Hooked on treatment: Marylanders pay clinic millions, but diagnoses questionable

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Kevin Brown knew he was hooked on crack cocaine. That was obvious each time he set off on another smoking binge. But Brown says he never imagined that he also suffered from a mental illness until he walked into Baltimore Behavioral Health Inc.

A day or so after he went to the private, nonprofit Southwest Baltimore clinic in 2007 hoping to kick his drug habit, a psychiatrist diagnosed him with major depression. Soon, he was living in one of BBH's houses, taking antidepressants and spending hours each day in group therapy, half of it focused on mental illness. The treatment lasted months and cost taxpayers thousands of dollars.

But Brown, 46, doubted that he had a psychiatric illness or needed medication. And for good reason, says Amy Jackson, a University of Maryland mental health social worker who counseled him over a recent six-month stretch after he'd relapsed: He never was clinically depressed.

"Once he was no longer using the substance, he was no longer showing signs of the depression," Jackson said. In other words, he suffers from a chemical addiction, and when that is under control, his mind is not burdened by mental illness.

Brown, an addict diagnosed with a psychiatric illness that some outside health providers do not think he has, illustrates a recurring theme at BBH.

Addicts who step into BBH from the city's drug-racked streets are three times more likely to be deemed mentally ill than are addicts treated at other centers across Maryland, state records show.

And BBH has long funneled patients into the costliest outpatient treatment programs available to poor Marylanders — programs they would not qualify for without a diagnosis that they have a psychiatric illness. In some years, state data show, the West Pratt Street center has swallowed up 85 percent of the  taxpayer funds spent on intensive outpatient mental health care across Maryland.

From modest beginnings in 1997, Baltimore Behavioral Health grew by last year into a $17 million-per-year operation, with more than 250 staff members tending hundreds of patients a day, making it one of the region's largest providers of drug treatment. It has diagnosed and treated thousands of the city's most broken and desperate, offering many a bed in its network of area rental homes, then busing them daily to the center for state-funded treatment.

But former patients and employees, as well as outside doctors, say BBH has been diagnosing mental illness — and collecting public money to treat it — in some patients whose main affliction is drug addiction.

BBH is an outpatient mental health clinic that specializes in treating co-occurring drug abuse and psychiatric illness. It mostly bills Maryland's public mental health system, principally Medicaid. And in order to bill that system, a patient's main affliction must be psychiatric rather than drug addiction.

In May, Chief Executive William "Kris" Hathaway said BBH is committed to providing quality care to its patients by blending kindness and clinical rigor to address their physical and mental needs.

"We work very hard to fulfill our mission," he said. "A significant portion of our patients are a very difficult and underserved segment of our society, though we do not wish to foster that image because everyone is equally deserving of respect and compassionate care regardless of their circumstances."

A Baltimore Sun investigation that included dozens of interviews with former patients, psychiatrists and other health professionals, analysis of tax and court records, and a review of state data, found:

•About 90 percent of drug-using patients at Baltimore Behavioral Health, many of them walk-ins, have been deemed to suffer from mental illness, according to the most recent seven years of state health department data. The average is 31 percent for all drug treatment providers in Maryland.

•BBH's frequent and extended use of intensive treatment, coupled with its practice of giving patients multiple chances to get clean, has fueled a boom in billings to the taxpayer-funded state system. Its claims rose from $5.5 million six years ago to more than $17 million in fiscal 2009 before dipping in the last fiscal year.

•BBH has a reputation on city streets, in jails and at area treatment providers for admitting addicts who say they feel depressed, triggering a psychiatric diagnosis that leads to more expensive treatment, according to more than a half-dozen former patients. Two prior patients told The Sun they were advised by BBH staff on what to say at intake — a practice that BBH says would be grounds for firing.

•State data show that by 2004, BBH stood out from other providers for its use of high-cost treatments. Yet state officials in charge of the public mental health system say they noticed this only in 2007. Even then, they did not take steps until fall 2009 to address BBH billings.

