By LINDY WASHBURN
Staff Writer

Keri Sohlman left the hospital in early January, six weeks after sinking into a depression so profound that a therapist called an ambulance.

The Saddle Brook teenager's descent had begun six years earlier, with the sudden death of her father. A brother's suicide in April 1999 had pushed her deeper into despondency. After that, she fell apart, drinking and smoking marijuana so much that her friends asked her mother to do something.

Keri spent the weeks at Holy Name Hospital under medication and in therapy. She received electroshock treatments and wrote in her journal.

She also slashed her wrists with a bottle, the first time she had hurt herself to that extent.

Her psychiatrist at Holy Name described her as "extremely fragile." Her "cutting behavior" was a bid to discharge tension and get help, the psychiatrist said.

But now, according to Oxford Health Plans, it was time for Keri to go home.

Hospital care was no longer necessary, the insurer's medical director said. Guided by a combination of length-of-stay criteria, symptom assessments, and the bottom line, the managed-care plan instead decided to pay for a "partial hospital" or day-treatment program.

Keri's psychiatrist argued against the discharge.

Keri's mother argued that her daughter wasn't ready to deal with the outside world and needed the safety of a hospital.

Their pleas made no difference.

Keri went home to her family's house in Saddle Brook. She followed instructions, attended the "partial hospital" program, and took her medication.

And 18 days later, on Jan. 22, she jumped from a bridge onto the Garden State Parkway.

Keri's suicide ended not one, but two troubling stories.

The first was her own painful journey through family loss, grief, and despair.

The second was the story of her treatment in the age of managed care, a tale of fragmentation in the mental-health system, limits on coverage, financial pressure, and disagreement between the insurance company and the professional treating her.

Did these stories have to end on the shoulder of the Garden State Parkway? Could Keri's suicide have been prevented?

Those involved offer different answers. Keri's mother believes her daughter would be alive today if Oxford had not insisted that she be discharged from Holy Name. Her psychiatrist there wonders whether Keri would have done better had she been given a freer hand in treating her. The medical director for Oxford Health Plans believes the company acted appropriately.

Keri's story, though, illustrates a larger tale: It shows how much medical care today depends not on what is available or what is best, but on what insurance will pay for.

In Keri's case, "what insurance will pay for" may have meant the difference between life and death.

Photo albums thick with pictures are stacked in the kitchen as Francine Sohlman and Matthew Mingle, once Keri's best friend, pore through them.

Keri's scruffy, excitable terrier, Taji, barks and bounds around the blue split-level home on a quiet street near Saddle Brook's Smith Elementary School. The dog still plays with the squeeze toy Keri bought her on her last day at home.

Sohlman bought the puppy as a Christmas present for Keri in 1994, the year her 49-year-old husband, Lars, died unexpectedly of pneumonia. Keri was 12 then, the youngest of four children, and the only girl. Daddy's girl.

His death, Sohlman says now, "started everybody's depression."

Keri would later write: "You left us all. I needed you. We all needed you. . . . You meant so much to me and to so many more people. I was so scared."

She worried about how her mother could cope, about who would walk her down the aisle on her wedding day, and about who would take care of her mother when the children grew up and moved out. In poems, she described the days around her father's illness and death as "the end."

Outwardly, though, she seemed an ordinary child.

Keri played the mellophone, similar to the French horn, and Matt the trumpet in the Saddle Brook High School band when the two became friends during freshman year. By senior year, Keri had auditioned and become one of two drum majors.

Each band trip had its own picture album -- Florida, Louisiana, Canada, California. She gazes from the photos with clear blue eyes, ponytailed, strong, and athletic, surrounded by friends.

"She was goofy, silly, always making weird faces for the camera," said Jen Anderson, her "soul mate." One summer when Keri worked the overnight shift at Dunkin' Donuts, she regularly woke Jen up with coffee and rolls.

The two beeped each other back and forth with a secret code for "Hi." They could tell, just by catching a change in expression amid the laughter and fooling around, when the other had dropped into "a sad zone."

"We'd point at each other and say, 'No,' " said Jen. "We brought each other up a lot."

Keri's class elected her to the student council. She was a cheerleader in competitions and at basketball and football games. A Beatles fan. Her locker, No. 1043, was covered with magnets, stickers, and pictures of Mr. Potato Head.

But as senior year was winding down, on a Friday morning, her oldest brother, Eric, killed himself with a shotgun in the basement of their home. His two brothers found him. Keri and her mother were on a band trip. He was 24.

