Star special report: Barriers make mental health treatment elusive

The Star begins a series on mental illness today. Reporters examine what is available - and what is missing - in resources for people with serious mental illness, their families and loved ones. It's a conflicted picture, because the potential for what a person can do with the right balance of therapy, medication and individual support runs smack into the reality of what a person can do within the constraints of limited insurance coverage, social stigma and a public-health system that shortchanges thousands.

While the connection to the Jan. 8 shooting, and the questions and concerns about mental illness that surround the actions of the man charged in the rampage, is unavoidable when we talk about serious mental illness in our community, it's a much more complicated, nuanced and pervasive picture.

Thousands of people in Pima County receive mental-health treatment through the public system, also referred to as AHCCCS or Medicaid. No one knows how many more seek help through private insurance coverage - or how many people simply go without, by choice or necessity.

We must talk about serious mental illness and acknowledge it. Mental illness is a medical condition, not a character flaw. The people interviewed in the news stories who talk about their personal experiences, including Star reporter Carol Ann Alaimo, who tells her own story of growing up with a mother who had serious mental illness, have started the discussion.

We must all take part, because we are all affected by serious mental illness. It's human nature to ignore a problem, even when it matters in the big picture, until we are touched directly by it, in our family or circle of friends.

The Star editorial board is spending this year focusing on mental illness and how we, as a community, address the challenges it presents to our families, schools, employers, neighborhoods and social fabric.

The instant the shooting began the morning of Jan. 8, every Tucsonan became a person touched by serious mental illness. We must be clear that we don't know the specific situation of the man charged, but what is public about his behavior before the shooting raises clear questions about his mental state. Those questions are now before the court.

The need to talk about serious mental illness runs through the planning of the April 27 free public forum on mental illness. The Star is partnering with the Schorr Family Award to present "A Delicate Balance: Creating a better, post-January 8th system to protect the public and help persons with serious mental illness."

A panel of local and national experts will talk about topics that clearly need examination - such as mental illness and violence, and how schools deal with serious mental illness - and that will be followed by a Q&A, when panelists will respond to questions from the public.

Please join the conversation.

Arizona Daily Star

Ask a question

Panelists will take written questions from the audience during the event.

You can also submit a question in advance by emailing it to mentalhealth@azstarnet.com before Friday, April 22.

Moderator Nicholas Breitborde will pose a mix of questions that come in during the event and those sent in advance.

If there are too many questions to pose at the forum, we plan to continue to answer them in the Star and on our website, azstarnet.com

The Forum

The free and public forum "A Delicate Balance: Creating a better, post-Jan. 8 system to protect the public and help the seriously mentally ill" will be held April 27 at Centennial Hall on the University of Arizona campus.

The event will include a forum with experts followed by a Q&A session.

The Star is partnering with the Schorr Family Award organization in the shared belief that mental illness is a paramount issue in our community. Go to www.cpsa-rbha.org and click on the "Schorr Family Award" link for more information.

The event begins at 1:45 p.m. and ends at 5. Translation services will be available upon request.

Dr. Thomas R. Insel, director of the National Institute of Mental Health, will give the keynote talk, "Trying to Understand Serious Mental Illness After January 8th."

A discussion panel of local and national experts will be led by Nicholas Breitborde, an assistant professor of psychiatry at the UA.

Panelists will be:

• Neal Cash, president & CEO, Community Partnership of Southern Arizona

• Dr. Ken Duckworth, assistant professor, Harvard Medical School; medical director, National Alliance on Mental Illness

• Joel Dvoskin, assistant clinical professor in the department of psychiatry at the UA College of Medicine

• Laurie Flynn, executive director, TeenScreen National Center, department of psychiatry, Columbia University Medical Center

• John Pedicone, superintendent, Tucson Unified School District

• Clarke Romans, executive director, National Alliance on Mental Illness of Southern Arizona

After the panel discussion, participants will answer questions from the public.

Ron Barber, district director for U.S. Rep. Gabrielle Giffords, will speak after the Q&A. He was seriously injured in the Jan. 8 attack.

It's the question every Tucsonan has asked since Jan. 8: Accused shooter Jared Lee Loughner showed so many signs of mental illness, but apparently didn't seek help and wasn't forced into treatment.

Why not?

Only he - and possibly his family - knows why he chose the path he did. But an Arizona Daily Star investigation reveals a system full of hurdles and contradictions that make help elusive for people with mental illness.

State law requires a residential-treatment system for those who need help, but supporters of the law have agreed it won't be enforced this year - and perhaps beyond - because of the state's budget woes.

Money problems also prompted the state to end case-management services and stop providing name-brand drugs to 28,000 lower-income Arizonans who don't qualify for Medicaid. The changes prompted a Sierra Vista woman - no longer able to get the medication that kept her illness at bay - to kill herself.

There are so few psychiatrists in the state that those reaching out for help often can't get an appointment for up to three months.

Arizona lets people petition to force others into mental-health treatment - even if they're not an immediate threat to themselves or others - but the law is largely unknown, difficult to navigate and results in compelling someone to get treatment only about half of the time.

Over all that is a shroud of stigma that only got darker when stories of Loughner's rants and writings - which experts say show signs of a disturbed mind - became public.

Even patients coping well with mental illness worried after the arrest that the public would see them as scary and dangerous. Actually, though, few people with mental illness are violent - and those who are typically hurt only themselves.

Today: Persistent stigma keeps many people from seeking help for mental illness.

Monday: A state law guarantees treatment, but a back-office budget deal means it's not being enforced. And the end of case management and brand-name-drug coverage left many marooned.

Tuesday: Forcing someone into treatment is possible but difficult. And a shortage of psychiatrists in Tucson means that even if you find a doctor who will see you, your first appointment might be months away.

Wednesday: Unless you're living in poverty, your insurance may not cover mental-health treatment.

 

For some Tucsonans touched by the tragedy of Jan. 8, sorrow was tinged with a sense of dread.

Scores of locals being treated for mental illness cringed to think the public might paint them with the same brush as shooter Jared Lee Loughner, whose chilling grin and bizarre rants made headlines across the globe.

"Are they going to start locking us up again?" a woman with schizophrenia asked two days after the shootings, at the start of classes she was taking to help her lead a healthier life.

"Am I now the enemy?" asked a man among her classmates.

Beth Stoneking, a psychologist who oversees a local wellness program for people with mental illness, led the angst-filled question-and-answer session that day.

"A common theme was, 'Now what do we do? They hate us, and they're afraid of us,' " Stoneking recalled.

The comments were painful to hear, she said, because people striving to recover from mental illness already face widespread prejudice.

"The last thing they need," she said, is for Loughner to be perceived as their poster child.

For months, mental-health experts nationwide have been weighing in on the tragedy, and there's one point on which they are adamant: If the public's takeaway message was that those with mental illness are dangerous, then the public got it wrong.

In fact, they say, violence toward others is rare among the one in 17 U.S. adults - more than 44,000 people in Pima County - who live with severe mental illness. If they harm anyone, it is most likely to be themselves.

Violence tends to occur only in severe, untreated cases, such as when someone has psychosis, paranoia and hears voices that give commands, said Dr. Wayne K. Goodman, head of psychiatry at Mount Sinai Medical Center in New York City; and Dr. Dennis S. Charney, dean of its affiliated medical school.

They worried the Tucson shootings may cement negative attitudes toward those with mental illness - driving more to try to hide their conditions and avoid treatment.

"The spotlight on Tucson could deepen the already profound stigma," they wrote in a recent column for The New York Times.

Stigma can cause more harm than the illnesses, said California psychologist Stephen Hinshaw, a pioneer in the field of stigma research.

"The pain engendered by mental illness is searing enough, but the devastation of being invisible, shameful and toxic can make the situation practically unbearable," he wrote in the 2008 Annual Review of Clinical Psychology.

Stigma is rooted in myths that those with mental illness are immoral, or lazy, or simply victims of bad parenting, Hinshaw said. Such myths persist, he said, despite mounting medical evidence of the roles genetics and brain chemistry play in determining why some people get sick and others don't.

Many are devastated when diagnosed, said H. Clarke Romans, head of the local chapter of the National Alliance on Mental Illness, an education and support group.

"This is a club no one wants to join," Romans said. "People would rather be told they have colon cancer or leukemia."

To help dispel myths, some Tucsonans who have lived for years with mental illness have agreed to tell their stories. All are receiving treatment through the public health system, the local veterans hospital or workplace insurance.

EX-MILITARY

Former sailor George Leon first heard voices while stationed aboard an aircraft carrier, the USS Constellation.

