The costly revolution in mental health care Cutoff: Insurance spending limits affected the psychiatric treatment of Benjamin Scott Garris and Jane DeCosta before the teen-agers became suspects in a slaying.

THE BALTIMORE SUN

Benjamin Scott Garris tried to kill himself with sleeping pills, alcohol and cough syrup -- yet his psychiatrist planned to discharge him from a hospital emergency room once doctors flushed his stomach with charcoal.

Jane DeCosta, a chronic runaway who once threatened to jump from the fifth floor of a Towson parking garage, was admitted 11 times to psychiatric hospitals over the course of a year. Her typical stay: three days.

The stories of Ben and Jane -- two teens charged in the October slaying of a counselor at Sheppard and Enoch Pratt Hospital -- have raised fears about the risks faced by rebellious teens. But they also reveal much about the economic revolution that is transforming psychiatry.

In both cases, parents battled insurance companies to get extended care for their troubled youngsters. And both were told the same thing: Their managed care plans didn't allow for long-term hospital stays, even after their children had put their lives in grave danger.

Although Ben's parents overcame their insurance limits, Jane's spent themselves into bankruptcy trying to get the care she needed. After reaching into their pockets to buy extra days in the hospital, the Timonium couple closed their home insulation business and lost their house.

Efforts to trim mental health costs have driven managed care companies to shorten hospital stays and limit outpatient visits. In response, Sheppard Pratt in Towson has closed more than a third of its beds, and other hospitals have made cutbacks. These days, therapists spend more time writing prescriptions and less giving psychotherapy.

It's a revolution that troubles patients, families and psychiatrists.

"The patients haven't changed, the severity of illnesses hasn't changed," said Dr. Robert Temple, a psychiatrist who is the former director of inpatient services at Sheppard Pratt. "It puts patients and physicians at risk for not being able to do the job right together."

Less than a decade ago, it was common for depressed teen-agers to spend months in psychiatric hospitals, working through torments that had driven many to thoughts of suicide. In 1989, the average stay for teen-agers at Sheppard Pratt was four months, though stints of nine months or longer were not $H uncommon.

Today, managed care parcels out stays that are usually measured in days or weeks. Two weeks is now the average stay for a teen-ager at Sheppard Pratt.

Steve Garris recalls the "horrendous" scene at Frederick Memorial Hospital last March when his son, Ben, was having his stomach flushed after a suicide attempt. The boy's psychiatrist emerged from the room where Ben was being treated.

"He comes into the [waiting] room to us and says, 'Well, he's not going to try to kill himself anymore,' " Mr. Garris said, recalling the words of the psychiatrist, who died this year. "He can go home."

A spokesman for MDIPA, the insurance company, refused to comment directly on the case. He said only that the insurance company would offer more generous benefits if employers chose to pay higher premiums.

Mr. Garris said he was outraged when the psychiatrist explained that the boy, by managed care standards, qualified for discharge because he promised not to hurt himself again.

Protesting vigorously, the parents persuaded the psychiatrist to diagnose the boy as a danger to himself and refer him to Sheppard Pratt. There, they were told the insurer had authorized four days -- no more. Upon further review, Mr. Garris said, the company extended the stay to two weeks.

Then, the insurance ran out. Insiders at Sheppard Pratt, along with Mr. Garris, say hospital authorities refused to discharge Ben because they were afraid the teen-ager would take his life. To keep him longer, they tapped the hospital's endowment and obtained subsidies from Frederick County, that county's school system and the state of Maryland.

Ben spent two months in inpatient units and five in the more relaxed Fordham Cottage, a group home on the hospital grounds. All told, it was an extraordinarily long stay for a psychiatric patient.

The hospital wanted to transfer him to a more secure "residential treatment center" off hospital grounds, but hospital officials had trouble finding an opening in a suitable facility.

Still, the Oct. 8 slaying of counselor Sharon Edwards shocked many who knew of Ben's case. Therapists were afraid Ben, 16, would kill himself -- but said he never showed signs of the violence for which he stands accused.

"A lot of people felt sad and angry that we hadn't helped this kid after so much had been devoted to his care and treatment." said Dr. Steven S. Sharfstein, president of Sheppard Pratt.

Jane DeCosta -- bright, athletic and pretty -- showed the first signs of depression when she was 5 years old. Parents Richard and Peggy DeCosta said she had trouble concentrating in school and hated going there. They remember her as sad and frustrated.

When she was 12, she ran away, disappearing for three days before being traced to a Boston train station. Back home, she was admitted to the Gundry-Glass Psychiatric Hospital in Baltimore, and was diagnosed with severe depression.

The company that managed her benefits, Green Spring Mental Health Inc., authorized a two-week stay and assigned a series of outpatient visits once she was discharged, her parents said.

A week later, she was gone again.

By her parents' count, she ran away 20 times between the ages of 12 and 15.

Between June 1993 and May 1994, she was hospitalized 11 times at various hospitals -- usually for two or three days, but never for longer than two weeks.

"It became such a game to her," her mother said of Jane, who is charged as an accomplice in the slaying. "She'd meet all these kids who were also there for little bits of time."

At different hospitals, she saw different doctors. And she received different diagnoses: severe depression, bipolar disorder, borderline personality and oppositional behavior. She was given anti-depressants, tranquilizers and lithium, a drug for bipolar disorder -- and sometimes several drugs at once, said Mrs. DeCosta.

Along the way, police coaxed her from a parking-garage ledge at Towson Town Center, said her parents. At one hospital, she scored her wrists with a nail file.

Dr. Jonathan Book, a psychiatrist who is Green Spring's chief medical officer, declined to comment directly on her case. But he said it is a mistake to think that all behavioral disorders can be solved by long hospital stays.

"The treatment comes over quite a long course" -- combinations, perhaps, of hospitalizations, foster care, residential treatment and outpatient therapy, he said. "Our approach to managing care is matching patients with appropriate levels of care."

Dr. Sharfstein, who has reshaped Sheppard Pratt to meet the realities of managed care, said a small portion of a hospital's caseload is ill-served by shorter stays.

He calls them "catastrophic patients" -- people prone to relapse despite repeated efforts at treatment. Some are depressed, teen-age runaways.

"At this point, with managed care, there is very little interest in trying to provide for that kind of care," he said.

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