Frequent Fliers

Like many mentally ill people in Texas, Jackson Ngai may now be getting the best care of his life, in jail. At the very least, jails usually provide a controlled environment, plenty of free medications, and someone to make sure that you take them. Compared to the state's underfunded, outdated system of community health centers and state hospitals, that's relative security. Chances are that even if Danielle Martin were still alive, Ngai would have landed in trouble. Institutionalized twice within a few months, he was well on his way to becoming what people familiar with the system call a "frequent flier."

Frequent fliers are the system's most glaring failures. They cycle through state hospitals and community health centers – and emergency rooms, courts, homeless shelters, and jails – never stabilized for much longer than it takes them to be discharged. There's no exact count for the number of frequent fliers in Travis County, but APD estimates that half of all the mentally ill people they take into custody have been picked up before.

The reasons for relapse are complex, but most mental health advocates lay some responsibility on the hospitals and community health centers. A 2002 study by Dr. Marcela Garces of UT's Center for Disability Studies found that the best predictor of whether a mentally ill person will be hospitalized was whether they have been hospitalized before. It may be an exaggeration to conclude from this, as some in the advocate community do, that the old system was making people sick. But clearly too much of the time it wasn't making them well.

When mental health patients relapse, Garces found, it's usually because, like Ngai, they've stopped taking their medications. Medications are no silver bullet, however. Garces' study also found that for patients to stay on medications generally required a complex system of other supports: friends and family, stable living environments, responsive doctors, and some understanding of their own illness. A prescription alone was nearly useless, Garces found, but it was all that most community health centers and state hospitals were able to provide.

Mental health advocates echo that finding. "We've been real good at giving people pills," says Mike Halligan, executive director of Texas Mental Health Consumers. "But to someone living under a bridge, a pill's not going to do a lot of good."

The question of why our public mental health system fails so often and so badly is hotly debated, and some theories fall just shy of conspiracy. Some accuse community centers of treating Medicaid-qualified consumers before indigent ones, since Medicaid reimbursements recoup at least some of the costs of care. There's also a widespread perception among mental health advocates, consumers, and even some state mental health employees that some community centers skim the mentally ill population for the least-sick consumers, who are cheapest to treat.

The simplest reason why community centers don't provide holistic care – the reason that encompasses most conspiracy theories – is that they can't afford to. Texas ranks 47th in per capita spending on mental health care. The state sets the number of clients community centers must serve in annual performance contracts. Targets are not set by the number of mentally ill people in the area, but by how much the state is able or willing to spend. In 2003, ATCMHMR served 50% more patients than contracts required; even so, the center still treated only 36% of eligible adults seeking treatment, and 23% of the children.

Much of the system is also outdated, experts and advocates say, a relic from days when all mental illness was considered a lifelong, incurable burden. Pharmaceutical and therapeutic research has proved that assumption wrong, but the state system has been a long time catching up. In the past, rather than providing the extra services it would take to recover, the system has provided, at best, continuous medication, with hospitalization for times when medication inevitably fails. "There is this idea that once you are in the system, you are a lifer," says Linda Parker, CEO of the Hill Country MHMR in Kerrville. "That's why the system is perpetually overcrowded. You cram everybody you can in the front door, and you say, 'That's it. That's all we can take.'"

Under Parker's direction, for the past three years the Hill Country center has been a pilot model for "disease management" – the state's new approach, fully implemented Sept. 1, that is supposed to revolutionize mental health care. (See "Managing Disease – or Money," p.34.) Disease management is based on the idea that people with mental illnesses may get well, either permanently or for long periods of time. Since implementing the system, Parker says, the center has seen fewer hospitalizations for mental illness in the area, and a drop in the demand for crisis services. Parker points to numbers like these as indicators that the model is working. "Mental health is fluid," Parker says. "People can and do recover. They deserve to recover. It is possible."