Curt Chisholm literally knows Montana's mental health system inside and out. Yet he didn't recognize his youngest son's struggle with depression until the illness overcame his son and he killed himself.

Gary Mihelish's family is fighting to keep various relatives alive, as they battle bipolar, schizophrenia and major depression disorders.

Sue Wilke is a lifeline to her daughter who's being treated for the obsessive compulsive disorder that took over her world.

Mike Caruso is a gifted guitarist, cheated out of an upper-class lifestyle by his bipolar mania.

Chisholm, Mihelish, Wilke and Caruso are members of a club no one wants to join, a handful of the millions of ordinary people worldwide whose lives are transformed by mental illness.

Of the nearly 1 million people who call Montana home, nearly 40,000 suffer from a serious mental illness.

Their journey is terrifying at times, a dark trip down the Alice in Wonderland-like rabbit hole of mental health care in Montana. For now, they've dragged their relatives and each other out of the upside-down world of mental illness. For how long, they're not sure.

They've emerged bruised and battered, not quite whole anymore, a little more fragile yet a bit stronger from their descent into the deep recesses of the mind.

The Treasure State, along with the nation, has made great strides in caring for people with a mental illness. After more than 40 years of advocacy for community-based care centers, people finally often can stay in their homes, or at least receive care in a home-like setting, while receiving treatment in Montana's larger cities.

Since the debacle of managed mental health care in the 1990s and early 2000s, money to help those with mental illnesses finally is easier to obtain.

After decades of jailing mentally ill people who commit crimes, the state and the nation are moving toward addressing the illness first before seeking penalization and incarceration.

And every year, new studies better show how mental illness is a physical ailment, treatable if not always curable.

Recovery, not just stabilization, is the new goal.

Yet holes remain in the system, through which many tumble and only some return.

No one thinks it will happen to themselves or a family member, yet almost 66,000 adults were enrolled in Montana's mental health programs in 2007. Each year, about 700 people are involuntarily committed to the Montana State Hospital in Warm Springs.

Too often, the stigma associated with a mental illness diagnosis makes doctors, therapists, patients and families reluctant to go down that road, so the ailment goes unaddressed. That stigma also keeps people from seeking help before the situation swirls out of control.

The onset of mental illness often occurs during the high school years, when teens may be testing boundaries, and is mistaken for drug or alcohol abuse, or "typical" teens rebelling against authorities.

Teens, as well as adults, tend to self-medicate, which leads to co-occurring disorders. New health privacy laws are making it more difficult for parents to participate in their children's treatment, especially when youths turn 18.

Montana has a shortage of psychiatrists, especially for the young. Waiting lists are the norm, rather than the exception, for both youth and adults seeking help.

Crisis hotlines are answered too often by a machine or by someone who isn't trained to handle a crisis. Sometimes, they're not even answered by someone in the community.

A recent report to Montana's Legislature showed that in fiscal year 2007, the Department of Public Health and Human Servicesspent $176.3 million on mental health services, an increase of $4.2 million (2 percent) from FY 2005, but a decrease from $180 million in FY 2006.

Despite the odds, people like Mihelish, Chisholm, Wilke and Caruso continue the fight to drag mental illness in Montana out of the shadows and into the spotlight by highlighting the struggles of dealing with mental illness, the difficulties and the triumphs.

Their hope is that perhaps some day, mental illness will be seen as a disease like diabetes or cancer, chronic perhaps but not terminal, and that one day soon the help people need will be available in every community, big and small, across Big Sky Country.

Biologically based mental illnesses

Five kinds of mental illnesses are deemed to be biologically based. Those include:

Clinical depression affects one in 10 men, and one in five women. Symptoms include a markedly diminished interest or pleasure in almost all activities, feelings of worthlessness, recurrent thoughts of death, and sad or empty feelings.

Schizophrenia affects 1 percent of the population of all societies. The illness can result from genetic, neurological, biochemical and environmental conditions, as well as physical trauma, advanced age or drug use. Symptoms include hallucinations, delusions, disorganized speech, emotional dullness, false ideas.

Bipolar disorder is sometimes called manic depression. Symptoms include anything from lethargy and a loss of interest in activities to sleeplessness and hyperactivity, and inflated self-esteem. It occurs in 1.2 percent of the population, including about 3 million Americans.

Acute anxiety is like a panic attack that happens without warning. Symptoms can be physical, like chills, chest pain, dizziness and shaking, along with a fear of losing one's mind, or dying or being detached from oneself. It affects women twice as much as men, and is thought to hit 1 to 2 percent of Americans, usually striking before the age of 24.

Obsessive compulsive disorder typically involves recurrent thoughts, images and impulses that cause intolerable anxiety, like a fear of contamination, with rituals that are performed over and over to try to relieve the unbearable anxiety related to the obsession. People with OCD are not delusional and do not have hallucinations.

