Elaine[1]was an internist’s challenge. She had a huge combination of issues, mostly as a complication of long-standing diabetes. Renal failure was an issue. And then the ever-present dizziness to sort through.
I marched forward with confidence. I girded myself with the internal medicine sword and worked my way through the complex interaction of her various medical problems and medications and their impact on her. Getting her more stable was not a one-time event. It was a long meticulous process of tweaking and adjusting. That challenge is oddly what attracted me to internal medicine. Slowly we made progress.
Howard was Elaine’s husband. He was a strong blue collar 1950’s dominant male figure. Picture the crew cut and the firm way that he shook my hand and you can quickly get a good idea of the scene. He was clearly going to be in charge. He would pressure me to help Elaine.
Elaine was in the role of the quiet and submissive wife. She seemed happy in the role. It was clear that they had worked out this balance early in their marriage. Howard would come to every appointment and push to get answers for Elaine. He would talk more than she would. Elaine would nod in agreement. The three of us then launched into a pattern of regular appointments to work through Elaine’s problems.
One day my nurse brought me a phone note (days of paper charts) that told me that Elaine had called the office. Elaine was worried.
Their daughter Lisa[2]struggled with depression. Lisa was expressing hopelessness and thoughts of suicide. They were estranged from her. They didn’t know how to help her. But (and I hadn’t put this together) Lisa was one of my patients as well. Could I help her? Oh – and of course – to make it more challenging – I was not allowed to let Lisa know that they had called me.
I let the phone note sit like a lead weight on my desk. How in the world was I going to do that? I had a busy practice. Even if I had time, I couldn’t just call Lisa to come in without some reason. They had put me in a very awkward position. “Dear Lord, how in the world am I going to be able to help here? Why did they call me?”
I worked on through my day but felt weighed down by that note.
Later that morning the nurse brought me another chart with a phone note on it. Lisa had twisted her ankle and wondered if she needed to have it checked.
Wow!
Ok. So, my answer was, “YES!!!”
I told the nurse to immediately work her into my schedule that day regardless of what it took! I then prayed. How was I going to get from an ankle exam to depression and then to suicidal ideation and what we could do to help her. This was before the era of routine screening questions for depression or anxiety. I had never heard of the PHQ-9[3]. I was going to be on my own (plus praying for a lot of help!) I decided I would have to just figure it out as I went. I would have to “wing it!”
Lisa came to her appointment. My years in the U.S. Navy served me well when it came to routine orthopedic injuries. Her ankle wasn’t very bad. Some rest and perhaps some physical therapy were all that she would need.
“How are you Lisa?” “Is everything going ok for you?”
She turned her eyes down and then answered, “It is funny that you ask that. To be honest I have been having a hard time lately.”
“Thank you, LORD!” was my very rapid silent prayer! The door was open. And when the door was open, I heard a flood of troubles over the years. I heard of her struggles with the mismatch between her personality and her father’s dominant personality. I heard of her own relationship issues. I heard of years of depression and repeated attempts at counseling that seemed to just go in circles.
I listened. I listened some more.
She admitted to having some suicidal thoughts. But now that we talked, she agreed to contract for safety with me.[4],[5] She would call me if she got that bad again. We talked about medications and counseling. She had not wanted to try medications in the past. She felt that she should be able to work through things on her own. After a period of discussion however she was willing to try a low dose SSRI[6]. We agreed to have regular office visits to monitor her progress.
When I first entered primary care practice, I hadn’t planned to prescribe antidepressants. I thought that I would just refer to psychiatry. I later discovered a lot of barriers. First, there didn’t seem to be enough psychiatrists. Second mental health was often not covered by insurance. Finally, there was a barrier on the part of patients not wanting to go to a psychiatrist. While they might talk to me, they did not want to be referred.
I went through an early career season of dealing with multiple somatic complaints and not the key issues of depression and anxiety. After this I decided that I had better step up and beginning treating the real diseases. Depression and anxiety disorders are both very common and very real. They destroy people’s lives and their health. If we do not treat them, it is like putting a Band-Aid over the wound from an open fracture without fixing the fracture. It is foolish and frankly unkind and dangerous. By the time I left primary care I had become somewhat facile at managing depression and anxiety.
Lisa came back to see me a month later. She was no longer suicidal. She was feeling apathetic but not depressed. I made some further adjustments in her antidepressant regimen.
