, but there is a shortage of data establishing it firmly as a cause.In Glasgow, a town of 14,000, the challenges are intensified by high rates of drug addiction and poverty and their effect on families.

On a rainy Thursday evening last spring, a 15-year-old girl was rushed by her parents to the emergency department at Boston Children’s Hospital. She had marks on both wrists from self-harm and a recent suicide attempt, and earlier that day she confided to her pediatrician that she planned to try again.At the E.R., a doctor examined her and explained to her parents that she was not safe to go home.“But I need to be honest with you about what’s likely to unfold,” the doctor added. The best place for adolescents in distress was not a hospital but an inpatient treatment center, where individual and group therapy would be provided in a calmer, communal setting, to stabilize the teens and ease them back to real life. But there were no openings in any of the treatment centers in the region, the doctor said.Indeed, 15 other adolescents — all in precarious mental condition — were already housed in the hospital’s emergency department, sleeping in exam rooms night after night, waiting for an opening. The average wait for a spot in a treatment program was 10 days.The girl and her family resigned themselves to a stay in the emergency room while she waited. But nearly a month went by before an inpatient bed opened up.The girl, being identified by her middle initial, G, to protect her privacy, spent the first week of her wait in a “psych-safe” room in the emergency department. Any equipment that might be used for harm had been removed. She was forbidden to use electronics — to keep her from searching the internet for ways to commit suicide or asking a friend to smuggle in a sharp object, as teens before her had done. Her door was kept open night and day so she could be monitored.It was “padded, insane-asylum-like,” she recalled recently in an interview. “Just walls — all you see is walls.”She grew “catatonic,” her mother recalled. “In this process of boarding we broke her worse than ever.”Mental health disorders are surging among adolescents: In 2019, 13 percent of adolescents reported having a major depressive episode, a 60 percent increase from 2007. Suicide rates, stable from 2000 to 2007, leaped nearly 60 percent by 2018, according to the Centers for Disease Control and Prevention.G’s story describes one of its starkest manifestations of the crisis. Across the country, hospital emergency departments have become boarding wards for teenagers who pose too great a risk to themselves or others to go home. They have nowhere else to go; even as the crisis has intensified, the medical system has failed to keep up, and options for inpatient and intensive outpatient psychiatric treatment have eroded sharply.Nationally, the number of residential treatment facilities for people under the age of 18 fell to 592 in 2020 from 848 in 2012, a 30 percent decline, according to the most recent federal government survey. The decline is partly a result of well-intentioned policy changes that did not foresee a surge in mental-health cases. Social-distancing rules and labor shortages during the pandemic have eliminated additional treatment centers and beds, experts say.Dr. Kevin Carney, a pediatric emergency-room doctor at Childen’s Hospital Colorado in Aurora. “Frankly speaking, the E.D. is one of the worst places for a kid in mental health crisis to be,” he said.An exam room at Children’s Hospital Colorado, where fixtures and other items had been removed to prevent harm.Absent that option, emergency rooms have taken up the slack. A recent study of 88 pediatric hospitals around the country found that 87 of them regularly board children and adolescents overnight in the E.R. On average, any given hospital saw four boarders per day, with an average stay of 48 hours.“There is a pediatric pandemic of mental health boarding,” said Dr. JoAnna K. Leyenaar, a pediatrician at Dartmouth-Hitchcock Medical Center and the study’s lead author. In an interview, she extrapolated from her research and other data to estimate that at least 1,000 young people, and perhaps as many as 5,000, board each night in the nation’s 4,000 emergency departments.“We have a national crisis,” Dr. Leyenaar said.This trend runs far afoul of the recommended best practices established by the Joint Commission, a nonprofit organization that helps set national health care policy. According to the standard, adolescents who come to the E.R. for mental health reasons should stay there no longer than four hours, as an extended stay can risk patient safety, delay treatment and divert resources from other emergencies.Yet in 2021, the average adolescent boarding in the E.R. at Boston Children’s Hospital spent nine days waiting for an inpatient bed, up from three and a half days in 2019; at Children’s Hospital Colorado in Aurora in 2021, the average wait was eight days, and at Connecticut Children’s Medical Center in Hartford, it was six.Emergency-department boarding has risen at small, rural hospitals, too, with “no pediatric or mental health specialists,” said Dr. Christian Pulcini, a pediatrician in Vermont who has studied the trend in the state. “There is one clear conclusion,” he told the Vermont legislature recently. “The E.D. is not the appropriate setting for children to get comprehensive, acute mental health services.”Doctors and hospital officials emphasize that adolescents should absolutely continue to come to the E.R. in a psychiatric emergency. Still, many emergency-room doctors and nurses, trained to treat broken bones, pneumonia and other corporeal challenges, said aid the ideal solution was more preventive care and community treatment programs.