‘Broken’ mental health system overwhelms Nevada

The man’s story was terrifying. He had been tortured at the High Desert Prison in Indian Springs outside Las Vegas. He had been starved, beaten. A snake had been implanted in his stomach to slowly poison him to death.

“I can feel the venom pumping through me every time it bites me,” he said.

Jon Norheim, a Clark County judicial hearing master, listened to this man’s accusations during a recent court session to determine whether to involuntarily commit him to a psychiatric hospital.

Norheim told the man his snake problem might go away if he took his medication for schizo­phrenia.

“I’d take the pills,” Norheim advised.

“I’d rather have it surgically removed,” the man said, refusing to take his meds.

The Hispanic man in his mid-20s glared at Norheim from across the room. He balled up his fists, muscles tensed against his shirt. Two doctors sitting near him stood and moved away. Two beefy orderlies drew closer.

“Your staff is draining me,” the man said. “They actually murdered me, but after 15 hours I resuscitated myself.”

The room went silent, the accusation hanging in the air.

“So am I being released?” the man asked after a pause.

“No,” Norheim answered. “We’ve got to fix the problem.”

“OK. Have it your way,” the man said then abruptly stood up to leave.

His was the last case on the docket of about two dozen patients who came before Norheim that Friday in a makeshift courtroom at the Rawson-Neal Psychiatric Hospital, a state-run acute care facility.

The disturbed man lingered in the cafeteria next to the room where Norheim held court. The agitated patient was left alone, with no attendants to escort him to his room. A guard who accompanies Norheim told the judge, court staffers and doctors in the room to hang tight.

The man wandered outside and walked across a grassy courtyard toward the reception area and main hospital entrance, his way barred by a locked door. A half-dozen hospital staffers surrounded him, moving slowly and speaking calmly.

“I’m legally dead!” the man shouted, then tried to rush the door.

Staffers took him down, pinning his arms and legs, and then securing him in a chair with restraints.

Undaunted by the drama, Norheim said he understood the man’s panic.

“To him, the snake inside him is real,” Norheim said. “Sometimes, they talk to people we can’t see. Las Vegas is a mecca for the mentally ill.”

MORE WORK ON THE WAY?

Norheim holds court twice a week at Rawson-Neal, hearing as many as 50 cases each visit. His job is to judge, with the help of psychiatrists and psychologists, whether severely mentally ill men and women are such a danger to themselves or others that they must be held against their will.

Involuntary commitments are rare in Nevada — only 170 cases in 2012 — because most patients quickly stabilize on medication or a psychic break caused by heavy drug or alcohol abuse resolves itself when the person sobers up, he said.

But Norheim’s caseload could increase under a proposal before the Nevada Legislature that would allow courts to retain control of mentally ill people without institutionalizing them. AB287 would allow police to forcibly take mentally ill outpatients to medication and counseling appointments under court order.

While the workload for judges would increase, Nevada health authorities hope the new legal tool, if passed, will ease the burden on crowded hospital emergency rooms and on Rawson-Neal, which has become a revolving door for thousands of mentally ill people each year.

The program would target several hundred patients who have “a history of noncompliance with treatment for mental illness” and are frequently in and out of hospitals and jail, according to the legislation. A plan of treatment would be developed and a mental health professional assigned to coordinate each case for six months. If a patient succeeds in treatment, the court order could be dissolved. It also could be renewed.

“The vast majority of these people are repeat people,” Norheim said. “People we’ve seen again and again and again. They go off their meds or their meds aren’t working and they’re back here.”

Norheim, who has heard commitment cases for 17 years for Clark County District Court, said he has seen some people dozens of times, and some predate his time on the job. He blames a lack of funding, housing, case managers, treatment facilities and intense supervision programs for the repeats.

“The most frustrating thing is we can’t do enough for these people,” Norheim said, noting many are homeless and lack a support system. “Families eventually just walk away.”

FEW OPTIONS

Erin Kinard, director of the WestCare Community Triage Center, said her nonprofit organization on April 1 launched a program called Safe Haven for intensive case management of 25 mentally ill people. She said group homes and treatment facilities come and go. Finding care is a challenge.

