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Head Games As mental health services get cut further, the number of people in need grows By Joy Lanzendorfer About two years ago, Dave Thompson was diagnosed with clinical depression. His illness was so severe that doctors put him on three different kinds of medication and sent him to a hospital in Concord for treatment. When he was released, doctors told him about a two-week follow-up program at Kaiser Permanente in Santa Rosa that Thompson was eligible for, even though he had no money to pay for insurance. The idea was that Thompson would get needed therapy, medication, and help getting back on his feet as he made the transition from hospitalization back to the real world. But it didn't turn out that way. When he came to Santa Rosa, Thompson found that he wouldn't be receiving help from Kaiser after all. He says Kaiser told him that since his illness wasn't in an acute stage--he wasn't about to kill himself or someone else--his problems were not serious enough for medical care. Since then, he has been trying to get help from every healthcare source he can think of, but every provider he calls just tells him to call someone else instead. "I have been able to get zero help, period," he says. "It has been an uphill battle all the way. The only people who can really get help are the people with a pocket full of money and the best insurance." With no healthcare and no money, Thompson has ended up homeless. In the daytime, he hangs out at Interlink in Santa Rosa, a membership-operated community center for people suffering from disabling mental problems. At night, he tries to find somewhere, anywhere, to sleep. Though he has used drugs and alcohol in the past, he says he's not using now. He's just trying to get some help. "Walking down the street today, I thought about how hard this world is," he says. "It seems like everybody is just in it for themselves. It's a pretty cold world." Thompson's situation, though extreme, is part of a larger problem with Sonoma County's mental health system. As the healthcare crisis tries to dodge the slings and arrows of recall elections and budget debacles, mental health has fallen to the bottom of most people's priority lists. After all, in a state where dental care is becoming more of a luxury than a right for many, who has time to care about the health of the brain? But Sonoma County's mental healthcare is undergoing a crisis of its own. As a state system (which many feel wasn't meeting the mentally ill's needs before there ever was a budget crisis), it has already faced cuts and may see more next year. The problem is that the longer mental health needs go unmet, the more it costs the community as a whole. Heads Up If you're looking for mental healthcare in Sonoma County, you have a few options. One is to pay for care out-of-pocket. Another is to pay for good insurance that covers mental health. If those two things are out of your price range, you can try the Sonoma County Mental Health Division, though it only serves a narrow population, primarily low-income Medi-Cal patients and the most acute cases of mental illness. "We have very targeted services," says Cathy Geary, director of the Sonoma County Mental Health Division's health services. "We are not here to provide mental health services for everyone who needs them, but for a very small slice of the population." That small portion of patients are often the ones most in need of care. Funding for the Sonoma County Mental Health Division was tight even before the budget crisis. Mental health is primarily funded through something called Realignment, which was enacted in 1991 partially to protect mental health from the whims of the state budget and to provide a steady flow of funding. Realignment, a combination of sales tax and the vehicle license fee (also known as the car tax), is supposed to go only to certain social programs, including mental health. At first, it provided enough funding, but over time it has not kept up with population growth or the rising cost of medial care. Then the state budget crisis came along. This year, Sonoma County's Mental Health Division was forced to trim $3 million from its budget, which led to the closing of three mental health clinics in Guerneville, Petaluma, and Cloverdale. As a result, the 600 patients those clinics served, many of whom are severely mentally ill, no longer have easy access to care. They are now expected to find their way to Santa Rosa for treatment. "Tell me how long it takes to ride a bus from Guerneville to Santa Rosa, and then add to that being mentally ill and trying to negotiate the bus system," says Kristine Laroux Siebert from the National Alliance for the Mentally Ill, a support group for family members of the mentally ill. "The county has tried to arrange meetings in coffee shops with some patients to make up for the lack of clinics, but that isn't adequate." When one part of the mental healthcare system is stressed, it puts more pressure on other parts. For example, with the closing of the three mental health clinics in Sonoma