I have just returned home from an emotionally exhausting shift at Pacific Free Clinic in San Jose. As is often the case, it was last patient of the day, a gentleman who spoke perfect English, who left a lasting impression on me and challenged my emotional capacity. RS, as the patient will be called, was a 48-year-old man who presented with an onslaught of medical issues. Highest on the list was an ongoing, lifelong struggle with depression that had been exacerbated in the past 2 months after he ran out of his antidepressant medications. RS expressed feelings of hopelessness, frustration, lack of motivation, and a general anger towards the world. His traumatic past and current situation was certainly a key contributor, if not a direct cause of his depression. His father had been abusive all his life—abusive towards RS and abusive with alcohol. He had grown up around violence in a world filled with hatred and fear. More recently, his mother committed suicide after succumbing to her own struggles with depression. His sister, who he described as ”borderline mentally retarded,” was a continual source of stress to the point that RS was forced to sever their relationship.
More recently, the sources of stress in his personal life have mounted. In 2009, he lost his job after a 15-year run at the same company . Since then, he has been both unable and unwilling to find work. He expressed feeling defeated, which has crippled him emotionally and rendered him helpless for pursuing work. Yet, at the same time, he admits that unemployment was the driver of his anxiety and frustrations with the world. His wife is currently employed, and his son and daughter are busy finishing their senior year of high school. He is left alone at home each day, by himself, to ruminate, to agitate, and to self-medicate. He has always taken to alcohol during tough times, but he admits that this time it is worse than before. He can easily finish a bottle of rum each day, and he takes to the bottle each morning as soon as he wakes. He explains that he is simple bored of life—there is no more joy and all he can think to do with his free time is drink in an attempt to forget it. It pains him to think of his wife at work all day while he is at home, being “useless” and unable to provide for his family. In essence, he feels robbed of his masculinity and ashamed by his inability to take action. Although his family provides a source of joy and pride, his frustrations and alcoholism are self-isolating and a strain on his relationships.
I feel helpless, as I am not adequately prepared to deal with this emotional burden to help the patient explore his illness. I try to narrow the scope of the discussion and focus on the more manageable health issues—his high blood pressure, high cholesterol, and back pain—even though I empathize that he is here in a desperate attempt to reach out for a human connection. I am a stranger, and the anonymity of our interaction provides a sense of safety to unload emotions. I realize that this depression is limiting his ability and willingness to take care of his other health issues and to tackle his addiction.
I imagine that RS is not the only patient who is suffering from severe depression due to unemployment. People are very much defined by their job. This provides a sense of purpose, pride as a provider, and a reason to get up each day. Loss of a job, especially for the family breadwinner, is a devastating experience that wrenches the soul. The economic situation in this country has forced many people, and then patients, to face this reality. It would not be surprising if unemployment were discovered to be one of the primary reasons for the recent uptick in the prevalence of major depressive disorder here in the United States. People need a reason to live, just as much as they need food, water, shelter, etc. RS is a very competent individual who is capable of managing his other chronic conditions. He has a handle on all of his medications, he is capable of caring for himself, and he is cognizant of the lifestyle changes that he must adopt in order to control his blood pressure, lipid levels, and potentially high glucose levels. He understands that he has an addiction to alcohol is ruining his relationships and jeopardizing his physical health. It is quite clear that the major roadblock to addressing all of these issues is his mental health. This serves as another reminder of how much remains unknown about the inner workings of the mind and how critical it is to treat mental health in order to optimize physical health.
Unfortunately, there is only so much help that we can offer at a one-stop free clinic. The key was to get RS to focus on two to three conditions on his list that were most concerning to him and that we could address right there in our limited time. With no job, and hence no health insurance, RS had run out of antidepressant medication. As soon as the medications ran out, he noticed increased anxiety and, in turn, increased drinking. It was easy enough to provide him with a new dose of the antidepressant medications. In addition, we referred RS to Valley Medical Center for follow up with a psychiatrist and continued care with a primary care physician. He had lab work performed to monitor his cholesterol and to check for elevated blood glucose levels as a screen for diabetes. We feel confident that providing a mechanism for continued care through a primary care clinic will at least help to coordinate RS’s complex and multifaceted health issues. Although this action plan was comprehensive given our limited resources, this does not fix the problem of course. This is a case that demonstrates the powerful impact of the broader economic and social situation on the mental health of the population. This speaks to the larger problem that we as a society face in facing and adequately treating issues of mental health. Perhaps if we could better understand the impact of mental health disorders on physical health, this would motivate us to study and allocate health care resources more equally. Until then, patients like RS will force an uphill battle, searching for motivation and encouragement to deal with their health problems while their minds tug in the opposite direction.