Suicide prevention: Idaho’s overburdened health care system | Idaho Statesman

She’d competed on horseback and in rodeo pageants for years. She made history at one national competition — becoming at age 15 the first African-American to win.

Now, a coveted title was hers. Jessie Jo Metcalf, in a white cowboy hat and a shirt covered in rhinestones, was the 2006 queen of the Caldwell Night Rodeo.

To celebrate her win, Jessie made a video thanking everyone who believed in her when she didn’t believe in herself. She couldn’t wait to use her award money to help pay for her next semester at Boise State, where she would later graduate with a degree in psychology.

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It was a turning point for the woman who’d had suicidal thoughts since her teenage years — but not the change everyone had hoped for.

Eight years later, Jessie died by suicide. She was 31.

Jessie was one of 320 Idahoans to die by suicide in 2014. Her mother and grandfather had long feared it would happen. It wasn’t the first time she had tried. After the Caldwell win, “things started spiraling,” said her mother, Myra Metcalf.

Idaho that year had the 6th highest suicide rate in the country.

Jessie’s friends still revisit the subtle warning signs leading up to her death: she’d lost weight, reached out to make amends, gave away bags of clothing. Her suicide — and her ability to get the care she needed — was complicated by mental illness. Her grandfather now thinks about the times a doctor would send Jessie home from the emergency room, back to friends and family who didn’t know what to do.

Jessie didn’t have health insurance to pay for therapy and medication. Her family and friends think she was released from a local hospital too early, without a lifeline to ongoing treatment. They believe Jessie didn’t get the help she needed for bipolar disorder.

Jessie’s story is not typical of a person with mental illness, said Kim Kane, director of Idaho’s state suicide prevention program. But other Idahoans face her same issues — and, Kane said, she’s an example of how people can “slip through the cracks.”

Do you or someone you know feel suicidal? Just need to talk? Text or call the Idaho Suicide Prevention Hotline at (208) 398-4357.

Illness made Jessie scared for her life

This is what people say about Jessie:

The party didn’t start until she got there. She loved dancing, Doritos and leftovers. She seemed to always be studying or in school, and sometimes she would drink wine coolers before tests to calm her nerves. She was, as far as anyone knows, the first black rodeo queen in Idaho. She wanted to become a professional barrel racer. She also wanted to become a nurse and took courses at the College of Southern Idaho in hopes of moving on to a four-year nursing school.

Her friends, rodeo pals and family say Jessie wasn’t afraid of anything.

That changed when she got sick.

At the peak of her bipolar disorder, she was so scared to be alone that she would sleep on the floor of her grandfather’s bedroom. Once, like a child after a nightmare, she spent the night in bed with one of her best friends, Jennifer Larson, and Larson’s husband.

Jessie believed people were spying on her through heater vents, her computer, her phone. She tore apart her car’s upholstery and floorboards in search of someone she believed was hiding in the vehicle.

“I didn’t realize the severity of it until she had shown up at my house at random and said she was hearing voices,” another friend, Hailey Ernest, told the Statesman in August. (Ernest was killed in a motorcycle crash in early October.) “She showed up at 1 a.m. ... She comes in kind of frantic and says, ‘I need you to close the door and shut the blinds.’ ... After we had locked all the windows, and the blinds were down, she sat down on the couch.”

Jessie started talking to someone who wasn’t there. According to Ernest, she said, “I know you want me to kill myself, but I’m not going to.”

Ernest later learned that her friend, someone she’d known since fourth grade, had been hearing voices during manic episodes for a while.

Jessie did at points have health insurance. But she was unemployed and had no insurance when she died, Myra Metcalf said.

Jessie was taken to the ER three or four times in the months before her death, her mother said. Once, after Myra called 911, Jessie was admitted to the hospital. Her mother and friends say she was discharged within days.

Jessie was furious at her mother, and at the friends who encouraged her mother to make the phone call. Larson said Jessie would not talk to her, except to text her a picture of the enormous hospital bill.

‘Helpless to do anything about it’

Tens of thousands of Idahoans have severe mental illnesses like Jessie’s bipolar disorder, according to the Treatment Advocacy Center.

“Suicide is not a natural outgrowth of any disorder,” Kane said. “The vast majority of people with mental health disorders don’t die by suicide.”

But they do need access to help.

