They’re victims of car accidents, they’ve been shot, or they threatened their parents. They have overdosed on cocaine, swallowed too many pills or passed out drunk. On an average Friday or Saturday night, they can make up about half of the sick, injured and wounded crowding the rooms and hallways of the emergency department at Denver Health.
And there’s one trait these patients have in common, says Dr. Chris Colwell, director of the department. Had they received needed prior treatment, they might not be there at all.
These ER visitors, for all their outward signs of trauma, suffer foremost from mental illness.
“The emergency room could have been avoided if they had gotten psychiatric care anywhere else,” he says.
Colwell believes uncontrolled behavioral health problems were also at the root of two events that he experienced up close: The mass murders at Columbine High School in 1999 and in Aurora last year. He was a physician on the scene at Columbine and also treated patients from the Aurora shooting.
“For every one of those that were a big high-profile event that everybody knows about,” says Colwell, “there’s a hundred that were either near misses … or resulted in violence, just not to the same extent.”
As inpatient psychiatric beds have disappeared across the state, he’s watched the problem get worse.
“I don’t think people understand the crisis that we’re in,” he says.
An initiative put forward by Gov. John Hickenlooper in December 2012 – after the Aurora shooting in July – and signed into law earlier this year is intended to improve mental health services in the state by putting nearly $20 million into walk-in crisis centers and a state-wide hotline. The money is needed, say healthcare providers and advocates for the mentally ill, to ease pressure on emergency rooms and jails.
But many of the doctors and professionals working on the front lines of the crisis say the money isn’t enough to fill a yawning gap in services to prevent and treat mental illness. A look back across three decades shows that public-sector funding for mental health services in Colorado hasn’t kept up with demand. Per-capita spending on mental health services in the state, when adjusted by the medical rate of inflation, dropped 28 percent from 1981 to 1990, according to data collected by the National State Mental Health Program Directors Research Institute Inc., or NRI.
Federal budget cuts and an economic crisis in Colorado during the ‘80s conspired to suck funding from state psychiatric hospitals and community mental health centers. And cuts made in that decade were never recovered. In 2010, the state spent the equivalent of 20 percent less per person on mental health services than it did in 1981, according to NRI data.
The persistent funding shortfall long ago made jails and prisons the primary residential treatment centers for the mentally ill in Colorado, clogged emergency rooms, boosted medical expenses across the board, and expanded the ranks of the homeless on the streets of Denver and other cities.
Two national policy shifts and an oil shale bust were behind the drop in funding in the 1980s.
President Ronald Reagan took office at the start of the decade on a pledge to limit government spending. The Omnibus Budget Reconciliation Act of 1981 ranked among his first triumphs, cutting costs in part by transforming funding for mental health services into block grants to the states.
In Colorado, these grants didn’t keep up with rising costs.
Less than a year after this national legislation was passed, on May 2, 1982, Exxon pulled out of its oil shale operations in the Western Slope. Known as Black Sunday, the move foretold a massive bust in Colorado’s energy sector, triggering a recession and a decline in state tax revenue. Mental health services weren’t alone in suffering cutbacks – but the effects were stark.
The state budget crisis took hold just as a broader philosophical shift was transforming the way mental health services were provided across the country.
Legislation signed by President John F. Kennedy in 1963 had called for the funding of community mental health centers, and initiated a broader discussion about the role of large institutions in the treatment of those with mental illness.
Youlon Savage led the movement toward deinstitutionalization in Colorado, and was executive director of the first community mental health center in the state to be funded under Kennedy’s initiative. He says the movement into community-based care was intended to help reduce stigma and promote integration.
“Mental illness was no longer manifested by sending people away from home into large institutions,” says Savage.
Even the mental health hospital at Fort Logan was conceived as a community center when it opened in the 1960s. Staff didn’t wear uniforms, they worked closely in collaboration with patients who lived in a largely open and unlocked campus, and they made home visits to keep people out of the hospital.
But broad slashes to the two state psychiatric hospitals in the 1970s deeply impacted both Fort Logan and Pueblo. By 1980, there were 1,103 public psychiatric beds in Colorado, down from 1,609 a decade earlier.
Over the next decades, public beds would continue to disappear, and by 2013, the two state hospitals had only 545 beds. It wasn’t only the beds but the staffing and services that disappeared – services like home visits, community outreach and vocational training.
“Fort Logan used to do all the things that the community mental health centers are supposed to be doing,” says Rebecca Watt, a former nurse at the hospital who believes that budget cuts have damaged the facility’s ability to treat its patients.
