But by using a computerized system for tracking mental health problems, Namar was able to steer the man's treatment in a completely new direction. Several months later, Namar said, the Merck employee was able to end therapy and lead a productive life.
"We saved a lot of unnecessary pain for the patient," said Namar, who works for Integra Inc., a mental health care company in Radnor. "He might have ended up in the hospital."
Not coincidentally, Namar saved Merck a lot of money.
This is the new world of mental health care. It's a world where a patient's innermost feelings may be reduced to a number, where progress in therapy can be tracked on a computer, and where a therapist might not have the final say about treatment.
It's all part of what is known as "managed mental health care," an effort by employers and insurance companies to curb rising health care costs by imposing stringent limits on spending for mental health.
Managed care, which hit medicine more than a decade ago, took longer to gain momentum in the mental health field. Now millions of Americans - including more than three million in the Philadelphia area - have mental health benefits overseen by managed care plans.
For many consumers, managed care has lowered out-of-pocket costs. People who were paying $80 or more for an hour of psychotherapy may pay as little as $5.
The savings have come about because of significant restrictions on the use of mental health services. In other words, some patients are denied care they might have received in the past.
Across the nation, managed care has made it harder for people to get into psychiatric hospitals and to stay there. And people who used to have virtually unlimited access to outpatient therapy can be restricted to 20 sessions a year.
As part of the change, insurers are encouraging therapists to make greater use of psychotropic medicines such as Prozac, a powerful antidepressant.
These drugs cut costs by helping some patients function better with less therapy.
The push to medicate is affecting not just adults. "If you aren't medicating a child, the (managed care) reviewers want to know why the child is even in the hospital," said a South Jersey psychiatric social worker who asked not to be named.
Many big employers have realized thousands - in some cases, millions - of
dollars in savings on employee benefits.
In the 1990s, IBM cut per-employee mental health expenses by 40 percent in a year. Chrysler Corp. chopped its bill by a third. Also in a year, Merck & Co.'s employee mental health care costs fell by 20 percent.
Without such cuts, some experts say, employers might have had to drastically reduce - or eliminate - mental health coverage.
While managed care appears to have produced savings, its effect on the quality of care is hotly debated.
Proponents say that care has improved, that more people are being served by programs that are more accountable.
"Managed care is synonymous with quality care," said Arthur Lazarus, a psychiatrist and medical director for TAO. The firm, a subsidiary of Green Spring Health Services Inc., oversees mental health care for about 2.3 million Philadelphia-area residents.
Lazarus and other supporters of managed care point to the extravagances of the 1980s, when entrepreneurs glutted the market with new psychiatric hospitals, when residential treatment programs for drug and alcohol abuse became costly revolving doors, and when patients could stay in talk therapy for years.
While such long-term therapy - the so-called Woody Allen syndrome of endless introspection - may provide people with insights about themselves, proponents of managed care question whether it should be subsidized by employers and the government.
"We have to draw cutoffs," said Lazarus, who cited instances of parents leaving their children in psychiatric hospitals while they vacationed. ''Resources are limited."
Critics of managed care do not deny that there have been abuses, that therapists need to be accountable, and that money is limited, but they contend that managed care poses unique and difficult problems in overseeing mental health.
"There's a hope out there that we are going to standardize mental health treatment," said Russ Newman, executive director for professional practice of the American Psychological Association. "But I have never seen two depressed patients who looked exactly the same," he said. "And you can't expect them to respond (to treatment) in exactly the same way."
Margaret L. Baker, a Wynnewood psychologist who chairs the professional affairs committee of the Philadelphia Society for Psychoanalytic Psychology, says patients are being hurt.
"Managed care came out with glowing statistics, but nobody hears about what happens to people who are denied care or who don't get enough care."
A Philadelphia-area father said he was so distressed by a therapist's inability to deal with his 14-year-old son's panic disorder that he pulled the boy out of therapy provided by a local health maintenance organization.
The father now pays $100 a session for a psychologist outside the health plan's network of mental health providers.
In another of many patient complaints about managed care, a Philadelphia woman said she was forced out of a psychiatric hospital after 11 days despite her suicidal depression. Her health plan entitled her to 30 days of hospital care a year. She said she had not known that the insurance company would decide how many days she could use in any single hospitalization.