•More than a dozen former patients and staff members describe illicit drug use by patients at BBH facilities and patient houses. Paramedics answering calls about possible overdoses have found people under the influence of cocaine and heroin.

State health officials began investigating BBH in May, after The Sun began its probe. Health surveyors recently examined files of 12 randomly chosen patients and found numerous deficiencies that can cause "a significant health or safety consequence, a violation of rights or infringement on quality of life." The state Mental Hygiene Administration is reviewing the findings.

"I look at this as part of an ongoing investigation," Dr. Brian Hepburn, executive director of the agency, said in October.

On Friday, Hathaway of BBH said in an e-mail that most of the alleged deficiencies resulted from state surveyors' unfamiliarity with its electronic records and that the audit was not based on the complete record.

Hepburn said Baltimore Behavioral Health is in good standing with his agency. And BBH is certified by the Joint Commission, a private group that accredits hospitals and clinics nationwide.

But Hepburn, a psychiatrist, said he was "very concerned" about BBH for reasons that go beyond billings. Patients suffer harm if they continue using illicit drugs while seeking treatment for substance abuse, mental illness or both problems, he said. Patients also suffer, he said, if they are misdiagnosed as mentally ill and given medicine they don't need.

"In the end, it actually works against the individual, because they now have a psych diagnosis and they're now on psychiatric medications, and that follows them wherever they go."

Co-occurring disorders

The BBH campus sprawls across two large brick buildings on West Pratt Street, next to the B&O Railroad Museum. On a recent day, dozens of people smoked cigarettes and milled around the clinic's courtyard, a short walk from neighborhoods awash in drug dealing. In the parking lot sat a fleet of white BBH vans bearing the company motto: "Turning Lives Around."

Inside, counselors led group therapy sessions for scores of patients. A brief tour last year showed clusters of patients engaged in classroom discussions.

BBH is a magnet for down-and-out addicts in a city teeming with them. The city's substance abuse authority, Baltimore Substance Abuse Systems Inc., admitted more than 16,000 people for treatment last year at providers across the city but says that twice as many went without needed care and that residential slots are in especially short supply.

As of the summer, BBH was treating about 800 patients, with nearly 150 living in its rental housing. Its chief executive declined requests for interviews. He agreed to answer questions in writing and replied to about a quarter of the more than 40 questions submitted by The Sun in June.

Dr. Nicholas Scotto, BBH's chief doctor, called the newspaper last month to elaborate on the organization's practices. "We're helping a lot of people, doing a lot of good for these people, that often nobody wants to help," he said.

In an earlier statement, Hathaway summed up his philosophy for tackling a person's drug problem and underlying mental illness at the same time.

"Treating only the addiction does not address the psychiatric disorder, which may lead to abusing drugs again to manage the depression," the company's chief executive wrote. "Conversely, treating the depression without addressing the drug addiction is a recipe for disaster, because there is a pharmacological component in addition to a psychotherapeutic component to managing depression."

The phenomenon of mentally ill drug addicts is well established in medical literature, where it is called "co-occurring disorders." But many experts say a minority of addicts in any population will be actively suffering from a psychiatric disorder not brought on by drug use.

Dr. Christopher Welsh, 46, an addiction psychiatrist at the University of Maryland Medical Center who focuses on heroin abusers, said fewer than half the addicts he treats use drugs to ease the effects of freestanding mental problems. These can include bipolar disorder, marked by extreme mood swings, and schizophrenia, a brain disorder that can cause paranoia.

Most are not mentally ill, Welsh said. "Substance abuse is often an independent disorder. You don't need another disorder to explain it. It happens in and of itself."

Feeling miserable, as addicts often do in the throes of addiction or withdrawal, is not enough to support a psychiatric diagnosis. The state stresses that the public mental health system should not pay for psychiatric treatment if someone has a "substance-induced" mental condition, that is, one caused by drug use and likely to fade with sobriety and drug counseling.

