29-01-2025
Alabama mental health care recovering slowly from recession-era cuts
Alabama's mental health system was gutted by funding cuts during the Great Recession. It has only slowly begun to recover what was lost. (Getty Images)
Alabama is dealing with the long-term aftermath of budget cuts and poor mental health planning and trying to find ways to cope amid an absence of reliable data.
Wednesday: The state is rebuilding its emergency care care network after devastating funding cuts during the Great Recession.
Thursday: Mental health services are critical for new mothers. Accessing them can be difficult.
Friday: School-based therapists are seeing more trauma in earlier grade levels and increasing demand for services.
Monday: The state's jails are poorly equipped to work with people with mental illness. That's led to tragedies.
Tuesday: Law enforcement officers are being trained to find more effective ways to help people suffering from mental health crises.
Alabama's public mental health system has been focused on one thing over the last decade: recovering services lost in the wake of the Great Recession.
The effects of those cuts are still being felt, years after the state began reducing beds in state mental health hospitals, said Hardy McCollum, a retired probate judge and former chairman of the Tuscaloosa County Commission.
Steep cuts in state funding in 2010 ravaged the system. The budget for the Alabama Department of Mental Health (ADMH) fell from $178.1 million in fiscal year 2008 to $117.1 million in fiscal year 2011. State psychiatric hospital beds, which primarily rely on state dollars, were among the hardest hit.
'That was really the only place that we could come up with a $40 million cut,' said Alabama Department of Mental Health (ADMH) Commissioner Kimberly Boswell.
McCollum called the closures a 'political decision' that left people with mental and behavioral health issues without adequate care, forcing many into homelessness or incarceration.
'A lot of them were living under bridges,' McCollum said in an interview. 'They just were left to fend for themselves, basically.'
Alabamians who need mental health care still struggle to get it.
In the first State of Mental Health in America report in 2015, Alabama ranked 49th among the 50 states and the District of Columbia in access to care, only trailing Mississippi and Nevada. In the nine years since, Alabama has moved up just three spots.
State funding for mental health services have been slow to recover from recession-era cuts, and they fell hardest on long-term care.
The state shut down several state-run psychiatric hospitals and decreased the number of beds in others. Over the five years that followed the austerity measures, Alabama lost more than 400 beds meant for long-term crisis care. Searcy Hospital in Mount Vernon, which shuttered its doors in 2012, had 228 beds. Greil Hospital in Montgomery, also closed in 2012, had 61 beds. North Alabama Regional Hospital in Decatur had 77 beds before it closed down in 2015, and a long term care unit at Bryce Hospital, with 62 beds, closed in 2014.
In the years following these cuts, Alabama's mental health system has been slowly putting itself back together. The state launched a 24/7 crisis care initiative in 2018 after calls to address mounting problems that arose from closing civil commitment beds.
'We had a lot of feedback from sheriffs, from hospitals, who engaged us and said, 'These folks are winding up in our hospitals, in the emergency department, where they're not really getting care, or they're winding up in jail,'' Boswell said.
Boswell acknowledged that building an effective mental health system after years of underfunding is a long-term project. Despite the economy improving in the years following the budget cuts, she said there were no increases until 2018 because the department didn't have a plan for rebuilding the system.
'We were sort of stuck doing what we had always done, and there was this big transformation going on in mental health services,' she said. 'Frankly, we were a little late to the party,' she said.
The Alabama Department of Mental Health's funding levels rose slowly each year but only saw large increases starting in 2018. The department only surpassed its total 2008 funding level in 2020, though when adjusted for inflation, it was still short over $40 million. In real terms, ADMH remained below its 2008 allocation until 2023.
But there are areas where the department is still playing catch-up. ADMH in 2008 allocated $100 million for mental health programs, which do not include substance use and developmental disabilities programs also administered by ADMH. Another $40 million went to developmental disabilities care, with the rest going to substance use treatment.
It doesn't require a genius to figure out if you close beds, these people are going somewhere. When they closed Bryce Hospital, it backed them up into not only the jails but in the community hospitals as well.
– Hardy McCollum, former Tuscaloosa County Probate Judge
In 2022, funding for mental health programs reached $100 million for the first time in 14 years. But $100 million in 2008 would be worth nearly $144 million in 2024.
McCollum said Tuscaloosa has not yet recovered from the austerity cuts. At its peak in 1970, Bryce Hospital in Tuscaloosa had more than 5,000 patients. The state' capacity for long-term beds as of July was about 700.
'It doesn't require a genius to figure out if you close beds, these people are going somewhere,' he said. 'When they closed Bryce Hospital, it backed them up into not only the jails but in the community hospitals as well.'
