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Hurdles to mental-health care abound
Budget cuts, area’s remoteness can hinder treatment
By Kelly Fox
A man is brought to the emergency room, chattering incoherently and describing things only he can see. He isn’t drunk or under the influence of another drug. A social worker is sent to evaluate him, and he tells her about his detailed plan for suicide.
It’s decided the man poses a danger to himself and possibly to others and that he needs immediate, intensive psychiatric care.
But where will the care come from?
When this scenario unfolds in Cortez, emergency-room personnel, mental health workers and a patient’s family and friends are faced with an often frustrating struggle to find help.
Even before a person reaches the point of needing hospitalization for a behavioral-health problem, there are many hurdles to obtaining adequate mental-health treatment in the Four Corners area. Consequently, many mentally ill people go undiagnosed and untreated.
Falling through the cracks
A study by the World Health Organization, the World Bank and Harvard University found that the “disease burden” created by mental illness in developed countries is more than the burden of all cancers combined.
Four of the 10 leading causes of disability in the United States are mental disorders: major depression, bipolar disorder (manic depression), schizophrenia and obsessive-compulsive disorder.
And mental illness isn’t a problem just for the sufferer. Individuals with behavioral-health problems who are under-treated or not treated at all often wind up in the hands of law enforcement, the judicial system and corrections agencies.
“I see cops in Cortez that have to go to a domestic (-violence incident) that may be mental-health, behavioral-health driven,” said Dave Guy, a counselor for Discovery Employee Assistance in Durango. “The police are doing basic social work and basic counseling trying to de-escalate the situation.”
But the importance of mental-health care isn’t reflected in local funding. In 2003, state budget cuts of more than $675,000 severely impacted the five-county area served by Southwest Colorado Mental Health Center, a nonprofit agency that relies heavily on government funding.
At the center’s Cortez branch – which serves all of Dolores and Montezuma counties – the loss of revenue led to the layoff of two child and family therapists, who each served about 20 patients per week. According to Ann Wetton, program supervisor at the Cortez center, many people at the time thought the center was struggling or closed.
“I think there were great concerns when we had the layoffs,” she said. “ (Clients) just stopped coming in for a while. We ended up seeing a lot more people on emergency because it would get to the point of a crisis rather than being able to do some preventive work.”
Guy said budget cuts have helped create a population of mentally ill people who have fallen through the cracks, often becoming concerns for other agencies and organizations.
“Colorado has taken so much (money) out of the behavioral-health and mental-health arena that we have too many folks walking the streets who haven’t really gotten help,” Guy said. “ So they are really marginalized. Then they do things that they perceive to be right, which gets them in trouble with law enforcement, and they get picked up. So now they’re stressed … their body chemistry and mental outlook is really challenged and they can be angry, they can be violent.”
Mental problems can be a factor in other social ills such as unemployment, crime, and substance abuse.
“A lot of people self-medicate. A lot of drug use is self-medication,” Guy said. If substance abusers aren’t treated effectively, he said, “they’ll cycle through (the system) again because they haven’t dealt with whatever the issues are that drove the (abuse).”
Barriers to care
The isolated nature of S o u t h w e s t Colorado – which provides peace and serenity for many people – often hinders individuals in need of treatment for a behavioral-health problem. Frequently, one of the biggest hurdles for such people is just deciding to seek care.
Research by the National Institute of Mental Health (NIMH) shows that people in rural areas have an incidence of mental illness and substance abuse at least as high as that in urban areas. But rural people frequently don’t seek treatment because they worry they can’t pay, lack information about available services, or fear the stigma.
“Seldom does a person with a real mental-health issue say, ‘I really think it’s time for me to get fixed.’ I’ve never had one in 30 years do that,” Guy said. “ For a person to go to a counselor, number one, they have to admit that they have an issue; and number two, they need to find a counselor they connect with.”
Wetton said many people don’t seek care because of the stigma attached to mental illness. “We only see a fraction of the people that could be using the services,” she said. “I think some of it is that this is a ‘mental-health center’ and they don’t want to go to that ‘crazy place’ because they’re not crazy.”
Cindy Irvin, director of the Good Samaritan Center in Cortez, agrees. Her center provides food, clothing and shelter for people in dire straits. Many of them are simply down on their luck, but others she sees could clearly benefit from mental-health treatment.
She said even though low-cost help is available for many poor people in need of treatment, most still will not seek it.
“They’re afraid,” she said. “They think if they go to mental-health treatment, (counselors) will find more wrong with them than what they think is wrong.
‘I don’t know how many people I’ve tried to send to mental health that won’t go. Others go, but they lack the capability, or they’re just stubborn, and they don’t follow through with the work they need to do on themselves to get better.”
Many times, Guy said, people with mental illness have to be brought to a hospital or counselor against their wishes — by a friend, family member or even a law officer.
A patchwork of coverage
But even people willing to seek help may have difficulty paying for it. Wetton said approximately 70 percent of the mental-health center’s clients are covered by Medicaid, the government program for the poorest people. The rest are self-pay or covered by private insurance.
