Gary Popiel had to drive more than 200 miles round trip to visit his adult daughters in separate behavioral health facilities as they received psychiatric and medical treatment.

It was 2000, and the family's only options for inpatient psychiatric beds were in Helena and Missoula — far from their Bozeman, Montana, home and from each other. Fast-forward 21 years, and Montana's fourth-largest city still lacks a hospital behavioral health unit.

"This would be just as traumatic now as it was then. We still would have to leave Bozeman," Popiel said. "Why should families have to witness their loved one being hauled off or take them themselves to another facility — or outside the state — to receive help?"

For years, health care workers and people such as Popiel who've had to travel for family members' mental health hospitalizations have been pushing the city's major hospital system, the nonprofit Bozeman Health, to add a behavioral health unit at its Deaconess Hospital. On Sept. 30, the system's board plans to consider whether to add one as part of an expansion of its mental health services.

Hospital leaders have said initial talks have been broad so far, without specifics on the number of potential beds and whether they're designed for adults or kids.

But even if Bozeman Health adds inpatient psychiatric beds, the gaps in emergency mental health care could continue. Across Montana, such units routinely hit capacity and some struggle to find enough workers to staff them.

Montana's quandary reflects a national shortage of inpatient psychiatric beds that can leave people with serious mental illnesses far from the services they need when a crisis hits. Ideally, patients would have treatment options to prevent such a crisis. But more than 124 million Americans live in mental health "professional shortage areas," according to federal data, and the country needs at least 6,500 more practitioners to fill the gaps.

The national nonprofit Treatment Advocacy Center, which aims to make care for severe mental illness more accessible, recommends a minimum of 50 inpatient psychiatric beds per 100,000 people. It is still debated, though, who should provide those beds and where they're prioritized on a long list of stretched-thin mental health services.

Given the patient capacity of Montana State Hospital and private hospital behavioral health units, Montana comes close to that recommendation. But those beds are concentrated in pockets of the state, so access isn't uniform.

For example, Bozeman Health sits in a city of 50,000 in a county of 120,000 and also serves two neighboring counties. The city has 10 crisis beds at the Western Montana Mental Health Center's facility there — the only beds for roughly 100 miles in any direction. The crisis center cares for roughly 400 people a year, providing nurses and psychiatrists who can offer safety plans and medication management, but it can't treat children or offer full medical services as a hospital could. The center also faced criticism for closing its two involuntary beds for six months last year because of a worker shortage amid the pandemic.

Bozeman Health's leadership estimated that on average 13 people who live in its primary three-county service area of Gallatin, Park and Madison counties are admitted to behavioral health units elsewhere each month.

Some patients leave handcuffed in the back of a law enforcement vehicle. Last year, the Gallatin County Sheriff's Office transported 101 people experiencing a mental health crisis — 85 of whom were taken to crisis centers hours away or the state hospital. That's up from 2019 when authorities took 36 out of 45 people in crisis outside the county.

"Every other major city in Montana besides us has managed to get inpatient care" at their hospitals, said Dr. Colette Kirchhoff, a physician in Bozeman.

One man went to Bozeman Health to have a cancerous tumor removed in early August, and the next day he had panic attacks that turned into suicidal thoughts. He was driven two hours in the back of an ambulance to the Billings Clinic. His wife, who asked KHN not to publish their names since her husband wasn't in a condition to give his consent, said she wished they'd had a closer option.

"I was there when he got strapped into a gurney and taken away," she said. "I had to book a hotel and get money from the bank and pack clothes."

Bozeman Health leaders have said the hospital hadn't actively considered a behavioral health unit until now because it had prioritized outpatient mental health services. In recent years, it added mental health treatment into primary care, including hiring licensed clinical social workers. It started telepsychiatry to help local providers with patient assessments. It also plans to provide short-term crisis stabilization and medication management.

"The gold standard is let's make the need for high-acuity inpatient care go away completely," said Jason Smith, Bozeman Health’s chief advancement officer. "Getting there may be impossible. At the very least, it's going to be difficult."

Elizabeth Sinclair Hancq, director of research for the Treatment Advocacy Center, is skeptical that would be possible. "Efforts to intervene as early as possible are an important step forward, but that doesn’t mean that inpatient beds will become obsolete," she said.

Smith said creating inpatient psychiatric services isn't as simple as adding beds. A construction project would be years away. Adding a unit also would mean ensuring discharged patients have access to additional services and recruiting mental health workers to Bozeman amid the national shortage.

"Whether we're going to be able to recruit the behavioral health professionals that are necessary to lead it and provide that care on a day-to-day basis is a major question mark," Smith said.

Dr. Scott Ellner, CEO of the Billings Clinic, said the number of patients who travel to his hospital for care is evidence the state needs more beds. Last year, the hospital treated 161 psychiatric patients from Bozeman Health's service area. Ellner said Billings Clinic loses money on its psych unit, but the service is part of the hospital's job.

"There’s so few resources across the state," Ellner said. "We strongly recommend that there be inpatient beds in Gallatin County."

Where the services do exist, they're often stretched.

Benefis Health System in Great Falls has 20 inpatient psychiatric beds. In an email, spokesperson Kaci Husted said those beds hit capacity a few times a week. When that happens, the hospital puts patients in overflow beds until a spot opens.

And in Helena last year, St. Peter's Health turned away 102 patients because its behavioral health unit was out of space or because a patient needed more care than the hospital could manage. Gianluca Piscarelli, the unit's director, said the system's eight adult beds are often full. The hospital also has 14 geriatric psychiatric beds — the only inpatient program in the state designed for seniors who may have dementia and a serious mental illness — but Piscarelli said the unit may deny someone a spot if it already has too many high-needs patients to manage.

Shodair Children's Hospital in Helena has 74 beds for kids in a crisis but, because of a shortage of mental health workers, the facility could admit only 40 patients as of mid-August, said CEO Craig Aasved. In May, a 15-year-old patient died by suicide there, with a state report blaming understaffing as a contributing factor.

The hospital is working on an expansion with a new building design that would make it easier to group patients by diagnosis, but staffing will still be a strain. He said that while more beds are always needed, some kids come from towns where they don't even have access to a therapist.

Having every hospital add psychiatric beds isn't a perfect solution, Aasved said. "The end result is we’ll just have a lot of beds and no staff."

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NEED HELP?

If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or contact the Crisis Text Line by texting HOME to 741741.

This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.