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.