Yellowstone County has seen involuntary commitments more than triple in the past seven years, driven in part by several dozen people being admitted and readmitted to the state hospital, up to five times a year. Critics say it’s an ineffective bandage for a problem with deep roots.
Involuntary commitments allow people deemed a public safety threat to be detained against their will, even though they aren’t being charged with a crime. The cases are handled by the civil division of the county attorney’s office. The commitments require a doctor’s recommendation, a judge’s approval, and a diagnosed mental health problem, like bipolar disorder or schizophrenia.
Yellowstone County saw 52 involuntary commitments in 2011 and 182 in 2016. (Those rates were lowest and highest, respectively, since 2004. The average number of commitments for that time frame is 98.) Of the 162 filed so far this year, more than a third are for people who have been admitted more than once.
“We’re just constantly cycling through the same people,” said County Attorney Scott Twito. “Local treatment needs to be buttressed.”
The commitments are designed for people who pose an imminent risk to themselves or others, or who are unable to care for themselves. That includes suicidal residents.
Often it’s police who bring people in to the hospital, but family members or community members can also do so. Billings Clinic handles most of the cases, but St. Vincent Healthcare takes some as well.
After a person is brought in, they are assessed for psychiatric care. If the person wants to leave but the hospital decides they aren’t ready, hospital staff file an emergency hold, and county attorneys seek a judge’s approval to commit the person to the state hospital in Warm Springs.
The average hospital stay is 11-14 days, and unlike with criminal cases, there is no wait list for people being civilly committed.
It costs about $550 per day to care for a person involuntarily committed at the state hospital.
And the work required to get a person there is significant: Deputy county attorneys must move quickly to file the necessary documents. Judges must carve out time in their busy schedules for the commitment hearings in a timely manner, as required by law. And sheriff's deputies drive the 250 miles to Warm Springs to drop the person off.
The increase in involuntary commitments mirrors a growing demand for mental health services in general, driven in part by a ballooning homeless population.
Billings counted 274 homeless individuals in 2011 and 431 in 2017, in annual surveys conducted on a single night. The Montana Rescue Mission anticipates it will serve 300 more people this year than it did last.
And with homelessness often come mental health problems. A third of the nation's homeless have chronic mental illnesses, and two-thirds have substance use disorders or some other primary health condition, according to the Office of National Drug Control Policy.
Billings Clinic runs the main inpatient psychiatric facility for much of Eastern Montana, northern Wyoming and the western portion of the Dakotas. It averages 14 emergency psychiatric evaluations a day, but the facility has seen as many as 32 in a day.
Dr. Eric Arzubi, department chair of psychiatry at Billings Clinic, said the local mental health care system is becoming “all or nothing.”
“So you either can get access to care by going to an emergency room and being put in a facility, or you’re in the community with nothing,” he said.
Providers say the network of services in Eastern Montana and nearby areas has been wearing away for years as organizations struggle to serve a growing, aging and increasingly transient population with limited resources.
And critics say Montana, unlike some other states, lacks the intermediate care facilities necessary to cut down on state hospital commitments, instead funneling people into and out of Warm Springs when longer-term, lower-level care shows better results.
That’s because those programs do more than keep people on track with medications, helping also with things like therapy, applying for public assistance benefits and finding work or schooling opportunities. And being closer to home, family and friends, when available, helps keep people stable.
Sometimes it’s simply structure that helps.
“Structure is actually what treats these patients,” said Dr. Amy Schuett of Billings Clinic. “A lot of mental illness gets better if you just provide structure. So even if you didn’t do meds, having structure, routine, provides therapy in itself to get patients better.”
The Mental Health Center in Billings provides case management, psychiatric services, therapy and other programs to people in 11 southcentral Montana counties. The MHC used to operate three eight-bed group homes that housed people with chronic mental illness.
But wages there have stagnated over the past decade, forcing two of the group homes to close after the organization struggled to fill and retain positions. (Starting hourly pay for group home workers is $10.40 and $15.28 for case managers.) The Billings region for MHC used to employ 164 people but is now down to 99.
Carl Eby, deputy director at MHC, said the picture has gotten worse in recent years, and the state has failed to adequately fund services.
“We simply can’t stabilize people in the community because we don’t have the facilities,” he said, “because the reimbursement rate (from the state) is so low.”
The Community Crisis Center, another point of contact in Billings for people with severe mental health problems, is also stretched thin, staff say.
MarCee Neary, the center’s program director, said that like other providers, the organization aims to curb the need for higher-level psychiatric care — the kind provided at Warm Springs. But with more people to serve each year, the center needs funding to grow. And while local sources are reliable, including Yellowstone County, Billings Clinic, St. Vincent Healthcare and a public safety mill levy, Neary said state funding has lagged.
Like Eby, Neary said the rise in involuntary commitments reflects underfunded community services.
“Montana’s suicide rate is (one of) the highest in nation,” Neary said. “Yet our mental health services just continue to be cut. And I don’t think this is going to help the situation in Montana.”