In his office at Marian Regional Medical Center, Dr. David Ketelaar described a mental health crisis.
He may not be a psychologist or psychiatrist, but he’s seen what happens when people with mental health needs or even emergencies wind up at the hospital’s emergency room:
A patient comes into the emergency room with a physical ailment, maybe chest pain. Through the evaluation process and multiple physician examinations, they conclude that the issue isn’t physical. It’s mental. Ketelaar said any number of mental health problems can be hidden underneath what appear to be physical ailments. It’s what makes them so difficult to diagnose.
What next?
Ketelaar said, depending on the issue, there may not be anywhere to send the patient.
Nationally, mental health problems—particularly suicides—are on the rise, and local doctors and emergency teams need to know how to respond.
A report from the Pew Research Center shows that 13 percent of U.S. teens in 2017 reported at least one “depressive episode.” The report, posted on the center’s website July 19, tracks teens between 12 and 17 years old. Using data from 3.2 million people, the report indicates the rise differs dramatically from a 2007 poll of 2 million people, showing that 7 percent of students reported having one major depressive episode that year.
But the local numbers aren’t quite so drastic. In Santa Barbara County, the number of mental health cases the county has processed through its services have gone up and down. Categorized by fiscal year, the county reports that there were 9,774 cases in 2015-16. That number dropped by more than 1,000 in 2016-17, and it jumped back up to 9,600 in 2017-18. The number of cases then fell again in 2017-18 to 8,645. By comparison, the number of mental health cases is much higher than the substance abuse cases in the county, which hasn’t risen above 4,550 in each of the last four years.
Ketelaar, the emergency services director at Marian Regional Medical Center, sees the county in crisis mode when it comes to mental health. His immediate goal is to expand services in Santa Maria for people who need more immediate and intensive help than a weekly visit to a meeting or a therapy session.
“The primary care doctors and the rest of our hospitals and clinics work with people before a crisis hits, and they need to have options to refer people to,” Ketelaar said.
“When I talk to the primary care doctors in our community, they have a lot of frustrations with the lack of options that are immediately available to refer their patients,” he added. “The primary care doctors do the bulk of the mental health work in our community. They’re the front lines.”
For other people, the front lines are out in the community—in their homes, on the street, wherever a mental health crisis may happen. Those are the places where the Santa Barbara Sheriff’s Office is aiming to help. It’s currently expanding its Crisis Intervention Team with special training that may include responding to someone suffering from a mental health crisis or episode.
Even professionals conditioned to the many frictions of a military career can fall prey to unhealthy impulses. The military has been facing its own mental health crisis with rising rates of suicide, a phenomenon that’s prompting military officials to instruct commanders at Vandenberg Air Force Base to take a day to stand down and address their soldiers in meetings to get real testimony on the problem at the personal level.
These intervention models are a bump up in the levels of immediate care some might need to stop a mental health issue from becoming a crisis.
On the hospital front, Ketelaar said there needs to be more options, particularly in Santa Maria. He pointed specifically to mental health care beds. There are none in Santa Maria.
“Every day we’re holding patients. The number can very. On average, every day we’re holding several patients—two or three patients waiting for that next step,” he said. “When we have a crisis stabilization unit, the vast majority of patients will be able to go right over to the crisis stabilization unit.”
The hospital’s plan is to open a crisis stabilization unit at a building the hospital received through a donation. It would be the kind of facility where people suffering from virtually any mental health malady could go and receive treatment. The hospital estimates that the initial project could cost $3 million, a funding goal Marian expects to hit in the near future. But Ketelaar said he wants the unit to provide more services, and hopes to convert other parts of that building into a mental health clinic that will have the beds that the city currently lacks. But that project could put the total cost of renovations and other expenses for the building as high as $10 million.
“We’re not making money off this,” Ketelaar said. “But it’s vital that we do it.”
Ketelaar has decades of experience in emergency services. He came to Santa Maria shortly after he graduated from the David Geffin School of Medicine at UCLA. That puts his time at Marian Regional Medical Center at more than 20 years where the MD uses his expertise in emergency medical services. Ketelaar represents one of the many medical professionals who has seen the mental health needs of patients because, he said, they often come to the emergency room first. That’s not always the best place for them, he said.
“We all have mental health, and our mental health will wax and wane in how good it is and how not good it is,” Ketelaar said. “To know the resources and to know where to turn to is really important.”
Crisis Intervention Team
Dr. Cherylynn Lee, a licensed clinical psychologist and the behavioral sciences manager at the Santa Barbara County Sheriff’s Office, began thinking about building a mental health crisis intervention unit when she met a deputy sheriff during her volunteer work in Santa Maria. In her mind, such a unit would have specifically designated and trained officers who would respond to calls involving people with mental health illnesses or other mental health needs.
A deputy from the Santa Barbara County Sheriff’s office approached her about establishing a unit in 2014. They began a correspondence to figure out how they would do it, what a program would look like. It was just an idea in search of a plan.
Lee’s involvement began in 2015 when she began to train law enforcement officers in an eight-hour course that helped them learn tools to deal with people suffering from mental health crises.
The county has consistently ratcheted up the kinds of services it offers. That includes the 2014 emergence of the Crisis Intervention Team over the entire county, not just in the south. Improved funding from the county and grants allowed them to expand the program as Lee joined. And there was the pilot co-response unit that Lee helped the sheriff’s department develop that began in 2018. Further funding in 2019 gave the unit the ability to expand its coverage to Lompoc and Santa Maria.
