After experiencing psychiatric care across the nation and even abroad, I can now say that Maine’s Outpatient Emergency Psychiatric care is abysmal. Why? Because it does not exist. Acadia Hospital has no walk-in care services, and the EMMC Emergency Department offers no psychiatric services.
It was 5:00pm on New Year’s Eve. I was standing in the parking lot of the EMMC Emergency Department, trying to breath through the sobs, knowing that I had seven hours until my healthcare coverage expired, with no access to my routine psychiatric medications after that. As an educated person who prides themselves on being resourceful I wondered “How did I get here?” As a person with Depression I asked, “And will I live to see next June?”
Here is my story:
Living with a mental illness is hard, and many of us with Depression need routine medications that are not controlled substances to carry on a normal life. Balancing work, family, medication management, and medical bills all take a toll, regardless of your diagnosis and how it affects your ability to manage these things.
We all have different triggers, and one of mine is finances. Therefore, I try to plan ahead. I call my health insurance advocate weekly to check in on claims, I read the fine print, all with a philosophy that even if I cannot afford it, as long as I can track, organize and manage it, then I have some sort of control.
So, this year as soon as I realized that I needed to attend an inpatient facility to manage my Depression, I put my research/control/planning cap on. Knowing that I would be making one of the largest financial investments of my life, I needed to make it count by attending the best program possible. That limited my insurance options, but I eventually found one that would work through Maine Community Health Options.
Throughout my six-week program in Arizona I spent time trying to plan my aftercare. I would be in Maine for only one month upon discharge, but I knew I would need someone to refill my medications. I called approximately 15 Psychiatrists and Primary Care Physicians (PCPs) in Maine. No one was taking new patients. My old PCP had moved to a new office so I was out of their system. My primary care physicians prior to her had all switched companies as well due to buy-outs and mergers. Although I was born and raised in Winterport and I spent much of my adulthood in Bangor, after two and a half years abroad I was a stranger to the system.
Knowing that I had no provider to transfer my care to in Maine my psychiatrist at the inpatient facility in Arizona extended my prescriptions beyond their typical policy. I bowed my head in the first of a series of “Oh holy medical provider” moments, and went on my way.
I went home to Maine for four weeks and moved to Ohio for the fall to be in a healthier emotional environment. Prior to moving I made more phone calls to get a Primary Care Physician or Psychiatrist in Ohio. No one was taking new patients there either. When my medications were nearly gone I visited a Psychiatric Emergency Department in Cincinnati. After two hours of waiting, a 4 minute consult with a Psychiatrist (my case is very straightforward and neither of my medications are controlled substances), and a $375 co-pay I had enough of one medication for four months and enough of the other for two months. Over the next few months I enrolled in a psychiatric day program in Ohio. The program wasn’t ideal for me, but at least I was in their system. When my prescriptions ran out I made one phone call and was set up for the next day to see a Nurse Practitioner. She and I spoke for five minutes and I walked out the door with renewed prescriptions.
Still in Ohio, I had back surgery the following month and was consumed with bills and insurance claims. I couldn’t wait to return home to Maine where my insurance company was well known and in-network. I also made a decision to prioritize my mental health by avoiding the dark months of winter, and spending January to June of 2016 in Costa Rica at a health-centered yoga community. With minimal income the cost of living in the US is over my head. Because I was leaving the country I did the math and determined that it was cheaper to pay out of pocket for therapy and medications there rather than pay for an American insurance plan that I would have no access to in Costa Rica. The December 15th re-enrollment due date for my current plan was approaching, and after much debate I called on the 14th and cancelled my plan, effective December 31.
Canceling my plan was a big mistake. Upon further research I found that my antidepressant is not available at any price in Costa Rica. It was wiser for me to be insured here. I called to re-enroll, and although I was still a current member of Maine Community Health Options I was told that since I cancelled on the 14th I was now out of the system and ineligible to re-enroll. Furthermore, they are not accepting new customers. I would have to choose a new, more expensive plan, and the soonest it could be effective was February 1, 2016.
