With more than 500,000 Texans suffering from serious and persistent mental illness and 1 in 5 Texans experiencing a mental health condition each year, behavioral health continues to be a problem with no long-term solution in sight.

Although lawmakers locally and statewide are working to allocate more money toward mental health services, health care providers and Greater Houston area officials have said funding is still not enough to keep up with the growing population and provide services needed to keep individuals with behavioral health problems off the streets and out of jail.

In Montgomery County alone, roughly 110,000 residents have a diagnosable form of mental illness, while approximately 23,000 individuals have a severe and persistent mental illness, such as bipolar disorder or schizophrenia, according to statistics from the National Alliance on Mental Illness.

“Our community continues to grow exponentially, so even with the increased funding and new programs, our growth in the community has been exponential,” said Theresa Fawvor, associate vice president for Memorial Hermann Behavioral Health Services. “There are just not enough specialists, not enough psychiatrists in the field. All those concerns and issues really have an impact on creating a well-accessed, simple system, community and access to those specialists, so it’s a multilayered [issue].”

Legislative solutions

Senate Bill 1—the Senate’s state budget for the 2018-19 biennium—allocated roughly $4 billion for behavioral health services, including state and federal dollars. Gov. Greg Abbott signed the bill into law on June 12.

The amount of funding has more than doubled over the past decade, up from $1.9 billion in 2012-13, according to the House Research Organization.

“The Texas Legislature, the last few sessions, has increased funding for mental health services, but we’re still running close to dead last nationally in funding of behavioral and mental health infrastructure for our citizenry,” Fawvor said.

As the state’s population grows exponentially each year, there is not enough funding in the state budget to adequately serve its residents’ mental health needs, Fawvor said. This often leaves counties and health care organizations having to bridge the gap locally.

“The burden, as it usually does, falls most heavily on programs and resources in bigger counties,” Montgomery County Sheriff Rand Henderson said. “Smaller counties [are] usually where funding goes.”

Tri-County Services, an organization that provides mental health services in Montgomery County, has been able to increase the number of individuals it serves because of the increase in funding from the state, Executive Director Evan Roberson said. In 2013, the organization was serving 1,480 adults annually, and today it serves approximately 3,000 each year.

“We add services as quickly as we can, but they get used up pretty quickly,” Roberson said. “Of course, population growth also drives that [demand].”

Mental health challenges

Mental health care needs in the Montgomery County Jail continue to be an issue, according to officials with the sheriff’s office. Over the years, the safety net for some individuals with mental health issues has become the county jail,  as there is no other program that compels those individuals to get treatment, Henderson said.

“It’s where a lot of those who have chronic or even acute mental health issues end up committing [an alleged crime]—whether that be theft, repeated criminal trespass or disturbance or they assault someone—that may be directly attributable to their mental health crisis,” he said. “So they end up in jail, and treatment gets started there because there is no other opportunity to have it done.”

The goal of the sheriff’s office in regard to mental health care issues is not to become a psychiatric facility but to ensure inmates do not harm themselves, Henderson said.

“If we can prevent recidivism—keeping them from coming back by getting them medication that stabilizes them and makes them part of society—then we all benefit,” he said.

Due to limited public resources, individuals with mental health problems who are chronically in and out of jail or emergency rooms are not able to access good, stabilizing treatment for the amount of time their mental health diagnosis really requires, Fawvor said.

Although Tri-County Services has been able to increase the number of individuals it serves in the past four years, it only reaches roughly 10 percent of the population in its service area with mental health problems.

“What I would like to see is the ability to more quickly obtain benefits and accompanying Medicaid for persons with severe and persistent mental illness,” Roberson said. “If we can get more folks covered with Medicaid, even if it’s short term, that would allow us to stretch our state dollars further for folks without insurance.”

Robert Sanborn, CEO for Houston-based Children at Risk, an organization that advocates for various children’s issues, said although mental health is still underfunded, there has been a shift in perception when it comes to discussing the issue. 

“I will say there was a time when we would talk about mental health with legislators and they didn’t want to talk about it,” he said. “I think we are seeing a change.”

Mental health disorders are also not uncommon with children in Texas, as 1 in 5 have a diagnosable disorder today, said Josette Saxton, director of mental health policy for Texans Care for Children, a statewide children’s policy organization.

“I think some barriers and challenges for kids with mental health [problems] are difficulties it can cause them in daily life, specifically in school,” she said. “There’s still public value and good by addressing how we can support the mental health of all kids and identifying concerns early before they mushroom into something bigger.”

Tri-County serves approximately 800 children annually, which is up from 219 in 2013, Roberson said. Roberson said reasons for the increase range from population growth to social media access to children being more willing to talk about mental health issues.

“The answer is it’s not one smoking gun: It’s 20 different bullets that would explain the bigger picture,” he said.

County programs, solutions

Roughly $14.1 million from Montgomery County’s $351 million fiscal year 2016-17 budget was allocated to mental health initiatives, including initiatives related to the jail and court programs. Although the county does have a hospital district, unlike Harris County it does not operate a hospital to which patients with mental health issues may go for services.

To reduce the number of individuals with mental health issues cycling through the judicial system, Montgomery County founded a new treatment court program last August. Program Director Gloria Kessler said judges felt there was a need to keep people with mental health issues out of jail.

“There’s criminal behavior, and there’s behavior that’s criminal due to mental illness,” she said.

The voluntary program has 15 cases and can take up to 60; Kessler said the court is applying for grant funding in an effort to serve more individuals. The program accepts cases that have gone through the legal system on a case-by-case basis.

“We only take ones who are able to care for themselves,” Kessler said. “In this court, they have to have some wherewithal to know they have to go to court once a month, they have to go to meetings every month. If they’re able to care for themselves and take care of business as far as probation goes, we let them in.”

Henderson said the sheriff’s office is looking into expanding the mental health care used in the jail today to include more comprehensive psychiatric care.

“We are in the contract negotiation phase with a different vendor, and he [would be providing] not only medical care but psychiatric services [in the jail],” Henderson said. “It’s greatly enhanced over what we have now, but that comes with a hefty price tag so we’re in the process of trying to see what we can afford without cutting services we know are necessary for our inmate population.”

The potential new services would also help with new state mandates regarding comprehensive suicide screenings in jails. Inmates on suicide watch must be evaluated to see if an acute crisis has been elevated, which has helped keep the number of suicides low. There have been 96 inmates on suicide watch in 2017, and while 10 have attempted suicide, none have been successful, according to officials at the sheriff’s office.

“We routinely have so many [inmates] on suicide watch that we run out suicide cells,” Henderson said. “It’s a problem we never had before, but we are also working harder to identify and prevent those inmates from hurting themselves.”