For those in rural Idaho without health insurance, the best options are to drive hours to a community clinic, pay cash for medication or therapy, or wait and hope their disease doesn’t progress into something catastrophic, sending them to a hospital or jail.

While the state Legislature has appropriated funds for behavioral health crisis centers — seen as a panacea for overburdened jails and hospital ERs — almost all of the centers are or will be in Idaho’s larger cities. The state has approved one rural alternative: a series of satellite crisis centers in North Idaho, with a total of 10 rooms set aside in hospitals in Moscow, Lewiston, Orofino, Cottonwood and Grangeville.

The single best way to get treatment for people with severe, persistent mental illness is to give them health care benefits of some kind, said Ross Edmunds, who runs the state’s behavioral health division.

Kane agreed. “Not having health insurance is clearly part of the problem, and maybe people around [Jessie] didn’t feel like they could get her the degree of help she needed because of lack of insurance,” she said.

Even one of Jessie’s CSI teachers saw “the problems that were eventually going to lead to [Jessie] not making it in this world,” said her grandfather, Richard Meiers.

“Her teacher just recognized it — that the problem was there and, in a sense, in her hands also, she was helpless to do anything about it,” Meiers said. “I think that’s the thing we take from this, is that we can see there’s a problem ... but nobody seems to be able to grasp, OK, how do we get past this point to where they can move on and have a good life?”

Kane said Jessie’s story is an example of when people who are suicidal don’t get appropriate treatment because of a lack of health insurance or problems navigating the system.

“Her mother knew and was worried, her teacher knew and was worried, her grandfather knew and was worried,” Kane said. “We need to do a better job to arm people with the information they need to be able to help those for whom they are concerned.”

No insurance? You likely won’t stay in the hospital as long

Families of people with severe mental health disorders have told the Statesman for years about their concerns that patients are released from the hospital too early and without enough follow-up. It’s difficult, they’ve said, to get someone involuntarily committed in Idaho even when they can no longer function.

The Statesman was not able to obtain Jessie’s medical records, discharge paperwork or bills. She cannot sign a privacy release, and her parents weren’t able to complete the process of getting her records released.

But research suggests her hospitalization likely was shorter than it would have been with insurance — especially Medicaid.

“I was really shocked at how quickly she was able to get out,” Myra Metcalf said.

Able-bodied, childless adults like Jessie currently do not qualify for Medicaid in Idaho. A ballot measure this November could expand Medicaid to those Idahoans.

One study of 262,000 U.S. psychiatric hospitalizations in 2006 found that patients without health insurance are discharged earlier than those who are insured.

Patients like Jessie who have bipolar disorder and no insurance stay in U.S. hospitals an average of five and a half days, the study found. Those with private health insurance like Blue Cross stayed six and a half days. Medicare and Medicaid patients stayed about nine days on average.

Their treatment was not cheap. The study found the average patient with bipolar disorder and no insurance got a bill for $13,000, in 2018 dollars, for a psychiatric stay at a community hospital.

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More hospital beds? Or is there a better solution?

Idaho has far too few hospital beds for people who need long-term psychiatric care. That’s true across the country — a side effect of the process that began decades ago to de-institutionalize the mentally ill. As institutions closed, access to mental health care outside the walls of a hospital didn’t keep up with the need. And the hospitals that remain are overtaxed.

It’s not uncommon now, numerous sources have told the Statesman, for a person with mental illness to sit in a local hospital emergency room for days, waiting for a bed in a psychiatric facility like Intermountain Hospital to open.

Once they’re admitted, Idaho patients spend less time hospitalized than elsewhere in the U.S., according to the federal Substance Abuse and Mental Health Services Administration. In 2016, patients spent a median of 35 days in Idaho’s state-run hospitals before they were discharged. The national median was 60 days. In other non-residential inpatient facilities, Idahoans spent a median of 11 days compared with the national median of 13 days.

Idaho is working to ease the shortage of psych beds. Edmunds said 20 more beds will open soon to adults at the state hospital in Blackfoot. A new, private psychiatric hospital is slated to open in Meridian next year, with capacity to treat 72 adults at a time.

But Idaho must also be smarter about whether to hospitalize most patients, one health care administrator said.