"If everything in your life is falling apart, you feel horrible, but that doesn't mean you have clinical depression," said Alice Jonas, a psychiatric nurse who runs Union Memorial Hospital's intensive outpatient program in North Baltimore. "There are people who, if you get them sober, completely off drugs and alcohol — oh, my God, a couple months go by, and there is no sign of what anybody could call depression or mood changes. They're good to go."

By contrast, a freestanding mental condition persists even after the person gets off drugs, she said. "Three months later, they still have their bipolar disorder or major depression. There is a very serious overlying mental illness."

One in eight drug abusers nationwide had a serious mental illness in 2008, according to the most recent available statistics from the federal Substance Abuse and Mental Health Services Administration. It defines serious mental illness as one causing major "functional impairment, which substantially interferes with or limits one or more major life activities." The agency excludes all "substance use disorders" from the tally.

Similarly, a study of heroin addicts in Baltimore published in 1997 found that while 39 percent had a psychiatric disorder, only 5 percent suffered from a "serious" illness such as psychosis, bipolar disorder or major depression, said Hopkins psychiatrist Dr. Van L. King, a co-author.

Since 2004, BBH clinicians have deemed nine out of 10 patients who arrived in the grip of drug addiction as having a separate mental health problem, according to the state Alcohol and Drug Abuse Administration. And the center has historically put most patients into treatment regimens designed for the severely mentally ill — those on the verge of needing inpatient therapy in a psychiatric ward.

BBH says it has a large overlap because its specialty is treating those with both mental illness and an addiction. Hathaway likened it to a pulmonologist with many asthma patients. "Most patients," he said, "are referred to us from other agencies with a psychiatric diagnosis."

But BBH submits annual reports to the state showing that up to two-thirds of its drug-addicted Medicaid patients walk in without a referral. A social worker who worked at BBH until last year estimated that half of the company's patients came in off the street.

With so many walk-ins, far fewer than 90percent of BBH patients would likely suffer from both mental illness and addiction, let alone need intensive psychiatric treatment, veteran practitioners say.

Dr. Michael Fingerhood, 50, an associate professor and addiction specialist at the Johns Hopkins University School of Medicine, says more than a hundred BBH patients have come under his care. Most told him they were assessed as bipolar by BBH staff, he said, but he estimates that just 10percent fit that diagnosis.

"The majority of them have adjustment disorder or personality disorders that are related to their drug use," he said of BBH patients he has treated for detoxification at the Hopkins Bayview Medical Center. With sustained sobriety, Fingerhood said, signs of the disorder often fade away. Though not a psychiatrist, he has more than two decades of clinical experience.

"Do I think BBH helps people? Yes," he said. "But I think … they're doing a disservice to people by labeling them as bipolar."

Even in the best clinical scenario, a psychiatric diagnosis is tricky, experts say; doctors have no X-rays to help apply the criteria defining a mental illness. Welsh said it's particularly hard in abusers of heroin, the drug most commonly used by BBH patients. "Because the withdrawal from heroin is so miserable," he said, "people can feel miserable for weeks or more as they're still detoxing."

Rather than withholding a mental health diagnosis and starting with drug treatment, BBH says it often puts patients on psychiatric medication straightaway. That, Welsh and others say, makes it hard to tell whether sobriety and drug counseling would have brought improvement.

Welsh said he believes many patients benefit from BBH. But "I know patients that go to BBH that I'm absolutely convinced do not have a mental illness."

Getting into BBH

They go to BBH for different reasons. Some patients clearly need help with interconnected drug addiction and psychiatric problems, such as schizophrenia or bipolar disorder, former patients and staff members say. Some are referred from hospital inpatient units.

BBH "saved my life," said Chris Schussler, 53, who says he was treated for mental illness last year at Sheppard Pratt before going to BBH for further treatment.