“There’s always a need and waiting lists,” Kinard said, adding that most of the patients have drug or alcohol problems they’re dealing with as well. “There aren’t enough resources.”

Dr. Dale Carrison, the chief of staff and head of emergency medicine at University Medical Center, is more blunt.

“The mental health system has been broken since I got to Las Vegas 22 years ago,” Carrison said. “There aren’t a lot of options for people. Every time they cut the budget they cut the mental health budget first. We do a very poor job of evaluating them and treating them. At some point, you’ve got to say the state just doesn’t care.”

UMC’s crowded emergency room is grand central for the Las Vegas Valley’s mentally ill. Often it’s the first stop for police, who take them to the ER for a medical check before determining whether they need to be committed because of their actions or are unable to care for themselves.

The process involves submitting a “Legal 2000” request to put a person in custody for 72 hours for psychiatric observation to determine if the individual is a danger to himself or others. Doctors, psychologists, social workers, nurses, clinical counselors, therapists and police can sign a Legal 2000 order.

On average, about 50 mentally ill people are sitting in emergency rooms in Southern Nevada each day for a medical examination required for a Legal 2000 petition, the Nevada Department of Health and Human Services said.

Most cases are resolved within 72 hours, and the person is released from the hospital because they stabilized and are no longer a danger.

More than 8,000 patients go through Rawson-Neal each year, according to the Nevada State Health Division. The average stay at the acute care facility is about a week but can range from a few days to a few months. It costs an average of about $850 per day per patient, according to 2011 testimony before the Nevada Legislature.

If insurance doesn’t cover the cost, state and federal programs for indigents will likely pay the tab.

About two-thirds of the patients are discharged to homes or private residences. Another 18 percent are sent to other residential and institutional settings, including group homes. Some 12 percent go to homeless shelters; 4 percent are sent to other agencies or treatment facilities; and 2 percent discharge to self-care, or a weekly motel.

Nevada’s mental health system recently came under fire after a schizophrenic man, James F. Brown, 48, told California homeless advocates that Southern Nevada Adult Mental Health Services in Las Vegas put him on a bus to Sacramento, Calif., dumping him in a city where he didn’t know anyone.

Nevada health officials acknowledged that discharge policies and procedures for Rawson-Neal weren’t followed in Brown’s case, and a state investigation turned up two more unsafe discharges. As a result, authorities instituted new rules that require a second doctor to sign off before discharge and for the head of the hospital to authorize all out-of-state transportation to ensure family, friends or a program is ready to help the patient on arrival.

“We blew it and we’re taking corrective action,” Mike Willden, director of Nevada Health and Human Services, told a state Senate panel in March during a public hearing examining the state’s psychiatric discharge policies.

NEVADA 39TH IN FUNDING

State Sen. Debbie Smith, D-Sparks, said the state has cut $80 million from mental health funding since 2007, when the recession hit. As chairwoman of the Senate Finance Committee, Smith said she hopes to restore some of the money despite a tight budget and competing needs for education and other services.

The 2007 Legislature approved $498.3 million in 2007-09 general fund spending for Mental Health and Developmental Services, according to the department. That compares to $418.3 million approved by the 2011 Legislature for the 2011-13 biennium.

Overall spending, including federal funding, dropped from $721.2 million in 2007-09 to $631.2 million in 2011-13. Nevada health officials said much of the savings came from being more efficient with pharmaceutical purchases, not cutting programs. A 19 percent cut in staffing was achieved by attrition.

Compared to other states, Nevada’s mental health spending of $57 per person is low, 39th place among the 50 states and the District of Columbia. The National Alliance on Mental Illness gave Nevada a “D” grade on its most recent report cards, in 2006 and in 2009.

“In a state with high rates of severe depression and other serious mental illnesses — as well as suicides — a strong commitment is needed to restore and expand the mental health safety net,” the 2009 report said. “Without one, Nevada will find its emergency rooms and criminal justice system overwhelmed — and costs being shifted to other sectors of state and local government.”

