Five Depressed Women, Depressed?

What is depression? A state of being, a feeling, a diagnosis, an affliction, a disease? I find no easy answer to this question despite the fact that I am a so-called expert. As one learns more and more about a subject, any subject, one realizes how little one knows. For over 40 years I have been treating depression in my office. I’m not even sure “treating” is the right word. Maybe “sitting with” or “confronting” or “exploring” or “observing” or “struggling with” would be better terms. Clearly “curing” depression is a foolish notion. Everyone gets depressed in some way. Do we cure being human? So, allow me to explicate the mystery with some very recent on-going cases. Yeah, I know, “case”, such a medical term. Forgive.

---------------------------------------------

Do we treat people or do we treat diagnoses? I think the former!

---------------------------------------------

Woman #1: “J.” I saw J. with her husband several decades ago, a childless couple with difficulties not at all unusual: miscommunications, sexual complaints, nothing eccentric or peculiar. When they moved north with hopes of early retirement, they presented me with a lovely clock which I still have in my office, the clock that determines when “time’s up.” J. contacted me last year. Her husband had died of lung cancer 6 years earlier and now she was confined, because of a chronic neurological disease, to a wheel chair. She was forlorn. I encouraged her to get into therapy. I also told her I thought of her every day (an exaggeration) because of the clock. “You’ve made my day,” she exclaimed, really more of a whisper. She is unable to speak loudly because of her neurological condition. Six months later, she again contacted me, “There are no good therapists in the state of ___.” She asked me (begged me?) to have phone sessions with her. I agreed: a hard of hearing psychiatrist and a whispering patient. I did hear one statement clearly, “I’m lonely, so sad, all memories.”

Woman #2: “A.” I started seeing A. shortly after she got married. I initially treated her in combined individual/group therapy and then only in a weekly 2-hour group therapy session. She was a star in the group, beloved of the other members because of her skill in ridiculing the group leader (me), shining a bright light on my every shortfall, inconsistency, and therapeutic blunder. This fireball began falling apart – not a good idiom – a year ago as she approached her perimenopausal “change of life” – a rather useful idiom. A. switched from being highly psychologically-minded to being a woman obsessed with vague and, for her, frightening, physical symptoms: dizziness, headache-like fullness, constriction in her throat, loss of appetite, changes in sleep pattern (less sleep), increased sexual desire, tinnitus. She consulted doctor after doctor: acupuncturist, holistic, GYN, ENT, neurologist, internist. She peeked into her chart when the last physician with whom she consulted left the room. It said “Hypochondriac, refuses to take her antidepressant.” I told her I disagreed with the diagnosis. “There is an old-fashioned term,” I said, “It’s called ‘masked depression’ whereby physical symptoms mask the underlying emotional struggle.” “Well, dammit,” she retorted, the old fireball, “You have to help me figure out what is that emotional stuff!” Indeed.

Woman #3: “Y.” Y. came to my office once a couple of years ago. It was a painful experience for her, for me, and for her husband. Barely able to walk even with her walker, she struggled up the 3 steps to my office, cursing and complaining. We never got beyond the waiting room! She had a left-sided (right-brained) stroke 6 years ago; her family complains that this 83-year old woman doesn’t try hard enough to get better. Coming to my office for weekly sessions would be horrible (for patient and therapist). So, after convincing me to reduce my fee (I don’t participate in the Medicare program. see previous blog), I agreed to phone sessions. Every session begins the same, “I’m worse every day, I’m scared, it’s hopeless.” She never misses a session. She always thanks me at the end of a session. By most clinical measurements her case would be considered a therapeutic failure. It’s not. I validate her, I challenge her – “You’re another day closer to death” – I explore her unsatisfying, painful relationship to her long gone mother. I recommended a book, “Tuesdays With Morrie” by Mitch Albom. Morrie is/was (now deceased) an extraordinary character who decided to embrace his terminal illness, Amyotrophic Lateral Sclerosis; Morrie has become Y.’s ego ideal. So Y. makes baby steps toward coming to grips with death and the indignities of extreme disability. She wrestles with her rage and guilt and shame. I receive a check in the mail promptly, 2 days after every session, from her husband. Evidently, he too values the respite from complaint that the session provides.

