“So ya, that’s everything that’s going on…”
There was a long silence before I responded, “that fucking sucks, it really does.”
“You’re telling me…”
I had just started as a resident doctor at a hospital in Ontario, Canada, and was working with one of the first patients I would ever follow in my outpatient psychiatry clinic. I met a woman, Ms. G, who worked as an engineer. Ms. G had been referred to the clinic by her family physician (known as a general practitioner outside of Canada) for an assessment of low mood and sleep disturbance.
As these things go, you get some information in advance of the consultation from the referral form. Ms. G had never been involved with the mental health system. She was in her 50’s, married, and had three adult children. She was also not presently taking any medications.
I’m excited. A blank slate, a canvas ready to be worked with. So much potential. I quickly opened my copy of Prescriber’s Guide, and reviewed the starting doses for all of the basic antidepressants. Would today be my first fluoxetine start? Sertraline? Maybe even escitalopram?
The consultation time quickly arrived and I stepped out into the waiting area to ask for my client. Ms. G was average height, was wearing business attire, and had been using her cellphone immediately prior to my arrival, which she peered at through a pair of thin, golden reading glasses. Ms. G shook my hand and we walked together to the office.
Ms. G and I spoke for almost an hour. She detailed her struggles with low mood, decreased enjoyment in life, poor sleep, poor appetite, and difficulties concentrating. There were profound feelings of guilt and worthlessness. Her mental status exam was actually relatively benign. You were certainly given the impression that this person was tired and frustrated, but you certainly weren’t put in mind of someone in the throes of a severe depressive episode. With this information, I was able to determine that Ms. G met criteria for a Major Depressive Episode, mild/moderate severity.
Ms. G also owned her house. Her and her husband had just renovated the home, and it was beautiful. That was before the flood. A month prior, Ms. G’s home was the most recent victim in a spat of Toronto city floodings. Everything in the basement was destroyed. A lot of the renovations, which included the downstairs bar and family room, had not even been properly enjoyed yet, only to be destroyed by the flood. Even worse, Ms. G’s home was the only one on her block to sustain significant damage.
“that fucking sucks, it does.”
“You’re telling me…”
Our consultation wrapped up and it was time to discuss the impression, plan, and treatment with Ms. G.
“Based on everything we have discussed, your presentation is not suggestive of any mental illness.” This peaked her interest.
“Then how do you explain what’s going on? I can’t sleep, I feel awful all the time…”
“Well, you have a lot on the go. You just renovated your home, spent tens of thousands of dollars, and now you’re faced with the flood. In a way, you’re re-traumatized every single day when you get home from work and have to be reminded of the damage, since the repairs are yet to be done. It makes sense to feel this way.”
Ms. G liked my opinion and asked me what she could do to feel better. I told her to hang in there, and to continue working on the repairs. I told her my suspicion was that she would feel a lot better once the repairs were taken care of. She would be able to move on.
I also told her I did not expect medications to have any effect on her mood. This wasn’t depression. This was an exaggerated form of a really, really bad day. I did offer a short supply of some sleeping pills which she gladly accepted.
I also told her I wanted to see her again, and I followed up with her twice over the coming months. At the second follow up, she was smiling, and I noticed the bags under her eyes were quite less pronounced.
“Good morning doctor.”
“Good morning Ms. G. How are you today?”
“I’m great – you were right!”
“I tend to be,” I said as I laughed. “But just so we’re on the same page, what are you referring to?”
“It’s finally over.”
“I’m so happy for you.”
“Thanks for everything, doc! You cured me.”
Editor’s note: I didn’t cure this woman – as these things often go, time in many ways heals most wounds. This was the natural history of getting through psychological distress following something like a home flooding. This is not what I would expect to happen with true and blue depression, which often needs a combination of therapy and medications.
Ms. G met criteria for depression; that does not mean she has depression. You can meet criteria for any number of mental illnesses, and it is up to you and your doctor to synthesize all of the available information, and to interpret it in the way that makes the most sense.
Dr. Travis Barron is a resident physician in Toronto, Canada.