Then 23, he thought maybe everyone heard voices at times.

"I thought it was my intuition, my inner child speaking," said Leon, a 1982 graduate of Palo Verde High School. "I didn't know it was schizophrenia."

The voices told him a shipmate was plotting against him, Leon, now 47, recalls. He avoided the fellow sailor, and left the Navy when his time was up.

Back in Tucson, the voices told him to do "weird stuff," like leave his apartment at 3 a.m. and walk across town to his parents' house.

Leon's mother insisted something was wrong and got him to a psychiatrist. After he was diagnosed, many members of his large family stopped coming around. Some stayed away for years.

"I remember me and my parents spending a lot of time alone. I had an uncle who asked, 'Am I going to catch it?' "

Treatment was tough. In the 1980s, antipsychotics often had awful side effects. They made him lethargic, stole his sense of self. At times all he could do was sit "with my mouth open and my tongue quivering," he said.

Sometimes he got fed up and threw away the drugs. The voices quickly returned.

"I thought my mother was poisoning me so I stopped eating," Leon said.

His mom took him to court to force him into the hospital. Only then did he face his situation, vowing to do all he could to get better.

He received psychotherapy at the local veterans hospital, and took part there in a trial of a new drug, olanzapine, that turned out to be life-changing.

"For the first time I had no side effects. I could sit down and have a conversation."

Today, there are many new treatments. "It's really a blessing compared to 24 years ago."

Leon's illness prevents him from working, but he volunteers for the National Alliance on Mental Illness, running a public-awareness program.

He still hears voices sometimes. Now he talks back to them, a skill he learned at the VA hospital.

"I just tell them to be quiet," he said.

WOUNDED HEALER

Beth Stoneking is a rarity among mental-health professionals. She lives with mental illness and is willing to say so publicly.

A psychologist with two Ph.D.s and a master's degree, Stoneking, 59, is an assistant professor in the University of Arizona's medical school and also runs programs aimed at helping people with mental illness live healthier lives.

Such achievements might not be possible without the psychiatric medications she's been taking for decades to control obsessive-compulsive disorder and generalized anxiety disorder.

Without the drugs, panic attacks left her drenched in sweat, heart pounding, gasping for breath. She checked doors repeatedly to see they were locked, endlessly adjusted seat belts and car mirrors, made mountains of detailed to-do lists.

"It was interfering with my life but I kept it a secret," Stoneking said of the disorders, diagnosed when she was 29.

Though she's never attempted suicide, she said, "I know what it's like to lay in bed and want to die."

Stoneking has had years of psychotherapy. She meditates, exercises and listens to calming music - all of which helps keep her mind in balance.

Seeing the mental-health profession from the inside has been eye-opening, she said, because stigma is common even among those trained to help.

"There's more discrimination, prejudice and stereotypes in the medical and behavioral health systems than in the general population," she said, a view echoed by those who study stigma.

Stoneking is sharing her story to help change that.

"It has to start somewhere," she said.

HIGHS AND LOWS

Scott Whitley isn't proud to admit it, but there were times his own mother couldn't stand being around him.

Before he came to grips with his mental illness, he would fly off the handle and yell at her for any perceived slight.

"It alienated me from my family for two years, and rightfully so," he said.

"My mother was afraid of me."

Whitley, 57, was diagnosed in 1989 with bipolar disorder, a condition that caused his moods to swing wildly between euphoria, anger and depressions so dark he once planned his own suicide in precise detail.

"I was going to drive out into the desert and end it," he said. He got a hose and duct tape to pipe in carbon monoxide from his car's exhaust.

"I was tired of being me," he recalled. "I got to such a state of self-loathing I went numb, and total hopelessness set in."

A friend found out about his plan and saved his life.

After years of hit-and-miss treatments, he's found a regimen that works for him and follows it religiously. He takes medication - mood stabilizers and antipsychotics - and attends peer support groups. He keeps a journal to track his moods and behaviors, such as a tendency toward impulsive spending when a manic phase kicks in.

He also works part-time at the local chapter of the National Alliance on Mental Illness.

Whitley and his mother made peace. For the last two years of her life, he visited her nursing home every other day.

"I feel that I can give back now and not just be a taker," he said.

"It's a good feeling."

Contact reporter Carol Ann Alaimo at calaimo@azstarnet.com or at 573-4138.

Now that my mother is dead, our relationship is the best it's ever been.

While she was alive, neither one knew what to do about the wall between us that existed as far back as I remember.

Mom spent most of her life behind a mask, trying to pretend she wasn't mentally ill. And I spent most of mine judging her harshly for things I did not understand.

In mid-20th century America - and often still, today - families didn't talk openly of loved ones having schizophrenia, or bipolar illness, or major depression, conditions so common that experts say they strike one in 17 adults.

Mental illness was considered a curse, a disgrace, a black mark on the clan. Elders made excuses - "She's just high-strung" - or looked the other way.

Children, in particular, were kept in the dark.

The silence left me and my only sibling - a brother who later would take his life - to grow up in chaos without knowing why, assuming, the way kids do, that we were somehow to blame.

I've had decades to consider what might have been different had my mother's illness not been cloaked in secrecy and shame.

MOTHERLY ADVICE

When Mom was doing well, she could be comical: A spirited blonde who sang and played piano, she had a laugh so loud it announced her presence in any room.

Sometimes she'd try to offer motherly advice, though often it was off the wall, colored by a suspicion of others that sprang from schizophrenia.

"Don't smile so much - people will think you're retarded," she'd counsel me.

Mom had a master's degree in education. She worked on and off as a teacher for years - until she was caught drinking on the job. She'd load up her purse with vodka - "it doesn't smell on your breath" - hiding it in empty brown cough syrup bottles she'd swig from in the darkness of her classroom coat closet.

"My nerves are bad," she said one morning as I watched her fill the bottles on the kitchen counter.

DARK SPELLS

Her dark spells - Mom also suffered from major depression - often lasted months. When they came, our split-level in Western New York seemed to mirror her inner gloom.

It would reek of unemptied trash and overflowing ashtrays, of sour dishwater and unwashed skin. Thick living room drapes were coated with dust, never parted to let sunshine in.

Often, the only light was from a TV screen. Bluish rays would flicker over Mom's crumpled form on the couch, day and night, in the same clothes she'd worn for weeks.

If someone knocked on the door, we kids knew to shut up, freeze and pretend no one was home.

Unannounced visitors were forbidden. Mom was afraid of strangers and, I now suspect, of anyone learning her children were virtually raising themselves.

Sometimes there wasn't much food in the house. By age 6 or 7, I'd figured out how to forage in the back of the freezer and kitchen cupboards, concocting dinners for my brother and me out of stale egg noodles or freezer-burned pot pies. We learned to run the washing machine, to get to the school bus on our own.

A woman in despair could hardly be expected to make rational choices in romance. Mom married three times to men with mental problems of their own.

Our birth father, who had bipolar disorder, left us when I was 2, not long after my brother was born.

Our next dad had a cruel streak. He once burned my brother's hands with a cigarette lighter - ostensibly to teach a lesson after the boy, then 5, was caught playing with matches.

I still can see my brother, hair shorn in a summer buzz cut, forced to stand with arms outstretched like Christ on the cross. Our stepdad flicked open a silver Zippo, the faint scent of lighter fluid wafting as flint struck metal.

A blue flame popped up. It was tipped with yellow, and my brother shrieked as it singed his skin. My mother looked on from a doorway, hands at her mouth.

I screamed at her to make it stop. She did nothing.

When it was over, we were sent to our rooms, where we wailed for what seemed like hours, then fell asleep, exhausted.

We figured then that no one was going to protect us. Who could we ask for help - a teacher? Our mother was a teacher.

Our next stepdad, an alcoholic, would punch my brother and once chased mom around the house with a cleaver, holding it to her throat in a drunken melee.

No matter what horrors had unfolded the night before, the next day everyone went about their business pretending things were fine.

By my teens, I was angry. And mouthy.

"What's WRONG with you?! You're not normal!" I would yell at my mother.

"You're crazy," was her standard reply. She'd insist that she was fine. Other people were the problem.

My brother and I emerged from childhood with post-traumatic stress disorder, our nervous systems overwhelmed by exposure to wrenching events.

I escaped by marrying the first man who asked me and moving to another country.

He escaped into a world of drug abuse.

DOCTORS, PILLS

I don't mean to make it sound like my mom was a monster. At times, when the fog in her brain would clear, I'd get a glimpse of the kind of parent I now believe she wanted to be, had it been within her power.

