Arizona authorized secure residential treatment facilities in 2019 to help people with severe mental illness who can't manage in the community, but seven years later, the state still hasn't opened a single facility. The delay has left an estimated 2,000 people with conditions like schizophrenia and bipolar disorder trapped in a cycle of repeated hospitalizations, homelessness, and crisis interventions that experts say rarely produce lasting recovery.

What Happened to Arizona's Promised Psychiatric Facilities?

In 2019, Arizona lawmakers recognized a critical gap in mental health care. The state had services for people who could manage treatment in the community and hospitals for acute crises, but nothing in between for patients too sick for outpatient care yet not sick enough to qualify for long-term hospitalization. These small group homes, capped at 16 beds each, were supposed to provide secure, court-ordered treatment where patients could stabilize on medication for three to twelve months.

The plan stalled almost immediately. The Arizona Health Care Cost Containment System, the state's Medicaid agency, awarded grant funding to a provider in 2020, but the project ran into delays finding properties, rising construction costs, and budget constraints. After the provider failed to meet the terms of its agreement, the state halted the project and ended the contract. It wasn't until April 2026 that AHCCCS began seeking new providers to operate the facilities, with no timeline for when they would actually open.

Who Falls Through This Treatment Gap?

The gap affects people with serious mental illness, or SMI, who have a specific challenge: anosognosia, a neurological condition that prevents them from recognizing they are ill. This is a primary reason people with schizophrenia or bipolar disorder refuse medication, leave treatment, and experience repeated relapses. One in four adults with serious mental illness also has a substance use disorder, which worsens psychiatric symptoms and makes recovery harder.

Advocates estimate that up to 3% of Arizona's roughly 63,000 people with serious mental illness could fall into this gap, meaning nearly 2,000 people have no appropriate treatment option. For comparison, according to an Arizona Health Care Cost Containment System report, nearly half of the roughly 8,000 people with serious mental illness discharged from unlocked residential facilities in fiscal year 2025 were hospitalized within a year.

"They cycle through things like group homes and homelessness and crisis centers and interactions with police and fire. All the while getting sicker and sicker and sicker, and almost irredeemable," said Josh Mozell, a mental health attorney and president of the Association for the Chronically Mentally Ill.

Josh Mozell, Mental Health Attorney and President, Association for the Chronically Mentally Ill

How Current Treatment Falls Short for Severe Mental Illness

Arizona's behavioral health system is built around a voluntary model, which works well for many people but fails those who cannot voluntarily engage in treatment. Most residential facilities are unlocked, meaning patients can leave whenever they want. A few days or weeks of care is rarely enough to stabilize someone with treatment-resistant schizophrenia or severe bipolar disorder, especially when they don't believe they are ill.

• Repeated Hospitalizations: People without access to secure treatment cycle through costly, short-term interventions. One man with schizophrenia was hospitalized at least 26 times in five years for a total of 280 days, with at least 10 stays in behavioral health residential facilities, yet never achieved lasting stability.
• Medication Non-Compliance: Without court-ordered treatment in a secure setting, patients with anosognosia often refuse antipsychotic medications, even when those medications work. Treatment teams can encourage care and monitor conditions, but have few options to keep patients in treatment unless they are in immediate danger.
• Substance Use Complications: When patients mix psychiatric illness with substance use disorder, treatment becomes even more complex. Current policy allows treatment teams to only encourage assistance for substance use when patients are ready, not to mandate it as part of psychiatric care.

What Difference Would Secure Treatment Make?

The case of Larry Bootsma illustrates what the gap costs. Diagnosed with schizophrenia at 23, Larry spent 25 years cycling through Arizona's mental health system despite intensive interventions including court-ordered treatment, specialized psychiatric teams, and a court-appointed guardian. Two days before his death from a drug overdose at age 47, his treatment team reported he was compliant with his court order and had picked up his medications. But he was also mixing methamphetamine with fentanyl and following it with alcohol, and the team had no authority to intervene beyond encouragement.

During his final hospital stay at Aurora Behavioral Health, Larry was on clozapine, an antipsychotic medication primarily used for treatment-resistant schizophrenia. His family said he was like his old self, cracking jokes and discussing football and music. In a secure environment where he could be required to take his medication, his parents believed he could have recovered.

The state's own reports acknowledge the problem. In a report to the governor, AHCCCS stated that conditions such as anosognosia mean some patients are "unable to engage voluntarily in interventions, including antipsychotic medication and community support," and that court-ordered treatment "may be necessary for stabilization".

A Separate Crisis: Postpartum Psychosis Going Unrecognized

While Arizona struggles with infrastructure for chronic severe mental illness, another gap exists in how clinicians recognize and treat postpartum psychosis. A consensus statement in Biological Psychiatry argues that postpartum psychosis should be recognized as its own distinct disorder in the DSM, the diagnostic manual clinicians use, rather than just a specifier of other conditions.

Postpartum psychosis is rare but serious, occurring in 1 in 500 to 1 in 1,000 births, and carries a high suicide risk of 4 to 11%. It typically begins within two weeks of delivery, peaking at 8 to 10 days postpartum. Most cases have strong bipolar features, presenting with mania, a mixed episode, or depression with psychotic features, often alongside confusion, agitation, and irritability.

Without proper recognition, clinicians often miss postpartum psychosis in favor of milder diagnoses like peripartum depression, leading to overuse of antidepressants, which can worsen the manic side of the disorder. Instead, experts recommend a bipolar-informed approach using lithium and antipsychotics acutely, with lithium for long-term continuation. Electroconvulsive therapy is also effective.

The good news: when treated correctly, remission rates are much higher than what is seen with general bipolar disorder. One large cohort study found a 98% remission rate using a stepwise approach of benzodiazepines, antipsychotics, and lithium, with lithium monotherapy lowering relapse risks over the following year.

Steps to Improve Recognition and Treatment of Postpartum Psychosis

• Screen for Bipolar and Psychotic Symptoms: When a woman presents with postpartum depression, clinicians should actively look for signs of bipolar disorder or psychosis, including unusual behavior, confusion, hospitalization or emergency department visits, and signs of irrational thought such as unusual questions or black-and-white thinking.
• Involve Family Members: People with psychosis often hide their most severe symptoms out of shame, paranoia, or fear of hospitalization. Speaking to family members is essential to identify severe changes in mental status, including puzzled expressions, anger, impulsiveness, severe insomnia, or worsening response to antidepressants.
• Plan Preventive Care for High-Risk Women: For women with bipolar disorder or a prior postpartum psychotic episode, specialists should provide care during pregnancy, develop a written plan for the postpartum period, and consider preventive lithium right after delivery to prevent recurrence.

The contrast between Arizona's stalled infrastructure for chronic severe mental illness and the emerging recognition of postpartum psychosis highlights a broader challenge in American mental health care: even when we know what works, systems often fail to deliver it. For thousands of people with schizophrenia, bipolar disorder, and other serious mental illnesses, that failure can mean a lifetime of crisis instead of recovery.