Chapter Two
THERE IS NO ROOM AT THE INN
Because Managed Care Has Not Pre-Authorized Any Stays
“If there were a physical disease that manifested itself in some particularly ugly way, such as pustulating sores or a sloughing off of the flesh accompanied by pain of an intense and chronic nature, readily visible to everyone, and if that disease affected fifteen million people in our country, and further, if there were virtually no help or succor for most of these persons, and they were forced to walk among us in their obvious agony, we would rise up as one social body in sympathy and anger. We would give of our resources, both human and economic, and we would plead and demand that this suffering be eased.
–Russell Hampton, The Far Side of Despair
“Increasingly, the mentally ill have nowhere to go. That's their problem and ours.”
–Michael Winerip, “Bedlam on the Streets,” The New York Times
The extreme symptoms of depression and anxiety I have just described did not come upon me overnight. The dissolution of my psyche was more akin to the gradual washing away of a sand castle by the encroaching ocean tides. I had hoped that my first hospitalization in September of 1996 would halt the downward spiral that had begun with the adverse drug reaction the previous week. However, I was released within forty-eight hours of my arrival, long before I had the opportunity to emotionally heal—a consequence of managed care. I was sent home with no recovery plan other than my psychiatrist's advice to “be your own physician” and to take low doses of Mellaril “as you see fit.”
For the first few days after my release, I maintained a shaky stability. I returned to work, hoping that the focus of a job would alleviate my anxiety. Instead, my moods turned inexorably downward. With each passing day, I felt more and more fragile. Early morning awakenings (a classic symptom of depression) intensified. My depressive moods blackened. The anxiety attacks, which had begun sporadically, increased in frequency to two to three times a week. I was less and less able to concentrate on my sales job, crying at the slightest upset. Like the Bizarro Superman I used to read about in the comic books, I felt as if the old Douglas had been replaced by some malfunctioning impersonator.
My predicament brings up a pertinent question that has enormous social implications—what happens to a person who is incapacitated by clinical depression? Where does he or she go when he reaches the point that he can no longer cope? There are no halfway houses for depressives, although with seventeen million Americans suffering from depression, you would think there would be. Neither are there any 12-step groups called Depressives Anonymous. Many people in the throes of depression “tough it out” and continue their daily routine in spite of the incredible pain, becoming what William Styron calls “the walking wounded.” I did not have that luxury. The symptoms of my anxiety were simply too extreme for me to be on my own.
Although I had many wonderful friends, they were busy with their jobs and family obligations and could not monitor me throughout the day. (It is also easy for friends to get burned out caring for someone who is clinically depressed.)1 My ex-wife Joan had moved in with me in September to become my caretaker, but was actively looking for a full-time job. This crisis was too big to be handled by friends and family alone—I needed the support of a therapeutic community.
During my previous depressive episodes, I had stumbled across two such environments. In 1976, I spent four months residing at Berkeley Place, Inc., a halfway house that transitioned hospitalized patients back into the community. (Although I had no history of hospitalization, I was allowed to stay because I was homeless.) Then, in 1983, my parents admitted me to New York Hospital for a one-month stay (at that time, a month was considered a short-term stint). During these respites my symptoms significantly improved, and by the time of my discharge I was on the mend. I believe that each of these institutions saved my life.
“The Sleep of Reason Produces Monsters,” by Francisco de Goya.
Now, however, it was 1996. With managed care insurance companies in charge of mental health treatment, the landscape was anything but patient-friendly. I consulted a number of psychiatrists and psychotherapists in the hopes of getting healed through outpatient therapy, but none of them would work with me. “You're too agitated and out of control to benefit from therapy,” they said. “You should spend at least four to six weeks in a residential setting in order to get stabilized.” The prescription was sound, but it overlooked a critical point—psychiatric hospitals no longer provided long-term care. Beginning with the 1960s, each decade has seen a gradual reduction of inpatient time allotted to the mentally ill.
For example, in the mid ’60's I knew a woman who suffered from schizophrenia and who spent two years getting well at McLean, Harvard's famous psychiatric teaching hospital.2 In The Far Side of Despair, author Russell Hampton recounts his six-month hospitalization for anxiety and depression during the early 1970s. In 1985, author William Styron spent six weeks in a hospital recovering from a major depressive episode. By the time my crisis hit, the average stay had been reduced to seventy-two hours. Even McLean, champion of milieu therapy, had switched over to short-term treatment.
“Slit your wrists and a hospital will have to take you in,” a friend advised when I told him of my predicament.
“If it were only that easy,” I replied, as I thought of my ex-roommate Dan, whom I had met during my first hospitalization. A high school physics teacher in his mid-thirties, Dan had been admitted after his wife found him wandering in the woods with a gun, threatening to blow his brains out.
“What is your treatment plan?” I asked over breakfast.
“I don't know,” he replied with an apathetic look on his face. “I get discharged later today.”
“But you're not ready to leave!” I said incredulously. “You were only admitted last night!”
“I can't help it. My insurance company said my time is up.”
