By Katie Kerwin McCrimmon

Veterans and young people of color are among the hardest hit as Colorado continues to lag far behind the rest of the country in funding for mental health care and drug and alcohol addictions.

A sweeping new study released today, The Status of Behavioral Health Care in Colorado, has found that Colorado ranks 32^nd nationally for publicly funded mental health care and spends just one-third of the national average on care for substance use disorders. (SUDs were previously known as substance abuse.)

The toll on the mentally ill is stunning. On average, people in the U.S. with severe mental illness die at age 53 of largely preventable causes. This average life expectancy is comparable to that of sub-Saharan Africa and the poorest nations of the world, according to the report.

“We are providing the wrong care at the wrong time in the wrong places,” said Dr. Andy Keller, chief author of the study. Keller has a PhD in psychology and is a partner with national consulting firm, TriWest Group.

People with severe mental illness die on average at age 53. That's comparable to life expectancy in sub-Saharan Africa. (Click on image to enlarge.)

While 1.5 million people – or three in 10 Coloradans – need either mental health care or SUD treatment, many simply don’t get it, especially those in rural areas. In remote areas of Colorado, increased use of telemedicine could help people right away. For instance, nearly all the pediatric and geriatric psychiatrists in Colorado live in Denver and Colorado Springs.

“They’re not going to move. And we don’t have enough people who speak Spanish,” said Keller. “We’re never going to have enough providers in rural and frontier areas. We need better telemedicine to access these people.  If people can Skype their grandma, why can’t we Skype with (behavioral health) patients?”

Money alone is not going to fix Colorado’s mental health woes, Keller said. Early intervention is key. Policymakers must better understand and reverse the genesis of mental health and substance use problems in children and young adults, and give them help sooner.

The study found that chronic health conditions among children have increased dramatically from about 13 percent in 1994 to 26.2 percent in 2006. Keller said part of that increase may be due to better reporting, but he said it’s still “a big problem.”

“Focusing on intervening earlier can be a really important way to help children,” Keller said.

Young people of color often don’t get any assistance with mental health issues or SUDs until they are already snarled in the juvenile justice system or behind bars. What’s more, the data are so poor in this area that Keller couldn’t accurately  count all the people of color who are underserved.

“It’s a travesty that we’re doing that,” Keller said. “It’s not because the system’s broken. It has never worked. It’s because we haven’t figured out how to do it better.”

Innovation and integration, not money alone, are the keys to improving care in Colorado, Keller and other policymakers said.

“We’re spending more per capita than anyone else (in the world) and we have more preventable health problems than anyone else. Clearly, it’s something in our delivery systems. We need to spend money differently,” Keller said.

Dr. Chris Urbina, executive director and chief medical officer for the Colorado Department of Public Health and Environment, thanked Keller and the four sponsoring foundations for the report. On behalf of Gov. John Hickenlooper, he vowed quick action.

“Mental health and substance abuse is going to be one of our winnable battles,” Urbina said.

While no new money will be available, Urbina said integration efforts in Colorado show great promise. Currently more than 100 innovators throughout the state are working to blend physical care with mental care and SUD treatment.

Keller said Colorado is lucky to have so many innovators who are working to blend behavioral health care with physical care.

“You are leaders in integrated care,” he said. “You are lucky to live here because of that.”

Nonetheless, he and other leaders of the integration movement said that the only way to truly save money and improve care is to unite funding for behavioral and physical care. Government programs and insurance companies separate funding for mental health and physical care, thus making integration a huge financial challenge.

“The only way we’re going to bend the cost curve is to reconnect the head and the body,” Keller said.

Suicide rates high

Colorado also continues to struggle with a disproportionately high suicide rate. While researchers cannot make a direct link between poor funding and increased suicides, Colorado ranks sixth among states for suicide and posted the highest single-year total of suicide deaths in state history in 2009.

The rate declined slightly in 2010, but remained very high with 867 Coloradans taking their own lives compared to 940 in 2009. Aside from poor funding, researchers believe other factors, including high altitude, plentiful guns and a stoic frontier attitude in rural Colorado, also increase suicide risk. (Click here to read about the risk of depression to men and the suicide this month of Denver restaurateur and philanthropist, Noel Cunningham.)

