Pervasive Crimes against Humanity in USA
http://www.chron.com/cs/CDA/ssistory.mpl/metropolitan/3004871Jan. 23, 2005, 12:43AM
MENTAL HEALTH SYSTEMS IN DISREPAIR
In the shadow of a crisis
A new law was supposed to streamline services and improve care for the sickest patients. But thousands still go without treatment.
By CLAUDIA FELDMAN and JEANNIE KEVERCopyright 2005 Houston Chronicle
Call him the money man.
He's schizophrenic, obsessive-compulsive and so ill he can't remember things from one day to the next. Until he was moved to a nursing home recently, he spent years entering downtown skyscrapers and holding forth on Hitler, Mussolini and the Beatles.
Security guards asked him to leave, but he couldn't, he had to get to the end of his spiel. Inevitably the police came, charged him with misdemeanor trespassing and put him in jail. From jail he went to a state mental hospital, and from there he recycled back to jail, the county psychiatric hospital and the streets.
He has cost taxpayers at least $2 million over the last 30 years, says a mental health expert who has followed his case, and even at that price tag he didn't get what he needed — long-term outpatient services or a spot in a supervised residential facility. He represents a state mental health system that's been broken for years.
Millions of dollars in tax money — the exact amount is untallied, but an informal survey of area mental health providers shows that it easily tops $70 million — goes to the treatment of mental illness in Harris County every year. While 25,000 received services from the public mental health system in 2003, almost three times as many did not.
Texas House Bill 2292, which became law in September, was supposed to fix things.
To streamline services, agencies for mental health and substance abuse were combined and eligibility requirements tightened. To save money, most mental health benefits were cut from Medicaid, the state-federal health insurance program for the poor, leaving nearly 128,000 Texas Medicaid recipients with mental illnesses without a way to pay for care.
To improve patient care, the law also implemented the concept of disease management. Instead of treating everyone with a mental illness with medication and little else, staffers at the Mental Health and Mental Retardation Authority of Harris County and other community mental health centers across the state now assign clients to one of four levels, with Level IV clients receiving the broadest range of services.
Legislators said the sickest people in the state would receive effective, even improved, treatment.
It didn't turn out that way, say those who work most closely with the mentally ill.
"Are we comfortable letting people die on the streets? Are we comfortable having a level of health care that may approach Third World status for some portion of our society?" asks Steve Schnee, executive director of the Mental Health and Mental Retardation Authority of Harris County.
Tom Mitchell, who has worked with the indigent mentally ill for 28 years, describes the four months since the law has been in effect "as the worst I've ever seen. The population is growing, and we're cutting services."
MHMRA, the region's largest provider of mental health services for the uninsured and underinsured, simply can't keep up with client demand. People not in crisis wait up to 3 1/2 months for an appointment. The day of the visit, they wait hours to see a doctor, who typically has a caseload of more than 600 patients.
According to a 2004 report by the Mental Health Needs Council, a local advocacy group, 84,000 Harris County residents who are severely ill with depression, bipolar disorder or schizophrenia depend on the public mental health system. Twenty percent of county residents in jail or prison and one-third of the county's homeless population are severely mentally ill.
Since September, mental health services in Harris County have undergone changes. Here's a look at what's happened and what the outlook is for the future.
Rationing of care
Only people with schizophrenia, bipolar disorder and major depression now are eligible for more than crisis care at MHMRA. People in acute psychiatric crisis are eligible for treatment, regardless of their diagnoses, but under the new law they may be forced out of the system once they are stabilized.
Theoretically, people with other serious mental illnesses — anxiety and panic disorders, obsessive-compulsive disorder and nonsuicidal depression — will be referred elsewhere, but they have few other places to go. The other main public provider, the Harris County Hospital District, has little capacity to absorb the overflow.
So far, about 125 clients who don't meet the new eligibility standards have been or soon will be purged by MHMRA, and 120 people, or 15 percent, are turned away each month, says Rose Childs of MHMRA.
At any one time, MHMRA juggles 8,830 clients, Childs says. That's one-tenth of those who need public treatment
Funding cuts
Texas already ranked near the bottom in per capita state spending for mental health care — 48th in 2002, according to a study by the National Association of State Mental Health Program Directors Research Institute. And spending has dropped since then. The local MHMRA has lost $8 million in state funding for mental health services since 2003; of its $129.1 million budget for this fiscal year, $35.1 million is for adult outpatient mental health programs.
"With all these budget cuts, I'm afraid one day I might not be sick enough to qualify for help," says Bobby Harper, who has spent much of his life homeless, severely depressed and occasionally suicidal.
