Mental health advocates have long described California’s fragmented mental health system with words like “struggling” and “broken.”

Evidence of its consequences can be found in our jails and prisons, our hospitals and clinics, our schools and colleges. The problem touches those living in comfortable middle class suburbs, remote rural towns, and on the streets of the state’s biggest cities.

In January 2018, a year before he was elected governor, Gavin Newsom laid out his concerns: “Our system of mental health care in California falls short, not for lack of funding. We’ve done the right thing in this state: Thanks to the vision of Sacramento Mayor Darrell Steinberg, we passed a millionaire’s tax in 2004 that now funnels more than $2 billion a year into services. We fall short because we lack the bold leadership and strategic vision necessary to bring the most advanced forms of care to scale across the state. We lack the political will necessary to elevate brain illness as a top-tier priority.”

The Legislature in recent years has tried to respond. Some efforts, such as the court-ordered treatment programs allowed by Laura’s Law, have been controversial. Proponents say such measures are necessary to get people into treatment; disability advocates worry that they curtail people’s individual liberties without addressing widespread shortages of housing and community-based services.

With fresh attention on mental health, advocates are hoping California embraces humane and effective ways of averting some problems and solving others.

This explainer and other parts of our continuing “Breakdown” series are supported by the California Health Care Foundation.

Graphics by Elizabeth Castillo

Who's affected?

Directly or indirectly, mental illnesses touch the lives of almost everyone in the state. The afflictions include:

  • severe bipolar disorder, characterized by dramatic swings between mania and depression
  • schizophrenia, which can involve symptoms such as delusions and hallucinations
  • severe major depression, characterized by persistent sadness and disinterest

These mental illnesses, and others, can impede people’s ability to function and carry out the normal activities of daily life. They are often compounded by stigma, making it hard for people to talk openly about their experiences.

Not only do a sixth of Californians experience some mental illness, but 1 out of every 24 have a mental illness so serious it becomes difficult for them to function in daily life.

Left untreated, these illnesses don’t only impact quality of life, they also impact survival: On average, Americans with serious mental illnesses have life expectancies 25 years shorter than the general population, in part due to untreated physical health conditions.

Problems emerging early

About three quarters of serious mental illnesses first appear before the age of 25. This makes children and adolescents particularly vulnerable, especially if early symptoms go untreated. One out of every six California adults experienced at least four potentially traumatic adverse events during childhood—abuse, neglect or domestic violence among them. This greatly increases their risk of depression, anxiety, suicide and post traumatic stress disorder.

Over the past decade, the state saw hospitalizations for mental health emergencies spike more than 40 percent among young people.

Even as a growing percentage of adolescents reported experiencing depression in recent years, less than a third reported receiving treatment.

Too often, these young people live in communities that have few options to care for them. Programs that target early psychosis, for example, can be very effective—but only if they’re available.

“If you have a child or a teen in trouble, there are vast areas of the state where there is no appropriate help,” says Carmela Coyle, CEO of the California Hospital Association.

Suicide rates are climbing

Suicides have increased dramatically, reflecting a national trend. More than 4,300 Californians died by suicide in 2017, a 52 percent increase from 2001.

The problem was particularly pronounced for the young: Suicides among adolescents aged 15 to 19 increased 63 percent.

Like so many other mental health issues, suicide rates vary a great deal in different parts of the state—and are especially acute in some rural Northern counties, where mental health services are in particularly short supply. Trinity County, in the state’s far north, lost an average of 34 residents per 100,000 to suicide, more than four times the rate in Los Angeles County.

Substance abuse is interwoven with mental illness

Some people living with serious mental illness simultaneously experience alcohol and drug use disorders, complicating diagnosis and treatment.

A third of adults who received county mental health services for serious mental illnesses had a co-occurring substance use disorder. The stakes for these individuals are especially high: People with drug or alcohol use disorders are almost six times more likely to attempt suicide than those without.

In this, too, geography matters a great deal. Lake County, for example, has an overdose death rate nearly nine times that of San Bernardino County.

People struggle to get help

A statewide poll shows that the top health issue Californians want their governor and Legislature to address is making sure treatment is available for people with mental health problems: 88 percent called it extremely or very important.

Yet most Californians think there’s not enough mental health care available in the state—especially if they’ve tried to get it.

In recent decades, the state and federal governments have passed laws requiring insurance companies to provide patients with equal levels of care for physical and mental illnesses. It’s called “parity.”

