State pays in blood for flawed mental health system
Laws kept suspects from care
The shooting rampage that left six dead Tuesday in Skagit County is the latest tragic incident involving a person with apparent mental illness who didn't get treatment in time to prevent violence.
Six more names to add to an already grim list: Sierra Club worker Shannon Harps, stabbed to death outside her Capitol Hill apartment last New Year's Eve; Jewish Federation employee Pamela Waechter, gunned down at work; Newport High School coach Mike Robb, shot in his car; firefighter Stan Stevenson, stabbed to death in a crosswalk walking back from a Mariners game; pregnant Kari Osterhaug, shot by her husband.
In each case, a person with severe, untreated mental illness has been charged or convicted in the killing.
And in each case, family members or others tried to intervene to get the suspect help before he committed a horrific crime but were stopped by Washington's strict commitment laws and overburdened, ineffective mental health care system.
Now it appears Isaac Zamora, 28, who was arrested after the shooting spree this week, may fit that same profile. His mother, who characterized her son as "increasingly psychotic," said she had tried for years to get him help without success.
"The laws are insane," Dennise Zamora said Wednesday. "He needed to be in a facility."
Her statements echo those of countless other families who say Washington's mental health system fails those who need it most.
A Seattle P-I analysis found the state is spending $1.8 billion on mental illness. But most is spent in courtrooms, squad cars, jail cells, homeless shelters and emergency rooms, not on prevention or long-term treatment. The biggest price taxpayers pay for mental illness in this state is not the cost of treatment -- it's the cost, and consequences, of failure to treat.
Isaac Zamora's lengthy court record contains a sprinkling of references to concerns over his mental health, including a 2003 reference to biting a staff member who was trying to restrain him at North Sound Evaluation and Treatment Center, a mental health clinic in Sedro-Woolley.
Zamora also was ordered by a Skagit County Superior Court judge to undergo a mental health evaluation as part of his court-ordered community supervision, said Department of Corrections spokesman Chad Lewis. Zamora was released Aug. 6, but that evaluation had not taken place before the shootings.
This pattern of not getting help soon enough is endemic to Washington's health care system.
The P-I's analysis found that of the taxpayer dollars spent on people with severe mental illness each year in this state, about seven of every $10 go to services that don't directly address underlying sickness. Little goes to long-term solutions such as treatment, housing and support for people whose symptoms are otherwise so severe they can't function. Of all the money the state spends dealing with mental illness, $530 million goes specifically to address mental health care.
To figure out where the money goes, the P-I interviewed prison officials, government workers, psychiatrists, families, attorneys, police, social workers, patients and others to put a dollar amount on ways the mentally ill interact with public agencies. In cases where specific dollar figures could not be calculated, the P-I prepared its own estimates based on public records and the views of experts.
With no central source keeping track of the money, the P-I built a database of these numbers. What emerged was a view of a largely disconnected system with multiple bottlenecks that mostly is driven by emergency or short-term care.
King County recognizes more needs to be done and has taken some steps toward dealing with the crisis, said Amnon Shoenfeld, director of King County Mental Health. A 0.1 percent sales tax approved last fall will infuse more than $50 million a year into substance abuse recovery and mental health services. The council is expected to take action on the plan later this month.
Families, and even many of those who work within the system, argue that the current crisis-response model doesn't work, makes people sicker and puts the public at risk.
There's a case for that argument: The state's second-largest psychiatric treatment center for the severely mentally ill is also a maximum-security prison.
At the Monroe Correctional Center's Special Offender Unit, the patients are prisoners first. Their psychiatric facility, originally built for maximum-security incarceration, is embedded within a matrix of cameras and massive steel doors that control and monitor access to their cells.
"Anything you see in a state hospital or emergency room or acute setting, you see here," said Eric Harting, who has worked in the mental health field as a counselor and caseworker for 30 years and now supervises 400 beds at Monroe.
Monroe also houses many of the state's designated "dangerous mentally ill offenders," those violent inmates considered to be high risk to the community. Most of the unit's residents -- up to 80 percent -- have alcohol and drug abuse issues on top of mental and personality disorders.
