Never Tell

Chapter Thirty-Eight

The only psychiatrists Ellie had ever known were ones who worked for the state. The experts who evaluated defendants who claimed insanity. The ones who’d shown up for civil-commitment hearings back when she was on patrol and concluded someone had crossed the line from merely off their rocker to an official danger to themselves or others. The ones she’d been forced to meet with for her own supposed benefit at various times in her career—after the Wichita Police finally caught the serial killer her father had spent his entire adult life hunting, after she had killed a man at Gerard’s Point, after she had witnessed her lieutenant put two bullets in the neck and stomach of a former friend.

Based on the appearance of his Upper West Side digs, Dr. David Bolt wasn’t like any of those state-employed shrinks. Rather than utilitarian faux-mahogany office furniture, Bolt had opted for sleek, minimalist decor. Small footprint, they called it. White irises adorned the corners of the waiting room. A faint scent of ginger lingered in the air. The terrace in his office offered expansive Central Park views.

It didn’t seem like a place for crazy people. The space reminded her of the day spas her ex-boyfriend the investment banker used to try to send her to. According to him, those hours were supposed to teach her the values of “rest and relaxation.” He was trying to persuade her to “spoil herself.” But Ellie’s idea of rest and relaxation was a bottle of Johnnie Walker Black and an entire season of 30 Rock in one sitting. Trapped in a dark room, being rubbed down like a piece of Kobe beef to the recorded sound of chirping birds, was her version of being drawn and quartered.

As for the man himself, she placed him at about fifty. She would have expected him to look slicker, based only on the office decor, but she’d already had a brief preview of his appearance online. Today he wore a gray wool sweater over a button-down shirt and black trousers. He had floppy, longish brown hair and a genuine smile.

As they explained the reason for their visit, he scribbled some notes on a Post-it and then crossed his arms like an umpire watching an instant replay.

“Ah, damn it. I’ve been out of med school twenty-six years, and, you know, this is only the third time I’ve been in this jam.”

“And what jam is that?” Rogan asked. Ellie noticed that Rogan had crossed his arms, too. Sometimes she wondered whether men had learned to mimic each other’s body language back in cave times.

“See? I am just not good at this. You come here asking me about someone named Casey Heinz. I’m not allowed to tell you whether I even know a person by that name. I guess you can probably draw some inferences from the fact I think this is a jam. My sister’s husband’s a cop. He’s in Detroit, though. My point is, I want to help you out.”

“So . . . sounds like we’re all on the same page,” Ellie said.

“Except I cannot reveal any individual person’s relationship to me as either a private client or a participant in a clinical trial. Were I to do so, I could have my ticket pulled by the American Medical Association and the American Psychiatric Association, not to mention problems with the FDA for my research approval.”

“Casey Heinz told us that he was under your treatment,” Ellie said. “That waives privilege.”

“Except it doesn’t,” Bolt said. “A patient can reveal the fact of a doctor-client relationship without intending to disclose all of the details of said relationship. Or, at least, that’s what I’ve been told during my required continuing education classes. Not to mention, police officers sometimes bluff about what they already know about a person’s identity as a patient—not you, I’m sure, but I have colleagues who have fallen for those sorts of stunts.”

“So I guess we’ll meet with the district attorney and get a subpoena.”

“I really would like to help,” he said.

“Obviously.”

Usually that kind of sarcasm directed by Ellie at someone in Bolt’s socioeconomic status triggered phone calls to the lieutenant or lectures about respectful treatment of the public, but Bolt laughed. “Wow, I’ve become that dick my brother-in-law’s always complaining about. Tell you what, Detectives. I can’t reveal anything about individual patients, but I can tell you a little bit about my work in general.”

He extended his arm in the direction of two chairs on the opposite side of his desk.

“Equivan is a new pharmaceutical treatment for bipolar disorder, also known as manic-depressive disorder, or simply manic depression. Both the diagnosis and treatment of bipolar disorder in young people are controversial. Critics argue that kids will be kids. They say, for example, that while impulsive life changes might be clinically abnormal in an adult, young people aren’t yet able to gauge the seriousness of these decisions. Similarly, they say feelings of hopelessness and despair might be red flags in adults, but are simply a normal part of adolescence.”

“We just talked to a teacher this week who believes his students are all overmedicated,” Rogan said.

“Easy to say until you’ve got a child who’s slipping away.” Ellie remembered the passion Bolt had displayed in the NYU debate when he spoke about the pain and frustration he saw in his underage patients. “That said, many of the drugs on the market are experimental, and their use in young people is highly contentious. That brings us to my research. The idea behind Equivan is to use the active ingredient of an antidepressant, which can be quite risky as a treatment for bipolar disorder, but in combination with a mood stabilizer that has been found to be more effective alone than an antipsychotic.”

