What Stops Intervention?
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Danielle Nordeen drives a 16-year-old Toyota Camry that doesn’t handle well on snowy mountain passes. In January, Nordeen had to make the drive from her home in Grand Junction to Pueblo often enough that she developed a strategy: Find a semi with its hazard lights on and follow it closely, prompting the other drivers to direct their wrath toward the trucker rather than her.
A 300-mile solo drive across the state in winter can be stressful under the best circumstances, but Nordeen’s reason for making the drive twice a week for three weeks was devastating: She was visiting her son in a psychiatric ward, after he lashed out at school and later threatened to kill himself and staff at a crisis-stabilization center.
Her son is seven.
Across the state, the same story plays out. A shortage of treatment options for people with mental illnesses means waiting months to see a psychiatrist, or driving hundreds of miles for a psychiatric bed. Police and emergency rooms bear the brunt of a splintered system that juggles crises, but falls short on treatment.
The questions that swirled after the brutal massacre at an Aurora movie theater in 2012 are the same ones that followed Jared Loughner’s attack on Gabrielle Giffords and her staff in 2011. They came even louder after the elementary school killings in Connecticut. They circulate privately after suicides. The signs of mental illness and the threats were apparent: Why didn’t anyone intervene?
Read other stories in our project "Untreated: How Ignoring Mental Illness Costs Us All"
Medical professionals and advocates cite a combination of barriers: Adults have the right to refuse intervention. Parents are often reluctant to call 911, when it can mean that their children are cuffed by police. Schools, employers and hospitals are too quick to say it’s not their problem. Acquaintances and friends feel ill-equipped to act.
“We regularly hear people say things like, ‘I knew something was wrong, but I didn’t know what to do,’” says Carl Clark, who heads the Mental Health Center of Denver, which counsels workplaces after suicides.
In response to the mass shooting in Aurora, the state recently passed a law that expands the duty of therapists to warn of threats against an institution like a school or theater, not just against a person. A plan for new crisis centers in Colorado—while stalled—is intended to relieve the burden on first responders.
Legal improvements, better education and increased capacity “don’t guarantee that bad things won’t happen,” says Clark. “But we’re going to decrease the likelihood it’s going to happen.”
Routine care can also be hard to come by, particularly in rural areas where psychiatrist shortages are acute.
“There are people saying there’s something going wrong and I have to get treatment,” says Clark. When treatment isn’t immediately available, “they throw up their hands and give up.”
For some people who live with mental illnesses and their families, efforts to make intervention easier can miss the point. They want help, they say. What they need is more support for treatment and recovery in the communities where they live.
Jennifer Hill, who manages a mental-health advocacy organization called the Colorado Mental Wellness Network and has personal experience with recovering from illness, says that recovery is stymied by a system that can seem to offer lock-up or nothing.
“You’re in or you’re out,” Hill says.
Better treatment requires more than an infusion of resources, and improved access, says Hill. People won’t sign up for treatment that isn’t therapeutic.
“It’s treating people with dignity and respect,” says Hill, “and not treating them like they’re dangerous and horrible people.”
The other second-graders have watched the police take Danielle Nordeen’s son away in handcuffs.
The latest crisis was set off when one of the other children reminded him of that very fact. The seven-year-old tore posters from the wall, kicked and hit the teachers, flooded the toilets. The Grand Junction elementary school went on lockdown.
Growing Pressure on Emergency Rooms
Growing demand for intensive mental-health treatment in the state and a decline in the supply of psychiatric beds have put added pressure on emergency rooms. In cases when patients pose a danger to themselves or others, ERs become the default holding place.But without the capacity to offer psychiatric treatment or support, these ER holds offer little therapeutic benefit to patients, and drain resources for other urgent care, doctors and health officials say.
No state agency or association tracks the number of emergency mental-health holds in ERs across Colorado, but it’s safe to say the number runs well into the thousands every year. Several of the state’s major hospital operators, including the non-profit Centura Health, which is Colorado’s largest hospital network, said they couldn’t provide the data for their own emergency rooms.An exception was HealthONE, part of the for-profit Hospital Corporation of America that runs several hospitals and emergency departments in the Denver area, including the Medical Center of Aurora, Rose Medical Center and Swedish Medical Center.In 2013, HealthONE emergency rooms had 2,600 mental health visits that resulted in mental-health holds because patients were a danger to themselves or others, or were gravely disabled. One in five was held in the ER for 24 hours or longer because no alternative was available.
Emergency rooms aren’t set up to offer patients long-term help. Just keeping patients secure can be a challenge. Occasionally, patients make a run for the door.In September, for example, a patient at Aurora Medical Center “was unable to clarify to the (physician’s assistant) that he was not a threat to others,” according to an incident report filed with the state. The patient was being read his rights when he bolted from the room, through three sets of doors, out of the emergency department and into the street. He hadn’t been found more than three weeks later, when the report was filed.
