The recent school shooting in Connecticut reverberated across Virginia five years after a mentally ill gunman, Cho Seung-Hui, took the lives of 32 of his fellow students at Virginia Tech in April 2007. Mental health professionals throughout the state reflected on changes Virginia has made in mental health care since — and more changes they say are still needed to prevent such tragedies.
"I'm feeling very vulnerable. It's going to happen again in Virginia. There are so many people not getting the services they need. We're just lucky we haven't had a major incident," said Chuck Hall, executive director of the Hampton-Newport News Community Services Board. In 2007, Hall was a member of the Virginia Commission on Mental Health Law Reform, which was six months into a 3-year review of Virginia's mental health care system.
The horror of the nation's worst school violence redirected the commission's efforts to the specific issues involved, including the monitoring of mandated outpatient treatment and the balance between protecting a patient's privacy and the community's safety. Hall acknowledged progress in those areas.
However, the change in criteria for mandatory outpatient treatment, making it the same as for inpatient treatment, hasn't worked, Hall said. "We probably haven't seen more than a dozen since Virginia Tech," he said. "Magistrates, the first tier in the judicial process, aren't going to risk outpatient when the criteria are the same as for inpatient." Jim Martinez, director of mental health services for the state's Department of Behavioral Health Services, who worked with the reform commission in a staff capacity, acknowledged that the use of outpatient commitment went down in 2009. To encourage its use, a 2010 law tweaked the process to allow a judge to authorize such treatment after involuntary inpatient commitment. The state doesn't have any data on the results.
Other changes recommended by the commission were successful. "There were several big, important outcomes," said Hall, citing the expanded training of first responders, more crisis stabilization units, and the establishment of advance directives for those with a psychiatric diagnosis.
Not enough funding
The will was there after Virginia Tech, but the funding didn't come through. "We didn't increase the other community-based resources, such as supervised housing, crisis response for children or more access to outpatient psychiatric services," said Hall. He pointed to the precarious situation of assisted living homes, such as Ashwood in Hampton, which is threatened with closure.
Virginia continues to be underfunded. In fiscal year 2010, Virginia spent $47 per capita on community based mental health services, including funds for those in jails or prisons. That puts it 36th out of the 50 states in per capita spending, according to the National Research Institute. The average is close to $88, according to Mira Signer, executive director of the National Alliance on Mental Illness Virginia. "Since 2008, it has been a yo-yo situation with cuts from 5 percent to 15 percent. Last year there was a little bit of money for children and jail diversion. A drop in the bucket," she said. She cited a recent survey that showed 4,500 Virginians waiting for mental health services — 3,000 adults and 1,500 children; and stated that almost 1 in 4 jail inmates have mental health issues and cost the system $13 million annually.
"Funding is nowhere what it should be for the community service boards; they are not staffed to where they should be to meet the needs of the people in the community," agreed Robert Williams, a Peninsula volunteer with the National Alliance on Mental Illness.
Are privacy laws the problem?
After Virginia Tech, the Health Records Privacy Act clarified how mental health records could be shared among providers and law enforcement, allowing for earlier intervention, and greater consistency and coordination for more effective treatment, said Martinez. "The aim was to make sure there were no impediments to the appropriate exchange of information," he said.
The involuntary commitment law came more in line with other states and, according to Signer, "strikes a pretty good balance" between protecting the patient's rights and the community's safety. "You want strong legal protections in place so people aren't being detained unnecessarily for psychiatric reasons. Virginia does a good job balancing the rights of individuals and treatment," she said. The change clarified the previous language requiring that a patient pose "imminent danger" to themselves or others to "substantial likelihood," an easier measure for the courts to define.
Signer believes the privacy laws are misunderstood. "They would never impede someone getting help for someone," she said. Bill Ritchey, executive director for health and counseling services at Christopher Newport University, concurred. "We're taking a larger scale view, less individualistic. We're trying to be more integrative in how we communicate and act preventatively," he said. In the past few years Ritchey has seen an increased awareness among the campus community and greater sensitivity to mental health needs. "The work we do today is very different. Students are much more amenable to seeking treatment," he said, and it's not unusual for them to want to include their parents. Ritchey has seen more and more of the center's referrals come from students who themselves have benefitted from counseling.
The peer model
The peer-to-peer model, along with education and awareness, is considered key to effective mental health care delivery to the general population. "Twenty five percent of the population is going to have a mood disorder in their lives," said psychiatrist Johanna Hoffman, board president of the advocacy group Mental Health America of Virginia. She's worried that publicity surrounding mass shootings prevents people from seeking help early on in their disease when it's most treatable. Like Ritchey, she believes in an integrative model involving the family. She also works to involve peers, those who've had a psychiatric emergency who can communicate with others. "As a physician I've never believed that a pill will do it. Using peers in the recovery movement — 'I've been there, done that' — gives people hope," she said.
The local chapter of NAMI offers several free peer-to-peer and family-to-family counseling and training groups and has recently adapted its programs to serve veterans, according to Williams, a NAMI volunteer.
Local mental health professionals all agree that improved access to mental health care is essential. Though private insurance companies are now required to offer parity between physical and mental health coverage, there is no uniformity among plans. "There's a mandatory minimum but it varies on whether it's individual or group," said Signer of NAMI Virginia. Often insurers limit care to inpatient stays and certain medications and don't cover long-term intensive supports, she said.
For those without private health insurance, the future isn't promising, according to Hall. He sees the separation of the state's overseeing agency, the Department of Behavioral Health Services, from the financing arm, as the core problem . "Public policy is to fund public mental health services with Medicaid. At the same time it's being described as the culprit, at 21 percent of the budget," he said. Yet Virginia has such stringent eligibility rules that it doesn't cover single adults. "Good luck getting them into health care," added Hall, whose agency served more than 15,000 people last year and spends $5 million annually in uncompensated care.
"We're at risk," he said.
Call your local community services board; or, the "warm line" at the Mental Health America of Virginia, 804-257-5591; or go to the web site of the local chapter of the National Alliance on Mental Illness, http://www.namihptnn.org. In an emergency, dial 911.Copyright © 2014, Los Angeles Times