That's especially true for those currently living in the community but seeking an elevated level of care, as they are last in a priority system that places patients from state institutions, general hospital units and hospital shelters before them, regardless of time spent on the waiting list.

Once patients get into an RRP — which is a full-time, intensive treatment option — they are likely to stay longer than their condition may require because other housing options are so scant and because some forms of disability support are cut off with departure, leading to a bottleneck coming out of the programs, Blankfeld and others said.

"We're looking at a system where you've got limited resources and where you've got a demand that exceeds the resources," said Blankfeld, whose office facilitates RRP placements.

"We frequently get the call or run into the situation where you have an aging adult parent who's been taking care of an aging adult child in the home setting, and that situation has gone along for various numbers of years, at various levels of stability. And it's been working out, but now with the parent aging, they aren't able to care for their adult child," Blankfeld said.


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In those situations, there is often a "recognition that the status quo arrangement may not endure" among service providers, but no RRP spot to offer, he said.

While many programs offer treatment and therapy services without housing, patients in those programs often start to regress because of housing instability, advocates said.

For those with mental illnesses, that instability often undercuts hard-won progress with their conditions, and creates obstacles to taking medicine on time and avoiding situations that trigger particularly intense episodes of illness, advocates said.

According to Sue Bull, Baltimore County's homeless services coordinator, a January survey of 881 homeless adults in the county's shelters and on the streets found that 20 percent had a mental illness, and 38 percent had a "disabling condition."

Budget flat as population climbs

State funding for mental health services has routinely been put on the chopping block in recent years as legislators fight to control Maryland's deficit, forcing advocates to wage yearly lobbying efforts inAnnapolis.

They have had some successes, most recently when Gov. Martin O'Malleyprovided a supplemental appropriation of funding in April to offset previous cuts to community mental health reimbursement rates for fiscal year 2012, said Herbert Cromwell, executive director of the Community Behavioral Health Association of Maryland, which is based in Catonsville and represents community-based treatment and housing providers.

The problem is that flat or even slightly higher levels of funding can't possibly meet the needs of a mentally ill population growing at a much faster rate, Cromwell said.

According to statistics provided by Cromwell, the PMHS is projected to serve 139,000 people in fiscal year 2012, up from 99,000 people served in fiscal year 2008.

"The problem is that the demand for services, particularly community services, far exceeds budget capacity year after year," Cromwell said.

Meanwhile, the state has substantially reduced its number of state psychiatric beds since 2003, and the Department of Health and Mental Hygiene is also currently in the process of procuring a new study of the short- and long-term patient capacity needs at its five remaining psychiatric hospitals, including Spring Grove Hospital Center in Catonsville.

The study, required by the legislature, likely won't result in additional capacity changes for years to come, said Betsy Barnard, director of the health department's office of capital planning, budgeting and engineering services.

But mental health advocates are worried regardless.

They agree the role of state institutions should decline, but said the state has a record of downsizing state psychiatric capacity while keeping funding for community-based alternatives flat.

"The reason that the state wants to close the beds is to save money, and in a bad economic situation, there's always the risk and the reality that the state will have that money revert to the general fund," said Laura Cain, an attorney with the Maryland Disability Law Center.

The state also issued in 2000 what amounted to a moratorium on new RRP beds in the state, despite the fact that providers would be eager to create more beds if allowed, Cromwell said.