Gone Baby Gone

The shocking case of Otty Sanchez exposes the holes in Texas' mental health care system.
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The first police officers at the crime scene were so shocked they could barely speak. When they arrived at the white-paneled house on San Antonio’s north side at 5 a.m. on July 26, officers found a bedroom doused in blood, the decapitated and mutilated body of a baby not even a month old, and his mother, 33-year-old Otty Sanchez, screaming that the devil made her do it.

Sanchez had left the baby’s father after a fight and was staying with her mother and cousins. Around 4:30 a.m., while the rest of the family slept, she’d attacked her infant son with a large kitchen knife. Police officers would describe the crime as one of the most gruesome they had ever seen. Some of them later needed counseling.

It was hard to imagine that anyone in her right mind could do such a thing. And it turned out that Sanchez was suffering from postpartum psychosis, a rare but severe form of postpartum depression in which paranoid hallucinations prod new mothers to violence. (Postpartum psychosis and its potentially tragic consequences gained national notoriety after the trial of Andrea Yates, the Houston woman who killed her five children in 2001.) Sanchez had been enduring a mental-health crisis for at least a week before the killing. But when she reached out for help—like so many Texans with severe mental illness—she was left to fend for herself.

Just six days before she killed her son, on July 20, Sanchez had met with a counselor at the obstetrics-gynecology clinic that ushered her through pregnancy. The counselor, Luinda Combs, could tell right away that Sanchez wasn’t well. Sanchez spoke of delusional, paranoid thoughts that other women were trying to breastfeed her baby. She was “hearing voices which have informed her others would like to take her baby away,” according to Combs’ notes from that session. “Client also reports visual images of other children’s faces transposed on her baby’s face.” (The Observer was granted access to these medical records with Otty Sanchez’s permission.)

Combs suspected right away that Sanchez had postpartum psychosis. She knew Sanchez had a history of depression and had been institutionalized a year earlier with paranoid schizophrenia. New mothers with severe mental illness are much more likely to suffer postpartum psychosis. Most alarming of all, Sanchez had stopped taking her anti-psychotic medication because of the side effects.

Combs told Sanchez she needed an immediate psychiatric evaluation and called an ambulance to rush her to the hospital. The counselor wanted to make sure Sanchez wasn’t mindlessly shuffled through a busy emergency room, so she called ahead to let Metropolitan Methodist Hospital’s psychiatric unit know that Sanchez would soon arrive with a likely diagnosis of postpartum psychosis. Combs wrote in her notes that the “hospital worker did not want to take information over the phone.” So she also gave “specific details of client’s delusions and hallucinations” to the EMS workers to pass along to the hospital personnel.

Combs’ message about the severity of Sanchez’s condition didn’t quite get through. At the hospital, Sanchez would be diagnosed with visual hallucinations and audible voices, but nowhere in Sanchez’s hospital records does the more alarming diagnosis Combs suspected—”postpartum psychosis”—appear.

The ambulance arrived at Metropolitan Methodist, a private hospital, at 11:39 a.m. Sanchez waited 20 minutes and was examined in the emergency room at 12:05, according to hospital records obtained by the Observer. Though Sanchez had been rushed to the hospital because of a mental-health crisis, for the next three hours, nurses gave her only physical tests and lab work and determined that her body was mostly healthy.

A little before 3 p.m., more than three hours after her arrival, Sanchez was finally examined by a member of the hospital’s psychiatric team—not a psychiatrist, but a trained counselor. The evaluation lasted 44 minutes, and the records of that session show the seriousness of Sanchez’s condition. She was experiencing “voices and hallucinations,” according to hospital records, and “sees babies [sic] face change.”

Sanchez asked to be admitted to the hospital’s 31-bed inpatient psychiatric unit. “[Patient] states she needs to be admitted for voices,” according to the records. Inpatient treatment had worked for Sanchez before. During a similar crisis in 2008, she had been hospitalized for more than two weeks until her mental condition stabilized. Now she was asking for similar treatment.

Sanchez was a good candidate for inpatient care. Here was a diagnosed schizophrenic who had been institutionalized a year before, who had recently given birth, who had stopped taking her meds, who was hearing voices and hallucinating, seeing her baby’s face change into other faces. “She’s got a big red light on her head saying ‘I’m going to explode any minute,’” says her lawyer, Ed Camara. “You think they would at least talk to her doctor or ask her about her history. But they don’t do anything like that.”

