Case Study of 1

A red ticket-dispenser in the psychiatric department instructs me to take a number and wait until it’s called. So, I do.

I am trying one last time to get mental health treatment. At least, that’s what I said two months ago to trick myself into following through on it. Suppressing doubts about whether this latest attempt would work, I looked up my health insurance’s list of local mental health care providers. The first few weren’t taking new patients. The next two said they didn’t take my insurance, even when I said I was sure they did. The next one was a hospital. The receptionist said there was no room for new patients. I told her that I could wait if needed and no, I am not suicidal, but I need help. She found me an appointment in two months’ time.

So two months later, I’m here. Another hour and I’m called to the registration desk. The receptionist says she isn’t sure if they take my insurance, and to go to the financial counseling department and then come back. Her coworker disagrees, so she just calls the counseling department instead, who confirm the hospital takes the insurance. The receptionist hands me a yellow paper square with my new number—“We call people by numbers here, not names,” she says—and instructs me to wait. The paper has a big “1” written on it. A good sign, I think, looking at the overflowing waiting room.

A nurse calls out “1” an hour later and I pee in a cup and return to waiting. Thirty minutes later, a therapist appears, asking for “1.” She seems nice, though she doesn’t look up from her computer when she asks if I’ve ever tried to kill myself. But when I tell her I how I’m doing, she tells me she is sorry and I decide that she sounds like she means it. We schedule a follow-up and she walks me to the psychiatrist’s office.

I enter and begin repeating the answers I’ve just given the therapist to the standard mental health questions. No, I am not suicidal. I live with roommates. I do not have children. If I’m out with friends, I can definitely down a few drinks, but that happens maybe once a week. I work full-time. I have tried Wellbutrin and Effexor, but they did not work. I am desperate for something to work and willing to do what is needed to get better. I am trying to be responsible.

***

I blame the medical bills.

They pile up in a corner of my room, collecting cobwebs under the bed. Every few months, I gather them up, opening a few. There are doubles, triples, of the same bill, differing only in their dates. Others are solo, lone socks in the pile. I consider using them all as wallpaper.

After I was hospitalized with a particularly nasty skull fracture a few years ago, something snapped; suddenly, I could barely call a doctor. It might have something to do with the way the hospital treated me—a nurse said that they had all believed I was uninsured and had given me “different” treatment because of it—but I think it’s the bills’ fault. They started showing up mere weeks after I was discharged. They never slowed down, no matter how often I wrangled with my insurance company on day-long phone calls. I was broke, and the bills broke me.

So after the first hospitalization, hospitalization became my health care strategy. If you have a severe injury, the hospital will find you a primary care physician and force you to book an appointment. For the skull fracture, they did likewise for a psychiatrist, among other specialists to deal with the aftereffects of the injury.

It seemed great, but my enthusiasm waned when I left the hospital. Each doctor is a co-pay, and that’s if you’re insured. Without insurance, my first hospitalization would’ve cost $39,000 (I made $10 an hour at the time). With it, I was still on the hook for a few thousand dollars. Dizzying diagrams of future appointments and work schedules began to dot my notebooks alongside unworkable budgets. But I was unwell, so I lost track. Within months, I was missing appointments. Soon enough, I couldn’t remember the doctors’ names.

Eventually, I was without care again until being hospitalized in a new city, New York, where I’d just moved. I had no doctors here, and my mental health was declining precipitously. I chose to interpret this turn of events as a gift.

After a false start—I went to a hospital in my neighborhood, Bushwick, only to be discharged because the doctors “couldn’t figure out what was wrong”—I found a hospital rich people go to that accepted my insurance. My wish had been granted: I’d lock down future doctors. Thank god for my prematurely decomposing body.

It didn’t work out. The doctors were understandably focused on my physical ailments. When I mentioned other health problems, they told me to wait until I recovered to worry about the rest of it.

The night I was discharged, I was groggy, floating on morphine. I had complications that required the procurement of an ambulance to drive me home. Follow-ups were scheduled hastily as I was rushed out the door. Someone from the hospital called with the PCP’s information while I was horizontal, strapped to a stretcher. I scribbled the information on the back of my discharge papers. When I got home, I realized the pen had been out of ink.

Despite this, I found the doctor. I couldn’t remember any details about the appointment, but I returned to the upper-east-side hospital and spent a day asking administrative employees for help. Finally, a saintly woman in a tucked-away office, packed with precarious piles of papers, the Office of Historical Memories or something, tracked down the information.

As it turned out, the PCP was actually a clinic; I was seen by different doctors-in-training every time. It was rushed, and no one seemed to have notes. I asked for a psychiatry referral. They told me they couldn’t do that, and to find a psychiatrist myself. After further prodding, they offered the numbers of two psychiatrists. I again scribbled this information on the back of medical forms and left.

