Hands On

When the sickest of Harris County's mentally ill break down, an ACT team is there to pick up the pieces and put them back together again

When he wasn't in the hospital, Devon was put in MHMRA's outpatient program. But he invariably missed his appointments, whereby the agency would close his file. "I am wondering why Devon is not in the ACT Program. [He] needs medication, treatment and monitoring," his mother wrote. "I believe with these, he can lead a fairly normal life. Without treatment, I believe that [Devon] could snap and start killing, beginning with his family or kill himself.

"Please let this letter serve to inform you and those that are responsible for treating [Devon] that, as of today, I hold you professionally responsible for the treatment that my son does not receive from the system that is there to do just that."

Following yet another commitment to Rusk, Devon was finally admitted to the ACT program in early January. Mitchell says he also has accepted a client just released from state prison. "He called me the morning he was released and said, 'I want back in,' " Mitchell says. "Luckily we had room."

Director Tom Mitchell worries that ACT could be privatized.
Deron Neblett
Director Tom Mitchell worries that ACT could be privatized.

But not for long. The state capped Harris County's ACT program at 300 clients last summer, leaving Mitchell with only a handful of open spaces. They probably will be reserved for people who are referred by criminal court judges to mental health outpatient care, he says. As for clients "graduating" to free up slots, no one's quite ready for that. "We've got a few people who are pretty doggone close, but even they need support to stay where they're at," Mitchell says.

According to MHMRA, another 600 to 800 patients who have fallen through cracks in the community-clinic system could really use ACT. But the program is expensive -- per-patient costs range from $7,500 to $10,000 per year. At those prices, meeting the need for ACT would require another $4 million to $8 million in state funding. Mitchell has talked with Rose Childs, MHMRA's director of clinical programs, about setting up an "assertive outreach" program that would offer ACT-like services to certain high-risk clinic patients. But there is no money available for that, either.

Apparently it's a matter of priorities. Since 1996, the state's budget for prescription drugs for the mentally ill has more than doubled, to $148 million, while funding to the community-clinic system has remained flat. In 1999 lawmakers scraped together $50 million for two years' worth of the new-generation antipsychotics, to be distributed by community clinics.

"It's a philosophy that you can treat everything with a pill," Mitchell says. "Don't get me wrong -- the new medications are great. But it's kinda like that movie Awakenings, where you wake up and you have no recollection of certain years. Then what?"

Indeed, Harris County appears headed for a rude awakening in the form of a mental health crisis. Grossly underfunded -- MHMRA receives less than $12 in state mental health funding per resident, compared to a national per capita average of $27 -- the agency's clinic system is in shambles. Last fall MHMRA eliminated 29 case-management positions, in effect telling patients to look after their own affairs. The clinics are so backlogged that all but the severest cases must wait three to four months for an appointment, which serves only to create more of the severest cases: Emergency-room visits by the mentally ill in Harris County have skyrocketed, no doubt hastening the downward drift of some of those patients.

Most of MHMRA's $120 million budget has been diverted to treating insured patients. Meanwhile, care has been rationed to the indigent, who are having to make do with prescription services. But even that effort has been a disaster: MHMRA recently had to forfeit $5 million of the $7.6 million in new-drug money it received from legislators two years ago because the agency's clinics couldn't get the medications to enough patients (see "Catch Us If You Can," by Brian Wallstin and Margaret Downing, November 9).

Unfortunately, the state has never shown much interest in providing adequate resources for the community-clinic system that was pressed on it 30 years ago by the federal government. During this legislative session, moreover, lawmakers are faced with a $350 million shortfall in statewide health-care funding. Almost every elected official solemnly vowed to fully fund the Children's Health Insurance Program. No one made a similar commitment to people with mental illness.

From the available evidence, ACT has done what was long thought impossible: It has provided the mentally ill with the necessary wherewithal -- sometimes in big ways, mostly in little ones -- that allows them to have as much of a normal life as they can handle.

Last year the state released an outcomes survey of 1,235 ACT clients around the state. In the 12-month period that ended in June 1998, state hospital costs were cut by more than $5.4 million, and total inpatient days decreased 56 percent. The before-and-after numbers for the Harris County ACT program were even better: The 52 clients surveyed spent an average of nine days in the hospital, compared to 48 days the previous year -- an 81 percent reduction. ACT saved Harris County taxpayers an estimated $286,000 that year, and that doesn't include savings from fewer bed days at the county psychiatric center.

During this legislative session, mental health officials from around the state will lean on lawmakers to start reversing their dismal record on mental health. Should additional funds become available, it's hard to know how much the state's ACT program would expand. An oft-repeated knock on ACT is that it breeds dependency -- although as Tom Mitchell points out, "We're all dependent to some degree" -- and besides, there are plenty of new medications on the market that might make everyone feel better.

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