Gaps in mental health care in Texas lead to jail time for many people with mental illnesses

From the San Antonio Express:

The call came at 3 a.m., waking Anne Holliday (pictured) from a deep sleep.

It was her son Micah, calling from his apartment, panicked. He was standing in the middle of his living room, naked because he thought his clothes were filthy. He had suffered from severe obsessive-compulsive disorder since he was 11, scrubbing his skin until it was raw.

As an adult, his illness had morphed into bipolar disorder, which had him careening between states of deep depression and violent agitation. He punched holes in the wall.

He was reaching out to his mother for help. Again.

Holliday's story is repeated countless times across San Antonio, as family members of those with serious mental illness confront what experts call the “revolving door” of mental health care — periods when their loved ones are stable, on medication, followed by periods when they go off the pills that help them, only to face repeated hospitalizations or, worse, run-ins with the law.

The case of Otty Sanchez — a schizophrenic woman with postpartum psychosis accused of killing her 4-week-old son last week — has made many in San Antonio aware of how easy it is for someone with severe mental illness to fall through cracks in the local mental health system.

Sanchez had sought help a week before the slaying, checking herself into a hospital after hearing voices. But she soon checked herself out, something she could do because she'd entered the facility voluntarily, as opposed to an involuntary commitment.

In the hours before she is alleged to have decapitated the baby at a North Side home, her erratic behavior around the child caught the attention of relatives and sheriff's deputies, but she never was detained because her behavior, though odd, was not deemed violent.

Mental health experts express outrage that more isn't done to force mentally ill people into treatment that might prevent such tragedies as the Sanchez case from happening.

“The only way a family can get relief is for their son or daughter to commit a serious felony, where the legal system can have a legal hold on them for the remainder of their sentence — put them in a halfway house or forensic outpatient program,” said Dr. Roberto Jimenez, clinical professor of psychiatry at the University of Texas Health Science Center at San Antonio. “But the majority of mentally ill people only commit misdemeanors and they just drift.”

Nor, he added, can mentally ill people be compelled to take their medication, except in rare court-ordered circumstances.

The Sanchez case plays out in a state where the mental health system is seriously stressed — chiefly because of lack of money.

Texas ranks 49th out of the 50 states when it comes to per-capita funding for mental health services. The National Alliance on Mental Illness each year issues a report card delineating how states do in mental health care, and in 2008 Texas earned an ignominious D.

The Center for Health Care Services, the crisis portal that seeks to serve people like Sanchez, is dramatically underfunded.

“Right now, we're serving way over 1,000 people than what we get funded for,” says the center's CEO, Leon Evans. “That causes us to stretch so far I really get concerned about the quality.”

From experience, Holliday knew what to do when her son called.

“I got him into my car and he just started freaking out,” she said. “I drove to the police station, thinking they would help me get him to a hospital, but they tried to put him in the back of a police car. He was like a frightened cat, screaming, ‘Please! Please! I can't! It's contaminated!' They put him in the car anyway. He kicked out the back windows.”

The episode with the police would be replayed on a subsequent day, with Micah again kicking out the windows and being taken to jail, this time on a felony charge. In jail, Micah's illness only grew worse, and he would call his mother, sobbing, saying he was hearing voices.

Before his contact with the police, he had been in and out of the hospital, including the state hospital, where he would stabilize for a short time on medication. But once back home, he would quit taking the pills that helped him and revert to florid psychosis.

For five months Micah, 24, sat in jail, his condition worsening. Finally, he was released; at a hearing he was given deferred adjudication and probation, the terms of which his mother knew he couldn't satisfy. Within weeks, he was threatening suicide.

By pulling some strings, Holliday got him admitted to the adult probation office's Mental Illness Offenders Facility, or MIOF, a 60-bed, locked facility where sick inmates receive psychiatric treatment.

He sounds haunted on the telephone.

“I don't know what's going to happen to him,” says Holliday, who has cancer and a dim prognosis. She weeps as she speaks. “He keeps saying when he gets out he's going to kill himself. I don't know what will happen to him if I'm not around. I'm so afraid he's going to screw up and then they'll send him to prison.”

The revolving door plays out like this: a person with major depression, schizophrenia or bipolar disorder gets sick enough to require hospitalization. Either voluntarily or involuntarily, they enter an inpatient psychiatric facility, a private one or the state hospital, where they are stabilized on medication.

Usually after a short stay — insurance generally doesn't cover many days — they are discharged. A percentage of mentally ill patients, once better, stop taking the medication, thinking they don't need it, don't like the side effects or believe it's “poison,” as one father put it.

Their symptoms return and, in due time, they are readmitted to the hospital — or end up in jail, like Micah and Sanchez. The criminal justice system now is the largest provider of mental health care to the mentally ill, a job it was never intended to do, say advocates.

