This is reprinted with permission from The News & Observer of Raleigh.

The number of people with mental illness in North Carolina rest homes has grown by 15 percent -- to more than 6,200 -- since 2002. Family members, doctors, lawmakers and residents themselves call the mix troublesome and, at worst, deadly.

Adult-care homes are designed and staffed to meet the needs of frail elderly people. Advocates for the mentally ill say it is challenging enough to serve this core population without adding adults who have schizophrenia, bipolar disorder and other kinds of mental illness.

But for lack of other options, some adult-care homes have become dumping grounds for mentally ill adults.

"That [dumping ground] characterization is a crude way of saying that we don't have that range of alternatives," said Carmen Hooker Odom, secretary of the state Department of Health and Human Services. "We haven't seen the necessary commitment of resources, locally or nationally."

Almost everyone with a stake in North Carolina's elder care and mental health systems -- including parents with mentally ill adult children, industry leaders, regulators and academics -- agrees that blending the two groups can be dangerous.

Rest home files, criminal records and state agency reports reveal problems when younger adults with mental illness are mixed in homes with older people.

-- Between August and November 2006, three female residents of a Louisburg rest home reported they were raped -- two of them, ages 63 and 80, by the same 20-year-old male resident with mental illness. In another case, a staff member is suspected of raping a 33-year-old woman with mental illness. The incidents remain under investigation.

-- In December 2005, a 71-year-old former cocaine user died a few weeks after setting fire to a living room at a Robeson County rest home. Employees had left him alone in a chair, his feet and chest bound in response to his agitated behavior. He suffered from smoke inhalation before rescuers could cut him free from the restraints.

-- In 2003 and 2004, adult-care residents younger than 60 who had mental health problems generated more than 380 instances of criminal activities and violent, threatening or inappropriate sexual acts, a statewide ombudsman reported in 2005.

"To place somebody who is 32, with bipolar disorder, in a room with someone who's 86, who's just had a hip replacement, that's not the best setting for either of those folks," said John Tote, executive director of the state Mental Health Association.

Needs Neglected

Such incidents focus attention on older people living side-by-side with those discharged from mental hospitals. But those with mental illness can also suffer when they do not get the kind of treatment their conditions require.

Jimmy Meadows, 60, has lived at an Angier rest home for 21 years. Diagnosed with bipolar disorder, the poetry-writing college graduate shares a room with a 23-year-old man recently discharged from a state mental hospital.

Meadows worries that when he feels "hairy," or at the manic end of his disorder, he could become aggressive toward other residents.

"I worry that I will," he said. "I can't fight good."

Advocates say people such as Meadows need an environment specifically tailored to people with mental illness. That means more privacy, structured daily activities and better monitoring of his illness.

At rest homes, state guidelines require a staffing ratio of one caregiver for every 20 patients during day shifts, and one caregiver per 30 residents at night. At Dorothea Dix Hospital, a state-run institution in Raleigh, the most recent records show a staff-to-patient ratio of about 1-to-4.

The mix of population often leaves mentally ill people with unmet needs, leading to problems. According to state records:

n A resident of a Cabarrus County rest home died in 2005 after the home failed to supply multiple psychiatric medications as ordered. The resident, not named in the records, hit his head and needed physical and chemical restraints on the way to the hospital.

n Over the past four years, the state Division of Facility Services has fined individual adult-care homes in Durham, Caswell, Forsyth, Buncombe and Pender counties for leaving residents with severe mental illness without any supervision. The problem is of long standing.

The state fined a Cumberland County rest home $10,000 in 2001, then shut it down, after a resident with a serious mental disorder overdosed on the pain reliever Darvon. The resident had no prescription for the drug.

n A 2003 inspection by state and county investigators found that eight mental health patients at a Four Oaks rest home weren't getting proper treatment, resulting in "confrontation, threatening outbursts, hallucinations, substance abuse, drug overdose, or suicide attempts."

Community Options Lag

In North Carolina, the umbrella term "adult-care home" covers state-licensed rest homes, assisted-living facilities and smaller family-care homes.

Faced with a 20 percent vacancy rate statewide, the industry needed to fill beds at the same time another kind of institutional care was losing beds: As part of North Carolina's 2001 mental health reform program, big, centralized hospitals have been closing, meeting constitutional requirements that patients with mental illness live in community settings whenever possible.

But the big central hospitals are closing more quickly than community-level services -- the treatment, jobs and housing that reform was supposed to provide -- are being developed.

In 1972, North Carolina's state mental hospitals had room for nearly 7,000 patients. By 2005, that capacity had declined to about 1,200. Two mental hospitals -- Dorothea Dix in Raleigh and John Umstead in Butner -- will close by 2008, and a hospital being built in Butner in Granville County will replace them. Mental health services once provided by county workers are now being outsourced.

Social workers and patients' advocates say patients once routinely sent to state hospitals and mental health centers must now be treated elsewhere, straining the limited supply of services.

Hooker Odom says the state has few choices for the relatively small percentage of mental health patients who are violent or behave aggressively.

"Every state is facing this explosion and lack of incentive for good providers," she said.

Given the increasing scarcity of government subsidies for affordable housing and community treatment for people with mental illness, rest homes often become the only choice for discharged or newly diagnosed mental patients.

State figures show that 20 percent to 50 percent of residents in adult-care homes have a mental illness.

"There's nothing to prevent those facilities from filling those beds with people that they are not necessarily qualified to care for," said state Rep. Alice Bordsen, a member of the legislative subcommittee on serving mentally ill residents in adult-care homes. "We are taking on the responsibility, but we are not demanding that these facilities demonstrate that they can provide the level of care that should be given."

Ample, Costly Needs

The issue of mixing diverse populations in adult-care homes has the attention of state legislators and policymakers, but the list of needs is daunting -- as is the cost.

"We went through mental health reform with a lot of bumps and not a parallel movement of change and money," said Bordsen, the state representative and a Mebane lawyer.

A recently released consultant's report said North Carolina should be spending in excess of $500 million more annually for people with mental-health or substance-abuse problems or developmental disabilities. During last year's legislative session, legislators allocated about $100 million to expand mental health services.

"That was a huge struggle," Hooker Odom said. "If $100 million is a huge struggle, $500 million would be that much more difficult. ..."

Recently, state Reps. Verla Insko and Beverly Earle, co-chairwomen of the state legislative subcommittee that serves mentally ill patients, began wrapping up recommendations they will make to fellow lawmakers when the legislative session begins later this month.

Without giving funding estimates, they said the state should provide more housing choices for people with mental illness, including transitional housing, 12- to 16-bed centers and special residential treatment programs for people with behavioral problems.

But mixing older people and younger people with mental illness is likely to continue. The legislative committee, aware of problems with often incompatible populations, suggested that new regulations should be written for such situations. They recommended that the state create a system for screening residents before admitting them to rest homes and that the state pay for 2,000 slots in assisted-living homes.

Picking Up the Tab

Such recommendations do not sit well with adult-care home industry leaders. Lou Wilson, a longtime industry advocate, said after a fall legislative hearing that she is "mad as hell" about the way the state is addressing the issue, after what she said was decades of not offering money or guidance.

Roger Bone, an adult-care industry lobbyist, said there is no way that homes can provide specialized care without more money.

Whatever the legislature does this year, taxpayers will continue picking up the tab for people with mental illness who need housing and treatment.

As Tote, the Mental Health Association director, said, "North Carolina's going to pay the cost whether they show up in one of our places, long-term care, in a jail or in an emergency room."