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'Epidemic Ignored': Oklahoma treats its mental health system without care

Daily Oklahoman (Oklahoma City) - 1/24/2016

Jan. 24--Even before Oklahoma was a state, leaders grappled with how to provide care to residents with mental illnesses.

By wagon, by horse, on foot, by train, thousands of people flooded into the Oklahoma Territory during the late 1800s. And with that deluge of people came a need for a mental health system.

At first, Oklahoma Territory leaders sent residents with mental illnesses away, by train to Illinois.

But in 1895, leaders decided that was too expensive -- $17,000 over the previous two years just to transport the residents. It was one of the costliest expenses in the territory's budget.

"I apprehend that aside from the savings in cost, it will be more desirable in every respect to have these unfortunates cared for near their friends and relatives and by citizens of the Territory," Gov. William C. Renfrow wrote in his 1895 address to the Legislature.

Renfrow had decided it was time to bring these residents back to receive treatment in Norman at a private psychiatric hospital. That was the inception of Oklahoma's mental health system.

Unknowingly, Renfrow had shared the same sentiment that eventually would change the nation's mental health system: the idea that residents should receive treatment close to home.

If territory leaders had embraced the concept of treating Oklahomans in communities where they lived, the mental health system would look much different today. Instead, residents were warehoused in large psychiatric hospitals, and for decades, many communities lacked any available mental health care.

After those hospitals were closed, Oklahoma leaders claimed they would invest in community mental health care. That did not happen.

Instead, in present-day Oklahoma, a fractured, arguably underfunded mental health system is suffocating.

But in a state that hasn't made a sustained, significant investment in its mental health system, the majority of low-income, uninsured Oklahomans with mental illnesses and substance abuse disorders who need help do not get it.

For decades, federal researchers and state officials have warned of the consequences of not making a long-term investment in mental health, and for decades, those warnings have been largely ignored.

Almost 80 years ago, the National Mental Hospital Survey Committee published a report that noted that Oklahoma would save money if it invested in its mental health system.

"Whatever the future may bring," the report concluded, "Oklahoma cannot look on itself with pride until provision is made for adequate care of its mentally helpless citizens."

That was in 1937.

Today, Griffin Memorial Hospital in Norman serves as a short-term, psychiatric hospital, largely for low-income, uninsured residents suffering from mental health crises. It can hold up to 120 patients and is usually full, although patients are continually discharged quickly.

The hospital's namesake, Dr. David W. Griffin, came to Oklahoma in 1899, fresh out of medical school in Virginia. The young psychiatrist from North Carolina was coming to work at a small, private psychiatric hospital, owned by the Oklahoma Sanitarium Co.

The hospital sat on a few acres of land, with some small wooden cottages and a store building that served as the administration building. There were 362 patients.

Early upon arrival, Griffin noticed that, on the stone gates of the hospital, it read, "For The Violent Insane." He chiseled it off himself.

Griffin did not like the term insane, and he often stressed to the public that Oklahomans with mental illnesses and substance use disorders could find recovery -- if given proper care. He forbid anyone in the hospital from using the word "crazy."

The two most common mental illnesses at the hospital were schizophrenia and manic depression -- now called bipolar disorder. Many of the early patients came to the hospital for alcohol abuse or venereal diseases that caused their mental health to decline.

In 1915, the state of Oklahoma bought the hospital from the private company. At this point, the hospital had more than 1,000 patients and 100 employees.

During the next several years, Griffin would discuss with anyone who would listen the conditions of the hospital and the dire need for more funding.

Griffin repeatedly asked for money to expand the hospital and hire enough staff to treat patients. He found some success -- but only after a fire broke out at the hospital in 1918 and killed 40 patients. The hospital's buildings were upgraded then, but even so, during the next 25 years, state hospitals would fall into disrepair.

Griffin started his job at a time when mental health advocacy groups did not widely exist.

"Like so many pioneers, he labored for years practically alone," columnist Edith Johnson noted in The Daily Oklahoman in 1953.

Estelle Blair, a former assistant commissioner at the Oklahoma Department of Charities and Corrections, wrote to Griffin in March 1915 after moving to Oregon. Blair wrote that she was hopeful the Legislature would recognize Griffin for the hard work and success he saw at the hospital.

"However, from the meager accounts received of that August assembly, it seems that they have seen fit to interest themselves mostly in passing oil legislation," Blair wrote.