In response to Southern Nevada’s greater need, Republican Gov. Brian Sandoval included in his 2014-15 budget request about $800,000 to open a 24-hour urgent care center for the mentally ill at Rawson-Neal. That could ease the burden on ERs. On April 2, the governor added another $4 million in proposed spending to help the mentally ill transition back into the community from jails and prisons.

Willden said now that Nevada is on the road to economic recovery he wants to rebuild the mental health system, starting with the 24-hour urgent care facility and transitional housing

“We all made tough decisions” during the recession, Willden said. “Was I happy to make those kinds of cuts? No. Now that the economy is improving, I think it’s important for us to get back on track and to get our priorities right.”

Still, there are not enough state beds for the severely mentally ill. Rawson-Neal, which opened in 2006, is budgeted for 190 beds, but another 100 beds from the older hospital remain mothballed.

Willden said the state is looking at reopening some of those older beds in the 1970s-era hospital building in hopes of creating a long-term mental health wing, which doesn’t exist now. He also said the state is looking for potential partners to lease space to treat the mentally ill’s drug and alcohol problems as well.

“Some of our patients require a longer term stay,” Willden said, adding the old building would need work.

That doesn’t take care of the staffing problem, however, after years of trimming way back.

Dean Nelson, director of psychology at Rawson-Neal, said he has just nine psychologists, down from 19 in 2007.

“It is bare bones,” Nelson said. “There are more services we could be delivering.”

He said hospital social workers help patients get into homeless shelters, group homes, assisted living situations, drug and alcohol treatment programs and offer other counseling and help, but there’s little follow-up.

“Some of them are just fragile people,” Nelson said. “If they don’t have that stable environment, it’s hard for the rest of their lives to get better.”

Dr. Angelene Lawrence, head psychiatrist at Northern Nevada Adult Mental Health Services, said she is quitting in frustration after six years. She said there is a push for state psychiatrists to treat people whose main problems are drug, alcohol and behavioral, but not necessarily serious mental illness.

“I’d say 65 to 85 percent of the problem is drugs,” Lawrence said. “A lot of these people kind of create their own illness. And I see it as getting worse. People believe criminal behavior is because of mental illness and therefore they should all come into the psychiatric hospital. They think I have the magical ability to fix them.”

GOOD AND BAD CHOICES

Norheim’s courtroom is witness to those broken lives.

The court allowed a reporter to watch the proceedings on condition that patients not be named to protect their privacy. The Review-Journal observed sessions on Feb. 20 and Feb. 22.

In one case, an 18-year-old woman who is a diagnosed schizophrenic refused to return home to her mother in Oakland, Calif. Instead, she said she wanted to stay in Las Vegas with a male “friend.”

Though social workers report that the woman’s mother told them the man is the woman’s pimp, the teen denied it. Tears streamed down her face as she wailed uncontrollably.

“I’m emancipated!” she cried. “I don’t want to live with her!”

Norheim told her that if the man would come to court he would release her to his care. She said he wouldn’t, and broke into tears as orderlies led her away.

Two days later, the teen’s male friend did appear. He sat silently, eyes down. She smiled widely. Doctors and social workers said the girl was stable and doing well.

Norheim asked if she would take her medication. She said yes. He asked if he could help her in any other way.

“No thank you,” she said. “Just besides the medication.”

After she and her friend had gone, Norheim shook his head. He had no reason to commit her. She was an adult who could make her own choices. Even bad ones.

“That makes me sick,” Norheim said. “That’s her pimp. I wish there was something I could do.”

In many cases, patients can’t kick their drug habits, contributing to their mental illnesses.

One 48-year-old cocaine addict who heard voices telling her to hurt herself refused immediate placement in a treatment program. Her eyes looked blank, her skin ashy, her teeth decayed.

“When a drug problem is so serious that you end up in a mental institution, for most people that’s rock bottom,” Norheim told the woman, who wouldn’t meet his eyes. “You’re going to end up dead.”