Woman #4: “H.” Every session begins the same, “I’m possessed by the devil. I’m trapped in my body. I can’t take care of myself. I want to die.” She lives in an extended care facility, refuses to drive, and has not worked (as a dental assistant) for 6 years. She may be a victim of psychopharmacological poisoning. When she first sought help for “depression” from her GP and then a psychiatrist, she was drugged with antidepressants and neuroleptics. She developed a movement disorder, tremors, and shaking throughout her body. To my amazement, after reviewing her medical records, no one, including NIH mavens, considered this an iatrogenic problem. It was after or during a 6-week hospitalization at a prominent Maryland psychiatric hospital, that she decided she was possessed. It took me 9 months to wean her off of her drugs. Was this a dementia? I sent her for neurological and psychoneurological testing. The tester concluded that she had profound deficits in executive functioning, probably could not take care of herself, and had a “structural apraxia.” Brain scan, EEG, and neurological physical exam were all essentially normal. Embarrassed, not knowing the answer to a question that I should be able to answer as the expert, I asked her, “H., do you think your problem is physical or psychological?” “Both,” she answers. Why do I continue to fall for the body/mind split? It’s always both. Sessions with H. are bawdy and rambunctious, often singing silly songs. “Who you gonna call? Ghost Busters!” She’s very nosy, “What are you going to do this weekend,” she asks. “None of your fucking business,” I answer. Gales of laughter! I tell her, “You know what the devil hates?” “No,” she replies, “what?” “He hates it when you laugh.”

Woman #5: “L.” “You’re the first psychiatrist in 35 years who ever talked to us (she and her husband). They [other psychiatrists] would just check off the symptoms and write a prescription.” L. has suffered from panicky depressions since before her marriage, controlled (suppressed is a better term) by drugs. She had been prescribed more than 20 different antidepressants and neuroleptics. Finally, a year earlier, she paid the piper. The drugs stopped working. So, on to ECT X 18 treatments. - BTW, did you know that each ECT treatment costs between $2,000 - $2,500? You can make quite a nice living off of damaging the brain – No benefit. More enlightened members of her extended family found me through ISEPP. Because she lived 200 miles away we needed to set up phone sessions with monthly in-person meetings.

Have the drugs poisoned her? I don’t know. But what I know drugging has done is seduce her and her husband away from self-examination. For help in this case, I have referred to Bert Karon’s classic (I think) paper on treating depression with psychoanalysis without drugs. (“Recurrent Psychotic Depression is Treatable by Psychoanalytic Therapy Without Medication” Ethical Human Psychology and Psychiatry, Vol 7 #1, Spring 2005) This is not really a technical paper but rather an exhortation. Bert projects 2 not usual psychoanalytic qualities: persistence and optimism. These patients are “geniuses” he says in convincing therapists that their “lives are hopeless and therapy is of no value.” (page 46) He forthrightly counters their pessimism, telling them, (paraphrase) “If you cooperate, meet frequently (2 to 4 times a week) you will get better.” Further, he makes it clear that whatever they are feeling, anger, shame, sadness, that these are the result of real happenings in their life, conscious or unconscious, present or past. Bert makes only one mistake: “… patients are more likely to make optimal progress without the use of medication or with temporary medication which is withdrawn as rapidly as the patient can tolerate.” (page 45) On the face of it, this statement is correct. The problem is when someone has been drugged for long periods of time, one is (I am) never sure what is happening. Is the drug making them feel worse or better? Is withdrawal making them feel worse or better? Is a setback in therapy due to a therapeutic blunder or is the therapeutic intervention irrelevant to what the drugging or the withdrawal of the drugging is doing to the patient? To paraphrase Freud, “A toothache takes precedence over neurotic anxiety.”

My imperfect approach to this dilemma is to assure the patient that it is in their long-term interest to be drug free. While they’re moving through this arduous process, they must practice “good mothering” to themselves with regular exercise, meditation, gentle calming herbs, tea, and dietary supplements.