Missing a Diagnosis That Hit Too Close to Home
Mike and I must have done a hundred psychiatric emergency admissions together — the hallucinating, the intoxicated, the violent ones, brought in by the police. Mike was known as a smart, confident, level-headed nurse, one of the few male nurses in the field, back in the 1980s. As a fledgling psychiatrist, I always respected his assessments in the E.R.; when he said, “This guy needs to be on a locked unit,” I listened. Even on our excellent nursing staff, Mike was known as the “top gun.”
One morning, as I arrived on our inpatient unit, I nearly froze in my tracks. Our overnight admission stood in the hallway, looking disheveled and sporting a dense 5 o’clock shadow. He had the vacant look of someone whose spirit had been snuffed out like a cold candle. Our overnight admission was Mike.
It turned out that he had been struggling with a ferocious bout of depression for several weeks. Even those who had been with him recently in the E.R. were shocked at his appearance; he looked as if his blood had been drained and replaced with skim milk. I resolved immediately that I would be the one to bring him back from the Land of the Unliving.
Before you can put some folks back together, as one of my supervisors liked to say, they need to fall apart. Mike certainly qualified on that score. He spent most of his time curled up in a ball, sleeping on his cot. He had the usual symptoms of major depression: low self-esteem, loss of pleasure in most activities, thoughts of suicide and a tremendous sense of guilt. The precipitating causes were not clear, and Mike seemed humiliated at our efforts to delve into them. He, too, saw himself as a sort of “top gun,” and he had been ignominiously shot down.
I treated Mike with two robust antidepressant regimens over the course of about two months. I saw him twice weekly in individual psychotherapy and made sure he attended group therapy three days a week. Yet nothing seemed to budge his depression. His lethargy and somnolence seemed almost contagious, and our staff clearly felt uncomfortable working with Mike. He was a disconcerting reminder of our own vulnerability to depression, to what Winston Churchill used to call “The Black Dog.” I no longer wanted to meet Mike’s gaze in the hallway for fear he would catch the look of failure in my eyes.
In those days before managed care, we could keep patients on our unit for eight weeks or even more. But after a couple of months, Mike signed out of our unit, against medical advice. He was not suicidal, and there was no legal justification to keep him. I sulked around the unit for days afterward, wondering how I could have let him down so miserably.
A few weeks later, I ran into him outside the medical center. He looked as if he had just come back from a vacation in Tahiti. “Ron!” he yelled, “Great to see you! Hey, you won’t believe it! I saw this private psychiatrist and he figured out my problem. I had atypical depression. He put me on this fancy medication called an MAOI. I hate giving up wine and cheese, but I feel like a million bucks!”
As I tried to work up a smile, I wished nothing more than to sink into the sidewalk. Atypical depression — how could I have missed it? I had actually written a paper with one of my supervisors on this very diagnosis. Atypically depressed patients often show a different clinical picture from those with “classical” major depression. They often oversleep and overeat, for example. (Indeed, Mike had not lost weight before his admission.) And instead of feeling more depressed in the morning, as is common in major depression, atypically depressed patients tend to “crash” in the evening.
Furthermore, as Mike’s private psychiatrist clearly knew, patients with atypical depression often respond better to MAOIs (monoamine oxidase inhibitors) than to standard antidepressants.
Why had I not prescribed an MAOI? Perhaps, on some level, I was afraid of exposing Mike to a medication I knew to be potentially lethal, if proper precautions weren’t taken. But the explanation doesn’t hold much water. After all, that very medication helped give Mike back his life.
I think something else may have been at work: a phenomenon that Dr. Jerome Groopman identifies in his new book, “How Doctors Think.”
Dr. Groopman observes that V.I.P. or celebrity patients sometimes short-circuit the physician’s normal diagnostic thinking. For example, these patients may be spared the doctor’s usual tests and procedures. As our “top gun,” Mike was just such a patient to me. Even as I entertained grandiose fantasies about curing him, my unconscious may have steered me away from doing everything I could to help him get better.