Growing demand on Mecklenburg County's mental health system has made it harder for dangerously ill patients to get the help they need, an Observer investigation found.
With perennial overcrowding at the county's 66-bed psychiatric facility, some patients who threaten themselves or others are instead given medicine and sent home - sometimes with disastrous results.
Since March, advocates have pointed to the case of Kenny Chapman as evidence that the mental health system is overwhelmed. Chapman told staff at the psychiatric hospital known as CMC-Randolph that he wanted to kill his wife. Hours later, he suffocated her and then killed two of his children.
The Observer investigated the system and found:
-- Demand for mental health services has surged over the past decade, while the number of psychiatric beds in the county has dropped sharply.
-- Fewer critically ill patients are getting beds. Last year, about 15 percent of visitors to CMC-Randolph's emergency department were admitted to a psychiatric hospital. That's down from 21 percent in 2004 - and well below the rate for some other hospitals.
-- A 2003 study found CMC-Randolph needed to be significantly expanded. Since then, demand has increased markedly - but the expansion plan went nowhere. State and local officials don't agree on who should pay for an expansion.
-- Mecklenburg's mental health agency gets less state money per resident than all but one of North Carolina's 24 mental health agencies. The state cut its funding to the county by more than $5 million last year.
The Observer interviewed more than a dozen people who questioned the treatment they or their relatives received at the hospital. One overdosed on drugs soon after the hospital refused to admit him. Another said he could not get a hospital bed in spring 2009, even though he'd just swallowed a bottle of sleeping pills.
A third, Philip Hunt, said he tried to kill himself after pleading with hospital staff not to let him go.
"I told them I'm ready to die," said Hunt, recalling how he was discharged from the hospital in 2008 following a three-day stay. "But they just sent me on my way."
Carolinas Medical Center runs the hospital under a $16million contract with Mecklenburg's Area Mental Health department. Those who run the hospital and the department have declined repeated requests for interviews over the past two months. They also did not respond to the claims of former patients who told the Observer they did not get the help they felt they needed from the hospital.
But in written statements, they said they do more to address the needs of the county's mentally ill than any other N.C. county.
Area Mental Health Director Grayce Crockett wrote that the state has not provided enough funding to meet local needs.
But Crockett has said that hasn't affected the quality of care. CMC-Randolph meets the industry's highest standards, she said. Both the hospital and the department have fared well in government evaluations.
Doctors and staff at CMC-Randolph often provide crucial help despite trying circumstances. Each year, the emergency department sees more than 16,000 patients - many of them critically ill, some suicidal and a few downright dangerous.
Most of those patients can't be hospitalized because beds are hard to come by, so clinicians are expected to make judgment calls that may mean the difference between life and death.
Cases like Kenny Chapman's illustrate what can go wrong.
Chapman, who killed himself after a shootout with police, twice sought help at CMC-Randolph. The first time, in February, he told staff he wanted to harm his wife. The second time, he said he wanted to kill her.
Both times, records show, Chapman eventually told clinicians he wouldn't act on his threats - and doctors sent him home with prescriptions for medication.
On March 16, just hours after Chapman left the hospital, police say he made good on his threat - killing his wife and two children. He forced two surviving children to carry on for two weeks as though nothing had occurred.
"When you start cutting corners ... that's the sort of thing that can happen," said Bob Evans, vice president of the local chapter of the National Alliance on Mental Illness (NAMI). "...Nothing good can come of it. The only thing that can come of it is tragedy - the loss of life, or lives."
The ranks of those needing psychiatric help soared over the past decade as Mecklenburg's population grew. The economic crisis made matters worse, as thousands of residents lost jobs and homes.
From 2006 to 2009, the number of people served by the mental health department swelled by more than 50 percent - to more than 52,000.
At CMC-Randolph, which treats mostly low-income patients at its low-slung brick building in southeast Charlotte, visits to the emergency department have climbed rapidly.
Those who are hospitalized tend to be sicker - and stay longer - than patients in years past, according to a recent report the hospital submitted to the county.
But funding hasn't kept up with needs: The county mental health department - which operates on a budget of roughly $90 million and contracts with treatment providers - was hit last year with $5.8 million in state and county cuts.
(Last month, county manager Harry Jones proposed a budget that would give CMC-Randolph $3.3 million more next year but eliminate 19 mental health positions, most of them administrative jobs.)
Mecklenburg spends more than $40 million a year on mental health - far more than any other N.C. county. But patients here have gotten relatively little help from the state. In per capita funding, Mecklenburg now ranks 23rd out of North Carolina's 24 regional mental health agencies.
"Mecklenburg has been generous with their county dollars and the state has taken advantage of that," said N.C. Rep. Verla Insko, a Chapel Hill Democrat, who says she has tried without success to make funding more equitable.
All of this has come during a decade in which the number of psychiatric beds has dropped. Mecklenburg lost about 200 beds with the closing of two private hospitals - Charter Pines and Cedar Spring.
CMC once could transfer several hundred patients a year to Broughton Hospital, the state's psychiatric hospital in Morganton. Now, Broughton is accepting fewer transfers as officials push to have short-term patients treated closer to home.
At a recent meeting of the Depression and Bipolar Support Alliance, group leader Michele Frio voiced her frustrations:
"If you have appendicitis and your temperature is 105, there's service for you. But if you're one of us, there's nothing."
'Not suicidal enough'
During the years he lived in another Southern state, John knew there was always a place to get help with his manic depression. From 1995 to 2007, he said, he was hospitalized about five times.