The state in March made an effort to crack down on the use of emergency rooms to hold patients against their will. The Office of Behavioral Health warned that facilities that aren’t specially designated to provide psychiatric services “would be in violation of state law and could face legal actions for civil liberty violations” if they house people in involuntary mental-health holds.
Dr. Patrick Fox, an official with the Colorado Department of Human Services, said the state was concerned that mental-health holds in emergency rooms weren’t being tracked. Undesignated hospitals and emergency rooms aren’t subject to audits or inspections that go along with involuntary treatment, Fox added.
The Colorado Hospital Association quickly objected, saying hospitals have an obligation to evaluate and stabilize patients placed on mental-health holds by police or doctors.
Gail Finley, the hospital association’s vice president of rural health, added that rural hospitals in particular often have no choice but to try to provide a safe place for patients.
“We have a shortage of mental health providers,” Finley said, and poor reimbursement for psychiatric services. “It leads to sort of a weak system in providing care.”
The state later rescinded its warning.
– Kristin Jones, Rocky Mountain PBS I-News
Nordeen showed up to find her boy rolling around in dirty water in the bathroom.
When a local crisis center placed him on an emergency psychiatric hold for his threats, only Parkview Hospital in Pueblo had a bed available. Nordeen works a low-wage job in Grand Junction, and had to return to work after leaving him there, or risk losing her apartment.
“I literally just felt like I was dropping him off and walking away,” says Nordeen, holding back tears, “which as a mom, that’s the hardest thing I’ve ever had to do.”
The number of people placed into involuntary mental-health treatment has jumped in recent years. Court filings show a 35 percent jump in 72-hour holds, short- and long-term certifications, and other court-ordered treatment between fiscal years 2009 and 2013. Mental health providers reported 31,317 emergency mental-health holds in fiscal year 2013, according to state officials, a 21 percent increase from just a year earlier.
But the growing demand for beds hasn’t been met by an increase in availability. Instead, the options for low-income Coloradans in particular have shrunk as beds at the two state psychiatric hospitals have closed. In 2014, the state mental health institutes at Fort Logan and Pueblo have 553 beds, down from 734 in 2000.
All told, there are only 1,093 inpatient psychiatric beds in all hospitals around the state, according to the state Department of Human Services, around 20 percent fewer than five years ago. That’s about 21 beds for every 100,000 Coloradans, among the worst rates in the U.S.
The state is in the process of evaluating what services might be lacking across its various regions. In part, says Dr. Patrick Fox, an official with human services, the hope is that private-sector psychiatric hospitals will meet some of the need. He gave the example of Clear View Behavioral Health, which broke ground in April on a 92-bed hospital east of Loveland expected to open in 2015.
For now, hospital administrators and family members describe large geographic swaths of scarcity. In Grand Junction, West Springs Hospital is the only psychiatric hospital between Salt Lake City and Denver. The hospital, which has 32 beds, opened in 2005, at the same time as neighboring St. Mary’s Hospital closed its inpatient psychiatric beds.
Like other private-sector hospitals across the state, St. Mary’s found that providing psychiatric services on top of other medical services was too costly. Even after closing its psychiatric department, the hospital absorbs about $300,000 in unreimbursed expenses each year related to providing mental-health services, says Dan Prinster, the hospital’s vice president for business development.
Now, West Springs finds that it’s often filled to capacity, and has to turn people away. Kim Boe, the hospital’s vice president, says the wait list generally hovers between six and eight people each day.
The vast majority of people with mental illnesses are not violent, but those who are receive more than their fair share of headlines and news broadcasts. The rate of violence among people with severe mental illnesses ranges from 8 percent for those receiving outpatient treatment to 37 percent among patients in the throes of their first episode of psychosis, according to a research review by Jeffrey Swanson, a Duke University psychiatry professor whose work on the issue is widely cited.
Ryan Conely / Rocky MountaIn PBS I-News
Some of the most significant mental health expenses in Colorado are largely due to untreated mental illness. Lost wages, preventable medical expenses and jail costs dwarf the $730 million the state spends on care, an investigation by Rocky Mountain PBS I-News and 9News has found.News
Suicide has a much closer tie with mental illness. More than 90 percent of those who take their own lives have depression or another mental disorder, or a substance abuse issue, according to one epidemiological study cited by the National Institute of Mental Health.
Much of the demand for psychiatric beds comes from people who pose a danger to themselves. The scarcity can make an already precarious situation even more traumatizing.
Grand Junction resident Rebecca Edwards has had a long history of mental illness, including depression, and has been through the whole gamut of available care. After she was administered electro-convulsive therapy a few years ago at Porter Hospital, she didn’t recognize the symptoms of a stroke that permanently affected her speech. She thought she was experiencing the side effects of shock therapy.
Edwards says she’s grateful for the mental health treatment that has allowed her to live in the community, supported by her peers. But when the stress of moving to an assisted-living situation in July sent her into a deep depression, she needed more intensive treatment.
