MARACAY, Venezuela — The voices tormenting Accel Simeone kept getting louder. The country’s last supplies of antipsychotic medication were vanishing, and Mr. Simeone had gone weeks without the drug that controls his schizophrenia.
Reality was disintegrating with each passing day. The sounds in his head soon became people, with names. They were growing in number, crowding the tiny home he shared with his family, yelling obscenities into his ears.
Now the voices demanded that he kill his brother. “I didn’t want to do it,” recalled Mr. Simeone, 25. He took an electric grinder from the family’s garage. He switched it on. But then, to spare his brother, he attacked himself instead, slicing into his own arm until his father raced in and grabbed the grinder from his bloody hands.
Now, thousands of mental health patients — many of whom had been living relatively normal lives under medication — are drifting into despair and psychosis because the country has run out of the vast majority of psychiatric medicines, leaving families and doctors powerless to help them, medical experts say.
Mental institutions have released thousands of patients because they can no longer treat them, according to physicians. The patients still being cared for now suffer in crumbling wards that can barely even feed them. Doctors and nurses fear violent attacks and say they have little choice but to tie their patients to chairs, lock them up or strip them of their clothes to prevent suicides.
In the city of Barquisimeto, the scenes at El Pampero Psychiatric Hospital are those of nightmares. (Go inside the dysfunctional state-run institution here.)
Food shortages had left one older schizophrenic man emaciated, like a walking skeleton in a concentration camp. An epileptic man bereft of medication fell into repeated seizures, while another untreated patient lay strapped to a bed, bound at the ankles. An older woman with no drugs to control her schizophrenia crawled across the floor, past a hungry patient eating fruit that had fallen into a pool of open sewage.
But most patients around the country are in the hands of families like the Simeones, doctors say. Family members must choose between going to work and watching over their loved ones. It is a life of searching for increasingly rare drugs, desperately hoping their relatives do not harm themselves, or others, the moment someone looks away.
“When I heard that he could hurt his brother, that broke me,” said Evelin de Simeone, Accel’s mother, recounting the day in June her son grabbed the electric grinder.
Venezuela, the country with the largest oil reserves in the world, once produced most of its own pharmaceutical drugs. In the early 2000s, the president at the time, Hugo Chávez, began a broad nationalization of Venezuelan drugmakers in an effort to produce cheaper medicines. Foreign companies like Pfizer and Eli Lilly filled in the gaps by shipping drugs.
Then oil prices collapsed. The government began running out of hard currency, leaving it unable to import raw materials for the state-owned factories supplying Venezuelan hospitals. Many foreign drug companies stopped sending medicines because the government owed them so much money.
The consequence: About 85 percent of psychiatric medicines are now unavailable in Venezuela, according to the country’s top pharmaceutical trade group.
“The most elemental things are gone,” said Robert Lespinasse, a former president of the Venezuelan Society of Psychiatry. “It’s like being impotent.”
For some, the lack of drugs has brought tragedy. On June 30, Yolanda Sayago, a 63-year-old with severe depression, went to the ninth floor of a building in the city of San Cristóbal and climbed onto a ledge. In her last moments, captured in a video that now circulates on YouTube, Ms. Sayago looks down once, leans forward and, with her arms spread, leaps to her death.
She had spent months unable to find antidepressants, said her son, Jesús Guillén, 43, who works for the state electricity company. She fell into a depressive relapse that pushed her toward suicide, he said.
“She was always saying medicines were impossible to find here,” Mr. Guillén said.
Hobbled by such shortages, Venezuela’s mental institutions now care for only a small portion of the patients they did a few years ago. In 2013, there were 23,630 long-term psychiatric patients in public hospitals, but only 5,558 last year, according to a report from the Health Ministry.
Publicly, the Venezuelan government denies that its hospitals are suffering, and has refused multiple offers of international medical aid. But at the invitation of doctors, journalists from The New York Times visited six psychiatric wards across the country. All reported shortages not only of medicines, but of food.
In El Peñón Hospital, the converted mansion of a former Venezuelan dictator in Caracas, the capital, only two patients remained, despite a capacity for 40. Doctors were turning away anyone hoping to be admitted because food had not arrived regularly in months.
In Dr. José Ortega Durán Psychiatric Hospital in Valencia, an 18-year-old schizophrenic man was tied to a metal chair. Hospital workers said it was necessary because they had no medications to treat him.