Bon Secours Hospital in West Baltimore refers some patients from its inpatient psychiatric unit, said Dr. Darryl M. Coleman, a psychiatrist there. "The majority of what I've heard [about BBH] is good," he said. "Of course, you hear some complaints about everywhere."

Other former patients told The Sun they simply wanted treatment for drug addiction and went along with a psychiatric diagnosis that they doubted because it seemingly was the price of admission.

Still others are drawn by the prospect of housing. BBH, though outpatient only, offered free beds for years before it began charging patients $150 to $200 a month.

For most patients, the road to BBH has usually started in Baltimore, sometimes after a suggestion from a friend, relative or fellow junkie. Some have gone straight from a city jail cell.

James Scriven, 44, was about to get out of jail in 2004 after a drug conviction when he heard of the program from a cellmate.

"He said, 'You can go to BBH, but you have to tell them you're dual diagnosis,'" Scriven recalled. "I said, 'Dual diagnosis?' [He said], 'You have to tell them you have a mental problem and a drug addiction. You tell them you're depressed, they'll put you on public assistance and they'll put you right in.' That's what happened."

Scriven said, "You know in order to get off the streets you have to be diagnosed with a mental disability. You're going to tell these people what they want to hear."

He says he went to BBH for treatment three times before getting sober in 2008 at the Helping Up Mission, an East Baltimore program. In 2007, he was convicted of drug possession, according to online court records.

BBH's success rate is unknown. The state says it can track patients' treatment only within Medicaid. BBH has no way to follow them after they leave, Hathaway wrote: "The majority of our patient population have a highly transient lifestyle and are frequently homeless. Thus, we have found it difficult to conduct any meaningful tracking of former patients."

New arrivals at Baltimore Behavioral Health are screened by admissions staff at the Pratt Street campus and seen by a social worker or licensed counselor. A psychiatrist does an assessment, makes a diagnosis and prescribes medication. Frequently that is Scotto, the chief medical officer.

In a statement to The Sun, Scotto said that "15 to 20 minutes with the psychiatrist is quite common." He said that is "a small part of the multifaceted process of diagnosing our patients," which can last five hours and include a checkup and mental health screening. "Most patients admitted to BBH," he said, "have had an extensive psychiatric history."

Scotto added: "Most patients are diagnosed and begin treatment within the first 24 hours of presenting for care. It is more efficacious to treat both psychiatric and withdrawal symptoms at the same time. They are more likely to leave and relapse otherwise. Holding off on psychiatric medications sets them up for a higher potential of not completing the detox protocol."

In the recent phone interview, Scotto rejected comparisons to broader populations, such as the federal government's nationwide estimates, saying that people who seek treatment at BBH are often unemployed and homeless and therefore worse off than most drug abusers.

"To wind up without anything in life and having nothing, usually there is something going on other than just a straight addiction," Scotto said. "Usually, it's an underlying mental illness that causes that."

He said about 10 percent of patients at BBH eventually are taken off medication and fare well. While "quite a few" patients receive their first psychiatric diagnosis at BBH, most have been previously diagnosed, he said. "They come to us with histories. That's not what we go on. We don't just keep the diagnosis that they're saying. They still undergo an evaluation."

Patients sometimes first meet a psychiatrist after spending a night or two in "the green chairs," the recliners where patients are detoxed under nursing supervision. Next, patients go over to the Hollins Residential Center, a 59-bed shelter on Poppleton Street, for a night or two.

From Poppleton, many patients go to the privately owned rowhouses that BBH rents in the area. None of the houses have professional staff. Instead, patients who BBH determines have been clean of drugs for at least 60 days serve as house managers, with duties that include unlocking a cabinet so other patients can take their prescriptions.

Early in the morning, BBH vans crisscross the quiet streets of Southwest Baltimore, ferrying patients from the houses to another day of group therapy at the brick buildings on Pratt Street.

