Dozens of states have slashed spending on mental health care over the last four years, driven by the recession's toll on revenue and, in some cases, a new zeal to shrink government.
But that trend may be heading for a U-turn in 2013 after last year's shooting rampages by two mentally disturbed gunmen.
The reversal is especially jarring in statehouses dominated by conservative Republicans, who aggressively cut welfare programs but now find themselves caught in a crosscurrent of pressures involving gun control, public safety and health care for millions of disadvantaged Americans.
In many states, lawmakers have begun to recognize that their cuts "may have gone too deep," said Shelley Chandler, executive director of the Iowa Alliance of Community Providers. "People start talking when there's a crisis."
About 30 states have reduced mental health spending since 2008, when revenues were in steep decline, according to the National Alliance on Mental Illness. In a third of those states, the cuts surpassed 10 percent.
As a result, nine state-run psychiatric hospitals were closed and another 3,200 beds for mental health patients were eliminated, dramatically reducing treatment options for the poor and people in the criminal-justice system. Thousands of patients were turned onto the streets.
Making matters worse, the cuts came as unemployment was rising, causing more people to lose private insurance and forcing them to shift to public assistance.
The steepest drop by percentage was in South Carolina, where spending fell by nearly 40 percent over four years — an amount that Republican Gov. Nikki Haley has called "absolutely immoral."
Now Haley, who took office in 2011, has pledged to bolster a mental health system that dropped case workers, closed treatment centers and extended waiting lists. She also wants to expand remote access to psychiatrists through video conferencing.
Both Pennsylvania and Utah have put aside plans to scale back their mental health systems.
And Kansas, which cut mental health spending by 12 percent from 2008 to 2011, announced this month a new $10 million program aimed at identifying mental health dangers.
"I don't think we're well set as a state at all to be able to deal with these intensive cases" of mental illness, acknowledged Kansas Gov. Sam Brownback, usually an avid proponent of downsizing social programs.
The sudden pause reflects anxiety from last year's shootings in a Colorado movie theater and a Connecticut elementary school. Although little is known about the mental health of either gunman, the attacks have shaken state legislatures that until recently didn't intend to consider more social spending. In some cases, gun-rights advocates are seeking mental health reforms as an alternative to more gun laws.
Jon Thompson, spokesman for the Republican Governors Association, said many budget-cutting governors are having second thoughts, including whether to reform mental health policies "to further invest in the safety of their citizens."
South Carolina eliminated 600 full-time case workers and closed five treatment centers. That led to an increase in the number of people with mental illness in jail in Columbia — so much that it now exceeds the patient total at the city's public psychiatric hospital.
"We've been unable to maintain those preventative measures to keep people out of jail," said Bill Lindsey, director of South Carolina's National Association on Mental Illness.
During former Gov. Mark Sanford's term, the fiscal pressure was inescapable. The recession cut state revenue by more than $1 billion from 2008 to 2011.
"It wasn't really Sanford's fault," said former state Rep. Dan Cooper, Republican chairman of the House Ways and Means Committee. "There just wasn't enough money to go around."
Revenues have since recovered somewhat, and are projected to be at levels last seen in 2008.
In Kansas, under then-Gov. Kathleen Sebelius, a Democrat, state psychiatric hospitals began treating only the most dangerous cases. Caseloads at the Johnson County Mental Health Center near Kansas City rose from the recommended 15 per caseworker to more than 30 in 2010.
Tim DeWeese, the center's clinical director, said one of his patients who had finished college and gotten a job and an apartment became homeless after his doctor visits were cut off.
"It came crashing down all the way," DeWeese said.
Oklahoma also cut mental health programs in 2010 and 2011. But Republican Gov. Mary Fallin, a conservative elected in the GOP landslide of 2010 on a promise to cut spending, reversed course last year after grim warnings about the effect on public safety, and after several teen suicides in Oklahoma City.
"There just weren't enough resources," said Harry Tyler, director of the Mental Health Association of Central Oklahoma.
Fallin approved a 20 percent budget increase and has pledged to make mental health a priority again this year.
"You'll see more emphasis on being able to identify people that might have mental health challenges," she said.
Tyler said he would encourage Fallin to provide more money for screening teenagers who could endanger themselves or others.
New Jersey Gov. Chris Christie, another Republican, has promised to fully implement a new program under which people are required to take medication and attend therapy if a judge believes they pose a risk.
Mike Hammond, executive director of Kansas' Association of Community Mental Health Centers, said his state's governor is looking for new ideas on mental health care.
"I think he's realized what's happening in our system," Hammond said.
To be sure, Republicans have not given up on keeping state government lean and taxes low. And some party members question how much mental health spending will be approved.
"I'm not telling you she gets the money," former South Carolina GOP Chairman Katon Dawson said of Haley.
Ty Masterson, Republican chairman of the Kansas Senate's Ways and Means Committee, acknowledged the same conflict: "There's obviously tension there."