Once a year or so, she would hire a cleaning crew and throw a party, inviting relatives who'd exclaim what a great job she was doing with her kids.

In later years, her illness seemed to go into remission now and then. During these times, she took great interest in my children, who have fond memories of her.

It's not like my mother never tried to get help, I now realize. I dimly recall her spending long periods in hospitals, while my brother and I lived with relatives.

At times, she seemed to have lots of doctors' appointments. A kitchen shelf became crowded with bottles of pills with strange-sounding names: Haldol, Thorazine, Prolixin, which I now know were antipsychotics.

The medicines may have quieted her mind, but they did awful things to her body.

Sometimes she'd sit for hours with her mouth agape, as if persistently astonished. Sometimes she seemed near-paralyzed, only able to walk by shuffling her feet in baby steps.

Medical knowledge of mental illness was in its infancy in the 1960s and 70s. Unlike today, doctors often couldn't do much to help.

Mom, I now suspect, would stop taking her medications when the side effects became too much to bear.

I used to worry a lot about becoming mentally ill myself. Not once, but twice - just to be sure - I took myself to psychiatrists who declared me sane.

Somehow, I escaped my mother's fate.

NEARING THE END

When the end came for Mom, it was like, well … something you might read about in a newspaper.

A county health department condemned her home, which was overrun with animal excrement from pets she'd stopped caring for.

The squalor came to light when Mom had a car accident, and paramedics found she had a fever of 104 degrees. Hospital tests revealed a massive e-coli infection, a likely consequence of the filth in which she'd been living.

During treatment, she had to go off all psychiatric medications. Only then did I see what schizophrenia looked like in the raw.

In terrified whispers, Mom told me how "rape squads" were attacking her in the hospital at night, how the rapists had infiltrated the ward by posing as physicians wearing white coats.

"There's one of them!" she hissed as a doctor walked by.

She hunched in a ball, like an armadillo trying to ward off a predator. Her hair was stringy, her eyes wild.

It didn't matter how many times I tried to explain that her mind was playing tricks on her. To her, the danger was real.

"Please! Pleeeeease!" she begged, clinging to me when visiting hours ended. "They're coming! Don't leave me!"

She died a few months later, on April Fools Day 2000.

MEMORIES, TEARS

With her passing, painful memories came flooding back to my brother and me.

His addictions escalated, landing him in jail. He did stints in rehab, but killed himself a few years later.

By grace, good luck or whatever one calls it, I was able to recover.

It took years of therapy, and rivers of tears, to untangle the web that stigma wove. I became a mom myself - a pretty good one, my now-grown kids say - and a doting grandma.

By some miracle, I now find myself at the center of the loving family I'd always craved. It is this, more than anything, that has given me compassion for my mom.

She missed out on this joy of deep connection. I put myself in her shoes and wonder: What would it be like to have kids you couldn't nurture? To have a chemical imbalance in your brain and be made to feel ashamed of it?

There's a lot that we, as a community, can't do about mental illness. We can't cure it, and we can't ever seem to find enough money to treat all those who need it.

But we can talk about it.

Talking gives others permission to talk, too.

And eventually, we start to unshackle one another.

Contact reporter Carol Ann Alaimo at calaimo@azstarnet.com or at 573-4138.

Dr. Randa Kutob spends much of her time teaching future doctors at the University of Arizona. Across town in another classroom, a different group of students is teaching her.

Each has a serious mental illness, and she finds them a pretty amazing bunch.

"The questions they ask are as good as the ones I get from my medical students," said Kutob, 46, who in 2007 was named one of America's best doctors.

"A lot of their stories are not happy ones. But the fact they are here asking questions and trying to help themselves, it's really inspiring."

These students are part of a pioneering program called Camp Wellness. It offers patients in the state Medicaid system eight weeks of classes in nutrition, healthy cooking, exercise and relaxation techniques, and other methods to promote physical and mental health.

Kutob is the program's staff physician, on top of being assistant medical professor at the UA and a family doctor at University Physicians Healthcare.

Having treated hundreds of Tucson families, Kutob already knew how common mental illness is.

"I don't know too many families who are untouched by it," she said.

But at Camp Wellness, she has the luxury of spending hours at a time with her charges, instead of the 15 minutes she typically has with someone at the doctor's office.

"Hearing people talk about their personal struggles has been eye-opening. You really get a sense of how these illnesses affect so many aspects of their lives."

The clientele of Camp Wellness includes nurses, teachers, Ph.D.s, office workers and others from an array of backgrounds, she said.

Often, their conditions are misunderstood even by loved ones.

"Family members will say, 'Why don't you just get over it and stop thinking like that?' They don't really understand that you can't 'just get over it.' "

Kutob is convinced mental illness could happen to anyone in any family. Even her own.

"My attitude now," she said, "is, you just never know."

About serious mental illness

Each mental illness has its own symptoms, but there are general warning signs that might alert you that someone needs professional help.

A person who shows any of these signs should seek help from a health professional:

• Marked personality change

• Inability to cope with problems and daily activities

• Strange or grandiose ideas

• Excessive anxieties

• Prolonged depression and apathy

• Marked changes in eating or sleeping patterns

• Thinking or talking about suicide or harming oneself

• Extreme mood swings - high or low

• Abuse of alcohol or drugs

• Excessive anger, hostility, or violent behavior.

Source: National Institutes of Health

COMING SOON

A new Pima County Crisis Response Center is planned to open in the late summer or early fall adjacent to the University of Arizona's hospital at the Kino campus at East Ajo Way and South Country Club Road. The center will have a separate area for children and adolescents in crisis. A new psychiatric emergency department will be in the same complex, along with inpatient units for people who need hospitalization.

The center will treat everyone regardless of insurance status or enrollment in AHCCCS (Arizona's form of Medicaid) but it will also have staff to assist people in determining whether they are eligible for benefits that would pay for treatment. You will be able to bring someone to the center or go there yourself and be evaluated and given guidance for future medical and behavioral care.

STIGMA

Sometimes people are hesitant to seek help or acknowledge they or a loved one has a serious mental illness because of negative stereotypes about what the illness is or what they think it means. These stigmas are usually based on false information. For instance, according to the National Institutes of Health:

"Very few people who have a mental illness are dangerous to society. Most can hold jobs, attend school, and live independently. A person who has a mental illness cannot simply decide to get over it any more than someone who has a different chronic disease such as diabetes, asthma, or heart disease can. A mental illness, like those other diseases, is caused by a physical problem in the body."

BIPOLAR DISORDER

www.nimh.nih.gov/health/publications/bipolar-disorder/what-is-bipolar-disorder.shtml

"Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. Bipolar disorder symptoms can result in damaged relationships, poor job or school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.

"People with bipolar disorder experience unusually intense emotional states that occur in distinct periods called 'mood episodes.' An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression. This is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.

"Extreme changes in energy, activity, sleep and behavior go along with these changes in mood. It is possible for someone with bipolar disorder to experience a long-lasting period of unstable moods rather than discrete episodes of depression or mania.

"A person may be having an episode of bipolar disorder if he or she has a number of manic or depressive symptoms for most of the day, nearly every day, for at least one or two weeks. Sometimes symptoms are so severe that the person cannot function normally at work, school or home.

"Bipolar disorder often develops in a person's late teens or early adult years. At least half of all cases start before age 25. Some people have their first symptoms during childhood, while others may develop symptoms late in life."

Source: National Institute of Mental Health

DEPRESSION

www.nimh.nih.gov/health/publications/depression/complete-index.shtml

"Everyone occasionally feels blue or sad, but these feelings are usually fleeting and pass within a couple of days. When a person has a depressive disorder, it interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her. Depression is a common but serious illness, and most who experience it need treatment to get better.

"Many people with a depressive illness never seek treatment. But the vast majority, even those with the most severe depression, can get better with treatment.

Symptoms include:

• Persistent sad, anxious or "empty" feelings

• Feelings of hopelessness and/or pessimism

• Feelings of guilt, worthlessness and/or helplessness

• Irritability, restlessness

• Loss of interest in activities or hobbies once pleasurable, including sex

• Fatigue and decreased energy

• Difficulty concentrating, remembering details and making decisions

• Insomnia, early-morning wakefulness or excessive sleeping

• Overeating or appetite loss

• Thoughts of suicide, suicide attempts

• Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment."

Source: National Institute of Mental Health

SCHIZOPHRENIA

www.nimh.nih.gov/health/publications/schizophrenia/complete-index.shtml

"Schizophrenia is a chronic, severe, and disabling brain disorder that has affected people throughout history. About 1 percent of Americans have this illness.

