The closure of the Augusta Mental Health Institute 15 years ago this weekend was supposed to be a symbolic end to a long and often sordid chapter in the state’s treatment of the mentally ill.

A new psychiatric facility, Riverview, was built to house the most acute patients, never more than 100 and only temporarily. The rest would live in the community with a promise that the state would provide resources tailored to their individual needs.

But year after year, Maine has failed to make good on its promise.

“Are we better off than we were when AMHI was operating? Yes. People are not dying in institutions,” said Jenna Mehnert, executive director of the National Alliance on Mental Illness of Maine. “But do we have any type of comprehensive community mental health system that meets people where they are at and gets their life back on course? I think, no, we don’t.”

Maine’s current system for treating the mentally ill was forged out of a landmark 1990 court decision, referred to as the consent decree, that settled a class action lawsuit brought on behalf of about 300 AMHI patients after a series of deaths in the summer of 1988. The facility was considered overcrowded even then, but at its height AMHI housed more than 1,800 patients. The 99-page decree lays out in detail a set of principles for the state to follow in treating the mentally ill, prioritizing patient rights and services in the least restrictive available setting and using hospitalization as a last resort.

But the consent decree was never a magic bullet. It doesn’t mandate any funding or even ensure individual access to services.

“I think the thing that has been missing is access to services in the community,” said Daniel Wathen, the former Maine Supreme Judicial Court chief justice who serves as “court master,” which means he monitors whether the state is meeting the requirements. Many times over the years, the state has fallen short.

Advocates and consumers said the failures can be tied to a fractured system made worse by geography, as well as a lack of urgency to address the problem.

As recently as 2013, Maine actually spent more per capita on mental health services than any other state, and more than twice what it spent per capita in 2004, according to the Kaiser Family Foundation, a nonprofit health care research group.

But that can be attributed to two things: Many of Maine’s mentally ill have higher service needs and many more are getting services primarily in jails and emergency rooms, which are far more expensive.

More recently, total mental health spending increased each year from $588 million in 2012 to $641 million in 2016 but has fallen the last two years and now stands at $603 million. At the same time, the number of people being served has increased.

“We have defaulted our mental health services to law enforcement,” said Cathy Breen, a state senator from Falmouth. “The system we have now isn’t treatment, it’s crisis management. You shouldn’t have to commit a crime to get treatment.”

Breen has two perspectives on the issue, one as chair of the Legislature’s budget-writing committee and the other as a consumer. She and her husband have been navigating the system for years on behalf of their adult daughter, who has schizophrenia. It hasn’t been easy, she said, and their family has resources. She thinks often of the ones who don’t.

Mental illness is a broad category of diagnoses that includes personality disorders, anxiety and depression and also post-traumatic stress disorder, eating disorders and substance use disorder. As many as 1 in 5 adults have a mental illness. Last year, about 115,000 Mainers were receiving some level of mental health services.

Serious mental illness is any disorder that results in functional impairment that substantially interferes with or limits one or more major life activities, according to the National Institute of Mental Health. This includes schizophrenia, bipolar disorder and severe depression. About 4.5 percent of the adult population has a serious mental illness. That translates to more than 40,000 people in Maine, although only about 12,000 qualify for full mental health benefits under MaineCare, a number that dropped after the LePage administration changed eligibility requirements.

The Portland Press Herald/Maine Sunday Telegram requested an interview with Maine Department of Health and Human Services Commissioner Jeanne Lambrew several times over the last two weeks but was told by department spokeswoman Jackie Farwell late last week that Lambrew was not available. Farwell did answer written questions and provide a statement that said an internal review of mental health services is underway.

“While more must be done to improve prevention efforts, the delivery of care in our communities and treatment for those in crisis, we are prepared to move beyond the consent decree to pursue that work,” the statement read.

Last month, lawmakers passed a bill Breen wrote that creates a working group to study Maine’s mental health system and come up with a plan for reform by December.

