Suicide, drug overdose deaths outnumber highway fatalities amid North Dakota's mental health crisis

Editor's note: This is the first of four stories on the mental health challenges straining North Dakota's criminal justice system .

FARGO — The coronavirus pandemic has forced the North Dakota State Hospital to reduce its capacity from 100 beds to 75 at a time when hospitals are struggling with increased demand for psychiatric services, exacerbating the issue of jails substituting for mental health centers in some parts of the state.

North Dakota’s frayed mental health system was further strained by the closure last year of Red River Behavioral Health, a 70-bed psychiatric care hospital in Grand Forks whose bankruptcy was blamed on the pandemic.

Since the hospital closed, Altru Health System, which has 23 psychiatric beds, had to turn away more than 500 patient referrals last year and is on track to do the same this year, said Janice Hamscher, Altru’s executive vice president and chief nursing officer.

As a result, patients are held in the emergency department until a treatment bed opens in another hospital — a scene that is repeated at hospitals around the state because of the shortage of psychiatric beds.

“It leads to overcrowding in the emergency department,” Hamscher recently told legislators. “That boarding often lasts for days, not hours.”

Grand Forks and the region it serves could use another 70 to 80 beds, she said.

The Legislature’s interim Acute Psychiatric Treatment Committee has been charged with studying the state’s need for behavioral health services and making recommendations for a new state hospital or regionalized system with the State Hospital as the flagship.

The board that oversees the North Dakota State Hospital in Jamestown this fall recommended building a new state hospital with an estimated cost of $150 million to $160 million, presumably on the current hospital campus, which opened in 1885.

There is widespread support for building psychiatric hospital beds in western North Dakota, where there are no beds and patients must travel to hospitals in Minot, Bismarck, Jamestown, Fargo or Billings, Montana, for treatment.

Carlotta McCleary, executive director of Mental Health America in North Dakota, said her organization supports building a new state hospital as well as adding eight to 10 beds to serve western North Dakota.

But new psychiatric treatment beds must go along with expanded access to community-based services and a greater emphasis on early intervention to prevent mental illnesses from becoming severe, she said.

Even patients who are treated at the State Hospital often deteriorate when they return to communities that lack the ability to deliver ongoing care, which can result in readmission, McCleary said.

“The real problem is the lack of community-based services that they go back to,” she said. “There’s nothing to transition them back home to. We have a completely inadequate community-based system.”

Rosalie Etherington, superintendent of the State Hospital and clinical director for the North Dakota Department of Human Services, said a new crisis response program that is in place in each of the eight regional human service centers will help alleviate the need for psychiatric hospitalization.

The crisis response services are available 24 hours a day, seven days per week, and mobile teams can respond within a 45-mile radius, Etherington said.

The State Hospital has been operating at between 95% and 105% of capacity, but Etherington said she is unable to say whether the 100-bed capacity is adequate, although she noted demand for beds is increasing. Determining the right number of beds depends on a number of factors, she said, including the results of the crisis response program.

Legislators have hired Schulte Consulting of Urbandale, Iowa, to help decide the mix of services, including psychiatric treatment beds, needed in the state. The interim committee will present its findings during the 2023 session.

“It’s apparent that this is one of the most critical areas of concern in the state,” said Rep. Jon Nelson, R-Rugby, the interim committee chairman.

The human toll of North Dakota’s mental health crisis is significant but largely hidden, he said. In 2020, North Dakota lost 146 people to suicide and 109 to drug overdoses compared to 100 highway fatalities, which receive much more attention, Nelson said.

Acute services must be more accessible to those living in rural areas, he said. That will be an important consideration when the committee weighs whether to continue with a single state hospital or to include satellite sites.

“Once you get out of Fargo, almost everyone in the state is underserved, in my opinion,” he said. “It’s a real problem.”

The mental health crisis is pervasive around North Dakota, Nelson said. “It’s across the state, so it’s not sneaking up on anybody. Every community has a crisis.”

North Dakota’s gap-ridden mental health system has been acknowledged to be in crisis since a 2014 report by Schulte characterized severe shortcomings as a crisis.

That report, which described jails substituting for mental health treatment centers and judges sentencing defendants to prison so they could get treatment, prompted the Legislature in 2016, 2018 and 2020 to work to strengthen mental health services around the state.

A person with a serious mental illness in North Dakota was just as likely to be sentenced to prison as to be treated in the State Hospital, according to a 2010 analysis by the Treatment Advocacy Center. The estimated population of prison inmates in 2005 with serious mental illness, 365, was essentially the same as the psychiatric inpatient population in 2004, 366, the group found.

Many admissions to the State Hospital, 41%, come from patients whose condition hasn’t improved or who refused treatment and were transferred by other hospitals, Etherington said. Jails account for 12% of admissions.

The North Dakota Department of Human Services has been working with a consultant, Human Services Research Institute, to develop a strategic plan that will be released next year.