"People with the disorder may hear voices other people don't hear. They may believe other people are reading their minds, controlling their thoughts or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated.

"People with schizophrenia may not make sense when they talk. They may sit for hours without moving or talking. Sometimes people with schizophrenia seem perfectly fine until they talk about what they are really thinking.

"Families and society are affected by schizophrenia, too. Many people with schizophrenia have difficulty holding a job or caring for themselves, so they rely on others for help.

"Treatment helps relieve many symptoms of schizophrenia, but most people who have the disorder cope with symptoms throughout their lives. However, many people with schizophrenia can lead rewarding and meaningful lives in their communities. Researchers are developing more effective medications and using new research tools to understand the causes of schizophrenia. In the years to come, this work may help prevent and better treat the illness.

"Schizophrenia affects men and women equally. It occurs at similar rates in all ethnic groups around the world. Symptoms such as hallucinations and delusions usually start between ages 16 and 30. Men tend to experience symptoms a little earlier than women. Most of the time, people do not get schizophrenia after age 45. Schizophrenia rarely occurs in children, but awareness of childhood-onset schizophrenia is increasing.

"It can be difficult to diagnose schizophrenia in teens. This is because the first signs can include a change of friends, a drop in grades, sleep problems, and irritability - behaviors that are common among teens. A combination of factors can predict schizophrenia in up to 80 percent of youth who are at high risk of developing the illness. These factors include isolating oneself and withdrawing from others, an increase in unusual thoughts and suspicions, and a family history of psychosis. In young people who develop the disease, this stage of the disorder is called the 'prodromal' period.

"People with schizophrenia often resist treatment. They may not think they need help because they believe their delusions or hallucinations are real. In these cases, family and friends may need to take action to keep their loved one safe. But when a person becomes dangerous to himself or herself, or to others, family members or friends may have to call the police to take their loved one to the hospital."

Source: National Institute of Mental Health

Who does what

Figuring out where to begin can be daunting. So many agencies are referred to by acronyms or weird-sounding names that it can be hard to keep track of who does what and what everything means. Here is an overview:

WHO QUALIFIES FOR THE PUBLIC BEHAVIORAL HEALTH SYSTEM (ALSO KNOWN AS MEDICAID, AHCCCS OR TITLE 19, WHICH IS OFTEN WRITTEN TITLE XIX)

AHCCCS, short for the Arizona Health Care Cost Containment System, is Arizona's Medicaid plan that covers low-income people.

To qualify for AHCCCS (Title 19), a family's household income cannot exceed the federal poverty level, which for an individual is $10,890 annually and for a family of four is $22,350.

People can see whether they qualify for AHCCCS by going to www.healthearizona.org or calling the Department of Economic Security, Family Assistance Administration at 1-800-352-8401.

Also, for persons seeking behavioral health services, the CPSA Comprehensive Service Providers can help screen for AHCCCS eligibility and help complete the application.

If you do not qualify, you are referred to as "non-Title 19" (or N-TXIX) because you are not eligible for many of the public health system's ongoing care - but you can receive crisis care and generic medications.

COMMUNITY PARTNERSHIP OF SOUTHERN ARIZONA (CPSA)

This private, nonprofit agency manages Arizona's publicly funded services for behavioral health (which includes mental illness and substance abuse) for people who live in Pima County. CPSA receives money from the Arizona Department of Health Services' Division of Behavioral Health Services, which receives it from AHCCCS and from state government.

CPSA then distributes the money to what are known as "comprehensive service providers." These are the agencies that actually see and treat people with mental illness. If you use the public behavioral health system, this is the network you are a part of and CPSA refers to the people who use the mental health services as "enrolled members."

LEARN MORE

Community Partnership of Southern Arizona

www.cpsa-rbha.org

Contact member services at 1-520-318-6946 or 1-800-771-9889 to discuss your needs. Translation services are available. Individuals with a hearing impairment may call 1-866-318-6960 for TTY.

CPSA member services is available 24 hours a day, but the best time to call is Monday-Friday, 8 a.m.-5 p.m.

FACT: In 2010, CPSA had 46,373 enrolled members, which was about 20 percent of all Arizonans enrolled in the the state's Medicaid behavioral health services.

ARIZONA DEPARTMENT OF HEALTH SERVICES: DIVISION OF BEHAVIORAL HEALTH SERVICES

The Arizona Department of Health Services oversees the Division of Behavioral Health Services. They're commonly referred to as "ADHS/DBHS" or "the division" and it's the agency that AHCCCS/Medicaid pays to oversee the state's behavioral health services. ADHS/DBHS in turn pays the Regional Behavioral Health Authorities (RBHAs) and Tribal Regional Behavioral Health Authorities (TRBHAs) to oversee the system in their areas and pay agencies and individuals to take care of people with mental illness.

LEARN MORE

Arizona Department of Health Services/ Division of Behavioral Health Services

www.azdhs.gov/bhs/index.htm

Behavioral Health Services:

150 N. 18th Ave., No. 200

Phoenix, AZ 85007

Phone: 1-602-364-4558

Fax: 1-602-364-4570

PRIVATE INSURANCE PLANS

If you have private health insurance, whether purchased by an individual or through an employer or family member, you are most likely not eligible to enroll in the public behavioral health network that's managed by CPSA. You are what people in the field call a "non-Title 19" person.

Private insurance companies do not have to cover mental health services, but federal law requires "parity" so that if your plan does cover mental health and substance abuse treatment, the co-pays and number of allowed visits must be the same as if you are seeking medical or surgical services. Contacting your insurance company and looking at the "explanation of benefits" is the best way to figure out what behavioral health services are covered.

If you are "non-Title 19" you can still get help if you are found to have a serious mental illness or are in a crisis or emergency, and your medications may be paid for, but only if they're generics.

ARIZONA STATE HOSPITAL (AZSH - PRONOUNCED "ASH")

If a judge decides that a person is so impaired by mental illness that he or she cannot function or be psychiatrically stabilized with treatment in the community, the person can be ordered to the Arizona State Hospital in Phoenix. It's the most restrictive environment in the state for adults and it's a last resort. The hospital has a secure forensic ward for people who are involved in criminal proceedings or have been convicted of a crime but have a serious mental illness, as well as a separate area for people a civil court judge has determined need such intensive care. According to the AzSH website, courts usually require a person to have spent at least 25 days in a hospital to attempt psychiatric stabilization before sending the person to AzSH.

LEARN MORE

Arizona State Hospital (ASH)

www.azdhs.gov/azsh/about_azsh.htm

Arizona State Hospital:

2500 E. Van Buren St.

Phoenix, AZ 85008

Phone: 1-602-244-1331

Fax: 1-602-220-6292

www.azdhs.gov/azsh/index.htm

COMPASS BEHAVIORAL HEALTH CARE (DETOX)

Compass is where to go for help with substance abuse. Call 1-520-624-5272 anytime, 24 hours a day.

Compass provides services for a variety of substance addictions, including alcohol, opiates, cocaine, meth, marijuana, benzodiazepines and amphetamines.

Detoxification facilities are at 2950 N. Dodge Blvd. (between East Glenn Street and East Fort Lowell Road). Compass is part of the public behavioral health system and some of its services are also available on a sliding scale for those who don't qualify for AHCCCS.

SOUTHERN ARIZONA MENTAL HEALTH CORPORATION (SAMHC, PRONOUNCED SAM-HACK)

SAMHC is where to go if you are having a mental health crisis and need immediate help. SAMHC will see you no matter how old you are, whether or not you have insurance or can pay.

SAMHC is open 24 hours every day. It's at 2502 N. Dodge Blvd. (the entrance is on Flower Street, a couple blocks north of Grant Road). The staff will help you figure out what's going on, evaluate your situation, help with crisis counseling, drug/alcohol assessment, figure out if you are eligible for AHCCCS /Medicaid and help you get connected to services.

If you can't get to SAMHC but are having a mental health emergency, call the Community-Wide Crisis Line at 1-520-622-6000 or 1-800-796-6762. They may be able to send a mobile team to you. Learn more at www.samhc.com

Public forum

The free and public forum "A Delicate Balance: Creating a better, post-Jan. 8 system to protect the public and help the seriously mentally ill," will be held April 27 at Centennial Hall on the University of Arizona campus.

The event will include a forum with experts followed by a Q&A session.

The Star is partnering with the Schorr Family Award organization on the event in the shared belief that mental illness is a paramount issue in our community. Go to www.cpsa-rbha.org and click on the "Schorr Family Award" link for more information.

The event begins at 1:45 p.m. and ends at 5. Translation services will be available upon request.

