People have come into my office having heart attacks. But after Masako walked out our front door, I felt more helpless and frightened than at any other time during my four and a half years of private practice. Thirty-four Japanese-born women killed themselves in our community in the past year, and I knew Masako, at age 33, was a real threat to be next.
Sixteen days earlier, she came to me asking for an antidepressant, a common request from educated patients in the 1990s. Working on her bachelor’s degree in music and helping to finance her education by giving piano lessons, she had canceled all of her lessons that week because she was too distraught, tired, and weak to work. So I began asking her the usual questions about what was going on in her life; you can’t just take a pill and expect to cure depression.
At that point, she closed her therapeutic doors. Looking down at her hands folded in her lap, allowing her elegant waist-length black hair to flow forward along her narrow, slumping shoulders toward a vulnerable face lacking any expression, her body and voice gave me the clear message; “I don’t want to talk.” I knew we were in trouble.
Japanese culture forbids the sharing of problems; each individual must manage his own. Masako had moved to the United States with her husband and (then) four-year-old daughter eight years ago, but she had absorbed little of our culture. She would not permit me, or anyone else, to help her with her current situation.
I decided to try some less specific questions. Were her problems new or old? For about 30 seconds, she only looked at me. “Both,” she finally offered. What did her husband and 12-year-old daughter think of them? “They don’t know; I won’t tell them.” Had she ever been this depressed before? “Many times.” Was she thinking of killing herself? She replied with an affirmative nod. How would she do it? She didn’t answer. Had she ever tried it before? “No.” Would she see a psychiatrist? “I don’t want to talk. I just came for some medicine.”
Because it is one of the few life-threatening illnesses of young adults, major depression requires immediate intervention. Masako's case illustrates why this can be difficult; the more severe the disease, the more impediments there are to treatment. People who feel hopeless, worthless, and unable to get out of bed in the morning often cannot and do not reach out to relative strangers to get help. Insomnia and appetite suppression further tax their energy and emotional reserves. When they have enough energy, their lack of self-esteem keeps them from “bothering” other people who have “more important things to do." Often, they would rather just die. This is why when a medical or mental health professional finds someone who seems to be an immediate suicide threat, the law allows us to hospitalize that person against his will for up to 72 hours if he will not consent to treatment. We call this a “5150," referring to section 5150 of the California Welfare and Institutions Code, which empowers us to do this.
Severe depression usually requires two forms of treatment; medication and cognitive therapy. As a family physician, I treat dozens of patients with depression every year, often prescribing the necessary medications, while a psychologist administers the cognitive therapy. But Masako was making it clear that she wasn’t going to give me permission to use other resources to help her, not even her daughter. I offered to admit her to the psychiatric hospital across the street from my office, but I knew I might as well have asked her to broadcast her problems on national television. After I gave her my after-hours emergency phone number, she did agree to call me if she felt like killing herself, and she made an appointment for the next day. I also wrote her a prescription for Paxil.
Paxil, the brand name for paroxetine, is a selective serotonin re-uptake inhibitor (SSRl) and a close relative of Prozac (fluoxetine). Both medicines act on the neural transmission of serotonin, one of two neurotransmitters (norepinephrine is the other) that play an important role in mood regulation, although we do not yet know how they do this. I told Masako what I tell all my patients taking these drugs. They are not “uppers.” What they do is let you look at daily situations in a more objective and accurate way. When we are depressed, we tend to ignore the good things that happen, and the bad things take on an oppressive, heavy, dark, and overwhelming character that makes us feel powerless, hopeless, and worthless. The SSRIs, over a two- to four-week period, help to change one’s frame of reference such that life’s circumstances and events seem more manageable.
I chose Paxil because it is a little less “activating” than Prozac, and I was afraid that if she developed insomnia, nightmares, diarrhea, or anxiety, she would discontinue the medication and our relationship.
She did come in the next day and claimed that she felt a little bit better. Her speech was less delayed and had a more fluid rhythm, but her overall affect remained flat and depressed. The immediate danger had passed, and when this happens in clinical situations, my mind opens to a wider variety of options. I remembered that our county has an Asian Mental Health Center, so I called them. Their Japanese specialist was on vacation, so I left a message for her.
The following Tuesday, near the end of my afternoon office hours, my medical assistant Sabra told me a woman named Noriko was on the line. Sabra, who is studying to become a physician’s assistant and is doing her clinical training in my office, noted the puzzled expression on my face and reminded me that I had left a message for the Japanese specialist. Noriko confirmed my fears: Masako was at high risk for executing a suicide, much higher than a “typical” suicidal woman in the United States. I here weren’t any special community resources for these Japanese women. Because Masako refused to see anyone else, I would have to treat her or have her committed.
I hung up the phone and called Masako. She had stopped taking her Paxil; she said it wasn’t working (of course not; it takes at least two weeks to start helping most people) and thought it was responsible for some recent headaches. Would she consider restarting the medicine? “I don’t care. I feel dead already." I noted the increase in my pulse.
“Why did you call me? You have other patients; don’t take up your time.”
