By Chris L. Jenkins
Washington Post Staff Writer
Sunday, September 2, 2007
Buried deep in the review panel's report on the massacre at Virginia Tech is a finding that many mental health professionals already knew quite clearly: The state's system for treating the mentally ill "has major gaps in its entirety."
It is a reality that Virginia has struggled with and ignored for years, they say.
But now, the panel appointed by Gov. Timothy M. Kaine (D) to investigate Seung Hui Cho's slaying of 32 people April 16 -- after Cho slipped through those gaps -- has homed in on the issue, raising advocates' hopes for change.
The report, released Thursday, makes 13 recommendations concerning the mental health system, but it does not contain any mention of a question that has thwarted change for decades: How would the state pay for improvements that could cost tens of millions of dollars a year?
Answering that question falls on Kaine and the General Assembly, which has commissioned a panel to examine the state's long-troubled mental health system. Leading lawmakers in both parties have said that addressing the issues will be a priority during the legislative session that begins in January. It won't be easy; the state is mired in a budget shortfall that is expected to top $600 million by June.
"No state has ever made substantial change to its mental health system without real leadership and commitment from a governor who made it a priority and a legislature that followed suit," said Ron Honberg, director of policy and legal affairs for the National Alliance on Mental Illness. "Governor Kaine and Virginia legislators have a chance to do that."
The Virginia Tech panel was highly critical of the mental health system, saying that there is a severe lack of funding and that it is plagued by vague laws that don't give clear instructions to local mental health officials on how to implement rules and regulations. Clearer laws and more beds, caseworkers and managers are needed to adequately meet the demands of the nearly 120,000 people who used the community mental health system last year, the report says.
In Cho's case, the report says, there was a lack of oversight after he was deemed to be a threat to himself and ordered by a judge to receive outpatient treatment. Cho never got the treatment. Kaine and others have indicated that the lapse is not isolated and that it is a flaw that must be addressed.
Kaine said Friday that he and his advisers will study the panel's report and make recommendations to state and federal lawmakers. He will also see what solutions he can implement.
"I think this is a huge issue," he said. "I know it's not just a problem in Virginia. It's a problem elsewhere. This is an issue that has recently gotten greater attention. . . . We need to fix this issue of follow-up. We need accountability."
The panel recommends changing the standard by which people can be admitted involuntarily to a mental health facility. That would allow "a broader range of cases" to come before mental health professionals, the report says.
The panel also calls for more options for people who are experiencing an emergency but don't need hospitalization. Experts said that such a change would give local providers more tools to assess and treat patients like Cho who need monitoring.
Perhaps most importantly, the panel calls for significant changes in the outpatient treatment process, saying that the state must develop a mechanism for tracking people who do not comply with a judge's order for treatment. Local mental health officials said that more staffing would be needed to comply with such recommendations.
Some local officials and state lawmakers have tried to put a price on some of the suggestions. For instance, ensuring that each of the state's 40 community services boards has 10 "crisis stabilization beds," as recommended by the panel and other mental health experts, would probably cost more than $20 million, state officials said. Community services boards serve as county and regional mental health agencies.
Additionally, altering Virginia's threshold for involuntary commitment, one of the nation's toughest, to something less than "imminent danger" could mean that more people would be admitted to state hospitals or mental health clinics.
"We don't know exactly what it would be, but if the involuntary commitment standard is changed, then it would mean more people in the system, and in doing so, there would be a need for more resources," said Meghan McGuire, spokeswoman for the state Department of Mental Health, Mental Retardation and Substance Abuse Services.
A state report issued last year by a special investigator found that Virginia needs more than 230 more local case managers to bring caseloads to the national average, echoing concerns raised by the review panel. The additional staffing would cost millions, officials said.
"People are going to have to come to grips with what they really want, because these could be expensive reforms," said Tom Geib, director of the Prince William County Community Services Board.
Virginia is not alone in facing problems in its mental health system. Other states have approached changes to their systems in various ways. Many have tried to retool infrastructure using federal grants without having to raise public money for services.
Some states have tried to pump significant public funding into their systems, usually after a high-profile event such as the Virginia Tech incident.
In 1999, New York passed a law to develop a structured outpatient treatment program for mentally ill people who don't need hospitalization so they can be treated in the community. Known as Kendra's Law -- named after a woman who was killed when she was pushed in front of a train by a mentally ill man -- it cost $40 million a year for the first several years after it was enacted for counseling, medication and other forms of treatment. California also recently increased spending on community mental health care by raising taxes on some of its wealthiest residents.
But some say the changes needed in Virginia shouldn't start with adding money into the system. Some could be addressed through federal grants. And existing resources that go to state hospitals could be reallocated for community care.
For years, Virginia has spent more per capita on state mental hospitals than most other states, but many are spending more on community-based care. Generally, institutional care is more expensive than community care. Some mental health officials have said that if Virginia moved money from the hospital system to the community-care system, it would reduce the need for new revenue.
"If we have the political will to convert the resources dedicated to state facilities, we would have a much more efficient community system and cost the taxpayer less," said Charles A. Hall, director of the Hampton-Newport News Community Services Board and a member of a state Supreme Court commission that has been examining the mental health system for almost a year.
Many mental health experts and advocates say that reforms, no matter how much they cost, will take time in terms of hiring, training and retooling community programs.
"I think it would be a tragedy to make a bunch of laws that make things clear but without the resources to support them," said Mary Ann Bergeron, executive director of the Virginia Association of Community Services Boards, a lobbying group that represents the local boards.
Families of those affected by the Virginia Tech shootings want something done soon.
"I want to make sure the recommendations are implemented," said Andrew Goddard, father of Colin Goddard, who was shot four times by Cho and survived. "I want to work with the other parents to keep pressure on the governor. . . . I don't want to see all of this fizzle out. For us, this report is not an end point."
Staff writers Anita Kumar and Sari Horwitz contributed to this report.