Blanca bites. Hard.
Diagnosed decades ago with severe schizophrenia, 49-year-old Blanca Livia Arcineiga once managed her condition. Not so long ago, she was stable enough to work part time as a maid. She helped her elderly mother in the kitchen. They slept in the same bed.
Now she lies alone and naked on a soiled mattress inside a fetid room. Her family has barred the door - to keep her from attacking them.
As socialist, sanctions-hit Venezuela reels from one of the worst economic implosions in modern history, Blanca is an example of one of its most dehumanising side effects: an escalating mental health crisis.
Blanca's condition deteriorated sharply in the past eight months, her mother said, because her family is unable to find or afford the medicines she needs. They're now able to source only one of her eight prescriptions - an anticonvulsant. As a result, Blanca has regressed to a savage state.
The family, with a household income of US$16 ($25) a month, is surviving on yuca and plantains. They could barely afford the prisonlike gate across Blanca's door.
"She hates me for it," said Aurora García Sánchez, her 81-year-old mother, pointing through the bars. "But I had to lock her up."
García looked down at her daughter's distant eyes.
"Here's my Blanquita," she said."I don't know who she is."
Years of failed socialist policies, economic mismanagement and corruption have exacted a heavy toll across Venezuelan society. For much of the population here, hyperinflation, joblessness, blackouts and shortages of food and water have reduced life to a daily struggle to survive.
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The impact on health has been acute.
The scarcity of medicines - aspirin and antibiotics, but also cancer drugs and antiretrovirals for HIV patients - have turned buckling state hospitals into squalid centres for hopeless, dying patients.
For the mentally ill, the sword cuts twice: The stress is exacerbating mental health symptoms and conditions to which the health-care system is no longer able to respond. Doctors say the lack of drugs and deteriorating conditions at state facilities are causing preventable deaths to soar.
At El Peñon hospital, one of the capital's main psychiatric facilities, 14 patients have died since 2016 - including three this year - from poor conditions and a want of medication, according to two doctors who work there. The fatalities, the doctors said, were mostly elderly patients in dire physical condition who were transferred there from other state facilities closed for a lack of public funds.
The hospital and Venezuela's Health Ministry did not respond to requests for comment. As public health has deteriorated, officials have stopped publishing data. But the doctors - who spoke on the condition of anonymity out of fear of government reprisals - said severe shortages of medical staff and drugs, including antipsychotic medications, have made deaths unavoidable.
"Their patients' immune systems were already weak, and the hospital is in bad condition with no medicines and terrible food, so they got worse," one doctor said.
More Venezuelans are also manifesting crisis-related stress, which doctors say has worsened mental illnesses, addiction and suicide rates.
Pedro Delgado, one of Venezuela's leading private psychiatrists, said demand for substance-abuse treatment at his clinic has more than doubled in the past year. Yet the number of patients he can treat has steadily gone down, because fewer patients can afford treatment.
To assist crisis-weary Venezuelans, he said, he has offered discounts and worked with a nonprofit foundation that covers mental health care for those who can't pay the full price.
"The biggest burden is on families," Delgado said. "Taking care of their relatives without treatment is the definition of a nightmare."
According to the World Health Organization, the suicide rate in Venezuela fell from 4.3 per 100,000 people in 2010 to 3.7 in 2014. With no official numbers available since then, the Venezuelan Observatory of Violence, which is conducting field research and tracking local media in several states, estimates that the number of suicides has at least doubled in the past four years to 9 to 9.5 per 100,000. In the state of Merida, it's now 19 per 100,000, the group's research suggests.
"It's highly probable that most of the cases are tied to the crisis," said Gustavo Páez, a researcher at the observatory
Luis Blanco, a 33-year-old IT technician who lives in suburban Caracas, is struggling to cope with his father's condition. The 61-year-old has bipolar disorder and clinical depression. Unable to find or afford medication, Blanco said, he becomes aggressive. He often returns home with bruises from fights. Sometimes, he disappears well into the night.
"Of course, dealing with this disrupts my life," Blanco said. "This week, I've arrived home late from work, and many times he's not here. The other day, I got here at 10 p.m. and he wasn't here, so I had to go out to try to find him. I couldn't. I just waited. I had to give him his medicine.
"I ended up going to sleep at 2am, after he showed up. And I have to wake up at 5am for work."
Relatives are struggling to treat the mentally ill at home in part because the mental health hospitals have all but collapsed.
The Psychiatric Hospital of Caracas - one of the capital's largest - comes into view on a hillside overlooking a warren of densely packed streets. Most of the hospital is unlit, because management can't afford new bulbs. Administrators have no food to give patients. Most of the rooms are in such disrepair that the 200-bed hospital now accommodates only 20 patients. Doctors are rejecting several requests for inpatient treatment each week.
The washing machines don't work, leaving patients in dirty clothes, even after soiling themselves. There are no supplies to clean the bathrooms. There's no potable water at the hospital. Patients survive off supplies brought by relatives, or drink filthy water from drains.
"We can't accept more patients, because without their medicines they can threaten the physical integrity of other patients as well as nurses," said Peter Williams Contreras, a union official at the hospital.
"The entire country is in crisis and we're in the middle of it," he said. "The government has no policy for health, even less so for mental health. It's a grave violation of the rights of people with mental health issues."
Nurse Johana Hernandez said a patient was recently brought in with an injured left foot. It became infected, she said, and the hospital had no medications to treat it.
"He got worms, and it kept getting worse," she said. "The patient, who had schizophrenia, died one month ago."
Behind the bars of a locked courtyard where female patients are kept, Dorelis Luz Díaz spoke of being scared. The 38-year-old has bipolar disorder. Since arriving here three months ago, she said, she has been kept in close quarters with a woman whom she and staff say is a violent schizophrenic who has been convicted of killing.
The woman threw her own feces into the courtyard as Díaz spoke.
Díaz has gone several months without her medication, including her once-regular doses of lithium, she and the nurses said. Speaking in breathless, rapid-fire sentences, she said her violent neighbor next door occasionally escaped her cell at night.
"The other day, in the middle of the night, she came and choked me, saying she wanted to take my clothes," Díaz said. "I got really scared, because she choked me hard. Afterward, I threw myself on the floor and cried."
Without medicine, Díaz said, "we get worse."
"We relapse. I get depressed, I want to cry. I want to shout. Now I'm in my days of menstruation, and I don't even have sanitary towels. I just get dirty."
The following day, she seemed even more distraught.
"I peed on my bed," she said. "I tried to clean the sheets, but there's no soap."
She looked down, gaunt, from behind the locked bars.
"I miss food," she said.