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To connect with others dealing with mental illness, join the Lowcountry Mental Health Group on Facebook at www.facebook.com/groups/LowcountryMentalHealth

An RV rumbles into a crumbling vacant lot on upper Meeting Street one recent morning to deliver much-needed hope to the mentally ill who have become mired in homelessness.

Lost Among Us

The mentally ill are under scrutiny and pressure like never before. Mental health budgets have been slashed. State inpatient beds are at historic lows. Emergency rooms, jails and prisons are the new front lines of care.

But there is promise for change. State funding increased this year. Research shows these illnesses are based in flawed physiology, not character flaws. And many who suffer are openly challenging stigmas. The Post and Courier has examined these issues all year. In this installment, we look at homelessness and the struggle to find a stable place to live while grappling with mental illness. Go to postandcourier.com/lost to read previous stories in the series.

With a bright Highway to Hope logo splayed across its side, the RV carries two Charleston Dorchester Mental Health Center staffers who open its doors to those in need.

Need help with housing?

Here are places that offer emergency, transitional and low-income housing assistance:

Charleston Housing Authority

Provides permanent affordable housing, has waiting list

550 Meeting St., Charleston

720-3684 or www.chacity.org

Crisis Ministries

Provides free meals, shelter and other help

573 Meeting St., Charleston

723-9447, email help@charlestonhomeless.org or www.crisisministries.org

Family Services Inc.

Offers homeless prevention and housing resources

4925 Lacross Road, Suite 205, N. Charleston

735-7802, email info@fsisc.org or go to www.fsisc.org

North Charleston Housing Authority

Provides affordable, permanent housing

2170 Ashley Phosphate Road, Suite 700, North Charleston

747-1793 or www.nchashousingauthority.com

Office of Special Housing Needs

Charleston Housing Authority program to provide private, low-income housing

900 King St., Charleston

723-5510, email acp@chacity.org or go to www.chacity.org/housing-assistance-public-housing-oshn.cfm

Palmetto House

Crisis Ministries program for homeless women and children

107 Elks Lodge Lane, Summerville

486-0861 or www.crisisministries.org

Ralph H. Johnson VA Medical

Provides housing and medical assistance for veterans

Walk-in clinic Monday-Friday, 9 a.m. to 11 a.m.

109 Bee St., Charleston

577-5011 ext. 15880# or charleston.va.gov

Salvation Army

Offers emergency help and transitional housing

4248 Dorchester Road, N. Charleston

747-5271 or www.salvationarmyusa.org

Socialserve.com

Online nonprofit helps connect people with affordable housing

www.socialserve.com

Star Gospel Mission

Provides residential, transitional housing

474 Meeting St., Charleston

722-2473 or www.stargospelmission.com

Trident United Way hotline

Connects people with various local resources

Call 2-1-1 or go to www.tuw.org/2-1-1-hotline

A middle-age man steps shyly aboard to share a life’s story of treating depression and anxiety with alcohol. He has five days worth of Paxil left and no job, no transportation, not even $4 to refill his medication.

If you go

WHAT: The 14th annual Stand Down Against Homelessness offers free medical and dental screenings and assistance, clothing, food, haircuts and job and legal counseling to hundreds of homeless people. Coordinated by the Ralph H. Johnson VA Medical Center and Goodwill Industries of Lower South Carolina.

WHEN: Thursday and Friday. Services offered from 8 a.m. to noon. Lunch served noon to 1 p.m.

WHERE: Armory Park, 5000 Lackawanna Blvd., North Charleston

COST: Free

MORE INFO: www.charleston.va.gov/Stand_Down_Against_Homelessness_2013.asp

“My big fear is having nowhere to go, not knowing what I’m going to do,” he says softly.

For now, he stays in an old trailer without running water or electricity.

Others like him, fresh from short-term psychiatric hospital stays or jails and prisons, lack even that.

Gone are the days when thousands of the state’s mentally ill lived in long-term hospitals. Where have they gone?

Local mental health experts say their clients increasingly live on the streets, crowd homeless shelters and wait for high-demand affordable-housing options.

“There are very limited places to go in this community if you don’t have the resources,” said Amy Zeigler, vice president for development at Crisis Ministries, the area’s largest homeless shelter. “We’re all coming from a place of frustration.”

Discharged to streets

Eileen McLaughlin is a senior social worker at MUSC’s Institute of Psychiatry, the region’s largest psychiatric hospital that treats many of its lower-income residents.

She now plans for discharges as soon as patients arrive in the throes of psychotic or suicidal breakdowns.