Passing such laws is one thing, enforcing them is another. While most insurers no longer limit the number of visits to providers or charge higher co-pays, pre-authorization requirements and determinations of “medical necessity” can still act as barriers to care.

Timeline: How we got here

Jails and prisons have become default psychiatric institutions

The largest psychiatric institutions in the state and nation are not hospitals—they are jails and prisons. Far more people in California with mental illness are behind bars than in hospital beds. Over 30 percent of California prisoners currently receive treatment for a serious mental disorder, an increase of 150 percent in nearly two decades.

“We’re going to end up with an incarceration system that’s mainly dealing with people that have serious mental health problems,” said Democratic state Sen. Jim Beall of San Jose. “It’s our own fault, in a way, for not having a good mental health system.”

Mental health courts provide one possible response to this crisis. Public defenders, prosecutors, judges and social service providers work together to connect certain defendants with services and treatment, with a goal of keeping them out of jail.

Judge Stephen Manley started one of the nation’s first such courts in Santa Clara County more than two decades ago. The model has expanded around California, but still serves only serve a fraction of the need.

“Everyone wants to tell me, ‘It’s so complex, we can’t solve it,’” he said. “And I say, ‘No, you can. Get together and figure out what you can do.’”

Inmates with mental illness can wait months to get into a state hospital

Another marker of the mental health crisis confronting the criminal justice system: growing numbers of inmates are waiting for state hospital beds, sometimes for months at a time. In the past five years, the number of California inmates deemed incompetent to stand trial and ordered sent to state hospitals increased 60 percent. Judges refer defendants to a state hospital when doctors determine the accused are unable to understand legal proceedings or cooperate with their attorneys.

But the result has been a backlog. Over the same period, the number of Californians deemed incompetent to stand trial and awaiting placement has soared 139 percent.

A few decades ago, fewer than half of state hospital patients came from the criminal justice system. Today, more than 90 percent do.

“That is a sad state of affairs in our society, that only when you get locked up does it become a priority to get you treatment,” said Los Angeles District Attorney Jackie Lacey.

Burgeoning numbers of mentally ill people on the streets

About a third of homeless people have serious mental illness, according to the Treatment Advocacy Center. With California’s homeless population nearing 130,000, that means an estimated 43,000 suffer from serious mental illness.

Sacramento Mayor Darrell Steinberg, a former state senate leader appointed by Gov. Gavin Newsom to lead a new commission on homelessness and supportive housing, calls the problem “horrendous.” Steinberg co-authored the Mental Health Services Act, a tax on millionaires intended to help address this issue.

“There’s nothing worse than seeing this increase in the numbers of people on our streets, many of whom are sick and who want to get off the street” he said.

As tent encampments proliferate, efforts to address this issue are gaining traction. In 2018 voters passed the No Place Like Home Act, allowing the state to borrow $2 billion to increase the supply of permanent supportive housing, which pairs affordable housing with mental health services.

Disappearing board-and-care homes

Licensed board-and-cares are closing at a rapid clip

There is no reliable statewide data tracking the facilities, which provide food, laundry and medication help and often serve as a safety net for people with serious mental illness who can’t live independently. But since 2012, San Francisco has lost more than a third of licensed residential facilities that serve people under 60, and more than a quarter of those serving older clients. Los Angeles has lost more than 200 beds for low-income people with serious mental illness in the past year.

As housing values soar and minimum-wage increases drive up staffing costs, government-set reimbursement rates have remained stagnant. The homes receive $1058—just under $35 a day—from tenants to pay for housing, 24-hour-care and three daily meals.

Advocates say the state needs to collect better data—and significantly increase reimbursement rates—if it hopes to save the remaining facilities.

“If legislators don’t get onto this, we’re in big trouble,” said Lisa Kodmur, who is contracting with Los Angeles County on the issue. “We will see more homelessness, more incarceration, more institutionalization, more people living on the streets.”

Emergency rooms feel the pinch

People in psychiatric crisis increasingly are landing in the state’s emergency rooms again and again. But not only do emergency rooms often lack space for these patients—they’re also not good environments for them.

“If you’re a paranoid schizophrenic, being in the ER is the worst place” says Carmela Coyle, CEO of the California Hospital Association.

Yet people in psychiatric crisis often wind up in the ER because they’re not getting treated elsewhere.

“Practically speaking, the emergency rooms of hospitals and jails are where people are taken for treatment, which is all wrong,” says Judge Stephen Manley, who started one of the nation’s first mental health courts in Santa Clara County more than 20 years ago. “The emergency room has no room for them and jails do not have expertise.”