Lisa came back another 4 weeks later. She had a smile on her face. She said that for the first time in forever her therapy sessions had become meaningful. She said that she now had the strength to work through the issues that had plagued her. She was going to reach out to her Dad and see if they could work through things. She wasn’t expecting him to change from the strong man that he was, but she was hoping to be able to love him nonetheless.
Elaine came back to see me. Of course, Howard was with her. She and Howard were very happy.
Her family was back together again. Elaine had her daughter back. More important to her was that Howard had his daughter back too. They had reconciled.
And then, about 6 months later, out of the nowhere, Howard was gone. Elaine came to her appointment, but Lisa, not Howard, was there.
Howard had died suddenly.
And I had chills. And tears. And wonder and amazement.
I had no idea that we had been functioning on a time limit. None of us knew that Lisa had a limited time in which she could reconcile and love on her father. But that is what she had been able to do. She had several months where she truly loved her father and he loved her back.
Even now I thank my Lord for the honor of being His servant. I thank Him for a sprained ankle. I thank Him for letting me be the one to listen. I thank Him for medicines that worked. I thank Him for His amazing timing. I thank Him for the reconciliation and love that happened between this strong domineering father and his daughter. I thank Him that He let me see this. I thank Him that He gave me the incredible honor to be a part of it.
What lessons are there in this story? I will suggest a few. Likely some of you will find other lessons as well:
- Primary care physicians can have an amazing role. Even though I am no longer in primary care I value their role immensely. They deserve our respect, our thanks and our support. Someone needs to be there to help work through the multiple and varied medical issues that come with being a human.
- Mental health problems are real diseases.They cause immense harm. They are as worthy of careful and meticulous treatment as end stage renal disease or diabetes. We are a cruel and foolish society if we want to Band-Aid everything else but ignore treating the real underlying problems.
- Medicines AND counseling can be a powerful treatment when used together. Depression can rob people of the strength to be able to be effective in counseling. For some patients the combination of the two can be a powerful tool for healing. I am not saying that we just put everyone on an SSRI, but many have been helped by these and other medications. A wholistic approach that uses all the tools that are available seems to be best. This can include medications. It can include counseling. It can include working on spiritual health as well. None are or should be exclusionary of the other.
- Some tweaking of the antidepressants is often needed. This was a side lesson on this case for me.
- God is in charge and He is gracious.This is my solemn belief. You may think it all coincidence, but for me I see with crystal clarity the gracious and loving hand of God. There are times when He will put ridiculous coincidences in my life. It is as though in those times He knows He needs to make it easy for me to believe. He has been exceedingly gracious to me. In those times, He makes it easy for me to see His hand. Amazingly He often lets me be a central character in the story. That is indeed a wonderful honor. But He also loved Lisa and Elaine and Howard. He gave them the answers to their prayers. I wish that Howard would have lived longer and that they would have had more time. But to this day I am so thankful that he lived long enough to have a restored relationship with his daughter. And I am thankful that the Lord let us watch this play out in His perfect timing.
This is not a Hallmark channel special. The story is true. Some of the details have been changed to “protect the innocent.” But the story is absolutely true. It reflects a wonderful mystery. There is so much more to our world and reality than just what is obvious. There is great meaning that can come to our lives if we are willing and able to be humble and patient servants.
[1]As is usual for my posts, the names and medical details are changed to protect patient privacy. Her name was not Elaine. The medical details have been changed but not in a way to not make the story truthful. They have been changed enough so that patient identification will not be possible.
[2]Again, all identifying characteristics and names have been changed. The essence of the story remains true.
[3]In fact the PHQ-9 wasn’t developed until 1999. These events were happening shortly before that.
[4]Drye RC, Goulding RL, Goulding ME: No-suicide decisions: patient monitoring of suicidal risk. Am J Psychiatry 130:171–4, 1973
[5]While the “contract for safety” has been debated for effectiveness, it was the standard at the time. I am not a psychiatrist or psychologist, but my understanding is that it can be effective if the patient views it as a rescue line that they can pull instead of reaching for suicide for that. It is felt better now to do a thorough discussion and assessment for suicidal risks. A full review of that is beyond the scope of this story. You can read more here: https://www.speakingofsuicide.com/2013/05/15/no-suicide-contracts/
[6]SSRI = Selective serotonin reuptake inhibitor
