A central issue in the case against accused Jan. 8 shooter Jared Lee Loughner involves his sanity: Does he suffer from mental illness, and if so, did that impact the events of that tragic day a year ago? Can he ever be restored to competency so he can be tried for the crimes?
The uncertainty of Loughner's mental state also led to an inquiry into whether available mental-health services in the region were adequate—or if more needed to be done to ensure that those who need help could find it.
A year later, those same questions are still being asked. While some improvements have been seen—most notably in terms of awareness—the collective feeling is that local mental-health services continue to trail demand.
"We still are seeing many people fall through the cracks," said Mindy Bernstein, whose Coyote Task Force employs the mentally ill. "There are not enough hospital beds for psych patients."
All of those interviewed about the state of mental-health services in Pima County agreed that things are as good as they're going to get given the current, decreased state-funding levels. Recent cuts to AHCCCS and other services have been felt heavily in the psychiatric community, and any further cutbacks could be devastating.
Bernstein, whose organization helps more than 100 people with a mental illness find work via efforts such as a clothing store and a restaurant, said that despite the cuts, she has seen some improvements in local mental-health care. The most notable advancement, she said, was the August opening of a mental-health crisis center at the University of Arizona Medical Center's South Campus, formerly Kino Hospital.
The center, which is in effect a dedicated urgent-care facility for psychiatric issues, enables those who need mental-health care to avoid going to an emergency room, where they might not get the help they need, Bernstein said.
"Psychiatric crises are just as significant as any other acute medical crisis," she said. "ERs are not set up to treat them. It could mean a very long wait for some people, and they could just walk off."
The South Campus facility is part of a network of facilities and other services meant to provide assistance to those seeking it, or to those who are identified by others as being in need of help, said Neal Cash, CEO of the Community Partnership of Southern Arizona.
This network, which has been in effect for three years, also includes a call-in command center with dedicated phone lines for both public calls and law-enforcement issues, all in an effort to avoid having "our hospital emergency departments and our jails as a mental-health system," Cash said.
Since Jan. 8, there has been a huge spike in the number of initial inquiries the network has received, Cash said, likely the result of the "hyper-awareness and vigilance" that is almost expected after a tragedy such as the one Tucson experienced.
"It's not surprising that people's awareness has risen," he said. "But at the same time the demand is kind of ramping up, the resources are diminishing. Everything we've done is to make sure we did the best with the resources that we had, that we've used them effectively."
Since Jan. 8, CPSA has held about 30 mental-health first-aid training sessions. Cash said the 600 attendees have included law-enforcement officers and other first responders, as well as parents, teachers and people from faith-based organizations. The sessions are meant to educate the general public on what to look for in someone who may be suffering from mental illness.
"It's really meant to look at how you identify early signs and symptoms, and how to reach out to people and let them know of the resources available," Cash said. "It's similar to first aid taught by the Red Cross. You can learn first aid even if you're not a (medical) professional; it's what you can do before the professionals arrive."
While some efforts are being made to improve the services available for people early on in a mental-health crisis, there are still many people who end up running afoul of the law, said Terri Rahner, the mental-health clinical coordinator for the Pima County Superior Court.
Rahner, who handles all of the county's court-ordered competency evaluations (known as Rule 11 evaluations), said about 700 Superior Court cases a year involve a defendant who may have mental-health issues. Many of those defendants, she said, might be facing charges because they were seen behaving erratically in public. And because no help is available on the outside, this situation often results in law enforcement "criminalizing that kind of behavior" in order to get a person assistance while incarcerated.
"Right now, the county jail is our largest mental-health provider in the county," Rahner said. "The availability of benefits in the community reaches into the courtroom just like anywhere else, and the lack of resources ... poses limitations."
The state's poor economy during the last few years has led to cuts in many services, not just health care, said Vic Williams, a state representative whose District 26 includes the shopping center where U.S. Rep. Gabrielle Giffords and 18 others were shot.
Williams said the Arizona Legislature has taken the appropriate steps to balance its budget, and as more revenue comes in, it can look to start increasing funding to some agencies, such as ACCCHS. But before doing so, he said, it's necessary to take a close look at how organizations are using their funding to ensure it is being spent properly.
"We obviously want to put money toward identifying people who are mentally ill or ... need to be helped," Williams said. "But before we can do that, we have to take care of the waste and fraud and misuse."
Tragedies such as the Jan. 8 shootings often lead to a wave of political efforts to make changes, but that didn't happen here, Bernstein said.
"There's a stigma to mental illness," she said. "It's a shame-based illness, no doubt, in the same way AIDS used to be. It's significant that the community understand that psychiatric issues are illnesses."
Accused Jan. 8 shooter Jared Lee Loughner remains in a Missouri federal facility, where he is being forcibly medicated in an effort to restore him to a level of competency that would enable him to face trial. Loughner, 23, faces 49 federal counts, but is currently not considered competent to stand trial, and no trial date has been set.
His defense attorneys have fought to prevent authorities from forcing medication on Loughner, with further hearings on the issue scheduled before the 9th U.S. Circuit Court of Appeals.
The most recent ruling on the case came in late November, when U.S. District Judge Larry Burns denied a request by defense attorneys to have Loughner's competency interviews videotaped.