Suicides Point to Gaps in Treatment

By Dana Priest and Amy Goldstein
Washington Post Staff Writers
Tuesday, May 13, 2008

Peasant farmer Jose Lopez-Gregorio, 32, left his wife and five children behind in Guatemala with two bags of corn, barely enough food for one month, when he decided to find work in the United States. Detained crossing the Mexican border and held in an Arizona immigration center, he felt guilty, he told guards, eating three meals a day. Lopez had been inside one month and eight days when he strangled himself with a bedsheet. Five days earlier, the staff had placed him on suicide watch, only to be overruled within hours by the center's psychologist.

Mexican Carlos Cortes Raudel, 22, hanged himself from a tree on the way to breakfast in a California compound. Korean Sung Soo Heo, 51, was on suicide watch, less than a week after leaving a psychiatric hospital, when he hanged himself from a ceiling vent in his New Jersey cell. Geovanny Garcia-Mejia, 27, a Honduran, wrote notes in blood on his Texas cell floor and hanged himself from a ventilation grate while supposedly under 15-minute checks around the clock.

"It goes without saying that the incident could have been avoided," the Newton County sheriff noted in an internal review of Garcia's death.

While tens of thousands of detainees inside immigration detention centers endure substandard medical care, people with mental illness are relegated to the darkest and most neglected corners of the system, according to interviews and thousands of internal documents, including e-mails, memos, autopsy reports and other medical records, obtained by The Washington Post.

Doctors and nurses who often have difficulty detecting and treating physical ailments are having even greater problems managing the nuances of mental illness, documents and interviews show. Treating mental illness is a challenge in any context, but inside this closed, overburdened world, some psychiatric patients undergo months and sometimes years of undermedication or overmedication, misdiagnosis or no diagnosis.

The records reveal failures of many kinds. Suicidal detainees can go undetected or unmonitored. Psychological problems are mistaken for physical maladies or a lack of coping skills. In some cases, detainees' conditions severely deteriorate behind bars. Some get help only when cellmates force guards and medical staff to pay attention. And some are labeled psychotic when they are not; all they need are interpreters so they can explain themselves.

Suicide is the most common cause of death among detained immigrants. It accounts for 15 of 83 deaths since 2003, when the Department of Homeland Security's Immigration and Customs Enforcement agency, known as ICE, took over facilities for foreigners whom the government is trying to deport. Inside these out-of-the-way compounds around the country, suicide attempts seem to be on the rise, according to internal documents: 16 in June, 21 in July, 20 in August.

No one in the Division of Immigration Health Services (DIHS), the agency responsible for detainee medical care, has a firm grip on the number of mentally ill among the 33,000 detainees held on any given day, records show. But in confidential memos, officials estimate that about 15 percent -- about 4,500 -- are mentally ill, a number that is much higher than the public ICE estimate. The numbers are rising fast, memos reveal, as state mental institutions and prisons transfer more people into immigration detention.

The influx is overwhelming the system, internal documents show. The ratio of staff to mentally ill detainees is out of balance, with far fewer staff members than in other prison settings, according to Dennis Slate, the top mental health official in the detainee system. In an e-mail to colleagues the morning of last May 31, Slate said the ratio in the Bureau of Prisons was 1 to 400. In prisons for the mentally ill, it was 1 to 10. But in the immigration detention centers, it was 1 to 1,142.

Immigration authorities contract with a private facility in South Carolina to care for seriously mentally ill patients. They said they are considering additional options for increasing care for such detainees.

Along with the crisis in care, the records also show soul-searching among doctors, nurses and administrators. "We need to stop looking for band-aid solutions for these problems," Slate wrote. "Step back, take a deep breath . . ."

It wasn't just patients that Slate and his colleagues worried about. They also worried that trading financial savings for substandard health care would come back to haunt the government. "Think about what we are trying to accomplish with limited financial and personnel resources we have," Slate wrote. "The little money managed care may save in the short run is going to be dwarfed by the millions that will be paid out by ICE when the lawsuits roll in."

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