There’s a hot pink suitcase on the floor of Shariah Vroman-Nagy’s bedroom. The 18-year-old is packing for a trip to Disneyland, one of several she takes with her family every year.

“Let’s see, I need a hairbrush,” she says, moving past the collection of Mickey Mouse ears on her dresser, glancing at the inspirational quotes from Marilyn Monroe on the wall.

The lyrics to a song called “Smile” hang in a frame over her bed.

“My mom made me that when I was struggling,” says Vroman-Nagy, “because that’s the song that I would listen to. Michael Jackson did a version of it, which I love.”

When she feels her depression creeping in, she sings it to herself.

Smile, though your heart is aching
Smile, even though it’s breaking
If you smile through your tears and sorrow
Smile and maybe tomorrow
You’ll see the sun come shining through, for you.

Three years ago, it was in this room, lined with porcelain dolls and stuffed animals, where Vroman-Nagy tried to kill herself. She was 15, a freshman in high school.

“Everything piled up, piled up, piled up until I just couldn’t handle it anymore,” she says. “So I had my anti-depressants and I took a handful of those. But then I thought better of it, and I told my mom. She took me to the emergency room.”

There’s no adolescent psychiatric hospital in Redding, the small city in far northern California where Vroman-Nagy lives. So she was taken from the local ER to a hospital in Sacramento, an hour and a half drive to the south. She was there for eight days.

The doctors diagnosed her with bipolar disorder. They wanted to keep her longer, but they told her the insurance company wouldn’t cover it.

“I didn’t feel like I was ready because I had just been put on new medications,” she says. “In the past I’ve had reactions to medications, and some have not worked. So I wanted to wait and stay for observation a little bit longer.”

Vroman-Nagy wasn’t alone with feeling that she was sent home too soon. Since 2010, the state received almost 900 appeals from patients saying their insurer unfairly denied inpatient mental health treatment, according to data from the Department of Managed Health Care, the main health insurance regulator in the state. The department overturned 47 percent of those decisions.

Insurers are allowed to deny coverage for certain treatments, if they determine that the care is not “medically necessary.” This determination is based on evidence-based clinical standards in both mental and medical care, but it has become a key battleground for mental health advocates.

They say insurers are able to deny mental health treatments more often than other medical treatments, because it’s harder to prove when mental health care is medically necessary.

Determining the best treatment for depression, bipolar disorder, or anxiety disorders relies heavily on the subjective report of the patient, so it can be difficult to demonstrate how ill a person is.

“There aren’t blood tests in mental health, there aren’t X-rays in mental health,” says Keith Humphreys, Stanford psychiatrist and former White House advisor on mental health policy. “So, it’s easier to deny care for mental health than it is for things we've got physical evidence for.”

Outside the Hospital, Care Still Difficult to Find

After Vroman-Nagy went home, the hospital helped her find a therapist to continue the work she had begun on the inpatient unit. But the insurance company, Anthem Blue Cross, said no to that, too. They said the therapist wasn’t part of its network.

“We spent quite a long time with the insurance company battling them trying to get them to cover visits,” Vroman-Nagy says.

Anthem wanted her to see someone on its list of approved in-network providers, Vroman-Nagy says. At the time, that list was just six people, a common scarcity in rural parts of the country.  When Vroman-Nagy started calling them, they either told her their schedules were full or they were retired. So Vroman-Nagy decided to stick with the out-of-network therapist.

Her father, Tom Nagy, supported the decision. “Because at that point, I’m mean you’re talking possible life and death issues,” he says. “That was my approach, to pay for it. Run up the charge cards.”

He ended up paying thousands of dollars out of pocket. Nagy is a teacher, and his wife is a nurse. They couldn’t afford to keep doing that.

By law in California, insurers are required to make special arrangements for patients to see an outside therapist if there are none in the plan, and they have to provide the care at the same copay or coinsurance as an in-network clinician. They can’t charge extra.

It’s unclear why Tom Nagy didn’t get that help. He had to fight and fight with the insurance company until he was finally reimbursed.

He went through "two or three denials," then filed an appeal with Anthem. That was denied. So he filed a second appeal.

“It was literally a year-long process,” he says. "As a parent, it’s hard enough to deal with these situations and be supportive, but then you get the whole financial thing, it just adds a whole other layer. It’s frustrating.”

Psychiatrist Keith Humphreys says it’s rare to see someone keep up a fight with an insurance company as long as Nagy did.

“It's the easiest fight in the world to win for an insurer,” Humphreys says.

Most people would have given up long before, he says. Take someone with depression who has trouble concentrating or can’t get out of bed.

“Now you're demanding that I fill out eight pages of forms?” Humphreys says. “It's canted heavily against the people wanting the services, by the nature of the condition.”

In a statement, Anthem Blue Cross said it is “committed to providing access to high quality and affordable health care, including mental healthcare.” It has a variety of resources to help people find the best provider for them, the statement continues, including an online listing of available mental health providers, and customer service staff who can help with a search.

The company also launched a new online psychology service earlier this year, called LiveHealth Online Psychology, so patients who live in rural areas where it can sometimes be hard to find a clinician, can “talk face-to-face with a licensed therapist or psychologist through high-definition video on your smartphone, tablet or computer with a webcam."

Looking Toward the Future

It’s Shariah Vroman-Nagy’s spring break from college, and the preparations for the family trip to Disneyland continue.  She says she really needs the vacation.

“They call it the happiest place on earth, and I really do feel that it makes me happy when I go,” Vroman-Nagy says. “I’m glad we get to go this week because I have been having a little depression going on.”

She and her parents run some errands before they leave town, including a stop at Walmart to stock up on snacks for the nine-hour drive.

“I have a question,” Vroman-Nagy says to the cashier. “You used to have Mickey Mouse shaped cheese. Do you not carry it anymore?”

Instead, she got Frozen-themed cheese sticks, with characters from the hit Disney film on the package. The radio in her car is primed with a series of Disney soundtracks, from Tarzan to Beauty and the Beast, songs which Vroman-Nagy knows well from her days singing with a show choir in high school.

Overall, Vroman-Nagy is doing much better. She works part time at the local In-N-Out Burger, and she’s training to volunteer for a suicide hotline. She’s also studying psychology and music at the local junior college.

She plans to become an adolescent therapist one day. But first, she’d like to be a character singer at Disneyland.

“I would love to be in their entertainment,” she says, and imagines herself in a princess costume singing and dancing in the park’s stage shows or parades. “That would be my dream.”

Have a story about mental health that you think KQED should cover? Email reporter April Dembosky.