Benjamin Hawkes had already rotated through the clinics and hospitals of Maryland's mental health system when, one day last February, he returned to the system's front gate -- a hospital emergency room -- on the brink of a catastrophic breakdown.
But the doctors at Howard County General Hospital elected not to admit him. His mother lamented in a prescient e-mail to another of her children that the ER was "overworked, understaffed and psychiatrically deficient."
"He really reached out for help this time," she wrote that night. "The mental health system is sick."
The following day, Hawkes entered his mother's home wearing only a bathrobe and an American flag draped around his neck and began attacking her and a houseguest. He sliced their necks with kitchen knives, then bashed their faces with a sledgehammer. Police found the 25-year-old Hawkes in the family room, naked, stained with blood and spattered with brain matter, listening to instrumental music at full volume.
The slayings stand today as a gruesome reminder of all that is unwell with Maryland's mental health system. Beyond the struggling of outpatient clinics, several of which have closed in the past year, the state has drastically scaled back its coverage for outpatient care. That has put emergency rooms on the front lines of mental health care, even though many are ill-equipped -- or unwilling -- to handle the most difficult cases.
"The denial of treatment is putting the most severely disabled mentally ill patients at risk," said Herbert Cromwell, executive director of the Community Behavioral Health Association of Maryland. "The system is being squeezed."
In the first half of 2001, hospital emergency rooms had a 17 percent increase in psychiatric cases from the same period in 2000, according to numbers still being analyzed by state health officials. Pegeen Townsend, a lobbyist for the Maryland Hospital Association, said the influx has been unmistakable.
"Around the state, I'm hearing ERs are being inundated by folks with mental illness, and they are finding it very difficult to find a place to put them," she said.
At the root of the mental health crisis are money problems that have plagued Maryland's mental health program since 1997, when the state changed the way it reimburses clinics and hospitals for the care they give uninsured and Medicaid patients. This year, budget analysts estimate the system faces a $20 million deficit, one that won't be solved easily given the current budget shortfall.
Maryland's crisis mirrors troubles in dozens of states that have experimented with managed care to pay mental health costs, according to Michael J. Fitzpatrick, director of state policy for the National Alliance for the Mentally Ill.
"What we're seeing out there is varying degrees of chaos," he said. "Look at the percentage of people with mental illness in jails or in the homeless population, and you realize this system is struggling."
For the past two years, Maryland mental health officials have acknowledged their state's crisis but have repeatedly insisted, even as clinics close, that the shortfall is not affecting patient care. But there is mounting evidence that patients are suffering.
The squeeze is being felt by such patients as Craig Ellington, 23, a Hyattsville man who has been treated in Maryland for bipolar disorder since he was 13. For years, Ellington traveled daily by bus from his aunt's home to a rehabilitation clinic in Rockville, where he was given medication and therapy and learned such skills as counting money and telling time so he could survive in the outside world.
In October, the clinic received word from the state's managed care contractor, Maryland Health Partners, that Ellington's treatment was no longer covered.
"Everything he had, the stability of a daily schedule, the certainty he would take his medication, it was cut off," said Lisa Coakley, 41, Ellington's aunt and primary caretaker. "All of his services were denied."
The clinic, Affiliated Sante Group, sent three pages of documentation appealing Maryland Health Partners' decision, to no avail. Without money to pay for his care, Coakley, a real estate agent, was forced to leave Ellington at home all day, locked in her house, where he would watch television or sleep. Within weeks, Ellington became noticeably more agitated, she said.
"He started losing sleep. He would babble and talk incoherently, and then he tried to break out of the house," she said. One night in November, he became so menacing that Coakley drove him to the Johns Hopkins Hospital emergency room in Baltimore. She went there, she said, because the ER had a history of admitting patients.
While hospitalized, Ellington showed bursts of violence, at one point injuring five staff members as they tried to restrain him. On Dec. 20, though, he was discharged with a recommendation that he resume the treatment in Rockville -- the very same care that had been discontinued two months earlier.
