State mental hospital backlog grows, new record exceeds 2,500 waiting in jail

In Texas, people charged with a crime who are too mentally ill to participate in their own defense are typically found incompetent to stand trial and ordered by a court to a state hospital for restoration. Since Texas’ state-operated mental hospitals are full, those individuals are put on a list and left waiting in lockup.

AUSTIN (KXAN) – If Adan Castaneda were charged with a crime and found mentally incompetent to stand trial in October 2022, he would be court ordered to a state mental hospital and stuck in jail for about two years before a hospital bed would become available.

Texas’ state hospital waitlist has grown almost continuously since KXAN profiled Castaneda’s case in 2020. He was a Marine sergeant and scout sniper whose mental health spiraled out of control after returning from the Iraq War. In 2011, he fired a handgun almost two dozen times at his mother and stepfather’s house while they were home. No one was injured, but he was charged with multiple felonies, including attempted murder.

It took years for justice to play out. Castaneda was found incompetent to stand trial, and, from 2011 to 2015, he bounced between Comal County Jail and the state hospital system. He was ultimately found not guilty for some charges and not guilty by reason of insanity for the remaining ones.

In Texas, people charged with a crime who are too mentally ill to participate in their own defense are typically found incompetent to stand trial and ordered by a court to a state hospital for restoration. Since Texas’ state-operated mental hospitals are full, those individuals are put on a list and left waiting in lockup.

“You’re basically locked in limbo. It’s like purgatory,” Castaneda told KXAN in a 2021. He spoke via Zoom from San Antonio State Hospital, where he was recommitted after missing a dose of medication.

Castaneda’s mental health has improved since that time. He left the state hospital and lives on his own.

Meanwhile, Texas’ mental hospital waitlist has worsened considerably. Thousands are now stuck in “limbo,” as Castaneda described it.

‘Just not right’

In September, there were 2,540 people on the waitlist – a new record high. The average wait time for a maximum-security bed was 699 days – also a record – and 241 days for a non-maximum-security bed, according to data provided at an Oct. 19 quarterly meeting of the Joint Committee on Access and Forensic Services. JCAFS is an advisory body that assists the Texas Health and Human Services Commission with oversight of state hospitals.

“I think that is horrible,” said Maria Anna Esparza, Castaneda’s mother. “To see it get worse just makes me feel like Texas is not the best place to live in, if you have any issues with mental health … 700 days, that's — that's just not right.”

Esparza has advocated for change and improvement to Texas’ mental health system for years, just as she advocated for her son when he struggled to navigate the state’s criminal justice system while dealing with mental illness.

In October, JCAFS members acknowledged the number of people waiting in county jails for a spot in a state-run mental hospital has continued to grow, wait times have lengthened and a significant portion of existing bed space remains unusable. Meanwhile, county jails that are typically ill-equipped to handle mental health cases are struggling and local taxpayers are footing the bill.

“This is a tragedy of epic proportion. It's an ongoing tragedy that we have been suffering for years,” State Sen. Sarah Eckhardt, D-Austin, told KXAN. “We simply don't have the capacity, even on a good day where we're fully staffed.”

Bed capacity is down 33%. Only 1,510 of the Texas’ 2,263 funded beds are available for use, HHSC data shows.

Most of the lost bed capacity is “simply due to staffing,” said Kristy Carr, HHSC associate commissioner over the state hospitals.

HHSC increased wages and offered bonuses to improve staffing and retention in March. Those pay raises stabilized the workforce but weren’t enough to bring a “significant” number of beds back online, Carr said.

HHSC’s efforts

HHSC officials at the JCAFS meeting, and through a spokesperson, outlined several ways the agency is trying to improve the waitlist.

HHSC is working on initiatives to “support diversion, crisis services, state hospital and community-based forensic services, training and technical assistance, and standardization of evidence-based practices,” agency spokesperson Christine Mann said in an email.

Mann said HHSC has hosted a “Jail In-Reach Learning Collaborative” since September 2021 to improve cooperation between mental health providers, law enforcement and criminal justice officials like judges, district attorneys and jail administrators.

HHSC is also funding “restoration services that people can access in jail or out in the community, including crises services,” Mann said. Jail services include court-ordered medication and outpatient care to help people avoid arrest.

‘Titanic has hit the iceberg’

JCAFS committee member Jim Allison said all those efforts are important and have an impact, but more needs to be done to reduce the waitlist immediately. Allison is the general counsel for the County Judges and Commissioners Association of Texas.

HHSC’s efforts are “great and wonderful,” he said, and everyone wants to find better ways to intervene in people’s lives before they need in-patient care. However, “that is not doing a darn thing for the people that are on the waitlist now, and we have got to address this.”

“We don’t seem to grasp that there is a crisis here,” Allison said. “We don’t seem to understand the Titanic has hit the iceberg.”

Lack of information

In addition to reporting on the backlog “crisis,” a KXAN investigation found the state doesn’t collect vital information about people on the waitlist, like whether a person is homeless or indigent. Experts say more layers of data collection could help reduce the backlog.

KXAN also discovered HHSC does not track when people die waiting for a state hospital bed. Our investigation uncovered at least 12 cases of people dying in jail since 2015 after being found incompetent to stand trial and ordered to a state hospital.

One of those individuals was Naquan Carter, a 23-year-old man who died in his Travis County jail cell in July 2018 awaiting transfer to a state-supported living center for further mental health restoration. Carter lived with an intellectual development disability.

On Tuesday, Sonja Burns — a mental health advocate who sits on the Texas Judicial Commission on Mental Health’s Collaborative Council — nominated Carter to be the namesake of Travis County’s probate court building.

“The naming of this building is very important for our community, and it should reflect and remind us of our vulnerable community members this court is intended to serve,” Burns said.

Burns testified Tuesday and told Travis County Commissioners Carter's name would "impel us all to action to better serve our most vulnerable."

Carter's guardian, Carla Thomas, told KXAN she was in favor of naming the building after him to remind the community of people with unique needs.

"Naquan represents a community of people that have a diagnosis of mental illness and developmental disabilities," Thomas said. "He also lost his life because people did not understand how to work with him.”

Carter was nominated for the naming of the building alongside longtime Travis County Probate Judge Guy Herman and pioneering civil rights activist Ada Collins Anderson, who died last year at the age of 99.

The three names will be sent to the Travis County Historical Commission for further review and consideration.

What’s next

With the state hospital backlog at record highs, lawmakers are expected to author bills that could improve the situation in the upcoming legislative session beginning in January.

In 2021, Sen. Eckhardt crafted a bill to create an Office of Forensic Services within HHSC. That bill didn’t pass, but, she said, the state “must have” it. She said Texas needs more nurse practitioners, increased use of telehealth and Medicaid expansion.

“Both victims of crime and individuals who are seeking fair and efficient and effective mental health care, both categories of individuals would be helped massively by inexpensive expansion of Medicaid,” Eckhardt said. “I will be looking at every way I can, legislatively, to expand access to mental health care before it becomes a crisis and one must search for a mental health state hospital."