DENVER — On Denver’s west side, an elderly man had been managing his solitude just fine until the pandemic hit, taking with it what social life he had and leaving in its place a loneliness he had not felt for years. Not far from his house, a young woman fights panic attacks after COVID-19 killed her grandfather and landed her in the hospital. Now, she fears the virus will come for her again and this time she will die.
In Fort Collins, the school district announces an early return to online learning, and moments later, a struggling mother calls the local mental health center: “I can’t do this again.”
On the Eastern Plains is a third-generation farmer, and if the pandemic does not weigh on him heavily, this year’s record drought and the crop failure it caused do. It sets off an irritability and dread that words do not capture in the same way they cannot capture the layering of crises that marks this time: the body blows dealt by the pandemic, the shaky economy, climate-change driven fire and drought, civil rights reckoning and a polarizing election.
Coloradans are on edge. As individuals. As families. As communities. Colorado already had greater demand for behavioral health services than it could provide. And the safety net that even the state’s top mental health official says has “too many holes” might be further frayed by the tight state budget.
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These crises have led to a well-documented flood of calls to crisis and referral lines, and nearly half of Coloradans recently reported experiencing anxiety or depression.
“Everyone is really struggling with the same things,” says Kristen Cochran-Ward, director of Connections, a mental health and substance abuse program at the Health District of Northern Larimer County. “I have heard people saying that we are all in the same boat. We are not all in the same boat. We are all in the same storm. And some people might be in a cruise ship and some might be on a tire raft.”
To capture the current psyche of our state, (name your news outlet) is partnering with nearly 100 others through the Colorado News Collaborative (COLab) to document how Coloradans are coping. Our hope is that in a state where stigma around mental health struggles runs high, this reporting and the conversations that follow will prompt better understanding of widely misunderstood and hidden experiences.
If there is a silver lining to this time – and we choose to believe there is – it is the realization that even if we find ourselves isolated, we are not alone.
“This has affected all of our wellbeing, all of us,” says Dr. Carl Clark, president and CEO of the Mental Health Center of Denver. “So, I think it has kind of washed away that us-them thing around mental health. I think it is making people realize: ‘Hey, it’s not us-them. It’s us.’”
'Too many holes in the net'
Colorado was in poor shape to handle 2020’s confluence of crises. This year’s heightened mental health needs have run headlong into a complex, ever-shifting constellation of decades-old challenges: the state’s higher-than-average prevalence of high-risk mental health conditions; a backlog of demand caused by a thicket of red tape among state agencies and private insurers; a behavioral health workforce shortage compounded by low rates of psychiatrists and psychologists who accept public or private insurance; cultural stigma; and slow public and political recognition that mental health is as important as physical health.
For communities of color that have a history of trauma and lack of access to health care, the need has been especially acute.
The Colorado Health Institute has been surveying residents about behavioral health and access to care since 2009 and found the situation generally deteriorating ever since. Based on its data, 870,000 Coloradans were in significant distress in 2019.
Nationally, Colorado has the third highest prevalence of mental illness among adults, according to the most recent annual report by Mental Health America. That report, based on data from 2017 and 2018, also finds Colorado has the nation’s highest percentage of adults with substance abuse disorder and the third-highest percentage of adults considering suicide. Colorado’s suicide rate hit nearly 22 per 100,000 in 2018 compared to an average of 14 per 100,000 people nationally. Our national rankings for young people are not much better.
Theories about what explains Colorado’s grim statistics run the gamut from altitude to higher rates of gun ownership to a culture of Western self-reliance that downplays emotions.
“‘Pull yourself up by your bootstraps’ is probably the most misleading statement ever,” says Colorado Department of Human Services Office of Behavioral Health chief Robert Werthwein, noting the credo wrongly assumes mental health hinges solely on individual will rather than on genetics, brain chemistry, trauma and other factors.
State government is partially responsible, Werthwein says bluntly. A recent study by the Colorado Department of Human Services finds fault with a bureaucracy in which 10 different state agencies run 75 different behavioral health programs, with hundreds of funding streams, thousands of billing rules, and no shared vision for care. Seventy-five programs “means there are 74 wrong doors,” Werthwein says.
“There are too many holes in the net.”
Some of the most gaping are sparsely populated communities, many of which have disproportionately high overdose and suicide cases and high rates of stigma around mental health challenges. The need for counseling or treatment doubled or tripled in many rural counties over the past six years.
In the state study of Colorado’s behavioral health system, lack of access to care was repeatedly cited as the greatest problem. Even as COVID began its spread, the state legislature cut hoped-for expansions of pilot programs and new money for mental health and substance abuse programs targeting people living in underserved communities and youth and adults in the criminal justice system.
The roar
The first recorded COVID death — an elderly woman in El Paso County — came on March 13. The state went under lockdown 12 days later.
People who could work from home did. Behavioral health care providers pivoted to telephone or video sessions. The number of people seeking help dipped across the state’s 17 regional behavioral health centers in what care providers describe as a calm before the storm.
By mid-April, unemployment claims had skyrocketed — a red flag among mental health experts who know job loss can lead to suicide, so-called “deaths of despair.” While the caseloads at some behavioral health centers remain below last year’s levels, the urgency of the need has deepened, providers say. Under the weight of uncertainty and isolation, “what was once acute has become very acute, and what was very acute has become a crisis,” says Carl Nassar, founder of Heart-Centered Counseling, the largest private outpatient behavioral health group in the state. Our cups were already full, he says, and now they are spilling over.
The smell of burning forests triggers an anxiety attack. A marital spat about the presidential election blows up into thoughts about divorce. A high school student descends into depression because he can’t hang out with friends. A young mom, cooped up with three little kids, crumbles.