'Rain or shine'

Debbie Niagado, 54, says she walked into BBH in March 2007 for one reason: to break an out-of-control cocaine habit.

Her first choice for treatment, Tuerk House, had no space, but a staff member mentioned BBH. There, Niagado said, an admissions screener advised her to tell the psychiatrist that she was suicidal if she wanted to be accepted into the program.

But Niagado said she was honest. She insisted that she'd never been suicidal or diagnosed with mental illness. She said she did feel depressed, in a way, "because of the dumb things I done, spending all the money on drugs when I work two full-time jobs."

Scotto, she recalled, told her she didn't seem like a candidate for BBH. That's when she says she started "acting" — crying and rambling about suicide. After that, "they told me I had depression and gave me [antidepressant] medication called Lexapro."

Scotto said he does not recall such an exchange.

Soon, therapy sessions filled her time "seven days a week, rain or shine." In chemical dependency class, she heard how cocaine affects the body and learned coping skills to fight the urge to use drugs. In mental health groups, patients shared personal experiences. Group sessions carried names such as Family Dynamics, Anger Management and Recovery Group.

Dr. Wesley Sowers, past president of the American Association of Community Psychiatry, said it can be hard for a psychiatrist to tell when a patient is feigning symptoms, and no one wants to dismiss talk of suicide only to have a person carry out the threat.

Jeff Richardson, chief executive of Mosaic Community Services, a Timonium-based health provider, said counselors might need multiple visits to assess patients.

"People do know what to do to get services," he said. "But if a clinician is savvy and smart enough, they'll know if a person is doing it to angle their way in the door."

Chris Lubold, 29, said that he walked into BBH last year "to try to get off of drugs" and that a woman at the front desk told him he needed a psychiatric diagnosis. He said he'd never before received one.

"I was like, well, I really don't suffer from this," he said. "She was like, you've got to suffer from something, you've got to be on some type of psych meds to be in the program."

Lubold, who was addicted to heroin and prescription pills, had doubts about meeting with the psychiatrist. "But they found that I did suffer from depression," he said.

Asked about allegations that BBH staff members have guided patients in what to say, Hathaway wrote, "Any staff providing such advice would be immediately released from employment." He noted that patients mislead clinicians: "It happens and challenges caregivers in all segments of the health care industry."

And, it is not uncommon for people with mental illness to be in denial, he wrote.

Anthony Tazewell, 48, went to BBH after hearing good reviews on the street. "I did not know how to stay clean," he said. "I had a mental problem. I was diagnosed with severe depression. I didn't know that until I went to BBH."

He was put on Lexapro. It is one of the more commonly prescribed drugs at BBH along with Seroquel, an antipsychotic and sleep aid.

Seroquel is "a big gun," said Dr. Christoph Correll of the Feinstein Institute for Medical Research in Manhasset, N.Y. A weeks-long course "can have potential side effects, like weight gain and metabolic issues that could even be associated with diabetes in the future if the medication is continued for longer times."

A 30-day supply of Seroquel costs the state $285. Over the past six years, state health department records show that Scotto and a BBH colleague wrote more than 6,000 Seroquel scripts.

A means to an end?

Lubold, Niagado and Tazewell told The Sun they were diagnosed with the same mental illness: major depression. Elana Bouldin, a mental health coordinator at BBH in 2007 and 2008 until being laid off, recalled one patient after another filing into therapy with that assessment.

But "once they got detoxed, a lot of times they were feeling better," said Bouldin, who facilitated group sessions and met individually with patients. That made her wonder whether they had a separate psychiatric disorder, much less one requiring hours of therapy day after day.

Most psychiatric diagnoses at BBH fall into two categories: major depression and bipolar disorder. Major depression is a disabling, often chronic, illness that makes it hard to work, sleep and eat, according to the National Institute of Mental Health. Bipolar disorder causes "shifts in a person's mood, energy and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe."