As he predicted, Dan was discharged later that afternoon, less than twenty-four hours after he was admitted. I frequently think of him, wondering if he is still alive, in spite of the system that failed him.3
As I struggled to find someone (or someplace) to be my caregiver, I imagined the ideal healing environment for someone in Dan's or my state—a restful, peaceful asylum in the country modeled after the old health sanatoriums of Europe. Here is the vision that came to me:
This center is designed to treat the whole person, combining the best of medical treatment (antidepressants and/or ECT) with alternative care—diet, exercise, light therapy, acupuncture, vitamin and mineral supplementation, prayer, psychotherapy, group therapy, vocational counseling, etc. Unlike traditional hospitals, the entire facility is a place of beauty. The buildings are open and spacious with plenty of natural light. Soothing classical music fills the air and gorgeous works of art decorate the hallways and walls of the patient's rooms. Nutritious meals are served using fresh foods from the ground's organic gardens. Various forms of physical therapy such as massage and whirlpools provide relaxation for patients and staff. Puppies and kittens are available for everyone to love. In short, the center provides a holistic “therapeutic milieu,” the goal of which is to return the individual to society as soon as possible, but not before he or she is ready.
Aside from its role in reducing the human suffering caused by mental illness, such a facility might well pay for itself by reducing the $43.7 billion annual cost that depression places on the U.S. economy.
Unfortunately, the only institution that remotely resembled my fantasy was the world-famous Menninger Clinic in Topeka, Kansas. While Menninger had an excellent reputation, the price tag was daunting—$30,000 for a month's stay—an amount that no insurance would cover. Moreover, I was scared of being transplanted to the Midwest without friends or family support. For the next five months I agonized about whether to take the radical step of going to Menninger.4
Just as I was about to give up hope, I learned of a residential clinic that seemed to fit my needs. Springbrook, a drug and alcohol rehabilitation center located forty-five miles southwest of Portland, had everything I had hoped for—a minimum 28-day residency (with a possible 60 day extension); group and individual therapy; recreational therapy that included a gym, a weight room and access to a city pool; a beautifully manicured twenty-five acre campus with walking paths; a balanced diet consisting of excellent food provided by Marriott Food Service (the only complaints about the food are that the servings are too big); and 12-step spiritual orientation. Finally (this is the most amazing fact), in most cases insurance companies would pay for 50 to 80 percent of the treatment cost.
There was, however, a small catch—one had to be an alcoholic or a drug addict to be admitted.
“I'm not an addict,” I explained to the admissions officer over the phone, “but I am in as much pain as one.”
“I'm afraid that you don't meet our criteria,” she replied.
“But I read in your brochure that you treat people for depression.”
“Only if you have chemical dependency as your primary diagnosis.”
“Let me understand this,” I said, pondering the absurdity of the situation. “If I were to self-medicate with drugs or alcohol to nullify the pain of my depression, and consequently developed an addiction, I would be able to pursue long-term recovery in an elaborate treatment center. But if I choose a healthier outcome and resist the temptation to abuse myself, I am limited to a 72-hour stay in the local psych ward.”5
“I see your point,” she said sympathetically, “but I have to abide by our policy.”
I had heard of people slipping through the cracks of society's institutions, but this felt more like falling into the crater of an active volcano. “It's no wonder that depression is the leading cause of suicide,” I thought, “when people can't get the help they need.”6
The issue, it seemed to me, is that depression is not a “tangible” problem like substance abuse. And since depressives as a rule do not make the headlines with their self-destructive acts—like driving a BMW into a tree while loaded on cocaine—their illness is not taken as seriously.
For a while, I contemplated getting hooked on drugs so that I might receive some decent care and attention. A few months later I read Elizabeth Wurtzel's Prozac Nation and discovered another depressive who faced the same dilemma. Wurtzel writes:
I found myself wishing for a real ailment, found myself longing to be a junkie or a cokehead or something…. It seemed to me that if I could get hooked on some drug, anything was possible. I'd make friends. I'd have a real problem. I'd be able to walk into a church basement full of fellow sufferers and have them all say, “Welcome to our nightmare! We understand! Here are our phone numbers, call any time you feel you're slipping because we're here for you.”
Meanwhile, there was no one—i.e., no institutional structure—that was there for me. As I paced back and forth, hitting myself furiously while I waited for Joan to arrive home from work, I was left pondering, “Where can I find a therapeutic environment that will nurture me back to health?” Discovering the answer to this question was becoming a matter of life and death.
“Melancholia,” by Albrecht Dürer
1 To find out what friends and family can do, please refer to Part Three, chapter 14, “When Someone You Love Is Depressed.”
2 Many celebrities have resided at McLean—including Sylvia Plath, Robert Lowell, Ray Charles, and singer James Taylor, who wrote about the experience in his first album. Novelist Susanna Kaysen also recounts her stay at McLean in the book Girl, Interrupted.
3 Not only patients, but psychiatrists are becoming increasingly frustrated with a managed health care system that puts profits above the welfare of the individual. One psychiatrist told me that he is forced to treat many of his severely ill patients—who at one time would have been hospitalized—on an outpatient basis.
4 Looking back, I am convinced that if long-term residential care had been available to me (as it was in 1976 and 1983), my recent illness would have resolved far sooner. The absence of adequate facilities for people suffering from extreme depression and anxiety is a major failing of our mental health care system.
5 I recently learned that guitarist Eric Clapton plans to raise $5 million for a drug and alcohol recovery center. Perhaps one day a famous depressive will start a treatment center for people with mood disorders.
6 Many people with mental disorders, especially the poor, end up behind bars. According to the U.S. Bureau of Justice and Statistics, prisons now house more than 280,000 mentally ill inmates (16% of the inmate population). People who are ill need treatment, not incarceration. See Mark Larabee and Michelle Roberts, “Jails, Prisons, Confront Influx of Mentally Ill Patients,” The Oregonian, October 24, 1999, p. A16.