A 32-year-old entertainment lawyer, incapacitated by bipolar disorder, loses her case manager and less than two months later tries to take her own life.
A 57-year-old registered nurse, who also has bipolar disorder, is forced to switch to generic drugs. She, too, begins a downward spiral as the drugs don't affect her well.
A 47-year-old laundry attendant with two diagnoses of serious mental illness fears she'll have to quit her job to get the mental-health coverage she needs.
The three Southern Arizonans are among 28,000 state residents affected by drastic cuts to behavioral health this year.
The cuts, which amount to a $65 million drop since 2008, affect Arizonans who need behavioral-health services but do not qualify for the Arizona Health Care Cost Containment System (AHCCCS), which is the state's version of Medicaid and is for Arizona's poorest residents. The cuts represent a 52 percent reduction over two fiscal years.
In addition to providing mental-health coverage for Arizonans on Medicaid, the state has historically offered mental-health services patients often can't get through their regular insurance. That included prescription-drug coverage, case managers, bus passes, cab fare and other therapeutic support. The latest cuts took away coverage for most name-brand drugs and slashed all other support services for non-Medicaid behavioral-health patients.
The cuts are unprecedented in Arizona and in the long term could impact taxpayers and health-care providers by putting more pressure on jails and emergency rooms. Also, some of those affected may quit their jobs - and perhaps go on public assistance - in order to qualify for AHCCCS, which still offers comprehensive behavioral-health benefits.
"We were a shining star, I think, the envy of many states," said Dr. Laura Nelson, deputy director for the Arizona Department of Health Services' division of behavioral-health services. "Our Medicaid-benefit package is incredibly robust compared to other states. Many other states don't cover substance-abuse services. We've had a very recovery-oriented program."
The number of seriously mentally ill non-AHCCCS patients needing crisis services at the Southern Arizona Mental Health Corp. has gone up by 123 percent since July 1 when the cuts took effect, said H. Clarke Romans, executive director of the Southern Arizona affiliate of the National Alliance on Mental Illness.
Romans said he knows one woman who is considering divorce in order to meet the AHCCCS income limits. But he fears those who aren't eligible for AHCCCS will increasingly end up in crisis or self-medicating with street drugs.
"This has been the most dramatic cut in (mental-health) services that I've ever observed on a statewide basis," Romans said.
About 5,000 people in Southern Arizona have been affected by the benefit changes, said Neal Cash, president and chief executive officer of the Community Partnership of Southern Arizona, which manages and provides oversight of the behavioral-health system in Pima County.
"When you reduce benefits like this to people who are seriously mentally ill who can do well with the right medication, there's a potential ripple effect in the whole community," Cash said. "They lost any kind of counseling benefit, hospital benefit. Prior to this cut they had the same benefit as people on AHCCCS."
To be eligible for AHCCCS, an individual would generally need to earn $10,830 or less per year. The number of people who are on AHCCCS and enrolled in the state's behavioral-health program is currently 132,000 - a jump of 24 percent over the last two years. Local mental-health experts predict that number will continue to climb.
But Nelson noted the AHCCCS budget is at risk, too: "I have fears we're vulnerable because of our ongoing fiscal crisis and that we may have to fight to keep that benefit package for our Medicaid population."
"It has been horrific. It has changed my life completely" Here are the stories of four Southern Arizonans affected by the state cuts:
Josie J. Ivey
Josie J. Ivey, a vibrant 32-year-old attorney with bipolar disorder, lost her case manager July 1 and on Aug. 25 tried to kill herself by overdosing on lithium.
She'd been trying to get an appointment with her psychiatrist for the previous four days in a row.
"You call, you get a machine and they ask you to leave a message after the beep," Ivey said. "It's not that my case manager calmed me down or anything, but he could work the system."
Her suicide attempt, which landed her in an emergency room, was the worst episode of her life, she said.
"It's so unclassy. I spit in a security guard's face. They had to use restraints on me," she said. "It's humiliating to think I did that to someone. I'm really lucky I wasn't arrested.
"I don't have a temper in real life, but when I'm like that, if someone looks at me the wrong way I want to tear them up."
A summa cum laude graduate of the James E. Rogers College of Law at the University of Arizona who holds an undergraduate degree from Colorado College, Ivey worked as a complex commercial litigator and then as an entertainment lawyer in Los Angeles before returning to Tucson, where her mother lives, in 2007 after trying to kill herself by overdosing on a California beach.