The units for the elderly, children and teens at Fort Logan were among the most recent to close, in 2009. Recently, there were 38 people waiting for beds at Fort Logan and Pueblo, according to the Department of Human Services. The average wait time varies between eight and 25 days.
As the money moved out of the state hospitals, community mental health centers say they never got the funding they needed to take up the slack.
Harriet Hall, the chief executive of Jefferson Mental Health Center, says facilities like hers sometimes got a boost from the state when the hospitals’ budgets were cut. But often, they got nothing.
“It was never like, we’ll just transfer this money to the communities from the hospitals,” says Hall.
Hall and others who lead the state’s 17 non-profit community mental health centers say that with adequate funding they can provide much better services than the large institutions ever did – by giving the routine care people need to stay integrated within the community and out of costly hospital stays.
But, they say, there are gaps in the services they can realistically provide, given their tight budgets.
“There’s still kind of a dearth of options for folks who have genuinely long-term needs, and (whose illnesses are) a bit more severe than nursing home placement or return to home allows,” says Liz Hickman, who heads the Centennial Mental Health Center, which serves rural communities in northeastern Colorado.
What’s more, non-profit community mental health centers say state funding doesn’t provide for the treatment of those without some form of public or private insurance or other payment source. Randy Stith, who heads the Aurora Mental Health Center, says that leaves them with no choice but to tell indigent patients to go to the emergency room for care.
“We’re referring people to the emergency room off the streets pretty regularly,” says Stith. “It’s costly but that’s what you do.”
At Denver Health, Colwell describes having to board psychiatric patients in the emergency room. On a typical night, as many as 10 or 15 beds may be taken up by people who are waiting for psychiatric services, while the psychiatrists on staff at the hospital are overwhelmed with other cases.
Those who pose a risk to themselves or others may be admitted to the psychiatric emergency department.
Dr. Kimberly Nordstrom, the medical director of that department, says more and more of the patients she sees don’t have primary care providers. That often means that she can’t prescribe medications – with their uncertain side effects and tailored dosing needs – even to those who are very ill.
“I can’t start medicine with somebody who’s not going to be seen for six months,” Nordstrom explains.
Others, says Colwell, are at the brink of posing a risk to the community or themselves – but aren’t there yet.
“Once their physical problems are taken care of, we can’t keep them,” says Colwell.
But that doesn’t mean they won’t be coming back.
Mark Maseros used to be a repeat customer at the ER – when he wasn’t in jail for drugs or theft.
Now 54, Maseros spent three decades living homeless in Denver. Hooked on heroin that he took to self-medicate what he now recognizes as an anxiety disorder, he was taken to the emergency room after overdosing. Or he walked in with panic attacks.
“It was always good to go to the emergency room, because you’d get things to deal with your uncomfortableness,” says Maseros. “If I said the magic words that I wanted to kill myself, they’d set me up in a bed.”
Over the years, Maseros said he was diagnosed “bipolar, tripolar” and any number of other psychiatric disorders.
But he never got the sustained care he needed until four years ago, when the Colorado Coalition for the Homeless found housing for him, and he joined group therapy to help get the better of his anxiety.
“I’m happy now,” says Maseros, who does rounds through downtown Denver on his bike, looking for others who are suffering as he once did. Maseros tries to point people to the services that are available in the city. He knows that without help some of them will end up dead.
The president of the Colorado Coalition for the Homeless, John Parvensky, says there are many more like Maseros who want help but can’t get it. His organization stopped carrying a waiting list for mental health services when it reached 2,000 people.
Parvensky believes there is a straight line between the decrease in funding for mental health –and especially the decline in inpatient capacity – and the increase in homelessness in Colorado.
He estimates that around 40 percent of the adult homeless in the state suffer from serious mental illness – diagnoses like schizophrenia, bipolar disorder or severe depression that keep people from working and living in housing.
“We saw the biggest spike in homelessness in the 1980s,” says Parvensky, “and it really correlated to both the deinstitutionalization as the state closed down the mental health facilities, and the funding that was promised to provide community-based services … never materialized.”
Patrick Fox, a state Department of Human Services official who oversees the mental institutes at Fort Logan and Pueblo, says that additional mental health funding pledged by the state will work to alleviate pressure on emergency rooms and jails—and care for the Colorado’s most vulnerable populations where they are.
But Parvensky, who has watched the state’s homeless population more than triple since he joined the non-profit in 1985, believes the chronic underfunding will be tough to undo.
“It’s a down payment,” says Parvensky, “but unfortunately it’s a drop in the bucket compared to the need we’re seeing here in the metro Denver area and across the state.”