>Mental health professionals are beginning to weigh in concerning the very distinct possibility that the perpetrator of the assassination of a Federal District Judge and the attempted assassination of a member of the U.S. Congress, the killing of staff members, an innocent young girl, and the wounding of others, was seriously mentally disturbed. [MFDL] As noted yesterday, we don’t know as yet — indeed, we may never know precisely — what filled this fragile mind. However, we do know that among the most common targets for state budget cuts is funding for mental health services. It happened in Arizona, and it is happening in Nevada.
The consequences may be not always be nationally tragic, but for families and individuals trapped by the debilitation of mental diseases the results are always tragic. And not always addressed — as demonstrated by this commentary from a nurse: “Having spent many years of my life working in a locked psychiatric unit as a nurse, I can attest that the majority of our schizophrenic clients, though sometimes frightening, especially to those not familiar with the illness, were not dangerous. However, clients diagnosed with paranoid schizophrenia will sometimes act on their paranoid delusions. I have personally seen how difficult our mental health system can be to navigate. Family members would call me and beg for help, but help is available only under a very special set of circumstances. Sometimes people will seek treatment voluntarily, however, in order to commit a person involuntarily they have to meet certain criteria, either DTS (danger to self), DTO (danger to others) or GD(gravely disabled). The greater problem is that now it is very difficult to obtain any type of outpatient treatment, as insurance generally will not pay for it, or pay only a very small amount. Most people simply cannot afford any more to pay for mental health treatment.”
We know that Loughner appears to have some traits associated with mental illness, including confused and distorted thought patterns, implying his receptivity to conspiracy theories, both internally and externally derived. We may infer that he acted on these, which adds another layer to the overall diagnosis. Those who had contact with him at Pima Community College report that he was removed from a math class by a counselor and a police officer, was suspended, and later agreed to withdraw from school in October. [WaPo]
What help he might have sought, or what assistance might have been sought for him, have yet to be revealed publicly. However, it’s clear that obtaining mental health services is at least as difficult as the nurse-commenter referenced above. Google “state mental health budget cuts” and you’ll get at least 22,200,000 results. Mental health advocates in Texas are worried about the impact of decreased funding, [KHOU] advocates in Mississippi are worried as well, they may be facing cuts of 15%. [LaurelLdr] Mental health budgets have been slashed in Oklahoma. [KRMG] At the top of the list of NAMI’s Ten States Hurt by the Mental Health Budget cuts, is Arizona. Nevada stands 7th on that listing.
The motto of Arizona, “Ditas Deus” means “God Enriches,” but there hasn’t been much enrichment of the mental health services budget in the Grand Canyon State from human means, and the budget cuts have been significant. “The budget cuts passed July 1 have meant that seriously mentally ill people who do not meet state Title XIX requirements for reimbursable services started losing funding. The cuts meant that anyone who does not qualify for Medicaid also does not qualify for aid. Now, these people are state-sanctioned only for generic medication and some crisis services. Previously, seriously mentally ill patients were provided name-brand medication, therapeutic services and in extreme cases, housing.” [AzSnNws] (December 2010)
November 2010, the same mental health advocate wrote to the Capitol Times: “These people do not go away when state services are slashed. They do not disappear when we close our eyes. With the recent draconian budget cuts to behavioral health services, many of these good people can no longer receive the outreach and medication they so desperately need. What Arizona lawmakers failed to consider is that without ongoing care, some of these people are beginning to mentally deteriorate, costing the state far more in emergency services such as police intervention, hospitalization or even incarceration. In addition, doctors and law enforcement officers are forced to deal with an increased number of mental health crises in an already overloaded crisis response system.” These words now seem tragically prophetic.
It was not for lack of interest from the Executive Branch that behavioral services were slashed. Mental health services are high on the Governor Brewer’s priority list. She is well informed about the need for supporting these services from tragic personal experience. When she told agency heads to justify their programs in the face of budget cuts to mental health services, “What was not widely known is the level of her knowledge about Arizona’s mental health system: Her adult son, Ronald, now 47, has been a patient at the state hospital for 20 years after being found not guilty by reason of insanity in the 1989 sexual assault of a woman.” [SVH]
By April 2010, the Governor was looking at: Arizona’s Behavioral Health System “Responding to Budget Cuts” stakeholders’s information publication. (pdf) $16.4 million was proposed for “crisis services,” which may not be increased in future years, although agencies did expect costs would inflate; and in the face of the fact that 40% of those in need of “crisis services” do NOT have medical insurance policies or policies that cover mental health services.
AZ Central provides a summary of the cuts: The cuts that take effect July 1 include: (1) Case management. People with mental illnesses will lose access to case managers who help to coordinate their care among medical doctors, psychiatrists and the rest of their team. Case managers check in with patients regularly to help them navigate the often confusing mental-health bureaucracy. (2) Medication. Only generic medications will be available, a cause of concern for people such as Ferry who rely on a name-brand medication to treat their symptoms effectively. (3) Transportation. Clients no longer will be given rides to and from appointments with their doctors. (4) Housing. The state will no longer subsidize housing for those who are not Medicaid-eligible. The state says people who are in housing will be allowed to stay there until a “safe and appropriate” alternative is found, although officials may eventually set a date for eviction if funding runs out.
A family advocacy group ran the numbers concerning the impact on Arizona citizens: “17,000 seriously mentally ill adults face dramatic reductions in services if federal matching funds are not restored. (1) 4,200 children to lose behavioral health services leaving children and families with no where to turn. (2) 6,600 people losing substance abuse services — leaving families abandon to addictions and children in those families at greater risk, stuck in the child welfare system, or people jailed or deaths or more emergency rooms visits and 911 calls. This is both cost shifting to local governments and other people and business paying health insurance premiums. (3) 11,000 people getting general mental health services — except for some very limited medication and medication management services.”