County, Interlink has seen an increase of attendance in peer-to-peer counseling and has heard that many in-patient clinics don't have enough beds to meet the need. And, as Dave Thompson found out, cuts contribute to the lack of resources and make it hard for healthcare providers to accept anything but the most serious cases--and in time, perhaps not even that. But this year's cuts may not be the end of it. With Arnold Schwarzenegger taking Governor Davis's place in office, the fate of the mental health system is up in the air. Either way, the budget must be balanced. "We're worried that if we are cut again, we will lose ground in a time when needs are increasing and we will be unable to come anywhere near meeting those needs," says Patricia Ryan, executive director of the California Mental Health Directors Association, which represents California's 58 mental health directors. "Much of the budget is not discretionary, and mental health is one of the few programs that could be cut. So we are concerned about that, and we don't know where Schwarzenegger stands on the issue." Failing Grades As far as mental healthcare goes, California does consistently poorly. According to the California Health Foundation, our public mental health system manages to serve fewer than half the people with serious, disabling mental illness. And that's just the tip of the iceberg. Take a recent study by the RAND Corporation, a nonprofit organization based in Santa Monica that does research to help with policy and decision making. The study, published in the online magazine Pediatrics, compared access to mental healthcare for children ages six to 16 among 13 states. The study found that in California, the need for services was average compared to other states, but California was the worst of all the states in meeting those needs. In fact, of the children RAND surveyed, 80.6 percent of children who needed care were not receiving it in California (compared to an average of 6 percent of the children across the states). And those who did receive services were usually wealthy. The difference in care between California and other states is a more important factor in access than disparities between ethnic groups, according to RAND. In other words, whether or not a child lives in California or another state is more of a determinant of whether that child gets mental healthcare than whether or not that child is white. "In some ways, that's encouraging," says Jeanne Ringel, who co-authored the study. "Our hypothesis is that state policies and healthcare market conditions are a lot easier to change than, say, to change whether a Hispanic is less likely to access care than a white person. It's easier to make a difference in government compared to demographics of the population." There are few recent studies on the state of Sonoma County's mental healthcare. In 2001, 5,979 people in Sonoma County received services from the public mental health system. In 1998 the California Department of Health listed Sonoma County as the 13th highest in the state for the number of deaths from suicide and drugs. It listed an average of 72 suicides annually in 1995­1997, a higher per-capita rate than either Marin or San Francisco counties at the time. Since then, there seems to be little data on the subject. The Sonoma County Department of Public Health said that there were 8.3 suicides per 100,000 people in Sonoma County in 1998. By 2001, that had jumped to 8.6 suicides per 100,000 people. All this says very little about the state of Sonoma County's mental health. But anecdotally speaking, most professionals believe that Sonoma County's mental health is doing as well as other California counties. "My impression is that Sonoma County is probably right up there in the average with everyone else in terms of our general mental healthcare," says Rick Carson, head of mental health at Santa Rosa Memorial Hospital. "Of course, there are glaring deficits. Sonoma County has no program for treating children or adolescent in-patients. And we have no programs for the elderly mentally ill." Hell for Homeless RAND is not the only group pointing out flaws in California's mental healthcare. The National Coalition for the Homeless called California the "meanest" state and San Francisco the second "meanest" city in the nation when it comes to government services available to the homeless. That includes mental health services. The word "homeless" is a broad term that can be defined many ways. Of the entire population of homeless people, meaning people with no permanent dwelling under their control, only about 10 percent are estimated to have a mental illness, according to NCH. Substance abuse, the high cost of housing, the recession, and a host of other factors may have as much to do with homelessness as mental illnesses does. But when dealing with the category of people who primarily live on the streets or in shelters, the percentage of mental illness is much higher and the availability of mental healthcare becomes more of an issue. "Mental health does not cause homelessness," says David Whitehead, executive