ďIf you can't help me, then just say soĒ
Dan hadnít been in to see a doctor since he was a teenager. But he was worried the first time I saw him, ďI think Iím dying.Ē He had been having abdominal pain for several months and it was steadily getting worse. Over the counter medicines were no help and he finally came to the clinic.
His pain could come on at any time and last minutes to hours. He didnít drink or use drugs, but he smoked about a half a pack of cigarettes a day. He had been losing weight over the past 6 months and food just didnít appeal to him. He was constantly tired and couldnít seem to get enough sleep.
He was six and a half feet tall and weighed 220 pounds, had dark hair and had a scowl that was more than a little bit scary. His exam was unremarkable, his blood pressure was normal and his chest x-ray was normal. I ordered labs and set him up to come back in a week to plan the next step.
A week later we went over his labs. He was not anemic, his blood sugar was normal, his thyroid tests were normal, vitamin tests and liver tests were normal.
I ordered an abdominal ultrasound and this was also normal. Because of his weight loss and his smoking history, I ordered a CT scan of his chest, abdomen and pelvis. All were totally normal.
I referred him to a Gastroenterologist and he had a scope of his esophagus and had a colonoscopy. Other than removing a single polyp in his colon, these studies were completely normal.
In the course of several visits, I came to find out that he lived alone and had not talked to his sister in over 20 years. ďThere was nothing bad, she just moved to Boston and I stayed in Seattle. Iím guess Iím not good at calling or writing letters.Ē
He worked in a machine shop and was around loud machines all day. He ate his lunch at his work station and didnít talk to or know any of his co-workers.
He never smiled. A depression screen came up positive, but he refused to consider that. ďMy mom was depressed, so I know what that looks like. She was crying all the time and it drove me and my sister almost as crazy as she was.Ē He denied suicidal thoughts.
He refused to take an antidepressant medicine, even as a trial. ďYouíre telling me this is all in my head, arenít you? Well, Iím not crazy and Iím not weak. If you canít help me, then just say so.Ē
He came back about 6 months later. He was still having his abdominal pain and had lost another 12 pounds. His labs and exam were still entirely normal.
Again, I brought up depression as a likely cause. He really fit the picture pretty well. He had no appetite and was sleeping all the time. He had no friends and nothing he enjoyed doing as a hobby. He refused to start any medicines and I didnít see him again for another 6 months.
Again, his labs and exam were normal. ďDr. Vainio, if I tried an antidepressant medicine, would you think less of me?Ē
ďNo, Dan, I wouldnít. Antidepressants are safe, have minimal side effects and are not addicting. They donít make you look at the world through rose colored glasses, but they do help you get some successes behind you. If it doesnít make any difference, you can stop taking it.Ē
Two months later he was back in the office. ďI donít think this is making any difference.Ē He had regained 2 pounds and he was smiling as he was telling me about a girl at work who seemed to make a point of walking past his work station, even if it meant going out of her way. He agreed to double his antidepressant dose and to follow up in a month.
He missed that appointment, but he did request a refill through the pharmacy. I gave him 6 months of refills and he requested another 6 months when that was done.
I didnít actually see him again until I was finishing my residency and getting ready to leave Seattle to come back home to Minnesota.
ďDr. Vainio, can I tell you something? When I came to see you, you were the only person I ever really talked to. I thought I was happy living by myself and being alone. I purposely chose to work in a machine shop because itís noisy and I have to wear ear plugs.
But I wasnít wearing them because of the machines. I was wearing them so I wouldnít have to talk to anybody and so nobody would have to talk to me. I ate my lunch alone and I didnít have any friends. Now I eat in the lunchroom with everyone else and I just bought myself a dog.Ē
Depression is very common and affects 5-10% of patients in a primary care setting. Classic symptoms and signs of depression are appetite changes, either eating more or eating less with resultant weight gain or loss. Sleep problems are common, either insomnia or sleeping all the time. Memory loss, difficulty concentrating, low energy level, excessive guilt and suicidal ideation are common. Family history is a strong risk, as are recent stressors, trauma or losses. Chronic medical illnesses also increase the risk for depression.
Most respond very well to antidepressants, behavioral health therapy or a combination of both. Depression is more common in women, but can affect anyone, even big strong machine shop workers. Many initially donít believe the diagnosis and donít want to take medicines. I see people with depression who start to feel better, then stop the medicine because they think they donít need it anymore. It can take months for them to realize theyíre right back where they started.
As I was finishing my last visit with Dan he told meÖ
ďDr. Vainio, I didnít believe you when you told me I had depression and that antidepressants would help. I really did think I was dying. My stomach doesnít hurt anymore and I think I was just worrying myself to death.
I called my sister a couple of months ago and weíve been talking on the phone ever since. I never realized how much we really needed each other.
I came here today because I wanted to say goodbye to you. And I wanted to thank you. When I first told you I didnít have suicidal thoughts, I was actually thinking about suicide almost every day. I spent fifty-seven years not knowing what everyone else feels like. I donít EVER want to stop taking these medicines.
Dr. Vainio, you gave me back my life.Ē
Arne Vainio, M.D. is a Family Practice Physician at the Min-No-Aya-Win Human Services Clinic on the Fond du Lac Ojibwe Reservation in Northern Minnesota. He can be reached at email@example.com.