Carol Agurs, a licensed clinical social worker who ran group therapy sessions on weekends at BBH in 2007 and 2008, thought many patients belonged but had doubts about others.

"Were some of them living with a true, treatable psychiatric disorder — a bipolar disorder, a major depressive disorder? I would question that," said Agurs, 53, who left BBH to teach. "Because a lot of times when you have people coming off crack, that will mimic depression, that will mimic a sadness at the bottom of the barrel."

Hepburn of the Mental Hygiene Administration contends that the misdiagnosis of mental conditions in addicts is "a national problem."

"If you go to any emergency room in the city or the state you'll find the same thing," he said. "Addicts are frequently given a diagnosis that's an affective disorder — by that I mean, either depression or bipolar disorder. … It's easier to get somebody into services if they have a psychiatric problem."

Because of the stigma that mental illness can carry and the potential side effects of psychiatric medication, Hepburn rejects the notion that such practice is a justifiable means to a desirable end: more drug treatment for more addicts.

To improve access to drug treatment, Maryland this year expanded Medicaid eligibility through the Primary Adult Care program. It also raised reimbursement rates. Many drug treatment providers in the city receive the bulk of their funding through state grants.

Over time, Hepburn hopes to see addicts and those with mental disorders treated as one group, in part to remove a financial motive to make questionable diagnoses. While the field is moving toward a unified system, it now has parallel funding tracks, one primarily for drug abuse and one for mental health.

BBH has overwhelmingly billed the public mental health system, where it is easier to receive payment for mental health care than for drug treatment and reimbursements have been higher.

A growing concern

Baltimore Behavioral Health opened in 1997 in response to a policy change: Maryland carved its mental health program out of the main Medicaid health program for the poor and disabled. That made it a fee-for-service system managed by a private company. If the vendor, now Value Options, authorizes treatment, providers such as BBH get a set fee from the government for every treatment, whether group therapy or a psychiatrist visit.

As long as a patient's main affliction is psychiatric, the mental health system will also pay for that person's drug treatment. The state also pays for "gray zone" patients, those who lack insurance but do not qualify for Medicaid, which the state and federal governments jointly fund.

BBH began small, reporting total revenue of less than $2 million in 1998, tax filings show. It grew steadily and in fiscal 2004 billed the state system $5.5 million. The next year, BBH nearly doubled its patient load from 1,090 to 2,008. The Mental Hygiene Administration says it cannot explain the jump, and BBH did not answer a Sun question about it.

BBH billings peaked at more than $18million in fiscal 2008 before falling to $17million in fiscal 2009 and about $11 million in the fiscal year that ended June 30, as the state reined in spending.

BBH's growth far outpaced that of the system overall. And BBH has frequently placed patients in more costly treatments — "intensive outpatient" and a more intensive category called "partial hospitalization" — meant for those at risk of needing inpatient psychiatric treatment.

To qualify for intensive outpatient care, a psychiatric impairment must result "in a clear, current threat to the individual's ability to live in his/her customary setting" and "all less intensive levels of treatment have been determined to be unsafe or unsuccessful," state guidelines say.

Medicaid pays $125 per day for adult intensive outpatient care at clinics like BBH and $197 for the full-day partial hospitalization that BBH offers. In either case, a patient can receive daily treatment for a limited time. By comparison, patients deemed stable would typically receive a batch of services — such as individual psychotherapy, medication management and group therapy — costing $200 or less, and they would receive them just once or twice a month, state health officials say.

In intensive outpatient, BBH accounted for 85 percent of billings statewide by 2004 and has dominated each year since then, state records show. BBH has also kept patients enrolled far longer than other providers. In fiscal 2008, its patients averaged 52 days of intensive outpatient treatment, at a cost to the state of $6,500, compared with 40 days statewide.

"Basically, when we see this, we are concerned that there may be something going on other than good clinical care," Hepburn told The Sun. He said his agency was concerned about the volume and duration of BBH's intensive treatment.

