Copy of Article Printed 1-13-2017
ANCHORAGE — A deadly shooting rampage at Fort Lauderdale-Hollywood International Airport this month has focused attention on the interconnection of public safety and mental illness and raised questions, especially here in Alaska, about one of the thorniest questions of psychology: how to tell if someone is delusional and dangerous, or merely delusional.
There is no dispute, law enforcement officials said, that the suspect in the Florida case, Esteban Santiago, was disturbed. When he walked into the F.B.I. offices here in Alaska’s largest city in early November, he said his mind was being controlled by the government. After a voluntary four-day evaluation in a psychiatric hospital, he was released, and soon reclaimed the handgun that the police confiscated when he was admitted. He is now charged with killing five people and injuring six more at the airport on Jan. 6.
In many ways, Mr. Santiago’s path through the mental health treatment system was unremarkable, similar to the one faced by people across the nation, the overwhelming majority of whom will never perform violent acts. Improved insurance coverage is now in place for many people — including an expansion of Medicaid for lower-income adults in Alaska — but a stigma about treatment, combined with a shortage of hospital beds and mental health professionals, keeps many people from getting or accepting care.
In Alaska, health care professionals and legal experts said the distinctive demographic, geographic and cultural stamp of the state also colors the often nuanced judgments that doctors, law enforcement officers and judges must make in deciding whether to hold a disturbed person against his or her will.
Alaska, they said, is ingrained with a deep tradition of tolerance — fueled by libertarian instincts holding that people should be able to believe what they want, however eccentric or irrational. And even when people are involuntarily committed for treatment, the median length of stay, at only five days, is shorter than in almost any other state. Only Wisconsin has a shorter median commitment time, at four days, according to the Treatment Advocacy Center, a national group that works to improve mental health laws and care. The national average is 75 days, with some states, like California, having a median of more than four months.
“Getting a commitment here is really hard,” said Merijeanne Moore, a psychiatrist in private practice in Anchorage.
The mental health needs are great here, too. Alaska has the nation’s second-highest suicide rate, after Wyoming, and some rural areas are by far the worst in America in rates of self-harm, federal figures say. Alaska also has among the highest rates of adult binge drinking, according to federal figures.
A study by the Kaiser Family Foundation ranked it 47th among states and territories in terms of the percentage of mental health care needs being met.
At the same time, the number of beds at the Alaska Psychiatric Institute in Anchorage, the state’s only long-term psychiatric hospital, is now half of what it was in the early 1990s, though many other states also cut their mental health treatment systems during the Great Recession.
“There’s a huge street problem, a huge drug problem and a lot of mentally ill people who don’t even have a finger grip on the lowest rungs of the ladder,” said Paul L. Craig, a neuropsychologist in private practice in Anchorage.
The state does have some mental health treatment strengths. The care system for Native Alaskans, paid for by the federal Indian Health Service, has an extensive mental health program for adolescents. The Department of Veterans Affairs and branches of the military treat tens of thousands of active-duty and retired military personnel.
Dr. Craig and other providers said, though, that those systems of care often function like autonomous empires, without coordination. “People fall through the cracks between them,” he said.
In part, the distinctively Alaskan way of thinking about mental illness may reach back to the era before statehood, which came in 1959. For decades up to that point, residents were committed and sent to a psychiatric hospital in Portland, Ore., from which some never returned. The grounds for commitment — effectively a kind of deportation — sound shocking by today’s standards, including a refusal to speak and excessive masturbation.
Partly in response to complaints about those past practices, Congress in the mid-1950s created the Alaska Mental Health Trust Authority, a unique land trust of one million acres, almost the size of Delaware, to produce income dedicated specifically to mental health. The Alaska Mental Health Trust Authority is still active, and has leverage through the millions of dollars it contributes to the state budget through its investments. The trust lobbied hard, in particular, for the expansion of Medicaid in the state.
Guns are also part of the fabric of Alaskan life. Ownership is widespread, and no permit is required for concealed carry. Until 2014, state officials were not required to report data on mental-illness diagnoses to the F.B.I.’s background check system, and Alaska is one of 17 states with no restrictions beyond federal law for keeping guns away from the mentally ill, said the Law Center to Prevent Gun Violence, a national legal research group in San Francisco.
Under federal law, a person who has been involuntarily committed is never again allowed to have firearms.
Mr. Santiago, who entered a no-contest plea last year on a misdemeanor domestic violence charge but has no record of being committed, told the F.B.I. and the Anchorage police in November that he did not want to harm anyone, F.B.I. officials said. He admitted himself to the hospital, so the federal law did not apply. It also meant, law enforcement officials said, that the gun he had in his car when he came into the F.B.I. offices had to be returned to him.
What this case illustrates, said John Snook, the executive director of the Treatment Advocacy Center, is that behavior somewhere short of dangerous may not count. “We use this outdated concept,” he said in a telephone interview. “Most people aren’t dangerous, so they don’t get care.”
And sometimes, establishing dangerousness is difficult.
Just before Christmas, a middle-aged woman who had been living in a 16-bed assisted-living home for the mentally ill in Anchorage began screaming and threatened other residents and the staff, said the home’s manager, Erin Terry. She called 911.
But when the police came, the patient refused to repeat her threats, so despite Ms. Terry’s pleas, the officers deemed the woman no danger and left. Several days later, Ms. Terry convinced a judge otherwise, and the woman was involuntarily committed and removed from the home.
“She was beyond our level of care,” Ms. Terry said. “We were terrified.”
Dr. Moore, the psychiatrist, said that in the last few years she has had two patients who, like Mr. Santiago, walked into F.B.I. offices to complain that the government was exerting control over them. Both were examined and released. One patient has since twice been involuntarily committed in other states, Dr. Moore said.
A version of this article appears in print on January 14, 2017, on Page A9 of the New York edition with the headline: Florida Airport Rampage Casts Stark Light on Alaska.