On June 25, two months later, Keri graduated from high school. She took a job grinding lenses at Lenscrafters and thought about college.

"Outwardly, you wouldn't know it was affecting her," Sohlman says of her oldest son's suicide. But "it brought up a lot of memories of her father." Sohlman repeatedly offered to take Keri for counseling, but Keri always refused. She didn't want to talk about it.

Matt, too, said, "It seemed like she was dealing with everything." She never wanted to talk about her brother.

Then she started drinking more and smoking marijuana more. "All of a sudden, she was no longer coping," said her mother. Some of Keri's friends called Sohlman, concerned that Keri's behavior was getting dangerous. Sohlman offered to make an appointment with a therapist, but Keri angrily refused.

"The more confused and depressed I got, the more I smoked," Keri wrote in her journal, looking back from the safety of her hospitalization. "The more I smoked, the more confused and depressed I got."

"She knew it wasn't working," her mother said of her daughter's drinking and drug use.

Finally, Jen persuaded her to see a therapist. She took her personally to the first visit in November, and Keri went on her own the second time.

But as Thanksgiving approached, Keri's depression became desperate.

On the Tuesday before the holiday, Keri didn't go to work. She drove around northern New Jersey all day, considering whether to kill herself. Police ticketed her in Passaic County for speeding, then let her go. Finally, she showed up unannounced and without an appointment as her therapist was closing her Bergen County office.

Startled, the therapist invited her in.

Keri wasn't talking much. "She was very, very quiet," recalled the licensed clinical social worker, who asked that her name not be used. "I felt she was reaching out for help, that she felt safe with me in my office." After an hour of sitting with her, the therapist asked Keri's permission to call a psychiatric hot line.

Three-and-a-half hours later, after an evaluation, Keri left in an ambulance.

"Tears came down her cheeks," said the therapist. "She cried very quietly. She must have been exhausted. She probably thought that she'd be taken care of, that this pain would be taken care of."

Keri was admitted to Bergen Regional Medical Center in Paramus around midnight, and was transferred the next day to Holy Name Hospital in Teaneck. Dr. Gladys Halvorsen was the psychiatrist on call.

Halvorsen diagnosed Keri with "major depression." She tried the full array of standard treatments: individual and group psychotherapy, medication, electroshock therapy. Keri was hard to reach, shrugging and silent in answer to questions.

Depression is considered highly treatable, with a response rate of 80 percent to 90 percent when standard treatments are used, either alone or in combination, mental-health professionals say. Keri's family history and substance abuse made her particularly vulnerable, but not beyond reach.

Psychiatrists consider suicide fundamentally avoidable. They approach each patient with the idea that there's always one more treatment to be tried.

Halvorsen spent an hour each day conducting "intensive, deep" psychotherapy with Keri, trying to open a pathway into the girl's grief. "It was very difficult," she said. "This girl had never mourned her father. . . . She was very private. Only after about 10 days here in the hospital did she begin to open up. We worked through her journal."

The spiral notebook became like a third person in the therapy sessions: Keri wrote in it between sessions, and then the therapist read it. They discussed it.

Halvorsen prescribed medication for anxiety, depression, and psychosis, as well as sleeping pills.

"She really wanted to get better," Sohlman said of her daughter.

Keri agreed to eight sessions of electroconvulsive therapy. This uses a controlled electric shock to induce a brain seizure, altering some of the electrochemical processes thought to be responsible for severe depression.It helped, Halvorsen said: "She began showing feelings of hope and brightness."

But even in the hospital, Keri slit her wrists -- "cutting behavior" to discharge tension and express her distress, said Halvorsen. The wounds were sutured. Another time, she hid in a closet.

Sohlman visited daily, sometimes with Taji, the terrier. After a while, Keri was allowed passes to go out with her mother. She spent Christmas at home. Jen has a photo of Keri and herself with a friend dressed up as Santa Claus that day. Keri's eyes are dull; they no longer shine.

By Christmas, Keri had exhausted her yearly 30-day maximum for an insurance-covered hospital stay for psychiatric care. Halvorsen kept her in, and Sohlman subsequently was billed for $16,400 by the hospital. The doctor says she canceled her own vacation. She knew she would not be paid. Ethically, she said, she could neither refer a non-paying patient to a colleague nor abandon Keri.

They all expected that on Jan. 1, when a new benefit year began and Keri was covered for another 30 days, her continuing treatment would be reimbursed. Keri told Jen that even though she didn't like the hospital, she was going to force herself to stay until she got better.

