TYLER, Texas — East Texas has historically struggled with mental health: access is scarce, suicide rates are among the highest in the state, and in previous years, Texas has ranked at the bottom of state spenders on mental health issues.
Mental Health in America, a non-profit center that advocates for policies to address gaps in care, recently released its annual report on the state of mental health in America with dismal numbers for Texas.
Out of all 50 states and the District of Columbia, Texas ranks third in the prevalence of mental health disorders and 50th in adults with a mental illness who are uninsured and 51st in access to mental health care.
And as new studies are showing COVID-19 negatively affects mental health, experts worry if the region’s already strained mental health care systems can handle the inevitable influx of patients.
“I really am concerned that our whole country is not prepared,” Dr. Jeffery Matthews, chair of Psychiatry at UT Health Science Center at Tyler, said. “What’s the aftermath? What's the next step once the virus is no longer the immediate threat? … I believe doing planning and looking ahead, it's now time to start doing that.”
Last month, the medical journal Lancet released a new study which found one in five people who survive COVID-19 are likely to develop a psychiatric disorder such as depression and anxiety for the first time in their lives.
“We're finding that COVID-19 infection is a larger risk to develop a mental illness than we initially thought,” Matthews explained. “Within the next 14 to 90 days [of recovery from coroanvirus], 6% of those people developed a mental illness, compared to 2 to 3% of people who had a similar severity or seriousness of an illness.”
The North East Texas Public Health District, which tracks COVID-19 cases in the East Texas region, has shown cases have been rising steadily over the last few weeks across most counties. They’ve also found all counties either have “moderate” or “substantial” community spread, the two highest severity levels of their pandemic measurements.
As the holiday season continues, local and national experts have warned COVID-19 cases are likely to spike again after large gatherings. And as these cases rise, so will the need for more access to mental health resources.
“That's one of the reasons, really, the [state] legislature funded our university for behavioral health workforce expansion,” Matthews said. “They really recognize that there's an overall shortage of behavioral health professionals, and that shortage is even greater in Northeast Texas than the rest of the state.”
In 2018, the Center for Disease Control released a report listing Smith County as having the highest suicide rate among the state's 25 most populous counties — a grim statistic Matthews partially attributes to “overall decreased availability for treatment.” This year, the CDC has also found twice as many people seriously considering suicide than in 2019.
“But the kind of frightening part is is even though Tyler has the highest suicide rate of the 25 most populated cities, every county around us in Northeast Texas has a higher rate than Tyler,” Matthews said.
Matthews has worked to expand UT Health’s Department of Psychiatry and Behavioral Medicine over the past seven years, adding new programs and positions like residency programs, psychology internship programs, and psychology postdoctoral candidates. He hopes those who go through the program will stay in East Texas and help fix the shortage of mental health care professionals.
Sandra Brazil-Hamilton, the president of the National Alliance on Mental Illness Tyler branch (NAMI), also sees these issues within her work.
“Because we're very rural here, it's hard to get services,” Brazil-Hamilton said. “They can't always find those services. People don't always know where to find a therapist, they don't know where to go.”
Brazil-Hamilton has worked in the East Texas region as a mental health care professional for over 20 years, and, like Matthews, understands the region has lacked essential mental health care systems that have led to the current crisis.
Her biggest concern is, as the pandemic continues and even once it’s gone, there will be a lack of access to the care those suffering from psychiatric disorders will need.
“We're working on some things that will help provide some things for people going through mental health issues,” Brazil-Hamilton said. “But who's to say if it'll be enough?”
That’s why she believes NAMI’s mission in Tyler is essential; NAMI provides free support groups for those who cannot afford therapy, as well as advocates for better care and education about mental illnesses.
“That's one of the main things about mental health, is that there's not a lot of support system [here],” Brazil-Hamilton said. “NAMI is that support system, for those that may not need counseling, but that do need a support system or those that maybe need some help to just learn to live in life.”
Brazil-Hamilton says NAMI has been overwhelmed since the pandemic began as people have flocked to use their services.
“There's a lot of backlash from COVID,” Brazil-Hamilton said. “It's causing depression, anxiety. It's sort of grief to people who are wanting their life back. They're wishing that they could have normalcy again, and it's not normal.”
But she also finds people coming to her with issues NAMI isn’t equipped to handle or asking where they can find professional help or financial assistance for prescriptions.
“They sometimes will go to their primary care physician, but that's not a specialist,” Brazil-Hamilton said.
But being able to find psychiatric care at someone’s primary care physician is “the single most important” step to fixing the mental health care crisis the region is facing, Dr. Andy Keller, the CEO of the Meadows Mental Health Policy Institute, says.
“But the reality is the way our systems are designed now, we don't actually give people care until they get to a crisis for the most part,” Keller said. “We make it so hard to get care that people wait.”
The Meadows Mental Health Policy Institute is a statewide advocacy and policy group that uses data to identify gaps in mental health care and then lobbies for change at both the state and federal levels.
“Before COVID, we had an epidemic of suicide ... suicide rates in East Texas were the highest rates ever recorded,” Keller said. “A lot of what we're going to focus on is helping local systems do a better job, figure out how to do the things that work, and then help the state figure out how to pay for that.”