Still, the biennial budget that was approved Friday night by the Legislature doesn’t include any significant additional funding for mental health. And lawmakers postponed action until next year on a bill that would have begun to unwind the almost 30-year-old decree and create a mechanism through legislation to ensure services.

Karen Evans of Portland was a patient at AMHI as a teenager back in the 1960s and is now an advocate for the mentally ill. She said the state is better off than it was 15 years ago, when AMHI closed, and certainly better off than when she was hospitalized there.

“Many years I’ve suffered because of what happened at AMHI, but I can say it’s the one place that kept me alive,” she said.

Evans said she’s lucky to have access to quality services but knows many who don’t. That’s why she speaks up.

“I can remember being in the back of the public hearing rooms and being told maybe I could speak, but only if there was time,” she said.

BUILT IN 1840

The Greek Revival stone structure that was built in 1840 to house AMHI (originally called the Maine Insane Hospital) still stands today, although it’s no longer used. It’s directly across the Kennebec River from the State House so that lawmakers would never forget the plight of the most vulnerable.

Several buildings were added on the campus in the first few decades to house a growing population. By the turn of the 20th century, more than 1,000 people lived there and there still wasn’t enough room. The state had to build another facility, Eastern Maine Insane Hospital in Bangor, later renamed Dorothea Dix Psychiatric Center after the pioneering mental health advocate who hailed from Maine.

Controversy plagued AMHI for much of its existence. Early on for its use of restraints on residents, later for shock therapy. Despite concerns that people were being housed there for no diagnosable reason, the population continued to grow, peaking at more than 1,800 residents by 1955.

Evans still has horror stories about her time at AMHI as a teenager in the 1960s, when she was hospitalized because she threatened to harm herself and heard voices. She remembers being in a unit of 30 people and the beds were touching. At that time, alcoholics and those with substance use disorders were among the residents. It was a warehouse.

It wasn’t long after Evans’ time there that the country started to deinstitutionalize, a process aided in part by the development of anti-psychotic medications. Over a five-year period in the 1970s, the population of AMHI dropped to about 300, which means 1,500 were released into the community. Nationally, the number of people institutionalized decreased from 558,239 to 71,619 between 1955 and 1994, according to the National Alliance on Mental Illness.

Many didn’t find stable housing right away and wound up on the street. Evans remembers being part of a group who established a tent city in Portland’s Lincoln Park in 1987 in protest. She said even three decades later, the number of people with severe mental illness who are homeless is staggering. Federal estimates put it as high as 40 percent.

Even with the dramatic drop in population through the 1980s problems persisted at AMHI, too, culminating with 10 patient deaths in 1988, including five in one month during a summer heat wave. That led to a class action lawsuit and the 1990 consent decree.

Kevin Voyvodich, managing attorney for Disability Rights Maine, which represented the class of people covered by the decree, said that while it was necessary, its impact has been largely overstated.

“The conclusion we’ve come to as class counsel is that the framework is good, but individuals still need to be able to access services for it to work,” he said.

The period after the consent decree was signed was messy, too. There were widespread reports that mentally ill people who were supposed to be living in supervised community settings were ending up in county jails.

In 1995, under then-Gov. Angus King, five top DHHS officials were fired, including AMHI’s then-superintendent, Linda Breslin.

Then there was Mark Bechard, who was among the AMHI patients released in the early 1990s after the consent decree. In 1996, he killed two nuns in Waterville who lived near his apartment. The incident drew national attention and was widely viewed as a systemic failure.

The next year, back inside AMHI, Wrendy Hayne was killed by another resident, Harold Pulsifier, inside a storage closet. Hayne and Pulsifier were a couple but both suffered from severe mental illness.

Evans said Hayne was a friend of hers.

The original AMHI building was placed on the National Register of Historic Places in 1982. It remains empty amid a campus of buildings that house various state offices, a symbol of the past.

