Many flaws of our broken mental health system resulted in the death of my son

By Allen Nelson

Allen Nelson resides in Santa Monica, CA. He has three sons with his wife Rose. Brandon resides in heaven, Trent in Boston and Justin in Santa Monica. Allen is advocating for California to pass stringent legislation regulating the mental health/SUD industry.

Over a 3-month period, my family experienced the worst of our nation’s and California’s private-pay mental health system. Our son Brandon, a 26-year-old UCLA engineer, had a psychotic break in January and again in March of 2018, and then died by suicide in a residential home that claimed to offer mental health services with a license from the state of California.

Brandon was a UCLA aerospace engineer working for a company that made parts for airplane manufacturers. In late 2017, Brandon learned that some of the parts being shipped were not made to spec. After management would not address the issue by recalling the parts, Brandon became a whistleblower to the FAA. Shortly after the FAA closed the case without requiring a recall, Brandon began to decompensate. He was terrified that planes were going to crash, and he would check the internet throughout the day to see if there had been any crashes.

On January 24, 2018, Brandon called a friend who was a police officer to meet him. Upon meeting, Brandon asked the friend to shoot him or give him a gun so he could shoot himself. Brandon’s friend called another police officer who had Brandon taken in for a 72-hour hold, known in California as a 5150. This was the beginning of the end.

We quickly learned from the friend that Brandon had been taken to a psychiatric health facility. We called the facility and asked to speak with Brandon, and this is where we ran into the first hurdle. They told us that given Brandon’s age, HIPAA laws would not allow us to speak with him unless he gave permission, even though he was not in a rational state to make a proper decision. Two days later, while we were working on trying to get permission but before we were able to do so, The facility told us that Brandon was having his hold extended for several weeks, in what is known as a 5250, and was being sent to an acute psychiatric hospital. It was becoming evident that Brandon was now in some system over which we, his parents, had little say or control.

Once at the psychiatric hospital, we did get permission to see Brandon. We visited on several occasions; it was heartbreaking to see him in a lockdown facility and still in psychosis. He was given many medications. Decades ago, my father had been in a psychiatric hospital for several months for Bipolar 1. He was given excellent treatment; his lithium levels were dialed in, and he went on to live a very productive life after his treatment. I assumed this would happen in Brandon’s case, especially since he had excellent health insurance from his employer.

This is where we ran into hurdle number two: Brandon’s insurance would only authorize a few days of treatment at a time. There is no way you can treat an SMI illness in a few days; you need months, as evidenced by my father’s case. Even though we frequently called Brandon’s doctor for updates, he only returned our calls twice over four weeks. The hospital said Brandon was ready for release to outpatient care after 28 days. They could legally release Brandon since they could check the three necessary boxes – no harm to self, no harm to others, and not gravely disabled. We contacted an outpatient facility who did a phone evaluation. They told us Brandon was not ready for outpatient care since he still thought he had a chip in his brain and that he was being monitored by the FBI.

The hospital agreed to keep Brandon a few more days while we were desperately looking for an alternative, and then they suggested what is known as a residential treatment program run by a company called Sovereign Health. Sovereign claimed to have a mental health-only program for young adults. They told us Brandon would have a psychiatrist, psychologist, case manager, and excellent care. This is where we ran into hurdle three – even though licensed by the state of California, Sovereign did not provide the services they promised.

Although Sovereign had a mental health program that they promoted to us, Sovereign’s main line of business was for addiction and “dual diagnosis” programs. As we have come to find out, fraud runs rampant in this industry for operators who don’t accept Medicaid. California’s vetting process for facilities that only accept private-pay insurance is cursory at best, and the requirements for the people who work in them are minimal. Fraudsters and charlatans have moved in and are exploiting vulnerable people for insurance money. In an irony that shows just how broken our system is, Brandon would have been better off had he not had private insurance and instead been put into a facility that had to adhere to federal Medicaid standards, not California private pay standards.