Despite the stigma, mental illness is common. Some 60 million people in the country have a diagnosable mental disease.

The ramifications of mentally ill people stopping their medication are serious: Like Sanchez, they can hurt themselves or someone else, although most aren't violent and are more likely to become victims.

But this vicious cycle is aided and abetted by current law, which experts say hasn't kept pace with science regarding the treatment of mental illness.

A person with mental illness by law cannot be forced to take medication, unless a one-year “order to compel” is issued by a judge — something rarely done because it's so difficult, say experts. And about the only time someone can be voluntarily admitted or involuntarily committed to a psychiatric hospital is if they are an imminent danger to themselves or someone else or are severely psychotic.

Advocates disagree with civil rights lawyers who declare that the mentally ill have a fundamental right to refuse medication: How can you make such decisions when your brain is sick?

Complicating this picture is a mental health care delivery system that is focused on crisis intervention, as opposed to providing care to the mentally ill over the long haul, something that would help keep them on their medications and out of the revolving door.

Long-term care is available to only the few who can pay the high price, said Ed Dickey, president of the local chapter of the National Alliance on Mental Illness.

“There are numerous obstacles,” he said. “Our insurance and state-funded mental health medical care emphasizes crisis treatment only. We have not evolved as a people to understand the value of preventive care.

“That to me is the core of the problem. We intervene only after people have declined into crisis, which means even higher dollars required for stabilization. We're misspending our dollars and are resources are being misused.”

That said, he added, crisis management is neither wrong nor ineffective.

But early detection and diagnosis is a key to helping people stay on their medication, he said.

You can't expect someone in the throes of deep psychosis, years after they've been sick, to understand they need their pills, he said. Education and long-term nurturing are required, not day programs that simply “warehouse” the mentally ill — the current arrangement, except in a minority of cases.

Additionally, under President George W. Bush, money that went to fund case managers — professionals who make sure mentally ill individuals get the help they need to avoid crisis — was eliminated, the center's Evans said.

“Individuals are left on their own, or families and loved ones are left to do case management, which is a totally unreasonable thing,” Dickey said.

Steps have been taken to improve the system: In 2007, the Texas Legislature granted $82 million to redesign mental health and substance-abuse crisis services — but, again, that focuses only on acute situations.

The news isn't all bad. Bexar County has been held up as a national model for its award-winning diversion program, which transfers mentally ill inmates out of jail and into treatment programs. It has police officers from all branches specially trained to intervene with the mentally ill. The various mental health institutions and programs here have worked hard to collaborate with families and advocates to provide the best care.

But even the crisis systems are stretched. The Center for Health Care Services, which provides an array of mental health and substance abuse care to adults and children, most of whom lack insurance, is the single portal for admittance into the San Antonio State Hospital. Compared with other states, Texas has a low number of state hospital beds.

Last year the center, one of 39 mental health care authorities in Texas, served 30,000 people, mostly low-income and most on an outpatient basis. Its funding ranks at the bottom of the barrel — since no new money has been allocated by the state to the city despite burgeoning population growth.

“We could do almost everything better,” Evans said. If you're not in crisis, it can take four to six weeks to see a doctor at the center, he said. His staff does the best it can to stabilize people, then refer them to mental health providers in the community.

“But there's really not enough out there for them once they're stable,” he admitted.

Texas spends $338 million a year for mental health services. The most recent legislative session saw $55 million in “new money” directed toward post-crisis and intensive ongoing services for the mentally ill. But Dickey said he's not holding his breath.

“I need to see the details,” he said. “I'm not going to badmouth it, but in the past when the details start rolling down and you find out what it will actually pay for and how it will be applied, we are often disappointed.”

A handful of programs in San Antonio seek to provide long-term outpatient care for the mentally ill.

A new one is the psychiatric nurse program of Patience Home Health Care. Each week, Susie Calderon, a nurse for almost 30 years, visits the homes of chronically mentally ill people, most of whom are on Medicare.

On a recent sweltering weekday she knocked on the door of Liza Delgado's apartment, which she shares with another woman at the Villa del Oro assisted living facility on the North Side. It took Delgado 10 years to get in; that's how long the waiting list was.

Much of what Calderon does involves observation — does a patient seem manic or depressed? The goal is to pick up on symptoms early, before they get bad enough to warrant hospitalization. If a patient is in a crisis, Calderon will call the police and have him or her taken to a hospital. If he or she is having problems with medication or less serious problems, she'll intervene by calling the doctor. She acts as a kind of sounding board for issues the patient may be having.

“She just makes me feel better,” says Delgado, a schizophrenic with a history of repeat hospitalizations. “She's someone I can tell my problems to. She asks me questions.”