“You’re losing us, Doc.”

“Basically, we’re trying to blend the best of all worlds here. Take the good and counteract the bad. Equivan is actually an off-label combination of two currently available drugs. Equilibrium is the mood stabilizer; Flovan is the antidepressant—hence the name Equivan. We’re testing it specifically on subjects ages ten to twenty. This allows us not only to measure the effectiveness of the drug, but also to determine whether there is any interplay with age. Perhaps what works like magic in a young adult twenty years of age is detrimental to a ten-year-old. Obviously we want to know that. To participate in the trial, subjects must meet the criteria for Bipolar I disorder, the classic manic-depressive form of the illness according to the DSM-IV.”

Bolt started to explain the acronym but Ellie waved him along. Given the prevalence of mental illness among criminal defendants, every cop had heard of the Diagnostic and Statistical Manual of Mental Disorders.

“Subjects cannot be under any other current medication for depression or other mental illness. They must agree to the conditions of a drug research protocol, which includes a provision that subjects are randomly assigned to receive either active treatment or a placebo.”

“Not all the subjects are actually getting Equivan?”

“That’s correct. The use of a control group is standard in any respectable drug trial. If we gave every subject Equivan, we’d have no way of knowing whether improvements in mood and stability were due to treatment or some other factor, like weather changes, better employment stats, or plain, old-fashioned coincidence. So a quarter of our subjects get Flovan, a quarter get Equilibrium, a quarter get the Equivan combo, and the rest get a placebo.”

“So let’s say the drug combo works,” Rogan said. “That means you’re knowingly depriving some of these subjects of treatment, all in the name of science. Sorry, Doc, that sounds a little cold.”

“It’s not easy, Detectives, but that’s the scientific method. And that’s why our subjects have to sign rigorous disclosure and waiver forms. If it makes any difference, we can’t yet say we’re really depriving them of anything. Every subject receives outpatient therapy from me, a service for which some people in this city pay healthily, if I may say so. The whole point is that we don’t know yet whether the drug even offers a benefit. Equivan might do nothing. It might even make matters worse.”

“Our understanding is that subjects are paid to participate,” Ellie said. The Casden kids pay a fortune to be numbed, while the drug companies pay to get the rest of the population hooked as well.

“That’s not unusual. It’s not a tremendous amount of money, just modest compensation for time and transportation.”

Maybe it wasn’t a lot to an Upper West Side psychiatrist, but a hundred bucks to a sixteen-year-old homeless kid like Brandon Sykes was an entire day of panhandling plus a lot of luck. “Could someone fake a manic-depressive diagnosis?”

“In theory. It has happened before. But the DSM includes criteria that are specifically intended to help weed out false reports.”

“Got it. Now, still sticking to general information . . . is it true that someone with manic-depressive disorder might be more prone to coercion?”

“Certainly. In a depressive state, the person might not have the will to withstand pressure. They don’t really care about the downside because they’re feeling hopeless anyway, plus they don’t have the mental energy to counter the coercion.”

“And in a manic phase?” she asked.

“That one’s less intuitive. You might think that mania would cause a person to fight back. But in a manic episode, the person is not thinking about consequences at all. They start out dropping a buck in a homeless man’s donation cup. It feels so good to help another person that they hand the guy a twenty instead. The next thing you know, they’re at the bank, closing out their accounts to hand out cash on the street. In the situation you describe, a manic person might comply with one request, and before they know it, they’ve lost all control.”

“What about credibility? Might a manic-depressive be more likely to lie if he thought it would somehow help him?” She was thinking now about the credibility of Brandon Sykes.

“I mean we’re talking generalities, but, yes, that would be fair to say, for essentially the same reasons.”

“What about murder?” she asked.

“Excuse me?”

“Might a manic-depressive suddenly become violent and kill a friend during what should have been a minor argument?”

“It has certainly happened before. Manic episodes can be completely uncontrollable.”

“So if we have a homicide defendant who may be manic depressive, we’ll need to know whether they were taking drugs for the condition, right?”

“Well, the whole purpose of treatment is we hope it helps people. We hope that, with continuous use, it keeps them at normal for longer periods of time. We may not be able to cure the disorder, but we try to reduce the frequency, longevity, and severity of the swings between the two poles.”

Ellie smiled. She had thought Dr. Bolt’s offer to speak only in generalities would be a waste of time. She jotted down his last sentence verbatim in her notebook. He had just given them what they needed to force him to turn over Casey Heinz’s and Brandon Sykes’s patient files.