Ashe County law enforcement and ER personnel continue to commit substantial resources to the process of involuntary commitment as the state’s mental health system struggles to serve the mentally ill in the face of budget cuts and breakdowns in mental health care reform.

“People don’t realize the number of departments involved with trying to deal with mental health in the county”, said Ashe County Commissioner Judy Poe. “We just have so much that’s spent on this.”

Ashe County averages 16 involuntary commitments per month, according to Poe, who also sits on the board of the Smoky Mountain Center for Mental Health, a regional coordinator of mental health treatment and support.

Involuntary commitment — the legal process by which people suffering severe mental illness are court-ordered into treatment — currently involves law enforcement and ER staff as escorts and caregivers for the mentally ill as they await placement at mental health facilities.

A waiting game

Involuntary commitments are issued by a magistrate of the court when individuals are determined to be a danger to themselves or others, and are civil rather than a criminal matter, according to ACSO’s Capt. Caroline Gentry.

“You can’t lock them up,” she said.

“We can pick up a commitment once it’s issued and it might take three hours to three weeks,” said ACSO Patrol Supervisor Lt. Steve Houck.

Once in custody, they remain in custody, with deputies attending them at the Ashe Memorial Hospital ER pending evaluation by ER staff and acceptance at another facility. “It’s a waiting game of mental health finding them a bed,” said Houck.

Houck said he often has difficulty maintaining adequate patrol and response coverage when involuntary commitments come in. Ashe County’s 12 patrol deputies work 12-hour shifts, four days on, four days off — only six are on duty at any given time.

If an individual is combative, or if two or more involuntary commitments run concurrently, two or three deputies might be tied up at the ER for days, he said.

“Last week, we had four in one day,” he said.

No data is currently available for man-hours ACSO spends at the ER, but Houck and Gentry gave 48-72 hours as an approximate average. Estimated cost for posting a deputy at the ER for three days, plus a 3.5 hour round-trip drive to a hospital, is $1,057, according to Gentry.

Based on this figure, keeping a deputy with an involuntary commitment for three weeks costs the ACSO $7,056.

After the mentally ill are committed, evaluated and treated, they are often released a few hours to a few days later, Gentry said. A deputy is then dispatched to transport them home.

Municipal police also oversee involuntary commitments. West Jefferson Police Chief Jeff Rose said his department had been handling an involuntary commitment for several hours when contacted for this story.

“We’ve got a lot of man hours tied up in them,” he said, but no numbers were available from his department.

“Ultimately, the county gets hurt because we are not providing services,” Gentry said.

But, she said, the real harm is to the involuntarily committed themselves: “How can it be OK to stick them in a little cubicle for days? We are abusing them.”

“It’s very frustrating,” Houck said. “Your hands are tied and you can’t do anything for them.”

“The saving grace is if that person is not combative they can be left with the hospital police.” he said.

ER resources taxed

Ashe Memorial Hospital (AMH) has six ER beds to serve Ashe’s population of over 27,000, and three full-time officers of the AMH Company Police to handle security, according to the hospital’s CEO R. D. Williams.

“The law enforcement agency that brings (involuntary commitments) in is responsible (for them),” Williams said, but the AMH police are also there to protect staff, patients and visitors.

The AMH police logged 4,500 man hours on involuntary commitments in 2012, he said, costing an estimated $80,000.

Since these individuals are usually not insured, he said, occupancy of ER beds also represents a loss to the hospital of roughly $1,000 per person per day.

Non-monetary costs of having fewer beds for medical emergencies are harder to get a handle on. A national benchmark defined as “left without being seen” is one index ERs use to assess their effectiveness in serving a community, Williams said.

Nationwide, ERs average 2 percent of patients leaving without receiving treatment. Last year, 2.9 percent of AMHs ER arrivals left without being seen, he said.

“We’ve had weekends with four commitments at one time,” he said. “People leave because they don’t want to wait.”

Like Gentry, Williams also feels the mentally ill are really the ones harmed by this system.

“You’ve got somebody who has convinced a magistrate that somebody is a danger to themselves,” he said. “They don’t want to be here, they’re being held here pending evaluation and acceptance.”

Mental health in crisis

A 2011 study by the National Alliance on Mental Illness (NAMI) entitled State Mental Health Cuts: A National Crisis found that, “from 2009 to 2011, massive cuts to…state mental health spending …have cut vital services for tens of thousands…living with the most serious mental illness…[including] community and hospital based psychiatric care, housing and access to medications.”

“One in 17 people in America lives with a serious mental illness such as schizophrenia, major depression, or bipolar disorder,” according to the study. “About one in 10 children live with a serious mental disorder.”

In N.C., Dorothea Dix, which served much of the indigent population, effectively shut down in 2010. Broughton Hospital now serves the 37 westernmost counties with 278 beds, according to its website, and frequently has a two-week wait for bed according to county officials.

The Mental Health Association of North Carolina — one of the state’s largest mental health providers and advocates for the mentally ill — imploded in 2010 in the wake of internal scandals and financial woes.

Mental health in N.C. has also suffered unintended consequences of the 2001 Mental Health System Reform Act, which aimed to cut spending by shifting to privatized care.

According to In the Public Interest, a Washington, D.C., resource center for privatization and responsible contracting, “the state privatized the provision of…mental health services by requiring that local jurisdictions contract out delivery of services. As a result, the quality of care that North Carolinians with mental illness receive has declined while allegations of fraud and waste have increased.”

Local mental health providers offer the best services they can under the circumstances. In November, the Jefferson Post reported that from Nov. 1 2011 to Sept. 30 2012, Daymark Recovery Services diverted 143 of 245 crisis contacts from involuntary commitment in Ashe County, stabilizing them as outpatients.

The remaining 102 met criteria for involuntarily commitment.