"I was furious" with the health plan, said the woman, who like other patients interviewed asked that her anonymity be assured.
Managed care is transforming the work life of therapists and the craft they practice. Some say they are so dismayed they are considering leaving the profession.
"It's more a question of the nature of the work (under managed care) than the salary," said Edward K. Silberman, director of Jefferson's residency education in psychiatry. "It's really impossible to conduct psychotherapy with a sword of Damocles over you."
For years, Xerox Corp. allowed its workers to tap into any mental health service they wanted, no questions asked.
"We had basically led people to believe that 'Mother Xerox' would cover this," said Helen Darling, who oversees the equipment giant's health care strategy. "If they had a problem, we were there to pay."
The generosity backfired.
The company's average employee cost for mental health care soared by 70 percent between 1988 and late 1990, when Xerox first imposed limits. Stricter requirements covering treatment were implemented in 1993.
The results have been startling.
Xerox saw its average cost per employee for outpatient care drop by 22 percent between 1992 and 1993. Hospital admissions declined by nearly 11 percent. And for those who were hospitalized, the average cost fell by 38 percent, to $7,153.
Not all employees were happy with the new system, which pays for six counseling sessions yearly unless more are medically neeeded.
Darling recalled one angry employee protesting the change, saying she'd been seeing a therapist twice a week for six years and was only beginning to " 'get in touch with my issues.' "
"We will pay for brief therapy, focused therapy," Darling said. "We are more than willing to pay for people who are mentally ill and help them get well. We cannot afford to pay for 'how you got to where you got to.' "
Unlike traditional indemnity insurance, which typically pays after medical service is delivered, the new system bird-dogs costs, often by setting limits ahead of time.
The new rules have shaken up the old order. "There's a real sea change," said Lazarus of TAO/Green Spring. "There's no question about it."
Just as Wal-Mart stores have gobbled business away from neighborhood shops, many experts believe managed care spells doom for therapists' cottage industry - where care often was delivered from cozy home offices and no one asked if it
went on too long.
The insurer, assuming the patient had coverage for mental health care, helped pay the bill if a legitimate diagnosis had been made.
Now therapists are being required to justify treatment plans to case managers - such as nurses and social workers hired by the insurers - who judge whether they will cover the care. If therapists don't buy into the system, they risk losing patients and income.
"It is a whole way of life, a practice style, that is rapidly dwindling," said Monica Oss, a Gettysburg-based consultant on managed mental health care.
Psychologists are in mourning, according to a survey commissioned by the American Psychological Association. They feel devalued, that their practice of therapy is being undermined by companies focused on saving money and standardizing care.
"There's a joke going around in therapy circles that we are seeing the field move in the direction of McTherapy franchises," said Farrell R. Silverberg, a Philadelphia psychologist.
He said he worried about the growing concentration of economic power among relatively few companies.
The most notable are 11 firms that specialize in managing mental health care costs. These "managed behavioral health care" companies, which have rapidly expanded in the last five years, now generate several billion dollars in annual revenues and oversee the benefits of almost one out of three Americans.
The companies work for employers, insurers and other managed care companies to trim costs by reining in therapists and hospitals. They also save money by employing cheaper labor for outpatient therapy. Psychiatrists and psychologists are being replaced by social workers.
Managed care's ax has also chopped away at long hospital stays, especially for adolescents - a practice that boomed in the 1980s. And they have cut back on the generous benefit packages that allowed alcoholics and drug addicts to try kicking their habits by spending a month or more in expensive 24-hour treatment facilities.
"The standing joke at the time was, 'Good news, Mr. Jones. You are cured. Your insurance has just run out,' " said Lazarus of TAO - the largest managed mental health care company operating in the Philadelphia region.
Now, patients are living at home while going to counseling programs. Advocates said the approach saves money and is better for patients.
Kenneth Abramowitz, a health care analyst for Sanford C. Bernstein, an investment management and research firm in New York, said that managed care firms arose because they saw that money could be made by reining in excesses.
The medical profession "didn't police themselves, so as a result a whole new police force was established," he said.
Government has gotten on the bandwagon, too. In Massachusetts, behavioral health costs for the state's Medicaid program fell by 12 percent in 1993 - the year after it entered into a contract with a managed care firm, according to a Brandeis University study.