Timeline of mental health care in Montana

1988 n A proposed plan for mental health services in Montana failed to include an outline for shifting more patients and funding from the state hospital to community-based programs, yet wanted to decrease the number of people sent to the state psychiatric hospital at Warm Springs. At that point, the hospital population was down to 300 beds from more than 1,000 in 1975.

1990 n A national report said Montana's services for the seriously mentally ill were among the worst in the nation, with no independent living opportunities for seriously mentally ill people, and practices that included detaining some mentally ill people in jails. At that time, Montana had about 4,000 people diagnosed with serious mental illnesses. Curt Chisholm, Department of Institutions director, told a state finance committee the institutions are antiquated and should focus on community-based care for the mentally ill, the developmentally disabled, alcohol and drug abusers and nonviolent criminal offenders.

1991 n The Mental Health Law Project, a national group, sued the state over conditions at the Montana State Hospital at Warm Springs. At one point the facility had only two psychiatrists for 300 people, no treatment program for the 60 percent of patients with drug and/or alcohol problems, no treatment plans for brain-injured patients or sex offenders, and an inadequate nursing staff.

1993 n The Montana Legislature passed a plan to bid out the state's $500 million mental health budget to a private contractor, starting the era of managed care, where independent third parties review medical treatment plans to determine if in-patient treatment is necessary.

1993 n House Bill 103 banned the jailing of mentally ill people charged with misdemeanors and those awaiting evaluations or commitment to a treatment facility. It was first passed by the Legislature in 1991.

1993 n Mental Health Services of Helena received a $350,000 grant to build a two-story building near St. Peter's Hospital to house its administrative headquarters and five clinical programs for low- and moderate-income residents from Lewis and Clark County. At that time, MHS had the Montana House on Last Chance and three facilities in other locations.

1995 n The State Criminal Investigation Bureau seized records from Mental Health Services Inc. The private, nonprofit agency that contracted with the state to provide services was later told to repay $249,000 in Medicaid funds that were overpaid from 1994-95.

1995 n After two years, the state finally came up with a plan -- the Montana Mental Health Access Plan -- to turn over almost half a billion dollars in publicly funded mental health programs to a private, managed-care organization for the next five years.

1997 n The state privatized the mental health system, issuing a $400-million, five-year deal with Magellan Behavior Health of Maryland to oversee statewide delivery of mental health care with public funds. Magellan called its Montana program the "Montana Community Partners." This was a joint venture of CMG Inc. of Maryland and the Care Coalition of Montana, a collection of 20 nonprofit groups. That company was to oversee all publicly funded mental health programs, including those at Warm Springs and services at the five regional mental health centers. It was an $80-million-per-year contract, the largest ever awarded by the state and the first of its kind in the country.

1999 -- The Legislature revoked the contract with Magellan after dozens of complaints from providers about not getting paid and poor treatment decisions for patients. After the contract failed, the state went back to a "fee for service" system with little management or treatment oversight, which according to Sen. Bob Keenan, R-Bigfork, "broke the bank once again."

2000 -- The state selected First Health Services Corp. of Virginia to review use of the state mental health system for the poor, hoping to save money by directing patients to less expensive alternatives. First Health Services is a subsidiary of First Heal, a managed-care firm based in Chicago.

2001 -- The state's mental health system for the poor faced a deficit of $17 million for the two-year budget cycle, due to cost overruns.

2002 -- Golden Triangle closed its New Visions mental health facilities in Helena, citing the need for more patients, but opened the Hannaford House for eight patients in a group-home setting. It also offered a Program Assertive Community Treatment, with in-home service and help managing crises for those who needed it.

2002 -- Drs. Michelle McCall and Nathan Munn, two of the three psychiatrists associated with St. Peter's Hospital, ended their affiliation with the hospital's mental health division. The hospital's Support Center, which had operated for 16 years and saw an average of 400 patients per year, closed three months later. The average stay for a patient was four nights, and was subsidized by the hospital from $300,000 to $1 million annually. Inpatient services provided at the Support Center included psychiatric evaluation, treatment planning, groups and classes as appropriate and discharge planning.

2005 -- Lewis and Clark deputies moved 144 mentally ill people out of the county jail and to some other facility, often Warm Springs.

2006 n The Golden Triangle Community Mental Health Center opened an eight-bed stabilization center for people in Helena who need three to 14 days to get back on their meds.

2009 -- The Montana Legislature passed a variety of bills related to mental illness, including the ability for counties to get matching state funds for crisis intervention, jail diversion and short-term in-patient costs; a requirement for the state to find beds for people outside of Warm Springs during times of crisis; and the ability to give a person the opportunity to agree to local treatment versus holding a commitment hearing. The federal government also passed a parity bill, which forces insurance companies to pay for mental illness treatments the same as it would for other medical treatments.

To view the complete series on mental health care services in Montana, click here.