In El Pampero Hospital, Jusmar Torres ran out of medication for a mood disorder and depression weeks ago. Now she was sitting behind bars in solitary confinement. She had been there, naked, for four days. Hospital staff members had stripped her because they feared she would hang herself.
Weeks later, a paranoid schizophrenic who ran out of medication threw herself on top of a bunkmate at night and bit off the woman’s nose. “It wasn’t me, I did not do it,” said the schizophrenic patient, pacing a dank solitary confinement cell with bars as nurses kept their distance.
Down the hall, the victim sat with her face covered in bandages, writhing in pain. All the nurses could offer her was an anti-inflammatory medicine similar to ibuprofen. A mosquito net blocked the swarms of flies drawn to her wound. Dogs and cats roamed the halls. The smell of urine hung in the air.
“This is too hard,” said the victim’s sister, Doris Villegas, gasping at the injury. “I look for her medicines, but I can’t find them now.”
The screams of Emiliana Rodríguez, another schizophrenic patient, echoed. She had little food and no medication for her glaucoma, leaving her hardly able to see. She could barely acknowledge those around her, but for a moment focused.
“I’m not crazy,” she said. “I’m hungry.” Evila García, the head nurse, looked up in anguish at the patients who had been left at the hospital. “No one wants a crazy person at their house,” she said.
That is not the case for Accel Simeone, the young man whose visions urged him to kill his brother. The family’s cinder-block home in the tropical city of Maracay remains a refuge, even after he took to his arm with a grinder.
Soon after, a psychiatrist prescribed a different medication — one that could be found, at least that month — and the voices haunting Accel grew quieter. It might have brought calm to the household if Gerardo Simeone, Accel’s brother, were not schizophrenic, too.
Soon it was Gerardo who was out of medication.
When Life Looked Good
The Simeones were true believers in Mr. Chávez and his Socialist-inspired revolution.
Mario Simeone, the father, was the son of a refugee from World War II Italy who had married in Venezuela, but the hard work of his parents did little to raise his prospects. When he and Evelin married in the late 1980s, their first home, in a run-down barrio, had neither a table nor a bed.
Mrs. Simeone finished a law degree at a free, state-funded university and began a practice specializing in lawsuits and wills. Her husband, a curious tinkerer, opened a garage to fix vehicles. In 2005, the two bought a new home and filled it with appliances: four televisions, two laptops, and a washer and dryer.
“Our refrigerator was always full,” Mrs. Simeone said.
But something was wrong with Accel. The affable young man, nicknamed El Gordo, or the Fat Man, had turned 18 and was starting to feel anxious, with a constant sense of being pursued. Voices told him that he was gay, or that they wanted to kill him for his money.
At 19, Accel attacked his father with a stick. A psychiatrist in Caracas immediately recognized the symptoms of schizophrenia and prescribed a number of drugs, then easy to obtain.
“Medication was the only way to win,” Mrs. Simeone said.
But the battle was only beginning. Accel’s younger brother, Gerardo, had long been the more talkative one, a raconteur and joke teller who broke into long discourses about the history he learned at school. Then El Negro, as his family called him for his dark features, suddenly fell silent.
“What surprises life gives you,” Mario Simeone said of Gerardo’s schizophrenia. “Who would have known it would have hit the two boys?”
In many respects, life remained the same. The medication calmed the brothers’ paranoia on all but a few days, allowing Evelin to continue working and Mario to fix cars in the garage. Accel even started working as Mario’s assistant.
Still, Accel and Gerardo, once pictured in photos as boys hugging each other with wide grins, now barely spoke. Accel took an interest in writing hip-hop lyrics and in cooking. Gerardo remained quiet. “He was so kind and loving,” Mrs. Simeone said, remembering Gerardo before he became ill. “He had such an amazing lexicon.”
Outside the home, other changes were afoot. Mr. Chávez, who had cancer, died in 2013, leaving a lesser-known successor, Nicolás Maduro. The next year, oil prices began to decline drastically. The country found itself unable to pay for goods, services and imports.
Lines for food became frighteningly common in the Simeones’ neighborhood. Basics like cornmeal and rice were hard to come by. By 2015, inflation hit triple digits, decimating the family’s savings and often leaving Evelin and Mario without clients.
