The Tipping Point

On mental health care, Austin comes up short

Reginald Demps' life should not have ended in the cold, gray stairwell of a North Austin hotel. But at the very least, his suicide ended one patient's tortuous journey through the revolving door known as the Austin/Travis County mental health system.

Demps' early exit from this world in late 2009 also chalked up another statistic, adding to Travis County's suicide rate – long the highest in Texas. It's a sad state of affairs when a nominally progressive city like Austin is ill-equipped to care for people barely hanging on by their fingernails – people who are suicidal or experiencing a psychotic break.

In this issue, staff writer Jordan Smith provides a broader picture of an overloaded, underfunded mental health system and the frustrations that go with it. In "Breakdown," Smith also pieces together Demps' final hours and his futile attempts to get the treatment he knew he needed to combat the symptoms of schizophrenia.

No Vacancy

It's unfortunate that Demps' last stop in the mental health loop was Psychiatric Emergency Services, a 24-hour walk-in clinic run by Austin Travis County Integral Care, more widely known by its former acronym, ATCMHMR. According to the clinic's most recent records, 10,707 people sought help at the East Austin facility between Sept. 1, 2008 and Aug. 31, 2009. Calculated by fiscal years, the annual caseload at the clinic has grown by nearly 1,000 each year since September 2005.

By some accounts, many psychiatric patients arrive at PES courtesy of a taxi voucher provided by one of two hospital emergency departments – St. David's Medical Center or University Medical Center Brackenridge, which is city-owned but operated by Seton. Five years ago, as part of the county's new tax-financed public health care district, the two ERs were tapped as the "temporary" solution to the growing demand for emergency psychiatric care. There, medical doctors trained to treat trauma wounds and other ailments are now required to make judgment calls on psychiatric patients. Sometimes the patient is treated, stabilized, and sent to Psychiatric Emergency Services for additional evaluation. In other cases, the ER doctor may determine the patient needs to be committed to an inpatient facility.

Therein lies the problem. It is a constant refrain from local medical providers, law enforcement, and court officials that the demand for psychiatric beds far outweighs the supply. There are 63 public beds in Travis County and 23 private beds at Seton's Shoal Creek facility and Austin Lakes Hos­pit­al, housed in St. David's medical complex on 32nd Street. As the fifth-largest county in the state, Travis lags well behind other counties, such as fourth-largest Tarrant County, which as of 2007 had more than 270 psychiatric beds, according to the Fort Worth Star-Telegram.

Jailed for Illness

Judge Guy Herman, who considers all applications for mental health commitments in Travis County, can recite a litany of anecdotal evidence to bear out claims that too many people in crisis are falling through the gaps of a tattered safety net. In the last two weeks alone, these "limbo" cases have included a 96-year-old woman who had been climbing into strangers' vehicles, a man who bailed out of a moving taxi en route to PES, and a young man who, according to Herman, was denied a bed at one of the private facilities because the last time he was there he tried to start a fire. "We're supposed to be treating these people," says Herman, "not turning them away."

Herman doesn't buy the argument that the two hospitals don't have the infrastructure to provide inpatient psychiatric treatment, and the medical staff isn't trained to treat people in a psychotic state. "Well, I wasn't trained to be a judge," the veteran judge argues, "but I got training when I became one."

Smith's reporting for her story included interviews with chief physicians at Brackenridge and St. David's emergency departments. They both acknowledge there is no financial incentive for either hospital to expand their psychiatric services. What few psychiatric beds there are at the two hospitals are there as a direct result of the 2004 voter approval of a publicly funded Travis County hospital district. While local and state dollars provided the funding to acquire the 23 beds, Medicaid doesn't cover the operating cost of beds housed in private facilities.

Without a stand-alone public facility dedicated to providing emergency and inpatient psychiatric care to Travis County residents, hundreds of people will continue revolving in and out of emergency rooms, jails, the county's walk-in clinic, or Austin State Hospital. Eventually they'll land back home or, in many cases, back on the street until the cyclical pattern begins again. "It's pretty easy for someone to end up in that jail," Herman says of the prevalence of mental illness among the county's homeless population. A homeless person picked up on a criminal trespassing charge, for example, can plead out in 10 days if he or she is deemed competent. In more serious cases, inmates can spend more than a month in jail waiting for a bed at Austin State Hospital, which serves 38 Central Texas counties. "We don't have any places to put them other than jail," Herman says.

'Coming Together'

Next week, mental health professionals and school district officials from across Texas will convene north of Austin to address the delicate topic of suicide, the 10th leading cause of death in Texas. Registration for this fifth annual statewide symposium, themed "Coming Together to Care," is at an all-time high – 400 people are expected to attend, and another 300 are on a waiting list to get in the door, says organizer Mary Ellen Nudd, vice president of Mental Health America of Texas, which is part of the Texas Suicide Preven­tion Council.

The hot topics this year: youth suicide and the rising number of suicide casualties in the military. Nudd sees the anticipated record attendance as a sign of hope. In her view, the more people talk about suicide, the greater the opportunities to identify and "catch" those who are on the brink of cashing in their chips. Nudd is also heartened by the incremental steps being made at the Legislature. Last year, Austin state Rep. Elliott Naishtat successfully shepherded legislation that allows local and regional entities to share suicide data without identifying the victims; the primary aim is to prevent suicide "clusters."

It's fitting that the first entities to sign off on a data-sharing agreement are the city of Austin and Austin-Travis County Integral Care. At next week's statewide conference, the two will receive a public policy award for being the first to step up to the plate.

Now all they have to do is deliver.

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mental health care, Reginald Demps, Guy Herman, Psychiatric Emergency Services, Austin Travis County Integral Care

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