Calls for change
MHMRA of Harris County juggles funding issues and the delivery of care. Some lawmakers and other experts want community mental health agencies across the state to choose between the two.
State Rep. John Davis, R-Houston, filed a bill earlier this month to regionalize state-funded programs for mental health, mental retardation, substance abuse, aging and services for the disabled. Among other things, it would prohibit agencies from both overseeing funds and providing services.
The local Mental Health Needs Council and other groups focusing on the system's shortcomings agree. They'd also like to see much greater coordination between the Harris County Hospital District, MHMRA and the county public health department. The newly formed Harris County Public Health Care System Council is supposed to oversee that coordination.
Harris County faces special challenges, including the fact that rural areas in Texas have historically received more money per capita for mental health services than the state's urban areas. Couple that with urban areas' attraction for people who need such services, and the problems become clear, said Harris County Judge Robert Eckels. The county's geographic sprawl complicates the problem by making it difficult for many people to reach clinics where services are available.
Several other urban counties have begun to address the challenges, but change has been slow to arrive in Harris County.
"There are people who think we (in Harris County) have the worst mental health system in Texas," says Lois Moore, administrator of the University of Texas-Harris County Psychiatric Center, which provides short-term inpatient treatment. "It's very dysfunctional."
Once, MHMRA operated seven outpatient clinics; it's down to four. The places almost smell of budget cuts that have been going on for years.
Outside the northwest clinic, clients smoke and keep wary eyes on a man who is shouting — to himself.
Inside, patients recline in well-worn chairs and wait. For hours, they wait.
Irene Castorino, a middle-age woman, skipped breakfast to make it to the clinic for her 9 a.m. appointment. Then she sat in the dusty waiting area until her name was called at 2:15 p.m.
She waited more than five hours for a five-minute meeting with a social worker. Had to, she says. She needs medication for her depression, but she can't see the doctor who will write a prescription until she gets past the gatekeeper.
"You have to put up with it," Castorino says. "If you don't come and keep your appointment, they drop you."
Castorino has been an MHMRA client since 1995. "The waits are so much longer now," she says. "Also, I used to come to group therapy. They stopped that."
Specific budget cuts are decided locally. But the major changes have been dictated in Austin.
Davis described the legislation as an attempt to bring mental health care into the modern age.
He and other proponents note that the old system was cobbled together before the explosion of information about brain-based diseases. Now that society knows more about mental illness, they say, treatment needs to change, too.
Combining effective, new drugs with meaningful therapy will help more people manage their mental illnesses, Davis said.
Most experts like the idea of disease management.
"In theory, it makes a lot of sense," said Betsy Schwartz, executive director of the Mental Health Association of Greater Houston. "But it's mandated without any new funding in a system already totally underfunded."
MHMRA, for example, has about $35 million a year to spend on outpatient adult mental health services.
That's not nearly enough, says Schwartz, who estimates roughly 35,000 mentally ill adults would seek services if the system were accessible.
Thousands of others are so sick they may not know they need treatment.
"It costs $10,000 a year, minimum, to give an adult the care he or she needs in an outpatient clinic," Schwartz says.
"It costs $55,000 a year not to treat that client. They cycle into crisis, and crisis care is prohibitively expensive. We pay now or pay later."
Sandra Robles' story
When Sandra Robles first called for help, she was so depressed she couldn't leave her bare west Houston apartment.
She lost her job as a nursery-school teacher when she took time off to help Steven, her adult schizophrenic son. At her next job, in a nursing home, a colostomy bag exploded in her face and caused an eye infection so severe she couldn't work.
Panicked about her bills, her son, her vision and her sanity, Robles called the Mobile Crisis Outreach Team, a free emergency service that is part of MHMRA. MCOT made several home visits, providing counseling and medication. Robles' employer also came through, giving her the temporary assistance she needed to pay bills and buy groceries.
Crisis averted, it seemed, for the licensed vocational nurse who feared she'd be living on the street. Her apartment was just a little box, she sobbed at one point, but it was all she had.
Two weeks ago, just as Robles planned to return to work, everything unraveled again.
Her doctor told her she wasn't ready — one eye was getting worse. A few days after she asked her employers to extend her medical leave, she was fired. That meant she lost the financial help. Then her mother died.
Thank goodness, Robles said, she had the anti-depressants from MCOT. Otherwise, she said, she'd be suicidal.
The MCOT services, designed to be temporary, actually came to an end before the latest series of crises. The MCOT counselor directed her to MHMRA's eligibility center, where the staff told her she qualified for services but would have to start paying $89 a month.
