Why experts say Virginia’s mental health system fell through the cracks

The access problem

Jafar Cooper said they may have never gotten the help they needed for attention deficit disorder if their mom hadn’t been a psychology major in college.

For Cooper and their mom, the symptoms of ADD were easy to spot since a young age. The manifestations of depression and anxiety, however, were much harder to identify.

The 20-year-old VCU theatre and African-American studies major is gay and gender non-conforming, which Cooper said caused tension with their mom, who instead blamed emotions associated with depression and anxiety on their gender identity and sexuality.

With no help from the public school system, it wasn’t until Cooper arrived at VCU that a friend suggested maybe they were suffering from mental disorders.

“It’s not that it was a problem that I had this thing, it was a problem that my teachers didn’t know how to approach it or what to do about it,” Cooper said. “I remember I felt let down by school a lot.”

Cooper’s narrative is just one of many which contextualizes a recent report by Mental Health America. The report indicates the Commonwealth of Virginia is failing to adequately address mental health problems, ranking the state 38th in the country for overall mental health treatment based on data from 2014.

The study is comprised of 15 criteria to compose each state’s cumulative ranking by examining both adult and youth measures, as well as each state’s capacity to adequately meet the need of mental health services.

In Virginia, for the criteria addressing youth with major depressive episodes who didn’t receive the appropriate care or services, the state fares even worse than its overall ranking — placing 49th overall.

According to Executive Director of Mental Health of Virginia Bruce Cruser, Virginia has gotten worse at addressing mental health in recent years. He said significant reason for that is the commonwealth’s poor distribution of services.

“You might have a lot of child psychiatrists practicing in Northern Virginia, but in southwest and southern Virginia you have very few so it’d be difficult to access,” Cruser said.

In Roanoke, for example, Cruser said there is a 14-week waiting list to see a psychiatrist, even if a person has insurance.

Cruser also cites a shortage of state funding for mental health services, which directly correlates to Virginia’s poor performance.

According to the Virginia Department of Behavioral Health and Developmental Services, the state spends about $88 per person on mental health services — far below the national median of about $120 per person.

Daniel Herr, the VDBHDS assistant director of behavioral health services, agrees Virginia’s lack of investment is an issue, but he said fixing it may not be as easy as just throwing more dollars into the system.

Herr said much of the commonwealth’s funding for mental health prioritizes emergency treatment like hospitals, opposed to primary care like community services and awareness projects.

Primary care investments, in Herr’s opinion, are more effective because they pursue preventative measures instead of waiting for an individual to reach a crisis, and then responding to it

“You have to make sure that people know how to stay well, first of all,” Herr said. “Then that they would have access to see a mental health professional early on so they could get treatment before the symptoms get worse and then you would still need some hospitals as a safety net.”

Herr said most states noticed better results when they shifted their focus in mental health spending from crisis-level treatment to primary services in the mid-90’s, but that was a change Virginia never made.

“(The state) funds a little bit below the national average, but just as importantly it spends its money in the most high-cost way,” Herr said.

For students like Cooper, this reactive approach to mental health care was potentially part of the reason why they were not aware of their mental health symptoms until college.

“There’s a big stigma of being not perfect,” Cooper said. “Especially since I was assigned male at birth so a lot of times there was expectation of me to be perfect. Striving for this concept of masculinity and toughness that I was never meant for.”

Herr said having a stigmatizing condition can make identity an even more complex thing to manage for minorities already dealing with discrimination.

“What we know is that women’s health care outcomes is often lower than men’s, minority individuals and individuals with English as a second language have significantly lower rates of accessing services and have poorer outcomes — that’s a significant factor,” Herr said.

In Cooper’s case, this may have contributed to their situation. Cooper said they felt let down by the fields of pharmaceuticals and psychology, because they felt there were a lot of factors contributing to their symptoms and manic behavior, but it seemed to them that all their doctors cared about was refilling their prescription.

“I don’t know if my therapist really ever understood that there were multiple facets to what was going on,” Cooper said. “The idea that something’s wrong with you is already a stigma.”

The silver lining of systemic failure: legislative response

It isn’t likely any member of the Virginia General Assembly feels more personally connected to the fight for an improved mental health system in Virginia than state Sen. Creigh Deeds (D – District 25).