But Oxford Health Plans surprised them. The average hospital stay for an Oxford patient with a mental-health diagnosis is 6.3 days, said Maria Gordon Shydlo, a spokeswoman. Keri had been "certified" for 30 days, and actually hospitalized for 37.

Further hospital care was medically unnecessary, Oxford's mental-health director, Dr. Satwant Ahluwalia, decided. "The patient's current signs and symptoms do not necessitate a psychiatric inpatient level of care," the case manager, Kathleen Breton, wrote to Keri on Dec. 30.

"She denied it completely," Halvorsen said of Ahluwalia. "She pressured me to discharge the patient." Halvorsen, a psychiatrist for 30 years with a specialty in adolescent psychiatry, disputed Oxford's assessment, saying her patient was "extremely fragile."

Halvorsen is not part of Oxford's network of physicians. She has chosen not to participate in any managed-care plan "because of the way they interfere with patients," she said. She took over Keri's care because she was on call when Keri was admitted.

Oxford's decision was based, in part, on guidelines called "managed care appropriateness protocols," said its chief medical officer, who responded to questions on behalf of the company. These protocols are purchased from The Oak Group, a Wellesley, Mass., company that specializes in developing length-of-stay criteria for health plans and hospitals.

The guidelines aim to answer a simple question: Do the patient's symptoms require the full services of inpatient hospital care, or can she be treated in another setting? "Everybody pays careful attention to what the symptoms are, and therefore assigns the right level of care," said the chief medical officer, Dr. Alan Muney.

It is more cost-effective, if there's no risk of harm to the patient or others, for the patient to transfer from a hospital that costs about $1,000 a day to a partial-hospital program costing $350 a day.

Decisions like this bring into focus "whether we just go back to the way it was, with uncontrolled utilization," Muney said, "or try to bring some rationality to it." He referred questions about the exact standards to The Oak Group, which declined to discuss specifics, saying they were proprietary.

Keri's case "did get a real careful review and a lot of discussion of symptoms," said Muney. "She was not acutely suicidal, not under constant supervision. Her mood had improved." Her suicide attempt had been earlier in her stay, he said.

Halvorsen called in a second psychiatrist at Holy Name, who evaluated Keri and concurred in the need for further hospitalization. She also alerted Keri's mother.

"The doctor told me that if Oxford refused to pay for it, Keri would feel she was unworthy," Sohlman said. "I felt she was safer in the hospital." Keri was under suicide watch there. She had no access to alcohol or marijuana.

Sohlman says she called Oxford shortly before noon on Friday, Dec. 31, to ask that the decision to discharge her daughter be reconsidered. She was told that the office was closing for the New Year's holiday and that no one in authority could be reached, she said. She explained about her son's suicide, and her deep concerns for Keri's safety, she said. The operator suggested she look for an emergency shelter, Sohlman recalled.

According to Oxford's log of the call, benefits were discussed, but no request for an appeal was made, said spokeswoman Shydlo.

On Monday and Tuesday, Jan. 3 and 4, Halvorsen tried to prepare Keri for her discharge. Oxford had agreed to pay for "partial hospitalization" at the Carrier clinic in Paramus.

Keri wrote about it in her journal:

"I am not exactly sure how I am going to handle being home on my own. It is going to be very hard staying away from weed and alcohol, first of all. Very hard. I don't have any idea how I'm gonna keep myself away from either one of those things. And I'm gonna have to go to this program every day. That's probably gonna suck very much."

"She felt very anxious and hopeless," said Halvorsen. "I tried to work with her to make it easier."

On Jan. 4, Keri returned to her family's Saddle Brook home, the house where Eric had committed suicide. The next morning, her mother drove her to Carrier's Paramus clinic.

Partial hospitalization's goal is to give patients more responsibility and autonomy than they can experience in a hospital, within a framework of daily support and supervision.

Because such care is less expensive, it also can extend the patient's insurance coverage. In this case, Oxford considered two days of partial-hospital care equivalent to one of inpatient care. Initially, six days were certified; later, extensions were made.

Although patients occasionally may be readmitted to the hospital, it is assumed that they know how to get help -- through their family, therapist, or a Carrier hot line -- if they feel suicidal, Carrier's medical director said. Readmission, said Lawrence Goldberg, the medical director, would be considered a setback.

Goldberg declined to discuss the specifics of Keri's care, but a lawyer retained by Sohlman made the records available.