This year, Pennsylvania hopes to expand managed care's role in the treatment of poor people in Philadelphia. New Jersey is also climbing on board.
"For the payer who puts managed care into place, it always saves some money," said Oss, the Gettysburg consultant. "The question is for how long and how."
One thing is certain to therapists: They aren't the ones getting rich.
As it is, psychiatrists share the bottom of the medical financial ladder with family doctors. Social workers are paid less than teachers. And as more patients are switched into managed care plans, therapists are being reimbursed at lower rates.
Some therapists say they are even discounting their rates further for patients who feel they need more therapy and don't have permission from their insurer.
"That's how I make peace with myself," said Elizabeth N. Kuh, a Bala Cynwyd psychiatrist. "I don't deal with the managed care companies if I have to compromise my treatment."
First the depression came in waves. Then it was all the time. He no longer played ball with his children or walked in the woods with his dog.
After four sleepless nights, he stole sedatives from the hospital where he worked as a nurse.
"I felt like the lowest piece of dirt on the earth," recalled the 41- year-old father of two. "This is the first time in my life I ever used any type of drug. I looked down on people who used drugs."
When the drugs didn't help, he tried to kill himself with a lethal injection, but the initial pain was too great, he said. He decided to use a gun. That day, though, he was confronted on the drug thefts and packed off to a psychiatric hospital.
A psychiatrist wanted to admit him for seven to 10 days. The managed care company wanted him treated as an outpatient. Finally, the managed care firm agreed to 72 hours in the hospital.
"It's a miracle that (his treatment) went as well as it did," said the psychiatrist.
Such battles over what constitutes appropriate care are common under managed mental health care:
* A woman was left with mild brain damage and unable to work after a car accident. Her husband filed for divorce, left the state, and took legal action to acquire their house. The woman said she no longer wanted to live. Her Philadelphia psychologist argued with her health plan to see the woman twice a week "so she doesn't die." The plan offered "every other week," the psychologist said, and finally granted 10 visits.
* The administrator of a religious organization was struggling with alcoholism and homosexuality, his Philadelphia psychiatrist recounted. When the man's insurance company questioned his care and demanded access to his confidential records, the man dropped out of therapy for fear that the private information might be passed on to his employer. A few months later, the man committed suicide.
* A woman suffering from severe postpartum depression - she stopped eating, sleeping and washing herself - began talking about running into traffic or overdosing. She asked to be hospitalized. Her Lower Merion psychiatrist said he tried to get approval from her insurer, but it refused. The woman and her husband had to agree to pay all hospital costs themselves to get her admitted.
Doctors at three of the city's largest private psychiatric hospitals - the Institute of Pennsylvania Hospital, Friends Hospital and Belmont Center for Comprehensive Treatment - say they routinely argue with managed care companies to get patients admitted.
"I'm lucky if I can keep you in the hospital for three days," said Emanuel E. Garcia, a psychiatrist at the Institute.
Psychiatrists contend that such short visits may allow them to stabilize patients but not to treat them.
At the hospital where she used to work, Kuh, the Bala Cynwyd psychiatrist, watched with dismay as the average length of stay for disturbed children dropped from a month or more to eight days.
She said that one managed care company would approve treatment for only three days at a time, making it impossible to come up with a treatment plan.
"It meant that you couldn't develop any kind of close relationships (with the child) because it would end, often precipitously."
As a staff psychiatrist, Kuh was under pressure from managed care companies to put children on psychotropic drugs quickly so their stays could be as short as possible.
"We were directed to get them on medication within 48 hours," she recalled. "Sometimes we wouldn't even have their laboratory results back before we started the medications. We'd just be shooting in the dark."
While managed care companies try to place people in alternative settings such as halfway houses and daylong counseling programs, hospital administrators say there simply aren't enough community settings to meet the need.
"Right now there is no continuity of care in the (Philadelphia-area) marketplace," said Gary L. Gottlieb, chief executive officer at Friends Hospital. "We, like others, are trying to build it."
Critics of managed care also raise troubling questions about the impact on outpatient therapy.
Some therapists question whether 10 sessions, or even 20, can make enough of a difference for people struggling with difficult issues such as sexual abuse, eating disorders or borderline personalities.