Psychiatric hospital beds in decline

For those experiencing a psychiatric emergency that requires a hospital stay, beds can be hard to come by. Since 1995, California has lost nearly 30 percent of its acute care psychiatric hospital beds. Having to travel long distances can make it hard for families to visit a patient and can also make it more difficult for hospitals to plan for safe discharge.

Almost half of counties had no adult acute psychiatric beds, and the vast majority had no psychiatric beds for children, as of 2015.

For adolescents, the picture is even worse. The state has only eight juvenile psychiatric beds for every 100,000 minors.

The lack of community treatment

When people in psychiatric crisis land in emergency rooms and jails, it’s frequently because because they can’t get treatment in the community—even when they ask for it.

California lags behind the rest of the country: 37 percent of Californian adults with mental illness received mental health services during the past year, compared to a national average of almost 43 percent.

It’s a problem even for those who have been so sick that they were hospitalized: Among those who have Medi-Cal, close to a quarter of children, and more than a third of adults, weren’t able to access outpatient services within a month of being discharged from a hospital.

Privately insured people face barriers to treatment, too. California patients in 2015 were more than seven times as likely to get treatment for mental health and addiction from providers outside their insurance plan’s network as patients who were seeking medical or surgical care.

Where are the mental health providers?

One big reason people can’t get care: California doesn’t have enough mental health providers. This can lead to long wait times, or long travel distances, for people trying to get treatment.

Depending on where you live, there might be a lot of mental health professionals—or virtually none. Such shortages are especially hard on people living in rural areas, those insured by Medi-Cal, and children and adolescents.

The Bay Area has more than 70 psychologists per 100,000 people; the San Joaquin Valley has less than 16.

But even in areas that have a lot of providers, many refuse to accept insurance. A study in The Journal of The American Medical Association reported that only 55 percent of psychiatrists accept insurance—compared to an average for all health care professionals of 89 percent.

The problem is expected to get worse as the mental health workforce ages. Of special concern: Close to half of psychiatrists and more than a third of psychologists in the state are older than 60, and many will retire or reduce their hours in coming years.

On-campus counselors are in short supply

Demand for mental health counseling is going way up on college campuses—and there aren’t enough counselors to meet the need.

Nationally, the number of students seeking help on college campuses grew five times faster than enrollment, according to the Center for Collegiate Mental Health consortium. Depression and anxiety were their chief complaints.

Many of the state’s colleges and universities fail to meet the standard of one counselor per 1,000 to 1,500 students. As of 2018, the community college system had more than 7,000 students for each counselor, California State University had more than 2,000 students per counselor, and the University of California had about 1,100 students per counselor.

The success of the Mental Services Act—and some concerns

One of the most dramatic changes to the state mental health system came in 2004, when voters passed Proposition 63, the Mental Health Services Act. The 1% tax on millionaires has brought about $2 billion a year of new revenue into the system.

report issued last year about the effectiveness of the money in Los Angeles County showed that it is making a difference there, both by providing prevention and early intervention services for young people who hadn’t previously accessed them, and by improving outcomes for people with serious mental illness involved with expanded full-service partnership programs.

But some aspects of the law have continued to prove controversial over the years—including tracking how counties are (or are not) spending the money. Most recently, an audit showed that the California Department of Health Care Services allowed county mental health departments to accrue $231 million in funds by the end of the 2015-16, money which should have either been spent or returned to the states.

The conservatorship debate

Conservatorship laws in California are tangled in a web of philosophical, legal and ethical questions. What is the government’s responsibility to care for people with serious mental illnesses who say they don’t want treatment? How should the right to liberty be balanced against the need for care?

For years, legislators have talked about amending long-standing conservatorship laws. Last year, out of several legislative proposals, only one ended up passing, and it was expected to affect relatively few people.

At the core of this debate is a law signed more than a half-century ago by then-Gov. Ronald Reagan. The Lanterman-Petris-Short Act ended the inappropriate and often indefinite institutionalization of people with mental illnesses and developmental disabilities, and provided them with legal protections, including limiting involuntary holds to 72 hours.

Those who want to revise it say it can prevent very sick people from getting the help they need. Defenders of current law say people with mental illness need better care and support from society, not intrusions on their civil liberties. If the state wants to help those with serious mental health issues, they say, it should address the housing crisis and struggling community mental health systems.

Mental health legislation to watch: 2019

SB 10 (Sen. Jim Beall, D-San Jose) would establish a state certification process for peer providers—including family members, caretakers and people recovering from addiction or mental illness—who can then help guide others.

