Matthew Milam told his parents he would kill himself. He dug a shallow grave in his backyard. He stockpiled rat poison, propane tanks and knives in his closet. He told his folks he’d kill them, too.

But his doctors determined he wasn’t sick enough to require long-term hospitalization, his father said.

To those who examined the 24-year-old Harahan man — whose behavior was consistent with bipolar disorder and paranoid schizophrenia — he was OK to be released, even against his father’s pleas for more treatment and a short stack of notarized affidavits he provided as proof of the dangerous behavior.

“I said that if you let him out, he’s going to kill himself,” Pat Milam recalled telling doctors. “They told me that they believed he would take his medicine.”

Just days after he was discharged from the hospital in 2011, Matthew Milam committed suicide with a homemade device using propane tanks and shotgun shells.

Milam is just one person in a small pool of violent and mentally ill patients who somehow never managed to be flagged by Louisiana’s mental health care system as dangerous until they hurt themselves or others.

It’s a system that has been under a spotlight for years, with many advocates complaining of shrinking resources, particularly the halving over the past decade of state long-term beds to treat the most severely mentally ill. State officials counter that they’re actually increasing spending on mental health, especially ramping up services provided outside a hospital setting.

The recent Lafayette movie theater shooting — in which gunman John “Rusty” Houser had a long history of treatment for mental illness and accusations of violence before opening fire at The Grand 16 Theatre — has put the focus back on whether states are doing enough for the mentally ill. Questions similarly are being raised about whether sufficient steps are being taken to keep the most severely mentally ill patients away from firearms.

Houser was essentially a stranger to Louisiana. But court records, officials and acquaintances in Georgia and Alabama paint a portrait of a volatile, paranoid man, accused of violent acts against both family and others.

Still, Houser was never convicted of any crimes, nor was he ever stripped of his gun rights because of his mental health problems, which enabled him to legally purchase the .40-caliber handgun used in the shootings.

Days after the Lafayette shooting, Gov. Bobby Jindal zeroed in on the fact that Houser avoided involuntary commitment to psychiatric treatment, meaning he wasn’t in a federal database of people with mental illness prohibited from owning guns. He touted a recent change to Louisiana’s laws that requires the roster of people who are involuntarily committed by a judge to be submitted to a federal database barring gun possession.

But mental health professionals, gun control advocates and loved ones of the seriously mentally ill say focusing on involuntary commitment does not adequately capture the difficulties of this thorny issue.

Involuntary commitment — sometimes called judicial commitment — is a complex process that involves a hearing before a judge. Many families feel thwarted in their quests to seek help before they ever reach that point. Mental health advocates argue that a key focus should be on availability of treatment, saying more long-term hospital help needs to be available for the sickest individuals.

At the federal level, the Lafayette shooting has spurred proposed tweaks to the existing system, mostly encouraging more states to participate in the existing background check system. But in some states, gun control advocates are pushing for broader changes, suggesting implementation of temporary restrictions on gun rights after any involuntary hospitalization for mental illness, a threshold far below a judicial commitment. That is an idea that is sure to provoke concerns from mental health and gun rights advocates who worry about infringing on the civil liberties of people who might not be violent.

Commitments

Louisiana involuntarily commits fewer people than at least two southern states with comparable populations. In 2014, Alabama had 2,158 involuntary commitments and Kentucky had 942. In Louisiana, there were 761.

The road to a commitment can begin with family members beseeching doctors or the parish coroner to order a temporary hospital stay for a patient, in which they must attest that the relative is a danger to himself or others. But an official involuntary commitment of longer than 15 days must be authorized by a judge after a due-process hearing.

Even though thousands of Louisianians are ordered to interim psychiatric treatment — East Baton Rouge Parish alone is on track to record 8,000 of these temporary stays this year — a much smaller fraction make it to the point of arguing their case in front of a judge.

The numbers in East Baton Rouge Parish help to illustrate how this plays out. Of the 6,518 times the coroner ordered a psychiatric evaluation in 2014, just 328 cases for involuntary commitment were filed in court, resulting in 118 involuntary commitments that year.

“As far as detaining someone against their will for treatment, for a lengthy process, yes, the bar is extremely high,” said Alison Boudreaux, president of National Alliance on Mental Illness Acadiana affiliate group and a St. Martin Parish sheriff’s deputy.

Much of this is justified, she said, because involuntary commitment involves stripping someone of their civil liberties.

Chuck Credo, an attorney for the Jefferson Parish Coroner’s Office since 1982, said many “actively psychotic” people have been able to evade the system designed to protect them and the public. He estimated as many as 50 percent of the mentally ill people his office sees in the midst of an episode have access to a weapon.

“Sometimes it’s because families don’t pursue the matter, but there’s also no structured place to put them,” he said.

Mental health cuts?

In 2005, there were 348 state-funded beds in Louisiana for those who needed long-term mental health care, a number that is 148 this year, according to the Louisiana Department of Health and Hospitals.

The cuts in those beds include the privatization of Southeast Louisiana Hospital in Mandeville, leaving only two other state hospitals for mental health care — one in Pineville and one in Jackson.

Mordecai Potash, a psychiatrist at the Tulane Hospital emergency room, said a shortage of state beds leads to doctors prematurely discharging patients.

“The reason why these psychiatric institutions are not keeping the patients longer is, where would the patients go? We don’t have the long-term beds,” he said. “The state says, ‘We have beds.’ Well, we do. But there are far fewer of them, and they are harder to access.”

