(Editor’s note: In the Sounder print edition of “Inside look at mental health in SJC,” the story incorrectly referenced Medicare, when it should have referenced Medicaid. Also in the print edition, the 24-hour crisis number is no longer valid. The correct number is 1-800-584-3578.)

The Sandy Hook Elementary School shooting left Americans horrified and confused as to how this could happen.

On Orcas, islanders gathered in response to this violence by holding a series of meetings to discuss everything from gun violence to psychological distress.

For Anne Gresham, an advanced nurse practitioner and clinical nurse specialist, the meetings have been positive, but she said the average person has no clue what they are up against when it comes to dealing with mental health.

“They don’t know how the system works and in Washington it’s quite complicated,” she added, “and getting more complicated everywhere.”

Anne works with her husband Steve Gresham at Full Circle Counseling and Recovery on Orcas. Steve is also a designated mental health professional for the county.

Over the years Anne has seen not only clients struggle to afford mental healthcare, but private therapists grapple with making a living. For instance, Anne currently has two clients who have Medicaid, United States health program for families and individuals with low income and resources, and through that program, Anne gets paid $0.75 for each person and the patients pay a $25 copay each.

“It’s getting harder and harder to provide mental healthcare,” she said.

The issues

According to the National Survey on Drug Use and Health, the United States spends $113 billion on mental health treatment. That works out to about 5.6 percent of the national health-care spending, according to a 2011 paper in the journal Health Affairs. According to the same national survey, the largest proportion of mental health care expenditures (31 percent) went to pay for outpatient care broadly, followed by inpatient care (24 percent) and retail prescription medications (23 percent).

But only a certain amount of people are even tapping into help – whether in the form of counseling or prescription drugs.

Although cost is a factor in people deciding to get help, studies show that nationwide, attitude barriers about the value of mental health care seemed to be the biggest obstacle.

“People tend to think getting help is a ‘weakness,’” said Anne. “There is a big stigma about it … that you should be able to pull yourself up from your bootstraps and just get over it and … that there is something wrong with you.”

A 2007 study in the journal Psychiatric Services looked at 303 mental health patients who had, in the past year, thought about going to the doctor but decided against it. Of those 303, 47 percent cited financial obstacles as a reason not to seek treatment. The most frequent response, from 66 percent of the patients, had to do with attitude: 71 percent agreed with the statement “I wanted to solve the problem on my own.”

According to Anne, the islands, often viewed as “paradise,” are not immune from national trends regarding mental health issues.

“We have a fair number of severe mentally ill people, major mental illnesses like schizophrenia or seasonal affect disorder. Alcoholism and drug abuse is a phenomenon here … it curls my hair,” she said. “Meth and heroine is huge and there are a bunch of young people who are in trouble with that.”

As far as crime in the form of DUIs, assault, domestic violence and theft, Undersheriff Bruce Distler said that you could relate all of those problems back to substance abuse, which goes hand in hand with mental health issues.

In 2006, there were an estimated 24.9 million adults aged 18 or older in the United States with serious psychological distress – 5.6 million were dependent on or abused illicit drugs or alcohol, according to the National Survey on Drug Use and Health. Rates were highest for adults aged 18 to 25 (17.7 percent) and lowest for adults aged 50 or older (6.9 percent). According to the National Survey on Drug Use and Health of adults with major depressive episodes in 2006, 24.3 percent were dependent on or abused alcohol or illicit drugs.

What happens next?

Distler said when officers answer a call they are required to determine on scene if there is a mental health issue or if the person is using drugs or alcohol, or both.

If the person is intoxicated, officers have to wait until they are sober before they can be evaluated by a county designated mental health professional, which is usually Steve Gresham or Mary Nash. This can require the officer to stay with the person for hours.

“Sometimes they just need to talk,” said Distler.

Anne said that the sheriff’s office often serves as the first contact.

“People believe that if there is a crisis there is no one to call and that’s not true,” said Anne. “In front of the phone book there are crisis numbers (see side bar) and people are not aware of it … 911 works here. They won’t arrest because you are having nervous breakdown. They will be the ‘go between.’”

If the person in question appears to have a mental health issue and is sober, the officer tries to get the person to volunteer to go into custody, said Distler, otherwise they are placed in protective custody. Then the officer calls for a mental health professional for the county. If the counselor decides the person needs further assistance they try to find a “bed” at a nearby mental health facility, which can be an issue because there is only one on-island facility (San Juan’s Peace Island Hospital)and spaces on the mainland are shrinking.

In the last few years, Anne has seen the closing of an evaluation treatment center in Sedro-Wooley and the cutting of bed space in most Washington hospitals. Sometimes those in need end up flying as far as Spokane or Yakima.

Designated mental health professionals also have the job of arranging transportation and other logistics, which can take up to 12 hours to complete.

Distler recalls one situations where he responded to call around 7 a.m. for someone who admitted to having suicidal thoughts. The person was seen by a mental health professional around 8:30 a.m. and it was determined that he needed greater care. The process took until 5:30 p.m. to find a “bed” that was available in an off-island facility.

Another scenario Distler has trouble forgetting is a suicidal person who was put into protective custody and taken to an off-island emergency room. Within 24 hours he had left the hospital with prescription medications and was on the ferry. While on the boat he consumed all his medications.

“So he was put back into protective custody and we went through the whole thing again,” he said.

Getting help

According to Anne, Compass Health, the island nonprofit that provides mental health and chemical dependency services, is really only helpful for those who have Medicaid, causing on-island private practitioners to take up the slack for treating mental health issues.

This creates a problem because it leaves many without affordable mental health care and causes therapists to struggle to make a living. This is just one of many problems Anne describes when she starts delving into mental health treatment on the island or nationwide. But there is hope.

“Medicaid up until now has been ruthless in their determining the bottom line … Obamacare is going to change that. Starting next year more people will be eligible,” she said.

The Community Wellness Program is another resources for those seeking help. The program, funded by the 1/10th of 1 percent mental health sales tax implemented in 2008, provides short term counseling services for individuals, couples, families, and children. Those who are eligible must be uninsured and can make up to 350 percent of the poverty level. The 2011 state guidelines put the poverty level for a family of four at $22,350. Participants get 12 sessions on a sliding pay scale from $5 to $30 depending on their income.

Erin O’Dell, director of the Orcas Island Family Resource Center, said that she never asks why people are seeking therapy, but often people will share without any questions. Mental health needs range from separation from children, substance abuse and domestic violence.

But she added that the majority of participants come to therapy to deal with relationship conflicts.

“Sometimes they end up finding that it’s best to separate and other times they find it best to stay together,” she said.

O’Dell said that 12 sessions is often not enough, but other therapists will continue seeing the person at the same sliding scale or pro-bono.

The future

While it may never be confirmed whether mental illness played a key role in the tragedy in Newtown, Conn., the shootings have triggered a discussion about mental health. Distler said people are talking, which is a step in the right direction, but mental health is a huge issue to tackle.

“In our community, we can’t address every mental health possibility,” said Distler. “They can’t do it in Seattle either.”

Anne said she doesn’t have the data to track all mental health issues on the island, but she and Steve often run into people they have interacted with under duress and receive positive responses.

Anne recalls going out for coffee with Steve and a woman ran up, put her arms around him and said, “thank you so much. I needed that so badly and I’m doing great.”

“Because we are  both connected to Compass Health we generally run into people and see them again,” Anne said. “With the right treatment serious mental illness can improve. The hard ones are addicts  – they don’t give up easily. It’s very hard and painful.”