Many of the mental health system's struggles went unnoticed until 1946, when Mike Gorman, a journalist at The Daily Oklahoman, wrote a series of stories, highlighting shameful, tragic conditions at the hospitals.

In the 1940s, Oklahoma ranked No. 45 per capita in the amount of money the state spent per patient. And within the southwest region of the United States, Oklahoma spent the least on its patients.

For example, in 1943, the Norman state hospital spent an average of $16.87 per patient per month. Meanwhile, at the Oklahoma State Penitentiary, it was $24.18 per inmate per month. And at the tuberculosis treatment facility in Talihina, the average monthly patient expenditure was $57.54 per month.

Gorman visited each of the Oklahoma psychiatric hospitals, which were segregated at that time. White patients went to Central State Hospital in Norman, Eastern State Hospital in Vinita, and Western State Hospital in Fort Supply. Black patients went to the Taft State Hospital for the Negro Insane in the small eastern Oklahoma town of Taft.

Each hospital was overcrowded and understaffed. Regardless of how hard physicians, nurses and attendants worked, they could not possibly address the magnitude of illness at each facility, Gorman wrote.

"A large percentage of patients in Oklahoma's mental institutions today do not receive psychiatric treatment," Gorman wrote. "Most of them do not receive even adequate custodial care; more serious than anything, a large number of them could be living happy constructive lives as cured persons. Instead they are wasting long years in institutions for lack of adequate care."

At that time, Oklahoma also had one of the worst doctor-to-patient ratios, ranking No. 43 in the United States. Additionally, the state ranked No. 45 for its ratios of nurses to patients. This was apparent at every hospital. Each of the doctors at Central State Hospital had a patient load of about 700 people -- one of the highest physician caseloads in the United States.

Every ward at Central State Hospital had about double the number of beds it should, producing a "frightful odor," especially on hot summer days, Gorman wrote. One building, where men with the most serious illnesses lived, was "the most unhygienic on the entire grounds."

"The seclusion rooms on this floor would frighten even the state legislators who begrudge present appropriations for state mental hospitals," Gorman wrote. "Caged in small rooms with a peep-hole slit in the door, many of these patients grovel nakedly about on a cold stone floor."

Some patients at Central State had lived there for months, but they weren't receiving much, if any, treatment. With proper care, they could have likely returned home.

"Some of these chronic patients have not been out on the grounds in 10 years," Gorman wrote.

A physician told Gorman that because of a lack of attendants -- one for every 37 patients -- they couldn't let some patients outside.

Meanwhile, Western State Hospital at Fort Supply was overcrowded with crumbling buildings and a skeleton staff.

"Supply is not only the worst of the three mental hospitals for whites in the state, but is perhaps one of the worst in the country," Gorman noted.

The hospital's bed capacity was 1,154 -- and somehow, 1,603 patients were crammed together. They slept on porches, in day rooms and even in hydrotherapy tubs. The hospital's buildings had fallen into major disrepair, with broken wooden floors, cracked walls and falling plaster.

Ward No. 9, a wooden building built in the 1880s, was repeatedly condemned by the fire marshal as a serious fire hazard. There were only four doctors to treat hundreds, and there were no nurses or social workers.

"The Supply hospital is the end result of years of neglect of our mentally ill by successive state boards of affairs and state Legislatures," Gorman wrote. "... The major weaknesses of Supply did not originate at that institution; they started at the state Capitol where indifferent legislators and administrators have practiced 'economy' in the treatment of the mentally ill in Oklahoma."

Despite the psychiatric field largely condemning the use of mechanical restraint, and the state Department of Health having a policy that "mechanical restraint is to be avoided," patients were regularly locked down in leather wristlets, locked belts around their bodies and leather locks around their legs.

"Practically every doctor in the Oklahoma mental hospitals is opposed to this excessive use of restraint, but explains it is due to the shortage of attendants," Gorman wrote.

Ward attendants made up a large part of the hospital workforce in Oklahoma, but each attendant often had at least 40 patients to watch over. And in some cases, hospitals hired long-term patients to work as attendants.

"If we had enough regular help, I wouldn't use one of them," Jessie Kellogg, superintendent of nurses, told Gorman. "If they were mentally competent, they would have been discharged from here."

Gorman was a proponent of the state building a hospital that would treat a range of patients, largely on an outpatient basis.

It would offer free care to the poor, and social workers would help patients find the resources they needed, while helping them develop a self-care plan to help prevent future crises.

