For Max Chorak, the signs of mental illness started early in life.
He would lash out, sometimes violently. At age 10, sheriff’s deputies were called to his home after he pulled a kitchen knife.
But after the deputies arrived, they didn’t know what to do with Max, according to his step-father, Matt Holzmann. There was nowhere in Orange County where a 10-year-old could be treated for a psychotic episode.
They eventually took him to Los Angeles for an evaluation at UCLA and was diagnosed with bipolar disorder and schizophrenia.
That was just the beginning of a 15-year cycle in which Max would rotate in and out of hospitals and jails as his illness wore on, Holzmann said.
Max eventually became homeless, and one day in 2014 was found in a catatonic state at a state park in Laguna Niguel. He was taken to UCI Medical Center in Orange, one of the few hospitals in the county that handles such cases.
Holzmann said his wife told the hospital that Max performed well on the medication Risperdal, and very poorly on another, Haldol, which can cause severe depression. But the hospital put Max on a high dose of Haldol, and later released him with just his clothes and a bus pass, Holzmann said.
And despite signing a waiver allowing his parents to be informed about his care, Holzmann said, “they just released him to the street without informing anybody.”
Max then took the bus to the UC Irvine campus, walked up five stories, and jumped to his death in front of several students. Spokespeople for UCI Medical Center didn’t return phone and email messages for comment for this story.
For Holzmann, his step-son’s story is an extreme example of what many, including medical professionals and the county grand jury, describe as a troubled mental health system in Orange County.
Like much of the United States, mental health care in Orange County is uncoordinated and sorely lacking in prevention and recovery treatment options, experts say. And on several measures, such as mental health beds per capita, Orange County faces an even greater shortage of care options than other metropolitan areas.
The consequences of this reality can be seen on the streets as cities grapple with an increasingly out-of-control homeless problem, and in its overflowing emergency rooms where doctors and nurses must cope daily with psychiatric issues that they aren’t specially trained to handle.
“The reality is, sooner or later, we all pay for this. And the question is, do you pay for it in the early stages when treatment and restoration of health is possible? Or do you wait until the person is so gravely disabled there’s not nearly as much you can do with it?” said Steve Pitman, an Orange County-based advocate. He was recently elected as president of the nation's largest grassroots mental health advocacy group, the National Alliance on Mental Illness (NAMI).
For years, problems with the mental health system were largely ignored by Orange County’s political leaders. But advocates and medical providers have been seeing signs of hope, with more talk from county supervisors about addressing the issues and efforts underway to add psychiatric beds and establish the county’s first year-round homeless shelter.
“Everything is kind of coming together to show that unless there’s a public private partnership to provide the spectrum of care for patients…we’re gonna be constantly handing these folks off and not really addressing” their needs, said Tom Loats, director of behavioral health services at St. Joseph Hospital in Orange.
But the pace of this halting progress remains slow.
A 2014 series by the Orange County Register noted that “a severe shortage of psychiatric hospital beds, tight space at longer-term residential facilities and reduced mental health capacity at community clinics has turned emergency rooms in Orange County and throughout California into virtual boarding houses for psych patients. There is not a single bed in the county for psych patients under 12 years old.”
And a follow-up grand jury report in 2015 found that while it’s recommended to have 50 mental health beds per 100,000 residents, Orange County only had 16.
“California is at half of the national average. And Orange County is 40 percent below that,” Holzmann said.
Two years after the Register’s series, the number of beds has actually been reduced even further, according to Holzmann. And there are still no mental health beds for children under 12 years old.
“Based on the current population of Orange County we should have about 1,500 psych beds. And we have less than 100,” said Lisa Bartlett, who as chairwoman of the county Board of Supervisors is among the five elected officials ultimately responsible for the county's public mental health system.
That lack of beds means many patients have to wait at an unequipped hospital for a day or more after a psychotic episode before they can see a psychiatrist. Local hospitals average between eight and 39 hours before its patients are transferred to a hospital with mental health beds, according to Loats.