Her training program came to be seen as an essential tool for the Sheriff’s Office because, Lee said, Santa Barbara County has the only sheriff’s department in the state that isn’t allowed to issue a 5150—a mandatory, temporary mental health hold for people in crisis and in need of treatment.
The Crisis Intervention Team uses co-response units that pair a patrol officer with a civilian, sometimes a clinician, who can write a 5150 or otherwise spot things the officer may not be able to.
Seeing how the CIT units could free up other officers for patrol, Lee and the Sheriff’s Office wanted to expand her role to full time.
“We went to the Board of Supervisors in 2018, and the board allocated funding for a year,” Lee said.
She and Sheriff Bill Brown returned to the Board of Supervisors again in 2019 to urge them to make her role permanent. The board agreed, but Lee said the program is still growing. The Sheriff’s Office has three units right now and is determining whether it needs to establish more units and where the money to fund them might come from.
The program’s goal is not just to create a better interface with people who need specific mental health treatment, but to streamline and make law enforcement more efficient. Lee said that a call regarding a mental health crisis can take two or three times longer to resolve than another call. With units specializing in resolving those types of situations, Lee said 911 emergency calls could be reduced and patrol officers would be able to return to their duties faster while the CIT personnel resolve the situation.
“I see my role as supporting them doing their job so it makes it easy to be patient about the work that I do,” she said. “I have never worked around such patient-motivated human beings.”
The department also runs a 40 hour training program or “academy,” which features intensive CIT training for taking calls that may involve people suffering from mental health problems or mental illness.
Marian hospital’s Ketelaar said he has been a guest lecturer for the program and is a big believer in what the Sheriff’s Office is doing.
“We saw that they were diverting people from the criminal justice system when it was safe and appropriate to do,” he said.
The Sheriff’s Office recently received a $6 million grant from the state from Proposition 47 funding. The entire fund contained $96 million, a pool of money created by the Department of Corrections for law enforcement departments that are downgrading certain felonies to misdemeanors. The Santa Barbara County Sheriff’s Office was one of 23 applicants for the money. Lee said a little more than $2.1 million of its grant funding would be going to the Crisis Intervention Team and co-response program.
The armed services
A September report from the Department of Defense showed an upward trend in the number of suicides among those in the armed services. According to the report, it was the highest number ever, with 24.8 suicides per 100,000 members. Those numbers, adjusted for age and gender, aren’t unlike that of the general population. But the year-to-year numbers in the armed services have gotten worse.
The same report shows that 325 active duty personnel took their own lives in 2018, up from 285 in 2017 and 280 the year before that.
The National Guard had a higher rate. Last year, it saw 135 deaths by suicide, or 30.6 per 100,000.
The trend has gotten the attention of top officials. Defense Secretary Mark Esper told military.com that the deaths are “caught up in what some call a national epidemic of suicide among our youth.”
At a recent meet-and-greet with the media, Col. Anthony Mastalir, who’s in charge of Vandenberg Air Force Base, discussed the trend in suicides within the armed services. The base commander was appointed over the summer and is in command of a sprawling base capable of supporting a population of more than 18,000.
He said his staff has been paying attention to how they can support the men and women under their command and what that support would look like. The focus on airmen’s mental health is part of a mandatory Resilience Tactical Pause, a mandatory one-day stand down or day off from normal duties, ordered by the chief master seargent of the Air Force in response to suicide deaths.
“We gave our unit commanders the opportunity to take a day, sit down with their folks, work on that connectedness, and really give them an opportunity to provide some raw feedback,” Mastalir said.
They also provided airmen with an email address that went directly to the Pentagon where they could send feedback. Mastalir said they facilitated this through small group discussions as a way to help understand what the airmen are looking for out of leadership.
“One of the things our airmen tell us is they want more interaction with their leaders. They want more communication with their leaders,” he said. “We’ve already implemented quarterly breakfasts with airmen.”
Those breakfast are scheduled every Monday at 7 a.m.
“There’s no chain of command,” he said. “We just have a conversation. We’re not writing down names. They’re giving me action items. They saying, ‘Hey boss, this is what we’d like to see. This is what would make our lives better.’”
He said sometimes saving an airmen who may be suffering is about getting them to reach out for help, and that reaching out to them and evaluating their needs will help jumpstart the dialogue required to get them help if they need it.
Another piece of feedback from the airmen was not to wait to have another day to discuss morale.
“It was this acknowledgement that we did it because we were kind of told to do it, but that we don’t have to wait to do it again, and we’re not,” he said.
He already has plans to hold another stand down on Nov. 1 to focus on resiliency. And this year, the event will be campus themed, he said, where airmen are encouraged to wear college gear of their choice and enroll in some classes for the day that include yoga or techniques to help them achieve better sleep.
“I know that there are airmen here at Vandenberg that are hurting. I know there are aimen here at Vandenberg who may not have the coping skills to handle the challenges of their lives,” he said. “The airmen, whether it’s an enlisted officer or the civilians, it’s our most cherished resource here.”
Staff Writer William D’Urso can be reached at wdurso@santamariasun.com.
This article appears in Oct 24-31, 2019.