Suicides Point to Gaps in Treatment

On the evening of March 21, 2005, Gene Migliaccio, then director of the immigration health services agency, sent a brief BlackBerry message to colleagues: "DIHS is concerned that detainee committed suicide, in medical pod, after being assessed a suicide risk."

Hassiba Belbachir, a 27-year-old woman from Algeria, had strangled herself with orange jail-issue socks, which she knotted together and wrapped twice around her neck.

Five days before her suicide, Belbachir had a panic attack in her cell in an Illinois jail and was moved to a medical ward. The next day, internal records show, she told a social worker she was hearing "parasites and radio waves" and that she wanted to die. "Death is dripping, drop by drop," she said. But she was not placed on suicide watch.

Immigration officials declined to comment, citing ongoing litigation in the case.

Belbachir had arrived eight days earlier at Chicago's O'Hare International Airport. The youngest of seven children, she loved books on religion and dancing the merengue. With a degree in Spanish, she thought of becoming a translator. "She wanted to visit the world," said an older sister, Houaria Belbachir, who lives in France.

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Belbachir had gotten married, and her husband had brought her to Chicago to live. After a month, she learned he had another wife. She fled to Spain, but without a visa, she was turned away at the airport. She flew back to O'Hare, asked for political asylum and, by federal policy, was taken into custody while authorities considered her claim.

Belbachir was sent to McHenry County Jail in the far suburbs of Chicago. The jail already had problems with its medical services: Detainees did not receive the required mental health screening, nor the standard screening for suicide risk, a recent review had found. Untrained staff members often did what screenings there were.

During Belbachir's intake screening, jail records show, she said she had tried to commit suicide once by drinking soap. The social worker who interviewed her noted that she had a "major depressive disorder" and needed to see a psychiatrist for medication. Belbachir was given an appointment for 6 p.m. on March 18.

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.x

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."

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.

Money is not the only factor that determines the quality of care. Poor practices, records reveal, created a crisis situation at the South Texas Detention Complex at Pearsall, outside San Antonio.

On June 15, Gustavo Cadavid, chief of psychiatry for DIHS, waved a red flag after discovering that Pearsall's clinical director, Erik Johnson, had "close to 140 chart reviews" pending, meaning 140 patients still needed care. Cadavid had complained to headquarters several times about Johnson. "[I]t is becoming clear that there exist a crisis in the mental health care at Pearsall," he wrote in June.

Two hours later, Slate gave Cadavid some advice. "It is my suggestion that [medical director Timothy Shack] issue a clear order for Dr. Johnson to begin to provide treatment to mentally ill detainees," he wrote in an e-mail. "If he fails to follow the order, then this behavior needs to be interpreted as insolence and insubordination and documented as such."

Slate titled his e-mail "Crisis in mental health care in Pearsall." He copied it to seven top ICE and DIHS administrators, including the interim director of DIHS, Neil Sampson.

Immigration officials said the mental health care program at Pearsall meets national detention standards. Reached by phone, Johnson declined to comment. He is still at Pearsall.

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Based on confidential medical records and other sources, The Washington Post identified 83 deaths of immigration detainees between March 2003, when the federal Immigration and Customs Enforcement agency was created, and March 2008.

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