"All you had to do is show up on the doorstep and say you wanted to die," said John, who asked that his real name not be printed. "And they'd let you in."
After arriving in Charlotte, he discovered things didn't work that way here.
In spring 2009, he had turned to cocaine to lift him out of a deep depression. He went six days without sleeping.
He swallowed a bottle of sleeping pills, planning to end his life. Changing his mind, he made himself throw up. He then called his mother, who persuaded him to go to the hospital.
After waiting about three hours at CMC-Randolph's emergency room, he got to talk briefly with a psychiatrist, who he said instructed a nurse to give him an antidepressant. He recalls a psychiatrist telling him: "I don't think you're suicidal enough to admit you to the hospital."
That, John says, is when he began yelling.
"You're going to shut the door on me? This is insanity," he remembers saying. "What do I have to do? Come here with slashed wrists?"
He was sent home nonetheless. Soon afterward, he checked himself into a substance abuse clinic.
After the experience at CMC-Randolph's emergency room, he said he would never return. "And I don't know where I'd go, to be honest."
Beds in short supply
Like John, most who visit Mecklenburg's psychiatric emergency department don't get a bed.
Only about 15 percent of those who visited the emergency room were admitted to the hospital or to Broughton last fiscal year, an Observer analysis found.
Frio, the support group leader, said she thinks it's "pathetic" that so few emergency room visitors are admitted.
"The folks that are going (to the emergency room) by and large ... need intensive treatment," she said.
In a sampling of other hospitals, the Observer found all of them more readily admitted psychiatric patients. At Presbyterian Hospital, about 35 to 40 percent of mental health patients who come through the emergency department are admitted, a spokeswoman says.
The figure was about 37 percent last year at Advocate Illinois Medical Center in Chicago. And at Providence Alaska Medical Center in Anchorage, about 30 percent were admitted to hospitals.
Overcrowding is probably to blame for CMC-Randolph's low admission rate. Last fiscal year, the inpatient units for adults operated at or above capacity 100 percent of the time. Six years earlier, that was true only 75 percent of the time.
Even then, the hospital knew it needed to grow. In a 2003 study, the 66-bed hospital concluded that it would need up to 67 more beds in the coming decade - an expansion that was expected to cost as much as $49 million.
"The current facility can not meet the needs of existing volume, much less future needs," the report said.
Since 2003, the needs have only intensified. Visits to the hospital's emergency department have grown 25 percent.
In March, when Chapman sought help, emergency department visits jumped to the highest number in 10 months and the hospital's adult units were running at 105 percent capacity. That same month, the number of calls to the hospital topped 24,000 - a record.
But the money for an expansion never came.
It's not clear why that didn't happen. But leaders of Mecklenburg's Area Mental Health department say they never asked state or county governments for the money to build the new beds.
"Establishing inpatient psychiatric beds is not typically the responsibility of county government; it is the responsibility of the State," department director Crockett wrote in response to questions.
Rep. Insko sees it differently: "Actually it's probably a very shared responsibility. ... I think the state and county and hospitals have to work together."
In a written response, CMC-Randolph President Laura Thomas said more money would improve access to care.
"Both Area Mental Health and (Carolinas HealthCare System) recognize that increased capacity is necessary to meet ongoing and future demand," Thomas wrote.
David Rains, former president of the Mecklenburg County's NAMI chapter, has seen the consequences of the bed shortage. He spoke of a young man with bipolar disorder who was recently taken to CMC-Randolph after experiencing a psychotic episode.
The hospital's staff chose not to hospitalize him. Soon after he was discharged, the man poured gasoline on his mother's house and set fire to it, Rains said. Firefighters were able to extinguish the flames.
"It is apparent to me they are turning people away and sending them back home - and they are going home before they should be home," said Rains, who runs support groups for the mentally ill. "...If you turn them away, you may be turning away another Kenny Chapman."
'It's not going to be good'
Expanding the county's mental health system would probably cost millions.
But, advocates warn, the cost of not doing so could be far greater: More homelessness. More crime. And, almost inevitably, more tragedy.
By May 2008, Philip Hunt said he had lost his desire to live.
He'd been struggling with psychiatric problems since 1985, when his two young sons were murdered in New York.
After moving to North Carolina, he broke up with his girlfriend in 2008 and went into a tailspin. He says he had no plan and no hope when he began walking the highway from Lexington to Salisbury. He came within a step of hurling himself off a bridge - and soon afterward was referred to CMC-Randolph.
There, he told clinicians he'd recently tried to commit suicide and was thinking of trying again. He had no home, no money and no insurance. He felt like hurting himself or someone else, he recalls telling them.
After about three days, the hospital discharged him with a bus pass and a prescription for an antidepressant.
He remembers telling a doctor he was still suicidal.
"I'm telling you, if you leave me in the state I am now, it's not going to be good," he recalls saying.
After leaving the hospital, he says he promptly got the prescription of Zoloft filled - and ate half the bottle. "I thought it would make me go to sleep and I wouldn't wake up," he said.
He passed out not far from Presbyterian Hospital. A nurse there found him on the sidewalk, and had him brought into the hospital, where staffers gave him treatment to keep the drugs from killing him.
He thinks CMC-Randolph staffers should have kept him in the hospital until they could be sure he wouldn't hurt himself or anyone else.
Now 50, he's taking his medications, holding down a job and trying to help others with mental illness.
But he says the decisions made at CMC-Randolph almost cost him his life.
"They should have gotten me help," he said, "not a bus pass and a prescription."
Staff writers April Bethea, Elizabeth Leland and Cleve Wootson contributed.