Fellowship Story Showcase
Mental health care breaking down in Stanislaus County
Seven years after voters passed Proposition 63 -- the landmark legislation that was supposed to radically improve mental health care in the state -- California is facing a deepening statewide mental health crisis. As the state struggles under the weight of a lingering recession and an enormous deficit, county mental health programs are often failing to provide care for even the sickest patients. In many cases, the minimal safety net that used to exist is disintegrating.
In the absence of care, many people with mental illnesses are instead cycling in and out of jails and emergency rooms. They are receiving treatment patched together by primary care providers.
This series describes why these cuts are occurring and how they are impacting people with serious mental illness and their families. Articles in the series writen by Jocelyn Wiener include:
Part 1: Mental health care breaking down in Stanislaus County
Part 2: A family's never-ending cycle
Part 4: A shining light in Modesto
MODESTO -- They appear here after every other door has been shut on them. Some are haunted by multiple voices or schizophrenia, others paralyzed by anxiety and depression.
Inside this simply furnished room at the Stanislaus County chapter office of the National Alliance on Mental Illness, sick people with nowhere else to turn and their worried family members struggle to help one another navigate a shrinking mental health safety net.
In recent years, a faltering local economy has combined with ongoing state and county budget cuts to significantly reduce the county's ability to treat adults with mental illnesses, a trend reflected around California.
In four years, the county department of Behavioral Health and Recovery Services, which oversees mental health services, has lost more than 200 positions, some 37 percent of its staff. In 2003-04, the department was able to serve nearly 13,000 county residents. Today, that number has dropped closer to 9,000, but the need almost certainly has grown.
"It clearly is difficult to find services for them. There's no doubt about that, even if they'reseriously mentally ill," said Madelyn Schlaepfer, the department's director and herself a psychologist.
Schlaepfer notes that some of the decrease in staffing and patients served reflects the county's sale of the behavioral health center, an inpatient psychiatric facility, to Tenet Healthcare in 2007.
Joyce Plis, executive director of NAMI Stanislaus, says she scrambles to help families dealing with mental illness find psychiatric services, therapy or free medication programs. But after years of deep cuts to county mental health services, she doesn't always know what to suggest.
"It's almost impossible to send people someplace," she said.
Plis became NAMI's secretary after retiring from her job as an administrative assistant at Lawrence Livermore National Laboratory in 2002. She was elected executive director last year. Her son was diagnosed with schizophrenia 26 years ago, at the age of 20. Four years ago, he was taken to the behavioral health center after going off his medication and throwing items in his board and care home, she said. If the same thing happened today, she believes the shortage of services means he'd be taken to jail.
Increase in mentally ill inmates
She says she sees more and sicker people in NAMI's offices now than she did before the economic downturn and budget cuts began. She knows of several people who have ended up incarcerated for months, or even committed suicide, because they couldn't find adequate help. Others end up homeless or cycling in and out of local emergency rooms, she said.
According to Sheriff's Department data, the numbers of mentally ill inmates in the county jail increased nearly 50 percent between 2007 and 2011. During the same time period, at the emergency room of Emanuel Medical Center in Turlock, admissions of patients with a psychosis diagnosis more than doubled.
Back in 2004, California voters approved a ballot measure, the Mental Health Services Act, which levied a 1 percent tax on millionaires to fund innovative programs for the state's mentally ill. Stanislaus County officials say the funding has allowed them to institute several innovative programs in recent years. But, as funding for basic mental health services has eroded at the same time, officials here and elsewhere say the law is the only thing keeping many county mental health departments from devastation.
"Overall, it's the worst it's been in the 25 years I've been doing this," said Rusty Selix, executive director of the Mental Health Association in California and one of the act's authors.
Selix is guardedly optimistic that years of cuts may finally be coming to an end and notes that services should soon begin to expand, if federal health reform is not overturned. Until then, he says, the situation remains dire, particularly for adults who don't have Medi-Cal, the government insurance program for the poor.
Currently, the state is significantly reorganizing mental health care services — doing away with the state Department of Mental Health, and giving counties more responsibility for care and more money to pay for it. Selix and many advocates and local officials worry that it won't come with adequate oversight and funding.
Clinics closed, patient rolls cut
In Stanislaus County, the Department of Mental Health's budget has dropped $18.5 million in the past five years, about 21 percent. The county closed three out of five mental health clinics in 2006, and scoured its caseload, removing 365 of the more stable patients from its rolls. A few years later, state budget cuts cost the department more than $3 million for programs serving the homeless mentally ill.
Although the magnitude of funding shortfalls varies by county, similar access problems exist in many counties, especially for uninsured single, childless adults.
From 2009 to 2012, California has reduced its mental health budget by $765 million, more than a fifth, according to a report by the National Alliance on Mental Illness. Revenues from sales taxes and vehicle license fees, which help fund county mental health departments, have fallen as a result of the economic downturn. Meanwhile, those same departments have had to shoulder growing expenses for special education and Medi-Cal recipients. That's left even less funding to treat the uninsured.
The pain has been felt particularly acutely in parts of the Central Valley, where high foreclosure rates have reduced property tax revenues, slamming county general funds at the same time the percentage of uninsured residents has increased. As of the 2010 census, a quarter of county residents between the ages of 18 and 64 were uninsured.