"Over the years, thousands of Oklahoma's mentally ill have been relegated to the ranks of the incurables because we have had no hospital to treat mental illness during the stage when it can be cured -- the first few months after its onset," Gorman wrote.

One 1937 report recommended that Oklahoma double, or in some cases triple, its hospital facilities to address their serious flaws and prepare for the future. But the board that oversaw the hospitals did nothing.

After Gorman's piece was published, the state created a mental health section, overseen by the state Board of Public Affairs, according to the Oklahoma State Medical Association archives.

Dr. Griffin retired in 1950, after dedicating five decades to caring for people with mental illnesses. He died three years later.

From the 1940s into the 1960s, Oklahoma spent less than nearly all other states on mental health, according to historical documents. During this time, though, some states started increasing mental health funding, spending double the national average per patient in an attempt to convert their hospitals from custodial care institutions to facilities with active treatment programs. This was possible, in part, because some of the first antipsychotics were released.

"Oklahoma remains in the lowest 10 percent of states in terms of the amount of money it puts into its mental health programs," a 1961 Central State Griffin Memorial Hospital newsletter read. "Yet, we rank within the top 10 percent in the number of releases and our readmission rate is well below the national average."

In 1953, Dr. Hayden Donahue was selected as the first director of the state's Mental Health Department. During the next few decades, the Oklahoma-born physician would become one of the most respected psychiatrists in America.

Donahue walked into a system that hadn't seen significant reforms at its state hospitals, despite his predecessor's efforts, according to Oklahoma State Medical Association archives.

The state Mental Health Department, not yet its own agency, was "virtually powerless" without funding or independence from the state Board of Public Affairs, the archives note.

Donahue, 40, originally from Oklahoma, had moved back from Arkansas in hopes that he could help revamp Oklahoma's mental health system. At that time, there were 8,620 patients in Oklahoma's four psychiatric hospitals.

Donahue came to Oklahoma after serving as a flight surgeon and psychiatrist in World War II. During the war, he studied under Dr. Roy Grinker, a psychiatrist nationally respected for his research on depression and schizophrenia. Grinker had studied under Sigmund Freud.

Donahue helped lawmakers write legislation that created the state's mental health department along with a seven-member board to oversee the agency.

Dr. Ernest Shadid, an 85-year-old Norman psychiatrist, worked with Donahue for decades. Shadid spent most of his time away from the Capitol and let Donahue work to persuade legislators.

Donahue used to tell Shadid that if schizophrenia caused people's skin to turn green, then Donahue could probably get money for mental health.

"It's a political system that we have, and mental health was never high on the priority," Shadid said during an interview at his Norman home.

After Donahue's first year as director, the patient death rate declined 27 percent, and "for the first time in history, more patients were discharged than admitted," according to Oklahoma State Medical Association archives.

Donahue hired and trained more staff, and he ended the use of prefrontal lobotomies and punitive electroshock treatments, according to the medical association.

But after seven years in his job, Donahue felt bitter about the lack of energy for reforming Oklahoma's mental health system, Shadid said. Donahue resigned and moved to Little Rock, Ark.

"After a time, the Legislature gets to looking at you and says, 'We got you straightened out. Now it's education's turn or somebody else's,'" Donahue told a reporter for the Oklahoma State Medical Association's magazine. "Consequently, I hadn't been getting the funding I needed to upgrade the staffs and buildings at Eastern and Western State hospitals."

But Donahue returned. In 1961, he worked again for the state Mental Health Department and helped lead a major change for Oklahoma: the first community mental health center in the nation.

Donahue repeatedly traveled to Washington, D.C., to advocate for the community mental health services.

In October 1963, President John F. Kennedy signed the Community Mental Health Act.

After four years of politics, funding debates and trips to Washington, Oklahoma opened its center in March 1967 on the grounds of Central State Griffin Memorial Hospital. It provided inpatient, outpatient and crisis services to patients who lived nearby, allowing them to live independently while still receiving care. The plan was to build 16 centers across the state.

A place like this could be built in any community, Donahue told a U.S. Senate subcommittee in 1969.

"With a network of centers across the country," Donahue said, "I believe that many of the mentally ill who have previously been destined to vegetate for decades in custodial state hospitals can be enabled to lead socially useful and productive lives in their home communities."

When Terry Cline moved back to Oklahoma to serve as the state's mental health commissioner in 2001, a big job awaited him. The Legislature had been at odds with the department after arguments and alleged scandals about money and politics, and the three commissioners before Cline each had resigned.