“Frankly speaking, the E.D. is one of the worst places for a kid in mental health crisis to be,” said Dr. Kevin Carney, a pediatric emergency room doctor at Children’s Hospital Colorado. “I feel at a loss for how to help these kids.”‘Actually a good day’Dr. Carney on his rounds at Children’s Hospital Colorado in Aurora last month.The challenge was evident one day in late February when Dr. Carney arrived for his shift at 3 p.m. The children’s hospital has 50 exam rooms in its emergency department, which fill with patients who have gone through an initial screening and need further evaluation. By midafternoon, 43 of the rooms were full, 17 of them with mental health cases.“It’s breathtaking,” Dr. Carney said as he stood in the hallway. “Forty percent.”On clocking in, Dr. Carney had inherited a block of 10 exam rooms from a doctor who was clocking out. “Seven are mental health issues,” Dr. Carney said. “Six are suicidal. Three of them made attempts.”The adolescents who were deemed to be at physical risk to themselves or others could be readily identified: Their exam room doors were open so they could be monitored, and they wore maroon-colored scrubs instead of their own clothes. No shoelaces, belts or zippers.Throughout the day, staff members at the hospital had called eight inpatient facilities in the region, looking for available slots in treatment centers where the 10 young boarders, as well as 17 other adolescents boarding at three smaller Colorado Children’s Hospital campuses around the state, could be placed.One of the adolescents waiting in Aurora, a Denver suburb, was a 16-year-old who had been stabilized after attempting suicide and who needed a residential treatment spot. “But there are no beds,” Jessica Friedman, a social worker, said she had told the family.“I have eight or nine conversations like this a day,” Ms. Friedman, standing in the hallway, told a reporter; so far that day she had had only two. “This is actually a good day.”Jessica Friedman, a social worker at Children’s Hospital Colorado.A room at the Gary Pavilion Pediatric Mental Health Institute at Children’s Hospital in Aurora, Colo., one of eight inpatient facilities in the area.Standing nearby, Travis Justilian, a nurse and the interim clinic manager in the emergency department, said the flood of boarders “is crushing our staff.” He added, “We’re fixers and we’re sitting here doing nothing but watching them watch TV.”Colorado is struggling with the same shortage of services that has hit hospitals nationwide. The state has lost 1,000 residential beds serving various adolescent populations since 2012, according to Heidi Baskfield, vice president of population health and advocacy for Children’s Hospital Colorado. The state closed one 500-bed facility, Ridgeview, which served at-risk young people, in 2021 because of instances of poor quality and abuse. Another facility, Excelsior, closed its 200 beds in 2017 because reimbursement rates were not high enough to support ongoing operations, the chief executive officer said at the time of the closing.A major cause, Ms. Baskfield said, was the low reimbursement rates paid by Medicaid, the state insurance program. From 2006 to 2021, the daily Medicaid rate in Colorado allotted roughly $400 for a therapeutic residential bed — “less than some families spend to send their kids for a night to sleepaway camp,” Ms. Baskfield said.The low rates also accounted for some of the quality issues, she said; it was hard to hire experienced staff. (In the past year, Colorado has raised its reimbursement to $750 per day by using money from the American Rescue Plan, but new beds have yet to open, and that source of money is temporary).Travis Justilian, a nurse and interim clinic manager in the emergency department. “We’re fixers and we’re sitting here doing nothing but watching them watch TV,” he said.Lyndsay Gaffey, the hospital’s director of patient care services. The aim of inpatient care, she said, was to stabilize patients by having them work through trauma, receive therapy and interact with peers.Lisette Burton, chief policy and practice adviser for the Association of Children’s Residential and Community Services, a nonprofit advocacy group, noted that the closure of facilities and the loss of beds was the result of many