LV homicide puts mental health system under a microscope

By Steve Kanigher

Friday, Oct. 10, 2003 | 5:39 a.m.

Frank Lyles walked up to an innocent bystander, shot him to death, walked away and then wounded two policemen before he surrendered last month in central Las Vegas.

No one disputes that.

But no one truly knows why 26-year-old Lyles pulled the trigger.

Afterward, Lyles told Metro Police he "always wanted to kill a person" and in doing so had carried out his "dream," according to the arrest report. But he also told his interrogators that he was schizophrenic and under a doctor's care, the police report notes.

Lyles' attorney, James "Bucky" Buchanan, later said his client had been off his medication for days at the time of the shooting. State clinic workers had refused to give it to him two days before because Lyles had arrived late for his appointment, Buchanan said.

Because the state system failed to keep Lyles properly supplied with the medicine he needed, it now has blood on its hands, according to Buchanan.

Nevada's mental health care system has long been criticized as overburdened, underfunded and unable to handle its caseload. It is but one facet of a social service network that has not kept pace with Nevada's rapid population growth, resulting in a safety net that rates poorly when compared with most other states.

The question is whether the system was ripe for this kind of incident.

Buchanan says it was. If Lyles goes to trial, Buchanan said he intends to "try the state of Nevada for its indifference in not giving him his medication."

"The jurors will want to know why this guy didn't take his meds," Buchanan said. "It's only when you take him off his meds that he becomes violent."

Lyles became violent about 5:30 p.m. on Sept. 25. He had never seen 49-year-old Kevin Chandler before. Lyles picked him at random on the street, and the shooting was unprovoked, police said. Lyles just walked up behind Chandler and shot him in the back. Then, as Chandler pleaded for his life, Lyles shot him several more times, including at least once in the head, numerous witnesses told police.

As police arrived following a flurry of 911 calls, Lyles reloaded his .22-caliber handgun and fired at the head of the closest officer, striking him between the eyes and lodging a bullet in his sinus cavity. Another officer suffered a wound in the head. Police say both men are recovering.

Whether Lyles' rampage can be blamed on the state system is a question that the Nevada Commission on Mental Health and Developmental Services intends to answer as the Lyles case moves through the courts. Buchanan's plan is to have his client plead not guilty by reason of insanity to charges of murder and attempted murder.

Commission Chairman David Ward is reserving judgment but said the Lyles case is unusual for Nevada.

"I haven't seen a case of this nature before," Ward said. "It sounds like a terribly tragic situation and one that the commission will want to look at to see if any systemic changes need to be made. But I wouldn't second-guess anybody at this stage."

Clark County District Attorney David Roger said his office intends to prosecute Lyles as charged. He's not ready to embrace Buchanan's argument that the mental health system failed Lyles.

"I'm not sure if I'm the best person to discuss mental health care in Nevada," Roger said. "The two issues I see are, one, is he competent to stand trial? And the second issue is insanity. Did he know right from wrong?

"There are facts out there that would suggest he did know right from wrong at the time he shot the one man and then the two police officers."

Mental health professionals and advocates have long complained that mentally ill Nevadans have been neglected when it comes to state funding. They say the system has not kept pace with rapid population growth. In July there were 16,614 Nevadans who received mental health services from the state, a 9.7 percent increase from the 15,139 clients served by the state in July 2002.

The four Las Vegas Valley state clinics dispense medication to 6,500 uninsured or under-insured mentally ill people but mental health professionals say there isn't enough staff to properly serve all of them.

Lyles was supposed to receive his medication from the state-run clinic in North Las Vegas on Sept. 23, but he arrived late and was told to return on Sept. 26, his lawyer said. Lyles' apparently fragile mental state didn't hold together long enough for him to return on that day, however.

He had been without his medication for about five days on the day that clinic personnel sent him away without a refill, his lawyer says. On that same day he picked up the gun that he would use two days later.

But Roger said the fact that an individual was allegedly denied medication before committing a crime "may be a factor in explaining a person's conduct or state of mind but it's not a defense."

"You have to take a look at the person's mind at the time," Roger said of the crime.

Police concerns

Police have no idea how many mentally ill people are out in the community, Metro Officer Jose Montoya said.

"We can't predict the behavior of people so we don't know how many others are out there," Montoya said. "Most information on mentally ill people is personal information and won't show up in any system that we have here. If someone is in and out of a mental hospital, there's no way for us to know that."

Mentally ill people are not supposed to be able to buy handguns. But it was easy for Lyles to get around that prohibition. When Lyles filled out the paperwork for the gun, "he checked that he wasn't mentally ill," Metro Lt. Tom Monahan said.

"It is a system based on self-disclosure," Monahan said.

Monahan said that only a small percentage of homicides are committed by mentally ill people. The bigger concern for police, he said, are the hardships endured by patrol officers who come into contact with mentally ill individuals on the street.