PROBLEMS AT RIVERVIEW

Riverview was designed to be an improvement over AMHI and, in the simplest measure, it was. There have been only three deaths there and none under suspicious or neglectful circumstances.

But Wathen said staffing shortages plagued the facility for years, leading to ineffective treatment.

Problems at Riverview culminated in a 2013 federal audit – initiated after an attack on a staff member by a patient – that found numerous deficiencies. The hospital failed to ensure safety, failed to protect patients’ civil rights, failed to hold staff responsible for inadequate care and more. It lost federal certification and the $20 million in annual subsidy that came with it. Many feared that the state was repeating past mistakes.

Wathen said things have vastly improved since and credited new leadership.

“With a hospital like that, you can have a bad incident at any point,” he said. “You really have to stay vigilant.”

The bigger problems have always been in the community, but they are harder to track.

“There is a huge invisibility,” said Simonne Maline, executive director of the Consumer Council System of Maine, which represents individuals. “We’re not seeing these big institutions anymore, but people have sort of disappeared into their communities for better or for worse.”

Mental health services were targeted during budget cuts in 2007, the waning years of the Baldacci administration. Wathen later wrote that the reduction of funds or shifts in funding have affected services inconsistent with the consent decree.

Gov. Paul LePage didn’t prioritize mental health services, either. According to funding data provided by DHHS, total public spending on mental health dropped from $618 million in 2015 to $603 million last year. That’s a 2.5 percent decrease but only part of the picture. There were 15,000 more people receiving services in 2018 than in 2015. So the average amount spent on each individual dropped from $6,250 to $5,233, or 16 percent.

Last year, Sen. Breen drafted a bill that would have increased the reimbursement rate for medication management services, which had not been adjusted in more than a decade. The cost was $1.1 million, which would have triggered $2 million in matching federal funds.

Breen said it was enough to keep some existing mental health professionals but not near enough to attract new ones.

Her own daughter is eligible for 20 hours of in-home support services each week, but Breen said it often falls well short of that. There simply aren’t enough workers to handle the number of client hours.

Farwell, the DHHS spokeswoman, said the state is starting to see some strides in its behavioral health home model, which has reduced the number of hospitalizations. She also said the waitlist for community integration services, or daily life skills, has been drastically reduced, and said rental assistance programs have provided homeless individuals with mental illness housing support.

She said challenges remain in ensuring that providers promptly accept referrals for services and fulfill their contracts with DHHS to carry out those services.

Bob Reed, whose adult son has been hospitalized numerous times because of mental illness, including at AMHI in the 1990s, said policymakers have never been innovative or comprehensive when considering reforms.

“We’ve never made investments on the front end to help people,” he said. “And then we end up spending more when people end up at an emergency room or in jail.”

His son isn’t even in Maine anymore because Riverview cannot accommodate him.

There is also a shortage of psychiatric doctors, especially in rural parts of the state. Maline said her organization hosted an event recently in the Aroostook County city of Caribou. All everyone was talking about was a lack of services.

Fear and stigma about the mentally ill remain barriers, too. People think of Leroy Smith III, who killed and dismembered his father, or Will Bruce, who killed his mother, or Enoch Petrucelly, who stabbed his brother to death on North Haven. All were not getting proper treatment for their illness. All were found not criminally responsible for their crimes. All now have varying degrees of supervision within the community.

Mehnert, the NAMI Maine director, said persistent discrimination of people with mental illness thwarts progress. She said national data suggests that if someone with mental illness engages in a violent act, only about 5 percent of the time can that illness be considered a causal factor. Yet people with mental illness often are labeled violent. Similarly, she said, data shows that people with mental illness are 11 times more likely to be victims than perpetrators of violent acts.

“The idea that people aren’t dying anymore so it’s not a crisis … they are dying,” Breen said. “Look at the rates of suicide for people with mental illness. Look at police shootings.”

Breen said she was glad her task force bill passed but would welcome changes before then, too.

“What I hope is that we finally have an administration that will work with providers and individuals,” she said.

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