To all appearances, these people have no trouble functioning in life. They get up in the morning, go to work, socialize with friends, and sleep at night. But their deep-seated emotional problems get in the way of their leading fulfilling lives.
A professional woman who had been sexually abused in childhood said that it took years of therapy to allow her to develop a close relationship with a man.
Last January, just as the woman felt she was beginning to rebuild her life, her employer switched to a managed care plan.
Instead of getting her twice-weekly therapy sessions at 80 percent of cost, she was limited to 20 sessions a year.
"I'm 42 years old," said the woman as she broke down in tears. "I'm finally getting to experience what 'normal people' have all their lives - loving someone and allowing myself to be loved."
She chose to cut back counseling to once a week and is paying the $80 weekly bill herself.
"Human beings are very complex," said Jay Lappin, a social worker who practices psychotherapy in Collingswood and Marlton. "To say you can just knock it out in 10 sessions is ridiculous."
It often takes half a dozen sessions or more to get people who have been
sexually abused to trust their therapist enough to open up, he said.
To make sure their patients get appropriate care, some therapists say, they exaggerate clients' problems.
"It's made me have to make people (appear) sicker than they really are in order to justify their treatment. I tell the patients that ahead of time," said a Main Line psychiatrist.
Therapists also worry whether they can protect their patients' confidentiality.
Before, detailed records generally stayed in a therapist's drawer; only the diagnosis would be shared with the insurer.
Now, case managers - acting in the name of quality control - may require regular reports and sometimes ask to see therapists' notes. One Philadelphia woman dropped out of therapy rather than have her psychiatric records forwarded to her managed care company. The records included confidential information about an abortion that triggered a major depression.
"There is no such thing as confidentiality" in managed care, said Richard F. Limoges, the psychiatrist who treated the woman. "Again and again, the companies want to see my raw notes - and that's something I won't do."
Across the country, therapists and the organizations that lobby for them are trying to adapt to the new reality. Their trade journals are full of articles about surviving in a managed care environment; their workshops focus on topics such as how to deliver therapy in eight quick sessions.
"My view of managed care is that it is here to stay," said Bob Palladino, a therapist at Delaware County Psychological Services. "If I want to work with mental health, I have to work with that system."
Silverberg has an idea for working within the system. He's forming a group of more than 30 therapists that he hopes will have the clout to negotiate with managed care companies.
Other therapists say they are considering leaving the profession. Fewer aspiring doctors are choosing to specialize in psychiatry.
In the last five years, the number of psychiatrists studying at American medical schools dropped 35 percent.
Then there are therapists - from social workers to psychiatrists - who have decided to fight managed care through the national Coalition of Mental Health Professionals and Consumers, formed two years ago. It claims several thousand members, including some in the Philadelphia area.
In a speech last year to the New York State Psychological Association, Karen Shore, the Long Island psychologist who heads the group, branded managed care "fascist" and called on therapists to form a resistant movement.
The new mental treatment system, she said, is "destroying patients' ability to control what is happening to them. It's becoming a cold, industrialized assembly line. That's what makes people ill in the first place."
At 3:25 a.m. April 13, police brought a 26-year-old woman to Eastern Pennsylvania Psychiatric Institute in Philadelphia's East Falls section. She was so psychotic that she required involuntary commitment.
But doctors at Eastern did not admit her because the hospital did not have a contract with the woman's insurer, a Medicaid managed care plan.
Adding to the confusion, the insurer was fielding emergency calls that night from an office in St. Louis.
Shortly after dawn, the insurer called an ambulance to pick up its client and take her to Albert Einstein Medical Center on North Broad Street, a 15- minute ride away.
But the ambulance was mistakenly directed to Easton Hospital in the Lehigh Valley instead of Eastern. For eight hours, the distraught woman waited.
"You can laugh now that it's over, but you feel bad for the patient," said Carolyn Ulmer, Philadelphia's coordinator of emergency mental health services.
The incident is one of dozens chronicled in a log kept by officials at the Philadelphia Health Department. They fear that managed care will make a mess of mental health services for poor people.
"We already have case after case of managed care companies denying service" to poor people, said Nancy Lucas, who oversees managed care for the city's Office of Mental Health and Mental Retardation.