“If somebody is having hallucinations and they’re in the wrong place and nobody’s addressing that need, it actually can get worse,” said Loats, the behavioral health director at St. Joseph.
Research has found that 40 percent of homeless people have a chronic major mental illness, like major depression, bipolar disorder, or schizophrenia, he said.
Why Orange County is in such a troubled state when it comes to mental health care, is a difficult and multi-layered question to answer. And the bed shortage hasn’t always been this bad.
Back in the 1990s, there were roughly twice as many psychiatric beds in Orange County, according to the county Health Care Agency. But amid high costs for treating people in hospitals, insurance companies and Medi-Cal sharply cut the amount of time they would reimburse for psychiatric hospitalizations.
“Instead of treating someone for depression and the hospitals using therapies and longer-term recovery based treatments, these became outpatient options and inpatient became used only for those in imminent danger to themselves or others,” said Dr. Jeffrey Nagel, chief of behavioral health operations at the county's Health Care Agency, in a statement.
Hospital stays went from weeks and months to just a few days. Then the emergency room started becoming the only option for many people, Nagel said.
The Role of Politics
The county’s top policymakers have largely grown up in a political culture that has been reluctant to invest in social and health services. For example, county supervisors have tripled law enforcement’s portion of county discretionary spending since 2000, leaving much less room in the budget for social and health services as the need has grown.
However, a sea change in how policymakers approach mental illness is neither impossible nor unprecedented, say both mental health experts and local officials.
Rick Francis, assistant CEO of Costa Mesa, points to San Antonio, Texas, where a coalition of local agencies has set up a homeless service center that has been touted as make a huge difference in treating mental illness and reducing street homelessness, while actually saving the public $10 million per year.
When the center opened, “their homeless presence in downtown San Antonio just about went away overnight,” Francis said. “It is absolutely impressive what they were able to do.”
It might not fully translate to Orange County, he added, “but these are the kinds of things we need to start looking at.”
Interest in studying the San Antonio model appears to be growing, with Spitzer traveling earlier this month to visit the facility with Orange County’s new homeless services coordinator, Susan Price.
Spitzer’s trip is just one small example of the issue gaining traction in recent times among county leaders.
There are now plans for a 18-bed psychiatric unit for children under age 12 at Children’s Hospital of Orange County, which is slated to open in 2018. And the county recently won a $3 million state grant to start emergency treatment centers for people with psychiatric crisis.
County officials have also “sent letters to all OC hospitals inviting them to contract with the County for inpatient psychiatric services,” said Dr. Jeffrey Nagel, chief of behavioral health operations at the county's Health Care Agency, in a statement.
And the long-awaited countywide homeless shelter is inching closer to reality, with officials recently contracting with the non-profit group Mercy House to open a shelter in Anaheim in late 2017. However, the original timeframe was the end of this year.
“This is a very fragile and vulnerable population,” said Bartlett. “And it’s really important that the county do everything it possibly can to address these needs and ensure that these individuals are able to have a full and productive life.”
Her other colleagues on the Board of Supervisors who have taken an interest in mental health services – Andrew Do and Spitzer – didn’t return phone messages for comment.
Some advocates are pushing for a plan to redevelop part of the Fairview Developmental Center, a state-owned facility in Costa Mesa for people with intellectual and developmental disabilities. State officials are slated to close the 114-acre site in 2021, and Holzmann wants part of it turned into a service center.
“We would love to take a piece of that facility and turn it into a one stop shop for mental health,” Holzmann said, including a place for people to recover after psychiatric hospitalizations.
Whatever the ultimate solutions are, observers of the mental health system say there’s widespread agreement that it’s critical for a wide cross-section of society to come together and collaborate.
“It should be a joint effort” from hospitals, the judicial system, community health clinics, local churches, government leaders, and others said Glenn Raup, executive director of nursing services at St. Joseph.
“The time for action is now, and I think we’ve illuminated the problem. And now it’s a matter of putting some actions to the discussions.”
Nick Gerda covers county government and Santa Ana for Voice of OC. You can contact him at firstname.lastname@example.org.