factors, including a well-intended, decades-long effort to keep foster children and other children out of institutional settings. But the intended substitutes — more nimble and specialized treatment options — were never funded and remain largely unavailable, she said.Then came the pandemic, amplifying labor shortages and introducing social-distancing and quarantine guidelines that reduced the capacity for patients. “Demand went up, supply went down,” Ms. Burton said. “Now we’re in full-blown crisis.”On that February day in Colorado, one inpatient bed finally opened up. It happened to be in the 12-bed inpatient ward of Children’s Hospital Colorado,just a few minutes’ walk from the E.R.The ward’s hallways are wide, the walls painted light green and the lighting bright, to instill a feeling of comfort and calm. Each bedroom has windows looking outside and, next to the door, a glass panel enabling hospital staff to discreetly peer inside.In a small communal room, four adolescent girls in maroon scrubs sat on blue chairs and couches. One listened to headphones and sang aloud to the soundtrack to “Encanto.” Another worked on a jigsaw puzzle of the sea. Two others chatted with a counselor.The emergency department “is just a collection of rooms where patients are expected to stay in their rooms and comply with rules,” said Lyndsay Gaffey, director of patient care services at Children’s Hospital Colorado. In the inpatient ward, she said, the aim instead was to stabilize patients by having them work through trauma, receive therapy and interact with peers.But they must be closely watched here, too. When a reporter rested a pen on a countertop, a staff member swept it up. “You cannot have this here unless it is on your person,” she said. “If a patient walks over and grabs it, it can basically be used as a weapon.”Is it safe to go home?J on a neighborhood street in Denver last month. In February, he spent time in the E.R. after he was discovered searching the internet for ways to commit suicide.In severe cases of mental distress, emergency-room doctors can compel an adolescent to board in the E.R. until inpatient services become available, however long that takes. Often, parents opt to return home with their child, to try to manage there while waiting for a treatment opening. But that option requires family and doctors alike to work through a difficult question: Is the adolescent safe to go home?In early February, a 12-year-old boy, J, was struggling toward an answer at the emergency room of the Highlands Ranch campus of Children’s Hospital Colorado. (He is being identified by his first initial for privacy reasons.)He had arrived that morning with his mother, after she discovered that he had been searching the internet for ways to commit suicide. Over the course of his day in the E.R., he was asked several times how safe he felt to go home. The mother recounted one exchange:“Do you think you can go home?” the doctor asked.“What’s the other option?” J asked.“You’d be in the emergency room.”“I can go home with my mom,” J said. “But if I feel like I’m going to kill myself, what do I do?’”“You’ll come back to the emergency room,” the doctor replied.How to Help Teens Struggling With Mental HealthCard 1 of 6Recognize the signs.

One evening last April, an anxious and free-spirited 13-year-old girl in suburban Minneapolis sprang furious from a chair in the living room and ran from the house — out a sliding door, across the patio, through the backyard and into the woods.Moments earlier, the girl’s mother, Linda, had stolen a look at her daughter’s smartphone. The teenager, incensed by the intrusion, had grabbed the phone and fled. (The adolescent is being identified by an initial, M, and the parents by first name only, to protect the family’s privacy.)Linda was alarmed by photos she had seen on the phone. Some showed blood on M’s ankles from intentional self-harm. Others were close-ups of M’s romantic obsession, the anime character Genocide Jack — a brunette girl with a long red tongue who, in a video series, kills high school classmates with scissors.In the preceding two years, Linda had watched M spiral downward: severe depression, self-harm, a suicide attempt. Now, she followed M into the woods, frantic. “Please tell me where u r,” she texted. “I’m not mad.”American adolescence is undergoing a drastic change. Three decades ago, the gravest public health threats to teenagers in the United States came from binge drinking, drunken driving, teenage pregnancy and smoking. These have since fallen sharply, replaced by a new public health concern: soaring rates of mental health disorders.In 2019, 13 percent of adolescents reported having a major depressive episode, a 60 percent increase from 2007. Emergency room visits by children and adolescents in that period also rose sharply for anxiety, mood disorders and self-harm. And for people ages 10 to 24, suicide rates, stable from 2000 to 2007, leaped nearly 60 percent by 2018, according to the Centers for Disease Control and Prevention.