Colorado faces dramatic challenges in providing mental health care both for “the many” and “the few,” Keller said.

Hundreds of thousands of people need access to basic care for more common mental health challenges like depression, anxiety and grief. Meanwhile, a smaller population of severely mentally ill patients, with rare illnesses like schizophrenia, who also have physical ailments and SUDs, are costing the state millions. Many of the sickest wind up behind bars or trying to access care in multiple, fractured public health systems. That escalates their costs dramatically.

The study has found that Medicaid patients with the most complex behavioral health care needs accessed five or more state agencies in 2010, costing more than $30,000 per person, nearly 10 times the cost of typical Medicaid medical claims.

Click here to read about a program in Fort Collins where experts are using intensive case management and “radical realism” to sharply reduce taxpayer costs while giving better care to the “toughest of the tough”: severely mentally ill people with prolonged addictions to alcohol and drugs.

Among the findings:

• Nearly 1 in 12  – or 450,000 people — have a severe need for mental health or SUD treatment.
• Just over 50 percent of mental health and SUD care takes place in primary care settings.
• A low estimate put the amount spent on people with behavioral health needs in the Colorado criminal justice system in 2010 at more than $93 million. This estimate only includes metro Denver counties, but it alone represents more than one-fifth as much as is spent overall through the formal public behavioral health system.
• The number of mental health and SUD providers in Colorado has increased since 2003 from 10,564 to 14,217, but there are still too few in rural and frontier areas outside the Denver area and Colorado Springs.
• A 72 percent increase in Medicaid enrollment from 2002 to 2010 has driven much of the increased demand for publicly funded mental health services in Colorado.
• Spending on public mental health care in Colorado rose substantially from 2002 to 2009, with an increase in spending of $62 per capita to $84 per capita and from $1,664 to $2,256 per person in need.
• Spending on SUD care has also risen substantially, reaching a high point of $9.44 per capita in 2009, before falling back somewhat following cuts in 2010.
• Very few people receive care in psychiatric hospitals

Despite Colorado’s bleak mental health and SUD funding landscape, state funding has actually increased since 2003 when Colorado foundations came together to support the first Status of Mental Health Care in Colorado.

And Colorado is home to many promising pilot programs and innovations that seek to improve care through “medical home” models that blend behavioral health care with traditional medicine under the same roof.

Some of the best programs are emerging in the least likely places: clinics that care for the poor. (Click here to read about integrated mental health care at Salud Family Health Centers in northern Colorado.)

Primary care is critical to patients with mental health challenges. Of people who receive mental health care, more than half get it in a primary care setting nationally. There simply are not enough behavioral health specialists to treat everyone who needs help.

Groups with exceptionally high needs include:

• Veterans who have served in Afghanistan and Iraq since 2001. They suffer rates of suicide two-to-four times those of same-age civilians; elevated rates of trauma-related disorders and depression; untreated traumatic brain injury; and disproportionate rates of unemployment, divorce, substance use, homelessness and chronic (often acute) pain. Emerging behavioral health supports for veterans nationally are among the most innovative programs, and include web-based and peer supports outside formal veteran and active duty health systems.
• Youth and adults of color with mental health needs, particularly African Americans, Latinos and American Indians, often get behavioral health care only in prison or jail.
• People who are lesbian, gay, bisexual or transgender continue to face barriers to accessing mental health or SUD care.
• Those with hearing, mobility and vision disabilities are at greater risk for depression and experience a wide range of physical, linguistic and cultural barriers to care.

George DelGrosso is executive director of the Colorado Behavioral Healthcare Council and a national expert on mental health and SUD issues. He traces many of our country’s mental health woes to our history of institutionalizing the mentally ill. The move to treat patients in outpatient programs was wise, but money didn’t always follow the patients, DelGrosso said. And that many people often didn’t get the care they needed.

Today, about one-third of prisoners have serious mental illnesses.

“They’re institutionalized now in a different way. They’re in prison,” he said.

DelGrosso and others are hopeful that health reform both at the state and federal level will bring much better care.

“We’ve been fortunate in Colorado,” he said. Even in hard times, he said former Gov. Bill Ritter and Gov. Hickenlooper both saw the need to fund behavioral health care.

Said DelGrosso: “It costs so much to put people in hospitals and jails when they don’t get the care they need.”