“If we’re challenging ourselves to provide them the best level of care, what they need isn’t to be admitted. It’s a team that can provide ... the right care in that moment, and then connect them back to get them set up with care [that is] ongoing and in the community,” said Megan Stright, who oversees behavioral health for St. Luke’s Health System. (St. Luke’s did not treat Jessie for her psychiatric care.) “... We resort to inpatient psych too much, and then what that means is we don’t have the beds that we need for the probably 10 percent of the population that actually needs that care.”

Kane, the suicide prevention director, agreed.

She said that when it comes to suicide, getting someone help after they leave the hospital is key. That’s because after a first suicide attempt, the person continues to be in crisis for 30 days; after multiple attempts, for six months, she said.

“We do need access to beds for people just in [Jessie’s] situation, but hospital beds do not solve suicide. [They just] keep people safe for a short time,” Kane said. “They just need the right type of mental health care. Even highly suicidal people, with the right mental health clinician, their suicidality can be arrested in a number of sessions.”

She said even something as simple as a card in the mail or a phone call after being released from the hospital can reduce the likelihood of a patient completing suicide. Myra Metcalf said there was no follow-up after Jessie was released the last time.

Left with questions

Jessie’s friends and family wonder, if she’d been hospitalized longer or gotten the right ongoing treatment, would she have gotten better?

“There is hope, there is help,” Kane said. “Most people recover. Most people don’t kill themselves.”

Jessie’s first suicide attempt was in her teens. Her parents had her hospitalized then, set her up with a psychiatrist, and she started taking medication. But as an adult, Jessie was uninsured and in charge of her own decisions. Her mother suspects Jessie may have “been able to smooth-talk” her way out of the hospital before she was truly stable.

Jessie spiraled into depression, mania and paranoia.

She had recently gone through a breakup. Her illness had sabotaged her studies, and she was facing the fact that she might never become a nurse.

The day before Jessie died, she called Larson — one of the people she’d pushed away after the hospitalization. She invited her friend out to a horse-riding event called a “play day.” Jessie was unusually nice, after being angry for so long.

That night, Larson dropped off Jessie at her house in Eagle. It was quiet in the Metcalfs’ neighborhood, where each house has acres of pasture. That’s where Jessie loved to go, to spend time with her horses.

“She was still just as sick as when she went in [to the hospital] a month before,” Larson said.

Jessie’s loved ones started a scholarship in her name not long after she died. Every year, they host an “O-Mok-See” event, where children and adults compete on horseback in games Jessie loved, like barrel racing. It has given out thousands of dollars to students in the past three years.

At this year’s event, the crowd was full of people with their own stories: A man whose son died by suicide. A childhood friend of Jessie’s, whose sister has schizophrenia and has been shuttled all the way to Idaho Falls for the nearest available hospital bed.

They spoke of giving hope to others and of helping other families avoid the same heartbreak.

In the middle of everything was a table full of Jessie’s awards, photos and mementos — and the Caldwell Night Rodeo saddle that once had made her so proud.

If someone you know is in emotional crisis

Call the Idaho Suicide Prevention Hotline at 1-800-273-8255.

WARNING SIGNS TO WATCH OUT FOR:

▪ Talking about wanting to die.

▪ Talking about feeling hopeless or having no reason to live.

▪ Talking about feeling trapped or in unbearable pain.

▪ Talking about being a burden to others.

▪ Increasing use of alcohol or drugs.

▪ Acting anxious, agitated or recklessly.

▪ Sleeping too little or too much.

▪ Withdrawing or isolating themselves.

▪ Showing rage or talking about seeking revenge.

▪ Extreme mood swings.

OTHER THINGS YOU CAN DO TO HELP:

▪ Do not leave the person alone.

▪ Be direct. Talk openly and matter-of-factly about suicide.

▪ Listen. Allow expressions of feelings. Accept the feelings.

▪ Be nonjudgmental. Don’t debate. Don’t lecture on the value of life.

▪ Don’t act shocked. This will put distance between you.

▪ Don’t be sworn to secrecy. Seek support.

▪ Offer hope that alternatives are available but do not offer glib reassurance.

▪ Take action. Remove means, such as guns or stockpiled pills.

▪ Get help by calling the hotline or visiting idahosuicideprevention.org.

Source: Suicide Prevention Lifeline

This story was originally published October 27, 2018 9:00 PM.