Dee Fleming tried to protect her son from the voices in his head, the ones that told him he should die.

She chased after him the night he ran toward the neighborhood church with a baseball bat in his hand. She worried to the point of exhaustion when he didn’t come home at night, then returned beat-up and missing his watch. She thought she was holding it together, if barely.

One day last April, when he was oddly quiet and confused, almost catatonic, Fleming took him to Swedish Medical Center’s emergency room and told doctors he was suicidal.

They sent him home.

Two days later, Fleming’s son downed dozens of prescription medications and household cleaning supplies, doused himself with gasoline and set himself on fire in her front yard. He lived only because a neighbor called 911 to report something smoldering on the lawn. A police officer who knew him kept him conscious until an ambulance arrived.

What came next for the Fleming family was almost as shocking, a battle for treatment that epitomizes the massive breakdown in care for mental illness in Colorado and the nation.

Doctors treated his burns—but not his mind.

Despite the family’s pleas and a months-long battle, their 37-year-old son was released from Porter Adventist Hospital to a transitional shelter.

The mental health care system is in crisis. More than 50 years after states began shuttering mental institutions, the system hasn’t recovered—leaving emergency rooms, jails and shelters as last-ditch stops to handle the most severe cases.

Each year in Colorado, about 260,000 adults and children need treatment for the most severe mental illnesses—schizophrenia, bipolar disorder, major depression and serious emotional disturbances. Yet tens of thousands go without care; nationally, only about a third of people who need treatment get it.

Colorado is paying millions of dollars to treat people with severe mental illness after their disease has escalated to the point of catastrophe instead of investing more in care when it strikes. Of the $887 million spent in Colorado on mental health in 2010 from all sources, half went to treatment of needy patients in clinics and state psychiatric hospitals. The rest was spent in prisons, jails, hospital emergency rooms and psychiatric units, and the child welfare system.

The problem isn’t as simple as limited government resources. Hospitals get more money from insurance companies by fixing physical conditions rather than mental ones, and they refer to their psychiatric units—if they have them—as charitable operations.

The fallout from this shortage in care is severe: suicides, mass shootings, a huge population of prisoners, the homeless on the streets.

“It’s the only condition for which we wait until stage 4 to try to treat,” said Moe Keller, a former state senator and now vice president of public policy for Mental Health America of Colorado. “We wouldn’t do this with cancer. If someone went to their doctor with a tumor, they wouldn’t say wait until stage 4. But they do it with mental health.”

Families struggle to find help before it’s too late, navigating a confusing health system with too few options and battling a Colorado law they say is so weak that they can’t make treatment decisions when their loved ones are too sick to realize they need help.

Attempts to strengthen that law have failed, even after violent events in Colorado have raised alarms over failures of the country’s mental health system. And even as Colorado’s suicide rate has risen to the sixth highest in the nation.

The state ranks near the bottom in per-capita psychiatric treatment beds reported by hospitals, and in the bottom half in per-capita state and federal spending on mental health.

Fighting for help

Dee Fleming’s son—burned so severely on his torso, arms and legs that he had to wear a skin suit—spent 10 months in University Hospital’s burn unit. His mother recalls just four psychiatric visits during that time, and when his burns no longer required hospitalization, doctors said he was free to go. He did not need in-patient psychiatric treatment for his schizoaffective disorder, they said.

Only when the Flemings hired a lawyer and threatened to sue the hospital did University administrators find their son a bed at a psychiatric center called Bridge House. A psychiatrist there recommended a 90-day hold, diagnosing serious mental health issues that put him in danger.

But the burns were too severe for Bridge House to treat, and within days the center sent him to Porter Adventist Hospital. Porter kept him for just four days, determining he no longer needed in-patient care. The hospital released him to a temporary, assisted-living shelter for people with mental illness.

It was freezing cold in the middle of winter, and his burns were still healing. “They gave him a blanket and said goodbye,” Fleming said. “This is not humanity.”

Officials at Porter and University would not talk about the case because of privacy laws, only saying they cannot legally hold a patient who is not an imminent danger to himself or others. In other words, under Colorado law, if a person is not planning to kill himself or murder someone right now, that person does not fit the legal requirement for treatment.

The Flemings considered sending their son to a private psychiatric treatment center, without doctor’s orders and without insurance authorization. But it was $20,000 per month. Instead, they rescued him from the shelter and put him up in a hotel, then an apartment.

He has Medicaid and now receives treatment at the Mental Health Center of Denver.

“It’s too late for our family. What is done is done,” Fleming said. “But this needs to change for other families.”

Hours or days or never

Hospital emergency rooms are built to handle heart attacks and gunshot wounds. Not mental breakdowns.

Yet they are filled with patients having panic attacks or suicidal thoughts. People seeking mental health treatment at the ER usually are sent away with phone numbers of local therapists. The wait to see a psychiatrist in this city is about five months long. Colorado has only 15 psychiatrists per 100,000 people, compared with 92 primary-care physicians.

“You can’t stabilize a mental health crisis with a Band-Aid around the head,” said Scott Glaser, executive director of the Colorado branch of the National Alliance on Mental Illness.

At University Hospital, which closed its psychiatric department six years ago, about 750 people per month—or 10 percent of visitors to the emergency department—come for mental health reasons.

Colorado law mandates that hospitals can’t turn away someone who is suicidal, homicidal or so “gravely disabled” that they can’t manage to take care of themselves by finding food or shelter. But most hospitals have no place—other than an ER bed—to treat a mental health patient. Hospitals keep them until they can find a psychiatric bed at another hospital or private treatment center.