About half of the 509,000 Philadelphia residents on medical assistance are enrolled in HMOs. This year, the state intends to move everyone on public assistance in Philadelphia into managed care plans.
While managed care may give poor people more access to primary care physicians, it poses enormous challenges to mental health.
In Philadelphia, about 50,000 poor people use publicly funded mental health services, according to city health officials.
Among them are more than 20,000 people with serious mental illnesses, such as schizophrenia, and many with multiple problems, such as drug abuse and mental illness. These people are difficult - and expensive - to treat.
"HMOs and (managed behavioral care) companies have absolutely no capacity to deal with people with serious mental illness," said Trevor Hadley, a clinical psychologist who directs the Center for Mental Health Policy at the University of Pennsylvania Medical School. "They are not in the business to take care of people with long-term, chronic problems. They are in the business to turn profits for stockholders."
Already, many poor people in HMOs have gotten a rude awakening.
Instead of going to a neighborhood clinic for outpatient therapy, some are told to travel across town - or even to a suburban office - to see a therapist in their HMO's provider network.
"For a single mother without a car and with kids, going to a suburban clinic is like going to another world," said a therapist at St. Christopher's Hospital for Children.
Emergency services under managed mental health care plans have also imposed hardships on the poor. Among the incidents documented in the city's log:
* A teenager had to spend two days in the emergency room of a city hospital
because his managed care plan wouldn't approve a transfer to Allentown, which had the nearest available psychiatric bed for an adolescent.
* A patient needing immediate mental care at Temple University Hospital could not get it because Temple psychiatrists were put on hold for 37 minutes when they called the patient's managed care company.
* A patient spent 25 hours in a psychiatric emergency center while his HMO tried to decide whether it would approve an inpatient bed at Misericordia Hospital.
"The city funds the emergency rooms, and the managed care companies know that," Lucas said. "If they don't pay for the E-room, they know the city will."
Often, Lucas said, the managed care companies won't pay for treatment at the hospital where a patient is taken by city police. But they also won't pay for an ambulance to transport the patient to another hospital with which the company has a contract. As a result, the patient may languish for hours, getting more and more agitated.
These and other problems are among the reasons that city Health Commissioner Estelle Richman, an expert on mental health policy, is launching what she calls a "pioneering effort." She's formed the city's own nonprofit managed mental health care company - Community Behavioral Health Inc.
It plans to compete against for-profit managed mental health care companies to provide mental health services to all poor people in Philadelphia, beginning this year.
At stake in the competition is about $120 million in state and federal Medicaid dollars.
The city's approach "won't cure everything wrong with the system," Richman said. "But on a system-wide level, we will do a better job of providing services, particularly to those people who have the highest need."
Last summer, her uncle was diagnosed with lymphoma and her father had major back surgery. Suddenly, Ann, 27, began feeling anxious. "I'm really close with my family," she explained.
Although she was able to work at her ad agency job, Ann felt her heart racing. She felt faint. And she lost her appetite.
After an initial evaluation through her managed care plan, Ann was told she would be assigned a therapist, but couldn't choose her own - a situation she didn't like.
Ann met twice with the therapist, a woman with a master's degree in education. "I felt the therapy wasn't going anywhere," Ann recalled. "The therapist forgot from the first week to the second what we had covered."
After she complained, the managed care company assigned her to a therapist with a master's degree in social work and 20 years of clinical experience.
Ann saw that therapist eight times - the number approved by the managed care company. Her out-of-pocket costs each time were just $5. And she left with a practical tool to help keep her anxiety in check - a "guided imagery" tape made by the therapist and tailored to her needs.
"She definitely helped me understand the parts of my personality that lend themselves to having anxiety attacks," Ann said.
Ann is one of the success stories of managed mental health care. She had a problem, she dealt with it, and she didn't waste a lot of time - or money. Her managed care plan had an appeals process that worked.
Advocates say managed plans are a marked improvement over the past, when patients often maneuvered alone through an unorganized medical system, hoping they would find the right therapist and sometimes paying large sums out-of- pocket.
"The good thing about managed care is that it has forced us to be accountable for our treatment," said Lynne DiCaprio, clinical director of Delaware County Psychological Services. "I don't think it is OK to see people forever."
