"Funding for services for mentally ill people such as Seung Hui Cho has decreased nearly 10 percent in Virginia since 2000, eroding key programs for thousands of people with non-severe mental disorders, documents and interviews show.

For a decade, Virginia officials have increased state resources for the complicated needs of the severely mentally ill and patients recently discharged from state-run mental hospitals.

But that has come at a price. Money for people with less serious disorders, who live in the community but need mental health treatment, has been reduced after adjusting for inflation. These people are not eligible for Medicaid, the government health care program for the poor and disabled, because they make too much money or have too many resources, and they often aren't covered by private insurance.

In a handful of jurisdictions, almost exclusively in Northern Virginia and Hampton Roads, officials have tried to make up for inadequate state resources with local money. But in most cases, agencies have eliminated or reduced dozens of services, including outpatient treatment, leaving many to deal with their illnesses any way they can.

It is unclear how many people are affected by decreased funding because the state has no way of tracking those who seek services but don't receive them. But as Virginia officials sort out the future of the mental health system after last year's deadly shootings at Virginia Tech, one of the persistent challenges is how to allocate money for the vast and varied issues that confront the state's 118,700 mentally ill residents who receive community services.

Cho's rampage at Virginia Tech in April has heightened long-standing concerns among lawmakers, state officials and advocates that the system has funding holes and other problems that must be addressed. Now, for the first time in a decade, state officials have begun to address the shortfall for this population by appropriating money specifically for these kinds of outpatient programs.

Gov. Timothy M. Kaine (D) has included $42 million in the state's budget, including funds to expand the number of caseworkers and psychiatrists who can address people's mental health issues in their beginning stages.

State lawmakers have included budget amendments to add even more money. Those amendments will be considered today as lawmakers craft the budget. But because of the erosion of programs this decade, the state is still a long way from filling all the gaps in services for this group.

"The bottom line is that in most places, there's very often nothing available unless you're at rock bottom, coming out of a state hospital, or you show up and are basically a danger to someone else," said Byron Stith, a mental health outreach coordinator in Richmond who serves as a member of the state Supreme Court's Commission on Mental Health Law Reform.

Even as the General Assembly begins to modify the state code to address the gaps in the system exposed after Cho killed 32 people and himself, the major issue will be how to increase access to services. Until then, many argue, the system will continue to fail.

"Everything revolves around adequate funding . . . there's really no way around it," said Mira Signer, the Virginia director of the National Alliance for Mental Illness. "We have to find a way of helping prevent people from reaching a point of crisis, but we can't lose sight of those people who are most seriously at risk so that they don't become worse."

The overall impact of the change in priority over the past several years has been a drastic shift in who gets services in Virginia.

In Richmond, for instance, the local behavioral health authority no longer provides services for mentally ill people who qualify for Medicaid and aren't considered to have serious problems. That is because city money has fallen over the past five years and all of the city's dollars are geared toward mentally ill people who need expensive monitoring.

The same goes for many other jurisdictions, particularly in rural communities. Rural agencies report that they often can't even meet the demands of mentally ill clients who have been discharged from state hospitals.

In all, mental health agencies statewide are running a waiting list of 5,700 people for these community services.

That has some advocates concerned that the state is not moving aggressively enough to make up for years of slippage. Signer has called on the legislature to add $25 million to Kaine's funding proposal.

Lawmakers said that given other funding priorities, they can make up for past shortages only incrementally.

"Would it be nice to have the revenue available to address the immediate needs as well as to strengthen other parts of the community system? Yes. But you can't turn an aircraft carrier on a dime," said Del. Phillip A. Hamilton (R-Newport News), who chairs one of the House committees reviewing much of the legislation on mental health issues.

But even before the Virginia Tech shootings, the problem of getting help to such people as Cho was a concern. The state's mental health inspector general said in a report to legislators months before the shootings: "Community-based support and clinical services provided in the community do not have adequate capacity. As a result emergency service programs deal with crisis situations that could have been prevented if the [mentally ill person] had received more intensive . . . services."

For people with mental illness, it can mean long, difficult stretches with no treatment. With diagnoses of bipolar disease, post-traumatic stress disorder and other ailments, Yukiko Moynihan, 28, an Arlington County store clerk, has cycled through five hospital psychiatric wards in the past 23 months, according to her hospital records. She has been referred to the Arlington Community Services Board twice, according to two hospital discharge documents. Each time, she was given an appointment and told that she would be able to see a therapist in three weeks.

"As soon as you're out of the hospital, waiting for your appointments, you have all this time between the time you saw your hospital doctor and a new therapist," she said.

"And all that time when you're out alone . . . there's just too much time," she said. "Things can get bad that quickly."

In 1998, the state spent $45 million for basic mental health community services and $3 million for services targeted at those with severe conditions. Now, the state spends $51 million for community services and $86 million for those with such severe conditions as schizophrenia, bipolar disorder and severe depression. That is a 9.3 percent decrease in community services funding over seven years after factoring in inflation, according to an analysis by The Washington Post based on figures provided by the state.

In Cho's case, the New River Valley Community Services Board was responsible for sending a staff member to a commitment hearing, like the one Cho had 16 months before the shooting. No staff member attended, largely because that service had been cut, said Harvey Barker, the executive director. Also, no one from the board followed up on the order requiring Cho to seek outpatient treatment. Barker said the agency didn't have the staff at the time to keep up with someone such as Cho.

"We hardly get any funding from the localities to staff these kinds of services," Barker said. "And all of the state money is used for the more serious population."

State officials acknowledge that the funding structure helps those with severe disabilities and who are poor but not those who fall in between.

"The intensive services that many individuals with serious mental illnesses need are very expensive, and that affects our ability to care for those who don't fit into that category," said Raymond Ratke, deputy commissioner of the Department of Mental Health, Mental Retardation and Substance Abuse Services. "The issue is stretching the dollars to meet the needs of people with serious mental illnesses while at the same time trying to serve those with less serious illnesses."

Virginia is going through an unprecedented examination of its mental health system after the slayings at Virginia Tech. This is one in an occasional series of reports about problems in the system." (Chris L. Jenkins, The Washington Post, February 17, 2008)