To address mounting concerns from the local community, such as overcrowded county jails, Alabama began developing its crisis system of care in 2018, focusing on establishing crisis centers aimed at offering them more appropriate mental health interventions. These centers help people in immediate need, offering alternatives to emergency rooms and jails, where those facing crises have frequently ended up in the past. Between 2018 and 2024, the state received an additional $139.4 million in funding, a 94% increase.
Despite these efforts, Alabama's mental health funding still falls short. The state needs at least 11 crisis centers to properly serve Alabamians across the state, according to ADMH. It only has six, serving 20 of 67 counties.
'This year, we'll be laying out a five-year financial plan of what it would take to really get our infrastructure stable and develop the new services that we need based on the needs we have,' Boswell said.
The goal is to boost funding for existing services, particularly residential programs, while also expanding the number of crisis care beds available to both voluntary and involuntary patients. That's just to address crisis services in the state.
Alabama officials are also ramping up efforts to address suicide and traumatic brain injuries (TBI) among veterans, a condition they describe as a 'silent epidemic.' Alabama officials are looking at the links between TBI, mental health issues, substance abuse, and an increased risk of suicide among veterans. TBI symptoms often overlap with conditions like depression and PTSD, leading to inadequate treatment if the underlying brain injury is not identified. Nationwide, over 185,000 veterans are documented as having at least one TBI, though the specific number in Alabama is unknown.
The state is taking steps to expand TBI screenings through a federal grant that will integrate them into mental health and substance abuse treatment programs, which can be done remotely in just 10 minutes. Certain medications, such as benzodiazepines, could exacerbate symptoms for those with TBI, stressing the importance of tailored treatment plans.
Holly McCorkle, executive director for Alabama Council for Behavioral Healthcare, said that establishing crisis care centers was a step in the right direction, but the state has not increased funding for crisis residential units in community mental health centers since 2012. The state turned to these crisis residential units, capped at 16 beds per unit, to replace beds lost due to facility closures.
'So you're with individuals that are deemed a danger to themselves or others, and this is pretty intensive inpatient treatment, and we have not raised the funding level for that in over a decade,' McCorkle said.
Boswell sees promise in Alabama's mental health system, specifically in the implementation of Certified Community Behavioral Health Clinics (CCBHCs), which she sees as the next step in providing comprehensive mental health services, regardless of whether someone is in crisis or not. These federally funded clinics offer more comprehensive care by integrating primary health services with behavioral health and substance use treatment.
Alabama's mental health centers have traditionally provided outpatient care, but with the expansion of CCBHCs, there is a focus on same-day access and integrated care, which would allow people to 'move through the system more efficiently.'
'Programmatically, where we're going is really transforming and building out the kinds of services that people really need now: crisis services, obviously, 24/7 access to care, but also integrated behavioral health and substance use services, as well as primary care,' Boswell said.
But these are incremental changes, designed to prevent crises before they escalate.
'The longer someone waits for care, the less likely they are to show up. Same-day access ensures we're reaching people before it becomes a crisis,' she added.
And these CCBHCs, or crisis centers, still only serve a portion of the population. Mobile crisis teams serve 25 counties, often overlapping those with crisis centers.
'It's not a perfect system, but we have a lot more to offer people than we had, you know, 10 years ago or five years ago,' Boswell said.
Thurdsay: There is an urgent need for mental health care for new mothers — and many barriers to access.
The need for mental health services in Alabama is hard to quantify. The state ranked 21st among states with a prevalence of mental illness in the State of Mental Health in America 2024 report, according to Mental Health America National, a nonprofit that promotes care and treatment.
That may indicate a lower prevalence of mental health and substance use disorders than most U.S. states, or that Alabamians aren't reporting issues, either because of stigma or lack of access to care. Alabama also ranked 25th in adults experiencing any mental illness, and it was the state with the second lowest rate of adults with substance use disorders in the past year.
Expenses can be a barrier to care. In 2022, 58.9% of adults in 2022 nationwide with a mental illness in the past year who sought or thought they should receive mental health care said the reason they did not receive it was because they thought it would cost too much, according to a survey by the Substance Abuse and Mental Health Services Administration (SAMHSA). Alabama ranks 49th in the number of adults who are unable to see a doctor for frequent mental health issues due to costs, according to the Mental Health America 2024 report.
Alabamians diagnosed with mental illness are also more likely to be uninsured (14.4%) than the population with mental illness generally (10.1%). The state's lack of Medicaid expansion may also be contributing to the state's mental health crisis: nine of the 10 states that have not expanded Medicaid rank in the bottom 12 for health care access. Among these non-expansion states, 13% to 24% of the remaining uninsured population fall within the Medicaid coverage gap.
But even insured people struggle to access mental health services. Almost 16% of Alabamians who experienced a mental illness in the past year had private health insurance that did not cover mental or emotional problems, compared with roughly 10% nationwide. — Alander Rocha