"In all professions, people are being called to be more accountable, whether it's lawyers or accountants," said Gail Davidoff, a Philadelphia social worker with patients in 18 different managed care companies. "I'm not sure that we as therapists can hide behind our 'special relationship' (with the client) as a justification to say we are not going to be held as accountable."
Even opponents of managed care concede it isn't all bad.
"It isn't an unmitigated evil," said a psychiatrist at one of the city's largest psychiatric hospitals. "In the past, some patients did stay too long in the hospital."
He added: "I know middle-class families who depleted their savings for long-term care, with dubious results."
There's no question that managed care has made some mental health services more affordable to middle-class Americans.
"There are some people who, without being handed a mental health benefit, would not have used the mental health system," said Joycellen Young Auritt, a Philadelphia therapist in private practice.
And industry surveys show that most people enrolled in managed plans are generally happy with the mental health services they receive. One recent study reported an 89 percent satisfaction rate, according to the American Managed Behavioral Healthcare Association.
In the public sector, which is moving headlong into managed mental health care, officials can also cite gains.
For instance, in Massachusetts, managed care seems to have slightly increased access to behavioral health services for poor people while not measurably diminishing quality, according to the Brandeis study.
"Managed care is a viable approach to controlling costs while improving access and quality of mental health services," said James Michel, who oversees Massachusetts' new Medicaid program.
While there are no precise measures of quality, everybody seems to agree on one thing: Managed care does a good job of treating people with relatively minor problems.
Take the case of Ann, who asked that only her middle name be used. She was experiencing what psychologists call situational anxiety - fears brought about by a specific event. Many people have such fears and need psychological tools to deal with them.
"You don't see your family doctor every week because you might get the flu," Davidoff said. "So, too, you don't have to see me every week if you think you might have a problem later on."
What's emerging under managed care is a new mental health care model: short-term treatment of immediate problems that emerge at different points in a person's life cycle, rather than long-term treatment for underlying problems that aren't readily apparent.
"In the old models of therapy," Davidoff explained, ". . . the fear was that if you didn't work through everything, then the therapy would fail."
Despite what critics say, managed care advocates believe their methods promote quality, not just savings.
Elaine Selan, a manager for TAO, pointed to a chronically ill nursing home patient who suddenly became suicidal. No one knew why.
Her managed care firm paid a psychiatric nurse to investigate. The report revealed that the woman, who relied on a respirator to breathe, had been told by a doctor that she was dying.
TAO worked with other medical professionals and placed the woman in a hospital with psychiatric care.
"What the managed care process did was to tie together the mental and the medical, plus the legal and ethical," Selan said.
Managed care has been operating without much proof that it works in the mental health field. One psychiatrist called it "a huge, uncontrolled experiment."
Efforts are underway to change that.
Managed care companies, government and researchers are all looking for a way to bring scientific objectivity to an area riddled with subjective judgments.
When does someone with a mental health problem need to be hospitalized? For how long? Is outpatient psychotherapy warranted? If so, how to know if the therapy is working? How long should it go on? Are medications called for?
The lack of standards fuels the vigorous debate over managed behavioral health care.
"Part of the issue is that, potentially, there are several appropriate treatments for the same condition," said James Schuster, a psychiatrist at Allegheny General Hospital in Pittsburgh.
The debate on quality becomes even more difficult when pressures to cut costs are factored in. Some of the ways that treatment is evaluated "often get used in the service of simply cutting back to save money rather than being concerned with the effectiveness of treatment," said Newman of the American Psychological Association.
Peter Brill claims to have an answer to such criticism with his computerized tracking program used at Integra, which "makes both cost and quality part of the decision."
The Radnor firm, where Brill is chief executive, oversees mental health services for large employers - such as Merck and Conrail - that use the system. This year, 15 million people will be covered by plans that have adopted the computerized method.
"We want to make (our program) the standard of the industry," Brill said.
Brill's system, which he helped to develop, attempts to describe someone's mental health on a numerical basis - a "mental health index." Critics say it's overly simplistic.
"It's not a valid approach," said the head of a psychiatric hospital who must work with managed care companies. "It makes snap judgments."
But some say that at least the right questions are now being debated.