The region's mental health services system is struggling to meet a demand for services that was significant even before the closure of Mayview State Hospital nearly five years ago.
The shutdown of the South Fayette hospital -- where patients lived in locked buildings and needed permission to walk the grounds -- reflected a longtime national trend in deinstitutionalization.
But the hospital's closure has inflamed debates over treatment philosophy and placed additional demands on the justice system, community hospitals and outpatient treatment providers, who said funding was tight even before the state socked them with a big cut last fiscal year.
Mayview treated residents with serious mental illness -- some of whom also faced charges for violent crimes -- from Allegheny, Beaver, Greene, Lawrence and Washington counties. With the hospital's closure, outpatient providers must serve not only the 300 or so people moved out of Mayview from 2005 to 2008 but all of those with such conditions who might go to Mayview today if it were still open.
One in four American adults experiences mental illness each year, and one in 17 has a serious psychiatric condition, such as schizophrenia, according to data provided by the National Alliance on Mental Illness, an advocacy group. While the federal government says the prevalence of mental illness is holding steady, service providers report growing caseloads, possibly because people are more likely to seek care than in past years.
"This is a system of care under siege," said Dennis W. Nebel, executive director of Lawrence County-based Human Services Center, which operates home and treatment programs for people with mental illness and has seen his budget slashed as demand for his services has grown.
Among the region's mental health challenges today:
• Psychiatrists are in short supply, and some hospitals say their emergency departments and inpatient psychiatric units are strained.
• Housing for people with mental illness can be difficult to find, especially for those who are poor or have criminal records.
• Police departments and courts are implementing diversionary programs to slow the influx of mentally ill offenders into jails and prisons.
• Some caregivers face burnout because of pay freezes, workforce reductions and high stress.
• Mental health professionals are struggling to care for the types of high-need clients previously served at Mayview. Some have called for the opening of mini-state hospitals or a regional facility for persistently ill or violent clients.
Instead of ramping up services, however, the state has cut mental health allocations to counties, which passed on the reductions to service providers.
In 2012-13, the state slashed nearly $11 million in basic mental health funding for the five counties in the Mayview service area. Christine Michaels, executive director of NAMI Southwestern Pennsylvania, said the cuts were the most devastating she'd seen in nearly 30 years in the mental health field.
The cuts have reduced access to care, even as mass shootings at places such as the Washington Navy Yard just last week, Newtown, Conn., and Western Psychiatric Institute and Clinic in Oakland have focused increased attention on proper treatment of mental illness.
Over the past two fiscal years, the Lawrence County Human Services Center has had $600,000 cut from its budget. Over the past five years, Mr. Nebel said, financial pressures have forced him to impose wage freezes twice and eliminate or leave vacant 25 positions.
Budget reductions forced Mercy Behavioral Health, part of Pittsburgh Mercy Health System, to close a 15-bed care home on the North Side and a more structured, 12-bed program in Beaver County. Mercy Behavioral also scaled back intake services for those seeking treatment -- it's now doing 200 fewer assessments each month -- and ended a social-rehabilitation program that served 60 to 70 people.
Before the cuts, Mercy Behavioral's call center logged 5,400 calls a month from clients and would-be clients requesting service. Now, it averages 8,000 calls a month, a sign, the agency said, that budget cuts have reduced the capacity of service providers throughout the area and made it more difficult for consumers to find care.
Lynne Loresch, executive director of Mental Health Association of Washington County, said she's cut several positions and strained her staff with five years of pay freezes. She also eliminated a client-staffed help line, cut hours at a drop-in center and reduced client outings, even though people with mental illness often lack social opportunities.
Cyndee Russell, 37, of Beaver Falls, who has depression and schizoaffective disorder, said she lost her intensive in-home services to budget cuts. She said her doctor arranged the help to break her pattern of frequent admissions to the inpatient psychiatric units of local hospitals.
Ms. Russell praised her treatment team members, who visited her three to five times a week. "They basically were a lifesaver," she said, noting she was hospitalized only once during the year and a half she had the service.
Now, Ms. Russell walks to a nearby Glade Run Lutheran Services outpatient center for care. So far, she said, her illnesses remain in check, and she hasn't been hospitalized again, though she has less care than before.
State Rep. Thomas R. Caltagirone, D-Berks County, minority chairman of the House Judiciary Committee, said some politicians have no trouble cutting services for people with serious mental illness. He said the prevailing attitude is, "They don't vote. They can't be of any help to me. Why should I care about them?"
Funding cuts in other states also have been controversial. According to a November 2011 report by NAMI, 28 states and the District of Columbia cut funding for mental-health services between 2009 and 2012. As a result, the report said, "people go without the treatment they need."
Community care costs less than hospitalization, and some mental-health professionals -- including Richard Kuppelweiser, former Mayview CEO -- believe that saving money was a key reason for shutting down the century-old hospital.
