Opportunity born from tragedy: the Virginia Tech tragedy should motivate changes in Virginia's mental healthcare system.

The Virginia Tech tragedy has placed the nation's mental healthcare system under the microscope--with Virginia's public system being examined under high magnification. After the shootings, the American public was justifiably upset. People who normally don't think about mental healthcare wondered, "How can something like this happen in rural America?" "Could someone have stopped this from happening?" "Is the mental healthcare system broken?"

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Responsibility for the Virginia Tech tragedy is being placed squarely on Virginia's public mental healthcare system. The general public's reaction is understandable, but from a realistic point of view, this condemnation is totally unjustified. After all, the public mental healthcare system lacks adequate funding and the necessary resources to be able to prevent incidences like the Virginia Tech tragedy.

What We Know So Far

Yet there's no doubt about it: Seung-Hui Cho definitely slipped through the system's cracks. As early as a year and a half before the incident, Virginia Tech officials and students became aware of Cho's delusional and disturbing behavior. His writings depicted graphic and macabre violence. Virginia Tech Professor Lucinda Roy, former chairwoman of Virginia Tech's English Department, was so concerned that she pulled Cho from another instructor's class and taught him one-on-one. In December 2005, campus police met with Cho, acting on two female students' complaints that he had left graphic messages on their doors. Later that evening, Cho sent an e-mail to his roommate threatening suicide. The roommate relayed the message to his father, who called the campus police.

Following the campus police's intervention, Cho was taken to their campus headquarters, where the emergency staff from New River Valley Community Services Board, the local mental health agency in Blacksburg, prescreened Cho. The prescreening staff determined that Cho met commitment criteria and recommended hospitalization. A temporary detention order was issued, and Cho was taken to Carilion Saint Albans Behavioral Health clinic, a few miles from the Virginia Tech campus. New River Valley staff recommended that Cho receive medication management and outpatient counseling services upon his release.

The next day the actual commitment hearing was held by Special Justice Paul M. Barnett to determine whether to continue hospitalization or to release Cho back to the community. Although Cho was judged to be an "imminent danger to self or others as a result of mental illness," Barnett released Cho under an involuntary outpatient treatment order with a recommendation that he seek professional counseling. Cho did make an appointment at that time with the Cook Counseling Center on the Virginia Tech campus.

Records obtained from the University Counseling Center failed to clarify whether Cho ever received counseling. Gerald Massengill, chairman of the panel appointed by Gov. Tim Kaine to investigate the event, stated, "I think the absence of documentation might tell you something within itself." He added, "If in fact there was never any sign of violence, any indication of violence on his part, how would you anticipate anything like this?" He also said, "It's unfair to point a finger and blame the mental health community for something that may not have been detectable."

Until the investigation began immediately following the shootings, New River Valley CSB was never aware that an involuntary outpatient commitment order had been issued, according to Les Saltzberg, the former executive director of New River Valley CSB. No further information was available at press time.

The History of Virginia's Community-Based System

The Virginia Tech tragedy has brought to light the fragmented and poorly funded mental healthcare system in Virginia--and the entire nation. Understanding the history of the commonwealth's system will help decision makers take steps to prevent future tragedies across the state and country.

Virginia's public, community-based mental health system was created by legislation in 1968, which directed every political jurisdiction, either separately or in combination, to create an organization, referred to in the legislation as a community services board, to provide mental health, mental retardation, and substance abuse services to the citizens of the board's identified service area. Eventually, 40 CSBs were created. For the next 25 years, CSBs' primary funding source was state general fund dollars.

Virginia's community mental health system was transformed in the early '90s from a state-funded system into a Medicaid-driven system. Tens of millions of state general fund dollars previously allocated to community-based services were reallotted to Medicaid to receive matching federal dollars, but Medicaid funds can be used only for Medicaid-eligible consumers. At the same time, the state identified populations it considered priorities for treatment, which included the chronic populations within each of the disability areas.

These moves eroded the system's ability to provide services to thousands of previously served consumers in more traditional outpatient services. Although many new programs and millions of new state and Medicaid dollars have been put into the community system in the past few years, funding increases have not kept up with inflation, again causing CSBs to limit or eliminate services.

The Current Situation

Timely access to public mental health services continues to be a major problem in Virginia. In a Medicaid-driven system, lack of Medicaid eligibility can be the single biggest impediment to seeking mental health treatment. Medicaid eligibility is based upon federal poverty guidelines, but the states individually determine the eligibility level within those guidelines. Virginia's eligibility level is only 80% of the federal poverty guidelines for the aged, blind, and disabled, which includes the mentally ill population. This is one of the lowest rates in the nation, with some states' rates as high as 200%. At least 50% of the consumers with serious mental illness served by the CSBs in Virginia are not eligible for Medicaid reimbursement.

Behavioral healthcare is a small part of Virginia's ever-expanding Medicaid rolls, with most estimates around 10%. Virginia historically has supported institutional care at the expense of community services, as evidenced by its national rankings of 6th in financial support for institutional care and 38th for community programs (up from 48th in the past few years).

Recruitment and retention of professional and direct-care staff at CSBs continue to be problematic. Staff at Virginia's facilities are state employees and receive salary increases from the state. CSB staff are not state employees, and their salary increases are based strictly upon state funds, in most cases comprising only 30 to 40% of CSBs' total operating budgets. In many areas, state employees' salaries are 20 to 25% higher than comparable positions in the community.

Commitment hearings in Virginia are conducted by special justices, attorneys appointed by the chief judge of the jurisdiction, with special training in mental illness. A survey of judges and special justices, conducted by Dr. Elizabeth McGarvey of the University of Virginia as part of research efforts for the Commission on Mental Health Law Reform (more on that below), revealed that during May (the month following the Virginia Tech tragedy), more than 1,400 commitment hearings were held statewide. Eighty-six percent of those coming before the courts were hospitalized, although 30% agreed to be hospitalized voluntarily. Ten percent were released immediately following the commitment hearing because they did not meet the current commitment criteria. In two-thirds of these cases, the independent examiner failed to certify probable cause for commitment. Among those committed, only 6% were committed to involuntary outpatient treatment. CSB staff members were present at fewer than half of the hearings while independent mental health examiners attended approximately 60%, but they testified in fewer than half of the hearings. Sixty percent of the hearings were over in less than 15 minutes, and virtually all were completed in 30 minutes or less.

Kaine has taken a positive step in his recently released Executive Order 50, which explicitly details procedures to ensure accountability and follow-up for court-ordered treatment. However, EO 50 is directed at service providers and does not address patient noncompliance, aside from it being a factor that could trigger another civil commitment hearing. Additionally, EO 50 clarifies when involuntary treatment orders issued under Section 37.2-817 of the Code of Virginia would require notification to the Central Criminal Records Exchange, with the potential unintended consequence of further criminalizing mental illness, which now affects one in four adults in the United States. Procedural issues and linkages between all the involved parties certainly will be addressed during the upcoming General Assembly session in January 2008.

Virginia's Future