Calls for a renewed focus on mental health have emerged as lawmakers look for ways to prevent another tragedy in wake of the shooting deaths of elementary school children in Newtown, Conn., last week.

All areas of state governments felt pressure to trim budgets in recent years, and mental health funding has been no exception. The National Association of State Mental Health Program Directors (NASMHPD) estimates states cut at least $4.35 billion in funding for mental health agencies from fiscal year 2009 through 2012.

“Mental health has in most states been part of a painful solution of budget reductions,” said Robert Glover, the association’s executive director. “It’s been very problematic when, at the same time, the public mental health system has had increased demands.”

Many programs and agencies were forced to make cuts resulting from budget shortfalls. In fiscal year 2010, total state mental health agency expenditures declined for the first time in more than 30 years, according to the NASMHPD Research Institute.

The vast majority of allocated state money funds community centers and clinics operated by nonprofits and private firms, while the remainder supports state hospitals.

Historically, state agencies experience a greater need for mental health services during tough economic times, and this has played out during the recent recession. About half of states reported increased demand for community-based mental health services and another 27 percent saw a need for added crisis services, according to NASMHPD.

Glover said there’s no single area of mental health treatment states can target and expect to prevent incidents like the Newtown shooting. Instead, they should aim to provide a full range of services, including residential care, inpatient care, crisis services and medication. Identifying and treating patients earlier in their lives is also key, he said.

Part of the problem also stems from a reluctance by those suffering from mental illnesses to seek treatment. Some fear doing so would harm their careers.

“We’ve got a ways to go to open up a dialogue to deal with the disease itself and make it normalized,” Glover said.

Adam Lanza, who authorities say killed 20 Sandy Hook elementary school children and six adults after shooting his mother, was diagnosed with Asperger’s syndrome, a mild form of autism that experts have not linked to violent behavior.

Agencies have responded to reduced mental health funding in different ways. Over the past four years, 12 states closed or are considering closing public psychiatric hospitals. Some states even reduced program funding used to match federal dollars.

The following chart, provided by NASMHPD, shows the percentage of state mental health agencies reporting various types of cuts from 2011 to 2012:

Poor mental health systems and understaffed facilities have sparked scathing reports or lawsuits in some states.

The U.S. Justice Department sued Georgia after an investigation launched in 2007 found high rates of preventable deaths and assaults occurring in the state’s mental hospitals. A resulting settlement reached in 2010 laid a path for the development of community-based mental health services, but the state has since fallen behind schedule. Georgia’s behavioral health department asked for, and was granted, a one-year extension in August to establish a network of teams in communities to care for mentally ill patients.

In Illinois, a prison reform watchdog group issued a report last week raising concerns about one of the state’s juvenile detention centers. Only eight of 17 staff positions were filled at the Illinois Youth Center at Kewanee, a facility providing intensive mental health treatment for severely ill delinquent youth.

Spending for state mental health agencies varies greatly across the country. The District of Columbia and Maine reported the highest spending per capita in fiscal year 2010, more than three times greater than many other states. Idaho recorded the nation's lowest mental health spending, at just $36.64 per person.

Several factors can explain spending discrepancies among states. Some hospitals perform different functions than others. In areas like Alaska, psychiatric services cost more.

The following table shows FY 2010 state mental health agency total expenditures, including per capita rates for the entire population and those living in poverty:

State Total Expenditure Expenditure Per Capita Per Capita Rank Poverty Per Capita Expenditure Poverty Per Capita Rank Notes Alabama $373,100,000 $78.19 37 $327.57 40 Alaska $214,200,700 $310.01 3 $1,785.01 2 (1) Arizona $1,414,300,000 $221.27 7 $827.56 15 Arkansas $122,468,795 $42.02 48 $169.39 50 (1) California $5,674,396,088 $152.60 15 $645.55 22 (2) Colorado $443,227,875 $88.41 31 $517.79 28 Connecticut $675,500,000 $189.34 9 $1,659.71 3 (3) Delaware $95,000,125 $106.04 26 $605.10 24 (3) District of Columbia $217,069,846 $360.57 1 $1,391.47 6 Florida $742,227,938 $39.55 49 $178.81 47 Georgia $449,147,633 $46.54 47 $177.81 48 Hawaii $224,800,000 $169.99 11 $960.68 12 Idaho $57,400,000 $36.64 51 $172.37 49 Illinois $1,030,100,000 $80.43 36 $370.94 35 Indiana $530,148,000 $81.73 34 $390.68 34 Iowa $409,900,000 $134.46 19 $810.08 16 Kansas $375,700,000 $132.33 20 $629.31 23 Kentucky $232,300,000 $53.69 45 $210.42 45 Louisiana $282,060,590 $62.37 43 $205.43 46 Maine $459,680,997 $346.92 2 $1,972.88 1 (2) Maryland $944,700,000 $164.11 13 $1,089.62 10 (2) Massachusetts $714,300,000 $109.07 24 $665.70 20 (1) Michigan $1,177,100,000 $119.23 21 $557.87 27 (2) Minnesota $797,029,922 $150.18 16 $982.77 11 Mississippi $339,500,000 $114.95 22 $361.55 37 Missouri $518,428,093 $86.75 32 $413.75 32 Montana $171,381,791 $173.59 10 $831.95 14 Nebraska $147,191,849 $80.73 35 $509.31 29 Nevada $184,000,000 $68.32 41 $301.15 41 New Hampshire $192,590,991 $146.40 17 $1,356.27 7 New Jersey $1,758,813,000 $200.09 8 $1,288.51 8 (2) New Mexico $191,789,054 $93.37 28 $346.19 38 New York $4,965,000,000 $256.31 5 $1,147.45 9 (2) North Carolina $1,565,147,892 $165.64 12 $721.60 18 (2) North Dakota $64,315,281 $96.37 27 $584.68 26 Ohio $843,055,168 $73.13 39 $370.90 36 Oklahoma $198,100,000 $53.05 46 $222.09 44 Oregon $602,389,187 $157.08 14 $789.50 17 Pennsylvania $3,568,718,516 $280.78 4 $1,628.07 4 (1) Rhode Island $94,919,347 $90.51 30 $494.37 30 (4) South Carolina $275,500,000 $59.95 44 $260.15 43 South Dakota $69,392,215 $85.35 33 $453.54 31 Tennessee $490,700,000 $77.40 38 $334.49 39 Texas $979,600,000 $38.99 50 $145.86 51 (2) Utah $177,688,669 $64.17 42 $394.86 33 (2) Vermont $150,000,000 $239.84 6 $1,485.15 5 Virginia $717,200,000 $90.72 29 $599.16 25 (2) Washington $761,100,000 $113.57 23 $656.12 21 West Virginia $135,000,000 $72.88 40 $299.33 42 (3) Wisconsin $615,198,301 $108.15 25 $703.08 19 (2) Wyoming $74,766,713 $133.24 18 $900.80 13

Poverty per capita expenditures are for the population less than 135 percent of the Federal Poverty Level.

Source: National Association of State Mental Health Program Directors Research Institute

Notes on individual states:

(1) Medicaid revenues for community programs not included

(2) Totals include funds for mental health services in jails and prisons

(3) Medicaid revenues for community programs and children's mental health expenditures are not included

(4) Children's mental health expenditures are not included