Medicaid clients don’t pay anything out of pocket at Southwest Mental Health, and have no set limit on treatment. Private insurance generally pays for only a limited number of sessions and requires co-payments. Not all private insurance is accepted by the mental- health center, though most is. People covered by Medicare also have a co-pay.
For those not covered by private insurance or Medicaid who fall within certain income guidelines, the fee is approximately 30 percent of what the full charge would be. After the center’s initial budget cuts, that rose to 50 percent, but recently it was reduced again because the center received some additional funding.
“Funding for indigent care is still a huge problem,” Wetton said. “We have just recently reduced the (self-pay) fee because we‘ve gotten some money. It‘s made it a little more accessible for people. Without that money, it’s been tough to offer services to people who are indigent or have no insurance. There are a lot of people who are working that have no insurance coverage.”
The mental-health center works with clients who don’t have the resources to pay, Wetton said, reducing the fees even further. The goal is to provide treatment and do preventive work so those with mental-health problems don’t end up hospitalized, which proves even more costly in the long run.
Seven beds for the Western Slope
Just as with other types of illness, mental disorders grow worse if they are untreated, possibly resulting in emergency treatment being necessary.
Trying to help clients who need acute care and hospitalization — something Wetton deals with about once a month — is a huge challenge. The process of involuntarily committing someone usually takes six to eight hours, she said. “It’s incredibly cumbersome. We start making our phone calls … and nobody ever has any beds. “ It’s a nightmare.”
For the general adult population — patients other than children, geriatric patients or prisoners with felony charges — there are only seven beds for the entire Western Slope, Wetton said. If she is able to secure one of those few beds, Wetton said, the nearest public, in-patient psychiatric facility is in Pueblo — a seven-hour trip by car. And in order to involuntarily commit someone she must obtain a court-approved transportation order from the district attorney — a process that can take considerable time.
Then, after a bed is found and transportation arranged, the patient’s ordeal has just begun. Typically, psychotic patients are medicated to keep them calm during transport and, as an added indignity, they are restrained in shackles throughout the trip.
Wetton said the trauma that patients suffer during transportation is distressing, but it is sometimes the only option for those in acute psychotic episodes.
“I hate it – I absolutely hate it,” Wetton said. “It’s the worst thing in the world because a lot of the people we’re hospitalizing are having PTSD (post traumatic stress disorder) reactions to something. And here we are throwing them in shackles in the middle of the night for a seven-hour trip over the mountain passes. It’s just horrible. It’s barbaric, but that’s the option we have if somebody is in that much danger.”
So Wetton and her colleagues at the mental-health center strive to avoid the need for hospitalization by offering as much preventive care as they can.
Who needs help
Mental disorders are classified in more than a dozen categories, from depressive disorders to schizophrenia, anxiety disorders to Alzheimer’s Disease. According to the NIMH, 22 percent of Americans over the age of 18 — about 1 in 5 adults — suffer from a diagnosable mental disorder.
In the Four Corners area, a common issue is bipolar disorder, according to Guy. “We get manic or hyperactivity on one end and depression on the other end, so folks cycle from depression to mania.”
More than 2 million American adults have bipolar disorder, a condition characterized by unusual shifts in mood, energy and ability to function, according to the NIMH.
Guy also sees clients for problems ranging from relationship and family issues to severe depression and chronic mental illness.
“Depression is the common cold of behavioral health,” he said. “A person can be depressed and still function at a fairly good level if they have resources, if they have a network of folks they can talk to.”
But for people without friends and family to rely on, behavioral-health problems can go unrecognized, often coming to light in a dramatic way.
“There are those who are extreme – the psychotic, the antisocial,” Guy said, “ folks who have no sense of their own well-being or the well-being of others. Those are the hardest ones to deal with and are least receptive to therapy.”
Those extreme cases often end up in the hospital emergency room or county jail.
Irvin, of the Good Samaritan Center, said some of the people she sees “act out once in a while and get thrown in jail,” which may be the worst place for the most seriously ill. “They can’t stand that confinement,” she said.
The hospital or jail will seek assistance from mental-health professionals when necessary.
“If somebody at home gets into a mental-health crisis, they can either call the emergency line we have or the police,” said Wetton. “The police will do a health and welfare check and if they felt that (the person) needed an assessment and maybe hospitalization, they would transport them to the emergency room. Then we get called and go over and do our piece, then hospitalize from there if we need to.”
Aside from the extreme cases, mental- health workers in Montezuma County see a wide range of problems afflicting people from all walks of life.
“We see a lot of families with parenting issues, child-care issues, abuse issues,” Wetton said.
She added that the economic climate in Southwest Colorado is a factor that brings people to her doorstep.
“This is a hard area. It’s a poverty area,” she said. “And you get people that can kind of make it and then something slips — whether it’s a relationship, or some financial thing — they are able to keep it together to a certain point and then they just can’t.”
What help is available
For people who recognize they need help, finding adequate care can be a challenge.
“Cortez is an ‘arid’ place,” Guy said. “ There are not a lot of counselors who do general practice. It’s a challenging place to get help.”
Irvin noted that there is just one psychiatrist at the Cortez mental-health center “and there’s not enough of her to stretch around to take care of all the people that have need of her.”
