Most insurance policies limit the amount and type of psychiatric care children can get. And in many parts of the country, there aren't even any child psychiatrists to get an appointment with. So parents who have teenagers battling serious psychological problems often struggle to get treatment.
But for Amy, a sweet-faced, polite 16-year-old who has suffered bouts of major depression, her family could afford the best.
Several years ago, she ended up in the psychiatric wing of a general hospital.
"It was just a dirty place," she recalls. "I mean the cot is tiny that you sleep on, it's just uncomfortable. It's one blanket, one pillow. It's white all over, it's not welcoming."
And it was scary, she adds.
"The other kids, you know, they had behavioral problems and they were mean and I was so scared," Amy says. "I wanted to get out of there. I didn't care if I got help. All I wanted to do was leave."
She left the hospital after four days and saw a therapist regularly. Recently, sitting on a couch with her aunt, she was able to talk comfortably about it. But her brow furrowed and her big brown eyes squinched a bit when she remembered what happened soon after she got out of the hospital.
A Life 'Out of Control'
"I was a great student and my grades were just dropping and my friends noticed I was sad," she says. "I was crying in school and had trouble getting out of bed, it was a nightmare."
She had family problems to deal with and her own depression.
"I became suicidal and my life was out of control," Amy says. "I had no control over it. I was scared. This wasn't how I was or how my life was supposed to be."
She didn't want to go back to a psychiatric hospital.
"Of course I said no, I'm not going to a hospital where you have to stay, but I knew I needed the help, so eventually I said OK.
But this time her therapist got her into one of the premier hospitals in the country, Sheppard Pratt, which just last November opened a new psychiatric hospital designed for teens. It's called Overlook, and it's an eight-bed facility for adolescents diagnosed with major depression or psychotic disorders.
Tailored, Luxury Care
It's housed in a shady brick building on rolling hills north of Baltimore. The cost is $1,700 a day. That's straight out of parents' wallets, because Overlook doesn't accept any insurance. Patients get made-to-order meals, high-speed Internet and they stay in private rooms similar to those you would find in a premier hotel.
Her room comes with her own bathroom, a TV, phone, desk, a comfortable chair and a queen size bed.
But Amy doesn't spend much time there. She's busy virtually all day and evening with activities, led by trained psychotherapists, aimed at giving kids insight into themselves and getting them to enjoy life again.
Overlook psychiatrist Jack Vaeth lists some of the options.
"We have art therapists who not only conduct art classes in groups but who interpret the artwork," Vaeth says. "And many of the kids in here have gone on to take art lessons as a result of their experience."
There's music therapy, tai chi and meditation. Family members come in for therapy sessions. Since psychiatrists spend weeks or months with patients, they're able to fine-tune the psychiatric medications they're prescribing. And they give each patient almost unlimited hours of one-on-one talk therapy. Vaeth says it's often a form called cognitive behavioral therapy.
"Cognitive behavior therapy is a very practical therapy, nothing esoteric about it," Vaeth says. "They will sit down with you and come up with practical solutions for reframing your thought processes, because often your thought processes are, 'I'm not good because of one thing or the other.'"
Amy learned how to deal with her self-defeating thoughts, and she was taught how to set goals.
"You pick a goal that's hard, but you know you can do it," Amy explains, such as learning new coping skills.
There's group therapy as well. Amy remembers working with two others. They were given a rope and two buckets, one filled with plastic balls, and were told to move the balls to the other bucket without using their hands. They learned it could be done by just one person, moving the plastic balls with her feet.
Breaking Down the Insurmountable
Vaeth says exercises like these teach kids that often a problem in life that looks insurmountable can sometimes be easily solved.
"We listen very carefully," Vaeth says. "We have exactly what parents would like to have: one-to-one care, more groups, greater structure and more time to work with the kids. And, quite frankly, weekends are just as busy as weekdays, which you won't find anywhere at any hospital.
But at more than twice the cost of most other hospitals, is Overlook better? Vaeth says having an open-ended stay not controlled by insurers means doctors have time to make difficult diagnoses. At least two kids who came to Overlook had been diagnosed with social anxiety disorder. They both turned out to have a mild form of autism requiring very different treatment.
Insurers, however, say that treatment lasts as long as is medically necessary, and they would be interested in seeing data on whether the amenities or the level of clinical care make a difference in how kids do.
Cheaper in the End
Psychiatrist Vaeth doesn't have the data, but he thinks Overlook could prove cheaper than multiple short-term stays at other hospitals, and that insurers might learn from some of Overlook's approaches.
"If this program flourishes and does well and people say, 'Wow, if you have $1,700 a day, you will do well psychiatrically,' then why couldn't we develop a similar program but maybe scaled down to $1,000 a day?
That's closer to what insurance companies might be willing to pay.
Right now, Overlook is half full, and some other hospitals are considering luxury care, such as the Harvard-affiliated MacLean, which already offers an intensive therapy program. That program has fewer amenities like private rooms, but it is sometimes covered by insurance.
Amy left Overlook after four months, at a cost of about $200,000. Her aunt says her niece has gained enormous perspective and strength. Amy thinks so, too.
"I've changed, I've just become so much stronger, and I can handle things so much better, and I care about things," she says. "And it's the little things that matter to me, it's like when I walked in here, I was Amy, and I'm walking out of here as Amy times 10."
Today, Amy's at a regular boarding school. She calls back in to talk to Overlook nurses every week or so. She says she's going to make it.