For as long as he can remember, Joachim Mattox's mood has fluxuated between manic and depressed, a mental roller coaster made more difficult because of addiction issues and a lack of family support.
"They've made it very hard for me to open up, to trust," said Mattox, 34, of the swings brought on by his bipolar disorder, his attention deficit hyperactivity disorder, and the variety of other conditions he's been diagnosed with over the years.
"I sometimes put myself in positions where I don't make the best decisions," he said.
For more than two decades Mattox, who is from Eldersburg, has bounced in and out of hospital psychiatric units, treatment centers and other institutions, he said. Along the way, he's lost and regained family ties multiple times.
Since December 2008, however, his life has turned with the help of Prologue Inc., an organization that serves people with mental illnesses in Carroll and Baltimore counties, he said.
After leaving Springfield Hospital Center in Sykesville, Mattox entered one of Prologue's residential rehabilitation programs (RRP), which provides him with an apartment in Reisterstown and daytime activity and treatment options in Prologue's Pikesville facility.
The independence that the program has given him has taken some getting used to, but living in the community has been a blessing, he said.
"I've been in and out of institutions ever since I was 8 years old," he said. "This is, amazingly, the longest I've stayed out of the hospital."
According to mental health advocates, independent-living options for people with conditions like Mattox's provide the right mix of treatment and independence, bringing dignity, purpose and community connections.
Unfortunately, they said, there are far too few of these options available.
Advocates and officials say that across the county, and throughout the region, there is a severe shortage of affordable housing for those with psychiatric conditions, especially those with medical and psychosocial needs that can't be met in traditional living situations.
According to one 2010 national study, the Baltimore region, including Carroll County, is among the 30 least affordable rental markets in the country for those receiving disability support, and Maryland is one of the least affordable states.
Alternative housing options — whether through government subsidies and vouchers or through nonprofit support — are too few and far between, advocates said.
The shortage has contributed to crammed psychiatric units at hospitals throughout the state, years-long waiting lists for local RRP spots and homelessness within the community, they said.
"It's bleak," said Sendy Rommel, president and CEO of Prologue. "Everyone's backs are against the wall."
Housing is "absolutely" the largest problem facing local residents with mental illnesses, said Sarah Hawkins, head of the county's Core Service Agency, which is the local authority responsible for mental health services.
"It's the first question everyone asked when I came on," Hawkins said. " 'What are you going to do about housing?' "
Backlogs and homelessness
In Carroll County, there are more than 50 people waiting for one of the county's 66 RRP spots, some of whom are likely to wait for years before a placement, Hawkins said.
A key factor in the housing shortage is the half-century evolution of thinking on treatment and housing that has led to a shift away from state psychiatric institutions.
State institutions used to serve as the de facto destination for thousands of patients. Today, there's broad consensus that state institutions are not the best option for most patients.
Rehabilitation and reintroduction of patients to the community has contributed to a drastic decrease in the number of patients at state psychiatric hospitals and a proliferation of community-based treatment and housing alternatives.
Thirty years ago, about 70 percent of state mental health funding went to state institutions and 30 percent went to community programs, said Brian Hepburn, executive director of the Maryland Hygiene Administration, which oversees the state's public mental health system.
Today, those numbers are reversed — but there still aren't nearly enough housing options available for the mentally ill, who, advocates say, shouldn't be institutionalized, but can't pay rent on their own.
Once patients get into an RRP — a full-time, intensive treatment option — they are likely to stay longer than their condition requires because other housing options are so scant, and because some forms of disability support are cut off with departure.
That can lead to a bottleneck coming out of the programs, said Hawkins, whose office facilitates RRP placements.
"If you are housed in the community and you are waiting for a general level bed, you will be waiting for a very long time," she said. "It's always difficult to tell people who need housing that there's not much we can do, other than ... put your name on this list."
Hawkins' counterparts in Howard County, Baltimore County and Baltimore City reported similar backlogs of people waiting for placements, and said it's a statewide and nationwide issue.
Many programs offer treatment and therapy services without housing, but patients in those programs often start to regress because of housing instability, advocates said.
Advocates say that for those with mental illness, a lack of stable housing can undercut hard-won progress with their conditions, and creates obstacles to taking medicine on time and avoiding situations that trigger intense episodes of illness.