Robles didn't have the money and gave up on any hope of treatment. The MCOT staff stepped in again, assuring her that MHMRA would help her, even if she couldn't pay.
And that's what happened. Now Robles is trying to figure out how to come up with rent and put food in the refrigerator when she has no money coming in.
"I'm not going to cry — I can't cry anymore," she said. "I'm going to fight."
When Robles is not worrying about basic survival, she frets about her son. She wants to help him, she says, but sometimes the schizophrenia is a destructive force bigger and more powerful than either of them. Even when he gets free care, she says, he sometimes refuses it.
She's no longer surprised by that, she says. He's very ill. And sometimes they both question the value of 15 minutes of talk therapy here and there.
Tom Mitchell, the MCOT director, worries about the folks he and his team members lose while transferring them from their jurisdiction to the eligibility center and outpatient clinics. He feels particularly bad for the clients who are bounced because they don't have one of the big three diagnoses.
That, says Dr. Avrim Fishkind, is his biggest beef with the legislation: "It's almost a 'who should live and who should die' kind of decision."
Fishkind is medical director of MHMRA's NeuroPsychiatric Center, which provides assessment and treatment for people in psychiatric crises. Because of their emergency status, doctors can treat them without worrying about an approved diagnosis.
"But then what?" Fishkind asked. "There are dozens of psychiatric illnesses with the risk of violence and suicide as great or greater than major depression, schizophrenia or bipolar disorder. Think what would happen if doctors at Ben Taub (General Hospital) or the hospital district were told they could only treat cancer, diabetes and heart disease. That's how limiting (House Bill) 2292 is."
Joe Lovelace, executive director of the National Alliance for the Mentally Ill in Texas, acknowledges that some people will lose services, but he says the limits are necessary to ensure that those with the greatest needs get help.
"It's a rational rationing," said Lovelace, who got involved in mental health issues after his son was diagnosed with schizophrenia in 1988.
The legislation was an appropriate if difficult step to take, says Robert Black, a spokesman for Gov. Rick Perry. "2292 merged 11 state agencies into four, eliminated a lot of duplication and saved taxpayers dollars. With a $10 billion shortfall, legislators had to make some hard decisions."
For clients who get the ax, the Harris County Hospital District is the logical fallback. But it was stretched beyond capacity even before House Bill 2292 took effect.
Already Ben Taub and other emergency centers in the Texas Medical Center, including the NeuroPsychiatric Center, periodically go on diversion, too crowded to accept even the most critically ill patients.
"We will do everything we can, but we are not staffed and funded to provide adequate mental health care to everybody in Harris County," said Dr. John Burruss, chief of psychiatric services.
Those who call for outpatient treatment aren't denied outright. The waiting time is about three months. People wait, and often they cycle into crisis.
"They end up in the ER, they end up in jail, they end up dead," Burruss said.
Limited by the system
Bobby Harper had been homeless for much of his adult life when he moved to Houston in 1997. He would get a job, rent an apartment, buy a few appliances. Then he'd get fired.
Harper's fortunes changed when he met his wife-to-be, Deborah, in a church singles group. She suffered from severe depression, she told him, and she recognized his untreated symptoms. If he didn't take care of his own mental illness, they were finished.
Last year, at age 35, Harper sought help from the Safe Havens Transitional Living Center, an MHMRA facility for homeless, mentally ill men. He is stable now. He and Deborah are married, living in their own apartment and expecting a child. He would like to say all is well, love conquers all, but in their case, it hasn't.
Deborah can't work because of multiple health problems. She receives Social Security payments of $564 a month. He wants to work, but if he earns as much as $825 a month, Deborah loses her benefits. He can earn enough to jeopardize her income but not enough to pay for their living expenses, their health problems and a high-risk pregnancy.
"I'd feel better working," Harper said. "But the system penalizes me if I do."
Harper knows most people can't relate to him or his story. He's short, stout, and can't take care of himself very well. When he and his wife first learned she was pregnant, they were thrilled but also frightened. They didn't plan the pregnancy and they knew they couldn't afford to raise a child.
In the past few weeks, they've contacted an adoption agency.
"We're going to give up the baby," Harper said.
He knows most people don't understand chronic depression.
"You're depressed?" people ask him. "So am I."
He said, "I'm not talking about getting sad or a bad day. I'm talking about waking up and not wanting to live."
Harper is not an expert on House Bill 2292, but he knows it means even more budget cuts in the future, and the prospect terrifies him.
"I just can't be homeless again," he said.
jeannie.kever@chron.com
claudia.feldman@chron.com
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