Janet Lowrie tries to stay busy. She fills her days with chores around the house, walks in the park, writes in her journal - anything to keep from swallowing a fistful of pills, as she did last April.
Ms. Lowrie is one of thousands of mentally ill people in Texas who are having to fend for themselves now that the state has implemented its most severe cuts ever in mental-health services. She used to meet regularly with a counselor, a man who encouraged her and taught her how to stay positive. Now Medicaid no longer covers those sessions, and Lowrie can't afford to pay for them on her own.
"I feel pretty isolated and alone," says Lowrie, who has been diagnosed with bipolar disorder. "And that really scares me."
So far, this former nurse has cared for herself successfully, but many others haven't. Since the latest cuts took effect Sept. 1, emergency rooms, homeless shelters, and jails are bursting with the mentally ill in crisis.
It's a common scene across the country. States, facing their worst fiscal crises since World War II, have been making drastic cuts - and are considering more. And since healthcare programs such as Medicaid constitute roughly 20 percent of state budgets, they are often targets.
In the last legislative session, 29 states cut their mental-healthcare systems, according to the National Alliance for the Mentally Ill. But experts say lawmakers will regret their choices. The mentally ill need treatment one way or another - and prevention is far less costly than crisis care. A 24-hour hospital stay for a mentally ill patient in crisis can cost a state the same as six months of outpatient care. Jailing the same person for a misdemeanor, such as trespassing or panhandling, can cost as much as a year of outpatient care.
"State governments don't recognize that cuts in one place are going to show up somewhere else," says Michael Fitzpatrick, director of the Policy Research Institute at the National Alliance for the Mentally Ill. "With such a diminished safety net, more people end up in jail, in homeless shelters, in emergency rooms. We already had a fragmented system of care; now it's in dire straits."
Already the impact is clear in emergency rooms and prisons nationwide:
• In Massachusetts, Boston Medical Center's emergency room saw a 20 percent jump in psychiatric patients after recent cutbacks to MassHealth, the state's indigent-insurance program.
• In Oregon, which is in the process of reducing its budget for mental-health services by $200 million over the next two years, the state Health & Science University reported a 25 to 30 percent jump in psychiatric patients since cuts began.
• And across the country, 1 in 6 inmates is mentally ill, according to a recent report by Human Rights Watch - making prisons America's primary mental-health facilities. California and New York have more mentally ill people in prison than in psychiatric hospitals.
Historically, the mentally ill were cared for in asylums or state hospitals. But with advances in medications to treat such illnesses in the 1960s, states began closing those hospitals in favor of community-based treatment. Thousands escaped often-grim institutions, but experts say the new systems have never been adequately funded. Now, with this round of cuts, the system is even more strained.
Back in Texas, which will cut its budget by $60 million in the next two years, professionals are just beginning to experience the problems going on elsewhere. Patients cut off from benefits in September are just now running out of medication - and often winding up in trouble.
Already, jails and psychiatric centers in Harris Country are feeling the effects. Houston's Ben Taub Psychiatric Emergency Center typically sees 450 to 500 patients a month, but since Sept. 1, those numbers have steadily climbed. Medical Director Edythe Harvey blames state cuts in outpatient care. "When patients don't have that follow-through, they return to the emergency room in crisis, get their medications refilled, and return when those run out," she says. "These are people who don't need to be in a hospital."
Already this year, the Mental Health Mental Retardation Authority of Harris County has closed three clinics and eliminated hundreds of staff jobs, disrupting care to several thousand patients.
"We encourage our patients to get into a routine and then the state does things to disrupt that routine," says Tom Mitchell, with the Harris County agency. "Things have gotten totally out of whack."
He tells the story of a man who lost outpatient services, went off medication, and was arrested for trespassing. He was given a two-day jail sentence - but it took the state six months to get him mentally fit enough to serve those two days.
"So we are spending thousands of dollars on this one guy for a misdemeanor," says Mr. Mitchell. "And all because the services weren't there for him."
Mitchell is director of the Mobile Crisis Outreach Team, a new $1.3 million program that's bucking the trend of cutbacks. It was started in February and is funded entirely by the Harris County Commissioners Court. It's designed to help those in the early stages of mental-health crises. A team of doctors, nurses, and social workers reach patients in the community - making old-fashioned house calls in vans.
They provide medications and food stamps, connect people with clinics and counseling, even drive them to appointments and find them winter jackets. Many of the new calls, says Mitchell, come from the three areas in the county where clinics have closed. Today, the first call is near downtown Houston.
Kathy (not her real name) is sitting on a stone bench outside a grocery store when Dr. Tracie Dejarnette-Holly and nurse Annabel Elsner pull up. She's been diagnosed with severe depression, but since starting a new medication, she's experiencing anxiety and mood swings - enough that the shelter she's staying at wants her to leave.
"I'm on a roller coaster. I don't understand my emotions," says Kathy, her hands shaking as she fingers the tiny cross around her neck. "I just want to be normal."
Psychiatrist Dejarnette-Holly listens for awhile and recommends a lower dose of her medication: She'll take just enough to keep the voices from returning. Before heading to another appointment, the doctor and nurse set a time to meet with Kathy in the next few days, promise to call the women's shelter and explain her situation, and agree to return with a winter coat.
They are proud of Kathy. She's been following through with appointments, taking her medication, and going to substance-abuse meetings. "You need to know that you're doing very well," says Ms. Elsner, hugging Kathy goodbye. "A lot of people would fall back on old behavior, but you are hanging in there."
"Thank you," says Kathy. "I needed to hear that."