SB 11 (Beall) would strengthen enforcement of state and federal mental health parity laws, requiring health insurers to report annually to the state about their compliance with those laws. The information would be publicly available. Update: In May this bill was quietly, effectively killed for the 2019 session. 

SB 12 (Beall) would authorize creation of at least 100 drop-in centers to meet youths’ mental health needs.

SB 744 (Sen. Anna Caballero, D-Salinas) would streamline the local approval process and limit environmental challenges to prevent “Not In My Back Yard” opposition to supportive housing projects funded by the No Place Like Home bond measure passed last fall.

SB 331 (Sen. Melissa Hurtado, D-Sanger) would require counties to create and implement a suicide-specific strategic plan, especially for teenagers. Update: In August this bill was held up in the Assembly Appropriations Committee.

AB 890 (Assemblyman Jim Wood, D-Healdsburg) would allow nurse practitioners to diagnose and prescribe without supervision. Update: This bill stalled out in the spring of 2019, having never made it to the Assembly floor for a vote.

AB 565 (Assemblyman Brian Maienschein, D-San Diego) would forgive student loans for providers entering the public mental health workforce. Update: The Assembly passed this bill in 2019, but it ran aground in the Senate Appropriations Committee.

AB 50 (Assemblyman Ash Kalra, D-San Jose) would expand the state’s assisted living waiver program, which uses Medi-Cal funds to allow vulnerable people to stay in board-and-cares instead of nursing homes. The program is currently authorized to serve fewer than 6,000 people. This would broaden the program to serve more than 18,000. Update: This Assembly also passed this bill in 2019, but it was held back by the Senate Appropriations Committee.

AB 1766 (Assemblyman Richard Bloom, D-Santa Monica) would require the state to maintain data on board-and-care residents to better understand their needs.

The new governor

Gov. Gavin Newsom has labeled improving the mental health system a personal priority. Here’s what he told CALmatters in the spring of 2018:

YouTube video

On the January of his inauguration, he released a proposed budget including:

  • Early detection and treatment of early stage psychosis: $25 million
  • Screening for Adverse Childhood Experiences, which have been strongly linked with physical and mental illness: $45 million
  • Mental health counseling at University of California campuses: $5.3 million
  • Programs to expand the mental health workforce: $50 million
  • Training law enforcement on de-escalating encounters with people in psychiatric crisis: $20 million
  • Shelters and permanent supportive housing for homeless people with serious mental illness: $500 million
  • Expand “whole-person care” programs to offer intensive services to people with serious mental illness: $100 million

Newsom announced in late April his plans to soon name a mental health czar, who would be in charge of guiding state mental health policy.

CalMatters event: "If you think the system works, you're dead wrong"

A physician, an advocate, a public health specialist, a suicide-attempt survivor and a California state lawmaker gathered in downtown Sacramento today to offer their diagnosis of the state’s mental health system.

The consensus was summed up by Sen. Jim Beall: “We need to start from scratch.”

“I haven’t heard a lot of cheerleaders for the status quo,” said Beall, a Democrat from San Jose and the author of several bills that would expand access to mental health treatment. “If you think the system works, you’re dead wrong.”

The panel discussion, hosted by CALmatters and the California Health Care Foundation, builds off an ongoing CALmatters reporting project by Jocelyn Wiener and Byrhonda Lyons on the state’s fragmented, sometimes fatally dysfunctional mental health system.

Who are falling through the cracks? What is the state doing right? And where can policymakers improve?

Wiener put those questions to the panel, and then asked them to share solutions. Despite their array of professional and personal backgrounds, everyone agreed that the state is repeatedly failing to ensure quality care to those who suffer from mental illness.

YouTube video

Where to call for help

If you or someone you know is having thoughts of suicide, there is help available. Call the National Suicide Prevention Lifeline 1-800-273-8255 (TALK) for resources and support. Free, confidential, available 24/7.

Text “HOME” to the Crisis Text Line—741-741—to reach a trained crisis counselor. Free, confidential, available 24/7. More information and resources are here.

Consumers experiencing access issues, or other issues with their health plans, can reach the state Department of Managed Health Care Help Center at 1-888-466-2219 or online here.

The Breakdown: Mental Health series is supported by a grant from the California Health Care Foundation.

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Jocelyn Wiener writes about health and mental health for CalMatters, exploring the intersection between government policies and people’s lives. She has worked as a reporter in her native California for...