Mr M's diabetes remained stubbornly uncontrolled despite all appropriate clinical interventions. The day I read his first psychiatric hospital admission history I was stunned to see on paper what we had all missed in the flesh. What value is adherence to treatment in the face of sheer hopelessness?
Depression has many different faces, many different names. In medicine, it has come to be associated with a certain clinical sterility. In primary care, it’s been distilled to a self-administered questionnaire that returns a number-simple, informative and life-changing when employed in the right context at the right time.
Unfortunately, I didn’t think of it recently. Mr M’s chart had grown 4-fold in size since he first walked in to our primary care clinic-I had inherited him from another provider who had reduced hours. His problem list read like a small nightmare betraying his age of 45 years: chronic kidney disease, uncontrolled hypertension, uncontrolled diabetes, obesity, chronic back pain, narcotic dependence, post-traumatic stress and depression, among other problems. Since we started working together, his diabetes remained stubbornly beyond control even after months of counseling, education, insulin-all of the things a clinic or a provider was supposed to do. We didn’t know that behind a well-polished veneer of smart dressing and a flashy smile was a crumbling personal life, loneliness, unemployment, guilt, and most prominently, hopelessness.
I read about this when I was faxed his first psychiatric hospital admission history and physical. I recall feeling shocked, turning the pages like a thriller. I was discovering a new person-a complete stranger that had come before me countless times reviewing adherence to different therapies, discussing outcomes. His mental health care was being managed by a competent provider in an office just down from our clinic. He was on therapy, and never looked depressed. He spoke well, seemed put-together and joked with staff. Now, in the midst of his fourth admission for severe suicidal ideation, it was apparent we were all missing something.
Mr M and I talked about it at a recent visit between hospitalizations. More than anything, he was consumed by an overwhelming sense of being alone in the world, of a life without purpose and without substance. He described the utter despair of closing the door to his apartment at night and feeling the cool, dark air sink into his bones. He described the silence that drowned his thoughts. I watched as the grown man in front of me cried, sharing his hopelessness with us for the first time.
In truth, I was embarrassed and felt I had failed. By the numbers, his case is far from atypical-there is ample data on the interplay of depression and diabetes-so much, in fact, that that some have coined a new term: “diapression.” This stuff’s not rocket-science any more. It’s a PHQ-9 AND an A1c routinely administered in your clinic. It’s taking time to know the person sitting in front of you as a person-more than a collection of maladies. It makes a difference. I had been blind to these aspects of his life. I am no longer.
On a grander scale, though, this revelation introduced a far more profound barrier to improving control of his chronic conditions-Mr M’s belief that his life is without purpose. Motivation to adhere to medical therapies almost uniformly assumes an individual has meaning in life, agency to affect change in their environment, and wants to live to an old age by prolonging the time before death or disability through means you advise and they trust. All too often we take any or all of these assumptions for granted. Sense of a foreshortened future, inability to be effective in life-ultimately despair and hopelessness-they’re all wrapped up in what medicine labels as depression. They’re common in those with lifetime histories of trauma or loss of all forms, and they deeply complicate any efforts to achieve health.
Depression, as we know it in medicine, is treatable. From simple to complex, behavioral treatments are often predicated on addressing the fundamental-and flawed-assumptions about self-worth that lead to isolation and purposelessness. At times in my psychiatric training when patients were in the darkest hours of their lives, I remember believing that my role was simply to be an eternal source of hope and optimism until purpose could be found again. I think of the warmth and light many holiday celebrations bring to people around the globe, and reflect on the fact that they occur frequently in the darkest, coldest months of the year. No matter the face of Mr M’s despair, I hope he too can find solace this winter in the struggles of those before him and the renewable source of optimism this season has come to represent. It seems like an essential first step to better health, and one helluva New Year’s resolution we’ll be committed to making together.