Corina Canon, associate director of housing services for Human Services Programs of Carroll County Inc., said about 30 percent of those served by her organization in its shelters in the county have some sort of mental illness.
"Struggling with a mental illness is a barrier to housing stability," Canon said.
"I think it's tough for a lot of folks to maintain their housing stability," she said. "And then to add a mental illness on top can make it hard."
Budget flat as population climbs
State funding for mental health services has been on the chopping block in recent years as legislators fight to control Maryland's deficit, prompting advocates to wage yearly lobbying efforts inAnnapolis.
They've had some successes.
In April, Gov. Martin O'Malley provided a supplemental appropriation to offset cuts to community mental health reimbursement rates for fiscal year 2012.
But Herbert Cromwell, executive director of the Community Behavioral Health Association of Maryland — a Catonsville-based group that represents community-based treatment and housing providers — said flat or even slightly higher levels of funding can't meet the needs of a mentally ill population that's growing at a much faster rate.
According to statistics provided by Cromwell, the state's public mental health system 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 reduced its number of state psychiatric beds since 2003, and the Department of Health and Mental Hygiene is in the process of procuring a study of short- and long-term patient capacity needs at its five remaining psychiatric hospitals, including Springfield in Sykesville.
The study 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. They agree the role of state institutions should decline, but said the state has a record of downsizing 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.
Hepburn did not respond to requests for comment on that unofficial moratorium, but said cuts to state psychiatric beds since 2003 have resulted in more community-based housing options, including 12 new RRP positions opened with the closure of the Upper Shore Community Health Center in Chestertown last year. A total of 4,000 people received RRP services in Maryland in 2010, compared to 2,600 in 2003, he said.
Still, it's true that funding cuts at state institutions don't necessarily amount to dollar-for-dollar increases for community programs, he said.
Mixed grades for housing, care
In 2009, the National Alliance on Mental Illness, which has a Carroll County chapter in Westminster, compiled a report called "Grading the States," in which it evaluated mental health services across the country and gave each state a letter grade between "A" and "F."
No state received an "A," and the nation as a whole received a "D."
But Maryland was one of only six states to receive a "B," making the state one of the country's best in dealing with mental illness, according to the evaluation.
But when the affordability of housing for people with disabilities is considered alone, Maryland drops from the top of the class to the bottom, according to the national Priced Out in 2010 study conducted by the Technical Assistance Collaborative and the Consortium for Citizens with Disabilities Housing Task Force.
The study compares federal Supplemental Security Income payments — which are received by people with severe mental and physical disabilities and used for housing — to "fair market rents" for one-bedroom apartments in markets around the country, as calculated by the U.S. Department of Housing and Urban Development (HUD).
Only Hawaii and Washington, D.C., were less affordable than Maryland, where a one-bedroom apartment costs 164 percent of a person's $674 monthly SSI payment in 2010, the study found.
Among all HUD-defined rental markets in the country, only 30 had average rents for one-bedroom apartments that cost more than 150 percent of a person's monthly SSI payment.
In the market that includes Carroll County, the average rent was 156 percent of SSI.
Stability begins at home?
Advocates and mentally ill residents say that, overall, Maryland has a long way to go to shape a housing plan that meets the needs of the mentally ill population.
Namely, they say there's a need for independent living units that are subsidized in some way and which provide treatment and therapy services while allowing tenants to retain independence and privacy.
Mattox said his living situation with Prologue, in which he pays a $192 monthly rent out of his SSI, has been highly beneficial, helping him to control the mood swings that made him angry, and suicidal, in the past.
He recently got a job after a year-and-a-half search at the Walmart in Eldersburg, where Prologue plans to move him once it has completed renovations of a nine-unit apartment building that it recently purchased there with the help of federal funding.
"He had to overcome a lot of obstacles in his childhood, and he's really prevailed and done an excellent job," said Debbi Sauers, an Eldersburg resident who is one of Prologue's program directors who is close with Mattox.
With the help of Prologue's anger management classes and courses dealing with stress and other factors that trigger mood swings, Mattox is less explosive and quicker to apologize and to admit when he is wrong.
That was a struggle for him in the past, he said, but Prologue's support structure has helped.
"I know the staff's phone numbers, I know Ms. Debbi's number," Mattox said. "It's not like, 'You're in supportive housing, see ya, sayonara!' "