After closing three-quarters of Michigan’s 16 state psychiatric hospitals by 2003, the state put the task of caring for the mentally ill firmly — and appropriately — on the backs of Community Mental Health agencies. With hospital stays costing more than $800 a day, treating mental illness in the community is less expensive, more humane and in many cases more effective than hospital care, especially with advances in psychotropic medications and therapy.
But Michigan’s 46 Community Mental Health agencies, serving nearly 200,000 people a year, have struggled, and often failed, to fulfill the mission they were charged with, partly because they never received promised resources. The rapid and largely unplanned closures of a dozen state psychiatric hospitals between 1987 and 2003 left the community system overwhelmed by the increased demand for services, but money, which champions of deinstitutionalization promised would follow patients into locally operated care, never materialized. In fact, mental health spending failed to keep pace even with inflation.
Ten of the 12 hospital closures came during the tenure of former Gov. John Engler and his mental health and community health director, James Haveman. Gov. Rick Snyder has just tapped Haveman to reassume that post, an appointment that raises troubling questions about the direction of mental health care in Michigan.
CRIMINAL NEGLIGENCE: An unjust system for Michigan’s mentally ill
Over the last two decades, changes in state policy and funding cuts have pushed tens of thousands of mentally ill people into county jails, state prisons, homeless shelters and hospital emergency rooms. More than half of the 500,000 seriously mentally ill people in Michigan don’t get publicly funded mental health services. To make matters worse, Michigan is one of just seven states that lack mental health insurance parity laws, so the private sector can’t fill the gaps in the public mental health system.
Too few mental care beds
Michigan needs an adequately funded and more efficient Community Mental Health system. The state also needs sufficient psychiatric hospital beds to serve its most severely mentally ill patients. Even so, Michigan now provides the fourth-lowest number of public psychiatric beds, per-capita, in the nation, with about six beds for every 100,000 people, according to the Treatment Advocacy Center.
TAC, a nonprofit advocacy group, recommends a minimum of 50 public psychiatric hospital beds per 100,000 people. Meeting that minimal level would require adding about 5,000 beds in Michigan, which currently has fewer than 700. Michigan mental health experts and advocates have recommended a system that includes at least 1,500 beds across the state.
The movement to shift patients from hospitals to community-based treatment started in the 1960s. A legitimate debate continues over deinstitutionalization and how to balance institutional with community mental health care. Too often, however, deinstitutionalization is a misleading euphemism for shifting mentally ill patients from one kind of institution to another — specifically, county jails and state prisons, where at least 20% of the inmates are severely mentally ill.
“Community care is the dominant form of treatment — and should be,” said Mark Reinstein, president of the Mental Health Association in Michigan. “But the pendulum in our state has swung so far in that direction that we’ve lost our balance.”
At the very least, Michigan ought to impose a moratorium on eliminating more psychiatric beds while it considers whether more are needed. Local Community Mental Health agencies also need enough money to pay for hospital care when needed. Without it, many mentally ill people will continue to relapse and recycle through the system.
Michigan’s 46 Community Mental Health agencies, whether they are semi-independent authorities or county-run, must also operate more efficiently. With today’s technology, these agencies would better serve consumers, and taxpayers, by consolidating into fewer administrative units with more stringent statewide standards and stronger financial support.
To identify and treat high-priority cases, Community Mental Health agencies need a standard, statewide definition for what constitutes the most severe forms of mental illness and emotional disorders. A mental health commission under former Gov. Jennifer Granholm found that perhaps one out of every three clients in the Community Mental Health system does not meet the federal definition of a “serious” illness or disorder. A more uniform, central system would enable the state to better target scarce resources.
To be sure, there is no single right number for how many Community Mental Health agencies the state should have — or how many state psychiatric beds it ought to operate. Some of the experts serving on Granholm’s mental health study recommended reducing the number of Community Mental Health agencies from 46 to 18. A former state Senate bill also called for 18 agencies. It’s a good starting point for a debate on reorganizing the system.
More state control over a smaller number of CMH programs should increase accountability. Under a more centralized system, local recipient rights offices — which, in effect, serve as a watchdog on mental health practices — would report to the state rather than the Community Mental Health agencies that run them.
Finally, the state must adequately fund local Community Mental Health agencies, which today reach less than half of the people who need their services. Adequate community care costs upward of $10,000 a year for each person — about twice what Michigan spends on average.
