Wednesday, 28 November 2007

Severe Depression

A few patients have had almost identical problems over the last couple days.

One gentleman is typical of the issues. He's 86, retired and widowed (for 13 years, now, and is on sertraline 100mg to help with this). He lives alone in a property he's happy in, in the locale he's lived in all his life. Family live 2 hours away but drive to see him every week or so and 'phone daily. He's no local friends and doesn't use local amenities such as cafes, church, libraries, theatre, support groups or whatever.

Physically, time's taken it's toll and he's got a few complaints (heart pain, gastric reflux, joint pains) none of which are now serious but all of which erode his resolve and ability to cope. His joint pains are so signifiant that, despite joint replacement, he remains on morphine tablets to address the intensity of his pain (which is at manageable levels of discomfort now, most of the time). Non-pharmacological interventions have also been tried. Like many folk, it's impossible to get better symptom reduction without either major risks or unacceptable side effects, so his physical health is pretty much as optimal as things can get.

He keeps busy through the day, mostly doing DIY in his home (that's very well maintained) and has done fantastic paintings in oils that he's rightly proud of, displaying in his front room.

He's no major stresses. He's financially comfortable, no debts (ever), he's no family worries, no relationship difficulties, no problems with neighbours, no neighbourhood difficulties, no practical heating/lighting/home difficulties, no legal issues, there's nobody struggling with their health, no worries about self care or acitivities of daily living, in fact there are no clear stressors or precipitants/perpetuating factors affecting his mood at all.

But, he's low in mood. Not all the time, when he's distracted he's fine, but when he's on his own (as he invariably is) his thoughts surface, with notions that he's nothing left to live for, he's a burden to his family and life's empty now his wife's gone.

He's always been a private man, he's never sought help from anyone, he refuses to let us tell his family how he's faring and only has been seen by us over the last 2 days when his GP referred him after finding him in floods of tears (but discolsing no problems or risks).

He described how he wakes in the early hours of the night, feeling grim. I can imagine him lying in the darkness, in total silence, with just his thoughts strirring, feelings of hopelessness consuming him. Sometimes he gets up to distract himself, turning on the television, sometimes he simply lies there wishing to be dead. Often he thinks he should be dead. He's pondered different modes, seriously, and considered which owould be unacceptable and which he could do. Two days ago he ground up all his morphine tablets and went to sleep, awoke to take the powder and kill himself but thankfully couldn't find it. It's positive that he told me about his suicidal thoughts and intent when he'd not felt able to tell his GP, I suppose. He's nothing to live for, feels his family would be relieved if he killed himself (there's no evidence of this, they seem to dote over him) and he couldn't accept there'd be ripples with enormous guilt if he did.

He's put his affairs in order and signed his home over to his family. He has no plans for the future.

A patient who is male, elderly, somewhat physically unwell, in chronic pain, feeling he's a burden, feeling suicidal (with active suicidal ideation), feels hopeless and worthless, is planning the mode of death and has tried to act on this. He's not volunteered any symptoms to his family, GP or other services and hasn't sought help.

He's adamant he doesn't want to be in hospital.

Dismal for his first contact with mental health services, the first time he opens up and discloses his thoughts and feelings, to result in compulsory hospital admission . . .


Anonymous said...

It is a sad thing. It doesn't even sound like he was irrational either - other than by definition of the intention of suicide (much like delaring yourself homosexual used to be c.1960s).
It's one part of the ethos of the Act I struggle to reconcile in myself. Here is a man thinking clearly and, apart from an understandable dysphoria, has weighed it up, doesn't see much point and wants to quietly exit stage left. Societal consensus opinion does not permit us to allow that.
Yes, he may have some mood difficulties, but is that the cause or consequence of his situation that leads him to consider suicide? Tho I actually think his hesitation in doing anything (distracting himself, 'forgetting' where he put the morphine, accepting help) is an indicator he isn't that compelled to end it all and the admission order might provide him that sense of human worth he seems to be lacking. A short stay might provide opportunity to explore with him the realistic options for bettering his mood - which seems to be giving him more to live for than to die for (ie removing as much pain; improving his function ability; de-stigmatising taking help and support; providing him a sense of purpose). Either that or it will give him the remaining necessary impetus to turn ideas into actions. The guy's done his time, paid his dues and now, amidst his debilitations, yet in the keeping of his values and morals to burden no-one, lacks any ambition and wants no more.

I note you cite he is 13 years widowed - but that he has no relationship difficulties. I'm sure you aren't implying his being widowed is not an issue - but I think it also more significant to note that you cannot replace that relationship with anything that might even come close - and certainly not 100mg Sertraline.

The challenge to mental health is, if after 'treatment' and discussion he remains suicidal, how to accept that his decision to end it is a viable and 'informed' choice - and if so, how would you mentally/spiritually support someone in that decision?

Could you ethically support this man to see his life as being complete and satisfying, in order they may bring it peacefully to a close (even if we're not allowed to assist with bringing about his death)? Showing him how worthwhile his life has been might actually make him reflect that it actually has been, and still is, worth living.

Personally, I don't think it's for us to force him to have ambition or to 'get happy' about life. He's achieved his lot or cannot achieve any more and if he wants to go, so be it.

If this comment seems like I'm swaying from pro to anti suicide - it is an accurate reflection of my thoughts.

Typing that was a not easy - but that's my human nature voice wanting to say 'live man dammit, live' against my humanity voice saying 'But it's his life, his choice' - but only a tiny little bit louder.

The Shrink said...

Thanks for stopping by and sharing such well thought out considerations. And yes it's a dismal situation, really.

I agree that if a choice is made in clear consciousness, in the absence of mental illness, which is sustained over time, by a capacitated adult, then despite an urge to meddle he does have the right to make negative life choices (up to and including ending his life).

The crunch is he's not known to us so I'm not sure that's the scenario . . .