In 2013, three years after mounting an unsuccessful gubernatorial bid, Deeds’ son Austin, better known to those close to him as “Gus,” was evaluated for mental health issues under an emergency custody order.

The Deeds family was ordered to find Gus a psychiatric bed within six hours, but a mental health evaluator sent Gus home, claiming there were no available beds.

Deeds and his wife begged the mental health system to find a psychiatric bed for their 24-year-old son who had struggled with bipolar disorder for three years — but the unspeakable happened before their cries for help were answered.

Gus Deeds stabbed and slashed his father 13 times, placing the Bath, Virginia representative in critical condition. Gus then shot and killed himself with a rifle.

“Virginia’s mental health care system failed my son, Gus,” Deeds said in a statement immediately after his son’s death. “I am committed that my son’s needless death shall not be in vain and that no other Virginia family suffer this tragedy.”

Deeds came back to the General Assembly dedicated to improving the mental health system. In 2014, he founded the Joint Subcommittee to Study Mental Health Services in the Twenty-First Century, which he has chaired since its inception.

“When I came back to the General Assembly session after all that happened it brought the whole issue into a new focus,” Deeds said, “and because of that it’s forced a number of people to think about why we haven’t prioritized this in a correct way in the past.”

The committee, which will go into its fourth and final year in the 2017 General Assembly legislative session, is tasked with studying Virginia’s mental health system and the laws governing it, before making recommendations to the legislature.

According to Deeds, the committee has reaffirmed the importance of same-day access, which is partially contingent upon how the state funds mental health services.

Herr, the assistant director of behavioral health services at VDBHDS, said for serious forms of mental illness — such as schizophrenia and bipolar disorder — Virginia has only a 22 to 23 percent penetration rate, which refers to the percentage of people who require services and actually receive them. Nationally, Herr said the penetration rate is closer to 65 to 70 percent.

“That shows you just how big the gap is between folks who need something and folks who actually get it,” Herr said. “If we expanded same-day access and outpatient services, that would go the furthest in addressing that need.”

According to Cruser, the executive director of Mental Health America of Virginia, research indicates these issues are addressed most successfully if people have same-day access. For some mental health conditions, this accessibility could make all the difference.

“People who have an addiction, to really be successful, you need to be available to help them when they’re asking for the help,” Cruser said. “In two weeks, if they really have an addiction, they could be dead.”

Not only is the same-day access approach imperative in life-threatening situations, but according to Cruser it is a better way to spend money, too.

“If (a person) wants to see somebody, (they) can see somebody that day to at least get in the door,” Cruser said. “If (they) have to wait three weeks for that first appointment then the success rate is much less.”

Same-day access is one of the areas targeted in the Excellence in Mental Health Act, which Congress passed in 2014. The act committed $1.1 billion in grants to states to improve their mental health procedures.

Virginia was awarded $2 million in federal grants and subsequently created eight Certified Community Behavioral Health Clinics, also known as CCBHCs, which offer same-day access to all patients.

One of those eight clinics is in Chesterfield County, just outside the city of Richmond. The clinic is already reaping the benefits of same-day access, according to Debbie Burcham, the executive director of Chesterfield’s Community Services Board.

Burcham told the Richmond Times-Dispatch in October that since same-day access began in July 2015, wait times have vanished, wasted staff time dramatically dropped, the wait for someone to begin services in a program has been cut in half and patient retention rates have increased.

In Virginia, federal and state dollars are combined with money from Community Service Boards, which operate at the local level, to fund mental health services. The CSB’s provide about a quarter of funding for mental health systems, which Deeds said leaves localities with less money at a disadvantage compared to their wealthier counterparts.

“Part of the challenge is — for Virginia — it doesn’t provide the same level of funding for every community,” Herr said. “It provides much less funding than many other states just because of how it chooses to use its dollars and it does not have a core standard of services that everyone must provide.”

Herr said that CSB’s are required to match state dollars in funding for services — but that’s not always the case. In some districts, localities cannot afford to match the state in funding and in others, they have to outspend the state in order to meet their particular needs.

Deeds said that while it’s important to keep pushing legislators to prioritize funding mental health, he recognizes the reality of Virginia’s constrained budget may prevent the General Assembly and Gov. Terry McAuliffe from passing laws to invest in measures to better address Virginia’s mental health problems.