According to a May 2012 report by the five counties and Allegheny HealthChoices Inc., an agency that helped plan the Mayview closure, it cost as much as $144,900 annually to serve a person at Mayview. As of 2011, the report said, the cost of supporting a former Mayview patient in the community was about $53,000 annually.
While former Mayview patients said they're happy to have left the locked wards behind, the goal of integrating them into the community remains a work in progress. Many still live in structured settings and have limited opportunities for social interaction.
Critics feared that the closure would shift the state's burden of care to community hospitals and jails and, to some extent, it has. Because of deterioration in their mental health, for example, former Mayview patients had been admitted to local hospitals' inpatient psychiatric units dozens of times.
But Mayview's closure affected more than the 300 or so patients who were relocated; The five counties permanently gave up ready access to a state hospital bed for anyone.
One of these could have been Michael Lyles.
On Jan. 3, the 61-year-old Lyles walked out of a Beaver Falls personal care home and vanished. About a month and a half later, a worker from a hydroelectric plant in New Brighton, fewer than 2 miles from the home, found his body in the Beaver River.
The Beaver County coroner ruled the death a drowning of undetermined circumstances, but his brother, Nathaniel, and others say Michael Lyles really died because the mental health system let him down.
After funding cuts caused the elimination of a supervised residential program where he lived, Lyles entered a care home providing less oversight. With the change, he lost the supports that kept him going, Nathaniel Lyles said. "He went from living a decent life to a very bad life," he said.
Care for the severely ill
Has the push for community-based care gone too far?
Some mental health professionals said the loss of a hospitallike setting has made it more difficult to care for a small group of people -- the severely and persistently mentally ill -- who struggle in the community. Suzanne Vogel-Scibilia, a Beaver County psychiatrist, fears that the sickest aren't well served by, or don't have the ability to navigate, the outpatient system and that these people, instead of getting well, spiral downward.
"I just don't think you can recover when you're homeless, dead or in jail," she said.
Others see a need for special facilities to treat violent clients and those simultaneously battling mental illness and substance abuse disorders. The latter group has complex needs, and "I don't think we hit the intensity that we need," said Joseph Venasco, administrator of Lawrence County mental health and developmental services.
Michael Lyles, for example, lived on the margins of society, light-years from the state and county offices where officials decided how to parcel out the money and services supporting him. Nathaniel Lyles said the mental health system's desire to save money, coupled with unreasonable expectations about independent living, dealt his brother a fatal blow.
Lyles' lifelong mental health problems included delirium, limited his education and employment prospects, and required medication. Living most of his life in a rented Aliquippa home, he did odd jobs, enjoyed music, relished conversation and somehow acquired the nickname "Cool Train."
Deteriorating mental health eventually undercut his independence, and Lyles had been in residential programs operated by Supportive Services Inc. since 2007.
Jeff Huber, agency CEO, said Lyles built rapport with the staff, and Nathaniel Lyles said his brother benefited from the supervision. "He found a home," he said.
A special five-part series
Overview and portrait of former Mayview State Hospital patients.
Monday, Sept. 23:
Community hospitals struggle with mental-health caseloads.
Tuesday. Sept. 24:
Police, courts improvise to manage ill offenders
Wednesday. Sept. 25:
Housing a weak link in mental-health system
Sunday, Sept. 29:
The future of mental-health treatment
But last year, Mr. Huber said, the county cut Supportive Services' budget by $400,000, forcing the agency to reduce staff and forcing Lyles and the other residents to live mostly on their own. Gerard Mike, Beaver County's administrator for behavioral health and developmental services, declined to discuss Lyles.
Nathaniel Lyles said his brother, struggling with the change, lost weight and became withdrawn. He and Mr. Huber said many of the other 16 residents also struggled with the loss of supervision.
"They were trying to make them live on their own," Nathaniel Lyles said. "They couldn't do it."
Eventually, Mr. Huber said, 10 were transferred to facilities where they'd once again receive some degree of structure and supervision. Four went to long-term structured residences, three to group homes and three to personal care homes, according to his records.
In late 2012, Lyles entered Smith's Personal Care Home, a former elementary school on a quiet Beaver Falls street. But it was too little too late.
Nathaniel Lyles said his brother didn't like the home, where one-time classrooms have been converted into bedrooms, medications are dispensed from the old nurse's office and residents dine in the original cafeteria.
The home generally has about 60 residents, many of whom are poor and have mental health disorders, said Colleen Colella, who owns the home with her husband, Mike.
Ms. Colella said the home assists residents with medications and other personal tasks, but isn't permitted to stop them from leaving the premises.
On Jan. 3, Michael Lyles left Smith's and never came back. In a letter to Nathaniel Lyles after his brother's death, Mr. Huber said, "I think the mental health system failed Mike."
Joe Smydo: firstname.lastname@example.org or 412-263-1548. First Published September 22, 2013 4:00 AM