director of NCH. "But it does contribute to the situation. There needs to be a dramatic increase in the number of resources and facilities for people with mental health issues." In one count, the Sonoma County Task Force on the Homeless estimated 1,750 homeless people on the streets and shelters in Sonoma County, but the organization thinks the number is actually closer to somewhere between 5,000 and 8,000. No one knows whether that number is increasing or decreasing, though it seems likely with the rising housing rates that the situation must have gotten worse. "There's no question that the mental health's funding problems and the lack of services are affecting the homeless in Sonoma County," says Sonoma County Task Force on the Homeless executive director Georgia Berland. "The closing of those outlying mental health clinics have kept people from assistance. It's very disturbing." For people with mental illnesses, a lack of housing can aggravate mental illnesses. In addition, the stress of having no home can cause otherwise sane people to get disoriented. Not surprisingly, health officials say it is harder to treat people with mental illnesses when they don't even have something as basic as a roof over their heads. The mental health problem among the homeless may go back to deinstitutionalization of the late 1960s. Then-governor Ronald Reagan signed the Lanterman-Petris-Short Act in 1967, which was designed to protect the civil rights of the mentally ill by making it more difficult for them to be medicated or institutionalized against their will. The bill also emptied out the state's mental hospitals to save taxpayers money, a move that lead to an explosion of homelessness. When the mental hospitals were emptied, the state promised to still care for those patients. The intention was to replace institutionalized care with outpatient care, medication, and therapy. Many of the promises never materialized. "It's time for the state to live up to the promises made when deinstitutionalization happened," says Whitehead. "There are a number of programs that target the mental health of the homeless, but there needs to be more." Hole in the Head Of course, mental illness among the homeless is one of the most obvious kind of mental health issues. Who hasn't seen someone walking down the street muttering to themselves or been told a convoluted theory involving aliens and brain probes when riding a bus or sitting on a park bench? But many quieter mental illnesses take their toll on society as well. Depression, for example, is estimated to be the largest undiagnosed mental illness in the United States. Because depressed people are less likely to work productively, depression is actually thought to have an effect on the country's gross national product. It's that kind of immeasurable impact that makes mental illness an intriguing issue. It's estimated that one in five people have a diagnosable mental illness in the United States. In fact, professionals say that most families in the United States deal with some sort of mental illness. And yet, mental health is routinely pushed aside and ignored. Why? "Mental illness has a stigma attached to it," says Siebert. "It's the step-child of medicine. A lot of people even confuse the mentally ill with the mentally retarded, which is amazing to me." This stigma makes it harder for people to admit mental problems or seek help. It also makes it easier for people to dismiss the seriousness of some mental issues. The stigma also affects whether or not mental health gets funding and whether services are available. Ignoring mental illness can take a toll on society. Because the state requires emergency rooms to treat everyone who comes in, many people use them in place of usual doctor visits. These situations clog up emergency rooms, cost the hospitals a fortune, and contribute to long waits and lack of care. Cutting public services will only increase this problem, believes Carson. "The net effect of cutting public services is that people who would normally be served on an outpatient basis have fewer resources and end up in emergency," he says. "It's penny-wise, pound-foolish. It's treating people on an expensive, urgent basis instead of ongoing basis." Many mentally ill people also end up in jail. Since desperate people often do desperate things, and since there is no place to put them otherwise, many end up costing the state millions of dollars in legal fees. As many as one in five of the 2.1 million Americans in prison are seriously mentally ill, far outnumbering the number of mentally ill who are in mental hospitals, according to a recent study by Human Rights Watch. But beyond these societal costs is the human cost of allowing mental anguish to run rampant. "My perspective is that it is important for the whole community to pay attention to the needs of the mentally ill before they become too big and too visible," says Geary. "But we are slow to come to that as a people, as Californians, and as a whole country, for reasons I don't quite understand." [ North Bay | Metroactive Central | Archives ]