At the pandemic’s beginning, families worried what might happen, what they might lose, says Janis Pottorff, the director of Weld County’s North Range Behavioral Health’s Family Connects program. “Now we have families who have lost things, lost livelihoods, lost relationships, maybe some have lost family — actual physical death — lost confidence that they can manage the day, they can manage the week.”
Pottorff notes that stress has spiked since the late-fall announcements of an early return to remote learning in some school districts. “We are hearing that roar in families' emotions.”
Among those for whom the roar of mental illness predated this year’s crises, increased isolation and the sudden inability to see their trusted providers in person have made things even harder.
An August poll by the Colorado Health Foundation found one in two Coloradans reported increased psychological strain – “anxiety, loneliness, stress” – as a result of the pandemic. A more recent U.S. Census Bureau snapshot survey found that from Nov. 11 to Nov. 23, about 46 percent of Coloradans reported symptoms of anxiety or depression over the previous seven days. Meanwhile, the number of monthly calls and texts to Colorado’s crisis line has climbed from nearly 16,000 in January to nearly 25,000 in October, a more than 50% increase. Most people are calling about anxiety, depression and suicidal thoughts, some seeking immediate help, and others wanting information on providers or coping strategies.
“It’s called the Colorado Crisis hotline, but you define the crisis for yourself,” Werthwein says. “...I don’t want people not to call and say, ‘Well this doesn’t feel like a crisis,’ or ‘Other people are going through harder things ...’ No, call. It helps all of us the sooner that you call.”
But getting longer-term help can be tricky. It generally requires reams of paperwork and long waits for public providers or a string of calls to private providers who often don’t take insurance, are prohibitively expensive or not accepting new patients.
Pat Turner, a contractor in Meeker, sat on his porch twisting wires in his hands and drinking most of June and July as he sank into severe depression. He began disassociating from reality. His search for help drew him into a labyrinth of hold times, packed waiting rooms, 200-mile round trips to the regional behavioral health center in Grand Junction, and a doctor failing to follow up after writing an antipsychotic prescription. His family found a private psychiatrist 90 miles away in Steamboat Springs who is helping treat Turner’s newly diagnosed bipolar disorder.
“We have a real problem if the system doesn’t treat a cry for help as an emergency,” Turner says. “My mania got so intense that if my family hadn’t been there to help, I’d probably still be out there in the abyss, potentially committing suicide or homicide or something.”
For every person known to be in crisis, experts say there are more who are not known: Coloradans without a support system, people experiencing cognitive or traumatic impacts from COVID, students in remote learning whose suffering is unnoticed by teachers and school counselors. Care providers are especially worried about people who have hunkered down, convinced they can just muscle through in silence.
Time to talk
A few months into the pandemic, the Mental Health Center of Denver began using the video game Minecraft to help some of the young people it serves. Two clinicians each lead eight children as they mine materials and build worlds. The game feeds their need to connect to other kids, to play and to create environments over which they have some power.
MHCD also expanded its telehealth appointments from about five a week to 4,000 a week, a remarkable pandemic-spurred shift among all behavioral health providers in the state. Lawmakers allocated about $13 million in federal CARES Act funding for COVID-related behavioral health needs for smart devices, telehealth needs and other resources, such as PPE for therapists to meet high-need clients in person safely. Another $2 million federal grant has been helping Coloradans who have tested positive for COVID receive behavioral health care.
Meanwhile, apps are allowing lonely singles to meet for coffee or cocktails online and for virtual meditation groups among strangers. Social media, often divisive, also has become a place for callouts to check on one another and for admissions that things aren’t going well. “I need something to look forward to,” a man in Broomfield wrote on a recent Facebook post that elicited dozens of emoji faces hugging hearts.
Yet despite innovative ways to connect, we are still hurting. As COVID tightens its grip, infecting record numbers of Coloradans, many of us have again retreated to our homes beset by compassion fatigue and Zoom fatigue and plain old fatigue fatigue. The divisive presidential election has given way to a divisive aftermath. We are girding for a holiday season defined by remaining apart rather than coming together. And, as increased joblessness and evictions loom, a long winter awaits.
On the horizon are two glimmers of light: The promises of widely distributed COVID vaccines next year and of behavioral health reform in Colorado.
To tackle fragmentation, the state has been developing an online behavioral health registry — the first phase of which is expected to go live this April — with daily updates on available mental health and substance abuse disorder treatment. The Polis administration also has created a blueprint for ensuring people who need help are treated like people and not boxes checked for reimbursement.
But at a time when state revenues are stretched, how much can be done and how quickly are open questions. The fractures in Colorado’s behavioral health systems have been decades in the making and will not be mended overnight.
“None of us know when we’re going to experience a mental health crisis, and when we do, many of us don’t know how few and poor the resources are to weather it, even in the best of times,” says Vincent Atchity, president and CEO of Mental Health Colorado, the leading nonprofit pushing for state policy reform. “You can’t feel good about a community that fails to provide life sustaining support for people with serious mental health needs.”
This moment, he and other advocates say, presents not a hypothetical test of Colorado’s mental health policies, but an active emergency. Now, they say, is the time to get comfortable with uncomfortable conversations — lots of them. Now is the time to speak more deeply with each other without shame and to listen without judgement, to ask for and offer help: Are you eating? Are you sleeping? What do you need? What can I do?
“Do we show who we are by finding each other’s humanity and finding solidarity or do we tear each other apart?” Atchity asks. Support networks are critical, he says. “Be sort of gardener-like about maintaining those relationships. Best to keep calling so-and-so when you’re not in crisis, so when you are, they’ll be there.”
At least for now, still in the thick of it, our surest safety nets may be each other.
This story is brought to you by COLab, the Colorado News Collaborative. If you’re struggling, help is available on Colorado’s crisis hotline. Call 1-844-493-TALK(8255)
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