Meanwhile, then Gov. Frank Keating had decided it was time for Oklahoma to close Eastern State Hospital in Vinita.

In a recent interview with The Oklahoman, Keating said he made that decision believing that many of the patients at Eastern State could succeed in a much less restrictive environment.

"Some of those people were there forever," Keating said. "For long, long periods of time, they were housed. They weren't treated, and I thought if (they) can, through therapy and through medication, become a productive member of society, that's in our best interest to do that."

As Eastern State began downsizing, the cracks in Oklahoma's mental health system began to show.

Suicide rates increased in Tulsa. Emergency rooms were swamped with patients suffering from mental health crises with limited options of where to go. Downtown Tulsa businesses reported a doubling in the homeless population. And the Tulsa County jail's medical unit was full of psychiatric patients, according to The Oklahoman Archives.

People felt desperate. Eastern State had only 44 beds left, open for patients with mental illnesses who needed long-term care.

At one point, a sheriff showed up at the gates of Eastern State with someone suffering from a mental health crisis. The hospital couldn't admit the patient because there weren't enough beds. The sheriff handcuffed the patient to the gates of the hospital and left, forcing the hospital to admit the person.

An overflow of patients at Griffin Memorial Hospital slept on the floor in "cradle boats," plastic beds that looked like half canoes.

"So that's what I inherited," said Cline, who later served as head of the federal mental health agency. "It was bad, and it's because we hadn't built up the community-based system before we shut the hospitals. That was the problem. So with the limited beds you did have, we had huge overcrowding."

When the community mental health system started, it had a lot of federal support. The first centers were built largely with federal money. But as years went on, the federal dollars dried up, and states were left to pay the bill to build a community mental health infrastructure, Cline said.

"That's how the community mental health system started," Cline, a psychologist originally from Ardmore, said. "It had a lot of (federal) support. But the focus away from institutionalization was not coupled with dollars being adequate to build up a system of community-based care, which is unlike our general health care system or system for developmental disabilities or other institutional care, where you continue to get that support from the federal government, and I think that was because of the stigma that's associated with mental illness."

The deinstitutionalization movement happened later in Oklahoma than other states.

Although Oklahoma had trailblazers like Donahue who brought great change to the state, the follow-through of closing hospitals and building a community mental health system was slow to take hold.

"In terms of any large-scale de-

institutionalization, that really didn't start happening, I don't think, in my opinion, until the mid '80s," said Randy Tate, CEO of NorthCare, a large community mental health center based in Oklahoma City. "It was really gradually happening in the late '70s and '80s, but in terms of larger numbers, we were very delayed in it happening in Oklahoma. And I think it was probably the first oil boom-bust that probably got us on the national band wagon of deinstitutionalization because state hospitals were very expensive cost centers for the state of Oklahoma."

This past December, lawmakers were bracing agencies for the worst. There were rumors that the state could see a budget shortfall of almost $1 billion. Lawmakers had hearings at the Capitol to hear agency requests and talk about needs versus wants.

Before the Mental Health Department's budget presentation, Sen. Kim David, R-Porter, asked the agencies in the room to remember that the state likely would see a major budget shortfall, and there wouldn't be much money to go around. She told them not to expect much.

But when Commissioner Terri White, of the Oklahoma Department of Mental Health and Substance Abuse Services, took the podium, she told the panel of lawmakers that she was still going to ask for more money because it was too important not to.

"You're going to have tough choices," White told the group of senators in December. "And I know this isn't going to shock any of you -- I'm not going to make it easy for you. I'm not going to just say, 'Yep, I know it's tough choices' and not advocate for what I think is the best use of state dollars. So, my thought that we should all be thinking about is, 'How much is a life in Oklahoma worth?'"

White is known for her ability to rally a crowd. During a mental health advocacy day at the Capitol, White led a group of about 100 people in yelling, "Fund mental health now!" The chant echoed through the Capitol's marble hallways.

Under Gov. Mary Fallin's administration, the department has seen fewer budget cuts than other agencies. Fallin said she has told lawmakers during budget conversations that the state must allocate more money toward mental health. There have been times when she has made that a deal breaker, she said.

Fallin said she always wanted to bring more attention to mental health when she was in the Legislature and in Congress. Historically, lawmakers have not put enough emphasis on mental health issues, she said.

"That's why, when I had the opportunity to be elected governor, I decided I was going to make a change and try to put more funding, and put in best practices, and put in best systems of care because this is a very important issue for the state of Oklahoma," Fallin said.

