Karl, 51, faces a choice between his income and his health.
He can keep the federally provided medications that sometimes quiet the voices he hears and keep him from wanting to commit suicide.
Or he could try for a full-time job with benefits that would generate more than the $609 per month he lives on now.
But as a Social Security recipient diagnosed with a serious mental illness similar to schizophrenia and serious depression, he cannot have both.
Taking a job and then automatically losing federal disability health care as a result would seem a risk with the emotional roller-coaster Karl lives on, he said.
"I do real good on a job for three months, and then I mess it up and lose it," said Karl, who spoke on condition that his full name not be used.
Karl feels trapped in his situation.
Sadly, his dilemma is not the worst of what a lot of mental health agencies in Flagstaff are seeing a year after a series of state budget cuts occurred in the field.
-- Patients more depressed or mentally ill after losing jobs, homes and sometimes work-related insurance
-- Patients willing to hurt themselves to get care if previously refused
-- A nearly 69 percent increase in the number of psychological evaluations of patients this summer at Flagstaff Medical Center, compared with last summer.
-- Patients switched to cheaper medications that don't work as well, or losing counseling services and landing in the acute-care mental health unit at the hospital
-- More suicidal patients at FMC
-- Substantial new demand for help at some mental health facilities
SEVERITY GOING UP
"I think the severity of what we're seeing has gone up," said Todd Parker, a licensed professional counselor and the clinical manager of behavioral health at FMC.
He reports more use of assistants trained to ensure patients don't harm themselves, more patients saying they can't afford their medications, and more patients repeatedly landing in the hospital for treatable problems that had been under control previously.
Each agency contacted in more than a dozen interviews pointed to two main reasons for this trend:
-- People here have fewer options and more stress due to unemployment, loss of a house or job, and loss of insurance that the job may have offered.
-- Counseling or medical services that some had relied on are ending or being reduced, in some cases, due to state budget cuts (see related story).
THOUSANDS NEEDING HELP
Mental illness spans a spectrum of severity and description, and this region has no predominant population in age or economic class.
There are about 2,832 individuals receiving some sort of state-provided mental health help in Coconino County, and 894 of them are seriously mentally ill (such as schizophrenia, bi-polar disorder, mood disorders), according to the Northern Arizona Regional Behavioral Health Authority.
The true numbers are larger, because they don't count those individuals who receive mental health treatment outside of any state programs.
Flagstaff's most seriously mentally ill typically end up in one of three places during crises: the jail, the streets, or an acute-care psychiatric unit.
A seriously mentally ill individual lands in the Coconino County jail every other day, on average.
This year has seen more local mentally ill individuals in jail, and fewer traveling from afar.
You have free articles remaining.
Some are homeless, found in shelters or in the forests nearby.
Others land in one of the city's two bustling acute-care psychiatric units.
Sometimes those headed for a psychiatric unit spend one or three days waiting for a bed first, staying in the hospital's emergency room.
Sometimes people admit themselves for a psychological evaluation; other times, they're coaxed by paramedics or required by the courts.
FMC was doing an average of 30 mental health evaluations per month from April to July last year; this summer, it's 51 per month.
INVOLUNTARY EVALUATIONS ON RISE
Police can seek a psychological evaluation against a person's will if they suspect the person could harm him or herself, harm others or is gravely unable to take care of themself (example: running down the freeway with no clothing in the dead of winter).
Flagstaff police sought involuntary psychological evaluations about three times per week, on average, in 2008, their data showed.
So far in 2012, they have been averaging almost five per week.
Threats or contemplation of suicide are far and away the leading reason for police involvement.
LOST JOBS CAUSING DEPRESSION
People declining treatment have found other ways to get it or have begun "self-medicating" with substances they can find without a prescription, said Roberta Howard, head of NAZCARE, a nonprofit organization providing peer support and services for people with mental illness.
"We've actually had people go out and hurt themselves so that they can get admitted in emergency rooms," she said.
Or, they turn to old addictions with other substances.
"We're seeing self-medication, where people we've had clean and sober for three to five years, they can't find a job. They can't get services. They're going to start self-medicating and that leads to a plethora of other problems," she said.
The Guidance Center reports a stable number of patients coming for mental health services, but Chief Executive Officer Michael Puthoff says there's an increasing amount of depression among adults mid-career who have recently lost their jobs, their homes and sometimes their sense of purpose.
"If you have a lot of support, friends, that makes a heck of a difference," Puthoff said.
GETTING JOB TOO RISKY
Karl's been in state hospitals in Nebraska, Georgia, Illinois and Ohio for psychiatric treatment and he hears voices a few times a week even with the medication.
"It cuts the symptoms down, but it doesn't take them away," he said.
He lives in a house behind his sister's home in Prescott, where he says he has isolated himself much of the time for eight years.
He has few friends in his neighborhood, little energy and not a lot of hope sometimes.
"I mull suicide and hurting myself, but then I tell myself not to do it, and that it's stupid," he said.
The support groups he attends are sometimes helpful and sometimes not, he said.
Karl was in a program to get a job, until he realized he could lose his federal medical benefits as a disabled person if he takes one.
Rather than risk it, he has decided he will remain unemployed.
Cyndy Cole can be reached at 913-8607 or at firstname.lastname@example.org.