Montgomery County, Md., is redolent with the sweet smell of success as well as of honeysuckle on this summer evening. There are the multimillion dollar nouveau-riche mansions in Potomac, the laid-back intellectuals in Takoma Park, a growing number of successful high-tech companies, and probably one of the most respected research institutions in the world, the National Institutes of Health in Bethesda, of which the National Institute of Mental Health is a vital component.

But sitting on the back porch of his home in Rockville, Md., psychiatrist Peter Cohen, M.D., is not feeling flush with success, but angry. The county’s public mental health sector is in shambles, he contends. If anyone should know, it’s he. He was until recently medical director of the county’s child, adolescent, and adult mental health and substance abuse services.

His brown eyes burning with indignation, his arms gesticulating, he explains how things evolved into what he considers such a dismal state.

In 1994 the county executive marched in, announced a move toward privatization of public mental health clinics in the county, and then marched out. Cohen didn’t like the idea, but was ready to put up with it, and privatization got under way until one public clinic after another was turned over to private companies to manage.

Then the county’s Department of Health and Human Services, for which he worked, started taking away his power. "They told me that they wanted me to deliver direct services as a medical director and not be involved in any policy decisions. . . . For example, we had a local government board that is supposed to coordinate all the children’s services. Not only was I not welcome there, but was told by the director there that in speaking up in one meeting, I was intimidating consumers. I was specifically told that there were meetings that they did not want me at. These are the people who say they value professionals, yet limit them. So I found myself increasingly marginalized."

And then he found that there were not enough staff psychiatrists to cover the patients they still needed to take care of in spite of public clinics’ becoming increasingly privatized. He made it known to the Department of Health and Human Services throughout 1999. His memos, he claimed, stated the increasing urgency of the situation.

"The liability was exceptionally high; we didn’t have adequate people. The response internally was, ‘Nobody is going to sue us because the most they’ll be able to get out of us is a quarter-of-a-million dollars.’ That is arrogant, and not only that, it is insensitive."

He found himself increasingly having to give up his medical directorship duties to care for patients, and then it came to a real crisis one day where he not only had one staff psychiatrist who was sick, but the resident who was helping the staff psychiatrist had to go away. So Cohen had to cover for three service areas all at one time. "This is dangerous," he thought—a disaster waiting to happen. He again pressured people in his department to give him more staff psychiatrists. No luck.

"I can’t work in an administration like this," he decided. He tendered his resignation at the end of 1999 and left the department at the end of February.

Psychiatric News asked Mildred Holmes-Williams, the county’s chief of adult mental health and substance abuse services, whether she had an opinion about Cohen’s contention that decision making in the department had been taken away from him. She replied, "You know, he was the medical director for the Department of Health and Human Services, so he interfaced with [a number of different services]. Only he could share with you his feelings about participation. I don’t know what else to add about that."

When she was asked whether it was true that Cohen had not had enough psychiatrists at his disposal, she replied, "There is no way to say that we had absolutely every level of psychiatry service that we needed."

Thus, while it is not altogether clear why Cohen had a falling out with the department, and while it might be disputed whether Cohen had enough psychiatrists to help him cover patients’ needs or not, one thing is for certain: Montgomery County lost a psychiatrist who cared deeply about the population he served.

For instance, Iris Mersky, a social worker with the county’s Victim Assistance and Sexual Assault Program in Rockville, Md., said in an interview that he was wonderful with adolescents who had been sexually assaulted and that since he left the Department of Health and Human Services, there has been a void in her program. Moreover, Carolyn Sanger, executive director of the National Alliance on Mental Illness in Montgomery County, sent a letter to Holmes-Williams protesting Cohen’s departure.

Yet it is not only Cohen’s departure that has negatively affected public mental health delivery in Montgomery County. There seem to be some other problems as well. In fact, as William Legat, M.D., a Bethesda psychiatrist and head of the suburban Maryland chapter of the Washington (D.C.) Psychiatry Society, told Psychiatric News, "There is something drastically wrong going on that is much broader than the thing that he [Cohen] is emphasizing," and mental health services in the county, he believes, are deteriorating.

One of the problems in the county public mental health system is a deprofessionalization of psychiatry. Psychiatrists are being demoted into pill pushers, Legat said. Another challenge is the need for bilingual psychiatrists. The county has one psychiatrist on staff who can speak Vietnamese, and if that one psychiatrist were to leave the area, the county would really feel the loss, Holmes-Williams said.

There is also a dearth of psychiatrists in certain services in the county. For instance, Mersky pointed out, her program could use more psychiatrists, especially child psychiatrists.

The county could also use more money from the state to help cover children’s services, Holmes-Williams believes, since a lot of service coordination is required.

The county likewise suffers from a lack of coordination of services. This point was made at a town meeting hosted at Legat’s home in June. It was attended by various professionals in Montgomery County who are concerned about public mental health services in the county and want to improve them. Accessing mental health services should be made easier, those attending the town meeting agreed. In an interview with Psychiatric News, Holmes-Williams concurred.