I now had a deadline to get at least one month filled with refills by December 31. I had two weeks and was determined. Since Psychiatrists and Nurse Practitioners in Arizona and Ohio did not hesitate to fill my prescriptions I was not too worried. On the first business day back in Maine I called Acadia Hospital and explained my situation and my needs. I needed one month filled by December 31, with monthly refills while I was away. I was instructed to go to the Eastern Maine Medical Center Emergency Department, where they would send for a psychiatric consult from Acadia, and I would be seen and prescribed. After a few hours at EMMC a doctor came to see me. He said “You should not be here. We don’t prescribe psychiatric medications.” I said “I was sent here by Acadia. They said a consulting Psychiatrist would be called.” He said “We don’t do that. We don’t deal with social issues here.”
A social issue? I’m sorry, is it 1840? Psychiatry is a medical specialty, not a “social issue.” However, I was passed off to a social worker who acknowledged it is virtually impossible to get a new PCP or Psychiatrist these days, but that the Emergency Department had some pull to get openings for new patients. I was scheduled for an appointment with a PCP at Orono Family Medicine on December 30. I reminded the social worker that my healthcare coverage expired at the stroke of midnight on December 31, and she assured me that the PCP could help me. Upon leaving I was greeted with another $375 Emergency Department copay.
I had my medical records released from my inpatient program in Arizona and I asked my therapist, who is based in Bangor and has been a consistent support for over three years, to write a letter on my behalf.
The 30th arrived and I went to Orono Family Medicine to meet with my new PCP. The doctor sat down and quickly said “I cannot help you. I am not a psychiatrist. I don’t know you, so I won’t prescribe these medications.” I said “But I called Acadia, who sent me to EMMC, who sent me to you.” She said “I don’t know why they did that. I cannot help. I will give you a psychiatric consult for next week.” I explained “I won’t have health insurance next week, I have very little money, and I get on a plane the very next day. I’m not comfortable with that gamble.” She skimmed my intake documents only to say “Wow, you have a long family history.” She asked me nothing about myself or my history with Depression. I asked “What would you do if it was you?”. She said “I don’t know what I would do.” She got up and left.
I sat in my car sobbing. The thing is, with me, that when I feel triggered and overwhelmed by my mental illness, my thoughts immediately go to suicide. I think “If life is just a desperate effort to stay alive and still endure pain, what is the point? We will all die eventually. I have been through medication withdrawals and scarcity. If I cannot access my medications in Costa Rica I don’t want to endure that pain.” The catastrophizing went on and on. Once I arrived home in Winterport I called the Healthcare Marketplace again. There was still no way to re-enroll for January. I cried until I fell asleep.
In the morning, December 31, I had a therapy appointment. I brought sparkling cider and we toasted to this hellish year being nearly over. We made a plan for me to get my prescriptions refilled: I would call Acadia. I would call my old PCP again. I would call Spring Harbor and prepare to drive to Westbrook if necessary.
Three was no luck with the old PCP. Spring Harbor was the same as Acadia: An inpatient facility with no outpatient psychiatric services. Even if I drove there, no one would see me. I called Acadia again, and they told me no one would see me. I regrouped for five minutes and called back. I said “I have no options left. My health insurance expires tonight. I cannot afford any doctors appointments or my medications without insurance. If I do not take my medications there is a strong chance I will attempt suicide. I cannot stay in America because it is an unhealthy environment for me.” I was transferred to Access, who said no one could see me, but that they would call me back. They called back and said “Go to the EMMC Emergency Department. A Psychiatrist is there and will be waiting for you.” I reminded her that I had been to EMMC once before with no luck and a large bill. She assured me it would be different this time.
After two hours at EMMC a Physician’s Assistant saw me. He said “I don’t know why you are here. We do not prescribe psychiatric meds.” Through calm, quiet tears I explained my situation. He left to call Acadia and later returned to say “They sent an email letting us know you were on your way. But there is nothing we can do. No one here will prescribe you medications.” I showed him that I had a letter from my therapist. He did not read it. I asked what he would do if he were me, or if I were his daughter. He said “I don’t know.” I began to cry- the loud, embarrassing, ugly cry. I was handed discharge papers and I left with another $375 copay.