The population of prisoners with mental illness has been rising each decade since the big push during the 1960s to "deinstitutionalize" patients by releasing them from psychiatric hospitals into community care.
But the community care piece of the plan never materialized as social engineers envisioned. President Johnson's "Great Society" plan was to build 2,000 community health centers around the country to provide comprehensive care for people with mental illness who were being sprung from institutional care. Fewer than 500 were built, leaving the severely mentally ill, who were least capable of coordinating their own care, to scavenge for services and fend for themselves.
"The situation is considerably worse than it was 10 years ago," said E. Fuller Torrey, psychiatrist and author of several benchmark books on the social consequences of the deinstitutionalization of the mentally ill.
Funding for community health and hospital beds has been cut back, but the population of people needing those services, if anything, is increasing, he said. "Basically, to get help, you have to get arrested."
In an ironic twist, Zamora's alleged rampage took place just down the road from the old Northern State Hospital in Sedro-Woolley -- once a psychiatric hospital -- that closed in 1973. At its peak, it housed more than 2,000 patients.
Meanwhile, the percentage of state prison inmates diagnosed with serious mental illness has increased from 11 percent of the total inmate population in 2001 to 16 percent last year, said Karen Daniels, assistant secretary for Washington's Department of Corrections.
At the national level, the Justice Department estimates about 45 percent of federal inmates have serious mental issues.
Even using the state's more conservative figure, that means more than 2,500 of state inmates have serious mental illness. It costs an average of $85 a day to house a regular inmate. It costs $110 a day to house one who is mentally ill, which means an additional $23 million a year. The state now spends $7.2 million a year on psychiatric drugs -- 51 percent of its total prescription budget.
The King County Jail spends $8.7 million on inmates with mental disorders, and the Seattle Police Department spends $8.4 million responding to incidents involving people experiencing symptoms of their mental illnesses.
Washington spends more than $100 million a year incarcerating people with mental illness. Yet many of these incidents -- the petty thefts, vandalism, assaults, trespassing, public urination -- might have been avoided had those who needed it gotten effective treatment and support to begin with, said Torrey, who is now president of the Treatment Advocacy Center, a Virginia-based nonprofit working to eliminate barriers to treatment for people with severe mental illness.
The opinion that treatment can cut down on offenses has been borne out locally. The state's dangerously mentally ill offender program which provides intensive supervision of released felons resulted in a 37 percent reduction in recidivism rates. But only a select group of offenders qualify for this program.
Treatment might also have prevented some horrific crimes.
People with untreated schizophrenia and bipolar disorders committed about 1,000 of the estimated 16,000 homicides in the United States last year, according to figures kept by the Treatment Advocacy Center.
The names of victims are now memorialized in new treatment laws in many states:
"Kendra's Law" in New York was named for a young woman who was pushed under a subway by a man with untreated schizophrenia.
"Laura's Law" in California is named for a college student who was working at a public mental health clinic and was shot to death by a man who had been refusing treatment.
"Nicola's Law," the latest such effort, is named after a young New Orleans police officer who was overpowered by a suspect with paranoid schizophrenia and shot to death with her own gun.
The majority of people with mental illness do not commit crimes, but of those who do, it's frequently when they are not taking medication or sticking to treatment plans.
Currently, about 40 percent of the 4.5 million individuals with schizophrenia and bipolar disorder in the United States are not getting treatment, said Torrey.
In this state, more people don't get treatment -- or stay in it -- for a complex array of reasons: shortages of beds and housing, overextended mental health care workers and no legal means to treat people early on in the progression of their disease.
One of the key reasons, however, is that many people with severe mental illness don't believe they are sick and refuse interventions -- something Zamora's mother said was true of her son.
To address these issues, a growing number of states are moving toward "outpatient commitments" -- which are court orders mandating that people with serious mental health issues get treatment and take medication while out in the community. Sometimes called "assisted outpatient therapy," this approach works, in part, because treatment providers are also accountable to the courts for providing care.