Currently, they’re working with primary care doctors to set up three new initiatives Keller says is essential to catching and treating mental illnesses early: screening, in-house therapists and more care for those self-medicating with drugs and alcohol.
Keller says screening for mental illnesses should be common practice, like scanning for heart disease or cancer.
“As long as you were willing to be honest with me, if I gave you a questionnaire of nine questions, I could have a 90% likelihood of being able to tell whether you're depressed or not based on how you answer those questions,” Keller said. The Meadows Institute has been campaigning to get these questions added to regular checkups to catch illnesses like depression or anxiety early.
But many of the more than 3.9 million Texans who have filed for unemployment relief since mid-March after losing a job due to the pandemic have lost their employer-based health insurance. This bodes poorly for a state already ranking first in the number of uninsured residents — a staggering 29%.
“The thing that's pretty clear is … the effects on the economy absolutely correlates with increased deaths from overdose, increased substance use, increased depression and increased deaths from suicide,” Keller said.
The systems that could typically help those people, Keller said, are strained with an influx of COVID-19 patients. He’s been lobbying on Capitol Hill to ensure the next round of federal coronavirus relief aid will have funds dedicated to bolstering mental health care.
“I think the only way to really deal with that is for the federal government to pass this coronavirus relief package,” Keller said. “A disaster like this is too big for even the state of Texas to handle. We really need those federal funds.”
Matthews says, even with insurance and aid, it’s still difficult to find care.
“Traditionally, insurance companies will often carve out mental health benefits and really limit those, where other benefits for high blood pressure, heart disease, were not limited,” Matthews said. “But they would limit how much people could access care for mental health.”
Last year, insurance companies implemented a new policy that will pay doctors to have a psychiatrist or therapist attached to their practices, making it easier for people to be referred for help. Keller has been advocating for this change as well, but since the policy is relatively new, it’s taken time to execute.
Both Keller and Matthews point to new steps taken by the state and local municipalities to ensure more funds and access to mental health care as signs the region is taking the mental illness epidemic seriously.
“The last two to three legislative sessions, there has been specific funding for mental health across the state,” Matthews said. “More recently, there's been a large increase in funding for child mental health.”
But, Keller says, there needs to be a fundamental shift in the way mental health care crises are handled to start to shake the stigma of seeking help.
“We really do need to look at our emergency response, because it's not adequate,” Keller said. “When there's a [mental health] crisis … too often we have the police come or nobody comes. But the biggest problem is when you call 911, a police officer or sheriff's going to show up and they don't always know what to do.”
This is something Matthews has begun to tackle along with an organization he’s a part of, the Smith County Behavioral Leadership Team.
The team, which started nearly five years ago, has worked with leaders from law enforcement and medical fields to find new ways to ensure the safety of those suffering from a mental health crisis.
“One of our goals is to have what we call jail diversion,” Matthews said. “So someone whose charges are really related to mental illness, [we] get them into mental health treatments. It's better for them and it's better for our system in our community.”
East Texas is served by several mental health crisis centers, including the Andrews Center and Rusk State Hospital, but these centers usually fill up quickly and tend to stay full.
The University of Texas Health Science Center Tyler was given clearance to have 44 beds open for those suffering from mental illness crises. Thirty of the beds are to help with overflow in the state hospital system, and 14 are dedicated to helping local patients to treat them near home.
But, as Matthews explains, there are only so many beds that can be used with the shortage of staff.
“Those 14 beds only go so far,” Matthews said. “So if someone is needing a hospital, they may be in an emergency room waiting for a period of time until a bed becomes available. Even that bed will likely become available in our hospital before a bed at the state hospital system becomes available.”
Unfortunately, amid the pandemic, these changes may be too delayed to make an immediate change.
Many of the local mental health care programs set up by the Meadows Institute will lose funding next year, Keller said — right when people will need these programs the most.
“It's an investment for the future,” he said. “It takes time to reverse that trend, bringing awareness, getting people treated ... there's always the next step that you can do. There's people who are the most severely affected ... [who have] lost time at jobs lost, lost education ... those things take longer to reverse as far as those long term consequences of illness.”
But there are some bright spots, Keller said. There has been a huge boon for access to mental health care amid the pandemic: telehealth.
With the rules and regulations around telehealth being relaxed, Keller sees an opportunity for those in remote and rural areas to have easier access to mental health care.
“I would add that I do think there is a role for the state and I think the state has some important things to do, for example, taking these temporary telehealth waivers and making them permanent,” Keller said.
Another upside? Keller says people are more aware of their mental health than ever.
“We lose about 4000 Texans a year to suicide,” Keller said. “We've lost a lot more folks than that to COVID this year … I'm sort of like, Well, why can't we just do both? Like, why can't we help people COVID and help people with depression, because we know how to help people with depression.”
If you feel as though you need help, here are a few resources to use:
National Suicide Prevention Lifeline: 800-273-8255
Andrews Center: 903-597-1351
NAMI Tyler: 903-245-4231
East Texas Community Healthcore: 903-234-9200