Mental Health Neglected

Compare this to the same-day story about prison beds.–gm

Straining to serve, Texas mental health system is at a crossroads
Possible budget cuts, effect of state official’s exit worry advocates

By Andrea Ball
AMERICAN-STATESMAN STAFF
Sunday, July 02, 2006

It’s standing room only at Austin’s crisis center for people who are mentally ill.

Two young girls sit on the gray speckled tile floor. A muscular, tattooed man walks outside for a smoke. An old woman with a big hat and a garbage bag full of possessions mumbles to herself. This is Psychiatric Emergency Services, the last resort center for people who are poor, desperate and mentally ill. They come here depressed, delusional, psychotic or suicidal. And because they have nowhere else to go, they’re coming here more often.

“We’re seeing not only more people, but more of the same people over and over again,” said Jim Van Norman, medical director for the Austin Travis County Mental Health Mental Retardation Center, which runs the crisis center.

Visits to the crisis center have almost doubled since 2003. More than a quarter of the prisoners in the Travis County jail system are on psychotropic drugs. People can wait six to eight months just to get an appointment with MHMR.

“A six- to eight-month waiting list?” said King Davis, executive director of the Hogg Foundation for Mental Health, a University of Texas-based organization focused on mental health issues. “That’s extraordinary. That’s a very serious matter.”

Advocates say Travis County is a microcosm of a state mental health system that is overwhelmed and underfunded. Although the system has made progress over the past few years, garnering more state money, more public attention and new efforts to revamp services, there is uncertainty ahead.

The Legislative Budget Board and Gov. Rick Perry’s office recently told state agencies to assume a 10 percent funding cut when making budget requests to lawmakers. Legislators say that request is more of a planning tool than an actual threat. Two years ago, agencies were told to start off assuming a 5 percent cut, but by the end of the session, legislators increased state spending by $5 billion.

Mental health advocates still worry that any funding decrease could derail the momentum. And adding to the anxiety is the impending departure of Texas Department of State Health Services Commissioner Eduardo Sanchez, a certified family practice physician who has championed the cause of the uninsured.

“We think Texas is, in many ways, at a crossroads,” Davis said. “Where does it want to go with its mental health system? That’s part of the question, and it’s open right now.”

Texas ranks 47th nationally in per capita funding of mental heath services. As part of its work, the state pays community mental health centers to treat poor and uninsured people with medication, therapy and rehabilitation programs. It also runs 10 psychiatric hospitals.

In 2004, motivated by budget constraints and a desire to bring consistency to treatment practices, the state started rationing care. Instead of trying to serve everyone, policymakers decided to concentrate on those who are the most severely ill: people with bipolar disorder, schizophrenia and major depression. Thousands of people with other ailments, such as panic, anxiety and obsessive-compulsive disorders, were phased out of the system. New patients with those disorders are denied treatment unless they are in a crisis.

Exactly what is happening to those now-ineligible people remains unclear. Advocates say they are behind the rise in people showing up in emergency rooms, crisis centers and jails, but no one really knows because there is no way to track everyone.

However, even many people who still qualify for services can’t get them. Under the current budget, 596,000 Texans are eligible, but the state can serve only 16 percent of children and 24 percent of adults, according to the Mental Health Association in Texas, a nonprofit mental health advocacy and education group.

“I think people should be outraged at how few people are being served,” said Lynn Lasky Clark, executive director of the association.

A system checkup

Assessing the state of mental health in a place as geographically and economically diverse as Texas can be difficult. Some mental health centers operate emergency crisis centers; others do not. Some have waiting lists; others keep up with need.

Yet, it is possible to assess the system’s vital signs by spot-checking demand for mental health care in jails, crisis centers and hospitals.

For example, by the end of April, more than 1,300 people across the state were on waiting lists for help at community mental health centers — up 16 percent since August. Meanwhile, about 200 prisoners across the state are sitting in jails waiting for a bed at one of the state’s psychiatric hospitals.