They remain in my room, a monument to the vast reserves of the human spirit—I, of course, never got an appointment. The first time around, it took me a year, maybe two, to disappear from the health care system post-hospitalization. This time, it took weeks.

I spent a year like this. I’m fortunate to have never had the type of depression that brings suicidal thoughts and extreme highs and lows; mine is the flat-line variety. Someone who takes days to respond to a text message does not have the ambition required to die—no thanks, sounds like work. But the depression got worse than I’d believed it could. And the bills kept arriving! The calls from unknown numbers multiplied. Once a month or so I answered one. Every time, it was a debt collector.

***

So I am here, making a good-faith shot of it, answering the psychiatrist’s questions.

We get through all of them. After a brief silence, she says she cannot prescribe me medication. When I ask why, she informs me that I am an alcoholic, and antidepressants do not work with alcohol. I say I am aware of the “don’t drink on meds” rule, and if it’s really the case that the medication will not work if I drink, then so be it, I’ll drink lemonade at parties. “I am desperate, and willing to do what it takes to get better,” I restate.

“You could not quit drinking if you tried, and you will not try,” she says. She has known me for twenty minutes at most. “I will likely recommend you get addiction treatment, which entails three appointments a week, and then you can get on an antidepressant.”

Perplexed, I tell her I do not need addiction treatment, that I sometimes go weeks without a drink, and besides, I work full-time and what with my whole exhausted-depressive thing, there is no way I could follow through on three appointments a week. I think about a family member who was court-ordered to attend AA meetings three times a week after an arrest, and how little the judge cared that he might lose his job for taking that much time off. This is criminal, I think.

She says that she will add to her notes that I am in denial about addiction, and if I’d like to get my blood work done so she can see the results and formally decide what treatment to recommend, I can do so. In the meantime, can I quantify my drinking for her notes on my alcoholism, she asks.

“Would you say you take like, ten shots?” She actually says this. I can’t speak, so I laugh. She is withholding medication I need as a perverse moral means-testing, because I mentioned I get drinks with friends once a week. The only possible outcome, should I refuse to go along with it, is that I will go untreated, or will lie about my drinking habits to a future psychiatrist if I ever get to see one. She must know this.

“It took me so long to get this appointment,” I say.

She stands and gestures to the door.

I get the blood work done. As I leave, I stare at the room of waiting patients, some of whom were here when I arrived six hours ago. This is a hospital for poor people. I can’t stop wondering how many of them this psychiatrist will also withhold medications from unless they, too, agree to whatever preconditions she chooses. How many other doctors like her are there? The rich and the poor use drugs at the same rate, but there is no doubt in my mind this woman sees everyone here as an addict or a criminal and is determined to punish us for it. There are no consequences for her, but some of us will die.

I think about last year, at the Bushwick hospital. I doubt there were any millionaires in that packed emergency room. They’d discharged me late at night, on a cocktail of painkillers but still pulsing with pain, to walk home.

These hospitals are located in the heart of the city’s gentrification but apparently those who can, avoid them. I’d never step foot inside one of those places, friends say when I describe my day. Everyone knows not to go to those hospitals. But I didn’t, and neither did the hundreds of other people who were in the psychiatric department this morning. “Why are these places packed if everyone knows this?” I think, to distract from other thoughts, about how, exactly, I will wait out the months it will take to get a new appointment, with a new psychiatrist, in Manhattan.

Anyone reading this likely knows health care is a gruesome, deadly separate-but-equal system in the United States. Anyone who can avoid these hollowed-out institutions on which so many working-class people rely is acting quite reasonably in doing so. They are carceral and dangerous—sometimes filled with literal toxins, as if this country needed more symbolism. They kill us, even if we kill ourselves. They tell us we are criminals, and we agree—a plea deal is the best anyone can get. They say we are addicts, and we wonder whether we must be addicts if we are to survive. None of this is news, it’s just another data point. These are hospitals in the richest city in the country, but the funneling of resources away from them reproduces segregation—it’s how they got this way in the first place. And it is worse elsewhere.

I don’t have any proscriptions beyond what many people are already doing: pushing for universal health care so at least we can get rid of the damn financial counseling department and all the co-pays (today’s experiment left me $45 poorer), funding long-term mental health care, and otherwise creating a world with less alienation, less poverty, shorter workweeks.

I’m just mad, and the stakes are so high. US life expectancy has dropped for the third straight year, in part because more people are killing themselves. If I were the suicidal type, this might be the end of my rope. (I cannot insist enough that I am not, please do not worry.) I just wish all of it would be classified correctly, as murder: the mistreatment, the abuse, the insurance mix-ups, the lack of access in the first place, the disdain, the bills, what that psychiatrist did today. It’s homicide, on a mass scale: take a number, wait until it’s called.