On the morning of Jan. 8 - as Tucson was stunned by a mass shooting that killed six people and injured 13 - 40-year-old Monica Stefanov lay dying of an overdose inside a Sierra Vista home.
Her death followed a 30-year battle with serious mental illness - she'd been diagnosed with both bipolar and schizoaffective disorders.
People with mental illness tend to live shorter lives than those who don't - they are more likely to end up homeless and without health care, for one thing. They are also prone to killing themselves.
But Stefanov had more than mental illness working against her. She lived in Arizona, a state that jails or imprisons nine times more people with severe mental illness than it hospitalizes - the second-worst rate in the nation, says the nonprofit, Virginia-based Treatment Advocacy Center, which aims to improve treatment for mental illness.
A friend used a largely unknown Arizona law to force Stefanov into mental-health treatment, but she was released after five days.
What ultimately pushed Stefanov over the edge, her family says, was yet another cut to the state's behavioral health system. Last July, the state stopped funding case managers, therapeutic support and virtually all brand-name medication for the 28,000 seriously mentally ill Arizonans not enrolled in Medicaid. Stefanov didn't qualify for the health-care program for the state's poorest residents because her Social Security disability checks paid slightly more than the $10,830 per year general cap for a single person.
But the state still provided her services like group therapy, medication coverage and a case manager. Once those services stopped as part of massive state budget cuts, she was left alone with increasingly disturbing thoughts.
"I believe my sister would probably still be alive today if she'd gotten the service she'd needed," said Eric Harris, 31, Stefanov's younger brother. "July 1 came around and she had the carpet ripped out from under her. She suddenly had to do everything herself."
Since fiscal 2008 the state has cut 52 percent of its funding to non-Medicaid patients - a huge hit because so many people with mental illness, like Stefanov, earn too much from Social Security Disability to qualify for Medicaid, said Dr. Virgil Hancock, chief of psychiatry for Carondelet St. Joseph's and St. Mary's hospitals in Tucson.
Hancock said his two hospitals' emergency rooms are doing about 900 psychiatric consultations per month - an increase of about 25 percent from a year ago, he said. Many of the most severely mentally ill patients are in worse shape than their peers on Medicaid - who still have mental health services - because they have been sick for so long that they qualify for disability benefits from Social Security, pushing them a few dollars over the Medicaid eligibility cap.
"It's been horrific," Hancock said. "They ended up disenrolling the sickest patients in the system."
Diagnosed with bipolar disorder as a child, Stefanov's life had never been easy. While she could be a loving girl who adored animals, she had anger and hostility her family didn't understand. She once threw lit matches at her grandmother. She would get into fights, beating other children bloody.
"We didn't really talk about it. She was just crazy. You left it at that," said Harris, who heads a nonprofit agency in Sierra Vista that provides transportation to disabled and elderly people.
Stefanov grew up mostly in Tucson and dropped out of Catalina High School after several hospitalizations for psychiatric problems. She had a baby at age 16, which her parents raised.
At times in her life Stefanov kept her illness mostly under wraps. She worked for more than five years in tech support at America Online in Tucson. She also worked as a nursing assistant and a waitress, and was married twice.
But between her stable periods, she had bouts of self-medicating with drugs and would go through phases of heavy drinking. When she got older, she was diagnosed with schizoaffective disorder, which causes both mood problems and a loss of contact with reality.
In 2008 she tried to kill herself by overdosing on pills after she misplaced $100. She later told her family that losing the money showed she wasn't capable of anything.
By the spring of 2010, Stefanov was living with her two dogs in an apartment in Sierra Vista and attending computer and self-defense classes at Cochise College. Her family was hopeful that she was in a better place.
"She wasn't working, but she was functioning," Harris said. "She didn't rely on anyone for anything. She loved her dogs. She often would say she liked animals better than people. I think she felt the animals were more understanding."
On July 1, the state stopped covering the drug Invega, which had helped with Stefanov's psychoses. The drug has no generic version, so she went on a generic version of Risperidol.
Soon, she began developing conspiracy theories. She told her family that someone was following her wherever she went. She accused her neighbors of watching her and believed they were working with the FBI. She began calling the sheriff's department, reporting the presence of people who didn't exist.
After one of those calls, on Oct. 9, deputies arrested her for false reporting. She was released the same day and her family sent her to a friend's in Tucson, believing they shouldn't leave her alone. While shopping with her friend, Stefanov began ducking behind clothing racks, saying the people who had been following her in Sierra Vista were in the store, and that they were trying to get her.
Her friend filled out a petition to get Stefanov court-ordered treatment, and a judge ordered her into University Physicians Healthcare Hospital at Kino. When she was released after five days of treatment, she had no case manager to speak on her behalf, or to help her find a better medication.
"All these individuals have the same characteristic situation - many have been very ill, have recovered to some extent with the help of medication and support and in one fell swoop it was taken away," said H. Clarke Romans executive director of the National Alliance on Mental Illness/Southern Arizona. "There are lots of people like Monica who are marginalized and could easily fall off that edge."
After her release from UPH, Stefanov's condition worsened. On the Saturday after Thanksgiving, she crawled through a neighbors' dog door and held the neighbor up against a wall, threatening to kill her. She demanded to know the location of listening devices she believed had been planted in her apartment. She was arrested and sat in the Cochise County Jail until Jan. 5, when a judge ordered her to outpatient mental health treatment.
Evicted from her apartment and staying with her brother, Stefanov ended up in the emergency room after drinking an entire bottle of Nyquil to treat an upper respiratory illness.
She told doctors she had AIDS, and said they were lying when they told her she was fine to go home.
Angry, she stayed in bed most of the day Friday and on Saturday, Jan. 8, Harris asked another sister to watch Stefanov while he went to his parents' house with his wife.
About 30 minutes after he left - around 9:30 a.m. - his sister called to say Stefanov wasn't breathing. The Medical Examiner's report said she had Nyquil, Benadryl and a high amount of amphetamines in her system when she died.
"I was sitting in the ER and I got a text message about everything going on in Tucson," Harris said. "But it was hard for me to think about anything but my sister."
Contact reporter Stephanie Innes at firstname.lastname@example.org or 573-4134.