Why? Roughly one in five adults discharged from the Institute of Psychiatry has no place to go — no family home, no shelter bed, no residential care center.

So they are discharged without a reliable place to live.

“We really have no choice,” said Tom Robinson, development manager and a state board member of the American Foundation for Suicide Prevention.

Others in crisis, who often have been waiting for days in local emergency rooms, desperately need the hospital’s beds. And the hospital cannot sustain itself caring for patients whose insurance has stopped paying for care.

“This is a very expensive homeless shelter,” said Dr. Baron Short, psychiatrist and director of the institute’s adult general psychiatry unit. “Sometimes we look at each other and say, ‘We’re not in psychiatric care anymore. We’re in transitional housing care.’ ”

The hospital’s average adult stay has dropped to seven days or less.

“They get them patched up, put some meds in them and send them out the door,” said Joann Monnin-Debevec, past president of the National Alliance on Mental Illness, Charleston area. “You’re out, whether you are ready or not.”

When patients leave, they have a follow-up appointment with their local mental health center or a private therapist, Robinson said.

If they need medications, they either have a prescription to be filled or a supply. They receive a list of community resources and a directive to return to the ER if suicidal thoughts persist. (The hospital does not discharge children or senior citizens who lack housing.)

Short put it like this: Imagine someone took away your home, car, credit cards, savings and job — then sent you out the psychiatric hospital’s front door downtown with $20. Then add in a mental illness.

“How are you going to live like that?” he said.

Out of the hospitals

The idea was to save money and improve the lives of thousands of South Carolinians once condemned to “asylums.” Over recent decades, the state Department of Mental Health moved thousands of patients from its long-term facilities to their hometowns.

But then, several years ago, the economy tanked and lawmakers slashed the agency’s budget.

And that meant cutting local services rather than growing them to serve those released from its hospitals. At the same time, private hospitals closed many of their psychiatric beds as well.

The result: The mentally ill have wound up increasingly revolving through prisons, jails, ERs and acute-care hospitals, officials agree.

At Charleston County’s detention center, for instance, about one in four inmates is prescribed psychiatric medication, according to the Charleston Mental Health Center’s forensics team records.

Ditto at the maximum-security Lieber Correctional Institution in Ridgeville, where last month, 317 of its 1,415 inmates were classified as mentally ill. Nearly that many received psychotropic medications, according to the state Department of Corrections.

And where do those inmates — even the mentally ill ones — go after release? Often, to the hardships of homelessness.

Figuring the breadth of the problem is difficult. It is notoriously tough to count people who are homeless if they are not living in shelters.

However, in January 2013, the South Carolina Coalition for the Homeless conducted its fifth statewide “point in time” survey, in which it combs local communities to account for homeless residents.

Charleston was among counties with the largest increases in “unsheltered” homelessness, with 205 people found living in such conditions. Charleston also saw one of the state’s largest increases in first-time homelessness.

In all, survey teams found 404 total homeless residents in that snapshot, including 121 living in shelters and 77 in transitional housing. Berkeley County had 25 total homeless and Dorchester 49.

Of those people tallied, 16 percent reported mental illness, up from 13 percent two years earlier. However, experts agree that those numbers underestimate the problem, because they rely on those surveyed to self-report mental illness, something that still carries stigma and shame.

Nationally, about 26 percent of homeless people reported mental illness.

It’s a tough life. The average life expectancy for a chronically homeless person is 44 years compared to 78 years for the average American, according to a recent article in the journal Nursing.

“A sheltered environment is key, yet housing is the biggest problem people face,” said David Geer, executive director of Family Services Inc., a local nonprofit that helps people with disabilities become self-sufficient.

Frontline shelter

Crisis Ministries, the largest local homeless shelter and state’s largest homeless provider, has become the frontline for many facing mental illness.

Yet it shouldn’t be, Zeigler noted.

For one, self-sufficiency is required of the 84 homeless men who live in one highly communal area.

“This is a very stressful environment for someone who is fragile. This should be a last resort,” she said. “But we know that for some people, there is no other option.”

Last year, 31 percent of people living at the Meeting Street shelter suffered mental health problems; 14 percent suffered serious ones.

Where do they come from? About 1 in 10 of its clients came directly from a jail or prison, hospital or substance-abuse treatment facility. Of those, 63 percent reported mental problems.

Because Crisis Ministries often is full, MUSC’s McLaughlin will contact shelters in Columbia and Charlotte that occasionally have open beds. Then she must figure out how to get patients with no resources to a shelter that’s hours away.

“There is virtually no affordable housing. And the only way to get it is through the shelter,” McLaughlin said.