The waiting list for one of those spots is two to four months, on average, said Dr. Rochelle Head-Dunham, DHH’s highest-ranking authority on mental health.

But the way she sees it, state mental health care has improved in recent years because the state now contracts space in private hospitals, increasing the spots for patients in their communities.

“I honestly feel like we are in a better place than where we were before,” said Head-Dunham, who added the system has de-emphasized hospitalization as the go-to solution for mentally ill patients.

In an email, Jindal’s spokesman Mike Reed said spending on mental health has increased, from $606 million to $769 million between fiscal years 2009 and 2014.

Dr. Janet Bradley, a psychiatrist who formerly worked for the Southeast Louisiana Hospital, questions the state’s narrative of expanding mental health resources. She said after Southeast was privatized and became Northlake Behavioral Hospital, she was under “immense pressure” to discharge people quickly and make room for new patients because of the squeeze. Bradley recalled a time she was urged by other doctors to discharge someone even after the patient set fire to a house. That strain is what caused her to quit her job, she said.

Nicole McGee, of the National Alliance on Mental Health Louisiana, agreed that private hospitals don’t have the financial incentive or resources to absorb the overflow of patients needing long-term mental health treatment. Since “beds are almost never available,” McGee said, she’s seen patients seek care in neighboring Mississippi.

And, she added, because psychiatric patients are often shuffled repeatedly through hospitals, they can become fluent in the language of appearing competent in certain moments.

“A lot of times, people say the right things. They know what to say in order to not be committed,” she said. “Especially if they’ve been in the system time after time because it seems to be a revolving door.”

Head-Dunham, of DHH, denied that there’s any financial disincentive for hospitals to tell patients to go home before they should.

“These (contracted) hospitals are paid for their care service, so there is no incentive for them to discharge early,” she said.

Richard Kramer, CEO for Northlake Behavioral Health System where Bradley worked, said regardless of pressure from insurers, doctors have the final call on discharging a person. “We’re not going to release someone if we think they’re a danger to themselves or others,” Kramer said. “It’s the doctor’s final authority to determine whether a person should be released.”

Dr. Richard Dalton, the chief medical officer for Magellan Health, which manages the state’s mental health care offerings, said their system ensures that no one official makes that kind of decision.

Lack of help

Well before Houser opened fire last month in the Lafayette theater, killing two women and injuring nine others, and then turning the gun on himself, news reports in Louisiana were peppered with cases of mentally ill people accused of murder.

Bernel Johnson, accused in 2008 of killing a pregnant New Orleans police officer with her own gun, has spent almost all of his time since then at the state-run forensic mental hospital in Jackson. He’s been ruled incompetent to stand trial in the murder.

His family has described him as a paranoid schizophrenic, and not long before the shooting, he’d been forcibly sent to a mental institution after he created a disturbance at a local bank. But even after that episode, and one in which he shot himself in the chest and threatened to kill family members, Johnson was never judicially committed, despite his family’s attempt to make that happen.

And there’s Wilbert Thibodeaux, who is accused of murdering two people, including a police officer, in St. Mary Parish in 2013. His lawyer, Craig Colwart, said he was “the most mentally deranged client” he’d ever worked with.

Yet despite hitting someone with an ax and prompting his neighbors to report his bizarre behavior to police, Thibodeaux had brushes with law enforcement but apparently never even reached the point of being committed by a coroner.

Gun reform advocates say people like Houser, Johnson and Milam were clearly dangerous to themselves or others but still failed to meet the high threshold required to disqualify them from purchasing a gun.

Josh Horwitz, executive director of the Educational Fund to Stop Gun Violence, worked with other mental health and public policy experts from across the country to develop a series of recommendations for states to strengthen their laws to prevent dangerously mentally ill people from having access.

The consortium recommended that if a person is ever involuntarily hospitalized for mental illness, they would be barred from purchasing a gun for five years. Thousands of people in Louisiana are involuntarily hospitalized but never are even considered for a judicial commitment. Under current law, it is only at the point where a judge weighs in that gun rights can be stripped.

“The evidence is clear that one of the most dangerous times for a mentally ill person is immediately post-hospitalization,” Horwitz said. “You go back to the same community; you deal with the same stressors.”

He said the recommendation would allow people to challenge the five-year moratorium, with the burden being on the state to prove they are still dangerous.

He also points to California, which created a gun restraining order that allows family or law enforcement to seek an order prohibiting a violent person from having a gun for 21 days to a year.

Dan Zelenka, president of the Louisiana Shooting Association, said Louisiana has drawn the line at an appropriate place that balances safety with people’s constitutional rights.

He said he has serious concerns about laws like California’s, which allow people to be stripped of their gun rights without having the opportunity to make their case before a judge.

“It allows a police or family member to go to court, without any notice to you and put evidence out there without you being able to hear it or without you being able to rebut it, and without you being able to face your accuser,” Zelenka said.

Credo, with the Jefferson Parish Coroner’s Office, said he believes there’s a fair argument to exploring whether the line in Louisiana needs to be redrawn.

“The standard is evolving as more examples of unprovoked violent acts by those with mental illness will continue,” he said. “Personally, I do believe in the balance between Second Amendment right to bear arms, but the increasing number of seriously mentally ill people who end up with firearms is a reason for us to evaluate what the federal standard is.”