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Texas falls short on mental health access, spending

June 1, 2017 | By Marie Leonard, Wendy Cawthon and Zac Ezzone

With more than 500,000 Texans suffering from serious and persistent mental illness and 1 in 5 Texans experiencing a mental health condition each year, behavioral health continues to be a problem with no long-term solution in sight.

While lawmakers locally and statewide are working to allocate more money toward mental health services, health care providers and Greater Houston area officials say funding is still not enough to keep up with the growing population and provide services needed to keep individuals with behavioral health problems off the streets and out of jail.

“The biggest problem we have with mental health is the [number] of people with mental health issues [that] end up in Harris County Jail,” Harris County Judge Ed Emmett said. “It’s the largest mental health facility in the state of Texas, and that is not something to be proud of. But the way our criminal justice and mental health system works, if you’re picked up on a minor crime, you go to jail, when in fact the real issue is a mental issue.”

Funding shortfalls

Senate Bill 1—the Senate’s proposed state budget for the 2018-19 biennium—allocates $3.4 billion for behavioral health services, including counseling, crisis intervention services, pharmacological management and hospital care services. As of press time, the bill had not yet been adopted.

The amount of funding has increased over the past decade, up from $1.9 billion in 2012-13, according to the House Research Organization.

“The Texas Legislature, the last few sessions, has increased funding for mental health services, but we’re still running close to dead last nationally in funding of behavioral and mental health infrastructure for our citizenry,” said Theresa Fawvor, associate vice president for Memorial Hermann Behavioral Health Services.

As the state’s population grows exponentially each year, there is not enough funding in the state budget to adequately serve its residents’ mental health needs, Fawvor said. This often leaves counties and health care organizations having to bridge the gap locally.

“The burden, as it usually does, falls most heavily on programs and resources in bigger counties,” Montgomery County Sheriff Rand Henderson said. “Smaller counties [are] usually where funding goes.”

County officials said they are hopeful as state lawmakers continue to allocate more and more money for behavioral health services, but until they do, resources will remain limited.

“The good news is, in a world that’s become very partisan and very uncivil in terms of politics, nearly everybody agrees that mental health is an issue we can all work on,” Emmett said. “That’s why we’re beginning to see more funding at the state level. I think we should be doing a lot more, but at least everybody is saying the right thing and we’re moving in the right direction. We just aren’t moving fast enough.”

Law enforcement involvement

Emmett said on any given night in Harris County Jail, there are as many as 3,000 inmates who need—or are currently on—prescription medication for behavioral health issues. To help lower this number, Emmett said the county is working on various programs to keep individuals from cycling in and out of jail, including a jail diversion program funded through the state.

As part of the program, the county works with law enforcement to identify individuals with multiple arrests who have potential behavioral health issues. Instead of booking them again in the county jail, individuals are referred to health care professionals for medical care.

“The next time they get picked up, rather than putting them in jail [and] going through the criminal justice system, we divert them to—if not the Harris Center [for Mental Health]—then some of the nonprofit organizations in town,” Emmett said. “Because they really aren’t criminals, they really have mental issues.”

In Montgomery County, officials have also been working to keep individuals with behavioral health issues out of jail.

In fall 2016, the county launched a mental health court designed to address the population of people with crime offenses associated with mental illnesses.

“The judges are the ones who had to see them all the time,” said Gloria Kessler, director of the Montgomery County Mental Health Court. “They were saying, ‘What can we do to help these people?’ Because they don’t belong in [the] system. There’s criminal behavior and there’s behavior that’s criminal due to mental illness.”

The court has about 15 cases in the system as of late May, with a capacity for 60. Kessler said the court has helped to cut down on repeat offenders who suffer from a mental illness, but many with more serious illnesses are not always good candidates for the court.

“There [are] still some people who cycle through. We can’t grasp them because they don’t see that they have an illness,” she said. “We only take the ones that are able to care for themselves. In this court, they have to have some wherewithal to know they have to go to court once a month. If they’re able to care for themselves and take care of business as far as the probation part of it, we let them in.”

For those in the jail system, Henderson said his department is working to better identify those with behavioral health issues to keep them from hurting themselves and others and expand the level of medical care.

“We have extremely basic mental health care in the jail now, [and] we are looking to expand that,” he said. “If we can prevent recidivism—keeping [individuals with behavioral health issues] from coming back by getting them med[ications] that stabilize them and making them part of society—then we all benefit.”

Increasing access

Local law enforcement and health care officials said individuals with behavioral issues are better off when they are in treatment and out of jail. However, finding a doctor for basic and emergency mental health services is a challenge in the Greater Houston area.

The state ranks 46th in mental health care accessability, according to national nonprofit organization Mental Health America. For individuals who do not receive ongoing care for mental illnesses, such as depression or psychosis, symptoms can become a crisis, resulting in a trip to the emergency room for medications or intervention, Fawvor said.

“Access is the significant problem, because of the limited number of specialists in the community providing ongoing outpatient treatment,” Fawvor said. “Even people with great insurance coverage have access problems. If you’re depressed or suicidal or psychotic—and you have great insurance—it’s still six to eight weeks out before you can get an appointment. So what they end up doing because of the access issue is they end up going to our emergency room.”

While the Tomball and Magnolia areas do have some access to mental health services, such as Lone Star Behavioral Health in Tomball and Tri-County Services in Montgomery County, funding sources differ from facility to facility.

Lone Star Behavioral Health in Tomball is an outpatient facility that offers treatment for depression, equine-assisted therapy and group therapy sessions as well as alcohol and drug rehabilition for substance abuse issues. The organization also operates a 24-bed inpatient hospital in nearby Cypress.

“It’s mostly Medicare is what we deal with and some private [insurance], but [we don’t receive] state funding at all,” said Nathan Ingram, owner and CEO of Lone Star Behavioral Health.

In comparison, Tri-County Services recieves all of its funding either from the state or private contributions, according to Tri-County officials.

Additionally, Fawvor said there are generally not enough psychiatrists in the Greater Houston area to work with patients, as it can often be one of the more demanding but underpaid specialties available to medical students.

To help combat the number of behavioral health patients ending up in ERs and jails, Favwor said Memorial Hermann Health System is working with primary care physicians in a pilot program—already taking place in the Greater Houston area—to reach patients before a disorder becomes unmanageable.

“What we’re trying to do with our behavior health continuum is try to move it from a crisis stage to more of a prevention stage,” she said.

The hospital system already operates three mental health crisis clinics in Houston that accept patients regardless of insurance or appointments. In 2015, the system also partnered with Harris County to operate a satellite clinic within the jail to connect behavioral health patients with services, such as ongoing treatment facilities, housing assistance and other basic services, to help prevent the same individuals from returning.

Because there are no plans to add more clinics in the near future, Fawvor said until more resources are added to the area, mental health will continue to be an issue locally.

“With our limited public resources, those individuals are just recycling in and out of jail, in and out of our emergency rooms, really not able to access good stabilizing treatment for the amount of time their mental health diagnosis really requires,” she said. “It’s really a broken system that is perpetuated by lack of access, lack of resources [and] lack of specialists.”

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