For years the state, through its vendor, paid BBH more as billings escalated. In September 2009, Hepburn clamped down, citing state budget cuts. No longer would the state reimburse any provider for intensive outpatient or partial hospitalization for uninsured "gray zone" patients.

A month later, Hepburn announced a second round of restrictions. Intensive outpatient care would be authorized for just 10 three-hour days spread over three weeks, a small fraction of the 52 days for which BBH was billing just a year earlier.

Hepburn acknowledged that the moves, which have led to multiple rounds of layoffs at BBH, were made with BBH in mind.

"What we did is try to be very aggressive going after the [intensive treatment] service, because we felt that was being overutilized," Hepburn said.

A revolving door of abuse

From a patient care perspective, questions about BBH go beyond the diagnoses and prescribing of medication. Some former patients told The Sun they kept using street drugs while in treatment that cost the state thousands of dollars a month.

"It was one big pill party at BBH," said former patient James Evans, 42, who enrolled last year. "It was a lot easier to use down there than it was to stay clean, because it was just prevalent everywhere.

"If I didn't use before I went to class, I used when my class ended at 10," said Evans, a heroin addict.

Although BBH's house rules begin with a warning about drugs, former patient Kevin Brown said patient-managers sometimes used them in the rental housing. The state does not require BBH to test patients, and Hathaway did not respond to questions about testing.

"Absolutely, there was drug use going on" among BBH patients, said Bouldin, the former employee laid off in 2008 amid cost-cutting. "A lot of people were using in the houses. There were frequent relapses."

Former staff members said patients would vanish around the first of the month when they received public assistance checks. Anyone who missed two days of treatment was automatically discharged, but Bouldin said they would soon return, creating what she described as a constantly revolving door.

"I didn't understand how people could continue to leave the program and come back a couple days later," said Bouldin, 24. "They were going out to use [drugs]. They would come back, get detoxed and do the same thing. … I questioned it and was told treatment is cumulative and no patient is going to get it right on the first try, and we have to keep accepting them back."

Mixed reviews

Dr. Orlando Davis is a psychiatrist who worked at BBH in 2008 and last year before going to work for another area provider. He defended the center overall, including the patient relapse rate. In an e-mail he wrote: "The drug use that occurs in BBH houses around the campus and at HRC" — the Poppleton Street shelter — "is not out of line with a provider of this size."

Davis, who called BBH's diagnoses "good to very good," said "detoxes and inappropriate abstinence programs" at other facilities create their own revolving doors. He noted that hospital-based programs cost the public far more per patient than do outpatient clinics such as BBH.

Taryn Toman, 33, a licensed graduate social worker there from May 2008 until last year, called BBH "a source of hope for many individuals who had no home, no family, no income and absolutely nowhere else to turn," even if it took multiple tries.

"After a lifetime of conditioning and instability, it unfortunately takes many attempts at treatment before one becomes comfortable enough with structure — a completely foreign concept to many — before finding the strength to make a commitment to change," she said.

Sometimes temptation floated through the window. Stephen Brown, 53, a former patient, recalls being at BBH one day when someone on Pratt Street shouted, "Testers, testers!" Soon, eight or nine people ran out of therapy to get the free drug samples. The program kicked them out, he said.

"They didn't care," Brown said. "They wanted to get high."

For Chris Lubold, the heroin addict who enrolled at BBH last year, it was his first attempt at drug treatment. He'd been caught with marijuana in 2006 and a year later was charged with attempted murder. (He says he was wrongly accused, and records show that the case was dropped.) Two weeks into his intensive therapy at BBH, he says, he resumed sniffing heroin.

"I was trying," he said, "but I know for me it was hard just seeing people high, like, all around BBH." New to the area, he sought tips on where to purchase "good dope." Using $185 a month in temporary state disability assistance, he began buying drugs nearby. After getting high, Lubold would go to his BBH-provided housing on Hollins Street or head to group therapy. In two months there, he was never tested for drugs, he said.