Brandon arrived at Sovereign on Friday, February 23, 2018. We believe that Sovereign neglected to give him his prescribed medication from the hospital, and on that following Monday, February 26, Sovereign had Brandon taken in on another 5150 to yet another different acute psychiatric hospital. Over a nine day stay at this hospital, Brandon did not seem to have a lead psychiatrist but was seen by six different psychiatrists. Eager to release him as soon as they could check all the boxes, they gave us a few hours’ notice that he would be going back to Sovereign on the evening of March 7.

Through depositions in our wrongful death lawsuit, we discovered that once he arrived at Sovereign on the evening of March 7, they neglected to get Brandon’s prescription filled and he did not receive it the next morning as was required. Brandon was in a group session later that day where someone who was unqualified to work with SMI individuals (Sovereign called them “clients”) asked the group if they could be an animal, what would they want to be. Brandon had always been fascinated with flying and said, “a bird, so I can fly and go into the military.” Another member of the group who had been a service member said that would never happen since Brandon was now marked as mentally ill. Brandon’s demeanor changed and he became very sullen.

A few hours later, Brandon began screaming, saying that he had not received his medication. The house manager called in a therapist who realized that Brandon indeed had not been given his medication. She finally administered it at about 6:00 pm – 12 hours too late. However, she knew nothing about Brandon’s history and did not know that he had just been in the hospital, even though Sovereign had sent him there. The house manager also told her that Brandon was screaming just because he was an attention seeker. Brandon’s housemates were telling the Sovereign staff that Brandon needed to either be taken to a lockdown facility or at a minimum be given 15-minute checks. Neither happened.

The therapist left at about 6:40 pm. While the rest of the housemates ate dinner and watched TV, Brandon went up to his room which had an exposed metal fire sprinkler on the ceiling, took the string from his sweatpants, and hung himself at about 7:45 p.m. At about 8:00 p.m., Brandon’s roommate went into the room to get a blanket and saw Brandon hanging. The house manager did not know CPR as required. When the house manager called 911, he did not know the address of the house and did not know Brandon’s full name. Brandon’s housemates tried to revive him, but it was too late.

What Brandon’s story tells us about our current mental health system:

• Insurance companies will not authorize long term treatments as is needed for individuals with SMI. Brandon never got a proper diagnosis but was likely Bipolar 1. There is no way that you can diagnose and determine the medication regimen that will work for each unique SMI case in a four day stay – it needs to be four months to start.
• Psychiatrists do not always give quality, individualized care. To be fair, this is likely due to the overwhelming demand for psychiatric service with a very limited supply of doctors entering the profession who are willing to work in psychiatric facilities as opposed to offices.
• In California, and many other states, fraudsters and charlatans realize that the demand exceeds supply and have developed schemes to defraud health insurance companies while providing little to no legitimate care for those with mental health and substance use disorders.
• The state of California refuses to pass significant legislation regulating these for-profit businesses, and it provides little oversight. From my vantage point, California is just looking for beds to get people off the streets with little regard for the type of care people receive.
• HIPAA laws can make it difficult to interact with loved ones who are not rational enough to decide with whom they should be speaking.
• Once the government takes over via 5150’s, your loved one can enter a system over which you have little to no control. Perhaps we would have been able to get Brandon the individualized long-term care he needed had he been returned to us from the outset.

The money we received from our wrongful death settlement will be going towards research on the genetic and epigenetic root causes of SMI. The only way out of the forest is to determine why SMI brains misfire and then, from there, figuring out how to heal them. This should be our nation’s audacious goal even though it will take many years, perhaps decades, to accomplish. Success would obviate the need for downstream care, which is sadly lacking.  Success would also save lives, both of those who take their own and those who tragically kill others. Just as importantly, it would save the suffering of family members who have loved ones afflicted with SMI.

(Author’s note: if interested, you can get more details by searching on Brandon Nelson, Orange County Register or KNBC-TV.)