Dr. Thomas R. Insel, director of the National Institute of Mental Health, will give the keynote talk, "Trying to Understand Serious Mental Illness after January 8th."

Insel is the recipient of The Schorr Family Award For Distinguished Contribution In Furthering Public Understanding of Mental Illness.

A discussion panel of local and national experts will be led by Nicholas Breitborde, an assistant professor of psychiatry at the UA.

Panelists will be:

• Neal Cash, president & CEO, Community Partnership of Southern Arizona

• Dr. Ken Duckworth, assistant professor, Harvard Medical School; medical director, National Alliance on Mental Illness

• Joel Dvoskin, assistant clinical professor in the Department of Psychiatry at the UA College of Medicine

• Laurie Flynn, executive director, TeenScreen National Center, Department of Psychiatry, Columbia University Medical Center

• John J. Pedicone, superintendent, Tucson Unified School District

• Clarke Romans, executive director, National Alliance on Mental Illness of Southern Arizona

After the panel discussion participants will answer questions from the public.

Ron Barber, district director for Congresswoman Gabrielle Giffords, will speak after the Q&A. He was seriously injured in the Jan. 8 attack.

After the forum there will be a public reception at the Women's Plaza of Honor (directly west of Centennial Hall).

Ask a question

Panelists will take written questions from the audience during the event.

You also can submit a question in advance by emailing it to mentalhealth@azstarnet.com before Friday, April 22.

Moderator Nicholas Breitborde will pose a mix of questions that come in during the event and those sent in advance.

If there are too many questions to pose at the forum, we plan to continue to answer them in the Star and on our website, azstarnet.com

Crisis help

Emergency/Crisis/Need to Talk

If you or someone you know is having a life-threatening mental-health emergency (if, for example, thoughts of suicide or weapons or a potential overdose are involved) always call 911. Tell the dispatcher and responders if mental illness or substance abuse is involved.

If your crisis is urgent but not immediately life-threatening, call the Community-Wide Crisis Line at 1-520-622-6000 or 1-800-796-6762. The Crisis Response Network will answer the phone and help 24 hours a day, 7 days a week, including holidays.

If you need to talk to someone but aren't having a crisis, try the HOPE Inc. Warm Line at 1-520-770-9909. It's operated from 8 a.m. to 11 p.m. every day. HOPE Inc. is a peer-support organization that focuses on recovery and mental illness.

DRUGS OR ALCOHOL CRISIS

Compass Behavioral Health Care (Detox) at 1-520-624-5272, Option #1.

OTHER CRISIS CONTACTS

24-Hour Crisis National Hotlines:

• 1-800-SUICIDE - HopeLine Suicide Hotline

• 1-800-273-TALK - National Suicide Prevention Lifeline

SUICIDE/CRISIS HOT LINES BY LOCATION

• Pima, 1-800-796-6762 or 1-520-622-6000

• Maricopa, 1-800-631-1314 and 1-602-222-9444

• Graham, Greenlee, Cochise and Santa Cruz, 1-866-495-6735

• Gila River and Ak-Chin Indian communities, 1-800-259-3449

• Yuma, LaPaz, Pinal and Gila, 1-866-495-6735

• Mohave, Coconino, Apache, Navajo and Yavapai, 1-877-756-4090

Definitions, terminology and jargon

TITLE 19/NON-TITLE 19 (TITLE XIX/N-TXIX)

A person whose income does not exceed the federal poverty line can qualify for the public behavioral health system and is called a "Title 19" client. Someone who does not is referred to as "non-Title 19."

BEHAVIORAL HEALTH

This includes mental health, mental illness and substance abuse.

SERIOUS MENTAL ILLNESS

This is when a person's emotions or behaviors, because of a mental disorder, are so affected that he or she has a hard time living day to day without ongoing support and treatment. It has a long-term impact on the person's relationships, employment and ability to get along with others, and makes it harder to function in other aspects of life. The term generally applies to persons age 18 or older, but research has shown some serious mental illnesses begin before that. Disorders such as bipolar disorder, schizophrenia and some types of depression are considered serious mental illnesses.

MEDICAL V. LEGAL COMPETENCE

Assessing a person's mental competency means different things in different venues.

In the medical or psychiatric arena, such as determining if a person with a serious mental illness should be hospitalized even against his will, the measure is if the person is a danger to self or others, persistently or acutely disabled, or gravely disabled.

These are civil actions involving the court. Terms such as "Civil Commitment Petitions," "Title 36," "pre-petition hearing," and "emergency petition" are all part of the process that allows a person who has a mental illness to be hospitalized if a judge, relying on expert and witness testimony, decides it's in the person's best interest.

That's different than determining competency in the context of a criminal proceeding. "Rule 11" is the short-hand for the need to figure out if a person who has been charged with a crime has the ability to understand the charge and the trial process and can assist his defense attorney.

After a person is evaluated under Rule 11, a judge must decide if the person is competent (which does not mean the person is not mentally ill), incompetent but restorable (with psychiatric medication or other treatment the person can be made to understand and assist in his own defense), or if the person is incompetent and not-restorable. This last category means the person cannot legally be tried for a crime, because he is not now, and never will be, in a mental condition to understand the legal system and assist in his defense. When that happens, if the person is diagnosed as having a serious mental illness he may end up being civilly committed to a hospital under Title 36. If the incompetency is caused by brain damage, for example, he will be released from jail but not necessarily hospitalized.

INVOLUNTARY COMMITMENT/HOSPITALIZATION

A person must be found by a court, which relies on psychiatric professionals, to be a danger to himself or others, gravely disabled or "persistently or acutely disabled" before he can be hospitalized (committed) against his wishes.

COURT ORDERS FOR MENTAL HEALTH EVALUATION AND TREATMENT/TITLE 36/EMERGENCY PETITION/CIVIL COMMITTMENT

In the Tucson area, seeking a court-ordered psychiatric assessment starts with a call to the 24-hour Community-Wide Crisis Line at 622-6000 or 1-800-796-6762 or visiting the midtown offices of the Southern Arizona Mental Health Corp., 2502 N. Dodge Blvd. Any responsible person may apply for a court-ordered evaluation of a person who isn't willing or able to be evaluated voluntarily.

Southern Arizona Mental Health helps people through the process, which varies based on whether the need is urgent. After paperwork is completed and notarized, the agency sends a team to evaluate the person. If there is reason to believe the person needs more evaluation, SAMHC works with the County Attorney's Office to ask the court for an order for evaluation, and then notify law enforcement to pick up the person and transport him or her to an evaluation hospital.

Once a petition is filed, law enforcement has 10 days to get the person to the hospital. If they are unable, the petition expires and the process starts again.

Hospitalized patients are evaluated by two psychiatrists within 72 hours to find out whether a petition for treatment is needed. If so, there is a hearing before a judge, with testimony from the psychiatrists and at least two other witnesses. The person chooses whether to testify, and a lawyer is appointed to represent the person's interests.

The result could be a court order for treatment, which typically involves a hospital stay until the person is stabilized, followed by outpatient care. If the person doesn't comply with treatment - by not taking medication, for example - the court can order the person back into the hospital.

The court order, which is good for one year, includes a certain number of days available for inpatient treatment. But the periods differ depending on whether people are deemed a danger to themselves (90 days), to others (180 days), "persistently and acutely disabled" (180 days) or "gravely disabled" (365 days).

Calls can be made anonymously to a crisis line to report concerns about someone's mental health. However, those who make formal petitions to the court are identified once the case is in the legal system.

If a person needs immediate evaluation because he might be a danger to himself or others, call 911.

DANGER TO SELF OR OTHERS

Under Arizona law (A.R.S. 36-501), a person is considered a "danger to others" if a mental disorder affects his judgment so much that he can't understand that he needs treatment, and if the person continues to go without treatment it "can reasonably be expected" (based on medical opinion) to result in "serious physical harm."

A person with a mental disorder is considered a "danger to self" if she has attempted or makes a serious threat of suicide; and, given the person's history and the circumstances, the threat seems likely to be carried out; and that the person needs to be hospitalized to prevent serious harm or serious illness.

"Gravely disabled" means the person is likely to experience serious physical harm or serious illness because he is unable to provide for his own basic physical needs.

Being unable to provide yourself a place to live or being homeless may be an indication of grave disability, but it does not mean a person is a "danger to self" under the law.

According to the law, "persistently or acutely disabled" means a severe mental disorder that meets all of the following criteria:

(a) If not treated has a substantial probability of causing the person to suffer or continue to suffer severe and abnormal mental, emotional or physical harm that significantly impairs judgment, reason, behavior or capacity to recognize reality.

