The state of mental health care in Mississippi has been in freefall for years.
As a consequence of the ripple effects of the financial crisis, Mississippi saw its state support for mental health care slashed by $42 million from 2009 to 2011, roughly 15 percent of the Department of Mental Health's budget.
The state, which had 1,156 psychiatric beds in 2010, has just 486 today.
In 2016, after years of failing to heed warnings from federal prosecutors, Mississippi was sued by the U.S. Department of Justice for failing to deliver adequate care to its residents.
The cutbacks in funding, however, have only continued, with another $14 million of cuts coming in 2017, amounting to another 6 percent of the Department of Mental Health's budget.
The consequences have been grim: Just last month, Mental Health America, a nonprofit organization dedicated to improving mental health services, issued a state-by-state scorecard for mental health care. Mississippi ranked last in access to care.
Amid such a wholesale evisceration of mental health care, no one in Mississippi is surprised that requests for money to address the state's backlog of prisoners awaiting basic mental health evaluations have been routinely denied or ignored. Those prisoners may be legally innocent; they may have waited for months, even years, for an evaluation involving their competency to stand trial. But they are not a priority.
The forensic unit at the state hospital where those evaluations take place had 35 total beds in the 1980s, 15 for pretrial evaluations. The number haven't changed since, despite repeated requests from the officials at the Department of Mental Health for money to expand the number of beds to 60 and improve the building's safety.
Mississippi Attorney General Jim Hood, the state's top law enforcement official, took a shot at trying to change things. On Feb. 5, 2015, Hood wrote a letter to the governor. He recommended spending $15 million to remake and expand the forensics unit.
"We currently have a dire problem in our criminal justice system," Hood wrote.
The proposal went nowhere. Just as others like it had before.
Today, Hood, who is considering a run for governor, said he expects Mississippi's health care failings, including the forensic unit, will be the target of another lawsuit. A court will step in, Hood said, and likely a federal one.
It's been a familiar experience for the state Department of Mental Health.
In 2010, the Southern Poverty Law Center and the Bazelon Center for Mental Health Law sued, alleging that Mississippi's mentally ill children were unnecessarily institutionalized and didn't have access to care in their community. The lead plaintiff was a 17-year-old boy who had undergone five hospitalizations, and spent time in 10 group homes and five residential treatment facilities. The suit was settled last summer when the last remaining plaintiff moved from a state hospital into a community setting.
In December 2011, the Department of Justice announced the results of its own investigation into Mississippi's mental health care system. It did not like what it found. In a letter, the DOJ warned Mississippi that it violated the Americans with Disabilities Act by over-institutionalizing adults with mental illness. A DOJ findings letter accused Mississippi of badly serving its population and relying on models that would barely have been considered modern 50 years ago. The DOJ found that Mississippi spent more money proportionally on institutions and less on community care than any other state.
In one survey of the Mississippi State Hospital at Whitfield in 2014, the Department of Justice found that 55 percent of the 206 adults in shorter-term care had been admitted two or more times before. Just over 11 percent had 10 prior admissions. One man, a 27-year-old, according to the DOJ, had over 22 prior admissions.
The DOJ had come after other states over the same issues. Delaware had received a similar letter in 2010 and settled in 2011, entering into a five-year agreement that resulted in mobile crisis teams, more housing for the mentally ill, a 24-hour crisis hotline and a reduction in inpatient stays. Georgia got its letter in 2009 and fought what became a $200 million lawsuit before settling. Mississippi negotiated for five years before the DOJ finally sued in 2016. Mississippi has decided to fight the suit.
A number of state lawmakers say all budget decisions are ultimately made by the governor, lieutenant governor and Speaker of the House. Gov. Phil Bryant's spokespeople ignored multiple requests for comment. Requests for comment made to the offices of the lieutenant governor and the Speaker of the House were declined.
"Nobody thinks about mental health until they have a family member in need," said Jay Hughes, a Democratic state representative who has made mental health a priority. He said the governor and legislative leaders didn't "give a rat's ass."
The consequences of a refusal to fund adequate mental health care can be quantified at Whitfield, the once formidable state hospital just outside Jackson. Gone is the community services division; the 29-bed acute medical psychiatric service unit, which provided services to people with severe mental disorders who needed close monitoring; the 42-bed male chemical dependency unit, which treated men with substance abuse disorders. (The state announced recently that it will reinstate 25 of the 42 beds.)