Sadly, before Arizona faced this budget crisis, it was making improvements in its mental health services. In 2006 the state was rated a “D” in the quality and quantity of care delivered by the National Alliance for the Mentally Ill. Three years later it improved to a “C” grade. The lowest subcategory grade came in delivering good practices, emergency room wait times, and the quantity of psychiatric beds available, in this regard the state got a “D”. Financing and core treatment earned a “B.” Consumer and Family Empowerment earned the state another “B” in 2009, and Community Integration and Social Inclusion categories earned a “C.”
Before anyone in Nevada is tempted to pass judgment on Arizona’s situation in terms of mental and behavioral health services, we should note that in 2006 Nevada received a “D” grade from the National Alliance for the Mentally Ill, and the same “D” grade three years later in 2009. In health promotion and measurement terms (evidence based practices, emergency room waiting time, quantity of psychiatric beds) Nevada got an “F.” Nevada got a 45% “D” for financing, Medicaid reimbursements to providers to evidence based providers, and more; another “D” for measures such as consumer and family access to essential information from the state, promotion of consumer run programs, and family/peer education and support. There was another “F” for state support of activities requiring collaboration among state mental health agencies and other state agencies and systems. Among the “urgent needs” suggested by the NAMI: (1) restore inpatient staffing levels; (2) increased support for case management, medications, and therapy; and (3) increased resources for supportive housing options.
We’ve known about these problems since 2005. UNLV summarized trends that do not show Nevada’s mental health services base-line in a very positive light: “Although Nevada fares quite well in mental health spending on a per-consumer basis ($5 ,067 compared to $4 ,917 nationally), when mental health expenditures are spread across the entire state population, Nevada ranks below most of its neighbors and well below the national average ($59 per 1,000 in population versus $92 nationally). Nevada state agencies serve a smaller portion of resident consumers than the national average (11.7 consumers per 1,000 versus 18.6 nationally). The percentage of mental health consumers served in psychiatric hospitals significantly exceeds the national average. In fact, the proportion of Nevada consumers served in state psychiatric hospitals is more than twice as high as its neighbors and the U.S. as a whole (7.7% compared to 3% nationally). With respect to the provision of funding for community-based services, Nevada ranks below all of its neighboring states (Utah, Arizona , and California), one exception being Oregon, if we consider per client spending (see Appendix for detail) National comparative statistics are not available). As to percentages of consumers being served in their own neighborhoods, Nevada again reflects substantial disparity with most of its neighbors and with the United States as a whole (88% compared to 96%).”
Nevada’s response? Caught between the rocks on the road to improving mental health care services and the hard places in the state budget, the FY 10-11 proposed budget (pdf) includes a 6% reduction in salaries for state health and human services personnel, and the suspension of merit pay increases. Hospital inpatient rate reductions of 5% implemented in FY09 are continued to a total reduction of 10% by FY11. 17 positions left vacant in the Northern Nevada Mental Health budget in the FY09 budget are eliminated altogether in the FY10-11 budget, another 13 positions are eliminated in the Dini-Townshend hospital, 8 state positions related to service coordination, between or among, psychiatric rehabilitation medical clinic and psychiatric ambulatory services were eliminated. The Lakes Crossing Facility for Mental Offenders was reduced from 76 to 70 beds. 25 positions were eliminated from the Rural Clinics budget, and 8 such clinics would be closed. 126 positions are being eliminated in the Southern Nevada Mental Health budget as a result of revised (upwards) staffing ratios. 10 Mental Health Technician positions were cut at SNMH, and converted to contract labor.
Cuts to the Sierra Regional Center included the loss of 2.51 full time employees, reduced allocations to families using self directed care, a cap on self directed Autism support, and a reduction of 6 staff members for crisis intervention. The Rural Regional Center is scheduled to see cuts of $147,000 in self directed care programs, and another $270,000 reduction in residential support costs. The number of families who can receive assistance with Autistic dependents is capped at 21. [NVhhs pdf]
No one should suggest that there is a direct causal relationship between the re-allocation or redistribution of resources within a Health and Human Services budget and the dramatic tragedies that can occur when mentally ill individuals act upon their impulses, or take action based on their delusions. However, if we learn anything from the tragedy in Tucson, it must be that when we replace efficacious brand name medications with generics (even though the generic may be less effective) merely to save dollars, or when we reduce the number of beds available in institutions for the mentally ill, or when we reduce the number of staff members available to respond to crisis situations, or when we have wait-times of 30 days or more for psychiatric treatment, or when we increase the case-loads for those managing mentally ill individuals — then we are asking for trouble. The following paragraph should guide our future discussions:
“If any good is to come out of this horrifying event it must be for legislators on federal, state and local levels to undertake immediate in-depth hearings that lead to a definitive change of America’s laws for treating mental health patients. Insurance companies must be required to provide the same health benefits for mental disease as they do for all other illnesses so that patients can be properly treated. Legislators must publicly interview expert witnesses who deal on a daily basis with the overwhelmingly bureaucratic and legal obstacles in their efforts to try to help people with mental diseases. To this end, legislators must listen to family members, law enforcement, medical professionals and the National Alliance on Mental Illness (NAMI); these are the ones who know the solutions as well as the obstacles.” [HuffPo]
We can only hope…and pray for the victims of the senseless violence in Tucson.
Desert Beacon 
>This is chilling – but not surprising – information.Send a link to the new Gov.He doesn't seem to think the problems run as deep as all that.-maven