Grading the States 2006
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Grading the States 2006: South Dakota - Narrative

South Dakota ranks last in the nation in funding its mental health agency services. On a per capita basis, it ranks 35th.

There may be explanations that help to understand the status of its mental healthcare system. But it's hard to accept them. South Dakota can do better.

Geography is an understandable challenge. South Dakota is a rural frontier state, with a population density of approximately 10 people per square mile, compared to the national average of approximately 80. Most of the population is concentrated in the eastern third of the state. In rural areas, access to care is limited - a function of distance, as well as shortages of providers.

Still, other states face similar challenges.

The backbone of the state mental healthcare system is 11 community mental health centers (CMHCs) spread throughout the state, which are primarily accountable for implementation of programs and services. At the same time, the Division of Mental Health (DMH) in the Department of Human Services (DHS) plays a role in providing leadership, resources, and accountability - all of which are sometimes in short supply.

By DMH's own admission, the state is struggling to implement evidence-based practices (EBPs). Only Assertive Community Treatment (ACT) and integrated treatment for co-occurring mental illness and substance abuse are in place, and even these, according to advocates, fail to meet national standards. A response to the survey used in preparing this report suggested that no significant innovation has been implemented in the past three years, other than an indigent medication program. Progress seems to occur slowly and in very small steps.

South Dakota has one state hospital - in Yankton. Advocates report that it periodically stops taking voluntary admissions, because of a shortage of beds, and that there are long waiting lists for case management. On the other hand, the state reports progress in decreasing rates of readmission.

Every system requires balance. That includes state hospitals for longer-term inpatient care, but also requires crisis centers and short-term acute inpatient and intermediate care facilities in communities - and outpatient community services like ACT, supported housing, and independent living options. When community services are not available at one level, the system backs up. Waiting lists result.

Inadequate capacity reflects inadequate investment.

Located in the extreme southeastern part of the state, Yankton is not readily accessible as a provider for the needs of a majority of the state's citizens. Those who are hospitalized often are deprived of ready support from family and friends, which can be an important factor in recovery.

An estimated two people per week take their own lives in South Dakota. There are states in which the rate is higher, but the losses obviously hit families, friends, and communities hard. For the state's American Indians, the rate reaches "epidemic" proportions. For every fatality, the state also estimates that approximately nine people make non-fatal attempts. The state has a statewide suicide prevention strategy, but such strategies usually require support from community services within the overall mental healthcare system.

There are some positive notes.

In recent years, South Dakota has reduced the use of restraints and seclusion by approximately 50 percent.

The state also has preserved access to medication for consumers. It has maintained an open formulary for psychiatric medications and avoided limits on thenumber of prescriptions for Medicaid recipients. Instead, it is addressing poly-pharmacy and over-prescription concerns through a physician feedback program on prescribing habits.

The state has a mental health insurance parity law. Periodically, it is threatened by proposals to repeal health-related mandates - even though such laws primarily prohibit discrimination among benefits already offered. Any repeal would represent a step backward, rather than forward - hurting middle class families and pushing them into the public system, imposing additional costs to the state, as families are forced to spend down assets or go without care.

Overall, the future for mental healthcare in South Dakota is uncertain. Geography may be a challenge, but the state needs to prioritize and invest in evidence-based practices.

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