That is why Metro has formed crisis intervention teams of patrol officers who are trained to deal with such individuals, Monahan said.

"Patrol officers routinely confront people in various stages of mental illness and have to deal with them with little support," he said.

Earlier this year, Metro secured funding from local governments, hospitals and the state to open a mental health treatment center at WestCare in Las Vegas, which provides substance abuse treatment programs. The mental health center serves as an alternative to taking mentally ill individuals to jail and has already seen 3,000 patients this year.

The problem is that Metro was counting on a $3.8 million budget for the center this fiscal year and is short $677,333, money it argues should come from the state. Metro will request the funding on Oct. 20 at a subcommittee hearing of the Nevada Legislature's Interim Finance Committee. Without those added funds, Metro has said there might have to be staffing cuts at the mental health center.

As for Lyles, his fate is a matter for the courts to decide now, say members of the policymaking state mental health commission.

But they and other mental health experts say that Lyles' case illuminates the chronic shortcomings of mental health care in Southern Nevada. Those shortcomings, they say, include woeful lack of funding, staffing, facilities and programs to care for mentally ill clients, and the fact that such individuals frequently skip or abuse their medication or miss clinic appointments.

Still recovering

Despite a 33 percent increase in state mental health funding over the next biennium, Nevada still hasn't recovered from severe funding cuts in mental health services attributed to the recession of the early 1990s, Dr. Rena Nora, psychiatry professor for the University of Nevada Medical School, said.

"We all recognize that we're still not near the ideal or required levels in terms of staffing both for outpatient and inpatient services," Nora said. "We haven't really been prepared for the population growth. And the other problem is a lack of space. We only have so many beds.

"This has been a very bad year for the state because of budget austerity. For mental health, we can't complain because we got an increase. But it's not enough to catch up."

While experts say they cannot recall another local case quite like Lyles', they say that there have been numerous situations nationwide where mentally ill individuals committed acts of violence after being off their medication.

Nora, a state commission member who was former chief of psychiatry for the Veterans Administration in Southern Nevada, said the impact of being off medication for at least a week depends on the individual.

"At least 85 percent will go into a relapse of their symptoms," Nora said. "If they are schizophrenic, they can have hallucinations or delusions and there could be feelings of hopelessness. It could result in poor judgment."

Buchanan said he had not yet ascertained Lyles' complete medical history. But the attorney said he understood that his client had been living with his parents as an adult, had no prior criminal history or known gun use, and had taken his medication regularly.

"What transpires when he doesn't have meds for seven days is the $64,000 question," Buchanan said. "I have had a lot of other clients on meds. You take them off meds and they commit a crime. I have two clients in prison now because of that. One was a sex (crime) and the other was an assault."

Lyles was a client of the state-run Southern Nevada Adult Mental Health Services clinic at 2121 Las Vegas Blvd. North in North Las Vegas. That agency, part of the Nevada Division of Mental Health and Developmental Services, operates the four valley clinics.

A fellow client in North Las Vegas, who requested anonymity, said Lyles was agitated as he left the clinic on Sept. 23 -- rejected and rescheduled for showing up late.

After learning about the shootings, Lyles' fellow client said she was surprised Lyles didn't get violent at the clinic.

"The blood is on their hands because he was definitely psychotic," she said. "It's a very bad system there. They didn't give him his medication because he missed his appointment. That's what he was complaining about."

Carlos Brandenburg, director of the state mental health division, said earlier this month that his agency intended to review its policies in light of the shootings.

Low-key bungalow

The North Las Vegas clinic in question is housed in an old bungalow-shaped building that is so low key it can easily escape notice by a passing motorist. Whether or not this is by design, one issue mentally ill individuals constantly grapple with is the stigma attached to mental illness, something medical professionals have tried to combat by educating the public.

The clinic is nestled along a stretch of North Las Vegas Boulevard that is frozen in time, passed up by newer development that has sprung up over much of the valley over the past 20 years.

The plain, rectangular-shaped lobby inside looks like a small bus terminal. Although only two individuals were waiting in the lobby one morning earlier this month, there was a constant flow of clients in and out of the facility.

While the state is not commenting on what happened with Lyles the day he arrived late for his appointment at the clinic, Jonna Triggs, clinic director for Southern Nevada Adult Mental Health Services, said the agency continues to be plagued by understaffing.

The four valley clinics combined are budgeted for 345 clients per doctor, but Triggs said the caseload is closer to 800 clients per doctor.

"That means we're swamped," Triggs said. "The Legislature approved a 33 percent increase in our funding but that's not enough. When we have 5,000 to 6,000 new residents a month and 7 to 10 percent have mental health issues, it's easy to see we're not keeping pace."