In states that do use outpatient commitment, data show it reduces homelessness, hospitalizations, arrests and violence, said Jon Stanley, lawyer for the Treatment Advocacy Center. In New York, "Kendra's Law," an outpatient commitment law in effect since 1999, reduced arrests of those involved in treatment by 83 percent, and 74 percent less of those in the program ended up homeless.
Technically, Washington's mental health law allows for court-ordered outpatient treatment, but it isn't used much. In 20 years, Dr. Peter Roy-Byrne, head of psychiatry at Harborview Medical Center, recalls it being used only twice.
Noose around the neck
In theory, the state's involuntary treatment act allows, or even encourages, the placement of people in a "least restrictive alternative" such as community treatment, but here's the catch: The primary reason people can be ordered to get involuntary treatment is for being in such a state they pose imminent harm to themselves or others.
By definition, those are not people who can be released to the community, said Shoenfeld, whose office handles involuntary commitments.
"Basically, to get a commitment now, you have to be climbing the telephone pole, with a noose around your neck," said a mother with a mentally ill son, who did not want to be named for fear of jeopardizing her son's current care situation. "You're forced to watch your child spiral out of control."
Many families are desperate to get help sooner rather than later for loved ones who are coping with mental illness. But unlike in more than 40 other states, families in Washington can't petition to get someone into involuntary treatment.
Instead they have to go through a gatekeeper called a designated mental health professional -- a county worker who gets called in to collect evidence and make that determination. A staff of 28 such workers -- the same number there has been for the last decade -- is responsible for King County's 1.8 million residents.
This approach means only the sickest get committed for involuntary treatment -- and then only to inpatient care, an approach that also means foregoing the opportunity to intervene sooner when treatment might result in better outcomes.
Even when patients do meet the threshold of being a danger to themselves or others, it doesn't guarantee they will get treated.
"The system is dramatically underfunded," said Roy-Byrne of Harborview's psych unit. "We don't have the capacity to see the people needed."
Washington has a severe shortage of beds -- about 19 beds per 100,000 residents, said Torrey.
The national recommendation is 50 psychiatric beds per 100,000 in population.
And the shortage is getting more acute. Budget cuts are forcing the closure of four more wards at Western and Eastern State hospitals by next year -- a total loss of 90 beds.
Meanwhile, some people put on involuntary holds simply wait them out in emergency rooms that aren't staffed to provide psychiatric care, a practice called "boarding." King County boards three to 19 patients a day in emergency rooms, depending on bed availability, Shoenfeld said.
Boarding patients in the emergency rooms is hazardous for the staff around them, and for the patients themselves, said Matt Goodheart, one of the county workers who has to make those involuntary detainment decisions.
"These patients are not receiving any psychiatric care and could go walking out of the ER they are in and hurt themselves or someone else."
A shortage of places to discharge patients also keeps them in the hospital longer than necessary.
"Today we have 120 people at Western State who are clinically cleared for discharge -- no longer at risk to self or others -- but who have significant support needs, and nowhere to go," said Richard Kellogg, head of the mental health division of the state Department of Social and Health Services.
"We wouldn't have backups if we had patient flow -- if we could get people out in a timely manner," he said. "In the short term, what is significantly lacking is housing alternatives -- housing connected to support services, employment and social networks."
Such housing, scarce to begin with, has been disappearing. King County recently closed several group homes with a total of 100 beds because of code violations, licensing and funding issues.
Bottlenecks impede care
The bottlenecks in the system keep people from getting better, which keeps them coming back to the emergency room, or jail, in crisis mode, which is where Goodheart sees them.
"I detained someone this week who had 19 previous psychiatric hospitalizations," said a weary-looking Goodheart, who spoke recently after coming off a night shift.
"Last night I evaluated someone who just came out of West Seattle (psych hospital) four days ago," he said. "People get let loose, and they are still really sick."
The trend is to push patients out the door with no follow-up, said Torrey. "They throw their medication in the garbage on the way out of the hospital."