In Berkeley County, mental health staff do not have local emergency or transitional housing options for their clients. They, too, call places like Crisis Ministries in desperate search of beds.

“We scramble to help clients in difficult situations. Sometimes the outcome has been relocation to another part of the state,” said Debbie Calcote, executive director of the Berkeley Community Mental Health Center.

The good news? Crisis Ministries is building a new, 30,000-square-foot men’s shelter and soup kitchen to meet demand. It will add a net 26 more beds and should be completed around summer 2014.

Drop in group homes

Once upon a time, the Charleston Dorchester Mental Health Center operated three group homes, called community residential care facilities.

The CRCFs, each staffed by the center and keen to the specific needs of the mentally ill, housed folks who couldn’t live independently.

But all are closed now, casualties of state budget and Medicaid cuts, said Deborah Blalock, executive director of the mental health center, a local arm of the state Department of Mental Health.

Blalock called closing them one of the toughest decisions she has made.

“Our clients had really good care there, and they were staffed really well,” Blalock said. “But they were expensive.”

It cost $500,000 a year to serve 16 people, money that could serve more people in a time of grim budgets and growing demand.

Instead, today about 1,350 mental health clients statewide live in private CRCFs, often amid a population of frail elderly residents.

Yet even as private CRCFs face greater demand to house the mentally ill, fewer are doing so, due to increased regulations and red tape and other factors.

From 2005 to 2008, the state saw a net loss of 687 private CRCF beds available to folks who rely on government programs to pay for their housing, which many seriously mentally ill people do. From fall 2008 to fall 2009 alone, there was a net loss of 51 of these beds for mental health department clients, according to the agency’s records.

The trend has continued since, said Mark Binkley, the agency’s general counsel and deputy director.

Part of the problem is that when Medicaid was created, lawmakers exempted “institutions for mental disorders,” defined as having more than 16 beds or more than 50 percent seriously mentally ill residents. If they do, CRCFs can no longer receive Medicaid, which most seriously mentally ill people rely on.

“Each year we badger them to see the idiocy of the IMD rule,” said John H. Magill, director of the state Department of Mental Health.

So far, no luck.

Independent living

For those who can live independently, cost looms as the major barrier. Long waits for public housing is another problem. Criminal histories, bad credit and behaviors related to their mental illnesses pose other common hurdles to finding affordable places to rent.

Some people can access rent subsidies, such as those offered by the state Department of Mental Health.

And those with serious and persistent mental illnesses can apply for Social Security Disability income or Supplemental Security Income, the two main federal programs for the disabled.

However, it can take from months to years to learn if they qualify for benefits, said Jeff Yungman, an attorney at Crisis Ministries.

That is too long for a person facing imminent hospital discharge or release from jail.

Those who do qualify typically receive about $730 a month for rent, utilities, transportation and other expenses.

In lower-income areas, rent for a one-bedroom apartment runs about $500 to $600. Yet these less-expensive apartments tend to be in drug-riddled areas, a dicey issue for the majority of mentally ill people who also struggle with substance abuse.

“We have to be careful of where we’re going to place that person,” Blalock said.

Family Services offers a Representative Payee Program that handles finances for those incapable of doing so themselves. This keeps money going to pay critical bills like rent and not to drugs and alcohol — or to those who prey on the mentally ill.

“Drug dealers know when to show up,” Geer said.

Back to the streets

Another middle-aged man climbs the stairs to the Highway to Hope. He cannot read or write and has multiple DUI convictions, thanks to medicating his schizophrenia with alcohol.

“All I want is to get an apartment and enjoy my life,” he said.

Fresh from prison, he has no driver’s license, no family, no job and no money. He stays at Crisis Ministries but struggles to sleep with 83 other homeless men in one room.

Yet Blalock sees hope for clients like him in the state legislature’s back-to-back increases to mental health funding. If it continues, the local mental health centers could help more people avoid homelessness.

And a new statewide task force, comprising advocate groups and state agencies, has begun meeting to study the gaps in housing for South Carolina’s mentally ill.

“We need more of all of it,” Blalock said. “It’s not a one size fits all.”

Back at NAMI, Monnin-Debevec agreed.

“Lord knows, I ponder this all the time. There is no money for housing, no money for treatment. It is very frustrating. Where do they go?” she asked, rhetorically. Because she knew the answer.

Many go to the streets. And then to an ER, maybe jail, or back to the hospital again — only to be discharged without a place to go. Again.

Reach Jennifer Hawes at 937-5563, follow her on Twitter at @JenBerryHawes or subscribe to her at facebook.com/jennifer.b.hawes.