Statistics provided by her agency show that the percentage of new clients who must wait at least 15 days for their first medication appointment after referral had climbed from about 33 percent in 2001 to more than 50 percent by June.

Triggs said the high client-to-staff ratio is compounded by the fact that clients miss their appointments 25 percent of the time. If clients miss an appointment but show up that day anyway, they are seen by at least a trained nurse for a medical assessment, Triggs said. Normally, only those individuals deemed to be in immediate crisis are dealt with at that time.

On standby

Others who miss appointments and are not deemed to be in immediate danger are given standby appointments to return, usually within the next two to three days, if not sooner, officials said. Although Triggs declined to comment on Lyles, citing confidentiality, he apparently got a standby appointment because he was asked to return later that week, according to his lawyer.

"We handle the standbys as fast as we can," Triggs said. "We triage all the time."

By "triage," Triggs means that the clinic's staff has had to set priorities about the individuals it deems to be in most need of immediate attention. That same medical philosophy is used in response to mass casualty disasters, when there is often a shortage of medical staff and supplies to treat all injured people.

Mental health professionals say that clients don't get automatic refills of medication without a medical assessment. Otherwise, many would abuse those medications or sell them to someone else to support a vice such as a cocaine habit.

"We have a lot of severely mentally ill patients who have a co-occurring disorder such as dependence on alcohol, cocaine or heroin," Nora said.

The state commission that will review Lyles' case is made up of mental health professionals and lay members appointed by the governor. The commission normally reviews homicides and suicides in Nevada involving mentally ill individuals with the intent of correcting flaws in the system.

Whether the system can be blamed for Lyles' actions is yet to be determined. He remains in Clark County Detention Center on charges of murder and attempted murder.

Buchanan said he intends to have at least two psychiatrists examine Lyles, and Buchanan said he may keep Lyles off medication for at least a week to try to replicate Lyles' mental state at the time of the shooting.

Buchanan said his ultimate intent is to have Lyles committed to a state hospital.

Ward, the state commission chairman who owns a Reno advertising agency, said one of the biggest problems in the mental health system involves individuals who skip their medications.

"That's a continuous problem that mental health workers constantly are facing," he said. "It's human nature to miss your medications but if you're mentally ill, it creates enormous problems. Workers in mental health care are constantly looking for new ways to keep patients on their meds.

"We have discussed issues having to do with the difficulty of access to medications and it is a continuing concern."

Medication, or the lack thereof, also is a key issue in another case involving valley resident Sylvia Ewing, who was charged last month with beating her two children to death with a baseball bat. Her husband told police that she was being treated for mental illness and saw a psychiatrist regularly but had stopped taking her medication. Ewing's lawyers say doctors have determined that Ewing suffers from auditory hallucinations.

Las Vegas psychologist Elizabeth Richitt, a commission member who used to work in the state mental health system, said that when mentally ill individuals are on their prescribed medication they typically are no more violent than anybody else. But violence can occur when the clients are off their medications, she said.

"What the mental health system tries to do is to prevent these kinds of events," Richitt said. "Part of what the commission does is to review an event and if something wasn't done, to find out why. We try to determine what could have been done differently."

But typically, a case involving an alleged homicide will work its way through the courts and be scrutinized by the state mental health division before the commission gets involved. Once the commission gets involved, it could still take months for a recommended policy change to be implemented simply because of the time it takes to hear testimony and review the information.

"Every time there is a death report we review all the factors that might have contributed to it," Ward said. "Nothing is off the table."

One criticism mental health professionals have is that the state does not do enough follow-up on the status of its mentally ill clients.

But the future of mental health care in Nevada is pointing toward increased use of community treatment programs that rely on teams of medical professionals -- psychiatrists, psychologists, social workers and substance abuse counselors -- to closely monitor clients to ensure they are taking their medications and becoming productive citizens.

The frustration for Reno resident Rosetta Johnson, one of Nevada's leading mental health advocates and the mother of a schizophrenic son, is that there is not enough state money for these programs.

Johnson said the advantage of community treatment programs is that members of the medical teams closely follow their clients.

"It's like a hospital without walls. But we need money for more workers," she said.

Johnson happens to have a friend in state Sen. Randolph Townsend, R-Reno, who has been working with her on mental health care improvements in Northern Nevada. Townsend, who served on a national mental health panel as an appointee of President Bush, is chairing the Nevada Mental Health Plan Implementation Commission that will review the national recommendations to determine whether they should be tried in this state.

Townsend, who wields major influence in state funding for mental health care, agreed with Johnson that future funding should be directed toward community treatment programs.

"That's where we want to concentrate our efforts," Townsend said. "But in our burgeoning society in Nevada there will always be a greater demand for services than supply. Usually, the challenges we face are a function of money. Growth is killing us, particularly in Southern Nevada."