As a new patient, Keri was evaluated and assigned to three group-therapy sessions a day, dealing with topics such as coping skills, stress management, appropriate use of medication, and "positive self-talk." She attended each session, where her affect was described as flat, her voice soft, and her mood depressed. She also had one private therapy hour a week.

The psychiatrist at Carrier adjusted Keri's medication to help her sleep better, the records show.

Keri attended the program faithfully. "She never missed," her mother said. In the off hours, she "hung around the house, visited a friend, did normal things." But she told her mother "she wasn't getting that much out of Carrier," Sohlman said.

"It is harder than hard," Keri wrote of the program in her journal after three days. "It's Mon-Fri., 9 to 3, and all groups. As you already know, it's not exactly easy for me to talk. And that's all it is -- talking. It sucks.

"I just sit there, shake my leg a lot and answer stupid questions very quietly or shrug my shoulders and say I don't know. There's a doctor who I don't exactly like very much and a caseworker who asks me daily if I feel like killing myself or if I'm gonna smoke weed or drink.

"I can't really tell her that I actually do want to die, so I just say no to all questions."

But no one was reading the journal anymore. Keri soon stopped writing.

Keri's mother was concerned enough to write a letter to Oxford:

Her "condition warrants hospitalization," she said she wrote in a letter to Oxford's appeals address. Sohlman provided a copy of the letter, dated Jan. 14, to The Record. "She is not ready to deal with the outside and needs the constant supervision and security of a hospital setting.

"Although she desperately wants to get well," Sohlman continued, "she feels she is at the end of her options. If you do not let her have the treatment she needs, I will hold you responsible for whatever may happen. I plead with you on behalf of my daughter to allow her to receive the full treatment she needs and deserves."

Oxford's Muney says the company has no record of this letter.

On Jan. 19, at a session with her mother and her Carrier caseworker, Keri said that she felt no different than she had before Thanksgiving, Sohlman said.

Keri's last talk with her Carrier therapist was on Thursday, Jan. 20.

The therapist noted, as she had at each of the two previous weekly sessions, that Keri was depressed and admitted thinking about suicide, "but denies any plan or intent to act on" these thoughts.

--------------------

On Saturday afternoon, Keri went grocery shopping for the family. Besides food, she came home with Infusium for curly hair, the toy for Taji, and a paperback edition of "The Green Mile."

It was dark and bitterly cold, a little after 6 p.m., when she borrowed her mother's car and said she was going out to visit friends. She was wearing a black jacket, jeans, a pair of gloves.

Keri did not go to a friend's house. She parked the car behind an apartment complex just off Midland Avenue in Saddle Brook, and started walking down the tracks of the Bergen Line.

On the car seat, she left her journal and several letters -- two addressed to her father, one to her brother, Eric, and one to her remaining family and "anyone who cares."

"It is so unfair," she wrote to "Daddy." "I don't understand why it had to be you. You were such a great dad. I loved you. . . . I love you."

Sometime later, Keri reached the railroad overpass across the Garden State Parkway. She jumped, falling 30 feet onto the cement barrier below.

When a state police officer arrived at 8:15, she was conscious but bleeding, coherent enough to tell him that she had jumped and not been pushed.

She died at Hackensack University Medical Center three days later.

Gladys Halvorsen, the Holy Name psychiatrist, is not certain that Keri would have been saved if she had stayed longer in the hospital. But she believes Keri's chances would have improved.

"The key thing for these patients is continuity," she said. "There was no continuity" she added, as Keri was passed from a private therapist to Bergen Regional Medical Center to Holy Name Hospital, and then to Carrier.

Said Halvorsen: "Given the opportunity, I would have continued to see her, so she could have had that one bond, that one very strong bond. The point is, I was pressured tremendously to release her. I treated her two weeks without any pay."

Said Dr. Lawrence Goldberg of the Carrier Clinic: "It sounds like this patient received very serious, quality, state-of-the-art treatment. . . . I think the only conclusion you can draw is that despite the best efforts of contemporary standards of treatment, some patients will commit suicide."

Said Dr. Alan Muney of Oxford Health Plan: "Regardless of diagnosis, some patients are going to have bad outcomes. Do we feel that we interacted appropriately with the physician, and followed criteria? We're comfortable with that. Ultimately, she was under the care of a physician."

At George Washington Memorial Park, the grass has not yet grown over Keri's grave. It lies under a tree, near those of her father and brother.

On May 19, Jen Anderson, Matt Mingle, and some other friends gathered around the freshly raked earth.

