Kimberlee Pearson, a 46-year-old resident of Tulsa, Oklahoma, works part-time as a janitor at the city's Mental Health Association. Herself a mental health patient, Pearson credits the job with aiding her emotional and mental stability.
"Working part-time has helped my anxiety and my depression. It gets me out and it gets me working with people," she said in an interview. But Pearson also depends on prescription drugs two anti-psychotics and one anti-depressant for her well-being at the price of $1,000 a month, currently picked up by Medicaid.
Under a new cost-saving measure introduced in Oklahoma, Pearson may have to choose between her job and her drug benefit, as the income from her janitorial work will put her above the new income limit for the state's Medicaid program.
Pearson's is a common dilemma. Across the country, mental health advocates are watching states scale back on services for those suffering from mental illnesses, eroding the quality of care in what many advocates and officials believe is an already under-funded area of state government.
"About a third of people with mental health needs actually receive care, and even fewer children. You have cuts coming to a population that is grossly underserved," said Dave Nelson, vice president for healthcare reform at the National Mental Health Association.
Buttressed by a 1999 report from then-U.S. Surgeon General David Satcher , mental health advocates have long claimed that most people with mental illnesses do not receive adequate care.
With many states facing significant revenue shortfalls, even this care is being cut. And advocates fear even more cuts will be on the way when many state legislatures convene in January in the face of tens of billions of dollars in new deficits.
Nelson said a recent canvas of state mental health associations organizations that advocate on behalf of mental health patients revealed that more than half of them have seen their state cut mental health services or develop plans to do so soon.
These cuts typically fall on low-income working citizens who make too much money to qualify for Medicaid but not enough to afford their own health insurance.
Such has been the case in Massachusetts, where a $13.8 million cut to the Department of Mental Health Services is ending a program that allowed working poor to receive care for depression, anxiety or anger management problems in a community health center. Now, only the severely mentally ill will be treated.
Those with less severe illnesses are being referred to private hospitals, where waiting lists are long and open beds are few.
"The whole system of community care for people with mental illness is being dismantled, and the impact is going to last for generations," Dr. Mary Ann Badaracco, chief of psychiatry at Beth Israel Deaconess Medical Center, told the Boston Globe.
In South Carolina, money for mental health was scaled back to help close the state's deficit. The Department of Mental Health lost $30 million in state funds and probably another $20 million in matching federal funds, said department spokesman John Hutto.
This translates into 822 fewer workers in mental health today than two years ago, 120 fewer adult psychiatric beds, the elimination of 25 school-based mental health programs and in some cases a doubling of doctor and social worker caseloads, according to Hutto.
"We have people going unserved," he said.
Caseloads at South Carolina's Columbia Area Mental Health Center, an organization that serves mostly low-income individuals, are becoming nearly unmanageable.
"We have case mangers trying to manage 150 patients. That's ludicrous," said Tom Ward, public affairs director for the center.
Ward said patients are having to wait days and weeks longer before seeing their case manager or doctor, possibly resulting in more serious problems down the road.
He added that there is one positive to come out of the budget crunch: the debate is forcing lawmakers to look at some of the benefits of preventive care.
"They're beginning to understand that when you don't properly fund this work you're going to see much higher costs when you go in-patient in prisons and hospitals," he said.
One problem advocates face in making their case to state lawmakers is a stigma attached to mental illness and a general lack of information about what constitutes mental illness.
As Thatcher put it in the surgeon general report: "[D]espite unprecedented knowledge gained in just the past three decades about the brain and human behavior, mental health is often an afterthought and illnesses of the mind remain shrouded in fear and misunderstanding."
Kyle Sargent, director of public policy for the Mental Health Association of Colorado, agrees.
"It's not a priority for us," he said. "What do you think when you think of mental illness? Most people don't talk about it."