State mental health system stuck in turmoil

Stacy J. Willis

Saturday, Feb. 17, 2001 | 11:36 a.m.

When Craig Smith's 25-year-old daughter told him the television was talking to her, he knew she needed help.

He took her to the Southern Nevada Adult Mental Health Center, where she was admitted through the emergency observation unit three times.

Each time a different medical team saw her, she was given a different diagnosis.

"First they told us that she had an eating disorder," Smith, whose name has been changed to protect his daughter's identity, said. "Later they told us there was nothing wrong with her, that she had just been smoking pot and was 'a little crazy' from it."

"Finally, she was diagnosed as being schizophrenic," he says.

From there the family faced the challenge of coming to terms with mental illness and, nearly as daunting according to Smith and mental health activists, the challenge of seeking services from the state's mental health care system.

But Smith's daughter is lucky to have family members helping her negotiate the system.

"Often the reason people end up homeless or in jail is because the mental health system has failed them," said Joan Stevens, president of the Southern Nevada chapter of the National Alliance for the Mentally Ill. "And a lot of the problem is just accessing help in the first place."

Nevada's mental health budget was gutted a decade ago under then-Gov. Bob Miller, but since 1995 funding to the Division of Mental Health and Developmental Services has rebounded by some 18 percent, and efforts have been made to make the system more user-friendly, according to Division Director Carlos Brandenburg.

But here in Southern Nevada, the needs of the mentally ill are especially demanding because of the general population growth. And according to critics of the system and documents from the division, those needs are going unmet despite budget increases.

The division's Mental Health Needs Assessment for the year 2000 shows that 9,387 requests by mentally ill people for emergency and permanent housing went unmet in Clark County, and another 8,641 requests for personal service coordination, or case management, went unmet.

Mental illnesses are disorders of the brain characterized by changes in thinking, mood and behavior, ranging from anxiety and depression to bipolar disorder and schizophrenia.

Twenty-three percent of adults suffer from a diagnosable mental disorder in a given year, but only half of those report impairment of their daily functioning, according to the national alliance.

But many of even the most debilitating conditions can, when treated, can be adequately managed.

About 12,000 people per year are served by Southern Nevada Adult Mental Health Services. Five hundred people per month walk into the cluster of buildings on its campus seeking help, according to Director Jim Northrop. Others are brought in by ambulances or the police.

Southern Nevada Adult Mental Health Services operates on a budget of roughly $30 million annually, employs about 300 full-time-equivalent workers and offers a wide array of services. The state pays for medicines for the uninsured, distributes medicine and services at four local out-patient sites and operates the only publicly funded, 86-bed psychiatric hospital in Southern Nevada. It also provides a host of out-patient services and residential programs.

And some clients report receiving services from the state that literally saved their lives.

"The state system is very important and without it I would certainly be dead, I would have killed myself," one client who suffers from bipolar disorder said. "The nurses and case managers there have been wonderful to me."

But other clients of the system are less enthusiastic.

A statewide task force of mental health providers and advocates prepared a position paper in December that points out dozens of shortcomings within the state system.

Gaining access

While the state is earmarking dollars to improve residential and community-based programs, one problem lies in the central access point to the system -- the emergency observation unit.

"That system is our heart and soul," Brandenburg said. "It's our window to the community."

Problems, critics say, start the moment a client walks in the door at the 10-bed observation unit on the Southern Nevada Adult Mental Health campus.

"Sometimes people have to wait for hours," Stevens said. "And the way they are treated when they come in can be very cold. We're talking about people who may be in a psychotic episode, and they are scared and sometimes their perception of reality is distorted. But they are greeted through a sliding window, told to wait -- but not for how long -- and then the window is shut."

"The danger is that they will give up and leave," Stevens said.

Chelsea Szklanya, director of performance improvement at the facility, said the staff is working to address the issue.

"The waiting area does have a protective window, and I understand the perception of coldness," Szklanya said. "These are real issues. In terms of staff attitude, we've recently started using peer counselors to constantly give the consumers' vision of things, and I think that will help."

The observation unit serves as a kind of gatekeeper for admission into the hospital or into the out-patient services system. Patients may stay in the observation unit up to 48 hours. With only 10 beds for the entire Southern Nevada indigent mentally ill population, the wait has increased from 30 minutes in 1998 to several hours today, a national alliance representative said.

Northrop said his department is planning to expand the observation unit to 20 beds this spring.

Another concern is that the observation unit does not have the ability to "medically clear" patients, although by law they must be medically cleared to be admitted. Thus, there is a well-beaten path between local emergency rooms and the mental health campus at 6161 West Charleston Boulevard -- and indigent patients who must be taken by ambulance for medical clearance must pay for their ride to and fro.

Local emergency room employees have been complaining for months that they have psychiatric patients taking up beds in their overcrowded ERs and cannot get those patients transferred quickly enough to Northrop's observation unit.

Last week Northrop implemented a new admission procedure in the observation unit in an attempt to alleviate that problem. Now one person is scheduled every half hour to be admitted from local emergency rooms.

"By all reports (it is) working well," Northrop said.

Further, there is no central computer system to make patient information about prior treatment within other branches of the system available around the clock to psychiatrists in the observation unit. Therefore paper patient files are often not available for several days.

Brandenburg said he has received $300,000 from the governor to prepare a "re-engineering plan" for the computer system, and that then his agency would go to the Legislature to approve funding for a new computer system.

After being appropriately medicated or guided through an acute period of psychotic symptoms, 65 percent of patients go from the observation unit back into the community with recommendations to pursue out-patient care.

However, there is a yearlong waiting list for a case manager, so many mentally ill people are released to fend for themselves -- and often stray from the system.

"We do have a waiting list," Szklanya said. "But most of the people who are seriously mentally ill do get assigned a case manager." There currently are about 125 people on the waiting list. Northrop said there are several vacancies for case managers -- and, he said, there are several vacancies for permanent psychiatrists on his staff.

"For some reason, it's difficult to recruit psychiatrists here," Northrop said. In lieu of permanent staff, Southern Nevada Adult Mental Health Services contracts with three "rent-a-doc" businesses from out of state, which provide psychiatrists to serve, routinely, three-month stints in the Las Vegas area. Northrop said there are 14 psychiatrists on staff, usually five onduty at the hospital during a shift, and none in the emergency observation unit on weekends -- "but one is always oncall," he said.

Future funding

"The state, in terms of mental health care, is a safety net for the indigent," Brandenburg said. "Our priority is housing and medication. But we work within budget limitations."

In 1995 the Legislature approved an $11 million increase in mental health services; in 1997, a $25 million increase; and in 1999, a $34 million increase. This year the governor's budget includes a $47 million proposed increase to cover increased medication costs and a new 12-bed residential program, among other things, Brandenburg said. "The explosion in growth down there (in Las Vegas) has had a tendency to tax the system," Brandenburg said. "But we're making a really concentrated effort to keep up." The agency plans to make its pitch to the Legislature for the increased funding on March 1.

"I'm optimistic. I think we've come a long way, and I think we're doing well -- within our resources," Northrop said.

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