The shortages of medicine struck hard. Mrs. Simeone was spending long periods each week scouring pharmacies for olanzapine, an antipsychotic drug, having little luck. By April, she was dividing the remaining pills between her sons and reducing the doses to make them last.
“I said, ‘My God, neither of them will have any soon,’” she recalled.
When the drug ran out in May, Accel felt it first.
The voices that had haunted him surged forward again. Specters adopting the names of hip-hop artists like Nicki Minaj and Ñengo Flow, a Puerto Rican singer, pelted him with insults. The dead did, too. Time and again, they told Accel that he was gay and should be punished.
Days before he attacked himself, Accel wrote a series of Facebook messages to his mother. The voices, he explained, were making absurd demands, asking her to make large purchases and threatening Accel if she didn’t. Frustrated, Evelin told him to go help his father in the garage and think of other things. Accel warned that the voices were becoming violent.
“They even throw grenades at me,” he wrote on May 30. On June 4, Evelin and Mario went to a relative’s house, leaving the brothers alone. That was when Accel’s voices told him to kill Gerardo. “They came and told me to do it, to do it, to do it,” Accel recalled as his brother looked on. “I didn’t know if I was alive or dead.”
Torn between the voices and his conscience, Accel left his brother and headed to a shed where his father kept tools. The voices continued, urging him on. “I felt the need to take a screwdriver and put it in my chest, just where my heart is,” he said.
Accel settled on a grinder on the floor. He plugged it in, switched it on. “They said I needed to keep sawing until I had cut off my arm,” Accel said. He had just started when Mario returned home and wrestled the grinder from his son’s hands.
“He was just standing there, like it was normal and nothing happened,” Mario said. The wounds did not hit any arteries or veins. The large gashes in his arms are now scarring. But the costs from the day the family now refers to as “the crisis” are still adding up.
Evelin, who had hardly been able to work in order to watch over the brothers, has quit work entirely. Mario fixes cars to pay for medication for his sons, when it can be found, lamenting how far the family’s fortunes have fallen.
He recalled when they bought their home in 2005. The price was 45 million bolívars, an amount that soon dropped to 45,000 after the government replaced the currency with a new devalued one in 2008. Now inflation has made that figure seem laughable.
“The price of our house is barely enough for a cellphone,” he said. He wanted someone to blame. “This is a fanatic state,” he said. “If you really love a country, how could you leave it without food, work or medicine?”
Sometimes It’s Too Much
Unlike his brother, Gerardo wasn’t prone to violence when his pills ran out. By July, when most of his medications were gone, he drifted into his own world, standing calmly in a corner for long spells as the rest of the family sat in the living room, watching television. He would look up and answer a question now and then, but it was as if he were dreaming elsewhere.
“We call him our Swiss Guard,” Mario said wryly. Waiting in line and scrounging for medicines are not the only daily struggles for the Simeone family. The real trial is holding the strained, at times violent, household together.
Accel still hears voices in his head, which now tell him that he can no longer sleep in his bed. He has moved to his parents’ room. Mario and Evelin’s grown son spends the night with them. Guilt haunts Evelin. She is troubled that she has not searched as hard as she can for medicine for Gerardo.
“I am tired,” she said. “This is too much sometimes.” She began to cry and walked away. Accel looked up, sensing something was wrong. “It’s allergies again,” she told him.
The tiny house feels cramped, with a sense of cabin fever. When there is enough medicine to clear his mind, Accel takes to writing new hip-hop lyrics. One is about his relationship with Gerardo. Another, called “The Lights Are Out,” tells of the constant blackouts in his neighborhood.
Accel opened his bedroom door and pointed at lyrics written on the wall. Every inch has been covered by his frenetic writing. Mario spends most of his days tinkering in the garage, muttering about parts that are no longer found in Venezuela. Gerardo’s silence now frustrates him.
“There are times I get mad at him,” he said. “I just don’t understand why he’s behaving like that. I tell him: ‘What’s wrong with you? Don’t act like a stupid person!’” Gerardo looked on, stone-faced and silent.
Mario looked ashamed, then ran across the room, grabbing his son, lifting him a few inches and twirling him around. When he let go, Gerardo was still expressionless. Then his eyes grew wide. A smile cracked across his face. The whole family started to laugh.
Gerardo looked at the floor and started laughing, too.