Suicides Point to Gaps in Treatment

By then, she had been dead for a day.

Investigation reports say a guard glanced into her cell at 3:40 on the afternoon Belbachir died. She was lying face down on the floor, but the guard could see only her lower back and legs. He asked a co-worker whether she "usually sleeps like that," and was told that she did.

Half an hour later, when the guard returned to deliver dinner, he opened the cell door to discover Belbachir unconscious with the socks around her neck, her face purple, her mouth bloody.

She left a five-page handwritten poem, in French, on a paper with "Visa Waiver Program" across the top. It began: "It's good, the death."

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Inside the detainee mental health system, treatment decisions often revolve around money. There are frequent battles, with doctors and nurses in the field on one side and the managed-care administrators in Washington on the other, looking for ways not to spend. The battles often prompt Solomonic choices.

One day, Slate and his colleagues engaged in an e-mail debate over a mentally ill detainee who was in the hospital but now well enough to leave. Should they send him to a detention center, where there was a bed available but no outpatient psychiatric care? Or should they keep him in the hospital, at greater cost, until space in a more appropriate immigration compound became available?

"We can not just leave these detainees in the hospital," insisted Linda Jo Belsito, the nurse in charge of managed-care decisions for DIHS. "Dr. Slate is advising leaving these detainees in-patient but I do not agree." Reached by phone, Belsito declined to comment.

Down the hall from Belsito's office at headquarters, Matt Kleiman, the head of behavioral health, strongly disagreed. Detainees such as these who are returned to the general prison population "will in all likelihood decompensate quickly," he warned, using a term that means to deteriorate psychologically.

Belsito and her managed-care associates were withholding treatment for many types of care, saving the agency millions of dollars. For mental health services, four denials for treatment of manic-depressive psychosis saved DIHS $18,145.36, according to an itemized record of the savings over a one-year period ending in August 2006. Two denials for care of "unspecified psychosis" saved an estimated $11,668.60. Nine denials for treatment of "depressive disorder not elsewhere classified" saved $43,158.57.

An immigration spokeswoman said the vast majority of requests are ultimately approved and the denials are usually because of insufficient information.