When Arizona Gov. Jan Brewer took office in 2009, she restored funding to a mental health and drug treatment program. She also forced state agencies to justify their funding requests by arguing why their needs were greater than those of programs for the mentally ill.
Throughout her political career, Brewer had championed mental health services, though rarely discussed one connection: Her son Ronald has lived in a state mental facility for much of the last two decades. He had been found not guilty of kidnapping and sexual assault by reason of insanity.
Yet, in 2010, Brewer agreed to cut in half state funding for the Department of Health Services, reducing services to about 14,000 mentally ill Arizonans.
Brewer's reluctant acquiescence to the cuts reflects not only the state's dire budget crisis — it must fill a $1.2-billion budget chasm this year — but the tough battle mental health advocates face in securing funding for such services.
Across the country, mental health advocates say, cash-strapped legislatures have been chopping services for the anxious, depressed and schizophrenic. Since 2009, states have shaved more than $2 billion from such programs and axed more than 4,000 inpatient beds, said Michael Fitzpatrick, executive director of the National Alliance on Mental Illness.
About one-fifth of states have passed or proposed cuts in mental health budgets for the next fiscal year, according to the National Conference of State Legislatures.
In California, Democratic Gov. Jerry Brown has proposed that funding remain essentially intact. The state has struggled since the late 1960s, when then-Gov. Ronald Reagan began emptying its psychiatric hospitals, with how to handle its mentally troubled population.
Brewer said scaling back mental healthcare was one of the most painful decisions of her career. Now lawmakers are expected to make even more cuts.
The proposals come even in the aftermath of the shooting that left six dead and a congresswoman badly wounded. There's no indication that the accused gunman, Jared Lee Loughner, was formally diagnosed with mental health problems. But the rampage and Loughner's widely documented incoherent rants have thrown a spotlight on the need for mental health services.
To be sure, the recession has drained money from most public services. But mental health advocates are burdened with significant disadvantages in pleading for more cash.
Explaining mental illness is messy. Its effects are often imperceptible, with no equivalent of a wheelchair or a wound. Its origins are often misunderstood, as is the costliness and complexity of treatment. Its advocates typically hold less political sway than teachers, firefighters and nurses.
Most of all, those who suffer severely from it, like the homeless and the imprisoned, draw little sympathy from outsiders. "Unless you got a family member or have some direct experience, you don't know and you don't care," said lawyer Charles Arnold, a longtime mental health advocate in Arizona. "It's dreadful, and it's sort of a time bomb."
Arizona provides an extraordinary case study.
In 2009, the state's mental health system was considered middling by the National Alliance on Mental Illness, or NAMI, which gave Arizona a C grade. But the group also praised several innovations, including screening and treating troubled inmates.
For example, a state law long guaranteed help to the mentally ill who sought it. "The test will be whether progress can continue in the face of the current economic downturn," said the NAMI report.
The observation proved prophetic — the guarantee of help has been suspended because of the economic crisis.
In the last fiscal year, revenue-starved lawmakers sold state buildings, froze enrollment in a children's health insurance program and slashed payments for organ transplants. At least two patients denied transplant coverage have died, according to news reports, prodding lawmakers to consider restoring funding.
Critics said the budget crisis handed the conservative Legislature an excuse to whittle down services it believed the government had no business providing. Republicans countered that they had little choice when confronted with such a yawning gap.
"There's no doubt that this governor has demonstrated a long track record and strong support of mental health funding for this state," said Paul Senseman, the governor's spokesman, who declined to comment on Brewer's familial link to the mental health system.
A former Republican state senator, Carolyn Allen, said Brewer had no choice but to cut programs dear to her. "I know in her heart that she cares," Allen said. "I know she is overwhelmed."
Allen too has a personal reason for defending psychiatric care. When she was a child, her father died in a state mental hospital and her brother in a public sanitarium. "I lived in my family with the ramifications of what mental illness does to destroy a family," she said.
Regardless, she said, the budget crisis gave lawmakers few options. "This state of Arizona is bankrupt," she said. "Not broke — bankrupt."
Mental health advocates, however, have long said skimping on psychiatric assistance swells homeless populations and fills prison cells. That has swayed few lawmakers.
Since Arizona's cuts took effect last summer, some emergency rooms and crisis clinics — the medical options of last resort — have reported a bump in people seeking psychiatric help. At University Medical Center in Tucson, for example, requests for psychiatric consultations in the ER have jumped 20%, said Dr. Steven Herron, a forensic psychiatrist there.
Other lives unraveled more privately.
Barbara Bursuk, 54, had suffered from anxiety and depression for decades. In recent years, the drug Seroquel helped tame her manic streaks and lessen her insomnia. When the state stopped covering the cost of the drug, her doctors prescribed at least three combinations of medications the state would pay for. None worked.
Bursuk was wracked by sleeplessness, anxiety attacks and a ceaseless excitability that sped up her thoughts and wore her down. By fall, she was desperate enough to pay for the $300-a-month Seroquel herself. Bursuk subsists on Social Security and, to afford the pills, was forced to curb her use of air conditioning during Arizona's scorching afternoons.
"I felt alone," said Bursuk, who has since qualified for a discount from the drug's manufacturer. "Look at me. I look fine. You don't know what's going on behind all this."
Still, Brewer's latest budget proposal, which the governor unveiled Friday, maintains last year's cutbacks. It also rolls back eligibility for the state's version of Medicaid, which could deprive at least 5,000 mentally ill patients of services, said Bill Kennard, executive director of NAMI's Arizona chapter.
Brewer's administration acknowledges how severe the proposed cuts are.
"Nevertheless," budget documents say, "making painful decisions about how to fund and who will receive health and welfare services is critical to balancing the state budget."
Times staff writers Nicholas Riccardi in Phoenix and Rick Rojas in Los Angeles contributed to this report.