In addition to the state institutions, Mississippi has a network of regional mental health and crisis centers that offer people emergency services and outpatient therapy. But they, too, are cash-strapped and can't keep up with an increased demand.
The Department of Mental Health is governed by the Board of Mental Health. The board has nine members, appointed in staggered terms by the governor and confirmed by the senate. The board appoints the agency's executive director. But while the board is able to set policy, they are entirely dependent on the legislature for funding.
"They're a punching bag," Tom Miles, a Democratic state representative, said of the Department of Mental Health.
The budget cuts last year forced the mental health department to shed 650 jobs. Many of the employees left, including those who work directly with patients, make about $8 per hour. The turnover rate as of 2017, according to Robert Landrum, chair of the state board of mental health, is 48 percent.
Landrum knows this intimately. He has a son in one of Mississippi's mental health facilities. When a direct care worker leaves, his son spirals for days, Landrum said. One day, his son's dorm supervisor was gone. Two days later, Landrum saw her at McDonald's, working as a chef supervisor.
"She said, 'I just can make more money at McDonald's,'" Landrum said at a legislative luncheon this year.
Lee Anne Livingston Palmer also sees the problems firsthand. She's the chancery clerk of Scott County, Mississippi, and part of her job involves overseeing involuntary commitments to mental facilities. She sees people cycle back and forth past her desk who are released out of an institution without any transitional care and then lose the ability to function without structure. She wishes there were better community resources or group homes to ease the transition.
"I'm here to tell you, there are some folks that really need that life-long stabilization," Palmer said. "They need that life-long care, because they cannot function in society on their own. They won't take their medicines. They'll end up getting hurt themselves."
Or hurting others.
Tyler Haire, who waited four years in the Calhoun County jail for a psychiatric evaluation after stabbing his father's girlfriend, had spent many of his first 16 years in need of care he never got.
The scorecard done by Mental Health America this fall found that just over 11 percent of youngsters in Mississippi suffering from severe depression receive any form of care. In Minnesota, the highest-ranked state in the category, 40 percent of youngsters do.
Reb McMichael has run the forensic unit at Whitfield since 1990. Several years ago, at a panel discussion at the University of Mississippi, he spoke bluntly about the state's vulnerability to violence in the face of such scarce mental health care.
"I don't know quite how to get at the cost of not providing the treatment people need, but I can tell you it's tremendous," McMichael said. "One dead child. One dead grandmother. And it happens all the time."
Private, for-profit health care companies have moved in to fill the void in other states that have scaled back their mental health services. But that has occasionally resulted in scandal: A Buzzfeed News investigation has exposed abuse after abuse by Universal Health Services, the nation's largest for-profit psychiatry chain. UHS has disputed Buzzfeed's findings.
Mississippi has its share of private operators, offering both inpatient and outpatient mental health care (Universal Health Services has four treatment facilities in Mississippi). The government itself contracts with private psychiatrists and psychologists to work at its institutions.
One of its larger forays into private contracting ended in turmoil. When Mississippi State Hospital closed its community arm in 2014, it contracted with a private health-care group named Guided Steps to help deal with patients. A legislative review board found that the private company managed to lose track of patients entirely.
"I remain wary of private, for-profit organizations," McMichael, chief of the forensics unit, wrote in an exchange of letters he had with the state mental health board. "But anything that might take some of these folks off of our plate would be worth looking into."
For now, Whitfield appears to be making do with the scant resources it has. It is offering free forensic training for Mississippi psychologists to expand the universe of people equipped to conduct competency exams. It is also helping with a pilot project with one of the state's regional mental health centers to provide jail inmates education in the basics of the judicial process.
The Department of Mental Health, for its part, no longer has any illusions about asking for added money. It has asked for flat funding in the 2019 fiscal year.
"That's a change and for them to come in and say we just need level funding when they've never done that," said Eugene Clark, a Republican state senator who chairs the appropriations committee. "Let's be realistic and say, 'Gee, it'd be a win if we don't get cut again.' Of course, everybody stood up and clapped when they said that."
Despite the department's modest request, the legislators tasked with drawing up budget recommendations nonetheless have suggested another $3 million cut for mental health in the upcoming year.