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The Invisible Epidemic

Poor and mentally ill in Georgia

By Misty Williams
The Atlanta Journal-Constitution

After midnight, Curtis Pinckney walked onto the field of a Stone Mountain elementary school. All of 21, he had endured too much. The deep depression. The trips to hospital psychiatric wards. The days spent hiding out in his bedroom.

Now he pressed a black 9mm handgun to his chest.

Things had improved for Curtis during his late teenage years. But then he aged out of the state’s Medicaid health insurance program for the poor. Without the comprehensive treatment the state had provided, Curtis lost control.

“It was just overwhelming,” said Ramona Deshield, Curtis’ adoptive mom. “He was tired. Everybody was tired.”

On the morning of April 6, 2014, Curtis shot himself, the bullet tearing through the left side of his chest and lodging in his back.

Deshield has no doubt that her son would still be alive if he hadn’t lost his Medicaid coverage.

But Curtis lived in the wrong state.

Nationwide, 30 states have expanded Medicaid under the Affordable Care Act — dramatically improving access to care for people with mental illness. Georgia, however, has not.

Instead, tens of thousands of people in Georgia remain uninsured and suffer from untreated mental illnesses — such as depression, bipolar disorder or schizophrenia — so severe they can’t function in day-to-day life.

Many rely on their families or charity care or show up in emergency rooms; some clog the jails; some wander the streets without a home; many die early, either at their own hands or often from chronic physical illnesses that run unchecked until they turn deadly.

It’s an invisible epidemic, as devastating as diabetes but out of the public eye. Look around you, at your family, your neighbors, your coworkers. Chances are excellent that you’ll see someone suffering from mental illness.

Nearly one in five adults in Georgia battles mental illness in any given year. Nearly half a million have had at least one major depressive episode, the latest federal data shows.

Nevertheless, Georgia ranked near the bottom in spending among state mental health agencies at $59 per capita in fiscal 2013, Kaiser Family Foundation data shows. The national average is about twice that. The Peach State also ranks among the worst for the number of mental health professionals at one for every 1,440 people, according to the nonprofit Mental Health America. Massachusetts, the leader, has one provider for every 248 people.

Those with health insurance often make modest co-payments for the medications and therapy sessions that help them go to work and take care of their families. Those without have precious few treatment options.

The state spends hundreds of millions of taxpayer dollars every year to care for these uninsured. Since 2010, Georgia hospitals have lost more than $150 million caring for uninsured patients with psychiatric disorders — resulting in higher hospital bills, insurance premiums and taxes for everyone else.

“You’re going to have to fight like hell if you’re uninsured,” said Deshield, who spent years navigating the state’s mental health system to try and help her son. “You don’t get the same help, you just don’t.”

‘That was his breaking point’

Life seemed on the upswing for Curtis Pinckney as a teenager.

While he had Medicaid coverage, mental health specialists checked in on him, made home visits and got him out of bed to exercise. He made friends, graduated high school, started classes at a nearby technical college and even worked for UPS for a short time.

But as Curtis transitioned from teenager to young man, he no longer qualified for the program. Medicaid mostly covers children and pregnant women – not single adults. The home visits stopped, replaced by 15 minutes in public clinics with providers he barely knew. When he took 35 Benadryl one time, he ended up in a state hospital surrounded by strangers, some of whom were severely disturbed and violent.

“I will never forget how humiliated my boy was,” Deshield said. “That was his breaking point.”

The young man with the bright white smile fell apart. And in the early hours of that April Sunday, he walked out of a friend’s home and killed himself at nearby Hambrick Elementary School.

Deshield doesn’t blame the state workers who tried to help her son.

“They see people every 15 minutes. How the hell can they function like that?” she said. “They do the best they can with what they’ve got.”

‘So far behind’

For more than a century, the typical prescription for Americans battling mental illness was to lock them up in state mental institutions.

Patients remained for decades. Many never came out.

At Central State Hospital in Milledgeville, workers buried more than 25,000 patients who died there, their graves marked with small metal stakes stamped with numbers but not names.

Over the past five years, the federal government has forced Georgia to pour hundreds of millions of dollars into its broken mental health system, following revelations in The Atlanta Journal-Constitution of the abuse and deaths of dozens of patients within the corridors of the state’s aging, decrepit mental hospitals. The resulting settlement between the state and U.S. Justice Department aimed to help 9,000 of the state’s most severely mentally ill citizens.