Outside I called my father through sobs, asking him to come pick me up. I paused to consider how I became so weak, dependent, and irresponsible. How did I get into this situation? My meds will run out in ten days. I have no way of refilling them. And here I am, having taken my meds on schedule for a long time, and still wishing to be dead.
My father picked me up and dropped me off at my car. I called Acadia to let them know I was on my way. It was 5:00pm on New Years Eve. They said “We cannot help you, but come anyway. We’ll see what happens.” My father offered to come with me as support, but I couldn’t bear him seeing me like this. His sister had killed herself and I didn’t want him listening to my suicidal ideations.
Eventually a clinician came to speak with me. He said he wasn’t sure how he could help, but he would perform an intake evaluation. He was the first person who asked me about my story. He asked about my symptoms. He read the letter from my therapist. Mid-way through our conversation I was approached by a Psychiatrist. It took me a moment to put the face to the name, but I had met him a few years ago. He was not someone I wanted to see me like this. I am no longer ashamed of having a mental illness, but I don’t want people to see me in despair. He had two prescriptions in his hand but was hesitant to hand them to me. He said, “I wouldn’t be here if I did not recognize your name.”
The three of us spoke for a while about the pros and cons of my current medication setup, and the Psychiatrist’s recommendations for me in Costa Rica. Eventually I was given a one month prescription with the refills I needed for my father to send to me while I’m away. I thanked him, with that “Oh holy medical provider” feeling that had become very familiar.
As I bundled up to leave the doctor came back and said “I expect to see this in your blog.” I was taken by surprise: This man has seen my blog? Did that affect my successful outcome? I left at a sprint for the pharmacy. Miller Drug was a dream following this hellish episode of “The Amazing Race: Psychiatry Edition”, and I rang in the New Year extremely dehydrated from tears, but with enough meds until my health insurance becomes effective again.
This adventure begs a number of questions.
First, “Why are there zero options for Outpatient Psychiatric Emergency Situations for people who are trying to be proactive and manage their medications?” I understand that if the patient is actively suicidal or hurting others they need to be admitted as inpatient. However, it should never have to get to this point for a case such as mine, someone who is simply trying to arrange for my medications and appropriately care for myself. I respect that most Psychiatrists want to get to know a patient prior to prescribing, but the definition of an emergency is a time sensitive situation, and I believe patients are at least entitled to a doctor who will listen to them and consider their situation. Not everyone can spend months in the same location just to be supervised.
Second, “Why are there no advocates available to support patients in similar situations?”
Third, “Does the Hippocratic Oath not apply to Psychiatry? Since when was Psychiatry a ‘social issue’?”
Fourth, “What would someone in my position do if they were unknown to the Psychiatrist?” And
Fifth, “What would someone in my position do if they were unable to advocate for themselves, speak up, and articulate their situation and the immediacy of their need?”
The questions continue…
I love Maine. Even when I choose to live abroad I speak proudly of my home state. Its people, its culture, and its values. However, the disorganized and inaccessible state of our healthcare system is something I am now deeply ashamed of. I was shocked by how often I was brushed aside and told “I don’t know what I would do if I were you [but I cannot, and will not try to help you].”
In an age where Psychiatry is undoubtedly a medical issue it is deplorable that there are no psychiatric services in any Emergency Department in Northern Maine. Whether the solution is a Psychiatrist available for walk-in care at Acadia or Dorothea Dix, or a Psychiatrist on call for the EMMC or St. Joseph’s ED, there needs to be a solution to this dangerous loophole.
The greatest gift this adventure gave me was, in fact, something hard to come by for Depressives: a sense of purpose and motivation. I have wanted to become an advocate for the mentally ill for a long time, and I am now more motivated than ever. The public perception of the mentally ill is still inaccurate, and the resources available to us are still ineffective. So, a great big “Happy New Year” and “Thank You” to a broken Maine healthcare system for helping to define my aspirations. It is time for those of us with a mental illness to stop being silenced by shame and speak up for our needs.