Because of disparities in access to care around the state, “countless” people in North Dakota struggled with undiagnosed, preventable conditions and never appeared in medical claims data, HSRI said in a report.

“An overarching theme that emerged in our analysis is that North Dakota’s behavioral health system — like many others throughout the country — pours a majority of its resources into residential, inpatient, and other institution-based services with relatively fewer dollars invested in prevention and community-based services,” HSRI consultants wrote.

By studying utilization patterns and need for services, the state can ensure that “people receive the right level of care at the right time,” the HSRI report said. The authors added:

“Such strategies will allow the state to disinvest from costly and undesirable institutional services and reinvest funding upstream to promote population health and prevent and reduce the need for intensive behavioral health services.”

North Dakota lacks outpatient services, not only in western North Dakota but throughout the state, said Josh Sayler, director of business development at Prairie St. John’s in Fargo. Expanded telehealth services could help fill the gaps, he said, but would require insurance reimbursement, a major obstacle to telemedicine.

Prairie St. John’s has 110 inpatient treatment beds and will have 128 beds when its new building opens late in 2022.

Last year, Prairie St. John’s treated 2,138 suicidal patients. The facility is on pace to treat 2,500 this year, Sayler said. North Dakota is capable only of providing “sporadic” care for those with acute psychiatric illness, he said.

So far, McCleary said, the state’s efforts to lay foundations and put systems in place haven’t resulted in a noticeable expansion of services.

“Are we serving more?” she asked. Mobile crisis teams are an important step, but their availability through each of the state’s eight human service centers isn’t yet widely known by the public, she said.

A key test of North Dakota’s years of effort to improve the mental health care delivery system is whether more people are able to get treatment, McCleary said. Families with children find themselves traveling all over the state because treatment is so scarce, she said.

State officials tout a new program that pays for residential treatment of substance use disorder for those who lack the ability to pay as a major expansion of access to addiction services.

The substance use disorder program became available last biennium, and demand was so high that enrollment of new clients had to cease after one year. Legislators have since doubled funding for the program, and it appears funding is sufficient to last through this biennium, said Pamela Sagness, behavioral health director for the Department of Human Services.

The program has served almost 450 clients, she said. Since 2018, more than 600 peer support helpers have been trained, and the Free Through Recovery addiction treatment program has had 1,100 participants, she added.

The state is striving to make more community-based services available and to prevent the criminal justice system from being a replacement for addiction and mental health services, she said.

“There’s a lot of work underway,” Sagness said, adding that the state is working to add treatment beds into other areas, including western North Dakota. One approach is to contract with private hospitals.

There is no debate in Bismarck about the need to act and for shared responsibility, Sagness said. Historically, physical health and mental health have not been treated equally, but she said that is changing.

“There is a will,” Sagness said. “There really is. I see that in all branches of government. We’re all engaged.”

Early intervention in children and adolescents can prevent cases from becoming severe in adulthood, McCleary said. “It lessens the severity of the disability,” she said. “It’s like with any chronic illness.”

The Department of Human Services is working with schools to deliver mental health services to children, Sagness said.

In order to expand its mental health services, North Dakota faces a daunting challenge in overcoming a longstanding shortage of behavioral health professionals.

Sen. Tim Mathern, D-Fargo, said members of the interim study committee are well aware of that shortage. He asked for solutions to that problem, not more descriptions.

Use of peer services, such as the peer support in the Free Through Recovery program, can be expanded to deal with the workforce challenge, McCleary said.

When peers are included, “We do have that workforce,” she said. “This would be a way of increasing people to assist with our mental health workforce.”

The state has been active in rolling out peer services, but should go further by providing reimbursement for supportive peers, McCleary said. “Peer support should be throughout the entire continuum.”

Sen. Rich Wardner, R-Dickinson, the Senate majority leader, believes the state should invest more in mental health services, including payment for longer outpatient stays, which he said could help reduce relapse rates.

“In reality, we’re spending more money,” he said, adding that mental illness and addiction also take a heavy human toll. "It’s really, really affecting our society and the quality of life we have. People are taken away from the workplace. I think investing in behavioral health is fiscally conservative and not investing is not fiscally responsible.”

• In the year leading up to a 2016 report, an estimated 17% of adults, or about 99,199 people in North Dakota, met the criteria for mental illness. That was below the national average of 18.3%. A total of 4% of adults, or 23,454, had a serious mental illness, similar to the national average.

• Among the 83% of adults with no diagnosed mental health condition, many could benefit from prevention and early intervention.

• An estimated 9% of North Dakota adults, about 52,247 people, had a substance use disorder, according to the 2016 report, higher than the national average; 34% of adults reported binge drinking in the past month, well above the national average. North Dakota ranked second in the nation in the percentage of adults who reported excessive drinking, including binge drinking or chronic drinking.

Source: Human Services Research Institute