Instead, the hospital employed another standard for admission to its psych unit. It mostly boiled down to a simple question: Did Sanchez feel suicidal or homicidal? New mothers will rarely answer this question honestly. Many will never admit to suicidal or infanticidal thoughts because—in addition to the societal stigma of saying they might harm their baby—they fear that, if they answer honestly, the government will try to take their child away. Sanchez was already having paranoid hallucinations about strangers lusting after her son.

It’s hard to know exactly what was in Sanchez’s mind at the time. (Because her case is pending, she couldn’t be interviewed for this story.) But whatever she was thinking, Sanchez told the hospital counselor that she was “not suicidal, not homicidal, no command hallucinations,” according to hospital records. (Command hallucinations are voices that instruct a person to take specific actions.) The counselor checked the “no” box on a form next to the line that reads, “Is the patient having suicidal or homicidal ideation and/or making threats?”

Otty SanchezAsked about the hospital’s standard for admission to the psych unit, a spokesperson for Metropolitan Methodist responded to the Observer by e-mail: “Qualified mental health professional perform [sic] a psych assessment, focusing on three things: whether patient is suicidal, homicidal or experiencing a deterioration such that, if we let them out of the hospital, they would be a danger to themselves or somebody else. The qualified mental health professional then gives assessment recommendation to ER doctor and doctor makes his own assessment on whether patient needs to be admitted. Doctors [sic] recommendation always stands. Doctor bears liability for decision.”

Sanchez was sent home with the name of a clinic she could contact for outpatient services, though she was given no address or contact information. She never made an appointment. That’s not uncommon. People in mental-health crises often can’t care for themselves. Their mental state is too debilitated and agitated for basic outpatient care; they can’t be relied upon to take medication or show up for appointments. They often need to be hospitalized for a short period until their minds stabilize to the point that they can function on their own.

The hospital also provided Sanchez with an information sheet—Camara calls it a “you’re crazy” document—that lists general descriptions of “Hallucinations and Delusions” and of “Schizophrenia.” The document instructed her to “Call your doctor or go to the emergency room right away if your symptoms get worse.”

As Camara puts it, “They’re telling a crazy person that ‘you’re crazy,’ and to take care of yourself.’”

And that was that. Just 11 minutes after her psych evaluation ended, Sanchez was discharged from the hospital, at 3:53 p.m.

Six days later, she was back in an emergency room, this time at San Antonio’s large public hospital. She was escorted by police officers. Her face was still smeared with blood from consuming parts of her son.

Texas may have the most beleaguered public mental-health system in the country. The state ranks 49th nationally in per-capita spending on mental health; only New Mexico is worse, according to the Kaiser Family Foundation. State lawmakers have shorted the system for years. The result of this miserly approach is that hundreds of thousands of Texans with severe mental illnesses must fend for themselves.

For many people, the public system—such as it is—remains the only option. Private facilities are often prohibitively expensive, and most insurance plans offer minimal coverage for mental-health care. A few days’ stay at a private treatment facility will usually exhaust the mental-health benefit offered by even the most decadent insurance plans.

Yet in Texas’ public system, only the lucky ones receive services. Texas operates a dozen state hospitals, which are almost always near capacity and difficult to gain admittance to because of limited bed space. A network of 39 community mental-health authorities offers counseling, medication and other outpatient services. But with extreme funding shortages, the community centers can offer help to only a sliver of the people who need it. State officials have estimated that the centers can afford to treat only about one-third of the Texans with severe mental illnesses, leaving at least 400,000 largely without care.

The irony of the Otty Sanchez case is that, of all the places in Texas to suffer a mental-health crisis, San Antonio might be the best equipped to offer treatment.

“We have a success story to tell,” says Leon Evans, who heads the Center for Health Care Services, the public mental-health clinic in San Antonio. The clinic, like many other community mental-health centers across Texas, is horribly underfunded by the state. But the center has forged alliances with the police, judges and other health-care providers in San Antonio to create some of the most innovative treatment programs in the country. Among other innovations, the center worked with San Antonio police on a program that trains officers how to spot and calmly subdue people who have severe mental illnesses without resorting to violence or arrests.

