January 17, 2011

Mark Foster, DO
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Bob–

About a month ago, I started caring for a fifty-five year old Filipino woman. She speaks English well, though with a heavy accent. She is very sweet-natured, always painfully respectful of me and my authority as a doctor, and says repeatedly, “Yes, doctor. No, doctor. Thank you so much, doctor.” She was originally diagnosed with depression ten years ago, shortly after she immigrated to the United States and was going through a difficult adjustment with the culture and language. She saw a psychiatrist and was placed on Zoloft at the time, but had never taken it steadily, only when she felt anxious. Then, about two years ago, she began having panic attacks, saw another psychiatrist, and was placed on Zyprexa, which she had also taken sporadically. From our interactions, I would guess that she never questioned the need for either medicine, because of the perceived authority of the doctors who prescribed them, though it is clear that the indications and directions for the meds were never really understood by her. At our first visit a month ago, she complained of feeling anxious and having insomnia. When I asked her about these medicines, she told me that she was taking each of them about twice weekly. I suggested they were probably not really helping her at that frequency, that they may in fact be harmful to her in the long-term, and that she just go ahead and stop them. Then she started getting headaches and panic attacks–not unexpected withdrawal symptoms which I had warned her about. When they got worse over a weekend, she went to the ER. The work-up there was negative, so they gave her some Xanax and Percocet and told her to see me.

At our Monday visit, she was very anxious, still with some residual headache, and she felt it was all due to her not being able to sleep. She wondered if she should resume the Zyprexa. She was not suicidal, was not endangering anybody else, and after some discussion, we decided simply to try Lunesta for sleep, and see if that helped her feel better.

It didn’t. She called my nurse multiple times on Wednesday, and then just showed up at the clinic on Thursday at her wit’s end. To her, the insomnia had become completely maddening. She was red-eyed and near tears. I was able to work her into my schedule, but didn’t have much time to spend with her, and so my strong temptation was to tell her to just resume the Zyprexa and see me again next week, where we would try and sort out these pieces when she was in a better frame of mind. But I felt that would be doing her a disservice, that that sort of snap decision was what had probably gotten her placed (and maintained) on those meds years ago. So I decided to spend some extra time and explore the issues more. I asked her why she thinks she can’t sleep. Did she think she was withdrawing from the medicine, or was this part of a disease? She said, “No, it’s the stress, doctor.” What is causing your stress? “It is my husband. He has lots of health problems. But mostly it is my son. He is still living at home, and he does not treat me with respect. He calls me ‘the angry old woman’ and treats me like I am lowly thing. In my culture, this is very bad for a child to treat his mother this way. It shows I am a bad person. I am very sensitive. My whole life I cry for no reason. This is the most hurtful thing that could happen to me.”

I said, I’m so sorry that you are having to go through this. It sounds very unfair. What can we do to improve this situation? Do you think you need a medicine? She asked, “What would the medicines do, doctor?” I replied, Well, really, they would alter your brain chemistry and make your mind numb to your emotions. They will make it so you don’t really care about these problems. She was taken aback by this, and responded, “But I don’t want to be numb, doctor. I am here to live, not to be numb, right?” This was a remarkably profound statement to me, offered by this woman off the cuff, and I said, Yes, we are all here to live, and I guess part of living is feeling pain. She thought for a moment, composed herself, and then said, “I think I know what I need to do. I need to open my heart to my husband and my son so they see how this hurts me. I need to let this out.” Surprised at how swiftly she offered this solution, I replied that I thought she was very wise, and then I asked rhetorically, Why is it that we hold onto things that hurt us? We hold the pain inside, and it just keeps hurting us. We need to let these things out, and then we need to let them go. She smiled faintly and said, “Yes, doctor.” I told her that I thought she had identified the real underlying problem, although some of her symptoms are also likely due to medication withdrawal. We decided that she would take the Xanax as needed for anxiety, and the Lunesta for sleep, but that we would not resume any other medicines. I emphasized the importance of daily exercise for her, and referred her to a mental health counselor. She already had an appointment with me scheduled for the next day, so I told her to keep that, and we would talk some more. Then I asked my wise and compassionate nurse to spend a few extra minutes holding her hand and talking with her, because by that time I was running half an hour behind.

Today, I was delighted to see her show up for her appointment smiling, with an air of calmness about her and her sister by her side. She was almost overflowing with gratitude and said she was doing one-hundred percent better. She had called her sister the night before, who had come to her house, and they had spent the evening talking about her problems until they both fell asleep. She slept uninterrupted through the night, after taking only one Xanax in the evening, no Lunesta, and nothing this morning. Also, on the advice of my nurse, she had started to pray, and felt that had made a big difference.

Now, I’m under no pretensions that this complete turn-around in mood from one day to the next is permanent. Hopefully, the worst of her withdrawal symptoms are over, but she’ll surely have some more mood fluctuations. (Then again, don’t we all?) But it is interesting that this dramatic overnight change was achieved basically without medications. Several seemingly small things came together–sisterly communication and tenderness, patience, perspective, and prayer, and limited use of benzos–and she seems to have pulled out of her spiral of desperate anxiety and insomnia. I would guess that most physicians (and myself previously) would have reflexively placed her back on Zyprexa, or sent her back to the ER for a psych evaluation. We were able to show some restraint and offer some alternatives, and hopefully she has taken a good step towards a healthier mental state.

The more I consider our psychotropic-intensive paradigm of mental health care, the more I see its circular ironies. Because we have come to simplistically label the symptoms of depression and anxiety as pathological, physiological diseases, it seems that we have come to miss out on the potential for healing that these moods carry within them. In the very act of mislabeling symptoms as diseases, we remove their power to induce a healing process. What if we could better integrate these mood disturbances into a cohesive picture of self and mental wellness? What if we viewed depression, anxiety or insomnia in the same way we view a fever? That is, as symptoms, not diseases in and of themselves, but manifestations that the mind is engaging in a struggle to achieve balance between internal and external forces. Then we might see these mood symptoms as almost desirable, as warning signs–even gifts–that are trying to alert us to the underlying unresolved tensions of the heart and mind. Sure, we can mask fevers with Tylenol so that we can get through our work day, or send our kids to school, but that bill comes due quickly enough, because for a short-term benefit we have deprived our bodies of the rest that the fever and the inflammatory cascade were trying to induce so that our immune systems could have the resources necessary to do the real internal healing. Thus, by masking symptoms, we sometimes prolong the disease. I’m increasingly inclined to think that we ignore or bury these emotional warning signs at our peril, and that by mislabeling and mistreating them, we develop fragmented, antagonistic views of our emotions and our selves.

In the case of this sensitive, gentle woman, I don’t think she ever needed a chronic medication for any chemical imbalance. She needed someone with authority to give her permission to explore, process, and resolve her mental anguish on her own, and she needed, not drugs, but human kindness from a sister and a nurse. With minimal prompting, she discerned the real problem, and identified what may well be a long-term solution. Her own mind discovered her personalized cure.

I remember once, when I was numb from the dentist, I bit my lip and didn’t even know it until I felt blood running down my chin. My numbness didn’t allow me to recognize that I was injuring myself. Luckily, novocaine wears off in a few hours, and although my lip was then painful, it soon healed, because the pain kept me from biting it again. But daily psychotropics don’t wear off so quickly, and can sometimes cause permanent damage.

There is a lot of wisdom in what this woman said: We are here to live, not to be numb.

Mark

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