"There's a crisis in our communities, and it's affecting nearly every family, our schools, our libraries, our hospital, even county adult/child protective services," says DCMH emergency room manager Misty Sakala. She's referring to the lack of resources to appropriately care for individuals who are experiencing a mental health crisis or psychiatric emergency.
The problem is not restricted to rural western Colorado, but is being felt across the state of Colorado, where a shortage of inpatient beds leads to patients being held for hours, and even days, in jail or the hospital emergency room.
By law, an individual placed on an M-1 hold can be held in the county jail -- without any charges -- for 24 hours. During the last legislative session, the County Sheriffs Association backed a bill that would have extended that length of time -- not because they want to house the mentally ill in their jails, but because there are few alternatives.
"Our issue is that many times we're unable to locate a bed within the required 24 hours and we find ourselves having to make a choice between the individual's safety, the community safety and the statutory limitations placed upon us," said Delta County Sheriff Fred McKee, who several times traveled to Denver to testify in favor of the bill.
The bill would have allowed the county sheriffs to petition to the court to hold those individuals for a longer period of time. By definition an M-1 is an involuntary hold where it's been determined by a licensed professional that the patient is a grave danger to themselves or someone else. The bill made it through the legislature but was vetoed by Governor John Hickenlooper.
"There was a lot of concern about due process for these individuals who are being held in our jails without any criminal charges," the sheriff said. "I was surprised how many people were not aware that was taking place, so if nothing else, we at least brought this issue to the attention of the legislators."
In the emergency room at Delta County Memorial Hospital, Misty Sakala and emergency room personnel were facing their own challenges. An elderly male who arrived in an acutely psychotic state was approaching his 30th hour in the emergency room, waiting for an opening in an appropriate facility.
"Generally, when they come here we clear them of any medical issues. Then we know we're dealing with a psychiatric issue. If they're intoxicated, mental health won't evaluate them until they're completely sober, so that can be another 12 hours," Sakala said.
If the patient is calm and stable, they require only occasional observation by the busy ER personnel. Other times, they may become violent or try to escape.
"A lot of these people have been around the system long enough, they know how to work it," Sakala said. "They'll tell you what they think you want to hear, to put themselves in a situation without much observation, then try to hurt themselves. That's the scary thing to me.
"This is a busy emergency room. Nurses have their hands full with other emergencies coming in. These people who need help, and who may want to hurt themselves or someone else, they're not receiving what they need to be safe. There's just no way to fully monitor someone in the ER."
Medications are administered as a last resort, but that can add another complication, Sakala said. "If patients are sedated, they can't speak to the mental health worker who comes in. If you give them something to calm them down, they seem fine by the time they're evaluated. It's kind of a catch-22."
For patients who are totally out of control, law enforcement is called and the individual is transported to jail.
"Sick, scared, in crisis. slapped into suicide smock and put in solitary ... it's a traumatic experience," McKee said.
When they wind up in the jail first, it's usually because of a failed suicide attempt.
"The jail provides a safe environment, but doesn't provide treatment. The ER can at least provide crisis stabilization treatment, but it doesn't necessarily provide the safe environment. It's a real predicament," said hospital administrator Jason Cleckler.
The nearest mental health inpatient treatment facility is Mind Springs in Grand Junction, which has a 32-bed capacity. The next closest is in Colorado Springs.
Transport requires the involvement of law enforcement or, occasionally, a private ambulance service from Montrose. Generally transport requires more than one officer.
"This being a smaller community, there's a lot of involvement from all the partners trying to help these people," Sakala said.
Once stabilized, with a proper diagnosis and the right medication, the patient is sent home to follow up with the Center for Mental Health's outpatient services.
Mary Gnandt, director of community services for the Center for Mental Health, explains, "Our intensive care manager follows up with a call to persons who have a face-to-face or phone contact the previous day to reassess their safety and to ensure they are linking up with recommended services. If someone is hospitalized we have a continuity of care coordinator who follows the person while in the hospital, gets updates from hospital staff and ensures they have follow up outpatient services when they are discharged. We also ensure that someone who is not hospitalized is set up with outpatient services as soon as possible."
"The key there is that person is now connected to a support team," said Cleckler.
"We really shouldn't look at this any different than the patient who comes in here with chest pains," he added. "We work them up, transfer them to St. Mary's. St. Mary's does a cardiac cath and now this person is connected with a cardiologist. It doesn't happen that way for mental health.
"It's very common for mental health patients to land in the ER first, however what happens now is there's no place to send them -- no crisis stabilization, no 'cardiologist' to intervene, to get them set up on an outpatient basis."
The sheriff, the hospital and the Center for Mental Health all agree a solution will only come through community and regional collaboration.
"The challenges are at least three-fold: lack of an in-region solution for clients needing a hospital and/or detox level of care, providing health care in a rural and frontier region as vast as ours, and funding the solution in general," Ed Hagins, Center for Mental Health, noted.
"A hospital and/or detox level of care for clients with acute behavioral health needs would serve our communities well, serve law enforcement and our community hospitals by allowing them to focus on their priorities, and ultimately provide a better continuum of care for all of our communities."