Psychiatric patients like Esteban Santiago often stay too briefly in Alaska Psychiatric Institute, the state's mental hospital. It is too small to serve everyone who needs help.
Santiago spent four days in a mental hospital in Anchorage in November after going to the FBI to tell agents about his paranoid delusions and fears he would hurt someone. After he got out, the police gave his gun back. Last week, he flew to Fort Lauderdale and killed five people.
Officials and doctors are speaking carefully now, but when I wrote about mental health last year, they said API releases patients before they are stabilized and sometimes before they have improved.
In recent weeks, API has diverted some potentially dangerous patients from Anchorage to Juneau or Fairbanks for involuntary 72-hour evaluations. As I reported a year ago, those diversions put patients detained for their mental instability on commercial airliners before evaluation.
When I wrote that column, one of the hospital's units was closed because of a doctor shortage. API was at full staff when Santiago sought help and remains so, said Randall Burns, director of the Division of Behavioral Health. But even at full staff the hospital is too small to handle its responsibilities.
Authorities won't say if Santiago was in the hospital involuntarily. Law protects his privacy. With blame for this avoidable tragedy circling overhead, ready to fall, agencies aren't saying anything they don't have to, and that includes the FBI.
Two months ago the FBI had as much warning of Santiago's intentions as it could ever hope to receive from a mass killer. Now it is investigating its own failure. We may never know exactly what happened.
But the inadequacy of Alaska's mental health system has been obvious for a long time.
Before 1994, API had 114 beds, which were almost always full. The hospital stacked extra patients in dormitory bunks.
State officials had worked on a plan for several years to shrink the hospital and use the savings for community-based care. They speculated the size of the hospital had discouraged community programs from starting.
In 1994 the Legislature took their advice, cutting API to 79 beds and pushing 25 adult and 10 juvenile patients out of the hospital. But instead of increasing community-based care, the Legislature kept the savings.
When the current hospital was built in 2005, the debate over its size had lasted 15 years. In the end, the Legislature decided the issue by default. Health officials built the largest hospital they could with the money provided.
It's a beautiful building, full of art and lit through peaceful courtyards. But it has only 80 beds when fully staffed, including those used for long-term dementia patients, adolescents, convicts judged guilty but mentally ill, and accused prisoners not competent to stand trial. Just 50 beds are for acutely ill adults.
Meanwhile, Alaska's population has grown 24 percent since the downsizing.
In 1997, mental health advocate Dorothy Peavey said, "How can they say community groups are going to take up the slack? We're going to end up with people on the street who should be receiving some type of treatment."
Last January, a homeless census found about 100 seriously mentally ill people on Anchorage's streets. They wander the woods of the greenbelts and parks, walking through the night in cold weather to avoid freezing to death.
When I researched the problem in June, Burns, the division director, said API doesn't have enough room to stabilize patients before releasing them. He said it can function more like a psychiatric emergency room than a hospital.
"The only way you can make it work at all is to discharge high numbers on a weekly basis," Burns said. "The pressure is intense, and if you look at the data, almost every day they are admitting as many as they discharge."
When we talked Wednesday, with API's lawyer on the line, Burns emphasized that staff feels no pressure to discharge patients who aren't ready. A doctor who worked there during medical training agreed.
I find that hard to believe.
Neuropsychologist David Sperbeck didn't want to talk to me Wednesday after the Santiago tragedy, but he did back in June. He said the speed at which API treats and releases patients is too fast, sometimes before they show any improvement.
Besides, Sperbeck said, some patients are not appropriate for community care. Patients lacking insight and who are unwilling to take medications may need extended hospital care.
"In my opinion it was not good planning to downsize API at the time," said Dr. Aron Wolf, a psychiatrist in private practice. "That was the money they had."
Wolf was not involved in the Santiago case, but questioned why he was released.
"How come he wasn't held longer?" Wolf asked. "Had he had a court evaluation and if he was still psychotic, he would have had a judge say he was mentally ill, and then he wouldn't have gotten his gun back."
The hospital can hold patients like Santiago three days (plus holidays and weekends) after receiving them. After a hearing, a judge can order commitment for 30 days.
But few patients make it that far, because the hospital and the patient both have an interest in avoiding a hearing.
For the hospital, commitment hearings are time-consuming and put doctors in an adversarial relationship with patients. For patients, the advice of public defenders is often to avoid official commitment by agreeing to stay voluntarily.
According to the state, only 77 hearings for 30-day commitment were held in fiscal year 2016.
Burns hopes to establish new facilities and services for those who don't need to be in API, freeing up space. The state is working on a study to submit to the federal Center for Medicare and Medicaid Services showing a new system would save money.
That study won't be done until summer and federal review could last a year or more. Meanwhile, any of us could have a family member who is mentally ill and gets no more care than Esteban Santiago.
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