But those 9,000 individuals make up just a small fraction of the Georgians who need help, and the state’s mental health system remains inadequate, advocates and experts say.

“We are so far behind,” Nadine Kaslow, a clinical psychologist and professor at Emory University, said of the state. “We want to make sure that people don’t die in the state hospital. That’s a good goal. But the people we serve deserve so much more than that.”

'We are moving as fast as we can'

The end date of the settlement agreement has come and gone, but the state isn’t stopping its work, said Judy Fitzgerald, chief of staff at the state Department of Behavioral Health and Developmental Disabilities. More than 2,400 people have obtained housing under the agreement; nearly 3,000 receive regular or intensive case management among other services.

The state, however, recognizes the need to build up services not just for the most severely mentally ill, those targeted by the state’s settlement with the Justice Department. For those with less severe conditions, the state also must strengthen core services such as individual and group therapy, which would help prevent people from reaching a crisis and needing more expensive, intensive care, Fitzgerald said.

The agency is also working with providers to get people same-day care and is evaluating how many people need housing help.

“We’re moving as fast as we can,” she said. “We absolutely agree with advocates and providers … the foundation is critical.”

Jennifer Barnett at the Bartow County Peer Support, Wellness, and Respite Center in Cartersville. (BRANT SANDERLIN / bsanderlin@ajc.com)

Jennifer Barnett at the Bartow County Peer Support, Wellness, and Respite Center in Cartersville. (BRANT SANDERLIN / bsanderlin@ajc.com)

‘I'm just a better person all around’

One wrong word and Jennifer Barnett knew she could end up locked away in a mental hospital.

“I could just die for making my daughter cry,” Barnett recalled saying once at a psychiatric appointment. The result: involuntary commitment for what she meant only as a figure of speech.

The Cartersville mom lost her job as a cashier at Target and her apartment.

“If I wasn’t being put in psychiatric hospitals, I was being put in jail,” she said.

Her appointments at a public behavioral health center lasted 10 minutes tops, said Barnett, who has bipolar disorder and depression. But with no health insurance, she had no other choice to get the medications she needed.

“You’re not treated with respect or dignity,” said Barnett, 52. “There was no eye contact. They wouldn’t even have a conversation with me.”

Barnett got her life on track after a court ordered her into a drug treatment program. At the Bartow County Peer Support, Wellness and Respite Center, she found a safe place for every-day support from others dealing with mental illness.

“We can sit here and share things with each other, and we don’t have to worry about what we say and get locked up,” she said.

Barnett started working at the center in 2011, and with the new job came private health insurance. She now sees a primary care doctor on a regular basis and no longer thinks that people look at her as a charity case.

“I’m a better mother, a better grandmother,” she said. “I’m just a better person all around.”

Motivational artwork at the Peer Support, Wellness, and Respite Center in Cartersville. (BRANT SANDERLIN / bsanderlin@ajc.com)

'Gov. Deal remains opposed'

Mental health advocates say expanding Medicaid under the Affordable Care Act, though not a cure-all, would greatly improve access to care for Georgians with mental illness.

Thirty states have expanded their programs to include individuals — most of them single adults — with annual incomes of up to roughly $16,300. Last year, however, nearly 1.1 million Americans with a serious mental health condition did not receive treatment because their home states did not expand Medicaid, according to a study by the American Mental Health Counselors Association.

Roughly 233,000 Georgians with serious mental illness or substance abuse conditions would gain health insurance if the state expanded, the study shows.

Georgia leaders, however, have said the state must not expand a broken program. Eighteen other states also remain opposed to expansion.

“Gov. (Nathan) Deal remains opposed to Medicaid expansion because Georgia can’t afford the program,” said Deal spokeswoman Jen Talaber.

Deal nevertheless has pushed the state in recent years to invest tens of millions of dollars in the state’s “accountability courts,” which help people with mental health and substance abuse problems.

Earlier this year, the governor also signed legislation that requires annual suicide prevention training for school employees.

SOURCE: Georgia Department of Behavioral Health & Developmental Disabilities

‘We are consistently operating at a deficit’

Still, charity clinics, hospitals and state-funded behavioral health centers continue struggling to keep up with the daily crush of mentally ill patients.

Mercy Care, a clinic in downtown Atlanta, estimates it will have 8,400 visits this year with patients who have behavioral health problems. The clinic often has to send patients elsewhere because it lacks staff to treat so many people.