Still, this next legislative session likely will be difficult for the state mental health department.

The state faces a major budget shortfall, almost $1 billion for the next fiscal year, and there likely will be cuts to several state agency budgets.

Commissioner White said she believes there's more at risk this year than in previous years.

"We've made progress finally over the last few years -- not that we got where we needed to be -- but we've made progress, and it feels like it's on the cusp of going backward," White said.

Although Oklahoma spends less than half the national average on mental health, the state has received national praise for the outcomes of its patients.

For example, Oklahoma had the fifth highest percentage, 81 percent, of adults reporting feeling more socially connected after receiving care, according to a 2014 Mental Health America report.

A report compiled by the federal mental health agency showed that, overall, the majority of Oklahoma adults, children and their families surveyed felt positive about the care they received.

But those good outcomes only apply to people who can get through the door in the first place.

The state mental health system is supposed to serve as a safety net for Oklahomans who cannot afford care.

Between 700,000 and 950,000 adult Oklahomans need services, but most are not receiving the care they need to fully recover from their illnesses. One of the barriers they face, because of how treatment is currently funded, is that someone has to be sick enough to get mental health and addiction treatment in Oklahoma.

For example, Oklahoma has 15 community mental health centers that serve as the backbone of the state's mental health system.

Under their contracts with the state mental health department, these centers are required to treat the sickest patients who come through their doors. That is decided using a four-point scale that ranks patients according to their illness.

A patient ranked as a No. 1 is suffering from a serious mental illness and must be treated. Patients ranked in the No. 2 category also must be treated.

And those two patient groups make up thousands of Oklahomans who receive care each year.

However, there are thousands of people assessed who fall into the No. 3 and No. 4 categories. The community mental health centers aren't required to care for them. They only treat them if they have money left over from treating sicker patients.

Verna Foust, CEO of Red Rock Behavioral Health Services, said her staff wishes they could treat all patients who come through their doors, but they can't.

Red Rock is one of the largest community mental health systems in the state, with facilities serving 24 counties and employing nearly 450 people. Countless Oklahomans who come to Red Rock don't meet the criteria to be seen.

"It's ridiculous," Foust said. "It's like a diabetic being told, 'Well you're really not sick enough, but when you're close to a diabetic coma, then come in and we'll help you.' "

NorthCare and Red Rock each provided $1 million in care that the state never paid them for, their leaders said.

But the backlog for care doesn't end at the community mental health system. The wait line for state-funded residential substance abuse treatment is 600 people long.

Without care, many struggle.

An Oklahoman with a mental illness and substance use disorder will die, on average, 35 years early.

Mental health leaders and advocates say that low-income, uninsured Oklahomans with mental illnesses and substance use disorders are at a heightened risk of becoming homeless, being arrested or dying by suicide.

That's in part because Oklahoma closed its large, long-term psychiatric hospitals -- but filled its prisons with a similar population.

"That's the tragedy in this story -- that's how we've really replaced the old state hospital system because we haven't invested at the level we need to invest in at the community service level," said Mike Brose, Mental Health Association Oklahoma CEO.

The Oklahoma Department of Corrections has seen the number of inmates with mental illnesses continue to grow.

Last year, more than half of the inmates in DOC custody -- a total of 16,533 people -- either had a history of mental illness or current symptoms. Many are in prison for nonviolent drug offenses.

The Corrections Department has a re-entry program to help offenders with mental illnesses prepare to leave -- but they don't have enough staff to help all those offenders. Without help, many with mental illnesses will return to prison.

"Despite the efforts of people not only within the correctional system but also the department of mental health and the community system, we are still, to me, going backward," said Janna Morgan, DOC's chief mental health officer. "We continue to bring people into the system who would be better served prior to prison, which is disappointing."

It costs an average of $2,150 a year for the mental health department to provide services to an Oklahoman in need. Meanwhile, mental health court, which can keep a person with a mental illness from going to prison, costs $5,400. Drug court is $5,000. And an inmate with a serious mental illness costs taxpayers $23,000 per year in DOC custody.

White has repeatedly referenced those cost differences in her presentations to lawmakers. And overall, after nine years as commissioner, White has started to see a better understanding of the importance of treating mental health and addiction.

"What I'm sort of waiting with bated breath for is -- does that translate into investing in the system the way it should have been invested in decades ago?" White said. "We're the people standing here now, so are we going to fix the problem that we've inherited so that we're not having this same conversation another 100 years from now?"

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