This can take hours. Or days. Or never. Colorado hospitals report fewer psychiatric hospital beds per capita than most states, according to American Hospital Association data.

Patients served Overall, more people are being treated at state mental health facilities, but fewer are receiving treatment at state psychiatric hospitals. Source: Substance Abuse and Mental Health Services Administration, Colorado Department of Human Services Community center service

State hospital service

Hospitals here, including University and St. Anthony’s, closed their psychiatric units because the units were losing money. One doctor called it an oxymoron to say “moneymaking psychiatric department.” The issue is that insurance companies reimburse hospitals at a higher rate for physical health care than mental health care.

The number of psychiatric beds at Colorado’s two state mental hospitals for patients whose care has been taken over by the state and those sent from state courts, in Pueblo and Denver, has slid from 611 a decade ago to about 550 today.

Finding an open bed can feel like a scavenger hunt.

“It’s an order of magnitude more difficult in Colorado,” said Dr. Rich Zane, chairman of emergency medicine at University of Colorado School of Medicine and who moved to Colorado two years ago from a hospital in Boston. “An order of magnitude would be a conservative description.”

Out of the 9,000 patients per year who come into University’s ER with mental health issues, just fewer than 1,000 are placed on 72-hour holds by doctors. Some spend the entire hold in an ER exam room because no psychiatric bed was found.

The majority of the 28,000 psychiatric holds in Colorado in 2012 were related to suicidal thoughts or attempts. More than 2,500 were people placed on more than one hold that year.

Mental health “parity”

The federal Affordable Care Act created “parity” for mental health care, requiring insurance companies to provide their customers the same coverage for mental health treatment as they do for other care. But the law does not affect negotiations between hospitals and insurance companies, said Ben Price, executive director of the Colorado Association of Health Plans.

Funding for mental health Colorado funding for mental health services to the needy comes from a combination of state and federal funds including Medicaid. Most of the spending is on 17 community clinics throughout the state and two psychiatric hospitals in Denver and Pueblo. Source: National Association of State Mental Health Program Directors Funding sources $516.9 million 2013 budget

Hospital officials say that despite the law, they recoup less from private insurance companies for mental care than physical care. Denver Health, for example, is reimbursed for 32 percent of mental health billing compared with 41 percent for other medical care, according to the hospital’s financial office. Other hospitals refused to disclose that data. Experts say it’s too early to measure how the new health care law is increasing treatment for mental health patients. Community mental health clinics, however, are seeing an influx of new Medicaid patients.

“It’s pretty remarkable that insurance companies treat psychiatric care different than they treat all other care,” Zane said. “For some reason, brain failure is different than heart failure. That is one of the intrinsic prejudices against psychiatric insurance, and it’s pervasive.”

Insurance company executives said while it’s true that psychiatric care generally is reimbursed at a lower rate than surgical care, rates negotiated between hospitals and insurance companies vary widely across medical specialities.

“I do understand that we do have a psychiatric problem in this state,” said Neil Waldron, chief marketing officer for Rocky Mountain Health Plans. “But how we negotiate with the hospitals is a mutually agreed upon thing.”

Denver Health Medical Center is one of the few hospitals that has psychiatric emergency services, a secure, nine-bed section separate from the main emergency department. The unit sees 3,800 patients each year, of which about 900 are admitted. Most come for evaluation after police or ER doctors have placed them on mental health holds.

Some patients are able to leave within hours, after family meetings and help dealing with their immediate stress. Others are sent to the 36-bed, long-term psychiatric unit, where the average stay is about seven days.

Kim Nordstrom, the medical director of psychiatric emergency services, also has a law degree. Her professional degrees are at odds when she encounters a homeless person with mental illness who chooses to eat from the trash and sleep in the cold, yet has no signs of dehydration or malnutrition.

“I would not want to live that way and we don’t like to see other people live that way, but they have a right to,” Nordstrom said. She can, however, hold a patient if the person’s psychosis is interfering with the ability to make a plan to find food and shelter.

The Medical Center of Aurora—which opened a 40-bed psychiatric unit in 2012, the first one to open in the metro area in 10 years—gets patients from as far as Pueblo and Wyoming. The unit is almost always filled to capacity, which it caps at 32 because there are not enough psychiatrists to staff a unit of 40 people.

Nationally, psychiatrists are scarce, their numbers dwindling further as the profession becomes less lucrative than other specialities. In some rural parts of Colorado, there are none.

For the past 10 years, Denver psychiatrist Randy Buzan’s voice mail has said he is not accepting new patients. He already has 400. “I’m buried. I just don’t have time for all these people,” he said.

Like many psychiatrists, Buzan does not take insurance and instead charges patients on a sliding scale because that’s easier than dealing with insurance companies, which he said “micromanage” services for patients. Buzan said he and some other psychiatrists are leery of taking suicidal or homicidal patients because of the risks of a lawsuit if patients end up committing murder or killing themselves.

The Medical Center of Aurora built its psychiatric unit as a “community service” because emergency rooms at all HealthONE hospitals in Colorado were warehousing patients in mental health crisis. Patients are not getting treatment before they reach crisis, and often not after leaving hospitals either, said Teresa Mayer, medical director of the psychiatric unit.

“We don’t have anywhere to send them. Imagine if you had appendicitis and there was nowhere to go for follow-up,” she said. “It’s terrible. What could have been prevented is not preventable when there is no one to care for them.”