And of the many problems that exist, a lack of housing for the mentally challenged is surely one of the big ones. A woman working at the county crisis center reported at the town meeting that the shelters are overflowing. As Stephen Howie, a scientist with the Environmental Protection Agency and a county mental health volunteer, pointed out at the same meeting that it is undoubtedly more than coincidence that as state psychiatric hospitals have been emptying during the past 30 years, the number of mentally ill persons in the county jail has been rising proportionally. About 20 percent of persons in the county jail are mentally ill, he said, which is about the same percentage as in other county jails throughout the United States. Only one-half of patients released from state psychiatric hospitals last year into Montgomery County found housing, Blair Ewing, a member of the Montgomery County Council, reported at the June town meeting. The others, he said, ended up on the streets or in homeless shelters or in jails. Holmes-Williams told Psychiatric News that she agreed that the housing problem is one of the most urgent ones that the Department of Health and Human Services needs to solve on the mental health front.

Last but not least, the shift during the past four years in the county’s mental health delivery system to managed care and privatization has left the county’s mental health delivery in a state of turbulence. In essence, what has happened is that the state of Maryland no longer gives federal Medicaid funds to Maryland counties via a grant system, but rather channels the funds through a managed behavioral health carevout called Maryland Health Partners, an offshoot of Magellan. When the state made the switch, the Montgomery County administration decided that it could no longer operate its mental health services without running a deficit, so it decided to turn the operation of most of those services over to private companies, with privatized clinics and their staff being paid by Maryland Health Partners on a fee-for-service basis. At this point most of the county’s services have been privatized.

"Despite efforts to ensure a smooth transition to the new system, the upheaval at the beginning, particularly for emotionally disturbed children and adolescents, was little less than chaotic," a fact sheet prepared by the Montgomery County League for Women Voters reported in June. "Problems in the fee-for-service arrangement became apparent almost immediately, although a limited number of grants from the state became available to fill some unmet needs."

Ewing wrote in April, "The mental health clinics that were once operated by the county government and have now been privatized. . . are not meeting the need. The evidence for this is that the private providers are struggling to provide numbers of staff adequate to meet the need, and that increasing numbers of children are being referred to the Silver Spring child mental health clinic [which is still run by the county]. There are said to be growing backlogs at all the clinics and continuing unease on the part of some providers about their continuing ability over time to operate the clinics at current reimbursement rates. . . ."

Legat went so far at the June town meeting to voice his suspicion that a good part of the county’s mental health service problems can be blamed on the state’s having turned Medicaid administration over to a managed care firm—Maryland Health Partners.

As Legat said he understands it, Maryland Health Partners must make a profit from Medicaid dollars, which were already inadequate to start with. And the way Maryland Health Partners makes a profit, he alleged, is by restricting services—what MHP calls making sure that services are medically necessary. As a result, he said, some patients are being discharged prematurely from hospitals; sessions with therapists are being limited; patients are being prescribed older, cheaper medications; and so on to save money.

At the same time, the county’s privatized clinics must collect fees from Maryland Health Partners to exist, yet Maryland Health Partners does not want to give out fees. So the clinics, he concluded, are "being stressed out," and "services are in a state of deterioration."

"That is not true," Karen Oliver, director of evaluation for Maryland Health Partners in Baltimore, said in an interview. "We are an administrative services organization, so we perform administrative functions for the state, but all of the service dollars are state funds. So we pay claims on behalf of the state, but it is the state’s money

. . . .The state is in control of the funds and determination of services."

Legat may be wrong about how Maryland Health Partners works if what Holmes-Williams had to say in an interview is correct: "They don’t get anything out of denial of claims. They have a set reimbursement in their arrangement with the state whether they pay claims or don’t or authorize services or they don’t."

But even Holmes-Williams admitted that "managed care presents pros and cons—there is no question about it. Managed care does take some of the decision making away from mental health professionals. It dictates in some instances the length of treatment, and you have to be authorized to be reimbursed, whereas in the former grant system, you as the professional decided what the treatment plan should be, the length of treatment...without seeking an external review."

In any event, when a switch to a managed care-privatized system is added to Montgomery County’s other public mental health woes—Cohen’s departure, a dearth of psychiatrists in certain services, a lack of housing for the mentally ill, and so forth—one ends up with a lot of services in trouble. And the question is, Are they fixable?

"I think we have our challenges ahead," Holmes-Williams said, "but I don’t think that they are insurmountable. The bottom line is that we want our residents to be safe, healthy, and self-sufficient."

Concerned professionals and citizens at the June town meeting are also taking action. One group will be trying to get the public more charged up over the troubling state of affairs by bringing certain cases to their attention—say, the psychotic woman who was banished from an Alcoholics Anonymous meeting because she smelled bad. Another group is planning to tackle some of the service deficiencies.

Meanwhile, dusk is turning into night. The birds have stopped twittering. Cohen is sitting on his back porch brooding about the status of public mental health care in Montgomery County.

"I really love doing this kind of work," he admits. "My background is in community psychiatry." But when asked whether he might return to the county’s Department of Health and Human Services, his reply is no.

"We Jews have a principle that admonishes us to repair the world," he explains. "The idea is to do the best you can do to make it a better place. My belief was that I could do it by staying there. But last December, in talking with my family, I came to realize that sometimes ‘repairing the world’ means you have to leave. I found myself enabling a system that was inept and that continues to this day to be inept. And it was better to leave."