A Patient’s Illness, A Patient’s Life
I’ve been practicing geriatric psychiatry since the early 1980s. Over this period, patients have come and gone; some left because they got better, some because they did not. But there is also a group of patients who neither get better nor leave. With time, they have become an increasing proportion of my clientele. A typical patient would be a 70ish, divorced/separated/widowed, African-American female, who along with her hypertension, obesity, arthritis, and diabetes has also been diagnosed with depression. The depression is relatively long-standing, and despite modest benefits from various antidepressants, most of which seem to produce only side effects, I continue to prescribe them.
During the course of her treatment, this patient probably would have had several sessions with my psychiatric social worker focusing on her life situation, but again, with little benefit. It is unlikely that her symptoms would significantly improve in the future, and therefore she would continue to see me until I retire or she dies. The details of each of such patients’ lives vary. Undoubtedly, if my practice setting was different—a private practice in the suburbs, for instance—the specifics might be dramatically different. But I suspect that the theme would be the same. The patient’s life and her illness are inextricably connected—but not because over the years her life has been insidiously warped by her psychiatric condition; she had no such problems until she was in her late 60s. Nor has the trajectory of her life been dramatically altered by the seriousness of her psychiatric illness. Her illness is not severe, and her life has continued on its course. Rather, her life and her distress seem one and the same. This patient and her associated problems can be viewed from many perspectives. From the sociological, she is a member of the African-American Diaspora who migrated north during and after World War II. This is why she lives on the South Side of Chicago, in an area that became predominantly black in the 1950s due to white flight.
Her uncles and aunts, if not already deceased, still live in the South, while her brothers, sisters, nieces, and nephews live in Detroit, Washington, Cleveland, and LA. Her children, some of whom have become successful, live in the suburbs or have been taken by their careers to distant cities. They are busy with their jobs, their spouses also work, and they have children and grandchildren of their own. Even those who live in the greater Chicago area see her primarily on holidays or her birthday. She lives on a Social Security check and spends the majority of it on her rent. She can shop for food and necessities at the corner convenience store, but there is no other retail shopping nearby. Shopping malls are in the suburbs, inaccessible to those without a car, and downtown stores where she might at least window shop require taking several buses. Her major means of transportation is the Medi-Van, which brings her to her numerous physician visits. She can visit distant relatives only when someone else pays the airfare. This means that she usually only travels to attend funerals.
She grew up on a farm, attended school through the eighth grade, worked in a factory, kept house, and brought up her children. Free time was spent at church or at family events. She had no time for tennis, bridge, or hobbies. Now she watches TV, talks occasionally on the phone, and looks out the window. On Sundays and holidays she still goes to church, but because of problems with transportation she no longer attends Wednesday bible study. She can do some light housework and still is able to cook, but since it is only for herself, she keeps this to a minimum. From a psychiatric perspective, she presents many of the features of depression. She complains of decreased mood with frequent crying spells, difficulty sleeping, low energy, poor concentration, and a decrease in self-esteem. She also describes episodes of intense anxiety when alone, particularly at night. She scored 11 on the Geriatric Depression Scale and was diagnosed with Major Depressive Disorder, Recurrent, Moderate 296.32. For these problems she receives an antidepressant, an anti-anxiety agent as needed, and sleeping medication. Since she began seeing me, these symptoms have not significantly improved; however, her frequent visits to the Emergency Room due to chest pains and palpitations have decreased. She has been willing to accept that these are “nerves” and no longer calls 911.
From her perspective, she is a person with many medical problems. It would be hard for her to see herself otherwise. She must take eight different medications daily, remembering which pill and how many of each must be taken at which times. She is also reminded of this by her regular appointments with a geriatrician, endocrinologist, rheumatologist, nutritionist, and psychiatrist. She knows that she is old and vulnerable. She does not leave the apartment when it is dark and often is frightened to be alone at night. She fears dying alone, but not the idea that she will die. She has a strong belief in a personal God and an afterlife. She feels that God has helped her deal with her loneliness and physical pain. But she also thanks her physicians for what they have done, while also wondering if there might be something new or better that might help more. I too wonder whether there is something that would help. What might it be and from where might it come? I doubt it will be from seeing me. She comes for 15 minutes every few months. She updates me on the frequency and intensity of her symptoms. She usually also talks about her various medical problems. I try to direct the conversation to what she has done in the interim and what she might do in the near future. But she has little to report. I encourage her to attend a senior group at the community center or to move to senior housing. Neither of these options holds much appeal. So I renew her prescriptions and, although I wouldn’t have anything different to offer in three months, I have her make another appointment.
One could argue that this woman’s problems are a consequence of social inequities. But, even if it were in a physician’s power to influence these matters, would this help her or prevent future cases? It could just as cogently be argued that her problems are actually attributable to our society’s progress in overcoming these inequities. If she had stayed in Mississippi and lived as her mother and grandmother had, she would not be seeing a psychiatrist for depressive symptoms. There probably were no psychiatrists available in those rural areas, and if there had been there was no Medicare or Medicaid to pay for it during those times. Also, before Social Security brought some measure of financial security to the elderly, she would have been too occupied with basic survival needs to be concerned with depression. Most importantly, a major source of her emotional problems—loneliness and fear of dying alone—would not have been issues. She would have been living with family. She and they would not have had the resources to live in separate homes. As well, her extended family would be nearby. Increased economic opportunities allowed her to leave the South and her children to move to the suburbs and elsewhere.
But social mobility is tied to geographic mobility. One might argue that although she benefited from societal changes, she was never prepared for them. She wasn’t told that she’d be living alone, with no family nearby and access to her church restricted by arthritis and lack of transportation. But if she had been, would she have had the time or inclination to prepare for life alone, establishing more social ties, developing a wider range of interests? Could she have put less into working, running a home, and caring for her family, and more into self-actualizing? Her life is what it is. I have no treatment to change the past and little that will help her with the present pain. Perhaps her pastor has something for that, but I do not.
Dr. Luchins is Chief of Mental Health Research, Jesse Brown VAMC, Chicago, IL, and Professor of Clinical Psychiatry, University of Illinois at Chicago.