Psychotherapists can provide skilled counseling but can’t prescribe medications, so clients needing a prescription must see the psychiatrist too.
Often, people will start with their family physician, who may recommend one of the many available medications for common disorders.
However, Guy said there’s more to treating a mental-health problem than chemicals.
“Western medicine believes that everything can be fixed by a pill or a splint or an operation,” he said, stressing that physicians should also encourage patients to get counseling if they have behavioral-health problems.
Individuals able to pay for their own care or covered by insurance can choose from a few local counselors and organizations listed in the phone book under “mental health services.” There are more listings under “counselors” — most in the Durango area — that offer services from arts and play therapy to equine-assisted psychotherapy and help with “spiritual quests.” But for people without insurance, the options dwindle.
At some companies, workers can take advantage of employee-assistance programs, but the extent of help is often limited.
“I see employee assistance as kind of a triage,” Guy said. “Employee-assistance programs are designed to be an initial assessment and problem-focused.”
Six or eight sessions are usually enough, he said, for a person doing fairly well in life to create a plan and start work on it. However, employees in need of long-term treatment may be referred to a psychiatrist for a thorough evaluation and follow-up care.
Coming to a crossroads
An option on the local horizon for more acute cases is a facility planned in Durango called The Crossroads. The 12,870-square-foot building on the new campus of the Mercy Regional Medical Center will house three units to be operated by Southwest Colorado Mental Health Center: a relocated detox unit, emergency services and a psychiatric urgent-care unit.
Bern Heath, CEO of Southwest Colorado Mental Health, said the new facility, while not a psychiatric hospital, will offer a choice for patients faced with the possibility of involuntary commitment to the state hospital in Pueblo.
“We can either transport (a patient) to the Front Range, to Pueblo,” Heath said. “And that’s either in shackles for seven or eight hours or by air flight at great expense … and out of reach of family, friends and support systems. Or (a patient) can voluntarily go to Crossroads, within range of family and friends — an hour from Cortez.”
Most people, Heath said, would likely choose the Crossroads option. However, the choice won’t be available for all patients. The facility will not be able to take highly agitated, acutely psychotic individuals or children.
“While the facility itself will not address these two populations,” Heath said, “by virtue of other mechanisms, we will actually have a resource that will serve all individuals, adults or children, Montezuma to Archuleta (counties), in psychiatric crisis locally.”
Money to construct the $2.8 million facility will come from municipal and county funding, donations from the community and grants. The mental health center was recently awarded $500,000 from the Governor’s Rural Healthcare Initiative, as well as approval for an additional $500,000 in federal appropriations. A request for $1 million has been made by La Plata County and Durango to the Energy and Mineral Impact Assistance Grant.
According to a report released in February by the Community Psychiatric Resource Task Force, the biggest funding challenge for the Crossroads project will be ongoing operational financing. Southwest Colorado Mental Health Center will operate the detox and triage units using existing funding. The psychiatric urgent-care residential component will be operated with a combination of the mental-health center’s current funding and other sources.
An estimated $610,000 in annual operational funds will come from the mental-health center and consumer revenues.
However, the task force anticipates a funding gap of $890,000 because of a large amount of uncompensated care. Planners hope to close this gap with state, county, municipal and special funding, including from the Southern Ute Tribe, Upper San Juan Health District, Montezuma Hospital District, Animas Surgical Center, regional municipalities and Fort Lewis College.
In November, voters in La Plata County will decide on additional operating funds when a proposed healthcare district appears on the ballot. The La Plata County Health Care District, if approved, would generate $350,000 annually for the new facility.
Wetton said the center will be an alternative to many of the hospitalizations she handles, and will provide clients with a new safety net.
“For some of the folks that are just totally chronic, really, really psychotic and a danger to themselves because of that, (the state hospital in) Pueblo is the only answer.” However, the new center “will certainly cut down the number of people that we have to send to Pueblo.”
No easy answers
Even with the advent of the new facility in Durango, more is needed to improve behavioral-health care in Southwest Colorado. Mental-health issues pervade every aspect of society, dramatically affecting the overall health of a community.
In order to address the problem, communities must first recognize it.
“People may say there isn’t a mentalhealth problem in Montezuma County,” Wetton said. “And it’s not there if you don’t acknowledge it.”
As modern lifestyles get more hightech, it’s easier for people to ignore mental-health issues in their neighbors, family and friends. Cell phones, e-mail and voice messaging can create barriers to face-to-face contact.
“We’re not as in touch with one another as we used to be,” Guy said. “We‘ve created silos of life. We’ve created distance.”
Guy said even when people notice a change in a friend or family member, few are brave enough to tell the person. He stressed it’s also important to recognize problems in ourselves, and he sees people who maintain their cars better than their psyches.
Relying on healthy people – and not just mental-health professionals – to be involved in the mental health of the community is a key to improvement.
For example, Guy said, a pastor could teach his congregation the early signs of suicidal behavior. “We could do earlier intervention if we had more folks understand what’s going on.”
By taking ownership of the issue, breaking down stigmas and stereotypes and educating citizens, communities can give mental-health programs a better chance of success.