In August, McAuliffe told the General Assembly to prepare to make tough decisions regarding spending cuts when he announced Virginia collected less income and sales tax revenue than expected. In other words — the commonwealth is projecting a $1.5 billion budget shortfall in budgets for fiscal years 2015, 2016 and 2017 combined.

“I remain confident enough in human nature. We’re going to have to find a way to pay for it and I think we will (…) it won’t happen overnight,” Deeds said. “It may be something we phase in over eight to 12 years if that’s what we can get.”

Lack of resources, the repercussions of stigmatization

Celia Delahunty found herself among a group of students the high school put through in-school counseling when W.T. Woodson High School in Fairfax County had a sixth student commit suicide in three years, between 2011 and 2014.

That was the first time Delahunty heard she may have depression. Now a senior at VCU, Delahunty is sure she does — and said the condition prompted her to drop two classes this semester. She thinks if she had gotten help sooner, she may have coped better.

Delahunty said she first went to University Counseling Services as a freshman at VCU, but didn’t get help until a year later as a sophomore.

UCS Director Jihad Aziz said long waits are the new normal in college counseling, and students around the country are experiencing four to six-week waits to get services.

“Historically, I think one of the challenges for university counseling services in general at any university, is there’s a trend that there’s more students seeking help than actual resources,” Aziz said.

According to Aziz, UCS had a 43 percent increase in students seeking services in the last four years. He said by his standard, the university has coped well in keeping wait times for students down to about two weeks.

Despite this, Aziz said 2015-16 was especially challenging for the office because five UCS employees left during the school year and some students had to wait as long as four weeks to begin receiving services.

In a given year, UCS sees about 8 percent of the student population, or about 2,500 students — which Aziz said is consistent with other large public universities.

Aziz said what concerns him the most, though, are not the students he sees, but rather the ones he doesn’t. According to Mental Health America’s study, youth battling depression in Virginia are some of the least likely in the nation to receive treatment for their mental illness.

Cruser said poor distribution of services plays into that, because not all young people may have access to services. Another challenge Mental Health America of Virginia faces is urging people to go seek help if they think they may be suffering from a mental health problem. Cruser said he believes downplaying mental health problems has played into a lack of people seeking services.

“For initial onset of major and even minor mental health issues, a lot of us tend to rationalize it, or even kind of dismiss it,” Cruser said. “We think ‘Oh, it’s just cause I haven’t gotten enough sleep or oh, I’m just really stressed right now. Parents do that a lot, of kids, particularly teenagers.”

Additionally, Cruser said a stigma still exists around being diagnosed with a mental health problem, despite the prevalence of public conversation surrounding the issue, which he said did not exist years ago.

“I’m concerned about the people who don’t walk in the door and are sitting in their rooms and suffering and no one is saying ‘I care about you, let me walk you to counseling,’” Aziz said. “I want to have a community where that’s the norm.”

For students like Cooper, stigmatization played a role in not seeking services until college.

“I think that’s evident in a lot of black communities and POC communities,” Cooper said. “It’s taught us that we should have to be super resilient, that we have to fix our problems ourselves. I almost thought going to therapy or seeking out extra help was a weakness.”

Herr, from the VDBHDS, agrees.

“They haven’t focused on so what does it mean to grow up in a poor neighborhood in schools that may be underperforming, in a minority family,” Herr said. “In a place where the socio-economic determinants of health would set me on a trajectory where all my health indicators are poor.”

According to Herr, Virginia Department of Health data indicates that people living within just 10 blocks of each other have different life expectancies of 10 to 15 years due to socio-economic factors that impact mental and physical health.

“SJ 47 (Joint Subcommittee to Study Mental Health Services in the Twenty-First Century) and Senator Deeds have made the conversations public, visible and much more okay to talk about,” Herr said. “But the conversations have almost all focused on emergency or crisis.”

For Deeds, Virginia’s mental health system is a crisis that is inextricably personal, and he is not ready to let the issue rest.

“Failure is not an option we have to build a better system that provides services to people all over Virginia. There are acute challenges (…) but they’re challenges that affect people’s lives and their opportunities to succeed,” Deeds said. “I’m not going to hang my head.”

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