With two of her three sons battling mental illness, Cindy Thomas visited almost every court, hospital, mental health center and police station in Baltimore.
Thomas's eldest son, Jordan McBride, developed severe depression with psychosis in his late teens and early 20s. His erratic behavior fluctuated between that of a caring, loving son and a depressed, quick-to-anger man, Thomas said. Several times, he tried to kill himself.
"Despite many hospitalizations and trials of medications, the depression was always there," Thomas said. "He felt hopeless and that he would never get any better. There were brief times of happiness, but they were fleeting and would not last."
In February 2013, at age 30, Jordan committed suicide.
"It was the thing I feared for so many years, and it finally happened," Thomas said. "It was indescribable."
Thomas did her best to get treatment for Jordan and her youngest son, Zachary McBride, 28, who has schizoaffective disorder, a condition that combines schizophrenia symptoms like hallucinations or delusions with mood-disorder symptoms like mania or depression.
But she faced a number of hurdles along the way, including cost, accessibility and the stigma of mental illness, the Fallston resident said. "My biggest one was getting my kids admitted to the hospital and keeping them there long enough until they were stable to come home."
A new national survey has found that 43 percent of Americans see cost as a barrier to mental health treatment, and one-third think mental health care is inaccessible. The survey also found that more than half of Americans think cost, lack of access, social stigma and lack of social support prevent people who are contemplating suicide from getting help.
Despite the barriers to care, the same survey showed signs that public awareness of mental health and suicide prevention is growing, said Dr. Mark Pollack, president of the Anxiety and Depression Association of America.
Sponsored by the Anxiety and Depression Association of America, the American Foundation for Suicide Prevention and the National Action Alliance for Suicide Prevention, the survey was designed to gauge public opinion on mental health and suicide awareness. More than 2,000 adults participated, with results released to coincide with National Suicide Prevention Month in September.
In the survey. 92 percent of respondents agreed that mental health services are fundamental and should be part of a basic health care plan, and 89 percent said mental and physical health are equally important. Yet 47 percent of those surveyed think they had a mental health condition at some point and 38 percent reported receiving treatment for one.
"There's a recognition that access is tough because of financial issues," Pollack said.
To try to pay her sons' medical bills, Thomas included them as disabled adults on her health insurance policy. Still, insurance companies denied her claims over the years.
Her insurance once refused to pay a bill because it listed "self-harm" as the reason for Jordan's hospitalization, Thomas said.
"I remember saying, 'So is obesity and smoking,'" she said.
At times, Thomas had to pay out of pocket for outpatient therapy.
Laura Pogliano frequently talks with parents who cannot afford their children's medications or therapy. She runs Parents for Care, an organization providing financial and social support to families caring for a loved one with mental illness. Her son, Zac, battled schizophrenia and died in January, at age 23, from heart failure possibly related to high doses of his medication.
A Towson resident, Pogliano said she was lucky because her family lived close to hospitals like Johns Hopkins. Still, with Zac admitted to hospitals 13 times in six years, she faced challenges paying for and finding care. Mental health care facilities often lacked beds or openings when she needed them.
"We were geographically close," she said. "But there were times we couldn't access health care because there were too many [people] ahead of us."
Zac's hospitalization also required cash deposits, she said. Those deposits, combined with the thousands of dollars spent each month on medications, added up.
"The paperwork and bills are overwhelming, and to stay employed myself, I had to hire a paperwork and billing person and also a driver to get him to daily therapy," she said.
But local experts said the biggest barrier to mental health care is stigma, which can lead to prejudice, fear, mistrust and inadequate insurance coverage for mental health services.
"Stigma can delay someone from getting treatment in the first place," said Dr. Jason Addison, service chief of Sheppard Pratt Health System's unit for young adults.
That stigma, however, may shrink as perceptions of mental illness change among younger people. The survey found adults ages 18 to 34 are more likely to consider mental health treatment a sign of strength than are those who are older. A majority of those who received mental health treatments found them helpful — 82 percent for psychotherapy and 75 percent for medication. Sixty-seven percent also said they would tell someone if they were having thoughts of suicide.
"In general, we're glad to see that Americans are now starting to recognize the importance of mental health as part of their overall wellness and that they value mental health care," Pollack said. "But with over 40,000 Americans every year killing themselves … it remains of significant concern that many Americans don't seek help or treatment, even if they think they have a mental health condition."
To keep numbers moving in the right direction, leaders need to continue educating the public about mental health, said John Snook, executive director of the Treatment Advocacy Center.
"This isn't a problem we can't solve," Snook said. "Not everything works for everyone, but there are a lot of things that are working. You want to have as many tools in the toolbox as possible."
For Thomas, the toolbox is deep one.
Before Jordan died, he created a mural in his home with hundreds of broken mirror pieces. In the center, it read, "Always have a determination of a mirror, which never loses its ability to reflect, even if it's broken into pieces. Keep shining."
Thomas keeps this quote in a frame as a daily reminder of Jordan's battle and as inspiration for the future.
"You've got to stay determined," she said.