Medicaid benefits can mean that a patient sees a psychiatrist or counselor within 48 hours instead of waiting weeks or even months, said Cathryn Marchman with Mercy Care.

Medicaid expansion would also help make the clinic’s behavioral health program sustainable, she said.

“We are consistently operating at a deficit,” Marchman said. “Behavioral health we took on without even having funding. We went out on a limb because we saw the need.”

‘Drive-by case management’

Individuals with severe mental illness die 25 years earlier on average than the rest of Americans, often not from suicide but from untreated diabetes, heart disease and other chronic illnesses.

“All of our health care advances have really passed this population by,” said Bryan Stephens, who heads the Cobb and Douglas Counties Community Service Boards, which provides behavioral health services.

A lack of mental health professionals is perhaps the biggest barrier.

“There are never going to be enough psychiatrists,” said Dr. Ben Druss, a mental health expert at Emory. “If you take 100 people with mental illness, only half will get any treatment at all.”

Primary care doctors are now more comfortable diagnosing such illnesses as depression and prescribing anti-depressants or anti-anxiety medications, Druss said.

But the shortage of psychiatrists, psychologists and other counselors remains acute.

“If you have a system that is as strapped as many of our community mental health systems are, (patients) end up in drive-by case management,” said Sita Diehl of the National Alliance on Mental Illness. “That’s completely inadequate.”

Curtis Pinckney's face is painted on a brick in Ramona Deshield's "love garden." (HYOSUB SHIN / hshin@ajc.com)

Curtis Pinckney's face is painted on a brick in Ramona Deshield's "love garden." (HYOSUB SHIN / hshin@ajc.com)

‘I don't want to fight anymore’

Today, Curtis Pinckney’s mother keeps a small “love garden” at her Stone Mountain home in his honor. A picture of him smiling is painted on a brick.

She runs an organization that works with families of children with mental illness and raises awareness about suicide prevention.

“I beat myself up every day,” Deshield said, thinking back on the decisions she made.

At one point, Curtis pulled out a gun and fired it into the air while in her backyard. At that moment, Deshield decided to take him to New York, where he still had relatives, and leave him there. She had driven all the way to Virginia before finally giving in to his pleas to let him stay in Georgia. She turned the car around and drove home.

She rented him an apartment on Glenwood Road in Decatur for $475 a month, all she could afford on her modest salary. More than a year later, she is still burdened by guilt of putting her son on his own.

“I wanted him not to hurt anymore. I didn’t want to fight anymore,” she said. “But I didn’t want it to end like this.”

Tim Porter-O'Grady, left, an advanced practice clinical nurse specialist, and Pankti Thakkar, a HealthSTAT volunteer, treat their client Rodney Davis, center, outside Central Presbyterian Church across the street from the state Capitol. A team of Mercy Care outreach specialists goes into the community to help the homeless. HYOSUB SHIN / HSHIN@AJC.COM

Mercy Care: A street-level approach to mental health treatment

By Misty Williams
The Journal-Constitution

The evening light fades as Dr. Liz Frye approaches the young homeless woman sitting on the stoop of Central Presbyterian Church downtown.

Across the street, the Gold Dome glows orange.

Schizophrenia runs in the family, 27-year-old Kreshendalea Cheney says, and she battles the illness too.

A year and a half, that’s how long Cheney has spent on the streets — her child in state custody, her belongings stolen, her mental illness gone untreated.

“I just don’t have any help,” Cheney says. She smiles, but her eyes glisten with tears.

This is how Frye and the Mercy Care team spend every Wednesday night — treating the physical and mental ailments that afflict Atlanta’s homeless. The stretch of Washington Street, directly across the street from the Capitol, is always their busiest.

“They get more frequent care a lot of times than the people I see in clinic,” Frye says. “A lot of times for people who are really acutely ill, we’ll see them every week.”

An estimated 4,800 people live in Atlanta’s homeless shelters or on the streets, according to the latest data available. More than 60 percent have a serious mental illness or substance abuse disorder or both.

For many, visits from the street medicine team are the only times they come into contact with doctors.

‘Not dying on the street’

A light breeze takes the edge off the 90-plus degree summer day.

The six-person Mercy Care team traipses single file along the street gutter to the first destination of the evening, Exit 248D off of the Downtown Connector. Or rather, under Exit 248D.