What she got instead was a disorienting ride across the mountains with strangers in the middle of the night. Placed in an involuntary mental-health hold because she was suicidal, Edwards was handcuffed. She landed at a hospital in Colorado Springs.
“I felt very afraid, very alone,” says Edwards. “When you get taken away from that support, it’s hard to deal with. It made me feel a lot more hopeless, like I was alone in my struggle with depression.”
Boarding in the emergency room
If people at the receiving end of flawed mental-health services feel frustrated, it’s a feeling often shared by those at the giving end.
Matt Skwiot is an emergency room doctor at Grand River Hospital in Rifle, an oil and gas town between Glenwood Springs and Grand Junction with a population of under 10,000. He sees workers injured by explosions, car accident victims, elderly people with broken hips.
And like other ERs, this one has become a holding pen for people in a psychiatric crisis.
Joe Mahoney / Rocky Mountain PBS I-News
Dr. Samuel Deloera prepares an intravenous solution for a patient with abdominal pain at the emergency department of Grand River Medical Center in Rifle, Colo., on Sunday, April 23, 2014. Unlike patients with strictly medical issues, emergency room patients experiencing a mental health crisis face a shortage of treatment options, and drain staff resources. (Joe Mahoney/Rocky Mountain PBS I-News)News
About once a week at Grand River Hospital, there’s just no psychiatric facility available to take a patient. So a room in the ER is cleared of equipment with cords and other tools that could be used in a suicide attempt. Security is called, and a camera is monitored.
For as long as three days, the patients are kept alone in the room. None see a psychiatrist, says Skwiot. And then, once they’re stable, they’re sent home.
“You’re trying to provide a safe place, you’re trying to provide the best care that you can,” says Skwiot. But ER doctors don’t have the training or skills to give people the therapy and other support they need.
“If it was me locked up in this room for 72 hours, with minimal interaction, minimal stimulation, I’m already depressed and suicidal, that seems like it … would make things worse,” Skwiot says.
Before the violence
On a sunny Monday in April two months after he came back from the hospital in Pueblo, Nordeen was playing with her son at a park behind their home. The gap-toothed kid was affectionate and energetic, alternately asking for and receiving hugs from his mom, and shouting captain’s orders in a game of pirates.
Things were calm and happy. But Nordeen felt like the family was in a holding pattern. Her son was out of school, with a psychiatrist’s note saying that school’s stresses would be too much for him. Nordeen was apprehensive about sending him back, and worried about the future.
“What’s scary,” says Nordeen, “is that who’s to say he’s not going to be one of those kids that follows through on his threats?”
Echoing complaints of people in similar situations, she says she can’t find the support she needs.
“I almost feel like I’ve exhausted every option in Grand Junction,” says Nordeen. “Because there’s not a lot of options available.”
Joe Mahoney / Rocky Mountain PBS I-News
Danielle Nordeen, right, plays a board game with her seven-year-old son at their Grand Junction, Colo., home on Monday afternoon, April 14, 2014. In January, Nordeen's son was sent to a psychiatric ward hundreds of miles from their home, after he lashed out at school and later threatened to kill himself and staff at a crisis-stabilization center. A shortage of treatment options for people with mental illnesses means waiting months to see a psychiatrist, or driving across the state for a psychiatric bed.(Photo by Joe Mahoney/Rocky Rocky Mountain PBS I-News)News
Community-based mental health treatment and support is chronically underfunded, mental health advocates say. An analysis by Rocky Mountain PBS I-News found that overall funding for mental health in the state hasn’t kept up with inflation since the 1980s. A well-intentioned push to remove people from institutionalized care led to the closing of state psychiatric hospitals beds, but equal attention was never given to building a replacement.
As a result, community mental health services continue to defer to first responders and emergency services when the threat of violence looms.
In Colorado Springs, the mother of Anthony Martinez says she has struggled for years to help their son get adequate treatment for schizophrenia. When he’s stable, Martinez, 34, is good-natured and loving. When he’s not, he can be violent. He’s been in and out of the state hospital in Pueblo, and sometimes jail, for years.
In August, Martinez was released from the state psychiatric hospital to live with his mother, along with his sister, her husband and their two young children. The family was told that no other place—including group homes—would take him.
The state hospital said they couldn’t discuss a patient’s case, said Dan Drayer, spokesman for the state Department of Human Services. He said that Martinez was not available for an interview.
In November, the family called 911 after Martinez threatened a family friend. When he returned home, they consulted with a community mental health center, expressing fears about their safety.
They were told to call the police again if they felt unsafe.
By January, Martinez was holding a large kitchen knife up to his mother’s face, threatening to kill her. With coaxing, Martinez laid down his knife, and was taken back to the state hospital.
The experience left Martinez’s mother, Patty Blakney, shaken and angry that her son had been discharged from the hospital while he was still unstable.
“I’m scared to have him living with me,” she says. “I’m not saying cage him. But what would help us would be a place where he’s going to live, where he’s not going to hurt someone, where they’re making sure he’s on his medication.”
They haven’t found it yet.