Think Out Loud

Oregon faces holes in mental health services

By Sage Van Wing (OPB)
March 15, 2023 8:05 p.m. Updated: March 20, 2023 9:11 p.m.

Broadcast: Monday, March 20

For too many Oregonians, having a mental illness or substance use problem means repeated failed attempts to get help, and then a crisis: an emergency department visit, isolation in a jail cell, or an involuntary stay at the state’s overwhelmed psychiatric hospital. OPB health reporter Amelia Templeton talked to experts throughout the state to learn about several of the most pressing elements of the crisis — and about promising strategies to address them. We talk to Templeton about her reporting.

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Note: The following transcript was created by a computer and edited by a volunteer.

Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. There is not one mental health crisis in Oregon, there are several. Which one seems most pressing depends on who you are and where you live. As part of OPB’s new series, explaining some of the state’s biggest problems and their possible solutions, our health reporter Amelia Templeton has been talking to experts who are working to address the complex mental health needs of Oregonians. Amelia joins us now to talk about what she has been hearing, and I should say, before we start, that we’ll be talking a little bit about people struggling with suicidal thoughts. Amelia, welcome.

Amelia Templeton: Thanks so much.

Miller: So I said that there’s not just one mental health crisis in Oregon, but several. Can you tell us what you mean by that?

Templeton: Yeah, I think when you say mental health crisis, people will sort of immediately think of one of two things: either street homelessness, and an association with mental illness and substance use disorder, or the sort of long term impact of the pandemic on lots of peoples’ mental health and well being, particularly children. And those are two of the sort of newsier aspects of how the state is grappling with a really weak and fragmented mental health system. But it really leaves out a lot of both the history and a lot of people who are touched by this in rural Oregon due to things like alcohol. We don’t usually think about that as part of the mental health crisis. So I think it makes sense to take a broader look.

Miller:  And let’s do that right now, going one by one. You mentioned youth services as one thing that people have probably heard a lot about recently. You found that since 2003, the state has lost more than 200 residential beds for young people. What happened?

Templeton: I think it goes back to changes in how the state pays for residential facilities for youth. To take just a little step back here, lots of young people [including] teenagers might experience a period of depression or anxiety [and then] might need some kind of support. I think a lot of families are finding extraordinarily challenging wait lists for therapists working with kids and teenagers. But there is a subset of kids and teens in Oregon who really need much more significant help. And these are kids who may have been in the foster care system, kids who may have experienced neglect or abuse or who might be struggling with a significant developmental disability or a significant mental illness and who need care that could go all the way up to hospitalization or residential care.

And these are relatively rare situations, so Oregon used to essentially pay for capacity, pay for beds in residential care facilities for youth. But as the state has tried to expand its Medicaid program, reform its Medicaid program to save money on services that aren’t as necessary, it stopped paying for unused beds. And essentially in order to stay in business, facilities could only bill Medicaid when there was actually a young person occupying a bed. And that meant that they had a much more inconsistent stream of revenue. It’s particularly significant in these facilities serving youth because if you think about it, people under 18 are actually a pretty small percentage of the population. And the way this was explained to me by a youth psychiatry expert at OHSU, which was essentially: we used to run these places like fire houses or fire stations where you pay for the firefighters to be there, whether or not you use them. And we don’t do that anymore.

Miller: What has that meant for young people who are facing mental health crises?

Templeton: It’s been absolutely devastating. It means that children in acute crisis, say, a teenager or a child who’s experiencing suicidal ideation gets sent to an emergency department. They might be evaluated and then, after the immediate crisis is over or stabilized, they’re discharged. And if they need residential care, they might be told that there’s literally nowhere that can see somebody who is as acute as they are. So they’re sent back home, often without adequate support.

Miller: What’s a possible solution?

Templeton: Well, I really heard two things here. On the financial side, the need to try to stabilize funding for the four existing residential facilities that still work with the highest need youth in the state, and the state is doing some things that may help. They’ve increased the reimbursements for providers in the behavioral health arena by about 30 percent. That may help some places retain staff and stay open. But the other thing that I heard was we really need more support for kids, teens who are sent home, and we need more support for their families to make it possible for them to stay home, safely.

I learned about a really interesting program that’s doing this through an organization [called] Youth Villages: the Intercept program. They essentially provide a sort of 24/7 counseling support for families. Each staff person in this program only works with five families at a time, so that they can really get to know the family and really be there around the clock for them. They do everything from safety planning up to educating families about mental illnesses and youth, and helping kids communicate with their family members and get their needs met to sort of de-escalate situations. So the thing that I heard really was the longer a young person stays out of their home and in a hospital or residential care setting, the harder it is for them to go back. So, really an interest in having state support in-home care and better support for families that are dealing with these things.

Miller: Right. So that’s Oregon’s youth. Another part of the crisis you’ve identified is the state’s rising levels of addiction. Can you give us a sense, just for some numbers here?