Funding cuts have costs
Since 2008, the state has slashed $50 million from Community Mental Health agencies, with Wayne County absorbing more than half of the cuts. For example, the annual budget for the nonprofit Detroit Central City, one of Detroit’s largest Community Mental Health agencies, has dropped from $11.2 million in 2008 to $8 million.
Those cuts mean fewer services. Detroit Central City President and CEO Irva Faber-Bermudez said her agency, serving 4,600 people a year, had to close an urgent care clinic in 2010 that diverted people in the Midtown area from costly emergency room visits at Detroit Receiving. DCC also had to eliminate an effective transitional housing program that provided homeless mentally ill people with places to stay for 30 to 45 days while they stabilized, filled prescriptions, established regimens of outpatient treatment and looked for permanent housing.
Budget cuts also forced the agency to reduce by almost half the number of vehicles used to transport clients to medical appointments and treatment, a vital service in a city with an inadequate and unreliable bus system.
Cuts in mental health care have cost Michigan dearly. State prison stays, for example, typically cost $35,000 a year per person — and often more if extensive health care is required. A University of Michigan study in 2010 found that more than 20% of state prisoners had severe mental disorders — and far more were mentally ill. The same study found that 65% of prisoners with severe disabilities had received no mental health treatment in the previous 12 months.
Community investments pay off. Detroit Central City’s jail diversion and prisoner re-entry programs, for example, report recidivism rates of less than 10% — four times lower than the overall state average.
At least a third of Michigan’s 100,000 homeless people are mentally ill and untreated. Disrupted by the uncertainties of street life, they often cannot manage the medications and medical appointments needed to control their illnesses and maintain their health. When they occupy police officers’ time or hospital emergency rooms, the public pays.
Nowhere is the need for improvements in mental health care greater than in the state’s urban areas. Concentrated poverty aggravates the problems of mentally ill people in cities like Detroit, where 20,000 people are homeless.
“The folks we serve have complex needs,” said Joseph Tardella, executive director of Southwest Counseling Solutions. “They have severe mental illnesses, but they’re also poor, many living on the $650 a month that they get from SSI. They have trouble getting housing. They lack transportation. Their health care has not been attended to. Poverty makes treatment more complicated and difficult.”
Some community mental health agencies use mobile outreach workers to reach mentally ill people in homeless shelters, soup kitchens and street venues, including parks and freeway underpasses. Even so, many — probably most — poor people who are mentally ill go for years or even decades without treatment.
Treatment can save lives
Meet Christine Yates.
Diagnosed with schizophrenia and bipolar disorder, she also has a history of drug and sexual abuse. Yates, now 54, was molested by a family member while growing up in a house with 14 other relatives. Her mother sold drugs to support a heroin addiction. Yates, of Detroit, later became addicted to heroin and Vicodin, a prescription pain killer often sold on the street.
Yates grew up fast. After dropping out of eighth grade, she was dancing in clubs at 14 to help support her family. The same year, she had a baby girl. When she was 17, she started working at a GM plant.
As a child, Yates heard voices. Sometimes the voices told her to kill herself, and she became convinced that everyone was talking about her. Still, her mental illness went undiagnosed until 1992, when she was 34.
A friend encouraged her to see a therapist at Detroit East Community Mental Health. After that, Yates started to receive Social Security disability benefits and taking medications, including Cogentin and Xanax. But she said she didn’t get real help for her mental illness until coming to Detroit Central City in 2006.
Yates got to DCC the hard way. On a day she planned to kill herself by overdosing on prescription pills, a police officer pulled her over for a traffic violation. She spent three months in jail for unpaid traffic fines.
After serving her jail time, Yates received therapy at Detroit Central City. In 2008, the agency placed her in a supportive housing program, after a family dispute left her with no place to go.
Today, Yates does volunteer work at local soup kitchens and homeless shelters, three or four days a week. “I’m giving back what they gave me,” she said.
Formerly illiterate, she earned a GED in January and enrolled in the Wayne County Community College District. She plans to earn a criminal justice degree and work as a corrections officer. With therapy and medication, her life is getting better. Yates’ daughter, now 40, works as a nurse. Her son, 22, studies accounting at Oakland County Community College. Yates credits much of her progress to Detroit Central City, especially her therapist, Sheila Scheppman, and her psychiatrist, Dr. Greg Washington.
“If they hadn’t gotten me, I think I would have been dead,” she said.
Tens of thousands more people like Yates remain untreated and even undiagnosed. Reaching more of them will require not a return to the failed policies of the past, but a better funded and more effective Community Mental Health system.