Beneath the freeway overpass lie piles of old blankets and towels, gravel littered with cigarette butts, a worn copy of a children’s book called “Monkey Me and the School Ghost.”

Anthony Shea, 53, is encamped next to a massive concrete pillar. He’s been seeing the folks from Mercy Care for four or five months.

The St. Louis native has lived on the streets of Atlanta for three years now. The team checks his blood pressure and inspects a rash that appears to be clearing up.

“They make sure I’m not dying on the street,” says Shea, a self-described “hard head.”

An alcoholic, Shea’s been sober for two months, he says, and is down to a pack of cigarettes every few days.

Substance abuse is common on the streets, experts say, and often goes hand-in-hand with psychiatric disorders as people try to self-medicate.

‘Mobility is the last thing they have’

On these Wednesday outings, the conditions Frye sees run the gamut — schizophrenia, bipolar disorder, traumatic brain injuries.

“We see a lot of depression,” Frye says. “We see a lot of PTSD.”

People have been raped, held at gunpoint, suffered violent attacks in jail or prison. She prescribes anti-depressants, anti-psychotics and sleep aids, on the spot when needed. Some people agree to come to the clinic for follow-up visits.

Often, the physical care these individuals receive provides Frye an opening to broach their mental health.

One member of the team specializes in treating problems with people’s feet, such as fungus from their shoes and socks being constantly wet.

“It’s one of the most vulnerable places you can touch someone,” says wound care specialist Tim Porter-O’Grady, as the team packs up from their second destination of the night on the edge of The Bluff, an area near downtown known for drug dealing, prostitution and blighted homes with boarded-up windows. “Mobility is the last thing they have.”

If people feel comfortable enough to have a doctor look at their feet, they typically feel comfortable enough talking about mental health issues, he says.

‘The most vulnerable’

The sun is rapidly descending as the group makes its last stop of the night at Central Presbyterian across from the Capitol building.

Four team members hover over a man with flashlights as Porter-O’Grady works on his feet, cleaning and clearing out pus.

Frye sees her opportunity and sits down next to the man, talking quietly while the rest of the group packs up.

The Mercy Care street medicine team has operated for two years now. Frye says she would do street medicine every night if there were money to fund it. There isn’t.

“It never quite seems to escape my mind that we are providing services for some of the people in this community who are the most vulnerable . . . right across the street from a place that could really decide to change that if our legislators wanted to,” she said.

This article was reported and written as part of the The Rosalynn Carter Fellowships for Mental Health Journalism at the Atlanta-based Carter Center.

HOW WE GOT THE STORY

Over the past six months, health care reporter Misty Williams has interviewed dozens of mental health providers, health care experts, hospital executives, lawmakers and individuals who live with mental illness. She has also reviewed hundreds of pages of state and federal data on the numbers of individuals who deal with mental illness and substance abuse issues and spending on mental health services, as well as key studies on mental health prevalence and treatment across the nation. Over the course of her reporting, Williams visited a local peer respite center, NAMI support group and behavioral health centers. She and staff photographer Hyosub Shin also rode along with a street medicine team who brings mental health care to Atlanta’s homeless population. Williams also traveled to Oregon to explore the impacts of Medicaid expansion on creating better access to mental health care there.

The AJC's "A Hidden Shame" series from 2007

The U.S. Justice Department investigated the state’s mental health institutions after a 2007 series of stories in The Atlanta Journal-Constitution, “A Hidden Shame,” brought to light the abuse and deaths of dozens of patients.

“We were not treating people with the dignity and respect they deserved,” said Frank Berry, commissioner of the state Department of Behavioral Health and Developmental Disabilities, at a meeting of mental health advocates, providers and experts earlier this year. “People need easy access to care.”

Under the five-year agreement, the state has created dozens of new community-based services, such as crisis stabilization units and case management teams to help individuals live healthy, productive lives in their own communities instead of being locked away in institutions. But Georgia's mental health system remains inadequate, advocates and experts say.

The big question is how to grow the system set up under the settlement agreement to help not just the 9,000 people it targets but the thousands of others who lack access to care, said Thomas Bornemann, who heads the mental health program at the Atlanta-based Carter Center.

“We know there’s a lot more people with mental illness out there who need services that aren’t available to them,” Bornemann said. “That’s going to be an ongoing challenge.”