The Center for Health Care Services, which treated Sanchez for three months in 2008, has also created jail-diversion programs aimed at keeping nonviolent offenders with substance-abuse problems or mental illness out of prisons. In 2005, the center helped open a 10-bed inpatient mental-health crisis center, where people can stay for 23 hours if they have nowhere else to go. (The crisis center accepts referrals from hospitals when their psych units are full. Metropolitan Methodist could have sent Sanchez to the 23-hour crisis center if the hospital’s psych unit had no room for her.) Combined, these programs are keeping nearly 1,000 people a month out of the county jail. That saves taxpayer money and, by providing people treatment instead of incarceration, greatly reduces the chances that they’ll break the law again.

But despite those successes, the lack of funding minimizes what these programs can accomplish. “Money is very tight,” says Gilbert Gonzales, who oversees the jail-diversion programs and also serves as spokesman for the Center for Health Care Services. “There’s only so many people we can treat because we literally don’t have enough money to meet the need.”

State funding for mental-health services hasn’t kept pace with demand. One main reason, Evans points out, is the way Texas doles out money to the community centers around the state. The funding is not based on the population of the area a clinic serves. Rural areas with shrinking populations receive far more money per capita than Houston, San Antonio and Dallas—cities with exploding populations and rising numbers of people with mental illness. There have been many attempts to change the way money is allocated. Most advocates realize that the level of mental-health funding should be based on population, but the Legislature has resisted this change; it’s been blocked largely by rural lawmakers whose sparsely populated districts would lose money.

Evans and his staff stretch the meager funds as far as possible. The state provides enough money for the Center for Health Care Services to treat 4,240 people a month. But the center stretches it to treat about 6,000 adults and children (42 percent above the state’s goal). Even so, the center can’t meet the need. There is now a waiting list for services of several hundred people per month. “We’re way under-funded,” Evans says. “Our employees’ heads are about to explode because they’re so overworked.”

It means that many people fall through the cracks. Otty Sanchez was one of them.

In Sanchez’s family, hearing voices or seeing the occasional hallucination isn’t unusual. Her mother, aunts and cousins have all had similar mental illness.

Sanchez was an only child and never knew her father. She grew up in a crowded household with seven other relatives, including her mother. The family moved often, living in at least three states during Otty’s childhood. They returned to San Antonio from California when Otty entered high school. Sanchez’s mother and two of her cousins turned down interview requests.

Although Sanchez would later be diagnosed with paranoid schizophrenia, her relatives had no idea she had mental illness until just last year, according to medical and court records (and to Camara, her lawyer, who has extensively interviewed the family). That’s partly explained by other relatives’ illnesses. But her symptoms were also easy to ignore; they didn’t obviously disrupt her life until just last year. In fact, family friends often described Otty as one of the most level-headed people in the family.

She has been hearing voices since age 5, according to the report from a psychiatric evaluation recently conducted on her in the county jail. The voices are often “good voices telling her everything is going to be OK,” according to the report by Brian Skop, a psychiatrist appointed by the court to evaluate Sanchez’s competency to stand trial. But she also hears “bad voices. … One voice in particular named ‘Lucy,’ which is telling me to do bad things like eat my hand,” she told Skop.

Sanchez was mostly able to live with these voices and mild paranoia for years. She finished high school and began taking pharmacy-technician classes. That’s where, in 2003, she met Scott Buchholz, who also is schizophrenic. The two began a dysfunctional, on-again, off-again relationship.

Sanchez’s mental illness worsened in the past five years. Her behavior became erratic. She had trouble staying employed, bouncing from one low-paying job to another. She worked at fast-food restaurants and briefly as a home health caretaker.

In late May 2008, Sanchez went to Austin with a friend. While her friend was getting an acupuncture treatment, Sanchez wandered off. She walked into a CVS and prowled the store for the next seven hours. Police arrived and took her to the Austin State Hospital, where she stayed for 16 days. It was the first time her family learned of the severity of her mental illness. After her mental state stabilized, Sanchez was released. The nurses at Austin State Hospital referred her to outpatient care at the Center for Health Care Services in San Antonio. They gave Sanchez the contact information, set up an appointment for her and later called to make sure she showed up.

