Florida is the fourth most populous state in America, yet its mental health funding ranks 49th out of the 50 states. Since 2009, state legislators have cut $100 million from the budget for mental health services — leaving state hospitals short-staffed and underfunded.

That has proven dangerous. Attacks by inmates toward other inmates in six of these hospitals doubled in recent years — which is investigative reporters from the Tampa Bay Times looked into the increased instances of violence in the state hospitals.

At least 5,000 people receive care in the state’s mental hospitals each year. Forty percent of them have committed crimes of some kind.

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Nearly 1,000 severely ill patients under constant supervision have injured themselves or others because of lax security and staff shortages. Fifteen of these people died — at least three because staff held off calling paramedics for fear of budget restraints.

“This is not the state to be crazy in,” said Dr. Harold Jonas bluntly. He is a licensed mental health counselor in Delray Beach, Florida. “If you want to get any treatment, you’ve got to go somewhere else.”

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At least 5,000 people receive care in the state’s mental hospitals each year. Forty percent of these patients have committed crimes of some kind — some even violent crimes — but they are considered mentally unfit to stand trial. Many others suffer from chronic illnesses that leave them unable to control their actions.

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The motivation behind the continued budget cuts remains unclear. “Gov. Rick Scott’s current budget allows for some huge tax breaks, so clearly they’re not [happening] because we’re lacking funds. Clearly there’s a surplus,” said Dr. Padam Bhatia, co-founder of The Center for Mind and Wellness in Miami, Florida.

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Last year, the Florida state legislature attempted to pass 22 bills to improve the mental health system. Not one passed.

Gov. Scott has tried to recoup some of the budget losses in recent years, Taryn Fenske, a spokesperson from the governor’s office, told LifeZette in an email. Last year, he signed a budget that allocated an additional $40 million to state mental health facilities, including money for personal alarm devices and video cameras in state facilities where staff safety has become an issue, the spokesperson said. Fenske added that the new budget also provides money for three pilot programs that will test different types of treatment to find more effective deliveries for services.

Still, a lot of this budget goes toward substance abuse services in Florida — not mental health. And although substance abuse and mental health problems often exacerbate each another, drug rehabilitation and mental health hospitals are not the same thing. These services don’t always intersect.

In addition to the increased violence and poor treatment in state hospitals, more patients are using the emergency room as their regular care.

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“Our acute care services are used to a higher degree, but we don’t get a lot of stabilization as a result. Emergency rooms are for crisis, not for maintenance,” said Dr. Ashish Bhatt, chief medical officer of Sovereign Health in Pompano Beach, Florida.

“The most important thing for any health issue, whether it’s medical or behavioral, is a support system and housing.”

Dr. Jonas said insurance companies often treat mental health conditions as they do other medical conditions. Because they can accurately predict from patient data how long it takes to heal a broken bone, for example, they have set quotas around other conditions as well — like schizophrenia or bipolar disorder. So patients who check in with severe mental conditions — who can’t get into a state hospital because of the extensive waiting list — are turned back onto the streets in five or six days.

“If they don’t have a support system outside, they’re going to deteriorate and wind up back in. It’s almost like a revolving door,” Dr. Jonas said.

The cost of repeatedly hospitalizing the same patients adds up very quickly. Dr. Bhatia said the average cost of a hospital stay is $2,000 per day, and most patients are coming for a week’s stay at least once a month. Multiply that by hundreds of thousands of patients, and yes, that could hypothetically equal $100 million. Hospitals just have to eat that cost or come up with some creative way to recoup it.

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Many of the people who come to the hospitals or community centers for help do not have insurance, or they’re homeless. Dr. Jonas works in private practice now, but he spent some time at a comprehensive treatment center for the homeless called Camillus House in Miami.

Taking care of the same patients continuously without progress can wear on even the most tolerant physician. “As a professional, we’re selling people on hope, on themselves, and on change, and sometimes they don’t buy it,” Dr. Jonas explained.

“They live in a field, they don’t have showers, they don’t have food, they don’t have shelter from the elements. All they have is this — this is as good as it gets for these people. We’re all idealists who really want to effect change, but we’re people as well, and it’s hard to watch people undo their good opportunities.”

More than 650,000 adults in Florida struggle with mental illness. Mental disorders worldwide seem to be on the rise. One study confirmed that mental illness and substance abuse combined comprise 23 percent of the global disease burden.

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The American lifestyle perpetuates certain habits that can leave people vulnerable to mental illness. Dr. Bhatt explained that having an intact family unit, strong support system, and cohesive community all bolster mental health.

Dr. Bhatt told LifeZette, “We’re very individualized. Other countries have a sense of family and community and culture. Often that has demonstrated a higher protective factor, especially for mental illness. Our society is constantly super competitive and stressful and work-oriented, and that plays a huge part in people getting stressed out. When you’re isolated and you go to work and you don’t have a support system, there is an increased susceptibility to anxiety or depression.”

He also explained that high rates of substance abuse and alcohol intake among the younger population, specifically ages 13 to 25, can contribute to mental instability later. Those substances impair executive function, he explained.

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The lack of community support and cohesion could be exacerbating the mental health crisis in Florida — as well as across the nation.

“The most important thing for any health issue, medical or behavioral, is a support system and housing,” said Dr. Jonas. “Without those things, people will not be able to get into a recovery process and stay that way. People are going to regress.”

He believes developing a state-run mental health app that would connect patients with coaches, housing resources, and symptom and medication tracking could help. But getting approval for such a program means wading through bureaucracy. Mental health professionals had hoped that some of Florida’s $1 billion surplus would go toward hiring additional staff and providing more treatment for these patients. No such luck.

“There’s not going to be enough money to cure the problem,” Dr. Jonas said. “All the money in the world isn’t going to make somebody ‘not’ bipolar — but it’s going to help them manage their illness better.”