Fresno County's mental health department has lost nearly 40 percent of its staff since 2005, including a stunning 71 percent of its staff in adult mental health services. Sacramento County eliminated 50 out of 100 beds and closed the crisis stabilization unit of its mental health treatment center in 2009, after the mental health department lost $35 million in funding over two years. Much of that funding has since been replaced.
Locally, the cuts to mental health services hurt all the more because Stanislaus County long has been regarded as a statewide leader in the field, known for its collaborative nature, strong leadership and innovative approaches to treating people with mental illness.
Raising the bar for service
As services have diminished, the bar for how sick someone must be before he or she can get care has lifted higher and higher.
Dr. Del Morris, medical director for the county Health Services Agency, says his department is treating many uninsured patients with serious mental illnesses who are no longer eligible for nonemergency care at the Department of Mental Health. Although Morris' department is required by law to help the uninsured, no such mandate exists for county mental health. That department is legally required to help people with Medi-Cal, but can now serve uninsured adults only in crisis and emergency situations, or through a few programs funded by the Mental Health Services Act.
Morris describes one patient from his primary care practice, a woman in her 40s who tried to light her neighbor on fire. The neighbor fled after the attack, so authorities determined that the patient no longer posed an immediate danger to anyone. Because she was uninsured, Morris was unable to find a psychiatrist who would see her. He treated her as best he could.
"We've pushed the envelope many times because we don't have any other thing to do for the patient," he said.
Marie Lopez said she first sought care from the county a decade ago, after the voices in her head began robbing her of sleep and telling her horrible lies about her family.
Because she fears the stigma related to her schizophrenia, she asked that The Bee use only her middle and last names to identify her.
Lopez said that, back in 2000, the county provided weekly visits with a psychiatrist and free samples of medication. But when the voices came back in October 2010, the county turned her away, she said. She started walking outside in her pajamas, eating flower petals and talking to angels. Eventually, neighbors called police to report that she was ransacking her house. Police brought her to the behavioral health center.
"I was just doing anything and everything and no one would help me," she said.
"It's beyond frustrating," said Susan de Souza, a NAMI volunteer who herself has bipolar disorder and is uninsured. "You just sit there and say to yourself, 'Where do I go now?' "
The 'in betweens'
De Souza, 43, said she chooses to speak out despite pervasive stigma that continues to exist around mental illness. She said she got tired of seeing the looks on people's faces change when she would tell them about her diagnosis, and, like many of her counterparts at NAMI, has decided to use her own story to educate others.
De Souza calls people like herself the "in betweens," not sick enough to be eligible for public help, too poor to afford insurance on their own. She tries to help others in their search for services, pointing them toward pharmaceutical company programs that offer medications for free.
She said she held various jobs — in a group home, elementary schools and a parking enforcement agency — after she was diagnosed with bipolar disorder 12 years ago.
She stopped working six years ago, after her illness made it too hard to concentrate.
Her husband is insured through work. Because he is on disability, de Souza says the family survives on $28,000 a year and can't afford $500 a month to insure her.
Turned away by the county and other providers, she saves up to see a primary care physician occasionally. If she feels herself slipping, she adjusts her medication.
"From a desperation standpoint," she said, "you do what you have to do."
Safety net clinics bridge the gap
As county services have been stripped away and the ranks of the uninsured have swelled, police officers and emergency room doctors have become de facto mental health crisis workers.
Those deemed sick enough to be transferred to Doctors Behavioral Health Center find few options for follow-up care upon their release. Dr. Tony Vartan, the center's administrator, said most uninsured patients are referred to low-cost clinics such as Golden Valley Health Centers or Aspen Family Medical Group.
"If the person has no coverage, no resources at all, then we have to be very creative in finding something," he said.
Such safety net clinics are trying to bridge the widening gaps in care. Elizabeth Morrison, Golden Valley's director of behavioral health, says the network of clinics has expanded its mental health services to respond to growing need, using revenues from their Medi-Cal caseload to bring in two psychiatrists, 10 therapists, a case manager and an addiction specialist to work alongside their primary care physicians.
Morrison says co-pays for doctor's visits, which start at $30, can be unaffordable for some. But Plis says the bigger complaint is wait times. People with mental illnesses can wait months to be seen at a clinic, she said. Morrison says the average wait time to see a psychiatrist for a nonurgent condition has consistently been about four weeks.
Plis refers most uninsured patients to Aspen Family Medical Group, which will see patients the same day and treats those with mental illness for free.
"There's a dramatic need. And somebody has to do it," said Matt Freitas, a nurse practitioner who founded Aspen two decades ago.
On a rainy Wednesday evening last month, Plis held a family support group in NAMI's "Possibilities" room. Because of an e-mail glitch, the normal reminder about the group hadn't gotten out, so instead of the typical eight to 15 people in attendance, just two family members showed up. After reading aloud NAMI's rules and principles — "We will see the individual first, not the illness" — Plis fielded questions. They talked about seeing their loved ones' suicide notes on Facebook, the stigma of taking mental health medication and the stresses of caregiving.
"Is it always so exhausting?" asked one woman. Plis assured her it was.
Another woman told Plis her adult son has bipolar disorder and is uninsured. In addition to paying for his medications, she and her husband shell out $190 for every doctor's visit, she said.
Every time she pulls up to a stoplight and sees someone holding a cardboard sign soliciting help, the woman said, she thinks: "If something happens to us, that's going to be him."
Bee staff writer Ken Carlson contributed to this report.
This article was originially published by The Modesto Bee.