Fire Department records show 13 calls about possible overdoses at BBH from last fall to mid-June. On Nov. 3, paramedics found a 27-year-old woman in a bathroom. A fire report said "she's been seeing demons and shadows" and had taken heroin and cocaine with prescription drugs. A month later, a 51-year-old man who had passed out in a bathroom at the Poppleton housing center reported having used heroin and cocaine 30 minutes earlier.

Hepburn said he had not heard about drug use at BBH. While relapses are to be expected, he said, "the fact it would happen on the premises of a provider, that's of great concern."

State health officials began to scrutinize BBH in May. Investigators with the Office of Health Care Quality visited BBH in August and reviewed 12 patient files chosen at random. Among other deficiencies, the records indicated that three of those patients had attended separate drug treatment sessions and mental health sessions at the same times.

Lissa Abrams, Hepburn's deputy, said Mental Hygiene Administration officials are reviewing the findings and will meet soon with Office of Health Care Quality staff. BBH has until early next month to file a plan of correction.

A separate review last year by the state's Medicaid administrator, Value Options, based on interviews with BBH staff and an examination of 20 randomly chosen patient files, yielded a favorable assessment.

Hepburn acknowledged that a better way to gauge the appropriateness of the diagnoses and treatment would be for outside psychiatrists to assess patients. But such a step is not under consideration.

"It would be very intrusive to the program and to the consumers, because you'd have to explain to the consumers why they're being interviewed," he said. "It could end up creating problems in the therapeutic relationship."

Hepburn said his agency may have waited too long to monitor and limit BBH billings. "There were probably things we should have been more aggressive about and could have been doing a better job on."

Hepburn also pointed to "a number of instances where we were getting inaccurate information" from BBH.

In submitting bills to the state, BBH reported vastly different patient diagnoses than it had while seeking state authorization to treat them, Hepburn said. BBH attributed the differences to clerical mistakes, he said, and insisted that the authorization data was accurate.

In 2007, the state received an anonymous tip that BBH might be billing for services it was not providing. That sparked a 2008 audit by the state health department's inspector general, which examined a sampling of 14,417 paid claims that added up to $1.5 million. The audit found that 10 percent of the claims had errors, including billing for therapy sessions that the patient did not attend.

BBH was ordered to repay $129,000. When a lawyer for BBH failed to appear at a hearing, an administrative law judge entered a default order allowing the state to hold back the sum from reimbursements.

Getting a handle on addiction

To Fingerhood, the addictions specialist at Bayview, a flawed psychiatric diagnosis carries significant consequences. Patients sometimes blame a relapse on a mental disorder that he doesn't think exists, using it as a crutch that keeps them from getting a handle on their addiction.

A former BBH patient named Otis Braswell, 44, said his psychiatric diagnosis became part of his identity. "Once someone tells you something like that, you grab onto it — damn, I'm depressed. You kind of buy into it, you be lying to yourself."

Dr. Michael Hayes of Maryland General Hospital says he has seen dozens of BBH patients who relapsed. While he expressed concerns about how frequently its doctors medicate patients, the addiction specialist said BBH helps fill a gap in a city without enough drug treatment: It's known for taking in and finding a bed for people who have flunked treatment and found the door shut at other programs.

"I wouldn't want to work there," Hayes said. "But I'm glad they're there. Baltimore needs every good or bad treatment program it can find. We have such a huge amount of problems that we can't do without anybody. Any treatment given to an addict is better than their getting it on the corners, honest to God."

But John Belcher, a professor at the University of Maryland's School of Social Work, said there are downsides to "pushing the diagnosis" in any treatment environment. "You may be overtreating the patient, overmedicating the patient, making the patient think they have something they don't really have," he said.

"We may be diverting money from people with serious mental problems to people who don't," Belcher said. "There are some people with serious mental health problems that don't get enough services."

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