(b) Substantially impairs the person's capacity to make an informed decision regarding treatment, and this impairment causes the person to be incapable of understanding and expressing an understanding of the advantages and disadvantages of accepting treatment and understanding and expressing an understanding of the alternatives to the particular treatment offered after the advantages, disadvantages and alternatives are explained to that person.

(c) Has a reasonable prospect of being treatable by outpatient, inpatient or combined inpatient and outpatient treatment.

DECOMPENSATE (OR "DECOMP")

"Decompensate" describes what happens when the condition of a person with mental illness who has been stable and functional, often on medication or other therapies, deteriorates and the person shows worsening symptoms of his illness. A decompensating person is likely to end up in a mental illness crisis if he's unable to get treatment.

RHBA (PRONOUNCED REEBA)

Arizona is divided up into geographical areas and a "Regional Behavioral Health Authority" or RBHA is the agency the state puts in charge of managing services for people who live in that area and qualify for public services. In Pima County, that's Community Partnership of Southern Arizona, or CPSA.

A Tribal Regional Behavioral Health Authority (TRBHA) does the same thing for eligible people who are residents of a tribal nation, like Pascua Yaqui. Members of the Tohono O'Odham Nation are served by CPSA.

CRISIS INTERVENTION TEAM TRAINING (CIT)

This trains law enforcement officers to help them identify when mental illness could be involved in a police call, defuse potentially dangerous situations and keep all parties safe.

RECOVERY

Recovery begins as soon as a mental illness is diagnosed and continues as the person's illness is managed. Education, support and, in some cases, medication help the person be responsible for his or her own progress. It includes overall health and wellness, relationships and opportunities to hold a job, help others with a mental illness and/or be active in the community.

How to help yourself or someone else

As others have said, if you see someone having a heart attack on the sidewalk you'd not hesitate to call 911 for help. But if someone is visibly agitated or displaying signs of serious mental illness, we aren't so quick to act - or to know what to do.

There is a process by which CPSA's Comprehensive Service Providers and SAMHC may make a determination about whether a person has a serious mental illness (SMI) and qualifies for the support offered to those individuals. It includes an evaluation by a licensed professional qualified to make a clinical determination of SMI. The licensed professional will use specific criteria to determine if a person meets requirements for SMI, including a qualifying diagnosis and how significantly the person's ability to function in daily life has been affected by that diagnosis.

We've tried to make the following list as comprehensive and up-to-date as possible, but you may be referred to a different agency or office, depending on your circumstances:

Our Family Services' Information & Referral Helpline (I&R) works in partnership with Community Information & Referral in Phoenix to collect the most up-to-date information available on community services all over Arizona, available free to the public. Call 1-800-352-3792 (available 24 hours a day) or go to the searchable online database at www.cir.org

CPSA Member Services can help you figure out whether you are eligible for services in the public behavioral health-care system and learn how to get such services. Member services is available 24 hours a day. Staff members speak both English and Spanish and have access to a telephonic interpretation service in 150 other languages. Call 1-520-318-6946, option 2, or 1-800-771-9889, option 2. Hearing-impaired individuals may call the TTY line at 1-866-318-6960. The website, www.cpsa-rbha.org, has regularly updated information on the CPSA system of care and community resources, presentations on mental health topics and links to other trusted sites.

The Health-e-Arizona website, www.healthearizona.org, can help you find out whether you are eligible for behavioral health benefits under the Arizona Health Care Cost Containment System, the state's Medicaid system. You also can call the Department of Economic Security's Family Assistance Administration at 1-800-352-8401. Other information is available at www.myazhealthandwellness.com or 1-602-417-7000.

NAMISA: National Alliance on Mental Illness of Southern Arizona (referred to as "na-mee-sa")

www.namisa.org

NAMI of Southern Arizona

6122 E. 22nd St.

Tucson, AZ 85711

1-520-622-5582

This is a place for people with serious mental illness, their families and friends to learn more about what's going on, talk to people who've been through similar experiences and find support.

They offer support groups, have a lot of information online and can help figure out the world of mental illness, treatment and services.

HOPE Inc.

1-520-770-1197

www.hopetucson.org

This is a "consumer-run, consumer-driven" agency that provides a variety of services to adults in Pima County who have a mental illness or substance use disorder. HOPE oversees the Nueva Luz Recovery, Wellness Reintegration Center, which provides recovery support including how to advocate for yourself and navigate the public behavioral health system. A "warm line" for non-crisis support is staffed by adults diagnosed with mental illness and is available from 8 a.m. to 11 p.m. daily.

Coyote Task Force

1-520-884-5553

www.opclubhouse.org and www.cafe54.org

Coyote Task Force helps individuals with serious mental illness re-enter the work community through pre-vocational and vocational rehabilitation. Coyote Task Force operates Our Place Clubhouse, which includes the Re-Threads Recycled Fashion thrift store, and a consumer-run restaurant/training program, Café 54.

Pima County Human Rights Committee

1-520-770-3100

The Pima County Human Rights Committee provides independent oversight of the public heavioral health system in Pima County. It receives complaints from mental-health consumers, reviews the actions of providers, and makes recommendations to the Arizona Department of Health Services.

PIMA COUNTY ADULT COMPREHENSIVE SERVICE PROVIDERS

CODAC Behavioral Health Services

Administration site

1650 E. Fort Lowell, Suite 202

Tucson, AZ 85719

1-520-327-4505

www.codac.org

CODAC

Intake site

3100 N. First Ave.

Tucson, AZ 85719

1-520-202-1840

CODAC

Intake site

4901 E. Fifth St.

Tucson, AZ 85711

1-520-202-1840

CODAC

Intake site, West Adult Services site

1671 W. Grant Road

Tucson, AZ 85745

1-520-202-1840

COPE Community Services

Administration site

82 S. Stone Ave.

Tucson, AZ 85701

1-520-792-3293

www.copebhs.com

COPE Community Services

Intake site, La Cholla case management

1501 W. Commerce Court

Tucson, AZ 85746

1-520-205-4732

COPE Community Services

Intake Site, Mesquite case management

2435 N. Castro Ave.

Tucson, AZ 85705

1-520-205-4732

COPE Community Services

Intake site, Mary Ann Coady, M.D. Clinic

8050 E. Lakeside Parkway

Tucson, AZ 85730

1-520-205-4732

COPE Community Services

Intake site

4601 E. Broadway

Tucson, AZ 85711

1-520-205-4732

COPE Community Services

Intake site, Green Valley/Villa Verde

170 S. La Canada Drive, Suite 90

Green Valley, AZ 85614

1-520-622-3835

La Frontera Center

Administration and intake site

502 W. 29th St.

Tucson, AZ 85713

1-520-838-3804

www.lafrontera.org

La Frontera Center

Intake site

2222 N. Craycroft Road, Suite 120

Tucson, AZ 85712

1-520-838-3804

La Frontera Center

Intake site, PPEP Behavioral Health

111 La Mina Ave., Suite 5

Ajo, AZ 85321

1-520-387-5232

La Frontera Center

Intake site

1141 W. Grant Road, Suite 100

Tucson, AZ 85705

1-520-206-8600

MHC Healthcare Behavioral Health Services

(Marana Health Center, The Hacienda)

13644 N. Sandario Road

Marana, AZ 85653

1-520-616-4976

maranahealthcenter.org/our-services/behavioral-health

MHC Healthcare Behavioral Health Services

Intake site, Marana Health Center, The Ranch

13549 N. Sanders Road

Marana, AZ 85653

1-520-682-4111

Pantano Behavioral Health Services

Intake site, Sells, AZ

Tohono Plaza, BIA Route 19, Suite 207

Sells, AZ 85634

1-520-623-9833

www.pantanobh.org

CHILD/ADOLESCENT COMPREHENSIVE SERVICE PROVIDERS

Casa de los Niños

Intake site

140 N. Tucson Blvd.

Tucson, AZ 85716

1-520-881-1292

www.casadelosninos.org

La Frontera Center

Administration and intake site

502 W. 29th Street

Tucson, AZ 85713

1-520-838-3804

www.lafrontera.org

La Frontera Center

Intake site, PPEP Behavioral Health

111 La Mina Ave., Suite 5

Ajo, AZ 85321

1-520-387-5232

La Frontera Center

Intake site

1141 W. Grant Road, Suite 100

Tucson, AZ 85705

1-520-206-8600

MHC Healthcare Behavioral Health Services

(Marana Health Center, The Hacienda)

13644 N. Sandario Road

Marana, AZ 85653

(520) 616-4976

maranahealthcenter.org/our-services/behavioral-health

MHC Healthcare Behavioral Health Services

Intake site, Marana Health Center, The Ranch

13549 N. Sanders Road

Marana, AZ 85653

1-520-682-4111

Pantano Behavioral Health Services

Administration and intake site

5055 E. Broadway, Suite C104

Tucson, AZ 85711

1-520-623-9833

www.pantanobh.org

Pantano Behavioral Health Services

Intake site

1477 W. Commerce Court

Tucson, AZ 85746

1-520-623-9833

Pantano Behavioral Health Services

Intake site, Sells, AZ

Tohono Plaza, BIA Route 19, Suite 207

Sells, AZ 85634

1-520-623-9833

Providence Service Corporation

Administration and intake site

620 N. Craycroft Road

Tucson, AZ 85711

1-520-748-7108

Crisis Hotline: 1-800-489-0064

www.provcorp.com/Locations/Arizona.asp

Providence Service Corporation

Intake site

3295 W. Ina Road, Suite 150

Tucson, AZ 85741

1-520-748-7108

Crisis Hotline: 1-800-489-0064

 

Arizona’s law on treating people with serious mental illness is strong — on paper.