“I’m going to help myself,” the woman finally said, her voice a whisper.

The woman’s daughter sat behind her, jaw set. Tearing up, she turned away to avoid looking at her mother.

Norheim released the woman. The daughter followed .

In a few instances, hospitalization served as a wake-up call, and patients were grateful for help.

One man said his life spiraled out of control after his grandmother and 3-year-old son died. He came to court with an IV port in his arm, midway through detox and needing intravenous fluids to avoid the DTs (delirium tremens).

“I was drinking a bottle and a half a day,” he told Norheim. “I don’t want to touch the bottle again.”

Norheim said the man could stay in a private hospital until he finished detox, and then could go home.

“Thank you again for the opportunity,” he told Norheim.

Several younger male patients had taken synthetic drugs and had gone temporarily mad, running down streets, getting into fights and causing disturbances. One patient, in his early 20s, kept rubbing the side of his face with his hands, almost as if to make sure he was there. He spoke slowly, the stupor not quite lifted.

“You’ve got to stay away from that stuff. It’ll mess you up,” Norheim said.

Some patients appeared ravaged by years of mental illness.

A Rwandan woman, brittle-thin, huddled in a coat draped over pajamas. Eyes wide, she seemed unaware of where she was. Voices had told her “everybody has to die.” She stopped taking food to silence the voices. Four weeks later her family had her hospitalized.

“Her sons and husband want her home, but they want the voices to go away,” a social worker said.

An interpreter, speaking Swahili, explained what the court session was about. Norheim continued her case to provide more hospital care.

DANGER TO THEMSELVES

Some patients end up at Rawson-Neal because they have nowhere else to go.

One seen by Norheim was an 84-year-old woman, suffering from dementia. She came to the hospital from an assisted living home.

“She wasn’t following the rules so they kicked her out,” her doctor said.

The woman, her gray hair tangled, looked around in silent confusion, eyes jumping from face to face.

The public defender who represents patients before the court asked that she be held at a private hospital until a guardian is appointed to ensure she gets proper care and is receiving Medicare.

In another case, an elderly woman refused to take her son home, saying a neighbor had threatened to shoot him if he goes onto his property. The man was arrested after beating the neighbor.

In his 40s, the man had long, blond hair and hadn’t shaved in days. He wept and told Norheim that he had tried everything from Alcoholics Anonymous to drug rehabilitation, “but they never seem to work.”

“I’ve never been so sober in my life,” he said, pledging to try again to give up drugs and alcohol.

The vast majority of cases involved patients who appeared to be more a danger to themselves than anyone else.

One man had tried suicide by banging his head repeatedly against a wall. His forehead appeared split in two.

A woman, shackled for her own protection, needed surgery to repair anal tears from sharp objects she had inserted. She stared straight ahead, un­responsive, eyes dead.

Another woman, listless and with stringy hair, overdosed on pills. She was released to her mother.

“It was a mistake,” the woman said of her suicide attempt. “I have two little girls. I have too much to live for.”

Some patients appeared deep in dementia.

A squat man with closely cropped hair refused to sit. Hands on hips, he claimed to be an FBI informant in the witness protection program.

“He’s highly dangerous,” Norheim said after the man left the courtroom.

Norheim committed the most violent patients, including the snake man, a man who was arrested three times for assaulting family members and a man arrested for threatening people with a baseball bat in the street.

One violent patient raised his voice, becoming belligerent when Norheim refused to release him. He said he would refuse medication — a court order would be needed to force him to do so. He would get a private attorney and sue them all, the man added, slamming his hand on the table.

“They done make me crazy, though,” he told Norheim, berating the police. “I don’t have a mental illness. I’m not going to take it. All you are idiots. I’m going to have to shut down the entire institution.”

Norheim said the man had back-to-back fights with police.

“He’s lucky to be alive. He told them he will kill them. One of these times, it’s not going to go well.”

Contact reporter Laura Myers at lmyers @reviewjournal.com or 702-387-2919. Follow @lmyerslvrj on Twitter.