Throughout the summer of 2008, Sanchez, who was uninsured at the time, received free outpatient treatment from the San Antonio clinic, including regular counseling sessions and anti-psychotic medication. She soon was feeling much better, according to her health records.

But in early September 2008, that all changed. The Center for Health Care Services—its budget strapped as ever—could no longer afford to provide Sanchez treatment. She would
ave to either p
y or qualify for a government benefit. Camara, her lawyer, says that Sanchez believed she could never afford the treatment. So when her next appointment rolled around, Sanchez didn’t show. The clinic workers didn’t have the time or resources to track her down. They moved on to the next client on the waiting list. A month later, the center classified Sanchez’s file as closed. “They let her drop out, and they have to, because they don’t have the money,” Camara says.

At about the same time she stopped receiving treatment, Sanchez reunited with Buchholz. In late September 2008, she got pregnant. You needn’t be a psychiatrist to see trouble looming for two schizophrenics, one off her medication, deciding to have a baby.

Yet Sanchez managed her pregnancy without incident. She gave birth to Scotty Buchholz on June 30, 2009. Her OB-GYN prescribed anti-psychotic medication—she had given up medication during pregnancy—but Sanchez said the drug made her too tired. She stopped taking it on July 17, nine days before she attacked her baby. Her doctor planned to offer her a different drug, but before that could happen, Sanchez had one of her frequent fights with Buchholz. On July 20, she left him and descended into crisis. Emotional stress often exacerbates postpartum depression. Sanchez soon found herself in the emergency room at Metropolitan Methodist, asking for help.

After the hospital ushered her out the door with little more than an information sheet, there was still one last opportunity to prevent the killing. On the afternoon of July 25, 12 hours before the attack, Sanchez visited Buchholz and his mother, Kathleen. Sanchez had been living with her relatives and wanted to retrieve from Buchholz the baby’s diaper bag and her medication. She hadn’t taken a pill in eight days.

Buchholz’s mother noticed that Sanchez seemed erratic and paranoid. Neither Buchholz nor his mother would agree to an interview for this story. A relative who answered the phone at Buchholz’s home said he’s no longer speaking with reporters. This account comes from Camara, the attorney, who has interviewed everyone who was present that afternoon. At one point, Sanchez refused to let Kathleen Buchholz hold the baby because she feared Kathleen was trying to steal her son or breastfeed him.

Scott Buchholz and Otty Sanchez

The Buchholzes told Sanchez that she needed to seek help. At that, Sanchez abruptly got up and fled the house. Kathleen Buchholz called law enforcement and told officers that Sanchez had run off with the child and was an unstable schizophrenic. The officers—members of the Bexar County Sheriff’s Department—took no action.

In the weeks after the attack, prosecutors confronted a difficult decision: Should Otty Sanchez face criminal charges or be sent to a state hospital for treatment? Despite the evidence that Sanchez was insane at the time of the killing, some in San Antonio openly called for the death penalty. They included Scott Buchholz, who told a San Antonio television reporter in late July that “I think she should be punished to the fullest extent of the law. … She killed my son. She should burn in hell.”

Prosecutors eventually decided to pursue a criminal case. In September, a grand jury indicted Sanchez for capital murder.

In jail, Sanchez has received the counseling and medication to which she had such spotty access on the outside. Her mental condition has stabilized, for the moment. As a result, she’s been found competent to stand trial after examinations by experts appointed by both the court and her defense attorney. Examiners concluded that she understood the legal process and the charges against her.

If she remains stable, Sanchez will likely stand trial this summer. Camara plans to have Sanchez plead not guilty by reason of insanity—just as Andrea Yates did. He thinks he has a strong case, but jury trials are unpredictable. Take the Yates case: At her first trial for killing her five children in 2002, she was convicted of murder and sentenced to life in prison. That conviction was later overturned on appeal, and in 2006, Yates was found not guilty by reason of insanity.

Prosecutors have said they plan to seek the death penalty for Sanchez. If they do, the very state that for years offered Otty Sanchez so little treatment and help for her mental illness will try to execute her.

Dave Mann has been with the Observer since 2003. Before that, he worked as a reporter in Fort Worth and Washington, D.C. He was born and raised in Philadelphia. He thinks border collies are the world’s greatest dogs, and believes in the nourishing powers of pickup basketball.