The law requires the state to care for all of Arizona’s seriously mentally ill by establishing a “community residential treatment system.”

It was groundbreaking when it passed in 1979, but now the statute lies dormant, a victim of the state’s budget crunch.

Gov. Jan Brewer threatened to repeal the law as part of her budget proposal in January 2010 — and she had the votes to do so. Instead, lawyers involved in a 30-year lawsuit forcing the state to provide certain mental-health services agreed in March 2010 to suspend their suit until June 30, 2012.

In effect, that left the state free not to enforce the law till then.

“Our statutes, our laws are the best in the country,” said Charles “Chick” Arnold, the Phoenix lawyer who filed the lawsuit in 1981. It forced Maricopa County to provide services to those with serious mental illness and established standards for the rest of the state to follow.

“We’ve got a statute, but it doesn’t do anybody any good. Under the cover of the fiscal crisis, this whole system is being emasculated,” Arnold said.

A week after the lawsuit was suspended, Gov. Brewer signed a budget that cut the benefits provided to 28,000 people with serious mental illness who are not enrolled in the state’s Medicaid program, the Arizona Health Care Cost Containment System. To save about $65 million, the state stopped paying for brand-name drugs, case managers or transportation for this group, though benefits remained the same for those enrolled in AHCCCS.

The suspension of the lawsuit was necessary for the cuts to go forward, said Joe Kanefield, the governor’s general counsel, who negotiated the suspension of the suit. Otherwise, the state would have been under court order to provide services it could no longer afford.

While the cuts have been painful, it was crucial to preserve the requirement that the state treat the mentally ill, said Anne Ronan, the attorney at the Arizona Center for Disability Law who agreed to suspend the lawsuit.

“It’s an important right that people have in Arizona that they don’t have in a lot of states,” Ronan said. “It’s been the driver that’s forced the various state agencies and the Legislature to pay attention to a population that doesn’t have a voice.”

Still, some say the suspension of the lawsuit — and thereby the enforcement of the law — simply reflects a long-standing reality in Arizona: The law works only to the extent that the Legislature will fund it. And if people don’t like how well the Legislature funds care for the seriously mentally ill, they can just change the law.

Said Robert Sorce, assistant deputy director for the state’s division of behavioral health: “We can only do what the Legislature appropriates money for us to do.” 

Contact reporter Tim Steller at 807-8427 or at tsteller@azstarnet.com

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."

ANGER, HOSTILITY

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.

COVERAGE STOPPED

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."

THREATENED NEIGHBOR

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 sinnes@azstarnet.com or 573-4134.

Yes, the 18-year-old man acknowledged, he did turn off his mother's car while she was driving it.

"There was a dog running behind us - that's what I thought," he told a judge in a small Pima County courtroom on the fifth floor of UPH Hospital at Kino.

But no, he said, he is not mentally ill - "just a little bit hyper."

The judge, Court Commissioner K.C. Stanford, disagreed and cited a particularity of Arizona's law - people can be forced into treatment even if they aren't a danger to themselves or others. Stanford ordered him to be treated, against his will, for one year.

Arizona law gives extra leeway to people seeking to have someone evaluated and treated for serious mental illness. Every state allows for involuntary treatment of people who are a "danger to self or others," and about half the states do so for those found to be "gravely disabled," or unable to take care of their basic needs.

But Arizona law also permits involuntary treatment of those who are "persistently or acutely disabled" - that is, likely to suffer severe mental or physical harm because of impaired judgment caused by a mental-health condition. That provision puts Arizona in an elite group of states, said Brian Stettin, policy director at the Virginia-based Treatment Advocacy Center.

"Arizona has one of the best, most-progressive laws," Stettin said. In Arizona, he said, "You're focusing on the fact that the person is suffering as a result of their mental illness and their inability to seek treatment for it."

That can be helpful in cases like that of the 18-year-old man, whose mother filed a petition for him to be involuntarily treated for severe mental illness. The judge denied an argument by a Pima County attorney that he was a danger to himself or others but agreed that the young man is persistently or acutely disabled.

NO PANACEA

Still, the law is no panacea, because the system can be hard for laymen to negotiate, and the patients have the right to fight forced treatment, even if it would likely help them. Since January 2008, only about 54 percent of the petitions to have someone evaluated for serious mental illness have led to petitions for forced treatment.

Cadie McCarthy discovered this, painfully, in the last two months. Her son Eric had been living on the streets in San Francisco for months before calling home the afternoon of Jan. 8, hours after the mass shooting that wounded U.S. Rep. Gabrielle Giffords.

The son, 22, did not acknowledge hearing of the shooting, McCarthy said, but a week later he called again and said he wanted to come home. When he got here in mid-January, McCarthy said, he was like he has been since symptoms of mental illness began emerging at age 17 - angry, anxious, delusional and scared.

On Sunday, March 6, he came into his mother's room and asked her to "euthanize" him, she said.

"Something snapped in me and I decided I couldn't take care of him," she said. "I think he knew what he was doing that night. He wanted help."

McCarthy had her older son call 911, and sheriff's deputies took Eric to Northwest Medical Center on what is known as a prepetition - a legal request to have a person evaluated for severe mental illness.

That first night, McCarthy signed an affidavit that was to be attached to the prepetition, but there was no notary present. A hospital employee called the next day and said she would have to sign a new affidavit with the notary present. Several abortive efforts later, the affidavit was finally signed and notarized on Tuesday, March 8, McCarthy said.

"Just trying to find my way through it all has been difficult," she said.

Upon arriving at the hospital, Eric agreed to stay there voluntarily on the condition he didn't have to take medication, McCarthy said. Evaluators there concluded he was a danger to himself, and he was sent to Sonora Behavioral Health.

But after several days at Sonora, doctors there decided they would not support a petition for involuntary treatment, she said. Her information is limited, because her son is an adult and entitled to privacy under federal law.

But the decision left her wondering: "The fact that he wanted to kill himself wasn't enough?"

PROFESSIONALS HAVE A ROLE

Professionals play a role in the petition process, even if it's initiated by a family member. In particular, social workers at Southern Arizona Mental Health Corp. often join first-responders when officers encounter someone who appears mentally disturbed.

They form the Mental Acute Crisis teams that police call in and which evaluate whether the person needs a mental-illness evaluation. Mental Health Corp. workers also check on people who are in nonemergency situations, to determine if they need evaluation.

After these "prepetitions" are filed, two psychiatrists and other medical workers have 72 hours to evaluate the patient. If they agree that the patient needs to be involuntarily treated, they file a request with the Pima County Attorney's Office, which files a formal petition to the court. These are heard in courtrooms such as the one in Kino hospital.

While Arizona's system gives some leeway to these professionals and the petitioners, it also gives the patient ways to fight forced evaluation and commitment. That, along with other circumstances, can lead to an allegedly mentally ill person avoiding treatment, said Paula Perrera, who heads the health-law unit at the County Attorney's Office.

"The mentally ill have as many rights as you and I," Perrera said.

However, she noted, when her office gets as far in the process as filing a petition for involuntary treatment, it is rare that it is turned down.

Mark Johnson often is the adversary to Perrera's attorneys in the fifth-floor courtroom. Johnson is one of the lawyers who regularly represent patients the county wants put into involuntary medical treatment.

On a recent Monday, Deputy County Attorney Dan Jurkowitz had a problem: He was supposed to call two psychiatrists to testify that another patient needed to be forced into treatment.