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Templeton: Yeah, I’ll start with some of the numbers I think are most compelling. So about one in five Oregonians self reports having a substance use disorder. Alcohol is the most common, and it’s actually really hard to say or to know if that is an increase over time. But what we do have good data for overtime is deaths. We can look at overdose deaths and we can look at alcohol related deaths. So currently there are six alcohol related deaths a day in Oregon and three overdoses a day. So I think the thing that’s most striking about that is there’s a lot of public awareness about overdoses and that makes sense. They’ve increased really dramatically just over the last three or four years.

I think there’s less public awareness about those alcohol related deaths and they are maybe, you know, less dramatic than the stories of Fentanyl overdoses that we’ve been hearing. But that is people who are dying in the hospital of very painful liver failure, essentially, or alcoholic liver disorder. That is people dying in car crashes related to alcohol. That is people dying of cancers and heart conditions that we now know alcohol is responsible for some percentage of. So, on the alcohol side, there’s a pretty clear trend of sort of a long slow uptick in these deaths.

And it’s also something you hear about from people working in emergency medicine in Oregon. Just the sheer numbers of people who are coming in for alcohol. It’s actually more, generally, than people admitted to the hospital for problems related to illicit drug use. And then on the overdose side we have this kind of a big surge in overdose deaths and it’s a little hard to tease apart whether that’s more people struggling with substances like methamphetamine and Fentanyl and heroin, or if that’s just the increased potency, specifically of Fentanyl. The public health people I’ve talked to believe there’s some of both going on that we probably have seen an increase in illicit drug use along with more overdoses because of these more dangerous substances.

Miller: The idea behind Measure 110, which decriminalizes illegal drugs, was to then funnel more money into addiction treatment. Is it working?

Templeton: I think that’s how a lot of people read Measure 110. But remember that the money, the pot of money Measure 110 had to work with is cannabis tax dollars. Cannabis remains federally illegal. So when you talk about addiction treatment, some of that is actually medical care, provided by medical providers; and Measure 110 Cannabis tax dollars can’t fund things that are also reimbursable by Medicaid. The state has kind of made that judgment call.

So what Measure 110 has done is put money into a lot of other services the state really needs: supportive housing and harm reduction, needle exchange programs, things like that. And I’ve certainly heard a tremendous amount of support for those programs amongst people working in addiction recovery. But there’s this kind of gaping hole when it comes to actual treatment, where we have not had a big influx of funding.

Miller: What other ideas are there to address this addiction crisis?

Templeton: Well, one of the things that is very much being talked about right now is the idea of an alcohol tax. That’s based on recommendations from a federal work group associated with the Centers for Disease Control, that’s found that alcohol taxes are an effective way to reduce use, that a lot of people are at least somewhat price sensitive and will cut back their drinking in response to higher prices. Oregon does tax alcohol, but our beer and wine tax has not changed, I believe, in 45 years. So that’s one idea, and that could provide additional funding that could be used to pay for detox treatment, prevention, and education.

And I’ve also heard a lot of support, particularly on the issue of alcohol, for some of the cultural changes that are going on. Things like “Dry January”, things like restaurants offering zero proof drinks. There’s just a tremendous enthusiasm for anything that kind of shifts the conversation, encourages everybody to take a more moderate approach.

Miller: Another piece of the crisis is the state’s challenges in treating people with serious mental illness. Are there any promising solutions to this piece of the crisis?

Templeton: Yeah. So these are people with disorders like bipolar disorder, with psychosis or schizophrenia disorders that can really change the course of a person’s life if they don’t get the right kind of treatment. There’s one really interesting approach here in Oregon, it’s called EASA [Early Assessment and Support Alliance]. It’s a statewide program and it tries to intervene immediately after somebody has had their first experience of psychosis. And there’s a couple of reasons for doing that. One is that people tend to be pretty young when they are first experiencing these types of mental illnesses. And if you can support somebody, they may be able to stay employed, they may be able to stay in school and graduate and kind of continue a more normal course of their life. They may also be able to maintain a closer, more functional family relationship and that family support can be really, really valuable as something learns how to manage lifelong mental illness.

The program also works with people who maybe have fears or valid concerns about medication side effects. There’s some really effective drugs that can treat psychosis that can help people not have hallucinations, but those drugs have serious side effects and so much so that it can be a real disincentive to take them. And so the program tries to take an approach of  “start low, go slow” and minimizing dosing for people because they view that as much more successful in the long term. The idea is to really, at the very onset of a mental illness, surround people with the right degree of support so that they can recover, and they’ve had some success.

Miller: We are out of time, but I should say the other components of these overlapping crises that Amelia looked into, and you can learn more about at opb.org, are mental health issues in rural Oregon and also places for people who have less severe but still debilitating mental illness can find treatment.

Amelia, thanks very much.

Templeton: You’re welcome, Dave.

Miller: You can read more as I noted about the state’s mental health crises and as well as strategies to address them at opb.org.

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