They ate some Dunkin' Donuts coffee rolls, Keri's favorite snack, and drank some coffee. Then they lit some candles, sheltering the flames from the wind as they sang "Happy Birthday."

Beneath the vase of flowers and the bouquets they had brought, Keri's friends left the cards and letters they had written.

"I still don't understand it," wrote one, wishing Keri peace on what would have been her 19th birthday.

Quietly, they stepped away.

The wind blew the candles out.

Staff Writer Lindy Washburn's e-mail address is washburn@bergen.com

By LINDY WASHBURN
Staff Writer

When four teenagers committed suicide in a Bergenfield garage in 1987, they focused national attention on the escalating rate of teen suicide.

But the rash of copycat suicides in the aftermath of the Bergenfield deaths led to something else: a muting of media coverage for fear of more imitators.

The fact is, suicide is now the third-ranking cause of death among teenagers nationwide. It accounts for more deaths among people ages 15 to 24 than all natural causes combined. From 1980 to 1996, the rate of suicide among people 15 to 19 years old increased by 14 percent. It doubled among 10- to 14-year-olds.

"Twenty percent of teens have thought about suicide in the last 12 months," said Dr. David Shaffer, president of the American Foundation for Suicide Prevention and chairman of the psychiatry department at Columbia University's College of Physicians and Surgeons.

New Jersey students match the national average, according to the most recent survey of risk-taking behavior conducted by the federal Centers for Disease Control and Prevention in 1999.

But the rate of suicide among young people in New Jersey, as elsewhere, has declined, for reasons that are not understood, said Celeste Andriot Wood, assistant commissioner for family health at the state Department of Health. Some mental health experts credit the use of new anti-depressive drugs with the downward shift.

Although suicide is the No. 3 cause of death among those 15 to 24 years old, they have done so less frequently: from 88 cases in 1995, to 69 in 1996, to 59 in 1997, Wood said.

Overall, New Jersey recorded the second-lowest suicide rate in the nation for 1996 and 1997, the two most recent years for which statistics are available.

Wood could not explain why New Jersey's rate was comparatively low, but said efforts continue nonetheless to reduce it. These include participation in a regional conference funded by the CDC this month in Massachusetts, at which participating state teams are to develop state suicide-prevention plans.

The conference is one outgrowth of an initiative by U.S. Surgeon General David Satcher, who announced shortly after his 1998 appointment that he considered suicide a major public health problem. "We must promote public awareness that suicides are preventable," he said, as he issued a "Call to Action to Prevent Suicide."

Girls are more likely to attempt suicide, but boys more likely to succeed. The most common method is a gun. Keri Sohlman, the Saddle Brook teenager who killed herself in January, was atypical in both her gender and her method -- a jump from a high place.

But many more more teenagers attempt suicide than succeed at it. Some studies say there are 100 to 200 attempts among young people for each suicide. And it is extremely difficult to predict which suicide attempters will actually kill themselves, experts say. A continuing retrospective study interviews therapists and analyzes cases in which a suicide victim had been in treatment.

The teenagers at greatest risk for suicide, according to Shaffer and others at Columbia University, report at least one of the following factors: a record of previous attempts, current thoughts about suicide, depression, or abuse of drugs and alcohol.

Each of the risk factors is something that can be addressed, mental-health experts say. Depression, for example, is considered highly treatable, through medication, psychotherapy, and electroshock treatments, these experts say.

Suicide affects not only those whose lives it claims. Each of the 32,000 suicides a year in the United States leaves a trail of emotionally wounded family members and friends, totaling hundreds of thousands of people. Their care is also an issue.

Researchers have reported a fourfold increased risk for suicidal behavior among immediate relatives of suicide victims. Dr. David A. Brent, who studied suicides among family members in Pittsburgh, also reported a higher risk for substance abuse and depression. One theory suggests that this may result from a possible genetic connection to the metabolism of serotonin, a neurotransmitter in the brain associated with mood.

But Brent stresses that the increased risk does not mean that suicide is inevitable. If anything, it should make professionals more alert to the signs of vulnerability so that they can intervene to prevent suicide, he said.

In other words, the suicide of Keri Sohlman's older brother identified her as a high-risk teenager and should have led professionals to exercise even greater vigilance in her care. Suicide need not have been her destiny.

If you have any more information regarding Keri, teen suicide in NJ, HMO's manipulation of the system to control the bottom line, please feel free to contact me.

Email: michael_macvicar@saddlebrook.k12.nj.us