Both of them were out sick, so Johnson asked the judge, Court Commissioner Julia Connors, to dismiss the petition. Reluctantly, she did.

"Under the circumstances," she said, "I have no choice."

Contact reporter Tim Steller at 807-8427 or at tsteller@azstarnet.com

A shortage of psychiatrists in Arizona means people with mental illnesses are getting less in-person care than they sometimes need.

Arizona has long been a place where psychiatry services have been limited and undercompensated, said Dr. Francisco Moreno, interim head of the psychiatry department in the University of Arizona College of Medicine.

"This issue has eroded the satisfaction and profitability of private practice," Moreno wrote in an email. "Nationally, the payer trends have influenced a decrease in the use of talk therapy to favor medication management by psychiatrists."

The continuing cuts to mental-health services in the public sector stress existing resources, making it tougher to help the growing number of people who need it, he wrote.

He said the local community mental-health system is increasingly depending on alternative medical providers such as videoconferencing consultations and nurse practitioners rather than in-person care from a psychiatrist.

"I try not to see anyone long-term. I don't have time. I have more people than I know what to do with," said Dr. Kevin Goeta-Kreisler, a psychiatrist who has been in practice locally since 1994 and specializes in working with older patients. "When I first started in 1994, we were doing 15-minute medication checks. Now I like to have a minimum half hour, so I am trying to leave myself open, to be there for people if they are really having problems."

Goeta-Kreisler said someone with private insurance who wants to see a psychiatrist will typically need to make multiple calls to find one, and then it could take up to three months to get an appointment.

That's not good for patients, he said.

"People can even make themselves physically sick with psychiatric issues," he said.

Citing the psychiatrist shortage, psychologists in some states are seeking the authority to prescribe medications. Psychologists are already allowed to prescribe in the military and the Indian Health Service, and in New Mexico and Louisiana, the American Medical Association says. The latest measures have been opposed by the AMA and the American Psychiatric Association, among others.

Moreno said enhancing public education about mental illness and improving mental-health coverage in both public and private insurance plans would help attract more medical students to become psychiatrists.

Contact reporter Stephanie Innes at sinnes@azstarnet.com or 573-4134.

When it comes to getting treatment for a serious mental illness, many Tucsonans would be better off being destitute.

Fewer than half of the 765,000 or so working-age adults in Pima County have employer-provided medical benefits, census data show. And such plans vary widely in what they offer in the way of mental-health care.

Some plans - such as a state-sponsored medical plan for small businesses that covers about 2,500 local workers - don't include any treatment benefits for mental illness.

That wasn't the case for Jared Lee Loughner, the accused Jan. 8 shooter. It isn't known if Loughner, 22, ever received treatment for chaotic behavior many experts see as suggestive of schizophrenia. But with a mother who worked for Pima County, his family was eligible for mental-health coverage that is generous compared to what's available for many workers.

The county's lower-deductible health plan covers 90 percent of mental-health-care costs within its provider network once deductibles are met. And it covers the children of county employees up to age 26, regardless of whether they are still in school.

For many who need mental-health care, money is a major stumbling block.

Crisis services - assessment and treatment to stabilize someone who is suicidal, for example - are available free of charge. But to stay stable and improve, most people require ongoing treatment their insurance may not cover.

That's why some people recovering from serious mental illness choose not to work - or to work very limited hours - so they qualify for the state-run Medicaid program.

The Arizona Health Care Cost Containment System, or AHCCCS, covers a package of services including behavioral therapy, name-brand medications, hospital stays, rehabilitation services and caseworkers who are critical to many patients in recovery. But it takes a poverty-level income to qualify: less than $10,890 a year for a single person or $22,350 for a family of four.

Last month in Pima County, about 6,900 impoverished adults with serious mental illnesses were receiving care through AHCCCS. Another 2,600 or so who couldn't qualify got minimal help from the state such as generic psychiatric medication.

"If you qualify for AHCCCS, no problem," said Neal Cash, head of Community Partnership of Southern Arizona, the local agency that distributes public money for mental-health care.

"If you don't," Cash said, "there's a big problem."

Andrew Harvey came face to face with that problem last year at the lowest point of his life.

The 27-year-old was close to suicide after he suffered a mental breakdown on the job at a local Geico call center. His symptoms came on suddenly one day, Harvey recalled. For no apparent reason, he began trembling, sweating profusely and sobbing in the middle of the workday.

"I completely lost control of my emotions," he said. "It was horrifying. I felt humiliated."

He was diagnosed with major depressive disorder and social anxiety disorder. Initially, his workplace medical plan covered his care. But he was too ill to return to work, he said, and six months later the insurer stopped paying.

With no income, Harvey ran through his savings, then stopped taking psychiatric drugs when he could no longer afford them.

He fantasized about hiking into the desert and cutting his femoral artery to make himself bleed to death. When such thoughts take root, he said, it's as if a hungry shark is circling inside his head.

"The shark never goes away. When I wake up in the morning it whispers 'There's an easy way to finish this …' "

Eventually, Harvey's fortunes deteriorated to the point he was poor enough to qualify for AHCCCS.

Had it not been for that help, he said, he might not be here today.

"I never, ever imagined this kind of thing happening in my life," he said. "Now I fight every day for the chance to have a future."

Cash, who oversees AHCCCS spending in Pima County, said stories about insurance woes are familiar to those in the mental-health field. Federal health-care reform could lead to improvements when its provisions take effect in 2014, Cash said.

For one thing, Arizonans won't have to be quite so poor to get coverage through Medicaid. Now their incomes can't exceed the federal poverty line: In the future they'll be able to make up to 33 percent more and still qualify.

Insurers will no longer be able to deny coverage for mental illness as a pre-existing condition, and mental-health care will be deemed an "essential benefit" that certain types of plans must offer, though details have yet to be spelled out.

Cash said such coverage may not be as comprehensive as what AHCCCS offers. Still, it should help makes things better for people who now have no mental-health coverage at all. Cash finds it heartening that public interest in mental health and mental illness is evolving in the aftermath of the Tucson shootings.

But "the real test will be if people are still talking about all this a year from now.

"My hope," he said, "is that when we look back, we'll be able to see how far we've come."

Contact reporter Carol Ann Alaimo at calaimo@azstarnet.com or at 573-4138.

 

A free, public forum, "A Delicate Balance: Creating a better, post-Jan. 8 system to protect the public and help the seriously mentally ill," will be held April 27 at Centennial Hall on the University of Arizona campus.

The event will include a forum with experts, followed by a Q&A session.

The Arizona Daily Star is partnering with the Schorr Family Award organization on the event in the belief that mental illness is a paramount issue in our community. Go to www.cpsa-rbha.org and click on the "Schorr Family Award" link for more information.

The event begins at 1:45 p.m. and ends at 5 p.m.. Translation services will be available upon request.

An R.S.V.P. to 784-5365 is appreciated, but not required.

Dr. Thomas R. Insel, director of the National Institute of Mental Health, will give the keynote talk, "Trying to Understand Serious Mental Illness after January 8."

Insel is the recipient of The Schorr Family Award for Distinguished Contribution in Furthering Public Understanding of Mental Illness.

A panel of local and national experts will be led by Nicholas Breitborde, an assistant professor of psychiatry at the UA.

Panelists will be:

• Neal Cash, president & CEO, Community Partnership of Southern Arizona.

• Dr. Ken Duckworth, assistant professor, Harvard Medical School; medical director, National Alliance on Mental Illness.

• Joel Dvoskin, assistant clinical professor in the Department of Psychiatry at the UA College of Medicine.

• Laurie Flynn, executive director, TeenScreen National Center, Department of Psychiatry, Columbia University Medical Center.

• John Pedicone, superintendent, Tucson Unified School District.

• H. Clarke Romans, executive director, National Alliance on Mental Illness of Southern Arizona.

After the panel discussion, participants will answer questions from the public.

Ron Barber, district director for U.S. Rep. Gabrielle Giffords, will speak after the Q&A. He was seriously injured in the Jan. 8 attack.

After the forum there will be a public reception at the Women's Plaza of Honor, directly west of Centennial Hall.

ASK A QUESTION

Panelists will take written questions from the audience.

You can also submit a question in advance by emailing it to mentalhealth@azstarnet.com before Friday, April 22.

Moderator Nicholas Breitborde will pose a mix of questions that come in during the event and those sent in advance. If there are too many questions to pose at the forum, we plan to continue to answer them in the Star and on our website, azstarnet.com

resource guide

To find a list of resources, definitions and information about how to help someone with a serious mental illness, go to azstarnet.com/mentalhealthresourceguide