Her first signs of bipolar disorder were severe episodes of depression during college. In law school she'd often go for days without sleeping, found herself speaking faster, and in one manic episode she bought a $50,000 car she couldn't afford. In the workplace, she said, her brain "wasn't cooperating."
"I loved living in L.A. I love the ocean, the fine dining, the diversity. I lived on the water," she said. "But an attorney with a broken mind is like a horse with a broken leg."
She's now facing another battle: a diagnosis of stage-four breast cancer. She's undergoing chemotherapy and has had to reschedule a few of her psychiatric appointments.
"It's impossible to reschedule. That's another thing my case manager would have done for me," she said.
Having breast cancer, she said, is easier than having bipolar disorder.
"People hear mental illness and think it's laziness that I'm not working right now," she said. "If anyone saw me in the ER I don't think they'd say that."
A divorced father of twins and avid churchgoer who works at an equestrian therapy ranch, 36-year-old Joe Williams has a busy life.
But as a person with paranoid schizophrenia, Williams says, management of his mental illness is a delicate balance of medication and therapy.
When the state cuts took effect in July, he risked losing the injections of Risperdal Consta he was getting to treat the symptoms of his schizophrenia. The option was a generic oral dosage, but Williams said oral tablets don't work well for him.
He also lost his case manager and the therapeutic support he received through the state.
His solution was to apply for AHCCCS. By including his children on the application, Williams was able to squeak in under the annual income limit of $18,310 for a family of three.
But if he gets even a slight raise in pay, Williams said, he may have to cut his hours to keep his AHCCCS eligibility. Under AHCCCS, Williams will keep getting his Risperdal Consta shots.
"Without the shot I deteriorate, decompensate," he said. "It will happen fairly quickly. I have delusions and I'm hearing and seeing things to a point where I'm not there at all. Heaven forbid I would have had those symptoms again."
Judi Maikoff is a mother, caregiver and retired nurse who lives in a tidy central Tucson townhome.
Program cuts in July had an immediate effect on Maikoff, who has bipolar disorder - she had to switch from her brand-name anti-psychotic drug Abilify to generic risperidone. Abilify is not available in generic form in the U.S.
The switch did not affect her well. She developed restless-leg syndrome and began feeling tightness in her throat. Within weeks she couldn't get out of bed and had suicidal thoughts.
Desperate to be healthy again, she searched for ways to finance her Abilify, which costs about $600 to $800 per month in the U.S. Maikoff, 57, ended up ordering the drug through a Canadian pharmacy. Abilify is available in generic form in Canada, so she was able to buy it for $75 per month.
Maikoff first developed signs of mental illness at age 25, when she was a new mother living in Chicago.
She worked hard to manage the wild mood swings, paranoia and negative thoughts that come with her disease, and survived a suicide attempt in 1989 that briefly left her in a coma. She was able to successfully work as a registered nurse for 23 years. Her most recent job was at Tucson Medical Center, but she quit 12 years ago because she felt her illness was affecting her job. She now works part-time with the local chapter of the National Alliance on Mental Illness and volunteers as a community caregiver.
Once she was unemployed, Maikoff qualified for Medicare disability and receives money through Social Security disability. But neither the Medicare coverage nor the Social Security income came near to covering the cost of the five daily medications she needs to manage her bipolar disorder, and her monthly income is too high to qualify for AHCCCS. That's why the state's behavioral-health program was important for her treatment, she said.
Stacy Lauman is afraid she'll lose her job.
A tall, wiry 47-year-old employee at a local laundromat, Lauman has suffered from serious mental illness since childhood. She'd found some hope managing the psychotic episodes from her bipolar disorder with Abilify. But state benefit changes forced her to switch to a generic drug instead.
"It has been horrific. It has changed my life completely," she said. "I haven't lost my job yet, but things have happened at work."
Since she stopped taking the Abilify, Lauman said, she's started hearing the "alters" again - voices that "are not all good."
Lauman lives on her own, which she said is how she gets along best. Her annual income at the laundromat is too high for her to qualify for AHCCCS. And though she'd get far better benefits by quitting her job and going on AHCCCS, Lauman wants to work. She does better when she has something to keep her busy and said she'd feel worthless without a job.
The anxiety is taking a toll. A friend gave her some movies and she hasn't watched any of them. The television and radio create too much noise, she said.
She used to like to go to Fourth Avenue, have coffee, do some shopping and maybe have a mushroom burger at O'Malley's.
But she no longer does those things she used to enjoy. Instead, she worries:
"I'm so scared it's going to be jail, an institution or death."
Contact reporter Stephanie Innes at 573-4134 or at firstname.lastname@example.org