"The whole cycle he went through was unnecessary and cruel," said Jeff Carswell, Affiliated Sante's director. "And he was not the only one to go through this."
Officials at Maryland Health Partners said they could not comment on a specific case, but they acknowledged that this summer was a turning point for patients like Ellington. At the request of state health officials, Maryland Health Partners began in July to change the way it approved or denied treatment requests from patients.
They began what Maryland Health Partners President Damian Briggs called "aggressively managing care." Coverage for such services as therapy, life skills training and medication management is now carefully scrutinized.
Oscar Morgan, director of the state's Mental Hygiene Administration, said, "We told MHP we need to make sure people are getting the right level of care."
Briggs said that in response to Morgan's request, his screeners asked clinics for more frequent reports justifying each patient's care, and they then began looking for ways to scale back. Briggs said patients have not been denied care they need, only the care that went beyond the patients' needs.
Clinics and hospitals, he said, have become accustomed to asking for more than what's needed, because no one was telling them no.
"I believe it's been a little behavior modification, and the providers are slowly accepting the new process," Briggs said. "It's just taking time."
The results, from a cost-cutting standpoint, have been remarkable. Since July, Morgan said, the state has saved about $15 million by reducing care. But the caregivers have bristled at the sudden rush of denials. Since July, they have filed more than twice the number of appeals of Maryland Health Partners care decisions as in the previous six months.
Lori Doyle, vice president of Revisions Behavioral Health Systems in Baltimore County, said she has filed several appeals for her patients, including clients who were denied care despite histories of suicide attempts and repeated hospitalizations.
"Cost containment is happening on the backs of people in dire need," Doyle said. "These are the folks who could kill themselves. These are the folks who hospitalize themselves as a last resort. To just say they don't need these services is putting their lives at risk."
Some clinics, unwilling to deny care to their patients, simply treat them for free. But as the clinics lose money, more patients are turned away. And as their cases become acute, they head to the nearest emergency room.
Under law, emergency physicians cannot deny care to the patients, even if they lack insurance. But the rates hospitals get paid for psychiatric patients don't come close to covering the costs, especially in difficult cases. Some mental health advocates believe this has proved a disincentive for hospitals to admit patients.
The hospitals say patients are suffering delays in getting admitted because they are short of beds for psychiatric care. Between 1999 and 2000, the number of beds available declined in Maryland by more than 1,800 -- to about 6,800. The shortage may be cost-related, since the rates set by the state don't make the beds profitable.
Michael J. Kaminsky, clinical director of the Johns Hopkins University department of Psychiatry, said hospitals have engaged in "active avoidance" when faced with difficult cases. "Clearly," he wrote in a letter to the Maryland Health Care Commission, "something is broken in a system that, almost on a monthly basis, leaves patients in our Emergency Department for 24 to 72 hours awaiting placement."
Emergency physicians have been meeting periodically since May to try to work around the bed shortage and reduce the risks posed by delaying care. One solution would use computers to track the location of every available bed in the state, so patients can be sent for treatment immediately.
"The ER physicians are very concerned about the lack of space to put these patients, especially children and adolescents, who are extremely difficult to place," said Barbara Brocado, a lobbyist in Annapolis for the American College of Emergency Physicians. "But there's no magic solution. I wish there was."
Howard County General Hospital officials said all the normal procedures were followed when Benjamin Hawkes entered their emergency room Feb. 10. He had spent the previous night at a party, muttering to himself and at one point pulling his pants down. Records show he told the admitting nurse that he had not slept, that he felt depressed and that he "had difficulty thinking."
During his 30-minute examination, the psychiatrist who treated Hawkes noted a previous diagnosis of schizophrenia. But this time, the diagnosis was anxiety. He was given a mild sedative and advised to make an appointment at a clinic.
At 3:15 a.m. Feb. 12, Hawkes was back at the hospital, this time in handcuffs. He urinated on a cot and flinched when he was offered water. Voices, he said, had urged him to kill, and he had listened.
A Howard County judge has since found Hawkes legally insane. At Clifton T. Perkins, the state's facility for the criminally insane, he is finally getting the treatment he needed.