I explained my fear that she would kill herself. “My friend did that last fall,” she admitted. How did that make you feel? “She did the right thing. She was divorced. She had a bad life. Now she doesn’t suffer anymore.” I saw a chance to get her to tell me something about herself.
“Are you divorced?”
“No, I want a divorce. But I can’t. I would lose my daughter."
“What would she do if you killed yourself?”
“She’s old enough now.” “She’s a child!”
I waited for her response, but none was forthcoming. Knowing she would refuse, I offered again to put her in the hospital. She did agree to restart her Paxil after I explained again that it doesn’t work right away. When I told her I would call her again tomorrow, she said that would be okay, and that was enough to convince me she would still be alive then.
Within moments after I hung up the phone, I had second thoughts. I knew that the
city of Berkeley had a mobile crisis mental health unit, which can send a mental health worker out to do an emergency evaluation, but Masako lives outside the city limits. Because of this, I would have to call the police, who would go to her home, serve her the 5150 papers, and dispatch an ambulance that would take her to the county hospital in Martinez, about 20 miles away. Imagining the police car and ambulance invading the privacy of her quiet neighborhood and household to haul Masako away from her husband and daughter to the chaos of the county mental hospital, I could not persuade myself to make the call. I didn’t sleep well that night.
She answered the phone the next day and sounded better. Claiming that she didn’t know why she had improved, she told me she had gone for walks each of the past few days, as I had recommended, and she had restarted the medication. She still did not want to discuss any of her life’s details nor see a mental health provider, but she agreed to keep her appointment with me two days later (a Friday). I indulged myself with the thought that my reaching out to her was, at least in part, responsible for her brighter outlook.
When I entered the exam room Friday afternoon, all evidence of brightness had vanished. Her sad, drooping eyes and almost catatonic slowness of speech and movement fueled my anxiety. I asked how she was, and she just nodded her head negatively.
She did tell me that a close woman friend from Japan had visited her two days ago, but just for one day. Masako had mentioned her troubles. “What did she say?” I wondered aloud.
After about ten seconds, she answered. “Nothing.”
“Not even ‘I’m sorry’?”
“In Japan, we do not do that. We do not say anything. If we say something and we are wrong, it is our fault, so we do not give advice.” I have not yet been sued, but I understood the concept.
She then slid out of her chair, spilling with her emotions onto the floor. Raising her head from her knees, she moaned, “I want to go home!” and made her exit before I could react. Believing I had lost all my influence and feeling rejected, I chose not to chase her.
I now felt as powerless as she did. It’s difficult to find a psychiatrist on a Friday afternoon, so I paged three of them; it wasn’t until six patients later, or about 90 minutes, that two of them called back. They agreed that Masako was not giving me enough information to convince me that she was not in immediate danger. Given that, I had to use whatever means necessary to get her into the hospital. In Japan, she might have the right to kill herself. “It’s my choice," she had said to me. Not here, it isn’t. Just as if she had threatened to kill me, I had to call the police.
The telephone receiver seemed to weigh 50 pounds. Part of me believed calling the police was cruel and unnecessary. As Masako confirmed to me later, it would create a scene similar to what I had imagined. Feeling that I had failed her, I did it anyway.
At first the police raised my hopes when they told me they could take her to the hospital across the street from me if I made the arrangements. Two phone calls later, that hospital was ready for her. But the law wasn’t; the county requires that all 5150s go to the county hospital, although she could be transferred to the local hospital if a bed was available, as it was in this case. The officer chuckled as he relayed to me that Masako had struck one of his colleagues and therefore had to be placed in handcuffs. Now I, too, just wanted to go home.
An unwelcome pager vibration interrupted my Cambodian dinner with my wife that evening. Scott, one of the mental health crisis workers at the county hospital, was evaluating Masako and wanted to know the situation, so I told him. Showing wonderful sensitivity, he thanked me for taking on such a difficult case and arranged for her transfer back to our hospital.
When I spoke to one of her nurses the next morning, I explained that I would be willing to see Masako and do the required history and physical examination, but I knew she would want a different doctor to do it. I was wrong; Masako wanted to see me.
Dressed in sweats, she sat up and smiled upon my arrival, something I had never seen her do before. “You must have really thought I was in bad shape to put me in here with these people," she offered. The previous day’s experience had changed her outlook, if for only a day or two. Her husband had, according to one of the nurses, offered to divorce her. “I will try harder to make it all work out,” she assured me.
At the nurses’ station, I ran into Chris, one of the psychiatrists who had advised me the previous day. “One of the nice things about doing this all the time is that you realize people turn out all right.” Masako’s hospital psychiatrist discharged her the next day so she could play a piano recital, and he scheduled an outpatient appointment with her for two days later.
Now, three weeks after her hospital discharge, her speech has slowed and softened again, she’s still not teaching piano lessons, and she won’t see the psychiatrist. She said she does not want a divorce because it would make her daughter more unhappy. As a child of divorced parents, I know otherwise, but in trying to convince her of this, I learned that she has never supported herself before and was afraid. Her husband had already moved out.
She refused my motherly suggestions on how to live alone. “It’s none of your business whether I kill myself,” she claims, denying that I have any stake in the outcome. But my hopes for her recovery remain as long as she continues to see me. She has an appointment next week.