In the Austin area, indicators show:

•Visits to Psychiatric Emergency Services, the 24-hour public mental health crisis center, increased 84.8 percent from Sept. 1, 2003, to Aug. 31, 2005.

•Mental health visits to 20 nonmental health providers, including Seton Family of Hospitals facilities and nine City of Austin health clinics, have increased 17 percent since 2004, according to the Indigent Care Collaboration, a nonprofit group that tracks medical care for poor people in Travis, Hays and Williamson counties.

•In Travis County, where the waiting list for nonemergency care currently hovers around 475, people who are not in crisis, coming from jails or recently released from a psychiatric hospital can wait six to eight months to get an appointment to see a psychiatrist. Two years ago, there was no waiting list.

•Twenty-six percent of the inmates in the Travis County jail system are on psychotropic medications for everything from anxiety to bipolar disorder, up from 15 percent in September 2004. Inmates who have been declared incompetent to stand trial usually wait a month for a bed at a state psychiatric hospital.

“They’re just sitting in the jail, eating up jail resources,” said Sgt. Kitty Hicks of the Travis County sheriff’s department.

At Austin’s Psychiatric Emergency Services, the crowds come in cycles. Some days are quiet, others chaotic.

After sitting in the waiting room for two hours on a recent day, a young woman with bipolar disorder got in to see social worker Robert Dole. The woman had run out of medication two months earlier, she told him. Consequently, she was seeing figures and shadows that she suspected didn’t exist. She heard things — a constant chorus of voices she couldn’t understand — and was sleeping two hours a night.

She said she was drinking a bottle of rum a day to dull the voices.

“Is that a lot?” she asked.

“I think it’s fair to say most people don’t drink a bottle of rum a day,” Dole answered.

The center set her up with an appointment for long-term services through MHMR. After urging the woman to stop drinking, the center psychiatrist wrote her a prescription for medication.

Despite gaps, gains

Despite the challenges currently facing the state’s mental health system, the past few years have had gains.

Last year, under health commissioner Sanchez, the Legislature restored cuts made in 2003, such as therapy benefits for Medicaid recipients. In February, the state approved $13.4 million for extra beds at its psychiatric hospitals.

The health department is revamping the way it provides crisis services to people with mental illnesses. Private grant providers such as the Hogg Foundation have increased their funding for community programs.

Then last month, citing family reasons, Sanchez announced his retirement. He will step down in
October, leaving the future of mental health services in new hands.

“It’s like things were looking good and we were making progress,” said Robin Peyson, executive director of NAMI Texas, a mental health advocacy and support group. “Now, there’s Sanchez leaving and this 10 percent thing.”

Advocates are rallying against potential budget cuts, revving up supporters with e-mail blasts, contacting legislators and telling anyone who will listen that Texas’ overwhelmed mental health system can’t take another blow.

Davis says state officials and advocates need to take a broad, long-term look at the kind of models and levels of service the state eventually wants to provide.

“There are huge gaps in the system, and I think everyone realizes that,” he said. “But there is no overall planning on what to do about it.”

Joe Vesowate, the state assistant commissioner for mental health and substance abuse services, remains optimistic about the future of Texas’ mental health services. He says he thinks the momentum will continue into the 2007 legislative session, which will begin in January.

Sanchez did a good job of educating people about the importance of mental health services, so the learning curve for legislators won’t be as steep, he said.

Mounting community pressure for better services will also work in advocates’ favor, Clark said.

“It’s our time,” she said. “Everyone is talking about it: law enforcement, judges, ER doctors. This is a very critical time.”

84.8%

Increase in visits to Austin’s 24-hour public mental health crisis center from Sept. 1, 2003, to Aug. 31, 2005.

17%

Increase in mental health visits to 20 Austin area nonmental health providers since 2004.

6 to 8 months

Waiting time to get nonemergency care in Travis County.

26%

Portion of inmates in the Travis County jail system who are on psychotropic medication.