Senator Eliot Shapleigh - El Paso, Texas

Two years after the state started cutting care for severely mentally ill Texans, Austin-area emergency rooms and health clinics are seeing far more psychiatric patients who need help.

In 2004, mental health diagnoses in 20 Austin-area hospitals and health clinics jumped 79 percent from the year before, according to the Indigent Care Collaboration, a nonprofit group that tracks medical care for poor people in Travis and Williamson counties.

During that time, Travis County's mental health officers handled calls at hospital rooms 63 percent more often than the year before. Also, the state's 10 psychiatric hospitals are over capacity.

It's a trend across Texas as people struggle to find psychiatric care in a shrinking system. And many mental health professionals blame the Legislature's budget cuts.

"The timing certainly is suspicious," said Dr. Alan LaGrone, medical director of psychiatric emergency services at Parkland Memorial Hospital in Dallas. "The lack of treatment that we as a society give to these people is a real indictment for us."

The Texas mental health system is the safety net for poor people. Psychiatric hospitals provide inpatient crisis care, and mental health centers provide therapy, medication and case management for people living in the community. Both are run with state money.

But Texas is among the stingiest states for mental health funding. The state ranks 49th in per-capita mental health spending, according to a recent report by the National Association of State Mental Health Program Directors Research Institute. In 2002, Texas allocated $38.46 for each person.

Shrinking resources

Things got worse in 2003.

That January, facing a $10 billion shortfall, Gov. Rick Perry instructed all state agencies to cut their budgets 7 percent. State-funded community mental health centers stopped filling jobs and started cutting services.

In the summer of 2003, legislators cut $14.8 million from the 41 mental health centers, a 5.11 percent decrease that forced agencies to drop services, lay off employees and turn away clients. They eliminated most therapy benefits for more than 128,000 Medicaid recipients.

On Sept. 1, 2004, the centers started accepting only people with bipolar disorder, schizophrenia and clinically severe depression. About 17,000 people with ailments such as panic, anxiety and obsessive-compulsive disorders are being phased out of the system.

Perry spokesman Robert Black said lawmakers did what they had to do to balance the budget without raising taxes and focused on the core needs of mental health funding.

"Last session, the Legislature faced a daunting task with a $10 billion shortfall, and the governor believes that they took prudent steps in that environment," Black said.

Getting sicker

But the consequences have been dire, said Lynn Lasky, executive director of the Mental Health Association in Texas.

Many mentally ill people are getting sicker. They are suicidal or delusional. Some are hurting themselves or others.

"This is a chronically underfunded system," Lasky said. "We've cut and cut, and we just can't take it anymore."

Since 2003, the Indigent Care Collaboration has been assessing the number of mental illness diagnoses for patients at 20 health providers, including Brackenridge Hospital, Seton Medical Center and 10 City of Austin community health centers.

Those diagnoses have been increasing steadily, said Paul Gionfriddo, executive director of the Indigent Care Collaboration. In 2003, the 20 providers noted 8,120 mental illness diagnoses. In 2004, they saw 14,516.

"They started to jump when the state started making cuts to services, and they've gone up and up ever since," Gionfriddo said.

The collaboration tracks diagnoses, not people. Officials can't say exactly how many more people are showing up with mental health needs, but health providers say they know they're seeing more mentally ill people.

At Brackenridge Hospital, where diagnoses jumped 15 percent between 2003 and 2004, the increase often forces the hospital to pay temporary "sitters" trained in mental health needs to keep patients safe and stable during their admission, said Jesus Garza, president of Brackenridge Hospital.

It also forces the medical staff to deal with illnesses best handled by mental health professionals, Garza said

"We're not a psychiatric hospital," he said. "We're not trained for this."

Central Texas' mental health officers are being called to emergency rooms more often. In 2003, the Travis County sheriff's office's crisis intervention team made 120 calls to hospital emergency rooms across the city. In 2004, that number jumped to 196.

LaGrone, who is also an assistant professor of psychiatry at the University of Texas Southwestern Medical Center, sees the same trends in Dallas. The psychiatric emergency room at Parkland used to see 600 to 650 patients a month, he said. Now that number hovers around 900.

"It's definitely been over the last 18 to 24 months that we've seen a huge increase," LaGrone said.

Crisis care costly

That kind of care isn't cheap.

Between January and September 2003, mental health visits to emergency rooms and community health centers cost more than $1 million, according to a 2003 report by the Mental Health Association in Texas. If those same people had gone to a state-funded mental health center, the tab would have been about $726,000.

Experts say hospital visits cost more because hospitals provide crisis care, with more staff, medication and other resources.

"We're certainly paying the price," Lasky said. "It's not the most efficient or effective way to treat people."

Meanwhile, with nowhere else to go, many poor people are ending up at the mental health provider of last resort: the state psychiatric hospitals.

Between Sept. 1, 2003, and Aug. 31, admissions to Austin State Hospital went from 3,971 to 4,320, an 8.8 percent increase.

The last four months of 2004 were particularly difficult for the whole system, said Kenny Dudley, director of state hospitals for the Department of State Health Services.

Between September and December, the 10 state hospitals routinely housed 51 more people than they are equipped to handle. Terrell State Hospital alone ran 9.5 percent over capacity by serving about 300 patients a day instead of the optimum 274.

Capacity problems make it hard on everyone. Patients have to wait longer for care. Employees struggle to handle the overload. The risk of injuries and mistakes goes up.

"Something will happen if you keep pushing," said Carl Schock, superintendent of Austin State Hospital. "The rubber band will pop."

Sharing the burden

Hospital officials are shuffling resources to distribute the burden more evenly, Dudley said. Officials recently started sending patients from Terrell, near Dallas, to state hospitals in Kerrville and Austin. The Austin facility cut some of its children's slots to create an 18-bed unit for adults.

The hospitals can't take much more stress, Dudley said.

"If this population keeps going up, it's over," he said. "I don't know what we'll do."

Whether legislators will address the issue in this session remains to be seen. Black, the governor's spokesman, said health care in general is a priority for lawmakers.

State Rep. Garnet Coleman, D-Houston, is skeptical. Mental health has been a low priority for state leaders, he said.

But Coleman remains hopeful that change will come. Republican leaders are talking about restoring cuts made in the Children's Health Insurance Program after feeling significant public pressure and seeing two leaders of the 2003 budget cuts, state Reps. Talmadge Heflin and Arlene Wohlgemuth, lose their seats in November's elections.

"I'm not optimistic without demand from the public that those programs would be restored," Coleman said. "This is a dynamic process."